Simulation of surfactant transport during the rheological relaxation of two-dimensional dry foams.

We describe a numerical model to predict the rheology of two-dimensional dry foams. The model accurately describes soap film curvature and viscous friction with the walls, and includes the transport of surfactant within the films and across the vertices where films meet. It accommodates the changes in foam topology that occur when a foam flows and, in particular, accurately represents the relaxation of the foam following a topological change. The model is validated against experimental data, allowing the prediction of elastic and viscous parameters associated with different surfactant solutions.

Anatomic distribution of endometriosis: A reappraisal based on series of 1101 patients.

OBJECTIVE: To reappraise the anatomic distribution of endometriosis lesions in cases with Superficial Implants (SI), Ovarian Endometrioma (OMA) and Deep Infiltrating Endometriosis (DIE). MATERIALS AND METHODS: A prospective observational study was operated between January 1989 to June 2009. A total of 1333 consecutive patients with a laparoscopic diagnosis of endometriosis, were extracted from our database. Due to missing data or repeated operations, 232 patients were excluded from the study. Finally, 1101 patients who met the selected criteria were included in the present analysis.. Primary outcome of study was the anatomic location of endometriotic lesions. Secondary outcomes were laterality of lesions as well as location of adhesions. RESULTS: Mean age of patients was 33.06 years (range 15-63 years) while the mean BMI was 21.5. The ovary was the most frequent site of endometriotic lesions (737 patients, 66.94%) followed by the utero-sacral ligaments (USL) (45.51%), the ovarian fossa (32.15%), the pouch of Douglas (29.52%) and the bladder (21.25%). Deep Infiltrating Endometriosis (DIE) was diagnosed in 159 patients (14.4%) with an increasing rate starting from the mid-nineties. The left side was predominant for all locations except fromr ovarian SI and fallopian tube, but for this latter location the number of cases was limited. 600 (54.4%) patients had adhesions wjth the adnexa being the most frequent site of location (47.4%). CONCLUSIONS: Ovary was the main site of endometriotic lesions followed by the utero sacral ligaments. Left side was predominant for all locations except for ovarian SI and fallopian tube. The diagnosis of DIE has constantly being increased since mid-nineties. The large cohort of patients included in the study has strengthened previous reported data.

Clinical presentation of endometriosis identified at interval laparoscopic tubal sterilization: Prospective series of 465 cases.

OBJECTIVES: Women seeking sterilization are usually parous and have no major complains, such as pelvic pain. This could be a good model to indirectly assess the prevalence of endometriosis in the general population. Prevalence of endometriosis in women undergoing tubal sterilization by laparoscopy has been assessed in 17 published reports. Results indicate a surprising wide variation of prevalence of endometriosis, ranging from 1.4% to 43.3%. This clinical study describes the prevalence and clinical presentations of endometriosis identified at interval laparoscopic tubal sterilization, as a close representation of endometriosis in general population. MATERIAL AND METHODS: From July 1989 to February 2009, 465 women undergone interval laparoscopic tubal sterilization and were included in this series. Surgery was realised in a non universitary centre of gynecologic surgery. All patients were operated on by the same surgeon. A complete assessement of pelvic organs was achieved with a particular attention paid for endometriotic lesions. Endometriosis when present was staged according to r-AFS classification. Biopsies were sent for pathological examination to assess endometriosis. RESULTS: Mean age of women was 40.7 years (range 15-49 years). 20 women were nulliparous and 12 others had a past history of endometriosis. Endometriosis was visually identified in 55 patients (11.82%), and confirmed by histologic examination in most of cases (50/55: 90.9%). The mean age of women presenting endometriosis at the onset of tubal ligation was 41.27 years. Cases with endometriosis were classified according to the r-AFS. 39,7,8 and 1 cases corresponded to stages I, II, III and IV respectively. In the 20 nulliparous women, the prevalence of endometriosis was 20% (4/20). At the time of laparoscopic sterilization, 91 women presented a painfull condition (dysmenorrhea mainly or dyspareunia). Endometriosis was identified in 16 of them (17.58%). In the group of 360 asymptomatic parous women, the prevalence of endometriosis was 10% (36/360). Nulliparity, associated pelvic pain and retroverted uterus were associated with increased prevalence of endometriosis, without being significant. CONCLUSION: In our study, the prevalence of endometriosis identified at interval laparoscopic tubal sterilization was 11.82%. In parous asymptomatic women, the prevalence of endometriosis was 10%. The prevalence of endometriosis was slightly increased in nulliparous women, when pain was associated and in women with a retroverted uterus.

[MINIMAL AND MILD ENDOMETRIOSIS: WHICH IMPACT ON FERTILITY?]. / ENDOMÉTRIOSE MINIME ET LÉGÈRE: QUEL IMPACT SUR LA FERTILITÉ?

Minimal and mild endometriosis (stages I/II) is frequently identified in subfertile patients, especially in case of unexplained infertility. The impact of those lesions on fecundity is still debatted and they have been considered as paraphysiological by some experts. In addition, they are heterogenous with variable spread, biological activity, induced inflammation and, sometimes, the presence of associated mild adhesions. Stages I/II endometriosis are the most frequent endometriotic lesions encountered in subfertile women. Reduced oocyte quality, anti sperm effects and, possibly, endometrial disorders appear as the most pertinent mechanisms involved. Spontaneous fecundity of women with minimal or mild endometriosis is reduced when compared to fecundity of women whose infertility is unexplained. Intra-uterine insemination with controlled ovarian stimulation improves fecundity. Laparoscopic ablation of endometriotic lesions modestly improves fecundity. This procedure has thus been recommended in view of the very small increased surgical risk. IVF is the most efficient method allowing to obtain pregnancy, with slightly reduced or similar results when compared to the performances of IVF in case of tubal infertility.

[Iatrogenic endometriosis during reproductive age: main issues?]. / Les endométrioses iatrogènes de la femme avant la ménopause: principaux enjeux.

Among endometriotic lesions a small proportion is secondary to various medical activities, and may be considered as iatrogenic. Any medical or surgical procedure increasing the menstrual flow or the retrograde flow bears a potential risk: conization, hydrotubation or copper intra-uterine device. Surgical procedures, by laparotomy or laparoscopic approach, are able to favor transport and cutaneous seeding of endometrial tissue, especially when a hysterotomy has been performed. Diagnosis and treatment of these lesions are today standardized. Few preventive measures are available, besides adequate surgical procedure, but none has been properly evaluated, mainly because these lesions are not frequent.

[Postoperative abdominal adhesions and their prevention in gynaecological surgery: I. What should you know?]. / Adhérences postopératoires et leur prévention en chirurgie gynécologique : I. Ce qu'il faut savoir.

Adhesions are the most frequent complications of abdominopelvic surgery, causing important short- and long-term problems, including infertility, chronic pelvic pain and a lifetime risk of small bowel obstruction. They also complicate future surgery with increased morbidity and mortality risk. They pose serious quality of life issues for many patients with associated social and healthcare costs. Despite advances in surgical techniques, including laparoscopy, the healthcare burden of adhesion-related complications has not changed in recent years. Adhesiolysis remains the main treatment although adhesions reform in many patients. The extent of the problem of adhesions has been underestimated by surgeons and the health authorities. There is rising evidence however that surgeons can take important steps to reduce the impact of adhesions. As well as improvements in surgical technique, developments in adhesion-reduction strategies and new agents offer a realistic possibility of reducing adhesion formation and improving outcomes for patients. This paper is the first of a two-part publication providing a comprehensive overview of the evidence on adhesions to allow gynaecological surgeons to be best informed on adhesions, their development, impact on patients, health systems and surgical outcomes. In the second paper we review the various strategies to reduce the impact of adhesions and improve surgical outcomes to assist fellow surgeons in France to consider the adoption of adhesion reduction strategies in their own practice.

[Postoperative abdominal adhesions and their prevention in gynaecological surgery: II. How can they be prevented?]. / Adhérences postopératoires et leur prévention en chirurgie gynécologique : II. Comment les prévenir ?

This paper is the second of a two-part publication. The initial paper provided a comprehensive overview of the evidence on adhesions to allow gynaecological surgeons to be best informed on adhesions, their development, impact on patients, health systems and surgical outcomes. There is rising evidence that surgeons can take important steps to reduce the burden of adhesions. In this second paper, we review the various strategies to reduce the impact of adhesions, improve surgical outcomes and provide some practical proposals for action on adhesions. As well as improvements in surgical technique, developments in adhesion-reduction strategies and new agents offer a realistic possibility of reducing adhesion formation and improving outcomes for patients. They should be considered for use particularly in high-risk surgery and in patients with adhesiogenic conditions. Further research into new strategies to prevent adhesions more effectively through an improved surgical environment, new and combination devices and pharmacological agents should be encouraged. Formal recommendations would ensure better prioritisation of adhesion-reduction within the French health system. Patients should also be better informed of the risks of adhesions.

[Forgetting hormonal contraceptive methods: expert opinion about their daily management in clinical routine practice]. / Oublis de la contraception hormonale : réflexions sur leur prise en charge en pratique quotidienne.

Many guidelines regarding the daily management of regular oral hormonal contraceptive methods have been proposed worldwide. Some of them may even appear to be conflicting. The search for the maximal contraceptive protection leads to a low acceptance of these guidelines, probably because of their complexity and their apparent discrepancy. We are deeply convinced that simplicity and pragmatism of guidelines should pave the way to both their better acceptance and compliance and, consequently, to their improved real-life effectiveness. We have considered physiology and pharmacodynamics before proposing the following rules for an effective management of hormonal contraceptive failures. We conclude that the risk of unwanted pregnancy is higher in case of a unique contraception misuse/a delayed start during the first week of the contraceptive cycle (or in case of multiple days of contraceptive misuses during the following weeks) for a combined contraception or at every cycle day for a non anti-ovulatory progestin only contraception. In such risky situations, we firmly recommend the restart of the regular contraceptive method and the use of condoms for the following 72 hours, provided no sexual intercourse has occurred during the past 5 days before the contraceptive failure. If sexual intercourse has occurred during the past 5 days before the contraceptive failure, we firmly recommend the intake of an emergency contraception, ulipristal acetate, the restart the regular contraceptive method and in this case, the use of condoms for, at least, the following 7 days.

Gynaecological endoscopic evaluation of 4% icodextrin solution: a European, multicentre, double-blind, randomized study of the efficacy and safety in the reduction of de novo adhesions after laparoscopic gynaecological surgery.

BACKGROUND: Gynaecological laparoscopic surgery outcomes can be compromised by the formation of de novo adhesions. This randomized, double-blind study was designed to assess the efficacy and safety of 4% icodextrin solution (Adept(®)) in the reduction of de novo adhesion incidence compared to lactated Ringer's solution (LRS). METHODS: Patients undergoing laparoscopic surgery for removal of myomas or endometriotic cysts were treated with randomized solution as an intra-operative irrigant and 1l post-operative instillate. De novo adhesion incidence (number of sites with adhesions), severity and extent were independently scored at a second-look procedure and the efficacy of the two solutions compared. The effect of surgical covariates on adhesion formation was also investigated. Initial exploratory analysis of individual anatomical sites of clinical importance was progressed. RESULTS Of 498 patients randomized, 330 were evaluable (160 LRS--75% myomectomy/25% endometriotic cysts; 170 Adept--79% myomectomy/21% endometriotic cysts). At study completion, 76.2% LRS and 77.6% Adept had ≥ 1 de novo adhesion. The mean (SD) number of de novo adhesions was 2.58 (2.11) for Adept and 2.58 (2.38) for LRS. The treatment effect difference was not significant (P = 0.909). Assessment of surgical covariates identified significant influences on the mean number of de novo adhesions regardless of treatment, including surgery duration (P = 0.048), blood loss in myomectomy patients (P = 0.019), length of uterine incision in myomectomy patients (P < 0.001) and number of suture knots (P < 0.001). There were 15 adverse events considered treatment-related in the LRS patients (7.2%) and 18 in the Adept group (8.3%). Of 17 reported serious adverse events (9 LRS; 8 Adept) none were considered treatment-related. CONCLUSIONS: The study confirmed the safety of Adept in laparoscopic surgery. The proportion of patients with de novo adhesion formation was considerably higher than previous literature suggested. Overall there was no evidence of a clinical effect but various surgical covariates including surgery duration, blood loss, number and size of incisions, suturing and number of knots were found to influence de novo adhesion formation. The study provides direction for future research into adhesion reduction strategies in site specific surgery.

[Endometriosis coaching]. / Le coaching de l'endométriose.

Coaching is a well-known terminology and an approach currently used, particularly in the worlds of company management and sport, but its use in the medical field appeared only recently. In the latter field, coaching bears behavioral and psychological aspects. It can not only be intended to a medical team, but also the practionner himself, for a better management of any disease, his patient for a better treatment effect and compliance and an optimal coping with the disease. In the case of endometriosis, a chronic disease, two key aspects are briefly reviewed to illustrate the benefits of coaching and to sensitize health providers to this approach. Thus, an appropriate diagnostic strategy should allow to reduce the delay in the diagnosis, so frequently blamed, and to identify other associated painful diseases. Also, management should be improved as well, not only by applying appropriate therapeutic recommandations, and alternative measures, but also by a better multidisciplinary support towards patient expectations with long-term guidance.

[Ovarian endometrioma and infertility: when not to treat?]. / Endométriome ovarien associé à une infertilité: quelle est la place de l'abstention thérapeutique?

Ovarian endometrioma is not infrequently encountered in infertile patients. Its etiopathogeny, its relations with attributed symptoms and the recommanded treatment to apply, are still debated. Various therapeutic tools are available, such as abstention, ultrasonographically guided aspiration and drainage, and surgery. Each option carries specific advantages and disadvantages. Ultrasonographically guided aspiration bears infectious risks. Among various proposed surgical procedures, cystectomy appears to offer the best performances. Results of IVF are slightly or not altered, neither by an ovarian endometrioma, nor by previous surgery, except in case of iterative surgery or if operated lesions were very severe. Laparoscopic surgery is still the first line treatment in many cases. Abstention can be applied in particular circumstances. Ultrasonographically guided aspiration needs to be further evaluated.

[Women with endometriosis: are they different from others?]. / La femme endométriosique est-elle différente?

The objective of this short review is to identify the particularities of women with endometriosis, especially those complaining of pain and with the most severe lesions. Genetic aberrations play, with a high probability, a major role in the development of this disease, its severity, its tendency to recur and also in its capacity to degenerate. The abnormalities of the endometrium, with exacerbated biological activities, are an example. The woman with endometriosis seems more sensitive to pain through various mechanisms, such as central hypersensitivity and decrease threshold to somatoceptive pain and several associated psychological disorders. Endometriosis is often associated with other painful conditions such as irritable bowel syndrome, interstitial cystitis and fibromyalgia. Finally, also appears also to have a higher risk to develop non Hodgkin's lymphoma or ovarian cancer. These particularities, some of them being still speculative or controversial, should be known in routine practise, in order to offer a better multidisciplinary management, not only for short term, but also long term issues.

[Diaphragmatic hernia in a rare complication of oesophagectomy for cancer]. / Caractéristiques des hernies diaphragmatiques après oesophagectomie pour cancer.

INTRODUCTION: Diaphragmatic hernia is a rare complication of oesophagectomy for cancer. We report a series of seven patients to determine characteristics of this entity. PATIENTS AND METHODS: Seven patients (six male and one female, 61 to 68 years old) were operated on for diaphragmatic hernia following oesophagectomy for carcinoma (adenocarcinoma N =4, squamous-cell carcinoma N =3). Oesophagectomy had been performed through abdominal transhiatal approach in four patients and transthoracically in three, with hiatal enlargement in all cases. RESULTS: Three patients, all symptomatic, underwent emergency surgery within two years following oesophagectomy. Of the four patients operated between two and seven years after oesophagectomy, two were symptomatic. Presence of symptoms were neither related with technique of oesophagectomy, nor to type of hiatal enlargement (anterior, or by crura division). All patients with hernia containing small bowel were symptomatic. All patients were operated through abdominal approach. Hernia contained colon three times, small bowel once, and both three times. Hernia reduction needed additional phrenotomy in six patients. Two patients underwent colectomy to treat peroperative colonic ischemia. Diaphragmatic hiatus was calibrated around the gastric tube by direct suture in six patients or with absorbable mesh in one. There was no death. No recurrences occurred with a follow up ranging from one to five years. CONCLUSION: The diaphragmatic hernia after oesophagectomy is due to excessive hiatal enlargement. Hernias occurring early after oesophagectomy are badly tolerated and need urgent reoperation. To prevent this complication of oesophagectomy, we advocate calibration of diaphragmatic hiatus fit to width of gastroplasty.

Clinical evaluation of a viscoelastic gel for reduction of adhesions following gynaecological surgery by laparoscopy in Europe.

BACKGROUND: Commonly used adhesion prevention devices either cannot be applied or are difficult to use via laparoscopy. A viscoelastic gel was developed specifically for adhesion prophylaxis during minimally invasive surgery. METHODS: Randomized, third party-blinded, parallel-group design conducted at four centres. Patients (18-46 years old) underwent laparoscopic surgery with second look 6-10 weeks later. Viscoelastic gel coated adnexa and adjacent tissues. Blinded reviews of videotapes were quantified by American Fertility Society (AFS) adhesion scores. RESULTS: In 25 treatment patients, surgery was performed on 45 adnexa. Coverage of surgical sites at risk for adhesions was typically accomplished with approximately 15 ml of viscoelastic gel which was delivered in approximately 90 s. In 24 control patients, surgery alone was performed on 41 adnexa. Treated adnexa showed a decrease in AFS score (11.9-9.1). In contrast, control adnexa showed an increase in AFS score (8.8-15.8). This difference in second-look AFS scores (42% reduction) is significant (P<0.01). Ninety-three per cent of treated adnexa did not have a worse adhesion score in contrast to 56% of control adnexa. Combining scores into prognostic categories also show significant treatment effect of the viscoelastic gel (P<0.01). CONCLUSION: Viscoelastic gel was easy to use via laparoscopy and produced significant reduction in adnexal adhesions. It provides benefits to patients undergoing gynaecological surgery.

Prospective clinical trial of SprayGel as a barrier to adhesion formation: an interim analysis.

STUDY OBJECTIVE: To evaluate SprayGel, a new sprayable adhesion barrier developed for laparoscopic and open pelvic and abdominal surgical procedures. DESIGN: Prospective, randomized, controlled, multicenter trial (Canadian Task Force classification I). SETTING: University clinic and private clinic. PATIENTS: Forty-five women, 24 randomized to treatment and 21 to control group. INTERVENTIONS: Open or laparoscopic myomectomy with and without application of SprayGel, followed by second-look laparoscopy (SLL) to evaluate postoperative adhesions. MEASUREMENTS AND MAIN RESULTS: Application of SprayGel was fast and easy. On average, 10 weeks after surgery, 18 treated patients (75%) and 13 (61.9%) controls had SLL. That procedure showed 5 (27.8%) of 18 treatment patients to be adhesion free versus 1 (7.7%) of 13 controls (p = 0.163). Patients randomized to SprayGel were 3.6 times more likely to be adhesion free than controls. Mean tenacity scores were significantly lower than in controls (0.5 vs. 1.7), a difference of 0.9 (95% CI 0.3, 1.5, p = 0.003) or 47% (95% CI 17%, 77%) less. Mean adhesion area was reduced in the treatment group (4.1 vs. 5.6) but not significant (p = 0.6747, 95% CI-5.4, 8.4). No adverse events regarding application of SprayGel were seen. CONCLUSION: SprayGel was effective in reducing postoperative adhesion severity, and showed a trend toward reducing frequency and extent of adhesions after laparoscopic and open myomectomy. Further studies are necessary to confirm the promising results of this interim analysis.

New adhesion prevention concept in gynecological surgery.

Postsurgical adhesion formation is a common but significant problem. This is the first clinical evaluation of a new barrier material designed to reduce or eliminate postsurgical adhesions. SprayGel can be delivered laparoscopically or via laparotomy to form a strongly adherent hydrogel film. In this multicenter study, we evaluated the safety and effectiveness of SprayGel absorbable adhesion barrier system in patients undergoing open or laparoscopic myomectomy procedures. Here, we discuss the results of our evaluation conducted at the University of Kiel and Polyclinic of Bordeaux, and assess some of the features of this novel adjunct to prevent formation of postsurgical adhesions.

[Physiopathology, diagnosis and therapeutic management of stage III and IV endometriosis]. / Endométriose stade III et IV: implications physiopathologiques, cliniques et thérapeutiques.

Stage III endometriosis is defined by a r-AFS score respectively ranging from 16 to 40 and stage IV over 40. Deep pelvic endometriosis presents essentially in the form of a painful syndrome dominated by chronic pelvic painful, dysmenorrhea and deep dyspareunia. Pathophysiology of pelvic pain associated with endometriosis remains unknown. In the literature, correlation between extension of the endometriosis and severity of the painful remains controversies. Contraception by levonorgestrel-releasing intra-uterine systems appears to decrease pain related to deeply infiltrating endometriosis. Surgery by laparoscopy remains the first intention treatment when infertility is associated with endometriosis, whereas medical treatment is only palliative in the majority of cases. Success of treatment depends on how radical surgical exeresis is. Spontaneous pregnancy rates are significantly increased after surgical treatment. Recurrent ovarian surgery is not recommended in women with infertility, as it might be deleterious for ovarian reserve. Medical treatment using Gn-RH agonists is indicated when recurrence occurs after surgery.

[Radiation-induced esophageal carcinoma: report of 11 cases]. / Cancers radio-induits de l'oesophage: à propos de 11 cas.

STUDY AIM: Radiation-induced oesophageal carcinoma can occur several years after mediastinal irradiation. The aim of this study was to report 11 cases of this rare entity with analysis of its diagnostic, therapeutic and prognostic special features. PATIENTS AND METHODS: From 1983 to 2001, 10 female and one male patients, aged 47 to 76 years, were treated for an oesophageal squamous cell carcinoma which was diagnosed 5 to 25 years after mediastinal irradiation. This irradiation (30 to 78 Gy) was administered in 8 women for breast carcinoma and in other patients for lymphoma. Only one patient had alcoholic consumption and 2 were smokers. An oesophagectomy was performed whenever possible. RESULTS: All (but one) oesophageal tumors were symptomatic. Ten patients underwent an oesophagectomy, including 2 without thoracotomy. Postoperative course was uneventful in 6 cases, 3 patients developed transient respiratory failure and one patient died postoperatively. At late follow-up, 6 patients developed distant metastases (mainly hepatic and pulmonary). These metastases were associated with mediastinal recurrences in 2 cases. No isolated mediastinal recurrence occurred. Median survival was 13 months. CONCLUSION: Clinical presentation and surgical treatment of radiation-induced oesophageal carcinoma are similar to those of other oesophageal squamous cell carcinomas. After oesophagectomy, isolated mediastinal recurrences seem to be rarer than with other cancers. These cancers, which are almost all symptomatic, have a poor prognosis.

Changes in haemostasis after laparoscopic surgery in gynaecology: contribution of the thrombin generation test.

Surgery induces immediate hypercoagulability by direct alteration of the vascular bed, release of procoagulant substances from the extravascular spaces and blood flow decrease, and delayed hypercoagulation in response to tissue damage which triggers inflammatory responses. Thus, the postoperative period represents a high-risk time for thrombosis. Recognition of high-risk individuals would make it possible to improve thromboembolism prevention. We studied in women undergoing laparoscopic surgery a series of markers known to be related to the thrombotic risk and confronted their results with those of a global test, the thrombin generation test (TGT) described by Hemker's group. Our results show that two groups of patients can be distinguished according to usual risk markers (PAI-1, TAT, body mass index): the higher risk group demonstrates higher initial TGT values, but also a postoperative decrease of the TGT values whose mechanisms remain to be defined.