Cyrille Huchon

Adnexal torsion: a literature review.

This review of the literature focuses on the diagnosis and surgical management of adnexal torsion. Diagnosis of adnexal torsion is difficult and is based on a range of elements obtained by questioning, clinical examination and additional investigations. Pelvic and Doppler ultrasonography are often incapable of revealing this pathology. When adnexal torsion is suspected and diagnosis can only be achieved by surgery, arrangements should be made for laparoscopy as soon as possible. Treatment consists essentially of untwisting the adnexa, even when necrosed, and completed as required by treatment of any cyst present and/or ligamentopexy.

Adnexal torsion: a predictive score for pre-operative diagnosis

BACKGROUND Adnexal torsion (AT) is difficult to diagnose and requires immediate surgery. The aim of this study was to develop a simple score for assisting in the pre-operative diagnosis of AT in women with acute pelvic pain. METHODS Using data from a retrospective cohort of 142 patients with acute pelvic pain, we developed a score based on multiple logistic regression after a jackknife procedure. We validated the score in a prospective cohort of 35 women with acute pelvic pain. RESULTS Five criteria were independently associated with AT confirmed by surgery: unilateral lumbar or abdominal pain [adjusted odds ratio (aOR), 4.1; 95% confidence interval (95% CI), 1.2-14.0]; pain duration <8 h at first presentation (aOR, 8.0; 95% CI, 1.7-37.5), vomiting (aOR, 7.9; 95% CI, 2.3-27.0), absence of leucorrhoea and metrorrhagia (aOR, 12.6; 95% CI, 2.3-67.6) and ovarian cyst larger than 5 cm by ultrasonography (aOR, 10.6; 95% CI, 2.9-38.8). The torsion score was based on these five criteria. Low-risk and high-risk groups were derived from values of the score [probability of AT, 3.7% (95% CI, 0-7.8) and 69% (95% CI, 53-84), respectively]. Application of these criteria to the prospective cohort confirmed the diagnostic accuracy of the score [probability of AT, 0% (95% CI, 0-16) and 75% (95% CI, 26-100) in the low-risk and high-risk groups, respectively]. CONCLUSIONS This easy-to-calculate score may prove useful for diagnosing AT in patients with acute pelvic pain seen at general or gynaecology emergency departments.

Five-Millimeter Trocar Site Small Bowel Eviscerations after Gynecologic Laparoscopic Surgery

Trocar site hernia is a known complication after laparoscopic surgery, especially at 10-mm and larger port sites. Only a few cases of herniation through 5-mm port sites are reported in the literature. We describe 2 cases of bowel herniation and bowel obstruction through 5-mm port sites. The patients were 63 and 74 years old; both had endometrial cancer and underwent an uncomplicated hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymphadenectomy with peritoneal drains left at the lateral 5-mm port sites. Each patient presented symptoms of small bowel obstruction after which the drains were removed and were found to have evisceration through a laterally placed 5-mm port site. The bowel was reduced locally, and a segmental bowel resection was needed in 1 case. Bowel herniation can occur through the fascial defect after placement of a 5-mm port, especially if drains have been placed at the port site.

Morbidity of diaphragmatic surgery for advanced ovarian cancer: Retrospective study of 148 cases

BACKGROUND Treatment of Advanced Ovarian Cancer (AOC) includes surgery with complete cytoreduction, one of the strongest prognostic factors. To achieve complete cytoreduction, diaphragmatic surgery is often required. There is currently a lack of information in the literature regarding the morbidity and impact of this type of surgery. The aim of this study is to report specific pulmonary morbidity and overall morbidity associated with diaphragmatic surgery in patients with AOC. MATERIALS AND METHODS We conducted a multicentric (6 centres), retrospective study that included 148 patients operated on between 2004 and 2008. Patient characteristics, surgical course and postoperative complications were collected. RESULTS The complete cytoreduction rate was 84%. The surgery was categorised by timing as initial, interval or recurrence surgery in 38%, 51% and 11% of patients, respectively. In 69% of patients, one or more postoperative complications occurred: pulmonary complication (42%), digestive fistula (7%) or lymphocyst (18%). The pulmonary complications were pleural effusion (37%), pulmonary embolism (5%), pneumothorax (4%) and pulmonary infection (2%). These complications required revision surgery, pleural evacuation, or lymphocyst evacuation in 13%, 14%, and 11% of the cases, respectively. Postoperative mortality was 3%. Risk factors for pulmonary complications were the addition of extensive upper surgery to the diaphragmatic surgery (p = 0.014) and the size of the diaphragmatic resection (p = 0.012). CONCLUSIONS Diaphragmatic surgery achieved complete removal of the tumour but resulted in pulmonary complications in addition to complications of radical surgery.

Measurement of acute pelvic pain intensity in gynecology: a comparison of five methods.

OBJECTIVE: To compare different methods for measuring pelvic pain intensity in a gynecologic emergency unit. METHODS: A total of 177 consecutive female patients, with or without pain, consulting in a gynecologic emergency unit, underwent initial pain evaluation. We used three self-report pain intensity scales: visual analog scale, numeric rating scale, and verbal rating scale, and two nonverbal structured behavioral indices (BI-1, first behavioral index, BI-2 second behavioral index). Diagnosis and treatment took place in routine manner. RESULTS: The five scales were unidimensional according to principal component analysis (Cronbach’s alpha coefficient=0.89). Missing data rates were greater for the two behavioral scales than for the self-report scales (n=177; 6.2% for BI-1 and 12.4% for BI-2). Patients had lower scores with the behavioral scales than with the self-report ones. Variations of pain intensity according to the pain physiology or the pain location were similar whatever the method of measurement used. The five methods were all sensitive to the physiology of the pain, the location and the severity of the illness, and pain as a main complaint. None of the methods used was affected by age, occupational categories, parity, or geographical origins. CONCLUSION: All methods adequately measured the pelvic pain intensity in gynecologic emergencies. The self-report scales were easier to use than the behavioral indices. Self-report measurements of pelvic pain intensity provide useful information at the time of triage in gynecologic emergency departments. LEVEL OF EVIDENCE: II

Does this woman have adnexal torsion

BACKGROUND No questionnaire is currently available for the presurgical diagnosis of adnexal torsion (AT). Our objective was to develop a predictive model for AT, based on the Self Assessment Questionnaire for Gynecologic Emergencies (SAQ-GE) designed for triaging women with acute pelvic pain. METHODS We performed a multicenter prospective trial conducted in five hospitals in France. Four hundred and ninety-six (496) women with acute pelvic pain (Numeric Rating Scale>4), including 31 with AT, were recruited from September 2006 through April 2008. An AT score was built using the SAQ-GE. RESULTS Five criteria were independently associated with AT confirmed by surgery: unilateral lumbar or abdominal pain [adjusted diagnostic odds ratio (aDOR), 23.3; 95% confidence interval (95% CI), 3.0-178]; absence of leucorrhea and metrorrhagia (aDOR, 7.0; 95% CI, 2.5-20), ovarian pain (aDOR, 5.5; 95% CI, 1.5-21), unbearable pain (aDOR, 5.0; 95% CI, 1.4-18) and vomiting (aDOR, 3.7; 95% CI, 1.6-9.0). The SAQ-GE torsion score was based on these five criteria and its values range from 0 to 10. The low-risk group (SAQ-GE torsion score<7), based on the score values, has a sensitivity (Se) of 96.7% (95% CI, 90.5-100), a negative predictive value of 99.7% (95% CI, 99.1-100) and a negative likelihood ratio (Lr-) of 0.05, ruling out AT with a probability of AT of 0.3% (95% CI, 0.0-0.9). Cross-validation of the model was performed using the jackknife resampling procedure, retrieving an unbiased Se of 87.1 (95% CI, 75.1-99.1) and a specificity of 74.2% (95% CI, 70.2-78.2). CONCLUSIONS The SAQ-GE torsion score may prove useful for screening for AT in patients experiencing acute pelvic pain.

Pregnancy loss: French clinical practice guidelines

In intrauterine pregnancies of uncertain viability with a gestational sac without a yolk sac (with a mean of three orthogonal transvaginal ultrasound measurements <25mm), the suspected pregnancy loss should only be confirmed after a follow-up scan at least 14 days later shows no embryo with cardiac activity (Grade C). In intrauterine pregnancies of uncertain viability with an embryo <7mm on transvaginal ultrasound, the suspected pregnancy loss should only be confirmed after a follow-up scan at least 7 days later (Grade C). In pregnancies of unknown location after transvaginal ultrasound (i.e. not visible in the uterus), a threshold of at least 3510IU/l for the serum human chorionic gonadotrophin assay is recommended; above that level, a viable intrauterine pregnancy can be ruled out (Grade C). Postponing conception after an early miscarriage in women who want a new pregnancy is not recommended (Grade A). A work-up for women with recurrent pregnancy loss should include the following: diabetes (Grade A), antiphospholipid syndrome (Grade A), hypothyroidism with anti-thyroid peroxidase (anti-TPO) and anti-thyroglobulin (anti-Tg) antibodies (Grade A), vitamin deficiencies (B9, B12) (Grade C), hyperhomocysteinaemia (Grade C), hyperprolactinaemia (Grade B), diminished ovarian reserve (Grade C), and a uterine malformation or an acquired uterine abnormality amenable to surgical treatment (Grade C). The treatment options recommended for women with a missed early miscarriage are vacuum aspiration (Grade A) or misoprostol (Grade B); and the treatment options recommended for women with an incomplete early miscarriage are vacuum aspiration (Grade A) or expectant management (Grade A). In the absence of both chorioamnionitis and rupture of the membranes, women with a threatened late miscarriage and an open cervix, with or without protrusion of the amniotic sac into the vagina, should receive McDonald cerclage, tocolysis with indomethacin, and antibiotics (Grade C). Among women with a threatened late miscarriage and an isolated undilated shortened cervix (<25mm on ultrasound), cerclage is only indicated for those with a history of either late miscarriage or preterm delivery (Grade A). Among women with a threatened late miscarriage, an isolated undilated shortened cervix (<25mm on ultrasound) and no uterine contractions, daily treatment with vaginal progesterone up to 34 weeks of gestation is recommended (Grade A). Hysteroscopic section of the septum is recommended for women with a uterine septum and a history of late miscarriage (Grade C). Correction of acquired abnormalities of the uterine cavity (e.g. polyps, myomas, synechiae) is recommended after three early or late miscarriages (Grade C). Prophylactic cerclage is recommended for women with a history of three late miscarriages or preterm deliveries (Grade B). Low-dose aspirin and low-molecular-weight heparin at a preventive dose are recommended for women with obstetric antiphospholipid syndrome (Grade A). Glycaemic levels should be controlled before conception in women with diabetes (Grade A).

Is a Standardized Questionnaire Useful for Tubal Rupture Screening in Patients With Ectopic Pregnancy

OBJECTIVES Physical examination, ultrasonography, and laboratory tests fail to reliably establish the preoperative diagnosis of tubal rupture in patients with ectopic pregnancy (EP), leading to a high rate of diagnostic laparoscopy. The aim of this study was to construct and to evaluate a clinical prediction rule for tubal rupture screening based on a self-assessment questionnaire, among patients with EP. METHODS A standardized questionnaire was constructed via semistructured interviews of patients with acute pelvic pain. Features associated with tubal rupture were then identified in 141 prospectively included patients with tubal pregnancy, including 30 with tubal rupture, in five hospitals. Multiple logistic regression was used to select the best combination of independent features for predicting tubal rupture. Cross-validation was with the jackknife method. The main outcome measure was diagnostic accuracy of the questionnaire for ruling out tubal rupture. RESULTS Eighty-nine items characterizing acute pelvic pain were identified. Among them, four contributed independently to the diagnosis of tubal rupture: vomiting during pain, diffuse abdominal pain, acute pain for longer than 30 minutes, and flashing pain. The presence of one or more of these features had 93% sensitivity (95% confidence interval [CI] = 84% to 100%) and 44% specificity (95% CI = 35% to 53%) for tubal rupture, with a negative likelihood ratio for ruling out tubal rupture of 0.16. CONCLUSIONS These results suggest that a standardized questionnaire may contribute to ruling out tubal rupture in patients with EP.

Prise en charge d’un antécédent de fausse couche tardive (14 à 22 SA)

OBJECTIVE To provide guidelines concerning management after a late fetal pregnancy loss: etiological assessment, follow-up and therapeutic management for subsequent pregnancy. METHODS French and English publications led to guidelines. RESULTS In case of a previous late fetal loss, exploration of cavity has to be done (grade C), except hysterosalpingography, which is not recommended (grade A). If uterine anomalies are found, it is recommended to correct them (grade C). In case of stillbirth or unknown foetal vitality before expulsion, antiphospholipid syndrome has to be looked for (grade A). In pregnant women, measurement of cervical length has to be done between 15 and 24weeks of gestation (grade B); in case of singleton pregnancy and short cervix (less than 25mm), a Mc Donald cerclage has to be done (grade A). A cerclage is also recommended in case of three previous fetal loss (grade B). In case of failure of a previous Mc Donald cerclage, a cervico-isthmic cerclage is recommended (grade C). CONCLUSION In case of a previous fetal loss, uterine cavity has to be explored. In subsequent pregnancy, cervical length has to be evaluated between 15 and 24SA to indicate a cervical cerclage.

Value of three-dimensional contrast-enhanced power Doppler ultrasound for characterizing adnexal masses

Aims:  The aim of this study was to assess the diagnostic performance of 3‐D contrast‐enhanced power Doppler ultrasonography (3‐D CEPDUS) for differentiating benign and malignant adnexal masses.