Inflammation and cancer: friend or foe?

Chronic inflammation plays a crucial role in the onset and progression of pathologies like neurodegenerative and cardiovascular diseases, diabetes, and cancer, since tumor development and chronic inflammation are linked, sharing common signaling pathways. At least 20% of breast and colorectal cancers are associated with chronic inflammation triggered by infections, irritants, or autoimmune diseases. Obesity, chronic inflammation, and cancer interconnection underscore the importance of population-based interventions in maintaining healthy body weight, to disrupt this axis. Given that the dietary inflammatory index is correlated with an increased risk of cancer, adopting an anti-inflammatory diet supplemented with nutraceuticals may be useful for cancer prevention. Natural products and their derivatives offer promising antitumor activity with favorable adverse effect profiles; however, the development of natural bioactive drugs is challenging due to their variability and complexity, requiring rigorous research processes. It has been shown that combining anti-inflammatory products, such as non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, and statins, with plant-derived products demonstrate clinical utility as accessible adjuvants to traditional therapeutic approaches, with known safety profiles. Pharmacological approaches targeting multiple proteins involved in inflammation and cancer pathogenesis emerge as a particularly promising option. Given the systemic and multifactorial nature of inflammation, comprehensive strategies are essential for long term success in cancer therapy. To gain insights into carcinogenic phenomena and discover diagnostic or clinically relevant biomarkers, is pivotal to understand genetic variability, environmental exposure, dietary habits, and TME composition, to establish therapeutic approaches based on molecular and genetic analysis. Furthermore, the use of endocannabinoid, cannabinoid, and prostamide-type compounds as potential therapeutic targets or biomarkers requires further investigation. This review aims to elucidate the role of specific etiological agents and mediators contributing to persistent inflammatory reactions in tumor development. It explores potential therapeutic strategies for cancer treatment, emphasizing the urgent need for cost-effective approaches to address cancer-associated inflammation.

Laparoscopic Cystectomy for a 20-Centimetre Ovarian Endometrioma in a Subfertile Patient: Α Case Report.

Large ovarian endometriomas may cause severe pressure symptoms and often require surgical management. The laparoscopic approach, although challenging, is feasible and safe when performed by surgeons with advanced minimal access skills, provided that certain rules are respected. We report a case of a 40-year-old, nulliparous patient with a history of endometriosis, low ovarian reserve, and subfertility who presented with a 20-cm left ovarian endometrioma and associated symptoms, managed successfully by laparoscopic cystectomy. Compared to non-excisional surgical methods, endometrioma cystectomy likely causes a more profound decline in post-operative ovarian reserve, which is particularly important in the context of subfertility. We discuss the technical aspects of this challenging procedure, potential alternative approaches, and clinical decision-making as to why cystectomy was preferred.

Management of a Large Endometriotic Nodule of the Right Parametrium Involving the Sacral Roots, Vagina, Rectum, and Sigmoid Colon, with Intraoperative Bleeding.

STUDY OBJECTIVE: Deep endometriotic lesions may involve the deep parametrium, which is highly vascular and includes numerous somatic and autonomous nerves [1,2]. Surgeons who dissect in this area must always be prepared to deal with major bleeding and to master the different techniques of hemostasis. The goal of this video is to show the steps of laparoscopic excision of deep endometriotic lesion of the parametrium and the steps taken to control the bleeding encountered from one of the venous branches. DESIGN: Surgical educational video. SETTING: Endometriosis referral center. INTERVENTIONS: Excision of the endometriotic parametrial nodule and the release of the sacral plexus, with excision of the vaginal involvement, rectal disc excision, and segmental resection of the sigmoid colon. The video shows the excision of a deep endometriosis involving the right parametrium, mid rectum, sigmoid colon, and vagina. The excision of deep endometriosis of the parametrium followed the 10 steps previously described [1]. During this procedure, careful dissection of arteries and veins branching from the internal iliac vessels is a crucial step. However, injury of one or more of the vessels can still occur. The video presents the different techniques used to control the bleeding from a venous injury faced during the dissection around the nodule in the parametrium, including energy use, clips, hem-o-loks, and direct continuous pressure. Of note, hemostatic agents are available; however, we have not yet successfully used them in the circumstances in which large veins were injured. The ultimate solution in our case was the clamping of the injured vessels, allowing meticulous dissection and sectioning of all the feeding vessels, while taking care not to injure the sacral roots that were just beneath these veins. Total operative time was 4 hours. CONCLUSION: Surgery of deep endometriosis involving the sacral plexus may be successfully done laparoscopically. Thorough knowledge of the deep pelvis anatomy is mandatory, and the surgeon should master various techniques of hemostasis, particularly on deep veins.

The role of immune checkpoints in antitumor response: a potential antitumor immunotherapy.

Immunotherapy aims to stimulate the immune system to inhibit tumor growth or prevent metastases. Tumor cells primarily employ altered expression of human leukocyte antigen (HLA) as a mechanism to avoid immune recognition and antitumor immune response. The antitumor immune response is primarily mediated by CD8+ cytotoxic T cells (CTLs) and natural killer (NK) cells, which plays a key role in the overall anti-tumor immune response. It is crucial to comprehend the molecular events occurring during the activation and subsequent regulation of these cell populations. The interaction between antigenic peptides presented on HLA-I molecules and the T-cell receptor (TCR) constitutes the initial signal required for T cell activation. Once activated, in physiologic circumstances, immune checkpoint expression by T cells suppress T cell effector functions when the antigen is removed, to ensures the maintenance of self-tolerance, immune homeostasis, and prevention of autoimmunity. However, in cancer, the overexpression of these molecules represents a common method through which tumor cells evade immune surveillance. Numerous therapeutic antibodies have been developed to inhibit immune checkpoints, demonstrating antitumor activity with fewer side effects compared to traditional chemotherapy. Nevertheless, it's worth noting that many immune checkpoint expressions occur after T cell activation and consequently, altered HLA expression on tumor cells could diminish the clinical efficacy of these antibodies. This review provides an in-depth exploration of immune checkpoint molecules, their corresponding blocking antibodies, and their clinical applications.

Laparoscopic Treatment of Benign Adnexal Masses During Pregnancy: A Comprehensive Evaluation of Treatment Basics, Efficacy and Surgical Techniques.

This review summarizes the evidence-based recommendations for how to approach and laparoscopically treat adnexal masses during pregnancy. We conducted a comprehensive review of studies related to the laparoscopic management of adnexal masses during pregnancy. Selected studies were independently reviewed by two authors. The overall incidence of ovarian tumors in pregnancy ranges between 0.05% and 5.7%, of which less than 5% are malignant. Diagnosis is based mainly on routine transvaginal ultrasound. More than 64% of simple cysts, less than 6 cm in diameter, will spontaneously resolve in less than 16 weeks. However, for persistent and complex tumors, the risk of acute complications can reach up to 9%. Surgical indications are similar to those in the non-gravidic setting, and include acute complications (torsion, rupture, hemorrhage), suspected malignancy and large (over 6 cm) persistent masses. Surgery must be scheduled between 16 and 20 weeks to allow for the spontaneous resolution of functional cysts. Furthermore, within that period, pregnancy becomes independent of the corpus luteum and enlargement of the uterus gives sufficient exposure for the surgery to be performed safely. A recent meta-analysis found that, compared to open surgery, laparoscopy is associated with significantly less preterm labor, blood loss and hospital stay, without differences in pregnancy loss or preterm birth rate. Since the main concerns about maternal-fetal safety are related to increased intraperitoneal pressure and the effects of hypercarbia (maternal hypertensive complications, fetal acidosis), a lower CO2 pressure (10 to 12 mmHg) and reduced operative times (less than 30 minutes) are recommended.

Designing a critical care solution using in-person and telemedicine approaches in the US-Mexico border area during COVID-19.

BACKGROUND: UC San Diego Health System (UCSDHS) is the largest academic medical center and integrated care network in US-Mexico border area of California contiguous to the Northern Baja region of Mexico. The COVID-19 pandemic compelled several UCSDHS and local communities to create awareness around best methods to promote regional health in this economically, socially, and politically important border area. PURPOSE: To improve understanding of optimal strategies to execute critical care collaborative programs between academic and community health centers facing public health emergencies during the COVID-19 pandemic, based on the experience of UCSDHS and several community hospitals (one US, two Mexican) in the US-Mexico border region. METHODS: After taking several preparatory steps, we developed a two-phase program that included 1) in-person activities to perform needs assessments, hands-on training and education, and morale building and 2) creation of a telemedicine-based (Tele-ICU) service for direct patient management and/or educational coaching experiences.Findings.A clinical and educational program between academic and community border hospitals was feasible, effective, and well received. CONCLUSION: We offer several policy-oriented recommendations steps for academic and community healthcare programs to build educational, collaborative partnerships to address COVID-19 and other cross-cultural, international public health emergencies.

An In-Person and Telemedicine "Hybrid" System to Improve Cross-Border Critical Care in COVID-19.

Background: UC San Diego Health System (UCSDHS) is an academic medical center and integrated care network in the US-Mexico border area of California contiguous to the Mexican Northern Baja region. The COVID-19 pandemic deeply influenced UCSDHS activities as new public health challenges increasingly related to high population density, cross-border traffic, economic disparities, and interconnectedness between cross-border communities, which accelerated development of clinical collaborations between UCSDHS and several border community hospitals - one in the US, two in Mexico - as high volumes of severely ill patients overwhelmed hospitals. Objective: We describe the development, implementation, feasibility, and acceptance of a novel critical care support program in three community hospitals along the US-Mexico border. Methods: We created and instituted a hybrid critical care program involving: 1) in-person activities to perform needs assessments of equipment and supplies and hands-on training and education, and 2) creation of a telemedicine-based (Tele-ICU) service for direct patient management and/or consultative, education-based experiences. We collected performance metrics surrounding adherence to evidence-based practices and staff perceptions of critical care delivery. Findings: In-person intervention phase identified and filled gaps in equipment and supplies, and Tele-ICU program promoted adherence to evidence-based practices and improved staff confidence in caring for critically ill COVID-19 patients at each hospital. Conclusion: A collaborative, hybrid critical care program across academic and community centers is feasible and effective to address cross-cultural public health emergencies.

Diaphragmatic endometriosis minimally invasive treatment: a feasible and effective approach.

The present review aims to analyse the current data available on the feasibility, safety and effectiveness of the minimally invasive surgical (MIS) treatment of diaphragmatic endometriosis (DE). Through the use of PubMed and Google Scholar database, we conducted a literature review of all available research related to diagnosis and treatment of DE, focussed on the minimally invasive techniques. The studies were selected independently by two authors according to the aim of this review. DE is an under-diagnosed disease affecting between 0.1% and 1.5% of fertile women. It is predominantly multiple, asymptomatic and highly associated with pelvic disease in about 50-90%. MIS techniques seems to be safe, effective and feasible in tertiary advanced endometriosis centre, offering definitive advantages in terms of hospital stay, post-operative pain and return to normal activity by using several surgical techniques as hydro-dissection plus resection, laser CO2 vaporisation, electrical fulguration, Sugarbaker peritonectomy, partial (shaving) and full-thickness diaphragmatic resection. Symptoms control range from 85% to 100%, with less than 3% of conversion, peri-operative complications and recurrence rate. All cases must be performed by multidisciplinary teams including at least a gynaecologist, thoracic surgeon and anaesthetist. The lack of prospective evaluation of DE interferes with the understanding about the natural history of disease and treatment results. Therefore, the development of adequate evidence-based recommendations about diagnosis, management and follow-up is difficult at this moment.

Peritoneal Retraction Pocket Defects and Their Important Relationship with Pelvic Pain and Endometriosis.

OBJECTIVE: The objective of this video is to demonstrate different clinical presentations of peritoneal defects (peritoneal retraction pockets) and their anatomic relationships with the pelvic innervation, justifying the occurrence of some neurologic symptoms in association with these diseases. DESIGN: Surgical demonstration of complete excision of different types of peritoneal retraction pockets and a comparison with a laparoscopic retroperitoneal cadaveric dissection of the pelvic innervation. SETTING: Private hospital in Curitiba, Paraná, Brazil. INTERVENTIONS: A pelvic peritoneal pocket is a retraction defect in the surface of the peritoneum of variable size and shapes [1]. The origin of defects in the pelvic peritoneum is still unknown [2]. It has been postulated that it is the result of peritoneal irritation or invasion by endometriosis, with resultant scarring and retraction of the peritoneum [3,4]. It has also been suggested that a retraction pocket may be a cause of endometriosis, where the disease presumably settles in a previously altered peritoneal surface [5]. These defects are shown in many studies to be associated with pelvic pain, dyspareunia, and secondary dysmenorrhea [1-4]. Some studies have shown that the excision of these peritoneal defect improves pain symptoms and quality of life [5]. It is important to recognize peritoneal pockets as a potential manifestation of endometriosis because in some cases, the only evidence of endometriosis may be the presence of these peritoneal defects [6]. In this video, we demonstrate different types of peritoneal pockets and their close relationship with pelvic anatomic structures. Case 1 is a 29-year-old woman, gravida 0, with severe dysmenorrhea and catamenial bowel symptoms (bowel distension and diarrhea/constipation) that were unresponsive to medical treatment. Imaging studies were reported as normal, and a laparoscopy showed a posterior cul-de-sac peritoneal pocket infiltrating the pararectal fossa, with extension to the lateral border of the rectum. Case 2 is a cadaveric dissection of a posterior cul-de-sac peritoneal pocket infiltrating the pararectal fossa, with extension to the pelvic sidewall. After dissection of the obturator fossa, we can observe that the pocket is close to the sacrospinous ligament, pudendal nerve, and some sacral roots. Case 3 is a 31-year-old woman, gravida 1, para 1, with severe dysmenorrhea that was unresponsive to medical treatment and catamenial bowel symptoms (catamenial bowel distention and diarrhea). Imaging studies were reported as normal and a laparoscopy showed left uterosacral peritoneal pocket infiltrating the pararectal fossa in close proximity to the rectal wall. Case 4 is a cadaveric dissection of the ovarian fossa and the obturator fossa showing the proximity between these structures. Case 5 is a 35-year-old woman, gravida 0, with severe dysmenorrhea that was unresponsive to medical treatment, referring difficulty, and pain when walking only during menstruation. A neurologic physical examination revealed weakness in thigh adduction, and the magnetic resonance imaging showed no signs of endometriosis. During laparoscopy, we found a peritoneal pocket infiltrating the ovarian fossa, with involvement in the area between the umbilical ligament and the uterine artery. This type of pocket can easily reach the obturator nerve. Because the obturator nerve and its branches supply the muscle and skin of the medial thigh [7,8], patients may present with thigh adduction weakness or difficulty ambulating [9,10]. Case 6 is a cadaveric dissection of the sacrospinous ligament and the pudendal nerve from a medial approach, between the umbilical artery and the iliac vessels. Case 7 is a 34-year-old woman, gravida 1, para 1, with severe dysmenorrhea and catamenial bowel symptoms as well as deep dyspareunia. The transvaginal ultrasound showed focal adenomyosis and a 2-cm nodule, 9-cm apart from the anal verge, affecting 30% of the bowel circumference. In the laparoscopy, we found a posterior cul-de-sac retraction pocket associated with a large deep endometriosis nodule affecting the vagina and the rectum. In all cases, endometriosis was confirmed by histopathology, and in a 6-month follow-up, all patients showed improvement of bowel, pain, and neurologic symptoms. CONCLUSION: Peritoneal pockets can have different clinical presentations. Depending on the topography and deepness of infiltration, they can be the cause of some neurologic symptoms associated with endometriosis pain. With this video, we try to encourage surgeons to totally excise these lesions and raise awareness about the adjacent key anatomic structures that can be affected.

Fluorescence-guided management of deep endometriosis.

OBJECTIVE: To demonstrate the advantages of the fluorescence-guided surgery using indocyanine green (ICG) in the management of deep endometriotic nodules toward more complete and safe excision of the disease in cases when rectal shaving is performed. DESIGN: Surgical video demonstrating the result of the application of a fluorescent dye (ICG) during deep endometriosis surgery. The local institutional review board was consulted and ruled that approval was not required for this video article because the video describes a technique and the patient cannot be identified. SETTING: Tertiary-care university hospital. PATIENT(S): The patient underwent rectal shaving due to a deep endometriotic nodule located at the level of the rectovaginal septum. INTERVENTION(S): The procedure started with exploration of the lesion and the anatomical structures. The nodule is approached using the "reverse technique." As the nodule is infiltrating the vagina, complete resection of the posterior vaginal wall is performed. At the start of the rectal shaving, ICG is injected and its fluorescence effect is used to provide navigation for the surgeon during the excision. At the end of the procedure the vascularization of the bowel wall and the vagina are evaluated with the help of the ICG. MAIN OUTCOME MEASURE(S): Visual assessment and distinction between the borders of the endometriotic nodule and the rectal wall as a result of the fluorescence effect of the ICG. RESULT(S): After injection of the ICG, the borders of the healthy rectum are delineated and a clear distinction between the endometriotic nodule and the bowel wall is demonstrated. In addition, the effect of the ICG was used to assess the vascularization of the infiltrated organs (vagina and rectal wall). CONCLUSION(S): Deep endometriosis at the level of the rectum usually represents a solid fibrotic nodule. The fibrosis plays a major role in the development of the disease. Indocyanine green is a fluorescent contrast agent, routinely used in a wide range of specialties to assess the blood supply and vascularization of different organs and tissues. Based on the fibrotic nature of the disease, the fluorescence could facilitate the distinction between healthy vascularized tissues and the endometriotic nodule. In the presented case, using ICG, a clear difference between the nodule and the rectum is demonstrated, as well as the vascularization of the bowel wall and the vagina. The implementation of ICG during endometriosis surgery could provide navigation for the surgeon toward a more complete and safer treatment of the disease, reducing the risk of complications and reinterventions. Additional studies are needed to further evaluate ICG fluorescence-guided surgery in the management of deep endometriosis.

Combined Laparoscopic-Hysteroscopic Isthmoplasty Using the Rendez-vous Technique Guided Step by Step.

OBJECTIVE: To demonstrate the surgical technique of Rendez-vous isthmoplasty for the treatment of symptomatic cesarean scar defect. In this video, the authors show the complete procedure in a step-by-step manner to standardize and facilitate the comprehension and performance of the procedure in a simple and safe way. DESIGN: Step-by-step video demonstration of the surgical technique. SETTING: Private hospital in Curitiba, Paraná, Brazil. INTERVENTIONS: The patient is a 36-year-old woman without any comorbidities, G3 C3, and with radiologic transvaginal ultrasound diagnosis of isthmocele grade 3 (over 25 mm) identified in the superior third of the cervical canal. The main steps of combined laparoscopic-hysteroscopic isthmoplasty using the Rendez-vous technique are described in detail. A combined laparoscopic-hysteroscopic approach was performed. Under general anesthesia, the patient was placed in 0° supine decubitus, with her arms alongside her body. Operative setup included 15 mm Hg pneumoperitoneum, created using the closed Veress technique, and 4 trocars: a 10-mm trocar at the umbilicus for a 0° laparoscope, a 5-mm trocar in the right iliac fossa, a 5-mm trocar in the left iliac fossa, and a 5-mm trocar in the suprapubic area. The procedure begins after a systematic exploration of the pelvic and abdominal cavities. Step 1: Identification of key anatomic landmarks and exposure of the operation field. Step 2: By carrying out blunt and sharp dissection with cold scissors or a harmonic scalpel, the visceral peritoneal layer over the isthmus area is opened, a vesicouterine space is developed, and the bladder is pushed down at least 2 cm from the lower edge of the isthmocele. Step 3: Final Phrase: By hysteroscopic exploration of the cervical canal using the vaginoscopic approach, identification and delimitation of the isthmocele its performed by recognizing the diverticular mucosal hyperplasia, and then the hysteroscopic light is pointed directly toward the cephalic limit of the scar defect. Step 4: Laparoscopic lights are decreased in intensity and the "Halloween sign" is identified (hysteroscopic transillumination). The light of the hysteroscope is pointed to the top of the cesarean scar defect allowing the laparoscopist to identify the upper and lower edges of the scar. Step 5: Laparoscopic resection of all scar tissue, excision of all the edges of the pseudo cavity. Step 6: Adequate intracorporeal suturing technique, with a 2-layer myometrial repair using intracorporeal running and interrupted stitches of polydioxanone 2-0, is done, while ensuring preservation of the cavity by not including the endometrial tissue in the myometrial suture [1-3]. Step 7: Installation of the methylene blue dye to locate any leakage. The surgery ended without any intraoperative complications and within 60 minutes. The patient was discharged on the first day postoperatively and became pregnant 6 months after surgery, with a final C-section delivery of a healthy term newborn at 39-weeks gestational age. CONCLUSION: Combined Rendez-vous isthmoplasty is feasible, safe, and effective in experienced hands, giving the surgeon a comprehensive evaluation of the anatomy of the isthmocele, and increasing the odds of a complete resection and restoration of the anatomy [4-7]. In this patient, the procedure was uneventful, without any intra- or postoperative complications, and the symptoms were completely controlled.

Laparoscopic Transabdominal Cerclage for Cervical Incompetence: A Feasible and Effective Treatment in 10 Steps.

STUDY OBJECTIVE: To demonstrate the surgical technique of laparoscopic cerclage (LAC) in nonpregnant women with a clinical diagnosis of cervical incompetence. In this video, the authors describe the complete procedure in 10 steps to standardize and facilitate the comprehension and performance of the procedure in a simple and safe way. DESIGN: Step-by-step video demonstration of the surgical technique. SETTING: Private hospital in Curitiba, Paraná, Brazil. INTERVENTIONS: The patient was 32 years old (gravidity and parity, G3A3; late progressive miscarriage), had no comorbidities, and had a radiologic diagnosis of cervical incompetence. The main steps of LAC are described in detail. A complete laparoscopic approach was performed. Under general anesthesia, the patient was placed in the 0-degree supine decubitus position with arms alongside her body. The operative setup included a 15-mm Hg pneumoperitoneum created using the closed Veress technique and 4 trocars: a 10-mm trocar at the umbilicus for a 0-degree laparoscope; a 5-mm trocar in the right iliac fossa; a 5-mm trocar in the left iliac fossa; and a 5-mm trocar in the suprapubic area. After systematic exploration of the pelvic and abdominal cavities, the procedure began. Step 1 involved identification of anatomic key landmarks and exposure of the operation field. Step 2 involved opening of the anterior peritoneum. The anterior peritoneal reflection was opened over the peritoneum uterovesicalis and then extended laterally until the uterine artery could be clearly identified on both sides. Step 3 involved dissection of the avascular space on each side of the uterus. The vesical-cervical avascular space was created, and the bladder was pushed down, away from the isthmus area. Step 4 involved preparation for a perfect stitch placement. A 5-mm Mersilene suture (Ethicon, Somerville, NJ) with a straight needle was introduced by a suprapubic trocar into the abdominal cavity before a complete identification of uterine vessels at both the sides using atraumatic graspers. Step 5 involved identification of the perfect space in the posterior aspect for Mersilene suture placement. Step 6 was to make a perfect anterior stitch. For this, the needle was grasped at the proximal portion in a 90-degree angle. In posterior position and when helped by a cranial and posterior uterine mobilization, the needle passed through the right, broad ligament in the avascular space created on the anterior leaf and medially from the uterine artery until the tip of the needle was seen on the posterior face above the uterosacral ligament. All steps were possible by synchronic uterine mobilization. Step 7 was to make a perfect posterior stitch. The procedure was then repeated contralaterally following the same anatomic and technical precepts but from posteriorly to anteriorly. Step 8 involved correct positioning and orientation of the Mersilene suture far away from the ureter and medial to the uterine arteries 2 cm over the uterosacral ligaments. Step 9 involved fixation of the Mersilene suture with an adequate blocking sequence. Step 10 involved fixation of the Mersilene suture and reperitonealization. The tape was knotted with an adequate blocking intracorporeal suturing sequence at the cervicoisthmic junction, and a Monocryl 2-0 stitch (Ethicon, Somerville, NJ) was made to fix the knot and left it horizontally. Finally, the procedure was ended with anterior reperitonealization, covering all the plica uterovesicalis and mesh, leaving it completely extraperitoneal. The surgery ended without any intraoperative complications and within 30 minutes. Patient was discharged on the first day postoperatively and became pregnant 6 months after surgery, with a C-section delivery of a healthy term newborn at 39 weeks of gestational age. CONCLUSION: LAC in nonpregnant women with a diagnosis of cervical incompetence is safe and feasible in experienced hands, adding all the intrinsic advantages of minimally invasive surgery and providing better obstetric outcomes. In this patient, the procedure was performed without any intra- or postoperative complications, and the patient had an uneventful term pregnancy in the follow-up period. We must remember that adequate standardization of surgical procedures will help reduce the learning curve.

Ghost Ileostomy in Anterior Resection for Bowel Endometriosis: Technical Description.

OBJECTIVE: To demonstrate our application of the ghost ileostomy in the setting of laparoscopic segmental bowel resection for symptomatic bowel endometriosis nodule. DESIGN: Technical step-by-step surgical video description (educative video) SETTING: University Tertiary Hospital. Institutional Review Board ruled that approval was not required for this study. Endometriosis affects the bowel in 3% to 37% of all cases, and in 90% of these cases, the rectum or sigmoid colon is also involved. Infiltration up to the rectal mucosa and invasion of >50% of the circumference have been suggested as an indication for bowel resection [1]. Apart from general risks (bleeding, infection, direct organ injuries) and bowel and bladder dysfunctions, anastomotic leakage is one of the most severe complications. In women with bowel and vaginal mucosa endometriosis involvement, there is a risk of rectovaginal fistula after concomitant rectum and vagina resections. Hence, for lower colorectal anastomosis, the use of temporary protective ileostomy is usually recommended to prevent these complications but carries on stoma-related risks, such as hernia, retraction, dehydration, prolapse, and necrosis. Ghost ileostomy is a specific technique, first described in 2010, that gives an easy and safe option to prevent anastomotic leakage with maximum preservation of the patient's quality of life [2]. In case of anastomotic leakage, the ghost (or virtual) ileostomy is converted, under local anesthesia, into a loop (real) ileostomy by extracting the isolated loop through an adequate abdominal wall opening. In principle, avoiding readmission for performing the closure of the ileostomy, with all the costs related, means a considerable saving for the hospital management. Also, applying a protective rectal tube in intestinal anastomosis may have a beneficial effect [3]. These options are performed by general surgeons in oncological scenarios, but their use in endometriosis has never been described. INTERVENTIONS: In a 32-year-old woman with intense dysmenorrhea, deep dyspareunia, dyschesia, and cyclic rectal bleeding, a complete laparoscopic approach was performed using blunt and sharp dissection with cold scissors, bipolar dissector and a 5-mm LigaSure Advance (Covidien, Valley lab, Norwalk, Connecticut). An extensive adhesiolysis restoring the pelvic anatomy and endometriosis excision was done. Afterward, the segmental bowel resection was performed using linear and circular endo-anal stapler technique with immediate end-to-end bowel anastomosis and transit reconstitution. Once anastomosis was done, the terminal ileal loop was identified, and a window was made in the adjacent mesentery. Then, an elastic tape (vessel loop) was passed around the ileal loop, brought out of the abdomen through the right iliac fossa 5-mm port site incision and, fixed to the abdominal wall using nonabsorbable stitches. Finally, a trans-anal tube was placed for 5 days. The patient was discharged on the fifth day postoperatively without any complications. The tape was removed 10 days after surgery, and the loop dropped back. Two months after the intervention, the patient remains asymptomatic. CONCLUSION: Ghost ileostomy is a simple, safe, and feasible technique available in the setting of lower colorectal anastomosis following bowel endometriosis resection.

Vesico-Vaginal Fistula: Nature and Evidence-Based Minimally Invasive Surgical Treatment.

The present review aims to analyze the current information available on the pathophysiology, clinical presentation and treatment of vesico-vaginal fistulas (VVF), with particular focus on the safety and efficacy of minimally invasive surgical (MIS) techniques. Through the use of the PubMed and Google Scholar databases, we conducted a literature review of all available studies related to MIS treatment of VVF, focusing on laparoscopic techniques. After abstracts were read to identify pertinent studies, full manuscripts were reviewed by two authors according to the aim of the review. Vesico-vaginal fistula is defined as an abnormal passage that connects the bladder to the vagina and affects over 3 million women worldwide. It can be classified according to its complexity (simple or complex) and mechanism (obstetric-related or iatrogenic). Laparoscopic treatment of VVF started in 1994 and is currently the gold-standard approach for this pathology. No differences in terms of efficacy or safety have been reported between MIS (laparoscopy, robotic-assisted laparoscopy and laparoscopic single-site) using extra-vesical and trans-vesical approaches, with success rates of 80% to 100%, and low rates of conversion (1.9%), recurrence (less than 1%) and intra- or post-operative complications (3%). Surgical principles for fistula repair, described independently by Angioli and Couvelaire, must always be followed. A bladder fill and integrity test with at least 300 mL should be performed before ending surgery, since this increases the success rate by about 6%. Other interventions such as flap interposition, number of layers in closure and expectant management (spontaneous closure with a Foley catheter alone) remain controversial. To date, no differences have been seen among the laparoscopic surgical techniques. The lack of prospective evaluations has hindered a better understanding of the natural history of the disease and the development of evidence-based recommendations regarding diagnosis, management and follow-up. Since no differences were found compared to a trans-vesical approach, extra-vesical repair is recommended to avoid bladder bi-valving.

Application of Indocyanine Green in Gynecology: Review of the Literature.

The present review aims to analyze the current data available on the different applications of indocyanine green (ICG) in gynecology. A semantic review of English-language publications was performed by searching for MeSH terms and keywords in the PubMed and Google Scholar databases. The studies were finally selected by one author according to the aim of this review. ICG is a highly water-soluble tricarbocyanine dye that fluoresces in the NIR spectrum. Approved by the FDA in 1959, it can be administered either IV (usual dose of 5 mg) or locally/submucosally (usual dose of 5-6.25 mg) according to the pathology or indication. It is used most often in the setting of oncology, endometriosis and other gynecological conditions. In oncological applications, ICG is used to identify sentinel lymph nodes (SLN) using near-infrared light in endometrial, cervical and vulvar cancers. The main advantages that it offers include a reduction of surgical time, improved SLN detection rates, and the ability to avoid radioactivity. In cases of endometrial (submucosal or hysteroscopic applications) or cervical (intracervical administration) cancer, ICG can detect SLN at an accuracy of 95% to 98%. For vulvar cancer, the SLN detection rate can reach 100%. In endometriosis, the lack of good evidence hinders the final evaluation of this method in both diagnostic and therapeutic scenarios. An analytical, well-designed, prospective study is currently underway.

Evaluation of Brucella abortus DNA vaccine by expression of Cu-Zn superoxide dismutase antigen fused to IL-2.

The Cu-Zn superoxide dismutase (SOD) antigen of Brucella abortus was previously identified to be a T cell antigen which induces both proliferation of and gamma interferon (IFN-gamma) secretion by T cells from infected mice. In an earlier study, we demonstrated that intramuscular injection of mice with a plasmid DNA carrying the gene for SOD leads to the development of significant protection against B. abortus challenge. It has been reported that the antigen-specific immune responses generated by a DNA vaccine can be enhanced by co-delivery of certain cytokine genes. In this study, we evaluated the effect of delivering IL-2 on the efficacy of SOD DNA vaccine by generating a plasmid (pSecTag-SOD-IL2) that codes for a secretory fusion protein of SOD and IL-2. Another plasmid (pSecTag-SOD) that codes for only SOD as a secretory protein was used for comparison. BALB/c mice injected intramuscularly with pSecTag-SOD or pSecTag-SOD-IL2, but not the control plasmid pSecTag, developed SOD-specific antibody and T cell immune responses. Upon in vitro stimulation with recombinant SOD (rSOD) antigen, T cells from mice immunized with pSecTag-SOD-IL2, in comparison with those from mice immunized with pSecTag-SOD, exhibited a lower proliferation response but produced significantly higher concentrations of IFN-gamma. Both DNA vaccines, however, induced similar levels of SOD-specific antibodies and cytotoxic T cell response. Although mice immunized with pSecTag-SOD-IL2 showed increased resistance to challenge with B. abortus virulent strain 2308, this increase was not statistically significant from that of pSecTag-SOD vaccinated mice. These results suggest that a SOD DNA vaccine fused to IL2 did not improve protection efficacy.

Intraspleen delivery of a DNA vaccine coding for superoxide dismutase (SOD) of Brucella abortus induces SOD-specific CD4+ and CD8+ T cells.

In the development of vaccines capable of providing immunity against brucellosis, Cu-Zn superoxide dismutase (SOD) has been demonstrated to be one of the protective immunogens of Brucella abortus. In an earlier study, we provided strong evidence that intramuscular injection with a plasmid DNA carrying the SOD gene (pcDNA-SOD) was able to induce a protective immune response. The present study was designed to characterize T-cell immune responses after an intraspleen (i.s.) vaccination of BALB/c mice with pcDNA-SOD. Animals vaccinated with pcDNA-SOD did not develop SOD-specific antibodies, at least until week 4 after immunization (the end of the experiment), and in vitro stimulation of their splenocytes with either recombinant Cu-Zn SOD or crude Brucella protein induced the secretion of gamma interferon (IFN-gamma), but not interleukin-4, and elicited the induction of cytotoxic-T-lymphocyte activity. Upon analyzing the SOD-specific T-cell responses, the pcDNA-SOD vaccination was found to be stimulating both CD4(+)- and CD8(+)-T-cell populations. However, only the CD4(+) population was able to produce IFN-gamma and only the CD8(+) population was able to induce cytotoxic activity. Nevertheless, although i.s. route vaccination induces a significant level of protection in BALB/c mice against challenge with the virulent B. abortus strain 2308, vaccination by the intramuscular route with a similar amount of plasmid DNA does not protect. Based on these results, we conclude that i.s. immunization with pcDNA-SOD vaccine efficiently induced a Th1 type of immune response and a protective response that could be related to IFN-gamma production and cytotoxic activity against infected cells by SOD-specific CD4(+) and CD8(+) T cells, respectively.

Tratamiento de una recesión gingival localizada adyacente a una zona edéntula mediante un colgajo posicionado lateral. Revisión y reporte de un caso / Treatment of a localized gingival recession, adjacent to an edentulous zone, by a lateral positioned flap. Review and report of a case

Las recesiones del tejido marginal han sido tratadas a través de los años por medio de diferentes procedimientos mucogingivales, dentro de los que se encuentran los colgajos posicionados laterales. Este artículo presenta la revisión de esta técnica y el reporte de un caso en un paciente con un defecto mucogingival localizado adyacente a una zona edéntula. El paciente fue evaluado en un examen inicial, en la reevaluación, 1, 3 y 6 meses después de llevar a cabo la terapia quirúrgica. Los resultados demostraron un mejoramiento de todos los parámetros clínicos evaluados (Indice de placa, índice de sangrado, nivel de inserción, profundidad al sondaje y nivel del margen gingival), logrando una cobertura radicular aproximada del 80 por ciento