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INTRODUCTION: Several policy and cultural factors still hinder the development of ambulatory surgery (AS) in France. Our surgery unit developed a day-surgery approach with extension of a non-medicalized post-operative stay in a hotel-like structure within the hospital, called an "ambulotel". The present study aims to evaluate the potential of this approach in increasing the possibilities of ambulatory surgery by comparing our stays to those of a nationwide database. PATIENTS AND METHODS: We matched 66 patients according to seven criteria in our one-day ambulotel program to the 2011 DRG national database and then compared their characteristics. RESULTS: Of the 10,428 patients in the database with one-night stays in a traditional surgery unit, more than half (52%) would probably have been eligible for ambulatory surgery with a potential theoretical savings estimated at €12,806,568. CONCLUSION: This estimated amount of savings represents a major medical and economic issue. The savings could contribute to increased ambulatory surgery activity in France by creating new dedicated Ambulatory Units, pooling conventional beds, or using night accommodation in non-hospital nursing homes, for example.

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INTRODUCTION: Nowadays, in France, development of the ambulatory surgery has stalled. This is probably related to the fact that ambulatory surgery is restricted by the law to the "day surgery" in 12 hours, and only 17 procedures are referenced for this surgery. Thus, conventional hospitalization remained the rule after surgery. In January 2010, our university general surgery unit was restructured. It evolved from a conventional unit to a predominantly ambulatory unit. Otherwise, our unit adjoins a hotel, even inside our institution, which accommodates patients, patient visitors and tourists. AIM: The aim of this retrospective study was to compare the postoperative accommodation modalities between two groups of patients. The first group consisted of patients admitted before January 2010, at the time of conventional activity, whereas the second group consisted of patients admitted after January 2010 in a restructured unit. METHODS: Inclusion of patients admitted from April 1, 2008 to March 31, 2009 (conventional hospitalization period) and from April 1, 2010 to March 31, 2011 (ambulatory management period), scheduled for one single surgical procedure excluding emergency. RESULTS: A total of 360 patients were retained: 229 for the conventional period and 131 for the ambulatory period, with a median age of 55 (range 15-87). No statistically significant difference was noted between the two groups as concerned median age, gender or ASA status. The number of postoperative nights varied significantly between the two groups with a mean of 3.8 nights (median three nights, range 0-32) for the conventional period versus 0.4 nights (median 0 night, range 0-10) for the ambulatory period (P<0.0001 by the unadjusted Mann-Whitney test and P<0.0001 by the Wald test [with adjustment]). DISCUSSION: Our results show that it is clearly possible to distinguish the need for care of the need for accommodation and significantly reduce postoperative conventional accommodation. They also raise the question of extending the legal period of 12 hours to 24 hours in order to expand the list of the referenced procedures.

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BACKGROUND: Gonadotropins administration have been demonstrated effective for the treatment of idiopathic male infertility, even if no clear data regarding their specific mechanism of action on semen quality are at the moment available. AIM: To evaluate the effect of highly purified FSH (hpFSH) administration on standard semen parameters, sperm oxidative stress, and sperm chromatin structure and DNA fragmentation. MATERIAL AND METHODS: In the current prospective baseline-controlled study, 36 subjects with male idiophatic infertility were enrolled. Baseline clinical and biochemical data were evaluated. Before and after 3 months of treatment with hpFSH, sperm samples were collected and standard semen analysis, reactive oxygen species (ROS) assessment and sperm DNA fragmentation were evaluated. RESULTS: A significant (p<0.05) improvement from baseline in standard seminal parameters was observed. A significant (p<0.05) reduction in sperm ROS levels and DNA fragmentation was observed. Statistically significant (p<0.05) correlations between variation in ROS levels and both seminal parameters and DNA fragmentation variations were detected. CONCLUSIONS: Three months of hpFSH administration seems to reduce ROS and DNA damage in subjects with male idiopathic subfertility improving semen parameters. Further evidences from well-designed randomized double-blind placebo- controlled studies are needed in order to confirm our preliminary results.

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OBJECTIVE: To compare the pregnancy outcome in patients undergoing in vitro fertilization-embryo transfer (IVF-ET) cycles, using human derived follicle-stimulating hormone (FSH) or recombinant FSH for ovarian stimulation protocols. DESIGN: Prospective, multi-centre, randomized controlled trial. PATIENTS: 115 infertile patients undergoing a first attempt of in vitro fertilization and embryo transfer were included in the study. The inclusion criteria were: female age < 37 years and use of GnRH agonist (GnRH-a) for pituitary downregulation. INTERVENTIONS: Long Protocol-controlled ovarian stimulation with human derived FSH or recombinant FSH for IVF-ET. MAIN OUTCOME MEASURES: Primary endpoints were implantation rate, clinical pregnancy rate and spontaneous abortion rate. Secondary end-points were total units of FSH injected, days of stimulation, peak estradiol levels at point of hCG administration, mean number of oocytes at pick-up, fertilization rate and cleavage rate. RESULTS: No statistically significantly differences in pregnancy outcomes were found in the patients receiving hFSH in comparison to patients receiving rFSH. CONCLUSIONS: This study did not demonstrate a difference between the use of h-FSH vs r-FSH for ovarian stimulation in terms of pregnancy outcome, in good prognosis patients undergoing their first IVF-ET procedure.

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BACKGROUND: In the present study, we report that D-aspartic acid (D-Asp) occurs in human ovarian follicular fluid and that a relationship may exist between the concentration of this amino acid and oocyte quality. METHODS: Samples of pre-ovulatory follicle fluid were obtained from 20 patients undergoing an IVF programme. The concentration of D-Asp was measured by using specific high-performance liquid chromatography (HPLC) combined with a d-aspartate oxidase. RESULTS: D-Asp occurs in human follicular fluid at a mean concentration of 14.98 +/- 4.51 nmol/ml. A significant difference in the content of this amino acid in the follicular fluid in relation to patient's age exists. In younger women aged 22-34 years (group A), D-Asp was found at a concentration of 19.11 +/- 1.91 nmol/ml, whereas in patients aged 35-40 years (group B), it decreased to 10.86 +/- 1.22 nmol/ml (P < 0.01). In addition, this amino acid was linked to oocyte quality; a relationship exists between D-Asp follicular concentration and the percentage of good quality metaphase II oocytes (P < 0.01), as well as the fertilization rate. CONCLUSIONS: In human follicular fluid, D-Asp is present at a relatively higher concentration in younger women than in older patients and there appears to be a relationship between the concentration of d-Asp and fertility outcome parameters. These findings suggest that follicular D-Asp concentration may be considered as an alternative or additional biochemical marker for oocyte quality in patients undergoing IVF programmes.

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Interleukin-10 (IL-10) can favour the development of fibrosis by promoting a relative shift towards T helper 2 responses. Three single base pair substitutions in the 5' flanking region of the IL-10 gene (G/A -1082, C/T -819 and C/A -592) influence the amount of IL-10 secreted in cell cultures: the GCC haplotype is associated with an increased production, while the ACC and the ATA haplotypes are associated with intermediate and decreased production. Accordingly, three phenotypes have been individuated: high producers (GCC+/GCC+), medium producers (GCC+/GCC-) and low producers (GCC-/GCC-). We hypothesised that IL-10 haplotypes and genotypes are differently expressed in patients with systemic sclerosis (SSc) with the limited cutaneous SSc (lcSSc) subset or the diffuse cutaneous SSc (dcSSc) subset. One hundred and sixty-one unrelated Italian patients with SSc and 94 controls have been included. Their DNA was extracted and stored before being analysed by polymerase chain reaction with sequence-specific primers. The GCC haplotype is overrepresented in patients with SSc; subjects with dcSSc were the primary contributors to these results (dcSSc: 52.2% vs controls: 37.2%; chi2= 8.519, 2 d.f., corrected P= 0.04). In Scl70-positive patients, the GCC haplotype increased the likelihood of presenting the dcSSc subset [chi2= 12.56, P < 0.0005; odds ratio (OR) = 3.89, 95% confidence interval (CI(95)) = 1.69-9.08]; these results were confirmed at the phenotypic level (chi2= 11.67, 2 d.f., P= 0.003). In Scl70-positive patients, the high-producing phenotype was associated with poor survival, independently from disease subset and gender (hazard ratio = 9.9, CI(95)= 1.6-61.27, P < 0.05). The IL-10 haplotype and genotype associated with high IL-10 production may alter the susceptibility to SSc and/or its expression, increasing the prognostic value of other well-known markers of disease severity.

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OBJECTIVE: To evaluate the feasibility of a bilateral multiple ovarian biopsy through minilaparoscopy under local anesthesia and conscious sedation and to assess the efficacy of this technique as compared to the traditional laparoscopic approach. STUDY DESIGN: Twenty-five infertile women with premature ovarian failure underwent bilateral ovarian biopsy plus chromoperturbation. Twelve patients were treated with minilaparoscopy (minilap group) and preoperatively received mepivacaine for subcutaneous local anesthesia and midazolam plus fentanyl for conscious sedation. Following minilaparoscopy, 40 mL of 0.5% intraperitoneal subdiaphragmatic lidocaine and 5 mL of ropivacaine, 7.5 mg/mL, for infiltration of the trocar insertion sites were administered. Thirteen women (control group) were treated with the traditional laparoscopic approach under general anesthesia. If necessary, ketoprofene or intramuscular ketorolac was administered following surgery. Postoperative pain score was evaluated by a 1-10 visual analogic scale immediately after surgery and in the following 24 hours; in addition, the quantity of ovarian biopsy material for the pathologist and the discharge and operative times were evaluated. RESULTS: The minilap group had lower postoperative pain scores postoperatively. Operative time was similar in both groups. The rate of discharge two hours after surgery was significantly higher in the minilap group. In all cases the amount of ovarian tissue was sufficient for diagnosis. Twenty-one patients were affected by premature menopause and four by resistant ovary syndrome. The need for postoperative analgesics was significantly higher in the control group. CONCLUSION: Minilap allows the performance of bilateral, multiple ovarian biopsy under local anesthesia and conscious sedation in association with chromoperturbation and the obtaining a sufficient amount of ovarian tissue for histopathologic diagnosis. Intraperitoneal lidocaine administration and ropivacaine infiltration of the trocar sites were beneficial for patients undergoing operative minilap in a day-surgery setting. The effect of these drugs was obviously temporary; however, low postoperative pain scores and low additional analgesic requirement permitted early discharge, within two hours after surgery.

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BACKGROUND: To evaluate the feasibility of ovarian drilling using minilaparoscopy under local anesthesia and to determine its efficacy in the surgical treatment of polycystic ovarian syndrome. METHODS: Prospective randomized study carried out in an out patient service on 62 women affected by PCOS divided into two groups: 32 patients (group A) underwent bilateral ovarian drilling by minilaparoscopy under local anesthesia and 30 patients (group B) underwent bilateral ovarian drilling by traditional laparoscopy under general anesthesia. RESULTS: Operation times were not different between the two groups. Discharge time was significantly lower in group A in comparison to group B. The rate of patients discharged after 2 hours was significantly higher in group A. The need for additional analgesia was lower in group A in comparison to group B. Serum LH, A and T levels were significantly reduced after surgery in both groups. Pregnancy rate after 1-year follow-up was higher, although not significantly in group A. Ovulation and abortion rates were not different between the two groups. CONCLUSIONS: Ovarian drilling in minilaparoscopy under local anesthesia is a new option for gynecologists, allowing similar therapeutical results to those achieved by traditional laparoscopy, but with the benefits of a less invasive technique that can be carried out in an outpatient service without the need for general anesthesia.

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STUDY OBJECTIVE: To evaluate the efficacy of intraperitoneal subdiaphragmatic instillation of 0.5% lidocaine and 0.5% bupivacaine infiltration of cannula sites to control pain after diagnostic microlaparoscopy. DESIGN: Prospective, randomized study. (Canadian Task Force classification I). SETTING: Day surgery unit of Endogyn Service, Private Endoscopic Associates, Naples, and Department of Gynecologic and Pediatric Sciences, Reggio Calabria University, Catanzaro, Italy. PATIENTS: Forty women treated for infertility. INTERVENTIONS: The treated group received 0.5% intraperitoneal subdiaphragmatic lidocaine 40 ml and 0.5% bupivacaine 5 ml infiltration of cannula insertion sites. The control group received no treatment. In all patients the procedure was performed with atropine 0.5 mg, fentanyl 0.1 mg, droperidol 5 mg, and local anesthesia. Postoperatively, depending on the need, ketoprofene 100 mg or ketorolac 30 mg was administered intramuscularly. MEASUREMENTS AND MAIN RESULTS: Postoperative pain score was evaluated by visual analog scale immediately postoperatively and 1, 3, 6, 12, 24, 36, and 48 hours afterward. The treated group had significantly lower pain scores at the end of surgery and at 1-, 3-, (p <0.01), and 6-hour intervals (p <0.05). No significant differences in scores between groups were observed starting from 6 hours postoperatively. CONCLUSION: Postoperative intraperitoneal lidocaine and bupivacaine infiltration of cannula sites offered a detectable benefit to women undergoing diagnostic microlaparoscopy. The effect was temporary, but induced a significant decrease in the postoperative pain for approximately 6 hours.

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