Fabrizio Barbieri

Preoperative Double-Contrast Barium Enema in Patients with Suspected Intestinal Endometriosis

STUDY OBJECTIVESnTo assess the usefulness of double-contrast barium enema (DCBE) in the diagnosis of endometriotic lesions of the bowel and to define its potential value in preoperative decision making for intestinal surgery.nnnDESIGNnRetrospective study (Canadian Task Force classification II-2).nnnSETTINGnGeneral hospital with a specialized endometriosis unit.nnnPATIENTSnOne hundred and eight women with symptoms suggestive of intestinal endometriosis who underwent DCBE before laparoscopic surgery.nnnINTERVENTIONnLaparoscopic complete excision of endometriosis.nnnMEASUREMENTS AND MAIN RESULTSnFifty-five patients were found to have an entirely normal colon on DCBE studies. Twenty-eight of these were found to have adhesions of the bowel at laparoscopy. Radiographic abnormalities suggestive of endometriosis were detected in 53 patients; 20 of these underwent laparoscopic bowel segmental resection, 10 laparoscopic full-thickness disc excision, 4 laparoscopic mucosal skinning, and 4 total laparoscopic hysterectomy with bilateral salpingo-oophorectomies. Fourteen patients refused intestinal surgery. One patient had no endometriosis but severe adhesions. In all cases but one, the radiographic findings on DCBE were confirmed by surgery and with histopathologic examination of the resected specimens (accuracy 99%). In these same cases, the preoperative choice of intestinal surgery remained unchanged during the procedure.nnnCONCLUSIONnOur data show that, in expert hands, DCBE correlated with a patients clinical history and clinical findings is capable of diagnosing bowel wall involvement due to endometriosis, which could require intestinal surgery. This allows for proper preoperative planning of surgical procedures and a thorough informed consent.

Pregnancy Outcomes and Deliveries after Laparoscopic Myomectomy

STUDY OBJECTIVEnTo assess pregnancy outcomes and deliveries after laparoscopic myomectomy.nnnDESIGNnRetrospective study (Canadian Task Force classification II-2).nnnSETTINGnGeneral hospital.nnnPATIENTSnThree hundred fifty-nine women.nnnINTERVENTIONSnLaparoscopic myomectomy and laparoscopic and/or hysteroscopic treatment of associated pathologies.nnnMEASUREMENTS AND MAIN RESULTSnFive patients (1.39%) were lost to follow-up. Seventy-two women were pregnant at least once after laparoscopic myomectomy, for a total of 76 pregnancies. Four women conceived twice and four are pregnant as of this writing. One multiple pregnancy occurred. Twelve pregnancies resulted in first-trimester miscarriage, one in an ectopic pregnancy, one in a blighted ovum, and one in a hydatiform mole. One patient underwent elective first-trimester termination of pregnancy. Thirty-one women had vaginal delivery at term and 26 were delivered by cesarean section. No case of uterine rupture or dehiscence occurred.nnnCONCLUSIONnOur technique of laparoscopic myomectomy appears to allow safe vaginal delivery.

Cornual pregnancy successfully treated by suction curettage and operative hysteroscopy

A 36 year old Italian woman, gravida 3, para 0, was admitted seven weeks after her last menstrual period because a transvaginal ultrasound examination had showed a gestation sac with yolk sac and fetal pole lateral to the endometrial stripe, raising suspicion of a right cornual pregnancy (Fig. 1). Both ovaries appeared normal and there were no adnexal masses or free fluid in the cul de sac. The plasma h-hCG level was 9237 mIU/mL and general physical examination was normal. She had previously suffered two ectopic pregnancies in the right fallopian tube, which had both been treated by intravenous methotrexate. A subsequent diagnostic laparoscopy and hysteroscopy had documented a normal uterus and adnexa, and a hysterosalpingogram had confirmed bilateral tubal patency. After three days of expectant management, the plasma h-hCG level was 14,934 mIU/mL and fetal cardiac activity was detected by sonography. By day 10 from admission, the plasma h-hCG level had risen to 48,944 mIU/mL, with normal vital signs and an unremarkable physical examination. A transvaginal sonogram revealed a 2.7 mm thick myometrium surrounding the gestational sac. At this point, in the eighth week of pregnancy, the treatment options were reviewed and active surgical treatment was tried. Under general anaesthesia, diagnostic hysteroscopy confirmed the diagnosis (Fig. 2). A single-toothed Braun volsellum was applied to the cervix and gentle traction was exerted to align the uterus. The cervix was dilated by Hegar dilators and the pregnancy was removed via a vacuum curette rotated carefully within the cavity in a downward spiral motion. Remaining gestational debris was removed using the Stortz hysteroscopic resectoscope under laparoscopic and ultrasound control (Fig. 3). Sorbitol/ mannitol solution was used as distention medium, using a pressure cuff inflated to 100 mmHg. During the 20-minute procedure, total fluid input was 2500 mL and output was 2400 mL. The Erbe electrosurgical generator (ICC 350 E, Erbe Elektromedizin, Tubingen, Germany) was used on a setting of 90 W cut and 70 W coagulation. The entire right cornual endometrium was resected. Bleeding vessels were coagulated with the rollerball. Vaginal bleeding was minimal at the end of the procedure. Laparoscopy showed an enlarged, mobile uterus with a distorted right cornual region. Both tubes and ovaries appeared normal and no blood was present in the pouch of Douglas. Given the normal aspect of the left tube and her obstetric history, a right laparoscopic salpingectomy was performed to prevent further ectopic pregnancies. The estimated blood loss was less than 100 cc. The patient had an unremarkable post-operative course and was discharged after two days when transvaginal ultrasound showed a normal uterine cavity and the plasma h-hCG level had dropped to 7427 mIU/mL. The pathology report confirmed a cornual pregnancy. At both one and three month visits, the patient was well and no signs of the previous cornual pregnancy were detectable both by sonography and by hysteroscopy.

Is early stage endometrial cancer safely treated by laparoscopy? Complications of a multicenter study and review of recent literature

BACKGROUNDnTo compare the complications after total laparoscopic hysterectomy (LPS) and abdominal hysterectomy with lymphadenectomy (LPT) for early stage endometrial cancer in a series of 226 women and to assess the disease-free survival and the recurrence rate.nnnPATIENTS AND METHODSnTwo hundred and twenty six patients with clinical stage I endometrial cancer were enrolled in a multicenter study and underwent surgical staging consisting of inspecting the intraperitoneal cavity, peritoneal washing, total hysterectomy, bilateral salpingo-oophorectomy, and in all cases we performed systematic bilateral pelvic lymphadenectomy by LPS or LPT approach.nnnRESULTSnOne patient of the LPS group had an uretero-vaginal fistula and another patient had an ureteral stricture temporarily treated with a stent. One patient of the LPS group had a bowel perforation due to dense adhesions with the peritoneum under the umbilicus, resolved with a bowel resection and an end-to-end anastomosis. In three patients of the LPS group we observed a vaginal cuff dehiscence and in one case a pelvic lymphocyst was reported.nnnCONCLUSIONSnThe low intraoperative and postoperative complications rate, observed in the LPS group, highlights the feasibility, safety and efficacy of this surgical approach. The operating time was longer in the LPS group but the recurrence rate and the complication rate appear similar and not more than what is traditionally expected with the LPT approach, although further studies and cost-benefit analyses are required to determine whether the use of LPS improves the outcome over standard LPT and whether the advantages of this technique could be extended to a larger proportion of patients.