Robot-assisted laparoscopy for deep infiltrating endometriosis: a retrospective French multicentric study (2008-2019) using the Society of European Robotic Gynecological Surgery endometriosis database.

OBJECTIVE: This study aimed at assessing perioperative results of robot-assisted laparoscopy (RAL) in the context of deep infiltrating endometriosis (DIE). METHODS: This retrospective French multicentric study included all patients with DIE who underwent surgical treatment managed by RAL (Da Vinci® System). From November 2008 to June 2019, patients were included in a single European database, in Robotic Assisted Laparoscopic Gynecologic Surgery, with Society of European Robotic Gynecological Surgery collaboration. Patients had different DIE sites as follows: gynecological, urological, or digestive, or combinations of these. Surgical procedures and perioperative complications were evaluated. To assess complications, patients were divided into the following four groups according to surgical procedure and DIE site: gynecological only; gynecological and urological; gynecological and digestive; and gynecological, urological, and digestive. RESULTS: A total of 460 patients treated at one of eight health-care facilities from November 2008 to June 2019 were included. Median operative time was 245 min (IQR 186-320), surgeon console time was 138 ± 75 min and estimated blood loss was 70.0 mL ± 107 mL. Among this patient sample, 42.1% had a multidisciplinary surgical approach with a digestive or urology surgeon in addition to gynecology surgeon (25.5% and 16.6% of cases, respectively). Among those with intraoperative complications (n = 25, 5.4%) were primarily conversion to laparotomy (n = 6, 2.0%), transfusion (n = 2, 0.6%), and organ wounds (n = 8, 1.7%). Overall, 5.6% had severe postoperative complications (Clavien-Dindo classification ≥ Grade 3). CONCLUSION: This is among the largest published series addressing RAL for DIE. Interest in this procedure appears promising, with no observed increases in blood loss or in peri- or post-operative complications. DIE laparoscopic surgery can require complex surgical procedures performed by multidisciplinary surgical teams. Thus, it may be one of the best candidates for RAL within gynecology surgery.

Lomboaortic Lymphadenectomy in Gynecological Oncology: Laparotomy, Laparoscopy or Robot-Assisted Laparoscopy?

BACKGROUND: The outcomes of paraaortic lymphadenectomy were compared for the treatment of gynecological malignancies to identify the most appropriate surgical approach. METHODS: Our retrospective, multicentric study included 1304 patients who underwent paraaortic lymphadenectomy for gynecological malignancies. The patients were categorized into the following five groups based on treatment type: transperitoneal laparoscopy (group A, n = 198), extraperitoneal laparoscopy (group B, n = 681), robot-assisted transperitoneal laparoscopy (group C, n = 135), robot-assisted extraperitoneal laparoscopy (group D, n = 44), and laparotomy (group E, n = 246). RESULTS: The prevalence of cancer types differed according to the surgical approach: there were more ovarian cancers in group E and more cervical cancers in groups B and D (p < 0.001). Estimated blood loss was higher in group E (844.2 mL) than in groups treated with minimally invasive interventions (115.8-141.5 mL, p < 0.005). For infrarenal dissection, fewer nodes were removed in group C compared with the other approaches (16 vs. 21 nodes, respectively, p < 0.05). The average operative time ranged from 169 min for group A to 247 min for group E (p < 0.001). Length of hospital stay was 14 days for group E versus 3.5 days for minimally invasive procedures (p < 0.05). The early postoperative grade 3 and superior Dindo-Clavien complications occurred in 9-10% of the patients in groups B-D, 15% of the patients in group E, and only 3% and 4% for groups A and C, respectively. The most common complication was lymphocele. CONCLUSIONS: Laparotomy increases preoperative and postoperative morbidity. The robot-assisted transperitoneal approach demonstrated a poorer lymph node yield than laparotomy and extraperitoneal approaches.

Robotic assisted laparoscopy for deep infiltrating endometriosis.

Deep infiltrative endometriosis is a condition affecting up to 15 % of women of childbearing age, defined by extra uterine location of endometrial like tissues. The symptoms of endometriosis range from severe dysmenorrhea to infertility, chronic pelvic pain, bowel dysfunction and urinary tract involvement to name the most common. Endometriosis has an impact on the quality of life of patients, with personal and social consequences. Although medical treatment is indicated in the first instance, surgery may be necessary. Standard laparoscopy has become the gold standard for this surgery. However, surgery for deep infiltrative endometriosis is known to be highly complex, and the significant development of robotic assistance in recent years has had an impact on the evolution of surgical practice. This comprehensive review of the literature provides an overview of the contributions of robotic surgery in the field of endometriosis and gives an insight into the next steps in its development.

Assessment of supplement use (including vitamin D) in Inuvialuit adults in the Northwest Territories, Canada.

BACKGROUND: Inuvialuit of Arctic Canada are at high risk for inadequate vitamin D status as a result of rapid dietary transitions and a lack of solar ultraviolet B exposure. This may have implications for the development of adverse skeletal diseases, cardiovascular diseases and cancers. Data are limited regarding supplement use in Arctic Aboriginal populations. The present study aimed to describe the type and extent of supplement use, emphasising vitamin D, and to identify differences between supplement users and non-users. METHODS: Supplement information was collected from a population-specific quantitative food frequency questionnaire in three communities in the Northwest Territories, Canada, as part of a cross-sectional study. Data were analysed for frequency of supplementation and types of supplements. Users and non-users were compared in terms of age, sex, body mass index, education, marital status, income support, employment and chronic disease diagnosis using nonparametric tests and the chi-squared test. RESULTS: Response rates ranged from 65% to 85%. Included in the analysis were 192 Inuvialuit (45 males, 147 females) with a mean (SD) age of 43.6 (13.9) years. Twenty-three percent reported using a supplement, with multivitamins being the most common. Three percent indicated taking a vitamin D-containing supplement. No significant differences between supplement users and non-users were found. CONCLUSIONS: Despite limited sun exposure for many months of the year, a small proportion of Inuvialuit adults were using supplements, and specifically vitamin D-containing supplements. Future population-based intervention strategies should promote consumption of vitamin D rich foods and encourage the use of vitamin D supplements if diet alone is unable to meet recommendations.

Ovariectomy and genes encoding core circadian regulatory proteins in murine bone.

SUMMARY: This study investigated the influence of ovarian hormone deficiency on core circadian regulatory protein (CCRP) in the context of bone loss. Our data suggest that ovarian hormone deficiency disrupts diurnal rhythmicity and CCRP expression in bone. Further studies should determine if chronobiology provides a novel therapeutic target for osteoporosis intervention. INTRODUCTION: CCRP synchronize metabolic activities and display an oscillatory expression profile in murine bone. In vitro studies using bone marrow mesenchymal stromal/stem cells have demonstrated that the CCRP is present and can be regulated within osteoblast progenitors. In vivo studies have shown that the CCRP regulates bone mass via leptin/neuroendocrine pathways. The current study used an ovariectomized murine model to test the hypothesis that ovarian hormone deficiency is associated with either an attenuation and/or temporal phase shift of the CCRP oscillatory expression in bone and that these changes are correlated with the onset of osteoporosis. METHODS: Sham-operated controls and ovariectomized female C57BL/6 mice were euthanized at 4-h intervals 2 weeks post-operatively. RESULTS: Ovariectomy attenuated the oscillatory expression of CCRP mRNAs in the femur and vertebra relative to the controls and reduced the wheel-running activity profile. CONCLUSION: Ovarian hormone deficiency modulates the expression profile of the CCRP with potential impact on bone marrow mesenchymal stem cell lineage commitment.

Expression profile of mRNAs encoding core circadian regulatory proteins in human subcutaneous adipose tissue: correlation with age and body mass index.

OBJECTIVE: Circadian mechanisms underlie the physiology of mammals as an adaptation to the earth's rotation on its axis. Highly conserved core circadian regulatory proteins (CCRPs) maintain an oscillatory expression profile in the central and peripheral tissues. The CCRP include both a positive and negative arm, as well as downstream transcriptional regulators. Recent studies in murine models have determined that the mRNAs encoding the CCRP are present in multiple adipose tissue depots and exhibit a robust oscillatory expression profile. This study set out to examine the expression of CCRP mRNAs in human subcutaneous adipose tissues. DESIGN: Retrospective analysis of total RNA isolated from subcutaneous adipose tissue. SUBJECTS: A total of 150 healthy female and male lean (body mass index (BMI) <25), overweight (BMI between 25 and 29.99) or obese (BMI >30) subjects of varied ethnic backgrounds undergoing elective liposuction or surgical procedures. RESULTS: The expression of the CCRP mRNAs displayed a significant correlation between each other and mRNAs representative of adipogenic biomarkers. Hierarchical cluster analyses of mRNAs isolated from the cohort of female Caucasian subjects (n=116) identified three major clusters based on expression of downstream CCRP mRNAs. The mRNAs encoding D site of albumin promoter-binding protein (DBP), E4 promoter-binding protein 4 (E4BP4), PPARgamma coactivator-1beta (PGC-1beta) and Rev-erbalpha were negatively correlated with BMI in a lean cluster (n=66), positively correlated with BMI in a younger overweight/obese cluster (n=19), and not significantly correlated with BMI in an older, overweight/obese cluster (n=31). CONCLUSIONS: These data confirm and extend findings that link the CCRP and circadian mechanisms to the risk of obesity.

[How to confirm acute fatty liver of pregnancy in case of emergency]. / Comment confirmer le diagnostic de stéatose hépatique aiguë gravidique en urgence?

Acute fatty liver of pregnancy (AFLP) is a rare disease of which prognosis could be adverse if diagnosis is delayed. Certain diagnosis is sometimes made complex because of undercurrent symptoms with pre-eclampsia or hemolysis, elevated liver enzyme, low platelet (HELLP) syndrome. Several reports announce an increase of incidence and illustrate cases confirmed by non-invasive methods. They permit early diagnosis and improve morbidity and mortality. Reviewing seven of the most important series of AFLP, we demonstrate how to use ultrasonography or computed tomography scan to confirm AFLP. However, liver biopsy should be realised after delivery in case of uncertain diagnosis.

The amidated PACAP1-23 fragment is a potent reduced-size neuroprotective agent.

BACKGROUND: Neurodegenerative disorders, such as Parkinson's disease (PD), are characterized by neuronal death involving, among other events, mitochondrial dysfunction and excitotoxicity. Along these lines, several attempts have been made to slow this pathology but none have been yet discovered. Based on its capacity to cross the blood-brain barrier and provide neuronal protection in vitro and in vivo, the pituitary adenylate cyclase-activating polypeptide (PACAP) represents a promising lead molecule. Pharmacological studies showed that PACAP interacts with three different G protein-coupled receptors, i.e. PAC1, VPAC1 and VPAC2. However, only PAC1 is associated with neuronal anti-apoptotic actions, whilst VPAC activation might cause adverse effects. In the context of the development of PAC1-selective agonists, PACAP(1-23) (PACAP23) appears as the shortest known PACAP bioactive fragment. METHODS: Hence, the capacity of this peptide to bind PACAP receptors and protect neuroblastoma cells was evaluated under conditions of mitochondrial dysfunction and glutamate excitotoxicity. In addition, its ability to activate downstream signaling events involving G proteins (Gαs and Gαq), EPAC, and calcium was also assessed. RESULTS: Compared to the endogenous peptide, PACAP23 showed a reduced affinity towards PAC1, although this fragment exerted potent neuroprotection. However, surprisingly, some disparities were observed for PACAP23 signaling compared to full length PACAP, suggesting that downstream signaling related to neuroprotection is distinctly regulated following subtle differences in their PAC1 interactions. CONCLUSIONS: Altogether, this study demonstrates the potent neuroprotective action of amidated PACAP23. GENERAL SIGNIFICANCE: PACAP23 represents an attractive template for development of shorter PACAP-derived neuroprotective molecules.

[MR angiography of peripheral arterial disease of the distal legs: is time resolved MRA (TRICKS) necessary?]. / Angiographie par Résonance Magnétique dans l'artériopathie distale des membres inférieurs: peut-on se passer d'une séquence multiphase (TRICKS)?

PURPOSE: To demonstrate the added diagnostic value of time-resolved imaging of contrast kinetics (TRICKS) in the evaluation of lower limb arteries compared to standard 3 level MRA with stepping table method. PATIENTS AND METHODS: Forty patients (30% diabetics) with lower extremity peripheral arterial disease (87.5% with chronic ischemia) underwent standard contrast MRA including TRICKS of the distal arteries. Five arterial segments were defined per leg, and 395 arterial segments were compared (one patient with amputation). Two reviewers evaluated the quality of arterial imaging, presence of venous return and degree of stenosis per segment. The degree of interobserver agreement for arterial stenosis measurement was calculated. RESULTS: More arterial segments could be analyzed on the TRICKS sequence (good or excellent analysis in 63.03%-66.32% of arterial segments compared to 41.51%-47.08% on routine MRA). There was less venous contamination on TRICKS images (25.57% to 27.60% gain). The degree of interobserver agreement was superior with TRICKS compared to standard MRA (kappa 0.85 vs 0.69). CONCLUSION: The TRICKS sequence can be added to standard MRA for pre-therapeutic evaluation of distal arteries in patients with peripheral arterial disease, especially with chronic ischemic with rest pain and/or trophic changes.

[Definition of endometriosis expert centres]. / Définition des centres experts en endométriose.

OBJECTIVES: The Collège national des gynécologues obstétriciens français (CNGOF), in agreement with the Société de chirurgie gynécologique et pelvienne (SCGP), has set up a commission in 2017 to define endometriosis expert centres, with the aim of optimizing endometriosis care in France. METHODS: The committee included members from university and general hospitals as well as private facilities, representing medical, surgical and radiological aspects of endometriosis care. Opinion of endometriosis patients' associations was obtained prior to writing this work. The final text was presented and unanimously validated by the members of the CNGOF Board of Directors at its meeting of October 13, 2017. RESULTS: Based on analysis of current management of endometriosis and the last ten years opportunities in France, the committee has been able to define the contours of endometriosis expert centres. The objectives, production specifications, mode of operation, missions and funding for these centres were described. The following missions have been specifically defined: territorial organization, global and referral care, communication and teaching as well as research and evaluation. CONCLUSION: Because of its daily impact for women and its economic burden in France, endometriosis justifies launching of expert centres throughout the country with formal accreditation by health authorities, ideally as part of the National Health Plan.