G. Mage

“Iatrogenic” Parasitic Myomas: Unusual Late Complication of Laparoscopic Morcellation Procedures

STUDY OBJECTIVEnTo describe our experience in diagnosing and managing parasitic myomas developing as an unexpected late complication of laparoscopic morcellation.nnnDESIGNnObservational study (Canadian Task Force classification II-3).nnnSETTINGnUniversity hospital.nnnPATIENTSnRetrospective chart review of all patients found to have parasitic myomas that developed after previous morcellation.nnnINTERVENTIONnLaparoscopic morcellation. Review of the recent literature correlated with clinical, surgical, and pathologic features of our cases.nnnMEASUREMENTS AND MAIN RESULTSnFour patients had heterogeneous pelvic masses after morcellation. In 3 patients, symptoms developed between 2 and 16 years after the primary surgery. One patient had no symptoms, and was referred because of a suspect pelvic mass. Vaginal examination revealed painful pelvic masses in the pouch of Douglas in 2 patients, and painless masses fixed to the vaginal vault and anterior vaginal wall, respectively, in the other 2 patients. Laparoscopic examination confirmed the presence of parasitic masses in 3 patients. In 1 patient, the mass was excised vaginally. Histologic analysis confirmed leiomyoma fragments in all patients. A well-differentiated endometrial carcinoma was incidentally found in 1 patient after hysterectomy.nnnCONCLUSIONnThese masses probably resulted from growth of missed fragments of uterine tissue after previous morcellation, culminating in development of symptomatic iatrogenic parasitic myomas. If morcellation is anticipated or required, exclusion of malignancy is mandatory. Meticulous inspection of the abdominal cavity is necessary after morcellation. In patients with a history of morcellation who have pelvic masses, iatrogenic parasitic myomas should be considered in the differential diagnosis.

Impact of intraperitoneal pressure and duration of surgery on levels of tissue plasminogen activator and plasminogen activator inhibitor-1 mRNA in peritoneal tissues during laparoscopic surgery

BACKGROUNDnOur objective was to evaluate the impact of intraperitoneal pressure (IPP) and duration of a CO(2) pneumoperitoneum on the peritoneal fibrinolytic system during laparoscopic surgery.nnnMETHODSnHuman study: Patients undergoing laparoscopic surgery were divided into two groups: low (8 mmHg, n= 32) or standard (12 mmHg, n= 36) IPP. Normal peritoneum was collected from the parietal wall at the beginning of surgery and every 60 min thereafter. Mouse study: Mice were divided into three groups: low (2 mmHg) or high (8 mmHg) IPP or laparotomy. Peritoneal tissue was collected at 0, 4, 8, 24, 48 and 72 h, and 5 and 7 days after surgery. Real-time RT-PCR was performed in humans and mice to measure the levels of tissue plasminogen activator (tPA) and plasminogen activator inhibitor-1 (PAI-1) mRNA in peritoneal tissues.nnnRESULTSnHuman study: The tPA/PAI-1 mRNA ratio was significantly decreased in the 12 mmHg group at 1 h [P < 0.0001 versus matched initial peritoneal biopsies (MI)]. The tPA/PAI-1 mRNA ratio decreased in both groups at 2 h (P < .0.01 versus MI). Mouse study: The tPA/PAI-1 ratio was decreased at 0 h, and the difference was significant at 4 h in both the laparotomy (P < 0.001 versus controls, 0 h, 5 and 7 days) and high-IPP (P < 0.0001 versus 0, 48 and 72 h, 5 and 7 days) groups. No changes in tPA/PAI-1 ratio were observed in the low-IPP group.nnnCONCLUSIONSnA low IPP and shorter duration of surgery appear to minimally impact the fibrinolytic system during a CO₂ pneumoperitoneum.

Endométriose et fertilité postopératoire. Étude prospective d’après les données de la cohorte Auvergne

OBJECTIVEnTo evaluate in infertile women the benefit of laparoscopic surgical treatment of endometriosis.nnnPATIENTS AND METHODSnAll infertile patients aged 18 to 43 years old, operated between February 2004 and March 2008, with a minimal follow-up of 18 months, coming from the Auvergne cohort of endometriosis has been, were included. The primary end point was the achievement of a pregnancy.nnnRESULTSnOne hundred and twenty-three patients have been included. Global pregnancy rate was 48%, which 47% was spontaneous with a mean postoperative delay of 6±4.5 months. Sixty-three patients had benefited from Assisted Reproductive Technology (ART) and 25 pregnancies were obtained (pregnancy rate: 39.7% with a mean delay of 10±3.8 months). Eighty-one percent of spontaneous pregnancies were obtained during the first 12 postoperative months. Duration of preoperative infertility and tubal involvement were significantly associated with lower spontaneous pregnancy rate. No significant differences were found between endometriosis stage I and II compared to stage III and IV, and between patient under 34 years old compared to older.nnnDISCUSSION AND CONCLUSIONnWith this first study on infertility from the Auvergne cohort of endometriosis, we are confirmed that surgery is one of the central issues in the treatment of infertile endometriosis patient. The postoperative delay to obtain a spontaneous pregnancy requires a quick management by ART after 6 to 12 postoperative month and an immediate management by ART in case of tubal involvement or former infertility.

[Are there anatomical and clinical correlations between minimal and deep endometriosis? First results of Auvergne's Registry of Endometriosis].

OBJECTIVEnWith a prospective study, to evaluate the existence of two distinct clinical diseases in the endometriosis syndrome, by comparing pain symptoms and quality of life from patients with minimal endometriosis (AFS-R<5) and data from patients with severe disease (deep infiltrating nodules and/or ovarian endometrioma).nnnPATIENTS AND METHODSnPatients with minimal disease (group A with AFS-R<5) and severe endometriosis (group B) are selected from the Auvergne Endometriosis Registry which started in January 2004. They have never been treated before for endometriosis. A surgical laparoscopic and a pathological diagnosis are required for the subjects to be included. Pelvic pain is assessed using a standardized questionnaire, and a visual analogue scale, quality of life using SF-36. The two groups are compared for the incidence and the severity of pelvic pain and for the impairment of their quality of life.nnnRESULTSnForty-seven patients have a minimal disease, whereas 111 have a severe endometriosis. Demographic characteristics are similar in both groups. Quality of life (SF-36) and pelvic pains included chronic pelvic pain, dyspareunia, dysuria, and defecation disorders are as common and severe in both groups. However, dysmenorrhea is more affected in group B than in group A (p=0.03).nnnDISCUSSION AND CONCLUSIONnWe find no relationship between severity of symptoms, quality of life, and the extent of endometriotic lesions at surgery. There would be no differences between minimal and severe disease. It could be explained by different painful mechanisms between minimal and severe endometriosis.

Hépatite auto-immune et grossesse : à propos de trois grossesses consécutives chez une patiente

Spontaneous evolution of autoimmune hepatitis during pregnancy is not well known, nor are its consequences on pregnancy evolution. Immunosuppressive treatment during pregnancy is sometimes necessary but the long- and short-term consequences are unrecognized. We relate a patients disease with autoimmune hepatitis and cirrhosis and three consecutive pregnancies with different obstetrical and medical complications.

Intérêt de l’échographie dans le suivi des patientes après promontofixation par cœlioscopie : étude préliminaire

OBJECTIVESnTo evaluate results of laparoscopic sacropexy with introital and vaginal ultrasonography, that is to observe dynamic behavior of the mesh, to measure precisely its position and to conclude on the feasibility of this exam.nnnPATIENTS AND METHODSnThe surgery was a laparoscopic subtotal hysterectomy and a suspension of the cervix with an anterior vesicovaginal mesh and a posterior rectovaginal mesh. These meshes are joined together and fixed on the sacrum. Ultrasound was performed in fifteen patients to see in the sagital plane the position of the mesh. The distance anterior mesh-bladder neck and the distance posterior mesh-anal sphincter were measured at rest, during straining and during retaining. The spreading out and the dynamic behavior of the mesh were studied.nnnRESULTSnThe distance anterior mesh-bladder neck is 12 mm at rest, 15 mm during straining and 13 mm during retaining. The distance posterior mesh-anal sphincter is 30 mm at rest, 26 mm during straining and 31 mm during retaining. The mesh is always seen as spread out, or folded, but never strained. Video recording shows that sacropexy does not block pelvic dynamics.nnnDISCUSSION AND CONCLUSIONnUltrasound imaging appears in this study as a simple and efficient exam to study and measure prosthesis. It could be a good help for clinical examination to explain failure or complication of surgery.

Comment je fais … la prise en charge d’un kyste de l’ovaire de gros volume par cœlioscopie

How I do . . . the laparoscopic management of a large adnexial mass A.-C. Philippe , N. Bourdel *, A.-S. Azuar , É. Lagrange , C. Vago , R. Botchorishvili , M. Canis , G. Mage a,b a Department of Gynaecologic Surgery, Pôle de gynécologie-obstétrique, CHU Estaing, 1, place Lucie-Aubrac, 63003 Clermont-Ferrand cedex 1, France b Centre international de chirurgie endoscopique (CICE), faculté de médecine, bâtiment 3 C, 28, place Henri-Dunant, 63000 Clermont-Ferrand, France

Comment je traite… un endométriome par cœlioscopie ?

How I treat. . . an endometrioma by laparoscopy? N. Bourdel , E. Lagrange , A.-S. Azuar , K. Jardon , B. Rabischong , J.-L. Pouly , G. Mage , M. Canis a,b a Pôle de gynécologie obstétrique, CHU de Clermont-Ferrand, 1, place Lucie-Aubrac, 63003 Clermont-Ferrand cedex 1, France b Centre international de chirurgie endoscopique (CICE), faculté de médecine, 28, place Henri-Dunant, 63000 Clermont-Ferrand, France

Description échographique d’une tumeur ovarienne de Sertoli-Leydig à l’aide du doppler énergie tridimensionnel

We report one case of unilateral ovarian Sertoli-Leydig tumor with intermediate grade and heterologous element, in a young woman with clinical and biological typical presentation. We discuss 2D and 3D ultrasonographic and doppler features.

Existe-t-il une corrélation anatomoclinique entre endométriose minime et endométriose sévère ?

OBJECTIVEnWith a prospective study, to evaluate the existence of two distinct clinical diseases in the endometriosis syndrome, by comparing pain symptoms and quality of life from patients with minimal endometriosis (AFS-R<5) and data from patients with severe disease (deep infiltrating nodules and/or ovarian endometrioma).nnnPATIENTS AND METHODSnPatients with minimal disease (group A with AFS-R<5) and severe endometriosis (group B) are selected from the Auvergne Endometriosis Registry which started in January 2004. They have never been treated before for endometriosis. A surgical laparoscopic and a pathological diagnosis are required for the subjects to be included. Pelvic pain is assessed using a standardized questionnaire, and a visual analogue scale, quality of life using SF-36. The two groups are compared for the incidence and the severity of pelvic pain and for the impairment of their quality of life.nnnRESULTSnForty-seven patients have a minimal disease, whereas 111 have a severe endometriosis. Demographic characteristics are similar in both groups. Quality of life (SF-36) and pelvic pains included chronic pelvic pain, dyspareunia, dysuria, and defecation disorders are as common and severe in both groups. However, dysmenorrhea is more affected in group B than in group A (p=0.03).nnnDISCUSSION AND CONCLUSIONnWe find no relationship between severity of symptoms, quality of life, and the extent of endometriotic lesions at surgery. There would be no differences between minimal and severe disease. It could be explained by different painful mechanisms between minimal and severe endometriosis.