288. Gynecol Oncol. 2006 Jun;101(3):549-50. doi: 10.1016/j.ygyno.2006.01.044. Epub 2006 Mar 9. Is thrombotic microangiopathy associated with antitumoral activity? Chopin N, Alexandre J, Chapron C, Moachon L, Goldwasser F.
Control of fatty acid homeostasis is crucial to prevent insulin resistance. During fasting, the plasma fatty acid level depends on triglyceride lipolysis and fatty acid re-esterification within fat cells. In rodents, Rosiglitazone controls fatty acid homeostasis by stimulating two pathways in the adipocytes, glyceroneogenesis and glycerol phosphorylation, that provide the glycerol 3-phosphate necessary for fatty acid re-esterification. Here, we analyzed the functionality of both pathways for controlling fatty acid release in subcutaneous adipose tissue samples from lean and overweight women before and after Rosiglitazone ex vivo treatment. In controls, pyruvate, used as a substrate of glyceroneogenesis, could contribute to the re-esterification of up to 65% of the fatty acids released after basal lipolysis, whereas glycerol phosphorylation accounted for only 14 +/- 9%. However, the efficiency of glyceroneogenesis diminished as body mass index (BMI) of women increased. After Rosiglitazone treatment, increase of either pyruvate- or glycerol-dependent fatty acid re-esterification was strictly correlated to that of phosphoenolpyruvate carboxykinase and glycerol kinase, the key enzymes of each pathway, but depended on BMI of the women. Whereas the Rosiglitazone responsiveness of glyceroneogenesis was rather constant according to the BMI of the women, glycerol phosphorylation was mostly enhanced in lean women (BMI < 27). Overall, these data indicate that, whereas glyceroneogenesis is more utilized than glycerol phosphorylation for fatty acid re-esterification in human subcutaneous adipose tissue in the physiological situation, both are solicited in response to Rosiglitazone but with lower efficiency when BMI is increased.
Endometriosis corresponds to ectopic endometrial glands and stroma outside the uterine cavity. Clinical symptoms include dysmenorrhoea, dyspareunia, infertility, painful defecation or cyclic urinary symptoms. Pelvic ultrasound is the primary imaging modality to identify and differentiate locations to the ovary (endometriomas) and the bladder wall. Characteristic sonographic features of endometriomas are diffuse low-level internal echos, multilocularity and hyperchoic foci in the wall. Differential diagnoses include corpus luteum, teratoma, cystadenoma, fibroma, tubo-ovarian abscess and carcinoma. Repeated ultrasound is highly recommended for unilocular cysts with low-level internal echoes to differentiate functional corpus luteum from endometriomas. Posterior locations of endometriosis include utero-sacral ligaments, torus uterinus, vagina and recto-sigmoid. Sonographic and MRI features are discussed for each location. Although ultrasound is able to diagnose most locations, its limited sensitivity for posterior lesions does not allow management decision in all patients. MRI has shown high accuracies for both anterior and posterior endometriosis and enables complete lesion mapping before surgery. Posterior locations demonstrate abnormal T2-hypointense, nodules with occasional T1-hyperintense spots and are easier to identify when peristaltic inhibitors and intravenous contrast media are used. Anterior locations benefit from the possibility of MRI urography sequences within the same examination. Rare locations and possible transformation into malignancy are discussed.
Republished in Gynecol Obstet Fertil. 2009 Jan;37(1):57-69. doi: 10.1016/j.gyobfe.2008.08.016. The relationship between chronic pelvic pain symptoms and endometriosis is unclear because painful symptoms are frequent in women without this pathology, and because asymptomatic forms of endometriosis exist. Our comprehensive review attempts to clarify the links between the characteristics of lesions and the semiology of chronic pelvic pain symptoms. Based on randomized trials against placebo, endometriosis appears to be responsible for chronic pelvic pain symptoms in more than half of confirmed cases. A causal association between severe dysmenorrhoea and endometriosis is very probable. This association is independent of the macroscopic type of the lesions or their anatomical locations and may be related to recurrent cyclic micro-bleeding in the implants. Endometriosis-related adhesions may also cause severe dysmenorrhoea. There are histological and physiopathological arguments for the responsibility of deeply infiltrating endometriosis (DIE) in severe chronic pelvic pain symptoms. DIE-related pain may be in relation with compression or infiltration of nerves in the sub-peritoneal pelvic space by the implants. The painful symptoms caused by DIE present particular characteristics, being specific to involvement of precise anatomical locations (severe deep dyspareunia, painful defecation) or organs (functional urinary tract signs, bowel signs). They can thus be described as location indicating pain. A precise semiological analysis of the chronic pelvic pain symptoms characteristics is useful for the diagnosis and therapeutic management of endometriosis in a context of pain.
The objective was to develop recommendations for the diagnosis and treatment of endometriosis and its associated symptoms. A working group was convened comprised of practising gynaecologists and experts in evidence-based medicine from Europe, as well as an endometriosis self-help group representative. After reviewing existing evidence-based guidelines and systematic reviews, the expert panel met on three occasions for a day during which the guideline was developed and refined. Recommendations based solely on the clinical experience of the panel were avoided as much as possible. The entire ESHRE Special Interest Group for Endometriosis and Endometrium was given the opportunity to comment on the draft guideline, after which it was available for comment on the ESHRE website for 3 months. The working group then ratified the guideline by unanimous or near-unanimous voting; finally, it was approved by the ESHRE Executive Committee. The guideline will be updated regularly, and will be made available at http://www.endometriosis.org/guidelines.html with hyperlinks to the supporting evidence, and the relevant references and abstracts. For women presenting with symptoms suggestive of endometriosis, a definitive diagnosis of most forms of endometriosis requires visual inspection of the pelvis at laparoscopy as the 'gold standard' investigation. However, pain symptoms suggestive of the disease can be treated without a definitive diagnosis using a therapeutic trial of a hormonal drug to reduce menstrual flow. In women with laparoscopically confirmed disease, suppression of ovarian function for 6 months reduces endometriosis-associated pain; all hormonal drugs studied are equally effective although their side-effects and cost profiles differ. Ablation of endometriotic lesions reduces endometriosis-associated pain and the smallest effect is seen in patients with minimal disease; there is no evidence that also performing laparoscopic uterine nerve ablation (LUNA) is necessary. In minimal-mild endometriosis, suppression of ovarian function to improve fertility is not effective, but ablation of endometriotic lesions plus adhesiolysis is effective compared to diagnostic laparoscopy alone. There is insufficient evidence available to determine whether surgical excision of moderate-severe endometriosis enhances pregnancy rates. IVF is appropriate treatment especially if there are coexisting causes of infertility and/or other treatments have failed, but IVF pregnancy rates are lower in women with endometriosis than in those with tubal infertility. The management of severe/deeply infiltrating endometriosis is complex and referral to a centre with the necessary expertise is strongly recommended. Patient self-help groups can provide invaluable counselling, support and advice.
OBJECTIVE: Our study investigated the rate of recurrence of cervical intraepithelial neoplasia (CIN) in HIV-positive women after surgery in the era of highly active antiretroviral therapy (HAART). METHODS: One hundred twenty-one HIV-positive women were followed-up with cytology, colposcopy, and histology after surgery for CIN. We conducted univariate and multivariate analyses to determine the relation between recurrence of CIN and risk factors using Cox proportional hazard models with left truncation. RESULTS: The rate of recurrence of any CIN was 22.3 per 100 patient-years and the rate of high-grade CIN was 8.6 per 100 patient-years during 166 and 279 patient-years of follow-up, respectively. In multivariate analysis, a positive margin was associated with a risk of recurrence of any CIN (relative risk [RR] = 3.5, 95% confidence interval [CI]: 1.2-9.8) and a risk of recurrence of high-grade CIN (RR = 9.0, 95% CI: 2.2-36.5). CD4 counts <200 cells/mm were associated with a risk of recurrence of any CIN (RR = 9.4, 95% CI: 2.7-32.7) but not with a risk of recurrence of high-grade CIN. HAART exhibited a protective effect on the recurrence of any CIN (RR = 0.3, 95% CI: 0.1-0.7) and of high-grade CIN (RR = 0.2, 95% CI: 0.1-0.7). CONCLUSION: CD4 cell counts <200/mm(3) and a positive margin were predictors of recurrence, whereas HAART had a strong protective effect. Although surgery is highly effective in immunocompetent patients, it seems to be effective only in preventing progression to cancer in HIV-infected women.
STUDY OBJECTIVE: To identify the preoperative factors affecting the risk of conversion to laparotomy during total laparoscopic hysterectomy (TLH) indicated for benign conditions (surgery performed in cases of genital prolapse and/or urinary stress incontinence was excluded). DESIGN: Retrospective comparative study (Canadian Task Force classification II-2). SETTING: University tertiary referral center for gynecologic endoscopic surgery. PATIENTS: Four hundred sixteen consecutive patients who underwent TLH during the first 5 years of our experience performing TLH. INTERVENTION: Total laparoscopic hysterectomy. MEASUREMENTS AND MAIN RESULTS: The rate of conversion to laparotomy was 7% (29 patients). Factors that were found to be independently related to the risk of conversion to laparotomy are the following: body mass index (adjusted OR 1.09; 95% CI 1.01-1.18); uterine width on transvaginal ultrasonography (US) between 8 and 10 cm (adjusted OR 4.01; 95% CI 1.54-10.45); uterine width on US greater than 10 cm (adjusted OR 9.17; 95% CI 2.74-30.63); lateral myoma measuring greater than 5 cm on US (adjusted OR 3.57; 95% CI 0.97-13.17); history of adhesion-causing abdominopelvic surgery (adjusted OR 2.92; 95% CI 1.23-6.94). CONCLUSION: Transvaginal US evaluation is essential before performing TLH. Awareness of the risk factors for conversion to laparotomy is essential for proper patient information and better selection of patients.
296. Am J Obstet Gynecol. 2005 Apr;192(4):1352; author reply 1352-3. doi: 10.1016/j.ajog.2004.10.611. Complications of laparoscopy: an inquiry about closed versus open-entry technique. Pierre F, Chapron C.
STUDY OBJECTIVE: To assess the results of complete surgical excision for patients with painful functional symptoms in a context of histologically proven deeply infiltrating endometriosis (DIE). DESIGN: Retrospective analysis (Canadian Task Force classification II-2). SETTING: University-affiliated hospital. PATIENTS: One hundred thirty-two patients with pelvic pain symptoms and histologically proved DIE. The DIE lesions were classified according to surgical classification: uterosacral ligaments (USL), vagina, bladder, or intestine. INTERVENTION: Complete surgical excision of DIE lesions. MEASUREMENTS AND MAIN RESULTS: A retrospective analysis was made of medical, operative, and pathologic reports as well as of questionnaires mailed to patients. Efficiency of surgical excision was assessed according to two methods: objective evaluation (numerical rating scale) and subjective evaluation (patients were asked to classify the improvement after surgery with one of the following: excellent, satisfactory, slight, or no improvement). For each symptom, the mean scores according to the numerical rating scale were significantly lower postoperatively. The difference between the preoperative and postoperative scores was 5.2 points +/- 3.6 for dysmenorrhea, 4.6 points +/- 3.1 for deep dyspareunia, 4.4 points +/- 3.7 for painful defecation during menstruation, 4.9 +/- 3.2 for lower urinary tract symptoms during menses, and 4.6 points +/- 3.4 for noncyclic chronic pelvic pain. Comparable results were observed for patients in each group according to the surgical classification of their DIE lesions: USL (n = 78 patients); vagina (n = 25 patients); bladder (n = 13 patients); and intestine (n = 16 patients). Subjective evaluation showed that the improvement was considered to be excellent in 40.2% of women (53 patients), satisfactory in 42.4% (56 patients), slight in 14.4% (19 patients), and nonexistent in 3.0% (4 patients). The patients' characteristics (i.e., age, gravidity, parity, body mass index, preoperative medical treatment, follow-up after surgery, number and location of DIE lesions, revised American Fertility Society stage, associated endometrioma) did not differ significantly according to whether the improvement was considered to be excellent (Group A: 53 patients) or not (Group B: 79 patients). Among the infertile patients (n = 78; 59.1%), there was no difference in pain improvement if the patient was pregnant or not in the 42 women who achieved pregnancy after the surgery. CONCLUSION: Complete surgical excision of DIE lesions results in a statistically significant reduction in painful functional symptoms. These results are observed whatever the main location of DIE lesions. The patients' preoperative characteristics have no significant influence on the result.
BACKGROUND: To derive a diagnostic model based on symptoms and history as assessed by a standardized questionnaire to predict posterior deep infiltrating endometriosis (DIE) among women with chronic pelvic pain symptoms. METHODS: 134 women scheduled for laparoscopy for chronic pelvic pain symptoms completed a standardized self-administered questionnaire, specifically designed for the study. We compared the symptoms of the women with posterior DIE diagnosed at laparoscopy with those of the women with other disorders, and used multiple logistic regression analysis to select the best combination of symptoms for predicting posterior DIE. Cross-validation was performed with the jackknife method. RESULTS: 51 women (38.1%) were diagnosed with posterior DIE and 83 with other disorders (61.9%). The following variables were independent predictors for posterior DIE: painful defecation during menses, severe dyspareunia (visual analogic scale > or =8), pain other than noncyclic, and previous surgery for endometriosis. The cross-validation procedure leads to a simplified diagnostic model that uses two independent predictors: painful defecation during menses and severe dyspareunia. The sensitivity of this model for diagnosing posterior DIE was 74.5%, its specificity was 68.7%, its positive likelihood ratio was 2.4, and its negative likelihood ratio was 0.4. It correctly classified 70.9% of our sample into a high-risk (with either severe dyspareunia or painful defecation during menses) and a low-risk (neither symptom) group. CONCLUSIONS: Standardized evaluation of painful symptoms is useful for screening women so that they may have adequate exploration and counselling before laparoscopic surgery for pelvic pain symptoms.
