C. Poncelet

Tracheal Intubation Using the Airtraq in Morbid Obese Patients Undergoing Emergency Cesarean Delivery

THE Airtraq (Prodol Meditec S.A., Vizcaya, Spain), a new disposable intubating device, was designed to provide a view of the glottis without alignment of the oral and pharyngeal axes. The Airtraq laryngoscope (AL) has recently been used in patients with normal airways 1 and in simulated difficult airways, 2 but no study has assessed its performance in difficult airway patients. After training on a manikin, five senior staff anesthesiologists covering the obstetric anesthesia unit of our university hospital performed the clinical learning process with the AL. Because of its efficiency in the case of difficult tracheal intubation, the AL was incorporated into our emergency difficult airway management algorithm as a second-step airway device in the case of failed tracheal intubation using a standard Macintosh laryngoscope. We report two cases of emergency cesarean delivery parturients in whom the trachea was rapidly intubated using the AL after failed direct laryngoscopy. We discuss the place of the AL in a difficult airway management algorithm in parturients.

Recurrence After Cystectomy for Borderline Ovarian Tumors: Results of a French Multicenter Study

BackgroundFertility-sparing surgery for borderline ovarian tumors (BOT) is feasible and effective and does not seem to have a negative effect on survival. Specific data on the effect of cystectomy, and notably on recurrence, are lacking.MethodsThis was a French retrospective multicenter study of 313 women with stage I BOT treated from 1990 to 2000 in 13 specialized gynecological units and 1 cancer center. Diagnosis and staging were based on International Federation of Gynecology and Obstetrics (1989) criteria. Surgery consisted of cystectomy, unilateral salpingo-oophorectomy (USO), or bilateral salpingo-oophorectomy (BSO).ResultsAfter cystectomy, persistent BOT and benign ovarian cysts on the operated ovary were observed in 15% and 65% of patients, respectively. Mean follow-up did not differ among patients receiving the three types of surgery. The recurrences after cystectomy, USO, and BSO treatment were 30.3%, 11%, and 1.7%, respectively (P < .0001). Recurrences were more frequent after cystectomy than after USO (P = .0001) and BSO (P = .0001) and when intraoperative cyst rupture occurred (P = .04).ConclusionsThese results suggest that cystectomy for BOT is associated with a high risk of intraoperative cyst rupture and of recurrence compared with USO or BSO.

Use of laparoscopy in unexplained infertility

OBJECTIVE The use of laparoscopy in unexplained infertility work-up is still a subject of debate, although laparoscopy remains the gold standard for diagnosis and treatment of several pelvic pathologies. The objective of this study was to assess the rates and types of pelvic pathologies observed during diagnostic laparoscopy, and the pregnancy rate in couples with unexplained infertility following laparoscopy. STUDY DESIGN Prospective study, from November 2003 to October 2009, including 114 infertile, spontaneously ovulating women with normal clinical examination, ovarian reserve assessment, pelvic ultrasound scan and patent tubes on hysterosalpingography. Semen analyses were normal according to the World Health Organization criteria. After three cycles of ovulation induction with or without intra-uterine insemination and no pregnancy, women were referred for diagnostic laparoscopy. RESULTS Laparoscopy revealed pelvic pathology in 95 patients. Endometriosis, pelvic adhesions and tubal disease were observed and treated in 72, 46 and 24 patients, respectively. Following laparoscopy, bilateral and unilateral tubal patencies were observed in 107 and five patients, respectively. Pregnancy was observed in 77 out of 102 patients who tried to conceive after surgery, 35 of whom conceived using their own tubes. CONCLUSION Diagnostic laparoscopy should be strongly considered in unexplained infertility work-up, and tubal efficiency should not be underestimated.

Intérêt du gel d'acide hyaluronique dans la prévention des synéchies intra-utérines après hystéroscopie opératoire : Étude cas-témoin

OBJECTIVES To evaluate the efficacy of auto-cross-linked hyaluronic acid gel in the prevention of adhesions after operative hysteroscopy using a case-control study. MATERIALS AND METHODS Fifty-four patients with an intrauterine lesion (myoma, polyp, uterine septa and adhesions) undergoing hysteroscopic surgery were divided into two groups: group A (30 patients) with intrauterine application of hyaluronic acid gel at the end of the surgical procedure and group B, which was considered as control (24 patients). The rate of adhesion formation, the score and the adhesion severity were estimated for each group using American Fertility Society (AFS) classification, by diagnostic hysteroscopy two months after surgery. No other treatment was associated. RESULTS Age, weight, parity, hysterometry were comparable in the two groups. Surgery indications were polyp(s), myoma(s), uterine septa, and adhesions (11, 8, 1, and 10 patients in group A and 6, 6, 4, and 8 patients in group B, respectively). No difference was observed in intrauterine adhesion formation between the two groups (33.3% for group A and B; p = NS). The median adhesion scores using AFS were comparable in the two groups (1.30+/-2.35 vs 1.42+/-2.47; respectively, p = NS). The severity of the adhesions showed no significant difference between the two (70% stage I, mild adhesions; 20% stage II, moderate adhesions; 10% stage III, severe adhesions and 62.5% stage I; 25% stage II; 12.5% stage III in the group A and B, respectively). No adverse effect with the ACP gel was detected. CONCLUSION ACP gel does not reduce the incidence and the severity of intrauterine adhesions after hysteroscopic surgery.Resume Objectif Evaluer l’efficacite du gel d’acide hyaluronique pur reticule dans la prevention des synechies intra-uterines apres hysteroscopie operatoire a l’aide d’une etude cas-temoin. Materiels et methodes Cinquante-quatre patientes, en âge de procreer, porteuses d’une pathologie intra-uterine (polype, myome de type 0 ou 1, cloison, synechies) ont beneficie d’une hysteroscopie operatoire et ete reparties en 2 groupes : groupe A avec application d’un gel d’acide hyaluronique dans la cavite uterine en fin d’intervention (30 patientes) et groupe B, considere comme controle (24 patientes). Le taux de synechies intra-uterines, le score et le stade adherentiel selon l’American Fertility Society (AFS) ont ete compares a l’issue d’une hysteroscopie diagnostique de controle, realisee 2 mois apres le geste operatoire. Aucun autre traitement pouvant avoir une influence uterine n’a ete associe. Resultats L’âge moyen, le poids, la parite et l’hysterometrie etaient comparables dans les 2 groupes. L’indication operatoire etait la presence d’un ou plusieurs polypes, de myome (s), de cloison uterine, et de synechies (11, 8, 1, et 10 patientes dans le groupe A et 6, 6, 4, et 8 patientes dans le groupe B, respectivement). Le taux de synechies lors de l’hysteroscopie de controle etait comparable dans les 2 groupes (33,3 % dans les 2 groupes ; p = NS). Le score moyen des adherences selon l’AFS etait comparable dans les 2 groupes (1,30 ± 2,35 vs 1,42 ± 2,47; p = NS). La severite des synechies n’etait pas differente entre les 2 groupes (70 % de stade I, 20 % de stade II et 10 % de stade III pour le groupe A et 62,5 % de stade I, 25 % de stade II et 12,5 % de stade III pour le groupe B). Aucun effet secondaire du gel n’a ete observe. Conclusion La mise en place d’un gel d’acide hyaluronique ne modifie pas l’incidence et la severite des synechies intra-uterines apres hysteroscopie operatoire.

Impact of serum tumor marker determination on the management of women with borderline ovarian tumors: Multivariate analysis of a French multicentre study

OBJECTIVE To evaluate the contribution of preoperative serum tumor markers to manage borderline ovarian tumors (BOT). STUDY DESIGN Retrospective multicentre study including 317 BOT. Serum tumor marker levels of CA125, CA19-9, CEA, and CA15-3 were determined by radio-immunoassay. RESULTS Among 181 women with serous BOT and 136 women with mucinous BOT, respectively 55 of 114 (48.2%) and 38 of 91 (41.8%) had at least one abnormal value. Women with preoperative tumor marker assays were more likely to have radical treatment (p=0.0001), full staging (p=0.004), and intra-operative histology (p<0.0001). Women with at least one abnormal tumor marker were more likely to undergo laparotomy (p=0.007), to have intra-operative histology (p=0.04) and complete staging (p=0.0008). In multivariate analysis, first-line laparoscopy was associated with abnormal tumor marker levels (OR=9.63; 95%CI=1.40-66.39; p=0.02), while laparotomy was associated with large tumors, bilateral tumors, and ascitis visible on sonography. CONCLUSION Serum tumor marker assays modified both preoperative assessment and surgical management of BOT.

Hepatic endometrioma: a case report and review of the literature: report of a case

Hepatic endometriosis has an extremely rare occurrence characterized by the presence of ectopic endometrium in the liver. A diagnosis of hepatic endometriosis is established after surgery. A 51-year-old multiparous female was referred to our unit for investigation of a liver tumor. The patient reported a 6-month history of epigastric pain and vomiting. She had undergone conservative hysterectomy for uterine leiomyomas several years earlier. The results of liver function tests and the levels of tumor markers (CA 19.9, CEA, CA125, αFP) were normal. Radiological imaging (USS, CT and MRI) suggested the presence of liver cystadenoma, liver cystadenocarcinoma or cystic metastasis of the liver in the left liver lobe extending to the diaphragm with left hepatic vein compression. Laparotomy was performed. The intraoperative frozen sections suggested a diagnosis of endometriosis. Anatomical resection was performed, including left lobectomy with diaphragm resection. The final histology confirmed the presence of hepatic endometrioma without malignant transformation. Fourteen cases of hepatic endometrioma have been described in the medical literature. We herein report the 15th case. Making a preoperative diagnosis of hepatic endometriosis is very difficult, despite conducting a complete investigation, in the absence of clinical and radiological characteristics. The diagnosis is made according to a histological examination of the whole surgical sample.

Non-ART pregnancy predictive factors in infertile patients with peritoneal superficial endometriosis

OBJECTIVE To study the predictive factors for non-ART pregnancy in infertile women after laparoscopic diagnosis and surgery for isolated superficial peritoneal endometriosis (SUP). STUDY DESIGN Retrospective observational study from January-2004 to December-2015 in a tertiary care university hospital and Assisted Reproductive Technology (ART) centre. Infertile women with laparoscopic surgery for SUP (with histologic diagnosis) were included. The surgical treatment was followed by spontaneous fertility or post-operative ovarian stimulation (pOS) using superovulation (gonadotrophins)±Intra Uterine Insemination (IUI). The main outcomes were the non-ART clinical pregnancy rates and its predictive factors. RESULT(S) Over the period study, 315 women were included. Of these, 133 (42.3%) women had non-ART pregnancy. The mean time to conceive was 6 months (±6days). Univariate analysis for non-ART pregnancy after surgery showed that: (i) no difference was observed according to age, length of infertility, Body Mass Index (BMI), the rate of previous pregnancy, and the pre-operative ovarian stimulation rate; (ii) diminished ovarian reserve and previous miscarriage were higher in the non-pregnant women group (8.3 versus 19.1%, p<0.05; 3.5% versus 9%, p=0.06, respectively); (iii) the mean EFI score and pOS were higher in pregnant women (7.7 versus 7.2, p=0.02; 49.2% versus 26.7%, p<0.01); and (iv) IUI did not show any benefit for pregnancy (22% after superovulation versus 27.2% after superovulation and IUI). In the multivariate analysis, only pOS (adjusted OR 2.504, 95% CI [1.537-4.077]) and DOR (aOR 0.420, 95% CI [0.198-0.891]) remained significantly associated with the incidence of pregnancy. CONCLUSION(S) After laparoscopic surgery for peritoneal superficial endometriosis related infertility, ovarian stimulation improved pregnancy rate, while diminished ovarian reserve had a worse prognosis for pregnancy.

Endometriosis Fertility Index ou classification de l’American Society of Reproductive Medicine pour les patientes infertiles endométriosiques opérées. Lequel est le plus pertinent ?

The revised American Fertility Society classification system has been most used after surgery by all consensus on endometriosis fertility. However, it does not predict pregnancy. The EFI score has been recently developed to aim at predicting clinical pregnancy after surgery. Several study performed its external validation. It may be a useful new tool to counsel couples for personalized postoperative management.

Hysteroscopic evaluation of endocervical and endometrial lesions observed after different procedures of embryo transfer: A prospective comparative study

OBJECTIVE Endocervical and endometrial damage observed after different procedures of embryo transfer (ET) were investigated using diagnostic hysteroscopy. STUDY DESIGN Prospective, descriptive and comparative study, in an Infertility centre, University Hospital. Hundred consecutive infertile patients with a normal uterine cavity, included in an IVF program, were enrolled between May 1st, 2006 and April 30th, 2007. All the patients had a diagnostic hysteroscopy immediately after trial ET using soft ET catheters: (i) IVF Sydney Set (Cook, Limerick, Ireland) (n=27), (ii) Elliocath (Ellios, Paris, France) (n=34), (iii) Frydman classic 4.5 (CCD, Paris, France) (n=19), and rigid ET catheters: Memory Frydman 4.5 (CCD, Paris, France) (n=20). All the procedures were recorded and blindly reviewed. Data were analyzed using a Kruskal-Wallis test for age and severity of endometrial lesions, or Fishers exact test for binary criteria. RESULTS Endocervical lesions were more frequently encountered in the soft (63%) and rigid (85%) Frydmans catheter groups compared to other groups (Elliocath: 29%, IVF Sydney Set: 26%; p<0.0001). Presence of blood on the catheter, and endometrial lesions were significantly less frequent in soft catheter groups compared to the rigid catheter group (p<0.0001). Severe endometrial lesions were less frequently observed when soft catheters were used (85%, 53%, 32%, 11% for Memory Frydman, Frydman classic, Elliocath and IVF Sydney Set, respectively; p<0.0001). The presence of blood on the catheter signed severe endometrial lesions. CONCLUSION All ET catheters can lead to endocervical and endometrial damage. Severe endometrial lesions were less frequent when soft catheters were used.

Second live birth after undergoing assisted reproductive technology in women operated on for endometriosis.

OBJECTIVE To determine prognostic factors for a second live birth, after a first child obtained through assisted reproductive techniques (ART). DESIGN Observational study from January 2004 to December 2014. SETTING Tertiary care university hospital and ART center. PATIENT(S) A total of 164 infertile patients with endometriosis, who underwent laparoscopy surgery and had a first baby obtained by ART, were included and 65 wished a second baby. INTERVENTION(S) No iterative surgery. MAIN OUTCOME MEASURE(S) Spontaneous pregnancy rate (PR) according to endometriosis fertility index. RESULT(S) Among the cohort, 27 patients (41.5%) gave birth to a second child through spontaneous pregnancy, whereas 23 patients (35.3%) required ART to obtain a second live birth. No difference was observed between patients regarding age, endometriosis staging, complete removal of endometriosis lesions and pelvic adhesion, except for the least function score, and the endometriosis fertility index. Taking into account irrespective of both mode of conception a total of 78% of patients obtained a second child, with a median conception time of 17 months. CONCLUSION(S) The second live birth rate in infertile patients with endometriosis and with surgical treatment was high (78%). Spontaneous PR was 54%. Endometriosis fertility index could be considered as a predictive factor for a spontaneous second pregnancy in fertility management. Our results need to be confirmed in larger prospective studies.