Biomedical subjects
Publications and source records attributed to L Boubli.
The complications in a series of 699 hysteroscopic resections are presented. These include 10 perforations, 8 métabolic syndromes, 1 endometritis et 2 haemorrhages. The incidents are rare, but can have serious consequences.
OBJECTIVES: To study retrospectively the long-term outcome after hysteroscopic treatment for intrauterine fibromas. METHODS: From October 1987 to January 1993, endouterine glycolol resection was performed in 239 patients with intrauterine fibromas. The operation had to be repeated in 39 patients due to incomplete resection or recurrent symptomatology. Patients presented with menometrorrhage, post-menopausal metrorrhage or infertility. RESULTS: Intra-operative complications were rare, mainly uterine perforations (7 cases) or metabolic syndromes due to reabsorption of glycine (5 cases). Mean follow-up was 2.5 years. The couple was sterile in 16 cases and 4 pregnancies were obtained (25%). Postmenopausal metrorrhage was present in 27 patients and the symptomatology disappeared in 24 (89%). In all, 196 women consulted for bleeding, good results were achieved in 81.1%. CONCLUSION: Endouterine resection is a sure, effective and long-lasting treatment for intrauterine fibromas.
Pelvic adhesions may be responsible for pelvic pain, at least partially, in the following conditions: sequelae of past infection, chronic active inflammatory state, endometriosis, post-operative adhesions. The problem in the presence of adhesions is to determine whether pain is mechanical, inflammatory and/or linked to associated ovarian dystrophy, and what is the psychological component. The postulate "adhesion = pain" is far from constant and there is no systematic relationship between clinical picture and anatomical findings. After careful clinical and laboratory evaluation, celioscopy is the key diagnostic procedure. It should include thorough examination of all pelvic organs, of the abdomen in general and the peri-hepatic region in particular. A diagnosis of psychosomatic pain can be made only in the absence of any macroscopic, histological and bacteriological lesion, though bearing in mind that this term certainly covers failure to recognise other causes.
In patients with locally advanced cervical cancer, most of the treatment failures occur within the pelvis. In an attempt to improve local control, 40 patients with bulky tumors (stage IB > 5 cm, stage IIB with distal parametrial invasion, and stage III-IVA) were treated between 1988 and 1992 with concurrent chemoradiation (CCR). The whole pelvis received a midplane dose of 45 Gy over 33 days. Daily radiation dose was 1.8 Gy, with twice-daily fractionation in the last 20 patients. Chemotherapy was administered on the 1st and 21st days of radiation therapy (RT) consisting of cisplatin (60 mg/m2), followed by 5-fluorouracil (600 mg/m2/day continuous i.v. infusion) over 96 hr (and decreased to 40 and 400 mg/m2, respectively, in the last 23 patients). CCR was first followed by a single intracavitary application and then by a parametrial boost in stage IIB-III patients and in stage IVA patients with disease reaching the pelvis side wall. Then surgery (colpohysterectomy with lymphadenectomy or pelvic exenteration) was performed in 35 patients. Median follow-up time was 2.6 years (0.6-5.6 years). Acute toxicity (WHO grade 3-4 diarrhea) in 13 patients led to 6 RT interruptions and 4 incomplete RTs. One patient died of a septic episode without leukopenia after completion of CCR. Five postexenteration complications required a second surgical procedure, of which one patient died with tumor and small bowel fistula. One patient developed small bowel late complication and another patient developed urinary late complications. No postoperative or late complications were observed in patients treated with twice-daily fractionation. Pelvic control was achieved in 32 of 40 patients (81 and 74% in stage IB-IIB and stage III-IVA, respectively). Sites of failure were the pelvis (6 cases), metastases (7 cases), and both (2 cases). Two-year survival and DFS rates were 61 and 66%, respectively, in stage IB-IIB and 77 and 65% in stage III-IVA. High SCC-TA4 values significantly worsened DFS rates. In patients with stage III-IVA tumors, additional surgery could be an important component of this treatment strategy and may be compatible with CCR using twice-daily fractionation radiotherapy. However, these results must be confirmed by a large-scale prospective study.
This paper reports a retrospective multi-institutional French survey carried out in 1992 to determine the incidence of laparoscopic management of malignant ovarian cysts. Of 5307 ovarian lesions treated endoscopically, 78 were malignant (1.47%) including 60 borderline tumors and 18 ovarian cancers. In 33% of cases preoperative diagnosis indicated that the tumor was benign. Preoperative findings were suspicious in 59%. Laparoscopic treatment was puncture in 23% of cases, partial exeresis in 51% and total removal in 26%.
Pregnancy related hypertension is the primary cause of perinatal mortality and morbidity. Its incidence is of the order of 10%. Serious forms, which account for 10% of all cases of pre-eclamptic toxemia, remain a potential cause of maternal mortality and morbidity. Retroplacental hematoma, neurological problems dominated by eclampsia, coagulation disorders, Hellp syndrome, and hepatic, pulmonary, cardiac and renal problems are the essential complications of this pathology. They are described separately here, but are often associated. These potential complications require the careful evaluation of the severity of materno-fetal status. The management of these patients requires cooperation between the anesthetist/intensive care specialist, obstetrician and pediatrician. Such teamwork results in appropriate management for each individual patient. The various types of treatment are reviewed. Maternal and fetal mortality and morbidity could nevertheless be reduced by the early and careful management of high-risk patients, in particular by the prescription of low doses of aspirin and by careful clinical, ultrasound and velocimetric monitoring.
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We report 2 cases of malignant ovarian tumours. These tumours had been missed at a first laparoscopic examination, and a second examination detected the presence of cancer cells disseminated in the peritoneum and the abdominal wall. The risk of propagation of an overlooked cancer makes it necessary to carry out a preoperative thorough evaluation based on clinical and ultrasonographic data before any attempt at laparoscopic surgery. If a laparoscopic treatment is decided, it must be performed under strict conditions and include meticulous exploration of the abdominal cavity, systematic peritoneal cytology, needle cytology of the cyst, emptying of the cyst in a water-tight manner, extemporaneous biopsy in case of doubt, peritoneal cleansing, and extraction of the cyst or the ovary in a bag. If malignancy is suspected, laparotomy must be performed immediately.
The repertoire of immunoglobulin expressed very early in human development was approached by cloning and sequencing 55 rearranged and 11 germ-line VH transcripts, after amplification by polymerase chain reaction of cDNA libraries derived from two fetal livers at 8 and 13 weeks of gestation. All families with the exception of VH2, were expressed as soon as 8 weeks, with preferential usage of certain germ-line genes. Very few somatic mutations, randomly localized, were identified. By contrast, in a series of clones derived from the same VDJ rearrangement using the VH6 family, extensive mutations had taken place, mostly accumulated in the third complementarity-determining region (CDR3) suggesting that the specialized enzymatic machinery was at hand very early during human development. Some other characteristics of the fetal repertoire also emerged, namely increased usage of JH3 and JH2, as compared to the adult pattern, where JH4 is dominant and reduced length of the D/CDR3 regions. All D gene families were identified, and their usage frequently involved D-D fusions. N diversity was present very early, and increased with age. Identification of germ-line transcripts pertaining to all six VH families including pseudogenes, in the E55 library, revealed a population very different as compared to rearranged gene transcripts. This suggests that a large portion of VH locus is accessible for transcription, bringing no evidence of correlation between preferential rearrangement of a given VH gene and its localization in the locus.
We report MRI of the brain in 45 fetuses; the findings were confirmed by pathological examination or postnatal neuroradiological studies. MRI necessitates medication to eliminate fetal motion; curare was injected into the umbilical cord, and MRI is therefore limited to cases in which umbilical cord puncture is indicated. T1-weighted images were obtained in axial, sagittal and coronal planes; the last of these were generally as the most useful as regards morphology. We demonstrated cerebral malformations (n = 13), brain haemorrhage (n = 1), a facial angioma (n = 1), a facial mass (n = 1), hydrocephalus (n = 5), unilateral ventricular enlargement (n = 1), atrophy (n = 4), a porencephalic cyst (n = 1) and normal appearances of the brain in 18 cases. Twenty-two of the fetuses were born alive, and the clinical and/or neuroradiological examination confirmed the antenatal findings. The diagnosis was also confirmed in 8 cases in which a neuropathological examination was possible.
We found magnetic resonance imaging (MRI) of the fetal brain to be effective in confirming or denying diagnosis of fetal cerebral defects when ultrasonography was inconclusive or incomplete. In this paper we describe 31 cases in which ultrasonographic evidence of fetal brain defects was verified by MRI. MRI was performed after curarization of the fetus. In 21 cases, ultrasonographic evidence was confirmed by histological study of the fetus or postnatal radiological examination. In 10 cases, ultrasonographic diagnosis was denied by MRI and healthy infants were born. In one case of cerebral toxoplasmosis, ultrasonography detected periventricular calcifications but MRI was normal. In 20 cases MRI ascertained or further documented the ultrasonographic findings. However in 4 of these 20 cases autopsy of the fetus was required to determine the exact nature of the lesion.
This study was carried out to assess the relations between plasma glycine concentrations and the biochemical changes occurring during intra-uterine resections (IUR) under glycine irrigation. Sixty patients with benign uterine conditions were included. They were all ranked ASA 1 or 2. The biological parameters were assessed before surgery (T0), at the end of surgery (T1) and 60 min afterwards (T2). They included the blood count and blood concentrations of sodium, potassium, chloride, proteins, bicarbonates, glucose, urea nitrogen, creatinine and glycine. Plasma osmolarity was calculated. The irrigation of the uterine cavity resulted in an increase of glycine concentrations (28% of cases), and a decrease of sodium (22% of cases), proteins and haematocrit (32% of cases). Mean osmolarity remained unchanged. Blood glycine concentrations were directly correlated with the volume of irrigating solution, as well as with the duration of surgery. Protidaemia was inversely related to the blood glycine concentration. Multiparous patients had lower glycine concentrations than nulliparous patients. This was probably due to the uterine cavity being less compliant in the latter. On the other hand, there was no correlation with the uterine pathological condition. In this series, five cases of uterine perforation occurred with very large biological variations, especially a decrease in haematocrit and osmolarity. In these cases a clinical and biological water intoxication syndrome may occur as a result of large volumes of irrigating fluid passing into the peritoneal cavity.
The knowledge of ocular growth during fetal life, when compared with other fetal biometric parameters, could not only provide a better definition of malformation syndromes but could also give a better understanding of certain pathological processes in premature babies and in newborns. As the literature concerning prenatal ocular dimensions contains few data, the aim of this study was to measure the axial length of the globe (AL) in fetuses and compare this measurement with their gestational age, weight, height, head circumference (HC) and thoracic circumference (TC) in order to compile a reference table. In the present study, 76 globes from 38 fetuses (18-41 weeks gestational age) from the Department of Pathology (Timone University Hospital, Marseille) were examined. Ultrasonography A and B were used to measure the AL, and a pathological examination determined fetal weight, HC, TC and height. We were interested to find out which of the parameters studied would give the best correlation with ocular growth. Statistical analysis showed that HC remained the most discriminant factor and correlated best with ocular growth. We thus obtained an equation for ocular size according to HC that could serve as a basis for detecting pre- or postnatal ocular defects.
In a previous study, we showed that the growth of the eye during fetal development compared with the other parameters of the fetus was above all connected to the head circumference, which appeared to be the most discriminant measurement. In a second study, we measured the growth of the orbit of the fetus in order to compare it with the growth of the globe and the cranial circumference. Another 60 eyeballs of 30 fetuses of 18-41 weeks gestational age were examined. The corneal diameter (CD) of the cornea was a measurement added to those used in the method in the previous study, and orbital radiography was carried out: the parameters used were the same as in the previous study measured in relation to the CD, orbital diameter (OD) and the biparietal diameter (BPD). The aim of this study was to show the links between the variations in the measurements and to estimate them in relation to fetal growth. The results confirm those of the previous study, and this study also shows that, in estimating the head circumference, the OD and CD are the most accurate indicators. This study was also concerned with the BPD: the best correlation is obtained with the OD, which can be estimated accordingly from the BPD. Although the OD is not in an area studied by ultrasonography (highly dependent on the sectional plane), this study shows that it should perhaps be reconsidered in the prenatal diagnosis of orbital malformation. It would then be necessary to take into account not only the BPD but also the relationship between the OD and the BPD.
The pelvis is a major site of failure in patients with advanced carcinoma of the cervix. Attempting to improve local disease control, 40 patients were treated between February 1988 and July 1992 with concurrent chemoradiation (CCR). Thirty three patients (group A) with bulky cervical tumors (> 5 cm) received this CCR as the first part of their treatment (stages IB: 4; IIB with distal parametrial involvement: 14; IV: 15). CCR was followed by brachytherapy and a parametrial boost if indicated, then by surgery. CCR was also given, as a postoperative treatment, in seven patients (group B) with a bulky nodal involvement on a previous hysterectomy with lymphadenectomy performed for an early stage. CCR was a pelvic radiation therapy (RT): 45 Gy/25 F/33 d (two fractions per day in the last 14 patients) and a chemotherapy delivering: CDDP 60 mg/m2 on days 1 and 21, followed by 5-FU 600 mg/m2 i.v. continuous infusion for 96 hours (respectively 40 and 400 mg/m2 in the 16 last patients). Median follow-up is 35 months (range 10-63 m). Acute toxicities were grade 3-4 diarrhea in 16 patients and another patient died from a septic episode without leucopenia after CCR. Five post-operative complications required a second surgical procedure. Among these five patients, one died and two other developed small bowel late complications. No post-operative or late complication were observed in patients treated with a bi-fractionated RT. Sites of failure were: pelvic: four; metastases: five, both: three. Thirty months survival and DFS rates were 67.5% and 58.4% in the whole series and respectively 64% and 52.5% in stages IB-IIB patients and 63% and 59% in stage IV patients. Surgery is an important factor of the treatment and a CCR with a bi-fractionated RT allows such a surgical procedure. These encouraging results must be confirmed by a prospective study to determine whether a CCR is able to improve local control and survival.
It has been possible to consider how delivery should be carried out in view of the progress that has been made handling scarred uteruses. Over 21 months 41 tests of uterine function have been authorized in our department out of 67 cases where there were two scars in the uterus (67%). 26 patients delivered vaginally (63.4%) and 5 had Caesarean sections because of failure of the test of the scar. When the relationship between the fetus and the pelvis was satisfactory, the fact that the cervix was not ripe and the presenting part was not engaged, did not prevent carrying out a trial of scar in 78% of cases. It is important to assess conditions continuously during labour and this assessment should include fetal heart monitoring, internal tokometry, fetal pH assessment and ultrasound of the scar at the onset of labour. Oxytocics had to be used in 96.2% of cases because there was at the outset marked dynamic dystocia. Epidural anaesthesia was used in 90.2% of cases. A full obstetric team must be present throughout the whole labour so that the conduct of the labour can be observed, and if necessary corrected quickly if anything in its progress is becoming abnormal. It has become reasonable to carry out tests of uterine scars even after two scars have been made in the uterus because of the absence of any maternal or fetal complications in this series or in the literature.