"A Space Odyssey" on Laparoscopic Segmental Rectosigmoid Resection for Deep Endometriosis: A Seventeen-year Retrospective Analysis of Outcomes and Postoperative Complications among 3050 Patients Treated in a Referral Center.

STUDY OBJECTIVE: To evaluate the feasibility of laparoscopic rectosigmoid resection for bowel endometriosis (RSE), reporting surgical and short-term postoperative outcomes in a consecutive large series of patients. DESIGN: A retrospective cohort study. SETTING: Third-level national referral center for deep endometriosis (DE). PATIENTS: 3050 patients with symptomatic RSE requiring surgical treatment. INTERVENTIONS: Nerve-sparing laparoscopic resection for RSE perfomed by a multidisciplinary team. After collecting intraoperative surgical characteristics, postoperative complications were collected by evaluating the risk factors associated with their onset. MEASUREMENTS AND MAIN RESULTS: Clavien-Dindo IIIb postoperative complications were noted in 13.1% of patients, with anastomotic leakage and rectovaginal fistula accounting for 3.0% and 1.9%, respectively. Postoperative bladder impairment was observed in 13.9% of patients during hospital discharge but spontaneously decreased to 4.5% at the first evaluation after 30 days, alongside a statistically significant change towards global symptom improvement. Multivariate analyses were done to identify the risk factors for segmental bowel resection in terms of occurrence of postoperative major complications. Ultralow (≤5 cm from the anal verge), low rectal anastomosis (<8 cm, >5 cm), parametrectomy, vaginal resection, and previous surgeries seemed more related to anastomotic leakage, rectovaginal fistula, and bladder retention. CONCLUSIONS: Laparoscopic rectosigmoid resection for RSE seems an effective and feasible procedure. The surgical complication rate is not negligible but could be reduced by implementing a multidisciplinary approach, an endless improvement in nerve-sparing techniques and surgical anatomy, as well as technological enhancements. Real future challenges will be to reduce the time for the first diagnosis of DE and the likelihood of surgical indications.

Heat can treat: long-term follow-up results after uterine-sparing treatment of adenomyosis with radiofrequency thermal ablation in 60 hysterectomy candidate patients.

BACKGROUND: Adenomyosis may induce pelvic pain, abnormal uterine bleeding or bulk symptoms. If hormonal treatment proves ineffective or contraindicated, hysterectomy may be necessary. For patients who desire to conserve the uterus despite severe symptomatology, uterine-sparing techniques have been introduced. Radiofrequency thermal ablation (RFA) consists of the local application of high temperature to eliminate diseased tissue, applied recently for adenomyosis treatment. The objective of the study was to analyze the efficacy of RFA for avoiding hysterectomy in patients with adenomyosis-related symptoms. METHODS: This is a single-center, retrospective cohort study performed in a referral center for endometriosis. The study population consisted of all consecutive patients who underwent Radiofrequency thermal ablation (RFA) treatment as an alternative to hysterectomy for adenomyosis between March 2011 and June 2019 in our institution. RFA was performed using laparoscopic access. To evaluate the impact of RFA treatment on symptoms, follow-up findings were compared to preoperative symptomatology using the ten-point visual analog scale (VAS) for pain assessment. RESULTS: Sixty patients were included in the study, 39 of them (65%), underwent a concomitant surgery for endometriosis in association to RFA. On a long-term follow-up (mean 56 months (range 10-115, SD 29), hysterectomy was performed in 8 patients (13%). The mean VAS score before vs after surgery was 7.4 vs 3.3 for dysmenorrhea, 3.7 vs 0.3 for dyschezia, 4.7 vs 0.7 for dyspareunia, and 4.0 vs 1.4 for chronic pelvic pain, being significantly reduced after RFA for all these pain components (p < 0.0001 in every case). Thirty-one patients (52%) suffered from AUB before RFA, this symptom persisted in 10 patients (16%) during follow-up (p < 0.001). Bulk symptoms were present in 16 patients (27%) and disappeared after RFA in all cases. CONCLUSIONS: RFA allows for hysterectomy avoidance in most cases. It leads to marked improvements in pain symptomatology, uterine bleeding and bulk symptoms.

Dienogest vs GnRH agonists as postoperative therapy after laparoscopic eradication of deep infiltrating endometriosis with bowel and parametrial surgery: a randomized controlled trial.

BACKGROUND: The recurrence of deep infiltrating endometriosis (DIE) after its surgical excision is a big problem: postoperative treatment is crucial. OBJECTIVE: To compare two postoperative treatments: Dienogest and GnRH agonists. DESIGN: Prospective Randomized Controlled Trial (RCT). PATIENTS: 146 women submitted to laparoscopic eradication of DIE with bowel and parametrial surgery. INTERVENTIONS: Patients were randomized into two groups. Group A (n = 81) received Triptorelin or Leuprorelin 3.75 mg every 4 weeks for 6 months. Group B (n = 65) received Dienogest 2 mg/day for at least 6 months. A first interview made after six months valued compliance to therapy, treatment tolerability, pain improvement, and side effects. A second interview at 30 ± 6 months valued pain relapse, imaging relapse, and pregnancy rate. MAIN OUTCOMES: The primary outcome was to demonstrate the non-inferiority of Dienogest about the reduction in pain recurrence. Secondary outcomes were differences in terms of treatment tolerability, side effects, imaging relapse rate, and pregnancy rate. RESULTS: Both Dienogest and GnRH agonists were associated with a highly significant reduction of pain at 6 and 30 months, without any significant difference (p < .001). About treatment tolerability, a more satisfactory profile was reported with Dienogest (p = .026). No difference in terms of clinical relapse, imaging relapse, and live births was found. CONCLUSIONS: Dienogest has proven to be as effective as GnRH agonists in preventing recurrence of DIE and associated pelvic pain after surgery. Also, it is better tolerated by patients.

Bizarreness in dream reports and waking fantasies of psychotic schizophrenic and manic patients: empirical evidences and theoretical consequences.

Several overlapping features have frequently been described between psychosis and the subjective experience of dreaming from the neurobiological to the phenomenological level, but whether this similarity reflects the cognitive organization of schizophrenic thought or rather that of psychotic mentation independent of diagnostic categories is still unclear. In this study, 40 actively psychotic inpatients were equally divided in two age- and education-matched groups according to their diagnosis (Schizophrenia and Bipolar Disorder). Participants were asked to report their dreams upon awakening and the Thematic Apperception Test (TAT) was administered to elicit waking fantasies; the same procedure was used in a control group of 20 non-psychiatric subjects. Two highly trained judges scored the collected material according to a Dream Bizarreness scale. The same level of cognitive bizarreness was found in TAT and dream reports of schizophrenic and manic subjects but was almost completely absent in the TAT stories of the control group. Two-way analysis of variance for repeated measures assessed the effect of diagnosis and experimental conditions (TAT stories and dream reports) on bizarreness yielding a significant interaction. Cognitive bizarreness seems to be a shared feature of dreaming and psychotic mentation, beyond diagnostic categorizations. Although these findings must be considered preliminary, this experimental measure of the cognitive architecture of thought processes seems to support the view that dreaming could be a useful model for the psychoses.

The dreaming brain/mind, consciousness and psychosis.

Several independent lines of research in neurobiology seem to support the phenomenologically-grounded view of the dreaming brain/mind as a useful model for psychosis. Hallucinatory phenomena and thought disorders found in psychosis share several peculiarities with dreaming, where internally generated, vivid sensorimotor imagery along with often heightened and incongruous emotion are paired with a decrease in ego functions which ultimately leads to a severe impairment in reality testing. Contemporary conceptualizations of severe mental disorders view psychosis as one psychopathological dimension that may be found across several diagnostic categories. Some experimental data have shown cognitive bizarreness to be equally elevated in dreams and in the waking cognition of acutely psychotic subjects and in patients treated with pro-dopaminergic drugs, independent of the underlying disorder. Further studies into the neurofunctional underpinnings of both conditions will help to clarify the use and validity of this model.

Cognitive bizarreness in the dream and waking mentation of nonpsychotic patients with Parkinson's disease.

Cognitive bizarreness is a shared feature of the dream and waking mentation of acutely psychotic patients. The authors investigated this measure of the structural architecture of thought in the dream and waking mentation of 20 nonpsychotic patients with Parkinson's disease after treatment with prodopaminergic drugs. Statistically overlapping levels of cognitive bizarreness were found in the waking fantasy and dream reports of the Parkinson's disease population, whereas almost no bizarreness was found in the waking cognition of the comparison group, suggesting it may be an inherent quality of cognition in Parkinson's disease patients, possibly related to the cholinergic/dopaminergic imbalance underlying this complex disorder.

The dream as a model for psychosis: an experimental approach using bizarreness as a cognitive marker.

Many previous observers have reported some qualitative similarities between the normal mental state of dreaming and the abnormal mental state of psychosis. Recent psychological, tomographic, electrophysiological, and neurochemical data appear to confirm the functional similarities between these 2 states. In this study, the hypothesis of the dreaming brain as a neurobiological model for psychosis was tested by focusing on cognitive bizarreness, a distinctive property of the dreaming mental state defined by discontinuities and incongruities in the dream plot, thoughts, and feelings. Cognitive bizarreness was measured in written reports of dreams and in verbal reports of waking fantasies in 30 schizophrenics and 30 normal controls. Seven pictures of the Thematic Apperception Test (TAT) were administered as a stimulus to elicit waking fantasies, and all participating subjects were asked to record their dreams upon awakening. A total of 420 waking fantasies plus 244 dream reports were collected to quantify the bizarreness features in the dream and waking state of both subject groups. Two-way analysis of covariance for repeated measures showed that cognitive bizarreness was significantly lower in the TAT stories of normal subjects than in those of schizophrenics and in the dream reports of both groups. The differences between the 2 groups indicated that, under experimental conditions, the waking cognition of schizophrenic subjects shares a common degree of formal cognitive bizarreness with the dream reports of both normal controls and schizophrenics. Though very preliminary, these results support the hypothesis that the dreaming brain could be a useful experimental model for psychosis.