Benoit Resch

Predictors of failed pelvic arterial embolization for severe postpartum hemorrhage.

OBJECTIVES: To estimate what factors are associated with a failed pelvic arterial embolization for postpartum hemorrhage and to attempt to estimate efficacy of pelvic arterial embolization in rare conditions. METHODS: This was a retrospective cohort study including all consecutive women who underwent pelvic arterial embolization trial for postpartum hemorrhage between 1994 and 2007 at a tertiary care center. Pelvic arterial embolization failure was defined as the requirement for subsequent surgical procedure to control postpartum hemorrhage. RESULTS: Pelvic arterial embolization was attempted in 0.3% of deliveries by the same radiologist in 87% of cases. Failures occurred in 11 of 100 cases (11%) and in 4 of 17 cases (24%) of placenta accreta or percreta. The major complication rate after pelvic arterial embolization was low (3%). Fifty patients (50%) were transferred from nine other institutions. Pelvic arterial embolization was performed in 11 cases (11%) after a failed conservative surgical procedure and in eight cases (8%) for secondary postpartum hemorrhage, with success rates of 91% and 88%, respectively. Pelvic arterial embolization demonstrated a patency throughout one ligated pedicle in 9 of the 11 cases of failed conservative surgical procedure (82%). Twin pregnancy, chorioamnionitis, operative vaginal delivery, hospital-to-hospital transfer, nature of embolizing agent and arteries embolized, failed surgical procedure, secondary postpartum hemorrhage, cause of postpartum hemorrhage, and more than one pelvic arterial embolization were not found to be significantly associated with failed pelvic arterial embolization. CONCLUSION: The only factors significantly associated with failed pelvic arterial embolization were a higher rate of estimated blood loss (more than 1,500 mL) and more than 5 transfused red blood cell units. Attempted pelvic arterial embolization after a failed vessel ligation procedure and for a secondary postpartum hemorrhage is a good option with high success rates. LEVEL OF EVIDENCE: III

Fertility after ectopic pregnancy: the DEMETER randomized trial

STUDY QUESTION Does treatment for the resolution of ectopic pregnancy (EP) affect subsequent spontaneous fertility [occurrence of an intrauterine pregnancy (IUP)]? SUMMARY ANSWER There is no significant difference in 2 years subsequent fertility neither between methotrexate and conservative surgery for less active EP nor between conservative and radical surgery for the most active EP. WHAT IS KNOWN ALREADY No randomized trial has compared radical and conservative surgery treatments. A recent review of the Cochrane database did not conclude about fertility due to insufficient data. Prospective studies from EP registries in two regions of France (Auvergne and Greater Lille) have suggested that fertility is similar after medical treatment and conservative surgery and lower after radical surgery. STUDY DESIGN, SIZE, DURATION This randomized controlled trial included all women with an ultrasound-confirmed EP. Women were divided into two arms according to the activity of the EP (defined by Fernandezs score). In arm 1 (less active ectopic pregnancies, i.e. Fernandezs score <13 and no haemodynamic failure), medical treatment was considered practicable, and women were randomly allocated to conservative surgery with a systematic post-operative i.m. methotrexate injection within 24 h or to an i.m. methotrexate injection alone. In arm 2 (active ectopic pregnancies), medical treatment was considered impracticable, and, thus, all women had to undergo surgery; they were randomly allocated to either a radical or conservative procedure, the latter including a post-operative methotrexate injection. Sample sizes (n = 210 in arm 1 and n = 230 in arm 2) were computed to provide a statistical power of 80% to detect a 20% difference in subsequent cumulative fertility rates between treatments in each arm. The total duration of the trial was 5 years. PARTICIPANTS/MATERIALS, SETTINGS, METHODS The trial took place in 17 centres in France from 2005 to 2009. Two hundred and seven women were included in arm 1 and 199 in arm 2. Cumulative fertility curves were drawn with the Kaplan-Meier method and compared with the log-rank test. Hazard ratios (HRs) were computed with the Cox model. Analysis was performed according to the intention-to-treat principle. MAIN RESULTS Arm 1: cumulative fertility curves were not significantly different between medical treatment and conservative surgery. HR was 0.85 (0.59-1.22) P = 0.37. The 2-year rates of IUP were 67% after medical treatment and 71% after conservative surgery. Arm 2: cumulative fertility curves were not significantly different between conservative and radical surgery. HR was 1.06 (0.69-1.63) P = 0.78. The 2-year rates of IUP were 70% after conservative surgery and 64% after radical surgery. LIMITATIONS, REASONS FOR CAUTION Inclusion in this trial was more difficult than expected, especially in arm 2 in which women were reluctant to radical surgery. In consequence, the sample size was slightly lower than planned. However, due to a lower proportion of lost to follow-up than expected (10% instead of 15%), the statistical power remained very close to 80%. WIDER IMPLICATIONS OF THE FINDINGS As it is a multicentre randomized trial, the results may be generalized with satisfactory confidence. The results of this trial invite gynaecologists to reconsider the management of EP and to modify balance between considerations of initial recovery and preservation of fertility. TRIAL REGISTRATION NUMBER NCT00137982 on the WHO International Clinical Trials Registry Platform.

Delayed functional outcomes associated with surgical management of deep rectovaginal endometriosis with rectal involvement: giving patients an informed choice

BACKGROUND The aim of this study was to compare delayed functional digestive and urinary outcomes following two different surgical procedures used in the management of rectal endometriosis. METHODS Women who had undergone surgical management of rectal endometriosis with at least 1 year of post-operative follow-up were included in a retrospective study. Post-operative symptoms were evaluated using specific questionnaires which focused on pelvic pain and functional outcomes. RESULTS There were 41 women who underwent surgical treatment of symptomatic rectal endometriosis. Post-operative follow-up was completed over 26 +/- 13 months (range 12-53). Colorectal segmental resection was performed in 25 women (61%) and nodule excision in 16 (39%). An increase in the number of daily stools > or =3 was observed in 13 (52%) and 3 (19%) patients managed, respectively, by segmental resection and nodule excision (P = 0.02). Severe constipation (<1 stool/5 days) was recorded in three women having undergone segmental resection. The probabilities of being free of dysmenorrhea, dyspareunia and non-cyclic pain at 24 months in women managed by segmental resection and nodule excision were, respectively, 80% (95% CI: 55-92%), 65% (95% CI: 42-81%), 43% (95% CI: 23-62%) and 62% (95% CI: 34-81%), 81% (95% CI: 52-94), 69% (95% CI: 40-86%). When pain recurrences occurred, a significantly lower post-operative score for pain was observed in both groups. No significant difference in pain improvement was found between surgical procedures. CONCLUSION Colorectal segmental resection appears to be associated with several unpleasant functional symptoms when compared with nodule excision. Information about functional outcomes should be provided to patients managed for rectal endometriosis, and should be considered when deciding on the most appropriate treatment of this disease.

Fertility and pregnancy following pelvic arterial embolisation for postpartum haemorrhage

Objectives  To determine and compare the fertility and pregnancy outcomes following embolisation with or without uterine‐sparing surgery for postpartum haemorrhage, and to attempt to identify specific risk factors associated with an increased likelihood of intrauterine synechia.

Liver resection for breast cancer metastasis: Does it improve survival?

PurposeTo assess the outcome and prognostic factors of liver surgery for breast cancer metastasis.MethodsWe retrospectively examined 16 patients who underwent partial liver resection for breast cancer liver metastasis (BCLM). All patients had been treated with chemotherapy or hormonotherapy, or both, before referral for surgery. We confirmed by preoperative radiological examinations that metastasis was confined to the liver. The survival curve was estimated using the Kaplan-Meier method. Univariate and multivariate analysis were conducted to evaluate the role of the known factors of breast cancer survival.ResultsThe median age of the patients was 54 years (range 38–68) and the median disease-free interval between the diagnoses of breast cancer and liver metastasis was 54 months (range 7–120). Nine major and 7 minor hepatectomies were performed. There was no postoperative death. The overall 1-, 3-, and 5-year survival rates were 94%, 61%, and 33%, respectively. The median survival rate was 42 months. Univariate analysis revealed that hormone receptor status, number of metastases, a major hepatectomy, and a younger age were associated with a poorer prognosis. The survival rate was not influenced by the disease-free interval, grade or stage of breast cancer, or intraoperative blood transfusions. The number of liver metastases was identified as a significant independent factor of survival according to the Cox proportional hazard model (P = 0.04).ConclusionsLiver resection, when done in combination with adjuvant therapy, can improve the prognosis of selected patients with BCLM.

B‐Lynch suture for massive persistent postpartum hemorrhage following stepwise uterine devascularization

Objective. To estimate the effectiveness and safety of the B‐Lynch suture for severe persistent postpartum hemorrhage (PPH) following vessel ligation before considering hysterectomy and its impact on menstruation and uterine cavity. Design. Cohort study. Setting. University‐affiliated tertiary referral center. Population. Fifteen consecutive women who underwent B‐Lynch suture for persistent PPH despite vessel ligation. Methods. Data were retrieved from medical files and telephone interviews. Main outcome measure(s). Hysterectomy, infection, hysteroscopy, future menstruations. Results. In 13 of the 15 cases (86.7%), PPH occurred after cesarean deliveries. B‐Lynch sutures controlled the hemorrhage and resulted in an avoidance of immediate hysterectomy in 12 of 15 cases (80%). The postpartum period was uneventful for 14 of 15 women (93.3%). In one case hysterectomy was required due to pyometra in an ischemic uterus. In the remaining 11 women where the uterus was preserved, ambulatory hysteroscopy was normal. No women reported any differences in menses or pain compared to that they experienced before pregnancy, or any clinical symptoms of early menopause. One woman reported a subsequent pregnancy with normal conception delay, whereas the ten remaining women had no desired pregnancy due to, in each case, the fear of PPH recurrence. Conclusions. B‐Lynch technique appears to be an effective procedure with a relatively low morbidity to control persistent severe PPH following a failure of vessel ligation before considering hysterectomy.

Long‐term psychological impact of severe postpartum hemorrhage

Objective. To estimate the long‐term psychological impact of severe postpartum hemorrhage in women whose uterus was preserved. Design. Retrospective study. Setting. University‐affiliated tertiary referral center. Population. All consecutive women who underwent embolization for postpartum hemorrhage between 1994 and 2007 and whose uterus was preserved were included. Methods. Data were retrieved from medical files and semi‐structured telephone interviews. In semi‐structured interviews, women were asked about their perceptions and memories of the experience. Main Outcome Measures. Perceptions and memories of the postpartum hemorrhage during and after delivery. Results. Follow‐up was successful for 68 of the 91 (74.7%) women included. Of the 46 (67.6%) who reported negative memories of the delivery and postpartum period, the main memory for 24 was a fear of dying (35.3%). Of the 28 (41.2%) who reported continued repercussions, 16 (23.5%) thought about this delivery and its complications at least once a month, five (7.3%) reported persistent fear of dying, four (5.9%) reported sexual problems, and three (4.4%) women considered that the event was, at least in part, responsible for their subsequent divorce. Of the 15 women who had a subsequent full‐term pregnancy, nine (60%) reported intense anxiety throughout the pregnancy, and one (6.7%) developed depression requiring antidepressant treatment during pregnancy. Conclusions. Severe postpartum hemorrhage may have a long‐term psychological impact on women despite uterine preservation.

Complications Associated With Two Laparoscopic Procedures Used in the Management of Rectal Endometriosis

This study suggests that bladder and rectal dysfunction occur more frequently with colorectal resection in rectal endometriosis compared with excision of the nodules alone.

Histopathologic features of endometriotic rectal nodules and the implications for management by rectal nodule excision.

Using data from 27 women with deep rectal endometriosis, managed by segmental resection, we observed that in 89% of cases active glandular endometrial foci were responsible for a deeper infiltration of rectal layers than that of fibrosis and smooth fibers by 5 mm on average. These data might be useful for surgeons performing rectal nodule excision, suggesting the benefits of administrating postoperative medical treatment to reduce the risk of rectal recurrences caused by remaining active endometriotic foci.

Surgical uterine devascularization for placenta accreta: immediate and long-term follow-up

Background.  To report immediate and long‐term outcome in patients with surgical  uterine devascularization for placenta accreta.