Relative distribution of HPV genotypes in histological cervical samples and associated grade lesion in a women population over the last 16 years in Burgundy, France.

Human papillomavirus is a predominant sexually transmitted viral pathogen. Our objective was to analyze the relative distribution of genotypes over time and to determine the genotypes associated with adverse clinical lesions. The study was based on data from adult women with cytological abnormalities from whom histological samples were obtained from 2005 to 2021. HPV genotyping was performed using PCR and INNO-LiPA assay (Fujirebio). Among the 1,017 HPV-positive biopsies, 732 (72%) were infected with a single HPV genotype and 285 (28%) were infected with several HPV genotypes. Most of the infections involved the high-risk genotypes 16, 31, and 52. Throughout the study period, HPV 16 was the most encountered genotype (541, 53.2%), while HPV 18 was rather under-represented (46, 4.5%), especially in invasive cervical carcinoma. HVP52 (165, 16.2%) was detected mainly from 2008 to 2014, and its distribution reached 19.7% in 2011. Such epidemiological data underlines the possibility of an emergence of a high-risk genotype. The most detected low-risk HPV in combination with high-risk HPV was HPV 54 in 6.5% of samples. Monoinfection by HPV 16 led statistically more often to severe lesions than multi-infection involving HPV 16 (p < 0.001), while for HPV 52, 31 or 33, multi-infections were significantly associated with severe lesions (p < 0.001 for each of these three genotypes). HPV 16 was involved in 55.2% of high-grade lesions and in situ carcinoma and 76.3% of invasive carcinomas. In severe lesions, HPV 16 participation was predominant, whereas diverse genotypes were seen in low-grade lesions. Importantly, we observed that high-risk genotypes, for example HPV 52, can emerge for a few years then decrease even without vaccine pressure.

Surgical Management of Urinary Tract Endometriosis: A 1-year Longitudinal Multicenter Pilot Study at 31 French Hospitals (by the FRIENDS Group).

STUDY OBJECTIVE: To describe the surgical management and risks of postoperative complications of patients with urinary tract endometriosis in France in 2017. DESIGN: Multicenter retrospective cohort pilot study. SETTING: Departments of gynecology at 31 expert endometriosis centers. PATIENTS: All women managed surgically for urinary tract endometriosis from January 1, 2017, to December 31, 2017. We distinguished patients with isolated bladder endometriosis or isolated ureteral endometriosis (IUE) from those with endometriosis in both locations (mixed locations [ML]). INTERVENTIONS: Surgeons belonging to the French Colorectal Infiltrating Endometriosis Study (FRIENDS) group enrolled patients who filled a 24-item questionnaire on the day of the inclusion and 3 months later. Data were collected on operative routes, surgical management, and postoperative complications according to the Clavien-Dindo classification in a single anonymized database. MEASUREMENTS AND MAIN RESULTS: A total of 232 patients from 31 centers were included. Isolated bladder endometriosis was found in 82 patients (35.3%), IUE in 126 patients (54.4%), and ML in 24 patients (10.3%). Surgery was performed by laparoscopy, laparotomy, or robot-assisted laparoscopy in 74.1%, 11.2%, and 14.7% of the cases, respectively. Among the 150 ureteral lesions (IUE and ML), 114 were managed with ureterolysis (76%), 28 with ureteral resection (18.7%), 4 with nephrectomy (2.7%), and 23 with cystectomy (15.3%). Concerning bladder endometriosis, a partial cystectomy was performed in 94.3% of the cases. We reported 61 postoperative complications (26.3%): 44 low-grade complications according to the Clavien-Dindo classification (18%), 16 grade III complications (7%), and 1 grade IV complication (peritonitis). CONCLUSION: The surgical management of ureteral and bladder endometriosis is usually feasible and safe through laparoscopic surgery. Ureteral resection, when necessary, is more strongly associated with laparotomy and with more complications than other procedures. Prospective controlled studies are still mandatory to assess the best surgical management for patients.

Risk Factors of Post-Large Loop Excision of the Transformation Zone Recurrent High-Grade Cervical Intraepithelial Lesion: A Prospective Cohort Study.

OBJECTIVE: The aim of the study was to identify the risk factors of post-large loop excision of the transformation zone (LLETZ) recurrent disease and the impact of colposcopic guidance at the time of LLETZ on that risk. MATERIALS AND METHODS: From December 2013 to July 2014, 204 patients who had undergone LLETZ for the treatment of high-grade intraepithelial lesion with fully visible cervical squamocolumnar junction were included. The use of colposcopy during each procedure was systematically documented. The dimensions and volume of LLETZ specimens were measured at the time of the procedure before formaldehyde fixation. All participants were invited for a follow-up. The primary endpoint was the diagnosis of post-LLETZ recurrent disease defined as the histologic diagnosis of a high-grade cervical intraepithelial lesion. RESULTS: The median duration of post-LLETZ follow-up was 25.8 months. Recurrent disease was diagnosed in 8 (3.6%) patients. Older than 38 years (adjusted hazard ratio [aHR] = 11.9, 95% CI = 1.6-86.0), history of excisional therapy (aHR = 21.6, 95% CI = 3.5-135.3), and the absence of colposcopy for the guidance of LLETZ (aHR = 6.4, 95% CI = 1.1-37.7) were found to significantly increase the risk of post-LLETZ recurrent disease. The dimensions and volume of the specimen were not found to have any impact. Only positive endocervical margins were identified to significantly increase the risk of post-LLETZ recurrent disease (aHR = 14.4, 95% CI = 2.0-101.1). CONCLUSIONS: Risk factors of post-LLETZ recurrent disease are older than 38 years, history of excisional therapy, positive endocervical margins, and lack of colposcopic guidance at the time of LLETZ.

Does mammogram attendance influence participation in cervical and colorectal cancer screening? A prospective study among 1856 French women.

BACKGROUND: We aimed to determine participation rates and factors associated with participation in colorectal (fecal occul blood test) and cervical cancer (Pap-smear) screening among a population of women participating in breast cancer screening. METHODS: From August to October 2015, a self-administered questionnaire was sent by post to 2 900 women aged 50-65, living in Côte-d'Or, France, and who were up to date with mammogram screening. Polytomic logistic regression was used to identify correlates of participation in both cervical and colorectal cancer screenings. Participation in all 3 screenings was chosen as the reference. RESULTS: Study participation rate was 66.3% (n = 1856). Besides being compliant with mammogram, respectively 78.3% and 56.6% of respondents were up to date for cervical and colorectal cancer screenings, while 46.2% were compliant with the 3 screenings. Consultation with a gynecologist in the past year was associated with higher chance of undergoing the 3 screenings or female cancer screenings (p<10-4), when consultation with a GP was associated with higher chance of undergoing the 3 screenings or organized cancer screenings (p<0.05). Unemployment, obesity, age>59 and yearly flu vaccine were associated with a lower involvement in cervical cancer screening. Women from high socio-economic classes were more likely to attend only female cancer screenings (p = 0.009). Finally, a low level of physical activity and tobacco use were associated with higher risk of no additional screening participation (p<10-3 and p = 0.027). CONCLUSIONS: Among women participating in breast screening, colorectal and cervical cancer screening rates could be improved. Including communication about these 2 cancer screenings in the mammogram invitation could be worth to explore.

Risk Factors of Inadequate Colposcopy After Large Loop Excision of the Transformation Zone: A Prospective Cohort Study.

OBJECTIVE: The aim of the study was to identify the risk factors of post-large loop excision of the transformation zone (LLETZ) inadequate colposcopy. MATERIALS AND METHODS: From December 2013 to July 2014, a total of 157 patients who had a LLETZ performed for the treatment of high-grade intraepithelial lesion with fully visible cervical squamocolumnar junction were included. All procedures were performed using semicircular loops. The use of colposcopy made during each procedure was systematically documented. Dimensions and volume of LLETZ specimens were measured at the time of procedure, before formaldehyde fixation. All participants were invited for a follow-up colposcopy 3 to 6 months after LLETZ. Primary end point was the diagnosis of post-LLETZ inadequate colposcopy, defined by a not fully visible cervical squamocolumnar junction and/or cervical stenosis. RESULTS: Colposcopies were performed in a mean (SD) delay of 136 (88) days and were inadequate in 22 (14%) cases. Factors found to significantly increase the probability of post-LLETZ inadequate colposcopy were a history of previous excisional cervical therapy [adjusted odds ratio (aOR) = 4.29, 95% CI = 1.12-16.37, p = .033] and the thickness of the specimen (aOR = 3.12, 95% CI = 1.02-9.60, p = .047). The use of colposcopy for the guidance of LLETZ was statistically associated with a decrease in the risk of post-LLETZ inadequate colposcopy (aOR = 0.19, 95% CI = 0.04-0.80, p = .024) as the achievement of negative endocervical margins (aOR = 0.26, 95% CI = 0.08-0.86, p = .027). CONCLUSIONS: Although the risk of post-LLETZ inadequate colposcopy is increased in patients with history of excisional therapy and with the thickness of the excised specimen, it could be reduced with the use of colposcopic guidance and the achievement of negative endocervical margins.

The Accuracy of Large Loop Excision of the Transformation Zone Specimen Dimensions in Determining Volume: A Multicentric Prospective Observational Study.

OBJECTIVE: The aim of the study was to determine which mathematical formula of specimen dimensions is the most accurate method of determining volume of the excised specimen at loop excision of the transformation zone. MATERIALS AND METHODS: A multicenter prospective observational study was conducted. A total of 258 patients who had a loop excision of the transformation zone performed as treatment of cervical intraepithelial neoplasia 2-3 were included. The dimensions and the volume of the specimen were measured at the time of the procedure, before formaldehyde fixation. The volume was measured by immersing the specimen in a graduated cylinder using Archimedes fluid displacement technique. The measured volume was compared with the calculated volume using different volume formulas, that is, a cone, a cylinder, a parallelepiped, and a hemiellipsoid. The main outcome measure was the relationship between calculated volume (using the dimensions of thickness, length, and circumference) and the measured volume of the specimen. RESULTS: The mean (SD) thickness, length, and circumference of specimens were 8.8 mm (3.8), 12.7 mm (5.9), and 45.7 mm (16.8), respectively. The mean (SD) measured volume was 2.53 (1.49) mL. Using the formula for the volume of a cone, a cylinder, a parallelepiped and a hemiellipsoid, estimated volumes were 1.03 mL (1.22), 3.10 mL (3.65), 6.20 mL (7.31), and 2.07 mL (2.44), respectively. The highest intraclass correlation coefficient between measured and calculated volume was observed when using the formula for the volume of a hemiellipsoid specimen (0.47, 95% CI = 0.36-0.56). CONCLUSIONS: The hemiellipsoid formula is the most accurate determinant of the excised volume. Other formulas do not allow for an accurate estimation of the excised volume.

Benefits of Direct Colposcopic Vision for Optimal LLETZ Procedure: A Prospective Multicenter Study.

OBJECTIVE: The aim of the study was to assess whether direct colposcopic vision (DCV) of the cervix during large loop excision of the transformation zone (LLETZ) is associated with a decrease in the volume and dimensions of specimens or affects margin status at histology. MATERIALS AND METHODS: A prospective multicenter observational study of 216 women who underwent LLETZ for grades 2 and 3 cervical intraepithelial neoplasia was conducted. The volume and dimensions (circumference, length, and thickness) of the surgical specimens were measured before fixation. Data were compared according to the use of colposcopy during LLETZ. The following 3 groups were considered: LLETZ performed without colposcopy (n = 91), LLETZ performed immediately after colposcopy (n = 51), and LLETZ performed under DCV (n = 74). RESULTS: Patient characteristics were comparable with regard to age, parity, history of excision, indication of the procedure, and the size of the cervix. We found a significant decrease in all dimensions of the specimens obtained under DCV (p < .001). Margin status was not affected. After adjusting for confounders, the mean volumes were significantly lower in the DCV group (adjusted mean difference = -0.66 mL; 95% CI = -1.17 to -0.14). The probability that negative margins would be achieved together with the attainment of a volume less than 5 mL and a thickness less than 10 mm was the highest in the DCV group (adjusted OR = 2.80; 95% CI = 1.13 to 6.90). CONCLUSIONS: Direct colposcopic vision is associated with a significant decrease in the volume and in all dimensions of LLETZ specimens with no compromise in the margin status.

About invasive cervical cancer: a French population based study between 1998 and 2010.

OBJECTIVES: The new French cancer plan provides the implementation of organized screening. To make an assessment of the situation, we aim to describe clinical, tumor and survival characteristics of patients with invasive cervical cancer. STUDY DESIGN: Data on women suffering from invasive cervical cancer and diagnosed from 1998 to 2010 were provided by the Cote d'Or breast cancer registry. Survival was described using the Kaplan-Meier method and prognostic factors of survival were estimated in a Cox proportional hazard model. RESULTS: On the whole, 1019 cancers have been collected including 311 (30.5%) invasive ones. The peak incidence was between 40 and 49 years, with an average age of 52 years (SD=16.4). Cancers were mostly squamous cell carcinoma (80.1%) and diagnosed at a localized stage (53.7%). Only 49% (71/145) of our population were up to date on their Pap smear follow up with lower rates in deprived women. The 5-year survival rate was 62% (15% for women with FIGO stage IV and 91% for women with FIGO stage I) with a median survival of 12.3 years [95% CI: 6.6-NR]. Multivariate analysis showed that risk of death was the highest for group age 50-59 (OR=4.93; 95% CI: [1.55-15.70]) compared to women aged less than 40, advanced stage (OR=3.12; 95% CI [1.82-5.35]), and non accurate follow up (OR=2.81; 95% CI [1.32-5.97]). After cancer diagnosis, no impact of the deprivation index on survival was found. CONCLUSION: This study confirms the poor outcome of advanced invasive cervical cancer and the importance of early detection of cervical cancer. Preventive communication should be even more developed and the implementation of a screening program may go through the provision of improved screening tools.

Enoxaparin for prevention of unexplained recurrent miscarriage: a multicenter randomized double-blind placebo-controlled trial.

It is common practice in many centers to offer antithrombotic medications to women with unexplained recurrent miscarriage, in the presence or absence of inherited thrombophilia. Although no benefit of aspirin vs placebo has been clearly demonstrated, a double-blind placebo-controlled trial on the effect of low-molecular-weight heparin is lacking. We enrolled 258 pregnant women with a history of unexplained recurrent miscarriage (≥2 consecutive miscarriages before 15 weeks' gestation) and a negative thrombophilia workup. They were randomly assigned to receive one daily subcutaneous injection of enoxaparin 40 mg or placebo until 35 weeks' gestation. We included 256 women (mean age 32 years, ≥3 miscarriages: 72%; mean gestational age 39 days of amenorrhea) in the intention-to-treat analysis; 66.6% of 138 who received enoxaparin had a live birth vs 72.9% of 118 who received placebo. The absolute difference was -6% (95% CI, -17.1 to 5.1), excluding a 10% increase in the rate of live-birth on enoxaparin (P = .34). In this first randomized, double-blind, placebo-controlled trial, enoxaparin (40 mg once daily) did not improve the chance of a live birth in nonthrombophilic women with unexplained recurrent miscarriage. This trial is registered at www.ClinicalTrials.gov as #NCT00740545 and the French National Health and Drug Safety Agency (EudraCT #2006-003350-18).

HPV vaccination coverage in French girls attending middle and high schools: a declarative cross sectional study in the department of Côte d'Or.

OBJECTIVES: To assess human papillomavirus prophylactic vaccine coverage among a representative population of French girls, aged 14 years and above, attending middle and high schools, and to determine factors associated with the initiation and completion of the vaccination protocol. STUDY DESIGN: This cross-sectional study, designed with cluster sampling, was conducted from October 2010 to May 2011, in 29 schools in the department of Côte d'Or, France. The schools were randomized according to their status (public or private) and location (rural or urban). Two classes per level were then included. All analyses were stratified on age. RESULTS: 948 questionnaires were collected (87.9% participation). Mean age was 15.2 years (SD=1.3), ranging between 14 and 19. Only 31.7% of 14-year-old girls and 61.4% of girls aged 15 and above initiated vaccination (one dose), and 7.8% of 14-year-old girls and 48.5% of girls aged 15 and above completed it (three doses). An urban school location and a physician's recommendation were independently associated with vaccination initiation in girls aged 14. In girls aged 15 and above, the parents' socioeconomic status, the family composition and a recommendation by a physician were independently associated with vaccination initiation. Once vaccination had been initiated, girls who attended private school, who belonged to families with higher outcomes, who lived with a single parent or who smoked were less likely to complete the vaccination protocol. CONCLUSION: HPV prophylactic vaccine coverage in girls attending school in Côte d'Or appears to be low. Physicians play a major role in vaccine acceptance.

Female urinary incontinence and intravaginal electrical stimulation: an observational prospective study.

OBJECTIVE: To assess the efficacy of intravaginal electrical stimulation in the management of female urinary incontinence. STUDY DESIGN: 359 Women with urinary incontinence (207 with stress incontinence [group A], 33 with urge incontinence [group B] and 119 with mixed urinary incontinence [group C]) were included in this multicenter prospective observational study. Patients were managed by home intravaginal electrical stimulation of the pelvic floor for 20-30 min per day, 5 days a week, for a period of 10 weeks. Identical clinical assessments were performed before and after pelvic floor rehabilitation, comprising a voiding diary and validated symptom and quality of life scores. RESULTS: Objective assessment demonstrated an overall cure rate of 63.5% (228/359): 65.7% (136/207) for group A, 57.6% (19/33) for group B, and 61.3% (73/119) for group C. The overall significant improvement rate was 15.6% (56/359): 14.6% (30/207) for group A, 24.2% (8/33) for group B and 15.1% (18/119) for group C. All domains of quality of life were significantly improved after pelvic floor muscle training (p<0.0001) with a patient satisfaction rate of 83.6%. Treatment was well tolerated with 1.4% (5/359) of patients describing pain at the highest stimulation intensities. No significant difference was observed between the various types of electrodes used (p<0.0001). CONCLUSION: The quantitative and qualitative efficacy in terms of social and psychological consequences and quality of life of home pelvic floor muscle training stimulators probably make this treatment modality one of the first-line treatments for female stress urinary incontinence.

Regression of high-grade cervical intraepithelial neoplasia with TG4001 targeted immunotherapy.

OBJECTIVE: We sought to evaluate the safety and efficacy of TG4001 in patients with human papillomavirus (HPV) 16-related cervical intraepithelial neoplasia (CIN) 2/3 at 6 and 12 months. STUDY DESIGN: In all, 21 patients with HPV 16-related CIN 2/3 received 3 weekly subcutaneous injections of TG4001. Regression of the CIN 2/3 lesion and the clearance of HPV 16 infection were monitored by cytology, colposcopy, and HPV DNA/messenger RNA (mRNA) detection. A clinical response was defined by no CIN 2/3 found on conization, or no conization performed because not suspected at cytology or colposcopy. RESULTS: Ten patients (48%) were evaluated as clinical responders at month 6. Nine patients experienced an improvement of their HPV 16 infection, by mRNA ± DNA eradication. HPV 16 mRNA clearance was associated with CIN 2/3 cytologic and colposcopic regression in 7 of 10 patients. At month 12, 7 of 8 patients without conization reported neither suspicion of CIN 2/3 relapse nor HPV 16 infection. The remaining patient was lost to follow-up. CONCLUSION: These promising data warrant further development of TG4001 in CIN 2/3 treatment.

Interest of uterine artery embolization with gelatin sponge particles prior to myomectomy for large and/or multiple fibroids.

PURPOSE: To evaluate the efficacy of pre-myomectomy uterine artery embolization with gelatin sponge particles to reduce operative blood loss and facilitate removal of fibroids. MATERIALS AND METHODS: This retrospective study included 33 women (mean age, 36 years; range, 24-45 years), of whom at least 18 wished to preserve fertility. They presented with at least one large myoma (mean diameter, 90 mm; range, 50-150 mm) and had undergone preoperative uterine artery embolization with resorbable gelatin sponge by unilateral femoral approach between December 2001 and November 2008. Clinical, radiological and surgical data were available for all patients. Mean haemoglobin levels before and after surgery were compared with Student's t-test. RESULTS: No complication or technical failure of embolization occurred. The myomectomies were performed during laparotomy (25 cases) or laparoscopy (8 cases). Dissection of fibroids was easier (mean, 3 per patient; range, 1-11), with a mean operating time of 108±50 min (range, 30-260 min). Bloodless surgery was the rule with a mean estimated peroperative blood loss of 147±249 mL (range, 0-800 mL). Mean pre-(12.9±1.3g/dL) and post-therapeutic (11.4±1.2g/dL) haemoglobin levels were not statistically different (p>0.05). There was no need for blood transfusion. None of the patients required hysterectomy. The mean duration of hospital stay was 7.5±1.3 days (range, 3-12 days). CONCLUSION: Preoperative uterine artery embolization is effective in reducing intraoperative blood loss and improves the chances of performing conservative surgery. It should be considered a useful adjunct to myomectomy in women at high hemorrhagic risk or who refuse blood transfusion.

Interest of using an underbuttocks drape with collection pouch for early diagnosis of postpartum hemorrhage.

BACKGROUND: Postpartum hemorrhage (PPH) is the principal cause of maternal death. Blood loss during delivery is often underestimated. The aim of this study was to evaluate the validity of using an underbuttocks collection pouch in the diagnosis of PPH. METHODS: The study included a prospective series of 122 patients, over a period of 6 months, from May to October 2008. Variations in levels of hemoglobin and hematocrit during the 48 h following the childbirth confirmed the diagnosis of PPH. The graduated underbuttocks pouch allowed us to evaluate blood loss. The diagnostic value of the pouch was analyzed. RESULTS: Mean age of the patients was 29.3 years. Mean pregnancy duration was 39.5 weeks of amenorrhea. Mean blood loss was 233.15 ml. Eighteen patients (14.7%) presented PPH and uterine arteries were embolized in two cases (1.6%). For a volume of 500 ml, the sensitivity of the pouch was 6.7%, and the specificity was 94.2%, The positive predictive value (PPV) was 66.7% and the negative predictive value (NPV) was 94.2%. For a threshold of 300 ml, sensitivity was 88.9%, specificity was 82.7%, the PPV was 47.0% and the NPV was 97.7%. CONCLUSION: The underbuttocks collection pouch is a simple, cheap and effective way to make an early objective diagnosis of PPH. It allows medical staff to implement appropriate therapy quickly thus avoiding risks due to delay. The diagnostic threshold to ensure optimal management remains to be determined.

Preoperative embolization or ligature of the uterine arteries in preparation for conservative uterine fibroma surgery.

OBJECTIVE: To compare the efficacy, feasibility and morbidity of two preparation techniques for conservative uterine myoma surgery: temporary embolization and temporary surgical ligature of the uterine arteries. DESIGN: Retrospective study. SETTING: Gynecological Surgery and Interventional Radiology departments, Centre Hospitalier Universitaire of Dijon, France. POPULATION: A total of 100 women undergoing myomectomy between 2000 and 2008. METHODS: Three groups were constituted: (1) no preparation (43 patients), (2) uterine artery embolization (UAE) (30 patients) and (3) temporary surgical ligature of the uterine arteries (SLUA) (27 patients). The choice of technique depended on the number, size and topography of the fibromas. MAIN OUTCOMES MEASURES: Quantification of peroperative blood loss, delta hemoglobin, complications, subsequent fertility. RESULTS: Blood loss and delta hemoglobin were both lower in group 2 (p = 0.026 and p = 0.0002) and in group 3 (p = 0.048 and p = 0.001), respectively, than in group 1. The two preparation techniques were efficient. SLUA increased the duration of the operation (p < 0.0001). Hospitalization was longer following UAE (p = 0.0001). The rate of complications was 16.3, 23.3 and 3.7%, and of synechiae 9.3, 13.3 and 0% for groups 1, 2 and 3, respectively. The number of pregnancies was 8, 5 and 6 after a mean postoperative period of 5.6, 4.3 and 3.9 years, respectively. CONCLUSION: Both UAE and SLUA for myomectomy are feasible, reproducible and effective techniques for reducing peroperative blood loss. Use of these techniques must be generalized in patients with a high risk of hemorrhage, but may be compatible with subsequent fertility.

Evaluation of pelvic posterior exenteration in the management of advanced-stage ovarian cancer.

PURPOSE: The main aim of this study was to show the interest of pelvic posterior exenteration to obtain complete resection of the tumor in case of invasion of the rectum by contiguity in advanced-stage ovarian cancer. The secondary aim was to determine the morbidity of this surgery. METHODS: It is a multicentric, retrospective study of a series of 41 patients, who underwent posterior pelvectomy for advanced-stage ovarian cancer, over a period of 18 years, from July 1989 to July 2007. RESULTS: The surgery resulted in macroscopically complete resection in 19 patients (46.34%), a residual tumor <2 cm in 19 patients (46.34%) and >2 cm in 3 patients (7.32%). In 34 patients (34/41), digestive continuity with satisfactory anal sphincter function was restored immediately or in the short term. The mean delay to the start of complementary treatment was 36 days. Median overall survival was 33 months. CONCLUSION: The main aim of surgery for ovarian peritoneal carcinomatosis is to obtain a complete resection. In the case of direct invasion of the rectum by contiguity, when there is no cleavage plane between the uterus and the rectum, pelvic posterior exenteration is an effective method to achieve this objective. Morbidity is relatively high, but acceptable given the poor prognosis of this disease, the improved survival after surgery, and improvements in post-operative quality of life and functions.

Hamman's syndrome associated with pharyngeal rupture occurring during childbirth.

Hamman's syndrome is the classical association of subcutaneous emphysema and pneumomediastinum, with or without pneumothorax. Its onset during the expulsive phase of childbirth is exceptional. We report here the first case associated with pharyngeal rupture at the level of the piriform sinus and describe the warning signs and the management by endoscopy.

Cesarean section in morbidly obese women: supra or subumbilical transverse incision?

The obstetrician is more and more frequently faced with the decision to perform a cesarean section in obese women. We describe a technique of supra or subumbilical transverse cesarean section (depending on the height of the projection of the upper edge of the pubic symphysis) specifically designed for morbidly obese women with a voluminous panniculus. We evaluated feasibility and associated morbidity in a retrospective descriptive series of 18 patients operated between 2003 and 2008. We assessed the quality of access to the lower uterine segment and facility to extract the fetus. The mean body mass index was 47.7 kg/m(2) (range 40.1-60.8). The incision was subumbilical in 13 women (72.2%) and supraumbilical in 27.7%. With this technique, the exposition, the section of the lower uterine segment, and extraction of the baby are simple. It can be easily generalized and quickly learnt.

Uterine necrosis following selective embolization for postpartum hemorrhage using absorbable material.

Embolization of the uterine arteries with resorbable material is an effective treatment for postpartum hemorrhage. Cases of uterine necrosis were already described but with non-resorbables particles. We report two exceptional cases of uterine necrosis with failure of conservative treatment following selective embolization with gelatine.

Acute voluntary intoxication with selective serotonin reuptake inhibitors during the third trimester of pregnancy: therapeutic management of mother and fetus.

Selective serotonin reuptake inhibitor (SSRI) antidepressants are preferred to tricyclics, because, for the same efficacy, they are better tolerated. The mechanisms of action are well understood. These drugs may be used during pregnancy. We present here the case of a voluntary intoxication with SSRI in the third trimester of pregnancy.