[Evidence-based ways of colorectal anastomotic complications prevention in the setting of digestive deep endometriosis resection: CNGOF-HAS Endometriosis Guidelines]. / Moyens de prévention des complications anastomotiques digestives dans la chirurgie de l'endométriose profonde, RPC Endométriose CNGOF-HAS.

Management of deep pelvic and digestive endometriosis can lead to colorectal resection and anastomosis. Colorectal anastomosis carries risks for dreaded infectious and functional morbidity. The aim of the study was to establish, regarding the published data, the role of the three most common used surgical techniques to prevent such complications: pelvic drainage, diverting stoma, epiplooplasty. Even if many studies and articles have focused on colorectal anastomotic leakage prevention in rectal cancer surgery data regarding this topic in the setting of endometriosis where lacking. Due to major differences between the two situations, patients, diseases the use of the conclusions from the literature have to be taken with caution. In 4 randomized controlled trials the usefulness of systematic postoperative pelvic drainage hasn't been demonstrated. As this practice is not systematically recommended in cancer surgery, its interest is not demonstrated after colorectal resection for endometriosis. There is a heavy existing literature supporting systematic diverting stoma creation after low colorectal anastomosis for rectal cancer. Keeping in mind the important differences between the two situations, the conclusions cannot be directly extrapolated. In endometriosis surgery after low rectal resection, stoma creation must be discussed and the patient must be informed and educated about this possibility. Even if widely used there is no data supporting the role of epiplooplasty in colorectal anastomotic complication prevention? The place for epiplooplasty in preventing rectovaginal fistula occurrence in case of concomitant resection hasn't been studied.

Imaging of intestinal involvement in endometriosis.

Deep gastrointestinal involvement in endometriosis is characterised by fibrous, retractile thickening of the intestinal wall. The most common location is the upper rectum, in contiguity with a lesion of the torus uterinus. As part of a preoperative assessment, it is essential to establish an accurate and exhaustive map of intestinal lesions so that the surgeon can plan his actions. Transvaginal sonography and MRI correctly analyse pelvic and rectal involvement. Given the frequency of multiple intestinal sites, particularly sigmoid and associated ileo-caecal lesions, water enema CT should be performed. The role of rectal endoscopic sonography is debated.

[Hepatic subcapsular hematoma: a case report and management update]. / Hématome sous-capsulaire du foie : cas clinique et mise au point actualisée sur la prise en charge.

Hepatic subcapsular hematoma (HSH) is a rare complication of pregnancy that keeps a materno-fetal high mortality rate. Given this severity, HSH management requires a prompt diagnosis and an appropriate care. Before focusing on the current management strategy of HSH, we illustrate this article with a clinical case presenting an original method of abdominal exploration, which has not been described to our knowledge. Thus, taking into account the presence of a moderate hemoperitoneum during a caesarean section procedure for HSH, introduction of laparoscopy through the same incision allowed a satisfactory evaluation of the abdominal cavity and hepatic area without performing an invasive midline laparotomy.

[Foetal rhinopharyngeal teratoma: antenatal diagnosis and prognosis. Case report]. / Tératome foetal du rhinopharynx : diagnostic anténatal et pronostic. A propos d'un cas.

Fetal teratomas are commonly found in the sacrococcygeal area. More rarely, these tumors may be found in cervicofacial forms. Rhinopharyngeal teratoma represent an extremely rare congenital tumor, often resulting in intracranial extension, obstruction of the respiratory or the digestive pathways and rapid asphyxia following birth. We report a case of rhinopharyngeal teratoma identified in a foetus at 18 weeks of gestation. The diagnosis was made by antenatal ultrasound and IRM. Tumor invaded the cavum and the right infratemporal region with no intracranial extension. The pregnancy was interrupted at 27 weeks of gestation. Authors discuss the difficulties to establish antenatal diagnosis by ultrasound, and those to decide what treatment to carry out.

Laparoscopic surgery in a patient with ventriculoperitoneal shunt: monitoring of shunt function with transcranial Doppler.

We describe the use of transcranial Doppler (TCD) monitoring during laparoscopic resection of an ovarian cyst in a young woman who previously underwent ventriculoperitoneal shunting for hydrocephalus. Shunt function was not altered by pneumoperitoneum, except during transient episodes of high intra-abdominal pressure. The role of TCD monitoring during laparoscopic procedures in patients with cerebrospinal fluid shunt is discussed.

[Vesico-uterine fistula occurring after a normal labor in a patient with a scarred uterus]. / Fistule vésico-utérine survenant après un accouchement normal chez une patiente porteuse d'un utérus cicatriciel.

We report a vesico-uterine fistula occurring after vaginal delivery in a woman with previous cesarean section. Diagnosis of this rare complication, only 2 cases reported in the literature, is based on clinical findings and retrograde cystography. Medical treatment should be attempted first, but laparotomy is often required for resection of the fistula and simple suture of the bladder and the uterus.

[Dissection of the ascending aorta in pregnancy. Apropos of a case and review of the literature]. / Dissection de l'aorte ascendante et grossesse. A propos d'un cas et revue de la littérature.

Dissection of ascendant aorta is infrequent during pregnancy. Given this low prevalence, diagnosis is often delayed or even unrecognized. This delay in diagnosis can have a highly jeopardizing effect on vital maternal prognosis. In this study, we report a case of ascendant aorta dissection in the 3rd trimester of pregnancy with maternal and fetal survival through combined surgery of a cesarean section and replacement of the ascendant aorta.

Detection of empty HLA class II molecules on cord blood B cells.

Fetal mononuclear cells are increasingly used in transplantation of hematopoietic cells due to a reportedly lower incidence of graft-versus-host disease. Previous studies of immune responses of fetal lymphocytes have indicated a general hyporesponsiveness in response to polyclonal stimulation. Fetal B lymphocytes display many features typical of the resting state such as a low level of HLA class II expression, but a large proportion of cells also carry the activation-associated CD23 antigen. We show here that despite a low cell surface level of all three HLA class II isotypes on fetal B cells, their allogeneic capacity, measured as the ability to elicit a mixed lymphocyte reaction, is similar to that of adult B cells. Allogeneic stimulation is believed to be peptide-dependent. Surprisingly, the majority of the HLA class II molecules on cord blood B cells appeared to be devoid of stably bound peptide as detected by the binding of a recombinant and soluble invariant chain, as well as by the absence of sodium dodecyl sulfate (SDS) stable alpha beta heterodimers in whole cell lysates. Immunoblot experiments showed that HLA class II molecules of fetal B cells were predominantly present in high molecular weight aggregates in stark contrast to B cells of adult origin. However, a sensitive cell surface labeling technique followed by immunoprecipitation enabled us to detect an SDS-stable 120-kD molecule on fetal B cells. We propose that the 120-kD molecules could correspond to HLA class II doubledimers or superdimers. We hypothesize that the 120-kD HLA class II molecule functions as the antigen-presenting molecule in the mixed lymphocyte reaction of fetal B cells, as it is the major species detected on the surface. Secondly, we suggest that a high level of empty HLA class II molecules may be indicative of a particular stage in B-cell ontogeny.

[Prenatal diagnosis of spontaneous thrombosis of the umbilical artery during the third trimester of pregnancy. Two cases with surviving infants]. / Diagnostic anténatal d'une thrombose spontanée d'une artère du cordon ombilical au troisième trimestre de la grossesse. A propos de 2 observations avec enfants vivants.

Thrombosis of the umbilical artery was diagnosed in utero in two cases at the echography examination performed during the third trimester of gestation. The infants were born live and in good health. This is the first report of such antenatal diagnosis. The lack of prospective studies hinder the evaluation of fetal morbidity and mortality. Nevertheless, umbilical artery thrombosis is a high risk obstetrical situation since the potential risk of another thrombus in the second umbilical artery would lead to fetal death in utero. Careful monitoring is required with extraction of the fetus as soon as term allows or whenever the elements compromise fetal development.

[Prenatal diagnosis of homozygous pyruvate kinase deficiency]. / Déficit homozygote en pyruvate kinase à révélation anténatale.

Two consecutive cases of severe neonatal anaemia due to severe deficiency in pyruvate kinase were observed in the same sibhood. The first child died one hour after birth and the second required major transfusion support. Pyruvate kinase deficiency is a rare cause of congenital anaemia with recessive autosomic inheritance. Clinically, this deficiency has a very variable expression, and neonatal forms are not always very severe. Several variant molecules in pyruvate kinase deficiency have been described. Recent progress in our understanding of the gene would suggest the possibility of new diagnostic and prognostic approaches.

[Diagnostic and prognostic elements of non-immunologic feto-placental anasarca. Review of the literature apropos of 7 new cases]. / Eléments diagnostiques et pronostiques de l'anasarque foeto-placentaire non immunologique. Revue de la littérature à propos de 7 nouveaux cas.

Non immunologic hydrops fetalis (NIHF) is relatively more frequent now since prevention and treatment of blood incompatibilities are common. Seven cases of NIHF were observed between November 1984 and April 1987; antenatal diagnosis by ultrasound scanning was possible in six of these seven cases. Fetal prognosis is usually poor. Only one of the seven children survived, four infants died shortly after birth; two women chose an elective termination of pregnancy at 18 and 23 weeks of gestation, respectively. The review of the literature shows that more than 150 etiologies are associated with this condition. An etiology was found in five of our seven cases, these were all different; renal vein thrombosis, cardiac malformation, cystic hygroma, osteogenesis imperfecta and one case of recurrent NIHF (four affected siblings). Two cases remained idiopathic. Diagnosis of NIHF is best oriented by three investigations: obstetrical ultrasound scanning, fetal echocardiography and any kind of amniocentesis, either for karyotype alone, or to evacuate pleural, pericardial of peritoneal effusions. Ultrasound scanning can evaluate the importance of these effusions and help to choose other etiological investigations. Fetal echocardiography is mandatory because out of the 150 etiologies described in association with NIHF, 25% are cardiac (malformation or dysrhythmias). As already mentioned, fetal prognosis in our series was poor, but perhaps more aggressive in utero treatment could have improve it.

[Antenatal diagnosis of holoprosencephaly and its consequences. Apropos of 2 cases]. / Le diagnostic anténatal de l'holoprosencéphalie et ses conséquences. A propos de 2 observations.

Cyclops represents the worst form of a rare malformation of the brain and face: holoprosencephaly. Two cases are reported, including one that was diagnosed at the 23rd week of pregnancy. Now, ultrasonography makes it possible to diagnose early; as soon as the 15th week of gestation. Ultrasound diagnosis is based on hypotelorism and anomalies of the mid-line, with or without facial abnormalities. The outcome is always poor. This malformation is associated with various conditions and a complete assessment, including the karyotype, morphologic studies of the fetus and of his family, and search for related minor facial dysmorphias (median labial or cleft palate with, with a single upper incisor) is mandatory. The condition recurs in 2 to 50% of cases depending on various associated conditions and on the family histories.

[The value of antibiotic prophylaxis using cefotetan in high-risk abdominal hysterectomy. Apropos of a prospective randomized study of 71 patients]. / Intérêt de l'antibioprophylaxie par le cefotetan dans les hystérectomies abdominales à risques. A propos d'une étude prospective par tirage au sort portant sur 71 patientes.

The advantage of antibiotic prophylaxis using a single dose of 2 g of cefotetan, administered during the induction of anesthesia, was studied in 71 patients undergoing an abdominal hysterectomy and presenting at least one of the following risk factors: obesity or procedure exceeding two hours. After random selection, 33 patients were treated, 38 were not and constitute the reference group. Comparison between the two groups shows a significant difference concerning the general morbidity, post-operative fever, urinary infection and abdominal wall abscess. Considering the excellent tolerance of the treatment and the fact that it is easy to use and inexpensive, antibiotic prophylaxis with cefotetan is quite interesting for this type of surgery.

[Prenatal diagnosis and treatment of auricular flutter. Apropos of a case and review of the literature]. / Diagnostic et traitement anténatal d'un flutter auriculaire. A propos d'un cas, revue de la littérature.

In newborns, atrial flutter is a rare, but severe condition. Late diagnosis was usual and based on fetal ECG. Now, fetal ultrasonography can differentiate in utero atrial flutter and other supra ventricular tachycardias; so it can be treated before development of cardiac failure. Among numerous and various available drugs, digoxin is universally recommended, but the delayed effect and the maternal serum levels to obtain effective fetal concentration of digoxin are not well known. Furthermore, endogenous "digoxin-like" substances have been found in maternal blood in late pregnancy; this finding raises the problem of the validity of monitoring the treatment only by serum digoxin levels. A case of atrial flutter, diagnosed in utero by ultrasonography and treated by digoxin before development of cardiac failure is reported. Neonatal echocardiography showed an aneurysm of the atrial septum, which needed simple monitoring. Its responsibility in the pathogenesis of the arrhythmia is unclear. Numerous cases of aneurysm of the atrial septum have been reported in healthy adults without atrial arrhythmias.

[Cutaneous angiosarcoma of the breast following surgery and irradiation of breast adenocarcinoma]. / Angiosarcome cutané du sein après adénocarcinome mammaire opéré et irradié.

We are reporting a localised skin angiosarcoma of the breast. As far as we can tell this is only the fourth time this condition has been published. The tumour appeared 6 years after a conservative lumpectomy with removal of lymphatics and follow-up radiotherapy had been carried out for an adenocarcinoma of the breast. This tumour was characterised by the presence of several round blue-coloured nodules in the skin with some inflammation surrounding them. The glandular tissue underneath was normal, as was the opposite breast, and there was no spread. The patient was pyrexial and a syndrome of inflammation persisted until the tumour had been removed by a simple mastectomy. We have discussed the clinical and histological aspects of this case and compared them with those found in the literature. Differential diagnosis with in particular Stewart-Treves syndrome has been emphasized. The treatment consists in wide excision and sometimes followed by radiotherapy or chemotherapy. The prognosis is very poor, survival never having been more than 22 months. Finally the role of irradiation in the causation of this tumour has been discussed. (Our patient is alive after 2 years without any sign of a recurrence).

[Rendering follicle tubes permeable again after post-partum sterilization. A report on 25 cases. Should post-partum sterilization be performed or not?]. / Repermeabilisation tubaire apres sterilisation du post-partum. A propos de 25 cas, faut-il remettre en cause la sterilisation du post-partum?

PIP: This article discusses the success of microsurgical reversal attempts after postpartum tubal sterilization and assesses the risk of later reversal requests after postpartum sterilization. 25 of 37 requests for tubal sterilization reversals received by the authors between January 1977-December 1983 followed postpartum sterilizations. The only criteria were contraindications to another pregnancy, a history of bilateral salpingectomy, and existence of a serious hypofertility factor. No minimal tubal length was required. All reversal procedures were microsurgically performed by 3 operators. The average age of patients was 26.7 years at sterilization and 32.5 years at reversal. Ages ranged from 25 to 41 at reversal. The parity of the women ranged from 2 to 9 and averaged 4.2 children. The sterilization was performed during a cesarean section in 19 cases, of which 8 were emergency procedures. The indication for the sterilization was medical in only 7 cases. 20 of the procedures were tubal ligations and resections, 1 was application of a Yoon ring, and 4 were bilateral salpingectomies. Reasons for reversal requests were change of partner in 16 of 25 cases, death of an infant in 1 case, fear of repudiation by the husband in the cases of 4 Muslim women, and change of mind by the couple in 4 cases. 6 of the 25 women were unacceptable candidates for reversal, 4 because of bilateral salpingectomy and 2 because of poor tubal state and failure of previous surgery. 17 women underwent tubotubal anastomoses and 2 had tubouterine reimplantations. The reversal operations resulted in 12 term pregnancies, 1 spontaneous abortion, and 1 extrauterine pregnancy. The delays to pregnancy ranged from 1 to 18 months and averaged 6.6 months. The intrauterine pregnancy rate was 83% for reversals within 5 years of sterilization and 61% later. Age of the woman appeared to play no role. The postpartum period does not seem to be an ideal moment for sterilization because of its association with later requests for reversal. Several factors seem to be involved in requests for reversal, including young age at sterilization, the unpredictability of death in small children, and haste in making the initial sterilization decision. The policy of automatically recommending sterilization after a 3rd cesarean section should be reviewed since in many cases a successful delivery is still possible. Factors in successful reversal include the length of tube remaining, which is related to the sterilization technique employed, and the site of the sterilization, with ligations at the cornu and fimbriectomies giving poor results. The least mutilating forms of sterilization should be used in young women. Clips, rings, and ligations using absorbable thread with limited resection of the isthmus are reliable methods which have the advantage of not definitively compromising fertility. They can also be done by a simple laparoscopic procedure after the postpartum period.^ieng

[The drug combination amoxicillin-clavulanic acid compared to the triple combination ampicillin-gentamicin-metronidazole in the treatment of severe adnexal infections]. / L'association amoxicilline-acide clavulanique comparée à la triple association ampicilline-gentamicine-métronidazole dans le traitement des infections utéro-annexielles sévères.

Forty-four patients with severe pelvic inflammatory disease were randomly divided into two groups. Single drug therapy with the amoxicillin-clavulanic acid was used in 22 patients (group A). The other 22 patients (group B) were given a combination of ampicillin, gentamicin and metronidazole. Clinical results were comparable in both groups with 91% successes and 9% improvements in group A, against 86% successes, 9% failures, and 5% non-interpretable results in group B. The difference between the two groups was not statistically significant (p = 11.6%). 30% of patients in each group had positive serologic tests for Chlamydiae. This had no influence on therapeutic results but led to secondary prescription of a cycline. Because amoxicillin-clavulanic acid is active against aerobic and anaerobic pathogens, including beta-lactamase-producing microorganisms, it is a satisfactory alternative to the ampicillin-gentamicin-metronidazole combination, especially as it is simpler to use, less toxic and less expensive.

[Should we still explore placental sulfatase deficiencies? Reflections apropos of a case report]. / Faut-il encore explorer les déficits en sulfatase placentaire? Réflexions à propos d'une observation.

The finding of low or very low levels of oestrogen during pregnancy should suggest the diagnosis of placental sulfatase deficiency, which is confirmed by performing dynamic biochemical tests. These biochemical tests also enable sulfatase deficiency to be differentiated from other conditions which may be accompanied by an abnormal decrease in oestrogens. The authors report one case and stress the harmlessness of sulfatase deficiency and the associated ichthyosis in boys and they question the value of the dehydroepiandrosterone sulfate test which only confirms an abnormality which is now well known and benign.

[Importance and significance of the determination of pH in the diagnosis of fetal distress during labor and delivery]. / Intérêt et signification de la mesure du pH dans le diagnostic de la souffrance foetale au cours du travail et à la naissance.

The authors have used a microprocessor which is calibrated by a cartridge to be used once only for measuring the pH; as they systematically monitor the fetal acid base balance by measuring the pH and blood gases at birth, as well as in labour, when there is evidence of fetal heart rhythm abnormalities. They have been able to compare the results that they obtained using a classical membrane apparatus as against that using a microprocessor. The two types of apparatus give identical results. The costs of using the two apparatuses, including maintenance and cleaning, are comparable. The significance of evaluating the degree of fetal distress from isolated pH measurements is discussed in connection with measuring the level of lactic acid in the plasma and blood gases coupled with the measure of excess base.