Robotic-assisted right colectomy. Official expert recommendations delivered under the aegis of the French Association of Surgery (AFC).

Twenty-seven experts under the aegis of the French Association of Surgery (AFC) offer this reference system with formalized recommendations concerning the performance of right colectomy by robotic approach (RRC). For RRC, experts suggest patient installation in the so-called "classic" or "suprapubic" setup. For patients undergoing right colectomy for a benign pathology or cancer, RRC provides no significant benefit in terms of intra-operative blood loss, intra-operative complications or conversion rate to laparotomy compared to laparoscopy. At the same time, RRC is associated with significantly longer operating times. Data from the literature are insufficient to define whether the robot facilitates the performance of an intra-abdominal anastomosis, but the robotic approach is more frequently associated with an intra-abdominal anastomosis than the laparoscopic approach. Experts also suggest that RRC offers a benefit in terms of post-operative morbidity compared to right colectomy by laparotomy. No benefit is retained in terms of mortality, duration of hospital stay, histological results, overall survival or disease-free survival in RRC performed for cancer. In addition, RRC should not be performed based on the cost/benefit ratio, since RRC is associated with significantly higher costs than laparoscopy and laparotomy. Future research in the field of RRC should consider the evaluation of patient-targeted parameters such as pain or quality of life and the technical advantages of the robot for complex procedural steps, as well as surgical and oncological results.

[Emergency contraception : practical guideline]. / Attitude pratique face à la contraception d'urgence.

The goal of emergency contraception (EC) is to avoid unintended pregnancies after unprotected sexual intercourse (UPSI) or incorrect use of regular contraception. EC is intended for occasional use and does not replace effective regular contraception. A thorough understanding of EC is mandatory for optimal use of EC by healthcare professionals. Three EC methods are available in Belgium : oral levonorgestrel (LNG), oral ulipristal acetate (UA) and copper intrauterine device (Cu-IUD). EC should be offered as soon as possible after UPSI. The guidance aims to summarise the available evidence on EC methods, mechanism of action, and advantages/disadvantages of each method.

La contraception d'urgence (CU) a pour but d'éviter les grossesses non désirées après un rapport sexuel non protégé ou une prise incorrecte d'une contraception habituelle. Elle doit être réservée pour un usage occasionnel et ne doit pas remplacer la contraception régulière. La connaissance des méthodes de CU est indispensable pour optimaliser leur usage en pratique quotidienne. Trois méthodes de CU existent en Belgique : la prise de lévonorgestrel oral (LNG), l'acétate d'ulipristal oral (AU) ou l'insertion d'un dispositif intra-utérin (DIU) au cuivre. Il est recommandé d'utiliser la CU le plus rapidement après le rapport à risque. Nous donnerons une description détaillée des méthodes de CU, leurs mécanismes d'action, leurs avantages et inconvénients.

[Obesity, bariatric surgery and contraception]. / Obésité, chirurgie bariatrique et contraception.

The use of hormone therapy is an important therapeutic choice in woman's life, both for contraceptive purpose to avoid unwanted pregnancy, as well as for treatment of menstrual disorders, or climacteric symptoms. Medical care must therefore be dynamic, tailored to individual requirements as much as possible, reflecting personal and family background, potential risks related to treatment, and of course patient's wishes. We will first discuss the modalities of contraception in presence of obesity, then the need for potential adjustment following bariatric surgery.

Le choix d'une médication hormonale est un acte thérapeutique important dans la vie d'une femme, aussi bien dans un but contraceptif afin d'éviter une grossesse non désirée, que dans le cadre d'une prise en charge symptomatologique accompagnant le cycle menstruel ou entourant la ménopause. La prise en charge se doit donc d'être dynamique, individualisée au maximum, en tenant compte des antécédents personnels et familiaux, des facteurs de risque potentiels liés au traitement et, bien évidemment, des désirs de la patiente. Nous discuterons, dans un premier temps, de la contraception dans le cadre d'une obésité et, dans un second temps, de l'éventuelle adaptation après chirurgie bariatrique.

[FIRST CONSULTATION IN TEENAGERS FOR CONTRACEPTION PRESCRIPTION]. / PREMIÈRE CONSULTATION DE CONTRACEPTION CHEZ LES ADOLESCENTES.

Adequate contraception prescription is mandatory for teenagers to avoid any unwanted pregnancy. Counselling and description of side effect improve compliance. Use of condom is important to avoid sexually transmitted infections. Combined estroprogestin contraception has multiple non-contraceptive benefits, e.g. dysmenorrhea improvement. Familial and personal history is needed before contraception prescription. Further consultation 3 months later has to be planned to evaluate compliance, side effects and to adapt contraception if needed.

[State of contraception in 2016]. / Etat de la contraception en 2016.

INTRODUCTION: The Pill and other forms of hormonal contraception, if taken correctly, are very effective and safe for millions of women, but since a few years, due to the debates and controversies about the third- and fourth-generation pills, other options have gained in popularity. OBJECTIVES: to provide a review of oestroprogestative contraception (OP), progesta-tive contraception, IUDs with a focus on their advantages and side-effects according to the specific needs of women. METHODS: literature review and lessons learned from clinical practice. RESULTS: The importance of family and individual history, the life-style and socio-economic conditions are critical factors for advising women on the 15 contraceptive choices available to them. The risk/benefit ratio of OP contraception needs a yearly follow-up. The progestative contraception is the preferred option for women who have contraindication for oestrogen, are older than forty, and/or have risk factors such as a history of venous thromboembolism, overweight and smoking. The IUD usually is well tolerated and causes few side effects. Among the other contraceptive methods, sterilization and diaphragms are briefly discussed. CONCLUSION: Among the many safe and effective contraceptive methods, it is important for general practitioners to know the advantages and the side effects of each method, as well as the specific conditions of the woman, to propose the best options available. In case of difficulties of follow up or adherence to daily uptake, in particular among adolescents, long-acting methods such as IDU or implants are preferable.

INTRODUCTION: Longtemps préférées des femmes, les pilules sont en recul en Belgique depuis les polémiques sur les pilules de 3e et 4e génération. Si le recours à la contraception orale a diminué, d'autres prat iques contraceptives se sont renforcées. OBJECTIFS: fournir une description détaillée des contraceptifs oestroprogestatifs (OP), des contraceptifs à base de progestatifs seuls et des dispositifs intra-utérins, en soulignant leur intérêt mais aussi les risques de leur utilisation. METHODE: revue de la littérature et expérience clinique. RESULTATS: l'importance des antécédents personnels, familiaux, et du style de vie est déterminante pour évaluer les indications des différentes méthodes. En ce qui concerne les contraceptifs OP, le rapport risque/bénéfice nécessite un suivi annuel. La contraception progestative est une option choisie par de nombreuses femmes, particulièrement celles qui ont plus de 40 ans, et/ou des facteurs de risque comme le tabac, le surpoids ou des antécédents de TEV. Le dispositif intra-utérin est généralement bien toléré comme méthode contraceptive car il présente peu d'effets secondaires ou de complications. Parmi les autres méthodes contraceptives, la stérilisation féminine et le diaphragme sont brièvement discutés. CONCLUSION: Parmi les nombreuses possibilités de choix contraceptifs, il est important de faire connaître les indications et contre-indications en tenant compte de la situation de la personne. En cas de difficulté de suivi et d'observance, en particulier chez les adolescentes, la prescription des méthodes à longue durée d'action est préférable.

A prospective and comparative study between stapled hemorrhoidopexy and hemorrhoidal artery ligation with mucopexy.

AIM: The aim of this study was to compare the efficacy between stapled hemorrhoidopexy (Longo technique) and transanal hemorrhoidal artery ligation with mucopexy (THDm) in the treatment of hemorrhoidal disease. PATIENTS AND METHODS: From June 2009 to January 2011, 81 patients having grade II or III hemorrhoidal disease underwent prospective evaluation followed by surgery at two centers (27 Longo and 54 THDm). Symptoms (bleeding, tenesmus, prolapse, fecal incontinence, pain) and the satisfaction score were compared on the first post-operative day and at 1, 6, 12, and 24 months thereafter. The follow-up was 24 months. RESULTS: There was no difference in mean length of stay. One complication (recto-vaginal fistula) was observed after Longo. The prolapse score was significantly lower after THDm than after Longo on the first post-operative day (P < 0.0015). Bleeding score after THDm was significantly lower on the first post-operative day (P = 0.04), but higher thereafter (P = 0.03 and P = 0.04). Tenesmus score after THDm was significantly lower for the first three months (P < 0.06 and 0.001). On the first post-operative day and at one month, the visual analog pain score was significantly lower after THDm than that after Longo (P < 0.0003 et P < 0.01). On the first post-operative day and at one month, the satisfaction score was higher after THDm than after Longo (P < 0.001). CONCLUSION: THDm was safe and effective. Short-term outcomes after THDm were better than after Longo but long-term results seemed to be similar.

[Premature ovarian failure, from genetics to clinical]. / Insuffisance ovarienne prématurée: de la génétique à la clinique.

Premature Ovarian Failure (POF) is a condition with complicated clinical presentation. An estimated 1% of the population is affected before the age of 40, with 0.1% affected prior to the age of 30. There are many causes of POI: genetic aberrations, auto-immune ovarian damage, iatrogenic factors following surgery, radiotherapy or chemotherapy, environmental factors (viruses, toxins, smoking) and metabolic. The majority of POF cases have idiopathic etiologies.

[Role of genetic and environmental factors in the development of endometriosis]. / Le role de la génétique et de l'environnement dans le developpement de l'endométriose.

Endometriosis is usually described as a complex multifactorial disease involving dysregulation of estrogen metabolism, inflammatory and immunological mechanisms. Recently, many authors have questioned the environmental pollution and toxins in the formation and development of endometriotic lesions. Therefore, while dioxins and PCBs have been implicated, insufficient data are available until now to confirm this theory. Endometriosis has also been considered as a genetic disease. Indeed, early familial aggregation and twin studies noted a higher risk of endometriosis among relatives. However, demonstration of a genetic component in the pathogenesis of such a multifactorial disease is quite difficult due to many limitations such as ethnic differences, involvement of environmental factors and size of needed patients cohorts. Over the last decade, the epigenetic approach (DNA methylation, histones modifications and microRNA) has allowed to consider many new perspectives. Indeed, dysregulation (hyper- or hypomethylation) of many genes has already been highlighted. This method of analysis is the subject of numerous studies in order to develop diagnostic, prognostic and therapeutic tools for this disease which is becoming a real public health problem.

Whole slide quantification of stromal lymphatic vessel distribution and peritumoral lymphatic vessel density in early invasive cervical cancer: a method description.

Peritumoral Lymphatic Vessel Density (LVD) is considered to be a predictive marker for the presence of lymph node metastases in cervical cancer. However, when LVD quantification relies on conventional optical microscopy and the hot spot technique, interobserver variability is significant and yields inconsistent conclusions. In this work, we describe an original method that applies computed image analysis to whole slide scanned tissue sections following immunohistochemical lymphatic vessel staining. This procedure allows to determine an objective LVD quantification as well as the lymphatic vessel distribution and its heterogeneity within the stroma surrounding the invasive tumor bundles. The proposed technique can be useful to better characterize lymphatic vessel interactions with tumor cells and could potentially impact on prognosis and therapeutic decisions.

[Management of estrogen deficiency after breast cancer]. / Prise en charge des conséquences de la carence oestrogénique après cancer du sein.

The prevention and the treatment of oestrogen deficiency induced by breast cancer treatments are crucial in the management of patients. The impacts of this deficiency must not be neglected: quality of life impairments inducing eventually premature withdrawal of hormonotherapies, and excess of bone and cardio-vascular morbidities and mortalities, especially in good prognosis young women. Management strategies of short and long term effects of this deficiency are reviewed and discussed here.

Ileal reservoir with ileo-anal anastomosis: long-term complications.

Coloproctectomy with ileo-anal anastomosis (CP-IAA) has been in use for 30 years. This intervention is the standard technique when surgery is indicated for familial adenomatous polyposis (FAP) and for ulcerative colitis (UC). Although the surgery is safe with mortality of less than 1%, it is associated with a morbidity of 18-70%. We thought a literature review about long-term complications would be enlightening. Pouchitis is the most common complication; it occurs in 70% of patients over 20 years follow-up; small bowel obstruction affects 25% of patients and pelvic sepsis occurs in 20-30% within 10 years. CP-IAA can impact the patient's sexual life due to erectile and ejaculatory dysfunction, dyspareunia, and incontinence of stool during sexual intercourse. Nevertheless, patients with long-standing UC describe an overall improvement in their sexual function after surgery. The failure rate varies from 3.5 to 15%; major causes of failure are sepsis, unrecognized Crohn's disease, and poor functional results. Cases of dysplasia and cancer have been reported in the reservoir, but more particularly when there is retained colonic glandular mucosa. The transitional zone should be monitored whenever there are risk factors for colon neoplasia. The relatively high morbidity of CP-IAA should not overshadow the good functional results of this technique.

[Therapeutic inertia in contraception]. / L'inertie thérapeutique en contraception.

The efficiency of contraception is linked to the method and the patient's compliance. The advice given by the physician about contraception use is essential to avoid unintended pregnancy. The accuracy of contraceptive choice and the individualized adaptation over time contribute to safe contraception.

Mixed origin of neovascularization of human endometrial grafts in immunodeficient mouse models.

BACKGROUND: In vivo mouse models have been developed to study the physiology of normal and pathologic endometrium. Although angiogenesis is known to play an important role in endometrial physiology and pathology, the origin of neovasculature in xenografts remains controversial. The aim of this study was to assess the origin of the neovasculature of endometrial grafts in different mouse models. METHODS: Human proliferative endometrium (n = 19 women) was grafted s.c. in two immunodeficient mouse strains: nude (n = 8) and severely compromised immunodeficient (SCID; n = 20). Mice were also treated with estradiol, progesterone or levonorgestrel. Fluorescence in-situ hybridization using a centromeric human chromosome X probe, immunohistochemistry (von Willebrand factor and collagen IV) and lectin perfusion were performed to identify the origin of the vessels. RESULTS: More than 90% of vessels within xenografts were of human origin 4 weeks after implantation. Some vessels (9.67 +/- 2.01%) were successively stained by human or mouse specific markers, suggesting the presence of chimeric vessels exhibiting a succession of human and murine portions. No difference in staining was observed between the two strains of mouse or different hormone treatments. Furthermore, erythrocytes were found inside human vessels, confirming their functionality. CONCLUSION: This article shows that human endometrial grafts retain their own vessels, which connect to the murine vasculature coming from the host tissue and become functional.

Development of an animal experimental model to study the effects of levonorgestrel on the human endometrium.

BACKGROUND: This study was designed to develop an animal model to test the response of endometrium to local progestin delivery. METHODS: Proliferative human endometrium was subcutaneously grafted in two groups of SCID mice that received, 2 days before, a subcutaneous estradiol (E(2)) pellet and, for half of them, an additional implant of levonorgestrel (LNG). Mice were sacrificed 1, 2, 3 or 4 weeks after endometrial implantation and grafts were histologically analysed. Proliferation, steroid hormone receptors, blood vessels and stromal decidualization in both groups (E(2) and LNG) were immunohistologically evaluated and compared with proliferative endometrium and endometrium from women with an LNG intrauterine device. RESULTS: Grafts presented normal morphological endometrial characteristics. The expression of progesterone receptors was significantly decreased in glands and stroma of the LNG group as compared with the E(2) group at all times. A significant decrease was also observed in the stromal expression of estrogen receptor-alpha in the LNG group. At 4 weeks, the mean cross-sectional area of vessels was significantly higher after LNG treatment. CONCLUSIONS: These morphological and immunohistochemical characteristics are similar to those observed in women treated with local LNG. This mouse model might facilitate further investigations needed to understand the mechanisms responsible for the breakthrough bleeding frequently observed in progestin users.

Persistence of an intact endometrial matrix and vessels structure in women exposed to VA-2914, a selective progesterone receptor modulator.

BACKGROUND: VA-2914 is a selective progesterone receptor modulator with potential contraceptive activity that induces amenorrhea, whereas progestins cause endometrial spotting and bleeding. This abnormal bleeding due to progestins is a consequence of focal stromal proteolysis by an increase in naked vessel size and density. OBJECTIVE: Our objective was to quantify the effects of VA-2914 on endometrial vascularization, fibrillar matrix, and vascular endothelial growth factor (VEGF)-A expression in endometrial biopsies from 41 women before and after 12 wk daily treatment with a placebo, or 2.5, 5, or 10 mg VA-2914. METHODS: Collagen fibrillar network was stained by silver impregnation. Vessel area, density, and structure were quantified with a computer-assisted image analysis system after double immunostaining using an anti-von Willebrand factor (endothelial cells) and an anti-alpha smooth muscle actin (vascular smooth muscle cells) marker antibody. VEGF-A mRNAs were quantified by RT-PCR and localized by immunohistochemistry. RESULTS: The endometrial vessels, collagen network, and mRNA levels of VEGF-A were identical during the luteal phase at baseline and in VA-2914 treated women. VEGF-A distribution was unchanged. CONCLUSIONS: VA-2914 does not alter the endometrial matrix and cells, and does not modify the endometrial vessel morphology as compared with baseline biopsies.

Human endometrial epithelial cells modulate the activation of gelatinase a by stromal cells.

Metalloproteinases (MMPs) are central effectors in endometrial physiology. Their production is tightly regulated by ovarian steroids and cytokines. Using zymography, we investigated MMP-2 production by human endometrial cells treated with estradiol-17beta + progesterone (E(2)+P) and by various key cytokines in endometrial physiology (IL-1beta, LIF, TGF-beta, and TNF-alpha). No gelatinase activity was detected in the culture media of epithelial cells. In basal conditions, stromal cells produced the pro form of MMP-2. MMP-2 production/activation was not directly affected by cytokine treatment. Interestingly, activated MMP-2 was only detected after treatment of stromal cells with culture medium from epithelial cells. Cytokine treatment of epithelial cells increased the capacity of conditioned medium to stimulate stromal cells to activate MMP-2. As the tissue inhibitor of MMP-2 (TIMP-2) is a regulator of gelatinase A activity, its concentration was measured by ELISA. TIMP-2 production by stromal cells was not affected by cytokines or by epithelial cell-conditioned medium. These results strongly suggest that regulation of stromal MMP-2 activation involves soluble factor(s) derived from the epithelial compartment.

Estradiol and progesterone regulate the proliferation of human breast epithelial cells.

OBJECTIVE: To study the effects of estradiol and progesterone on the proliferation of normal human breast epithelial cells in vivo. DESIGN: Double-blind randomized study. SETTING: Departments of gynecology and of cell biology at a university hospital. PATIENT(S): Forty postmenopausal women with untreated menopause and documented plasma FSH levels of >30 mIU/mL and estradiol levels of <20 pg/mL. INTERVENTION(S): Daily topical application to both breasts of a gel containing a placebo, estradiol, progesterone, or a combination of estradiol and progesterone during the 14 days preceding esthetic breast surgery or excision of a benign lesion. MAIN OUTCOME MEASURE(S): Plasma and breast tissue concentrations of estradiol and progesterone. Epithelial cell cycles were evaluated in normal breast tissue by counting mitoses and performing quantitative proliferating cell nuclear antigen immunolabeling analyses. RESULT(S): Increasing the estradiol concentration enhanced the number of cycling epithelial cells, whereas increasing the progesterone concentration significantly limited the number of cycling epithelial cells. CONCLUSION(S): Exposure to progesterone for 14 days reduced the estradiol-induced proliferation of normal breast epithelial cells in vivo.

Impact of percutaneous oestradiol gels in postmenopausal hormone replacement therapy on clinical symptoms and endometrium.

OBJECTIVE: To compare the effects on endometrium, climacteric symptoms and the menstrual cycle, and the clinical and biological tolerance of two percutaneous oestradiol gels used as hormone replacement therapy. DESIGN: A large open randomised multicentre study. SETTING: France and Belgium. PARTICIPANTS: Two-hundred and fifty-four women with an intact uterus and who had experienced a natural menopause received either Oestrogel (n = 126) or Estreva, a new formulation of oestradiol gel (n = 128), (1.5 mg of oestradiol/day) for the 24 first days of each calendar month during six consecutive months. Nomegestrol acetate (Lutenyl), a norprogesterone derivative, was administered (5 mg/day) from day 11 to day 24 of each oestradiol cycle. MAIN OUTCOME MEASURES: Examination of endometrial biopsies taken before treatment and between days 18 and 24 of the last treatment cycle, climacteric symptoms assessed using a modified Kupperman index, control of menstrual cycle evaluated by diary cards, and clinical and biological tolerance. RESULTS: Both treatments lowered the frequency and intensity of hot flushes and the global Kupperman index. 96% of the cycles were followed by withdrawal bleeding. Breakthrough bleeding or spotting resulted in premature discontinuation of treatment in one volunteer. Mastodynia occurred in 20 women and contributed to the premature termination of treatment in three of them. Endometrial biopsies taken at the end of treatment showed identical histologies in both groups, with a secretory pattern in the majority of women, and absence of hyperplasia. CONCLUSIONS: This trial confirmed that, when the two oestradiol gels tested were administered cyclically with nomegestrol acetate to postmenopausal women, they were well tolerated, effective and suitable for the treatment of oestrogen deficiency syndrome.

Localization of laminin, fibronectin, E-cadherin, and integrins in endometrium and endometriosis.

OBJECTIVE: To compare the localization of adhesion proteins (laminin and fibronectin) and their receptors of the integrin family in endometriosis and endometrium. DESIGN: An immunohistochemical study. SETTING: University Hospital, Department of Gynecology and Department of Cell Biology. PATIENT(S): Eighteen endometriosis patients undergoing laparoscopy for pain or infertility and nine control patients undergoing laparoscopy for sterilization or hysterectomy. MAIN OUTCOME MEASURE(S): The expression of adhesion glycoproteins (laminin and fibronectin), their receptors alpha 1 beta 1, alpha 2 beta 1, alpha 3 beta 1, alpha 5 beta 1, and alpha 6 beta 1, and E-cadherin was determined by immunohistochemistry on frozen sections. RESULT(S): The distribution of both adhesive glycoproteins, laminin and fibronectin, and their receptors was identical in endometriosis and endometrium. Fibronectin receptors (alpha 4 beta 1, alpha 5 beta 1) displayed distinct expression patterns in endometrium and endometriosis. No endometrial glands showed positive staining for the alpha 5 chain, whereas this integrin subunit was detected in almost all endometriotic lesions. The integrin alpha 4 chain was present in all endometriotic glands but was absent from endometrial glands in the proliferative phase of the cycle. CONCLUSION(S): No difference in cell adhesion molecule localization nor receptors was observed between endometriotic and endometrial samples, except for fibronectin receptors. Their expression persisted around endometriotic glands but not in endometrium. These results suggest that fibronectin receptors could play a role in the persistence of endometriotic lesions, despite menstruation in corresponding eutopic endometrium.