Association Between Endometriosis Phenotype and Preterm Birth in France.

Importance: Endometriosis is an inflammatory disease with a heterogeneous presentation that affects women of childbearing age. Given the limitations of previous retrospective studies, it is still unclear whether endometriosis has adverse implications for pregnancy outcomes. Objective: To evaluate the association between the presence of endometriosis and preterm birth and whether the risk varied according to the disease phenotype. Design, Setting, and Participants: This cohort study with exposed and unexposed groups was conducted in 7 maternity units in France from February 4, 2016, to June 28, 2018. Participants included women with singleton pregnancies who were followed up before 22 weeks' gestation along with their newborns delivered at or after 22 weeks' gestation. The final follow-up occurred in July 2019. Data were analyzed from October 7, 2020, to February 7, 2021. Exposures: Women in the endometriosis group had a documented history of endometriosis and were classified according to 3 endometriosis phenotypes: isolated superficial peritoneal endometriosis (SUP), ovarian endometrioma (OMA; potentially associated with SUP), and deep endometriosis (DE; potentially associated with SUP and OMA). Women in the control group did not have a history of clinical symptoms of endometriosis before their current pregnancy. Main Outcomes and Measures: The primary outcome was preterm birth between 22 weeks and 36 weeks 6 days of gestation. Association between endometriosis and the primary outcome was assessed through univariate and multivariate logistic regression analyses and was adjusted for the following risk factors associated with preterm birth: maternal age, body mass index (calculated as weight in kilograms divided by height in meters squared) before pregnancy, country of birth, parity, previous cesarean delivery, history of myomectomy and hysteroscopy, and preterm birth. The same analysis was performed according to the 3 endometriosis phenotypes (SUP, OMA, and DE). Results: Of the 1351 study participants (mean [SD] age, 32.9 [5.0] years) who had a singleton delivery after 22 weeks of gestation, 470 were assigned to the endometriosis group (48 had SUP [10.2%], 83 had OMA [17.7%], and 339 had DE [72.1%]) and 881 were assigned to the control group. No difference was observed in the rate of preterm deliveries before 37 weeks 0 days of gestation between the endometriosis and control groups (34 of 470 [7.2%] vs 53 of 881 [6.0%]; P = .38). After adjusting for confounding factors, endometriosis was not associated with preterm birth before 37 weeks' gestation (adjusted odds ratio, 1.07; 95% CI, 0.64-1.77). The results were comparable for the different disease phenotypes (SUP: 6.2% [3 of 48]; OMA: 7.2% [6 of 83]; and DE: 7.4% [25 of 339]; P = .84). Conclusions and Relevance: This cohort study found no association between endometriosis and preterm birth, and the disease phenotype did not appear to alter the result. Monitoring the pregnancy beyond the normal protocols or changing management strategies for women with endometriosis may not be warranted to prevent preterm birth.

Analgesia Nociception Index-Guided Remifentanil versus Standard Care during Propofol Anesthesia: A Randomized Controlled Trial.

The clinical benefits to be expected from intraoperative nociception monitors are currently under investigation. Among these devices, the Analgesia Nociception-Index (ANI) has shown promising results under sevoflurane anesthesia. Our study investigated ANI-guided remifentanil administration under propofol anesthesia. We hypothesized that ANI guidance would result in reduced remifentanil consumption compared with standard management. This prospective, randomized, controlled, single-blinded, bi-centric study included women undergoing elective gynecologic surgery under target-controlled infusion of propofol and remifentanil. Patients were randomly assigned to an ANI or Standard group. In the ANI group, remifentanil target concentration was adjusted by 0.5 ng mL-1 steps every 5 min according to the ANI value. In the Standard group, remifentanil was managed according to standard practice. Our primary objective was to compare remifentanil consumption between the groups. Our secondary objectives were to compare the quality of anesthesia, postoperative analgesia and the incidence of chronic pain. Eighty patients were included. Remifentanil consumption was lower in the ANI group: 4.4 (3.3; 5.7) vs. 5.8 (4.9; 7.1) µg kg-1 h-1 (difference = -1.4 (95% CI, -2.6 to -0.2), p = 0.0026). Propofol consumption was not different between the groups. Postoperative pain scores were low in both groups. There was no difference in morphine consumption 24 h after surgery. The proportion of patients reporting pain 3 months after surgery was 18.8% in the ANI group and 30.8% in the Standard group (difference = -12.0 (95% CI, -32.2 to 9.2)). ANI guidance resulted in lower remifentanil consumption compared with standard practice under propofol anesthesia. There was no difference in short- or long-term postoperative analgesia.

Use of Low-Thrombin Fibrin Sealant Glue After Axillary Lymphadenectomy for Breast Cancer to Reduce Hospital Length and Seroma.

BACKGROUND: Axillary lymphadenectomy for primary breast cancer produces a non-negligible rate of postoperative lymphorrhea, prolonged hospital stays, and multiple seroma punctures. We evaluated the impact of low-thrombin fibrin sealant glue on surgical wounds in patients undergoing axillary lymph node dissection for breast cancer. METHODS: We conducted an observational study of 149 patients who underwent axillary lymphadenectomy for primary breast cancer between January 2014 and December 2015. Data were obtained from 2 successive prospective studies. The hospital stay length and morbidity (seromas, punctures) were compared between 2 groups: patients who had padding sutures and low-thrombin fibrin sealant glue without drainage (n = 49) and patients with drainage alone (n = 100). Hospital costs were assessed from the hospital perspective. RESULTS: The mean hospital stay length was shorter in the fibrin sealant group (2.6 vs. 4.7 days; P < .001). Seroma magnitude and punctures were similar in patients treated with fibrin sealant compared with patients with drainage alone. The rate of needle aspiration for seroma was similar irrespective of whether or not a drain or fibrin sealant was used (30.6% vs. 33.0%, P = .77). CONCLUSION: Low-thrombin fibrin sealant glue does not significantly reduce the amount of fluid produced in the axilla after breast surgery; however, its systematic use may help reduce hospital stays and costs.

Long-term symptoms, quality of life, and fertility after colorectal resection for endometriosis: extended analysis of a randomized controlled trial comparing laparoscopically assisted to open surgery.

BACKGROUND: To evaluate the long-term symptoms, quality of life (QOL), and fertility after colorectal resection for endometriosis. METHODS: Extended analysis of a randomized controlled trial including 52 patients with colorectal endometriosis, comparing laparoscopically assisted to open colorectal resection. All included patients were invited to complete questionnaires evaluating the presence and intensity of symptoms and QOL using the SF-36 and fertility at a mean (SD) follow-up of 50.7 (13.8) months. We compared symptoms intensity and QOL before and after surgery at short- (mean follow-up of 19 months) and long-term (mean follow-up of 51 months). RESULTS: Persistent improvement in QOL was noted after surgery without differences between short and long term. Self-catheterization >6 months was the sole factor decreasing the long-term QOL (P = 0.02). No difference in symptoms and QOL was noted according to the route. Among the 28 patients (53.8%) wishing to conceive, 12 (42.9%) conceived within a mean (SD) time of 17 (13) months. No difference in fertility including pregnancy after IVF was noted between the routes, but spontaneous pregnancy occurred only after laparoscopy (P = 0.016). CONCLUSIONS: Symptoms and QOL improvements after colorectal resection last for over 4 years without difference between the routes. Thank to a lower intra- and postoperative complications and higher spontaneous pregnancy rate, laparoscopic colorectal resection should be the first surgical approach.

Hormonal prevention of breast cancer.

Breast cancer prevention can be provided by using SERMs or aromatase inhibitors depending on the ovarian status, with a global risk reduction of 50 to 60%. Prophylactic annexectomy offered to reduce ovarian risk in BRCA mutation carriers also lowers breast cancer risk by 50%. Main side effects include deep vein thrombosis for SERMs, hot flushes and joint pain (although less frequently than initially suspected) with aromatase inhibitors. Other strategies based on progesterone, insulin or prolactin signaling modulation may be offered in the future. Criteria for candidate selection remain to be established.

Consequences of emergency contraceptives: the adverse effects.

INTRODUCTION: Emergency contraception (EC) offers women an important strategy to prevent unintended pregnancy following intercourse. Despite the constant improvement of availability of different molecules and techniques already existing (Yuzpe regimen, levonorgestrel, intrauterine device) and the emergence of ulipristal acetate, the numbers of unintended pregnancies and unplanned births could still be reduced. AREAS COVERED: This review will evaluate all the information about the potential adverse effects and tolerability of each method of EC by putting them in balance with their safety and effectiveness. A literature search until December 2013 was performed to identify all trials studying the safety data available concerning EC. EXPERT OPINION: Different means of EC have been demonstrated to be generally safe and well tolerated. These data support women information in order to improve use and efficacy of EC.

Surgical and clinical impact of extraserosal pelvic fascia removal in segmental colorectal resection for endometriosis.

STUDY OBJECTIVE: To describe the characteristics of patients with colorectal endometriosis and extraserosal pelvic fascia (EPF) involvement and to assess the effect of EPF resection. DESIGN: Prospective cohort study (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS: Two hundred twenty-seven patients who underwent segmental colorectal resection to treat symptomatic deep infiltrating endometriosis between 2001 and 2011, with or without EPF resection. INTERVENTIONS: Segmental colorectal resection with or without EPF resection. MEASUREMENTS AND MAIN RESULTS: One hundred twelve patients (49.4%) required EPF resection. In these patients the total American Society for Reproductive Medicine endometriosis scores were higher (p = .004), there were more associated resected lesions of deep infiltrating endometriosis (p <.001), and the operative time was longer (p <.001). They were more likely to require blood transfusion (p = .003) and to experience intraoperative complications (p = .01) and postoperative voiding dysfunction (p = .04). CONCLUSION: EPF infiltration reflects disease severity in patients with colorectal endometriosis. Its removal affects intraoperative morbidity and leads to a higher rate of voiding dysfunction.

Role of protective defunctioning stoma in colorectal resection for endometriosis.

STUDY OBJECTIVE: To evaluate the role of protective defunctioning stoma (PDS) on the occurrence of digestive tract complications after colorectal resection to treat endometriosis. DESIGN: Prospective cohort study (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS: All patients undergoing segmental colorectal resection to treat colorectal endometriosis with and without PDS between 2003 and 2011 at Tenon University Hospital, Paris, France. MEASUREMENTS AND MAIN RESULTS: Patients were assessed at 1, 6, and 12 months postoperatively and each year thereafter. Median follow-up was 60 months. Of 198 patients included for analysis, 53 (27%) had PDS. Overall, 15 (7.5%) digestive tract complications occurred: 9 (4.5%) rectovaginal fistulas and 6 (3%) anastomotic leakages. All rectovaginal fistulas occurred in patients with a low colorectal anastomosis (p < .001) and 88% (8 of 9) in patients with a partial colpectomy (p < .001). PDS was associated with a decrease in the number of rectovaginal fistulas in women undergoing partial colpectomy and low colorectal resection from 27% to 15%, without reaching significance (p = .4). No anastomotic leakage occurred in patients with PDS. CONCLUSION: Our results support that PDS can be omitted in patients with mid-colorectal anastomosis without partial colpectomy. In patients requiring partial colpectomy or partial colpectomy plus low colorectal anastomosis, PDS remains questionable.