Indocyanine green fluorescence angiography after full-thickness bowel resection for rectosigmoid endometriosis: A multicentric experience with quantitative analysis.

OBJECTIVE: To evaluate effectiveness and reproducibility of qualitative and quantitative near-infrared indocyanine green (NIR-ICG) analyses as a tool for anastomotic perfusion assessment after full-thickness bowel resection for rectosigmoid endometriosis (RSE). METHODS: Symptomatic women with RSE undergoing minimally invasive full-thickness surgical excision of RSE and NIR-ICG evaluation from November 2019 to July 2020 were included. Study outcomes were the accuracy of qualitative and quantitative NIR-ICG analyses in predicting bowel fistula and their reproducibility. NIR-ICG predictive accuracy was assessed by calculating sensitivity, specificity, and area under the curve on receiver operating characteristic curves with 95% confidence intervals (CI). NIR-ICG reproducibility was assessed through Cohen's k coefficient to determine interoperator agreement between two observers. RESULTS: Of 33 patients, 2 (6%) developed bowel fistula. In predicting bowel fistula, qualitative and quantitative NIR-ICG evaluations showed sensitivity of 100% and 100%, specificity of 71% and 93%, and area under the curve of 0.86 (95% CI 0.67-1.00) and 0.96 (95% CI 0-1.00), respectively. Regarding interoperator agreement rate, it was reported as excellent for the qualitative analysis and very good for the quantitative analysis. CONCLUSION: Qualitative and quantitative NIR-ICG evaluations might be effective and reproducible tools for anastomotic perfusion assessment after discoid or segmental resection for RSE. Quantitative evaluation might be even more effective than qualitative evaluation in predicting bowel fistula.

Real three-dimensional approach vs two-dimensional camera with and without real-time near-infrared imaging with indocyanine green for detection of endometriosis: A case-control study.

INTRODUCTION: The complete surgical removal of endometriosis lesions is not always feasible because some implants may be very small or hidden. The use of intraoperative near-infrared radiation (NIR) imaging after intravenous injection of indocyanine green (ICG) coupled with robotic technical advances, including three-dimensional (3D) and high-resolution vision, might improve detection rates. MATERIAL AND METHODS: This is a retrospective, multicenter case-control study (Canadian Task Force classification II-2) on medical records of women with endometriosis who underwent surgery at the Catholic University of Rome (Controls) and the University of Bologna (Cases) between January 2016 and March 2018. Surgical and post-surgical data from the procedures were collected. We compared the visual detection rate of endometriotic lesions using near-infrared radiation imaging after intravenous injection of indocyanine green (NIR-ICG) in Real 3D (Cases) with the 2D Camera approach (Controls) in symptomatic women with pelvic endometriosis. RESULTS: Twenty cases were matched as closely as possible with 27 controls. The numbers of suspected lesions identified both with the white light and the NIR-ICG approach were 116 and 70 in the Controls (2D) and Cases (3D), respectively. Among them, 16 of 116 controls (13.8%) and 12 of 70 cases (17.1%) were identified using only NIR-ICG imaging and collected as occult lesions (P = .536). The overall NIR-ICG lesion identification showed a positive predictive value of 97.8%, negative predictive value of 82.3%, sensitivity of 82.0%, and specificity of 97.9% for the Control group, and a positive predictive value of 100%, negative predictive value of 97.1%, sensitivity of 97.1%, and specificity of 100% for the Case group, confirming that NIR-ICG imaging is a good diagnostic and screening test (P = .643 and P = .791, according to the Cohen κ tests, respectively for the laparoscopic and robotic groups). CONCLUSIONS: The few differences observed did not seem to be clinically relevant, making the 2 procedures comparable in terms of the ability to visually detect endometriotic lesions. Further prospective trials are needed to confirm our results.

Feasibility and safety of two different surgical routes for the eradication of recto-vaginal endometriosis with vaginal mucosa infiltration (Endo-Vag-r study).

INTRODUCTION: Recto-vaginal endometriosis surgical management needing partial colpectomy is a surgically challenging condition and has been associated with a notable risk of major postoperative complications. In the present study we sought to compare feasibility and safety of total laparoscopic (TL) and vaginal-assisted (VA) routes in women affected by symptomatic recto-vaginal endometriosis with vaginal mucosa infiltration scheduled for minimally invasive surgery. MATERIAL AND METHODS: Multi-centric, retrospective cohort study on medical records of consecutive reproductive age women submitted to complete macroscopic eradication of symptomatic recto-vaginal endometriosis with vaginal mucosa infiltration between March 2013 and November 2017. The two groups were compared in terms of preoperative data and surgical outcomes. RESULTS: 84 women were included in the study (TL = 57 and VA = 27). The two groups were comparable in terms of preoperative, surgical and postoperative data. The major postoperative complications rate was 5.3% (3 of 57) in the TL group and 7.4% (2 of 27) in the VA group, without a significant difference. In the TL group we reported one case of bowel anastomosis dehiscence and two cases of pelvic abscess. In the VA group, one case of small bowel perforation after extensive adhesiolysis treated with ileal resection and one case of rectal sub-occlusion after segmental resection and mechanical anastomosis were noticed. CONCLUSIONS: In women affected by recto-vaginal endometriosis with vaginal mucosal infiltration, perioperative outcomes do not seem to be influenced by the surgical route adopted.

Role of ultrasound in advanced peritoneal malignancies.

INTRODUCTION: Ovarian cancer is the seventh most common cancer among women in the developed world, and most women with ovarian cancer are diagnosed at an advanced stage of disease, when large intraperitoneal dissemination has already occurred. An accurate preoperative assessment of the tumor dissemination is pivotal for adequate counseling among risks and benefits of an aggressive surgical procedure, often required to achieve a complete cytoreduction. When performed by an experienced sonographer, ultrasound has an invaluable role in the primary diagnosis of gynecological cancer, in the assessment of tumor extent in the pelvis and abdominal cavity; however, there is a paucity of data on its use in the evaluation of the extent of disease of such patients. EVIDENCE ACQUISITION: The search retrieved 208 articles in the best matching results list. Selection by abstract and full-text, yielded 15 publications that contained information on the role of ultrasound examination in the assessment of diffused peritoneal malignancies. EVIDENCE SYNTHESIS: Sonographic appearance of metastatic nodules in peritoneum and omentum were firstly analyzed in preliminar descriptive studies, together with a systematic method to scan the abdomen and pelvis in in the staging of diffused gynecological malignancies. To date, three prospective studies mainly focused on the specific role of ultrasound (without comparison with other imaging modalities) in the evaluation of intra-abdominal tumor extension in ovarian cancer patients. In these studies, authors were in agreement to conclude that ultrasound has a very reliable role in the staging of ovarian cancer. In particular, ultrasound examination showed a high sensitivity (range 81.4-91%) and specificity (range 88-96%) in the diagnosis of peritoneal carcinomatosis, as well as in omental involvement (sense 67-94%, specificity 90%). In a recent prospective study ultrasound shows similar accuracy of CT scan in the staging of ovarian cancer patients (71% vs. 75%) when compared with surgical results. CONCLUSIONS: Even if ultrasound is a largely diffuse and practice imaging technique, there is a paucity of data in literature on its use in the evaluation of the extent of disease in ovarian cancer patiens. Nevertheless, this review has demonstrated that ultrasound has a high accuracy in staging advanced ovarian cancer patients. In certain settings, ultrasound has already replaced CT scan in the pre-operative evaluation of pelvic and abdominal disease. Finally, ultrasound allows to perform a biopsy in patients with peritoneal carcinomatosis obtaining an adequate specimen for histologic diagnosis.

Feasibility and surgical outcome in obese versus nonobese patients undergoing laparoendoscopic single-site hysterectomy: a multicenter case-control study.

OBJECTIVE: To assess the feasibility and perioperative outcomes of laparoendoscopic single-site (LESS) hysterectomy in obese and nonobese women. DESIGN: A multicentric retrospective case-control study (Canadian Task Force II-2). SETTING: Catholic University of the Sacred Heart and National Cancer Institute "Regina Elena" (Rome, Italy), Massachusetts General Hospital (Boston, MD), and Johns Hopkins Hospital (Baltimore, MD). PATIENTS: From July 2009 to April 2013, 120 women underwent LESS hysterectomy. Five women (8%) were excluded from the analysis. The remaining 115 women were divided into 2 groups: obese (n = 43, body mass index [BMI] ≥30 kg/m(2)) and nonobese (n = 72, BMI <30 kg/m(2)). INTERVENTIONS: Total LESS hysterectomies for malignant and premalignant uterine disease or at least for prophylactic intent were performed. MEASUREMENTS AND MAIN RESULTS: No statistical differences regarding perioperative outcomes were observed between the 2 groups. Conversion to standard laparoscopy occurred in 2 obese (5%) and 2 (5%) nonobese women (p = .62). Conversion to laparotomy occurred in 1 obese (2.3%) and 3 (4.2%) nonobese women (p = .212). The median operative time was 115 minutes (range, 48-300 minutes) in obese and 114 minutes (range, 55-342 minutes) in nonobese women (p = .787). The intraoperative complication rate was 11.6% and 9.6% in obese and nonobese women, respectively (p = .712). The early postoperative complication rate was 6.9% in obese and 4.1% in nonobese women (p = .516). CONCLUSION: Despite the fact that the present analysis was performed in a relatively small group of patients, this study suggests that obesity (BMI ≥30) does not preclude successful completion of total LESS hysterectomy. Further prospective studies are required to confirm these preliminary data and to clarify potential advantages and disadvantages of LESS in obese women.