Jean-Marc Ayoubi

Endoscopic exploration and lymph node sampling of the axilla: Preliminary findings of a randomized pilot study comparing clinical and anatomo-pathologic results of endoscopic axillary lymph node sampling with traditional surgical treatment

OBJECTIVE To describe the technique of endoscopic exploration of the axilla. To compare this technique to open surgical treatment by comparing the following variables: operative time, peri-operative complications, duration of hospital stay, nodes histology and morphologic aspects and esthetic results. MATERIALS Standard instruments for traditional operative laparoscopy plus a lipo-aspirator (0.8 Bar). PATIENTS Forty patients, 20 (group A) undergoing open surgery and 20 (group B) undergoing axilloscopy. All patients with early invasive breast cancer are eligible for conservative operative treatment. METHOD Randomized study. The technique is described and preliminary results are presented. RESULTS The operative time for axilloscopy is approximately double that for open surgery. A comparable number of lymph nodes is collected by axilloscopy and open surgery. The nodes collected by axilloscopy are more likely to be fractured. What is the clinical consequence? Two loco-regional relapses are observed in the endoscopic group. DISCUSSION Axillary sampling by endoscopic procedure gives the same pathologic information than surgical axillary sampling. Anatomo-pathologic aspects of nodes and possibilities of relapses were two drawbacks of this procedure. CONCLUSION Operative time is increased for axilloscopy compared with open surgery. The techniques yield comparable anatomo-pathologic results. It is still unknown whether this endoscopic technique is as effective as traditional surgery or if the frequency or severity of lymphedema is decreased by the endoscopic approach.

Detailed in utero ultrasound description of 30 cases of congenital cytomegalovirus infection.

The aim of this research was to describe precisely prenatal ultrasound (US) features in congenital cytomegalovirus (CMV) infection.

Rubella and pregnancy: diagnosis, management and outcomes

Rubella is a mild viral disease that typically occurs in childhood. Rubella infection during pregnancy causes congenital rubella syndrome, including the classic triad of cataracts, cardiac abnormalities and sensorineural deafness. Highly effective vaccines have been developed since 1969, and vaccination campaigns have been established in many countries. Although there has been progress, the prevention and diagnosis of rubella remain problematic. This article reviews the implications and management of rubella during pregnancy.

Fetal and neonatal abnormalities due to congenital rubella syndrome: a review of literature

Abstract Objective: Rubella virus infection during the first trimester of pregnancy can cause congenital rubella syndrome (CRS). We aimed to describe the abnormalities in order to define the ultrasound features to look for when performing prenatal scans. The goal of this review is to focus specifically on the signs of CRS accessible to prenatal diagnosis. Methods: We analyzed every case of CRS described before and/or after birth that we identified in the Pubmed database and classified them as accessible or not to prenatal diagnosis. Results: The most frequently reported malformations accessible to prenatal diagnosis were: cardiac septal defects, pulmonary artery stenosis, microcephaly, cataract, microphtalmia, and hepatosplenomegaly. Conclusion: This extensive literature review shows that the ultrasound features of CRS are not well known, even though rubella was the first teratogenic virus described. This review will help clinicians in the management of rubella during pregnancy by clarifying the findings to be sought.

Robotic Surgery in Gynecology.

Minimally invasive surgery (MIS) can be considered as the greatest surgical innovation over the past 30 years. It revolutionized surgical practice with well-proven advantages over traditional open surgery: reduced surgical trauma and incision-related complications, such as surgical-site infections, postoperative pain and hernia, reduced hospital stay, and improved cosmetic outcome. Nonetheless, proficiency in MIS can be technically challenging as conventional laparoscopy is associated with several limitations as the two-dimensional (2D) monitor reduction in-depth perception, camera instability, limited range of motion, and steep learning curves. The surgeon has a low force feedback, which allows simple gestures, respect for tissues, and more effective treatment of complications. Since the 1980s, several computer sciences and robotics projects have been set up to overcome the difficulties encountered with conventional laparoscopy, to augment the surgeon’s skills, achieve accuracy and high precision during complex surgery, and facilitate widespread of MIS. Surgical instruments are guided by haptic interfaces that replicate and filter hand movements. Robotically assisted technology offers advantages that include improved three-dimensional stereoscopic vision, wristed instruments that improve dexterity, and tremor canceling software that improves surgical precision.

Pitfalls in the diagnosis of congenital rubella syndrome in the first trimester of pregnancy

A 29-year-old woman, gravida 3 para 0, was referred at19weeks of gestation because of a maternal rubella infectionduring the first trimester of pregnancy. She consulted at5weeks for a rash, which, at that time, was considered tobe urticaria. Her serological status for rubella was unknownat that time, and as rubella infection was not considered,serological investigations were not conducted. At 6weeks,toxoplasma and rubella testings were performed asrecommended by the French High Health Authority [HauteAutorite de Sante (HAS)]. HAS only recommends IgGtesting for routine Rubella screening and both IgG and IgMtestings for toxoplasma.

Short-term outcome of patients with preeclampsia

Introduction Preeclampsia constitutes a cause of increased mortality in mothers and fetuses. Screening for promoting factors is essential for adequate prevention in the event of any subsequent pregnancy, and for the adequate follow-up of concerned patients. The aim of the present study was to evaluate the short-term outcome of patients with preeclampsia and to identify possible new factors predisposing them to the disease. Methods One hundred fifty-five patients having experienced preeclampsia between 2005 and 2010 from the Gynecology and Obstetrics Department of the Foch Hospital (Suresnes, France) were included in the study. All patients had undergone close clinical and standard biological follow-up immediately postpartum and then 3 months later with a reference practitioner. In severe cases, further investigation was carried out by full etiological examination with an assessment of both autoimmune and thrombophilic status. Results Obesity and gestational diabetes were observed to be major risk factors for preeclampsia, which were found in 46% and 15% of the cases, respectively. The etiological assessment showed abnormalities in 11% of the patients. Impaired thrombophilia was found in 3% of the patients, impaired autoimmune status in 4%, a combination of both abnormalities in only 1% of the patients, and detection of renal abnormalities in 3% of the patients were observed. In the immediate postpartum period, 66% of patients had maintained elevated blood pressure levels, and 66% had proteinuria > 0.3 g/24 hours. At the 3-month postpartum assessment, persisting arterial hypertension was found in 16% of the patients, requiring continuation of antihypertensive therapy, and 22% of the patients had proteinuria over the accepted threshold (0.15 g/24 hours). Conclusion Patients with preeclampsia have increased cardiovascular risk, necessitating lifestyle measures and long-term follow-up. Etiological assessment must be carried out, systematically aiming at the detection of promoting underlying diseases and adaptation of the management of subsequent pregnancies.

Association between amniotic fluid evaluation and fetal biometry: a prospective French “Flash” study

We aimed to study the association between three different methods of assessing the amount of amniotic fluid (subjective method (SM), deepest vertical pocket (DVP) and amniotic fluid index (AFI)) and estimated fetal weight (EFW) (in percentile or Z-score) after adjustment on maternal-fetal parameters. We performed a nationwide cross-sectional study through the French network of obstetric sonographers using the “flash” study method and including low-risk singleton pregnancies from 18–40 weeks. Crude and adjusted odds ratio were computed after stratification upon 2nd and 3rd trimester of pregnancy. 1667 ultrasound scans performed by 65 operators were included. Only Z-score of EFW was significantly associated with SM in both trimesters. For DVP and AFI, Z-score of EFW and male fetal gender was significantly associated with them in 2nd trimester. In the 3rd trimester, both Z-score of EFW and large (LGA) or small for gestational age (SGA) fetus were significantly associated with AFI. and DVP. Overweight woman and class I obesity women were also significantly associated with DVP modification. In conclusion, all three methods of amniotic fluid evaluation are significantly associated to estimated fetal weight. DVP and AFI appeared equivalent except that maternal-fetal factors seemed to have a higher impact in DVP than AFI.

Management of Cytomegalovirus Seroconversion during Pregnancy in France

Introduction: Guidelines for the management of cytomegalovirus (CMV) infection of the fetus are rare. Our main objective was to evaluate how health care practitioners in France manage cases of CMV seroconversion during pregnancy. Material and Methods: A questionnaire was e-mailed to health care practitioners potentially concerned by CMV seroconversion during pregnancy. They were asked if they would recommend amniocentesis, fetal cerebral MRI examination and fetal blood analysis (FBA), depending on the ultrasound results. They then had to indicate whether they would accept termination of pregnancy (TOP), depending on the results of these examinations. Results: A total of 380 health care practitioners responded, mainly obstetricians (73.9%) and midwives (20.2%). Overall, 57% of respondents recommended amniocentesis in the case of CMV seroconversion during the first trimester of pregnancy, ultrasound findings being normal. In cases of positive amniocentesis and a major ultrasound abnormality, 84.5% of respondents would perform cerebral MRI, and 44.4% would perform FBA. In this case, the rate of acceptance of TOP was not significantly different whether the examinations were normal (337/372, 90.6%) or not performed (339/374, 93.3%; p = 0.17). Discussion: Amniocentesis is too infrequently used and should be encouraged. The results of MRI and FBA are often not taken into account in the final decision concerning TOP. Guidelines are needed to clarify the management of CMV seroconversion during pregnancy.