Stefano Landi

Laparoscopic Colorectal Resection for Bowel Endometriosis: Feasibility, Complications, and Clinical Outcome

OBJECTIVE To evaluate the short- and long-term outcomes of laparoscopic colorectal resection for endometriosis. DESIGN AND PATIENTS This study included 357 consecutive patients who underwent colorectal resection. We evaluated intraoperative and postoperative complications, symptom outcomes, and long-term follow-up. MAIN OUTCOME MEASURE Three hundred forty-three patients (96.1%) underwent laparoscopic colorectal resection, and radical endometriosis ablation was in 334 patients (93.6%). RESULTS Fourteen (3.9%) required laparoconversion. Median operating time was 300 (range, 85-720) minutes, with a median estimated blood loss of 250 (range, 50-550) mL. Radical endometriosis ablation was achieved in 334 patients (93.6%). Median ileus was 4 (range, 1-8) days, with a median postoperative hospitalization of 8 (range, 3-36) days. Early and late complications were observed in 44 patients (12.3%) and, in 35 of these (79.5%), surgical management was necessary. Median follow-up after colorectal resection was 19.6 (range, 6-48) months. The median preoperative and postoperative dyspareunia scores were 8 (range, 4-10) and 3 (range, 0-10), respectively (P < .04), and the median preoperative and postoperative gastrointestinal tract symptom scores were 7 (range, 2-10) and 2 (range, 0-10), respectively (P < .05). During follow-up, 24 of 286 recurrences (8.4%) were registered. Patients who previously underwent surgery for endometriosis showed a higher risk of recurrence compared with patients undergoing primary surgery (13.2% vs 3.4%; P < .048). CONCLUSIONS Laparoscopic colorectal resection for severe endometriosis is feasible and markedly improved endometriosis-related symptoms. Despite the risk of major postoperative complications, the procedure shows good results in terms of recurrence rate and could be adopted as the primary approach for patients with symptomatic colorectal infiltrating endometriosis.

Laparoscopic Myomectomy: Technique, Complications, and Ultrasound Scan Evaluations

STUDY OBJECTIVE To evaluate the feasibility, limits, and complications of laparoscopic myomectomy, assess time to full recovery, and evaluate uterine wound healing by ultrasound in the early postoperative period. DESIGN Prospective study (Canadian Task Force classification II-2). SETTING General hospital. PATIENTS Three hundred sixty-eight women undergoing laparoscopic myomectomy. INTERVENTION Laparoscopic myomectomy and laparoscopic and/or hysteroscopic treatment of associated pathologies. MEASUREMENTS AND MAIN RESULTS In these women 768 myomas were removed laparoscopically. Mean operating time was 100.78 +/- 43.83 minutes, mean decreases in hemoglobin and hematocrit were 1.38 +/- 0.93 g/100 ml and 4.8 +/- 2.9 g/100 ml, respectively, and mean length of hospital stay was 2.89 +/- 1.3 days. Intraoperative complications occurred in 12 patients (3.34%) and intraoperative transfusion of autologous blood was required in 10. Main postoperative complications were continuing hemorrhage requiring blood transfusion in three women and second laparoscopy in two. Pyrexia occurred in 12 patients. Average time to full recovery was 10.58 +/- 6.68 days. At 1-month follow-up 12 of 282 women developed further complications: abdominal pain 5, vaginitis 4, metrorrhagia 2, and dysuria 1. Sonographic evaluation of the uterine scar showed a highly echogenic area with ill-defined margins. In 81 women who had sonographic evaluation 30 days postoperatively, the uterine scar was reduced by an average of 44.1% (p <0.001). Of 176 patients screened at day 30, 6 (3.4%) had anechoic areas adjacent to the uterine scar, possibly due to hematoma. A previously unknown myoma, two ovarian cysts, and two pelvic hematoma were also discovered. CONCLUSION . Laparoscopic myomectomy is effective and relatively safe. In skilled hands it has a low risk of complications and appears to be a valid alternative to the open procedure. Sonographic assessment allows detection of alterations in muscular echotexture, but its effectiveness in identifying women at risk of uterine rupture or dehiscence has to be proved.

Laparoscopic management of ureteral endometriosis in case of moderate-severe hydroureteronephrosis

OBJECTIVE To evaluate prospectively the efficacy of laparoscopic ureterolysis versus ureteroureterostomy in women with ureteral endometriosis. DESIGN Prospective study. SETTING Department of Obstetrics and Gynecology, Ospedale Sacro Cuore of Negrar, Verona, Italy, a tertiary care endometriosis referral center. PATIENT(S) Endometriotic patients with moderate-severe ureter dilatation. INTERVENTION(S) All women underwent laparoscopic endometriosis excision and concomitant laparoscopic ureterolysis, ureteroureterostomy, nephrectomy, or laparotomic ureterocystoneostomy. MAIN OUTCOME MEASURE(S) Clinical outcomes were evaluated. RESULT(S) Fifty-six patients with preoperative or intraoperative evidence of moderate-severe ureter dilatation were enrolled. Dysmenorrhea (91%) and dyspareunia (68%) were the symptoms more frequently reported; only two patients had typical obstructive uropathy pain. In 35 cases, laparoscopic ureterolysis, in 17 laparoscopic ureteroureterostomy, in 2 laparotomic ureterocystoneostomy, and in 2 laparoscopic nephrectomy was performed. 11 out of 35 (31.4%) major complications occurred in the ureterolysis group, and 2 out of 17 (11.7%) in the ureteroureterostomy group. Median follow-up time was 21 months. Ureteral endometriosis recurrence was surgically detected in three patients who underwent conservative ureteral surgery. CONCLUSION(S) Preoperative planning should be rigorous, and complete surgical excision of ureteral endometriosis should be ensured by a team of experts familiar with endometriosis, its multiple manifestations, and its management.

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

STUDY OBJECTIVES To 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. DESIGN Retrospective study (Canadian Task Force classification II-2). SETTING General hospital with a specialized endometriosis unit. PATIENTS One hundred and eight women with symptoms suggestive of intestinal endometriosis who underwent DCBE before laparoscopic surgery. INTERVENTION Laparoscopic complete excision of endometriosis. MEASUREMENTS AND MAIN RESULTS Fifty-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. CONCLUSION Our 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 OBJECTIVE To assess pregnancy outcomes and deliveries after laparoscopic myomectomy. DESIGN Retrospective study (Canadian Task Force classification II-2). SETTING General hospital. PATIENTS Three hundred fifty-nine women. INTERVENTIONS Laparoscopic myomectomy and laparoscopic and/or hysteroscopic treatment of associated pathologies. MEASUREMENTS AND MAIN RESULTS Five 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. CONCLUSION Our technique of laparoscopic myomectomy appears to allow safe vaginal delivery.

The Influence of Adenomyosis in Patients Laparoscopically Treated for Deep Endometriosis

STUDY OBJECTIVE A strong association exists between adenomyosis and endometriosis and a common pathogenetic mechanism was proposed. The aim of this study was to evaluate whether and how the presence of concurrent adenomyosis can affect the outcome of laparoscopic excision of deep endometriosis. DESIGN Data were retrospectively collected from our computerized medical records (Canadian Task Force classification II-3). SETTING General hospital. INTERVENTION Restrospective evaluation. PATIENTS From January 2003 through July 2005, 40 consecutive patients affected by concomitant endometriosis and adenomyosis were included in group A and another 40 affected by endometriosis only were included in group B. MEASUREMENTS AND MAIN RESULTS In group A, 20 women required bowel surgery (17 segmental and 3 full-thickness discoid resections) versus 16 patients in the other group (13 segmental bowel resections with end-to-end anastomosis and 3 discoid resections). Dysmenorrhea and dyspareunia after treatment improved (p<.01) in both groups, whereas dyschezia improved only in group A. The persistence of menometrorrhagia was more frequent in group B (p<.01). During follow-up, patients of group A underwent medical treatment for a longer time than those of group B (p<.001). Clinical detection of endometriosis recurrence was more frequent in patients with adenomyosis (p<.01), whereas no difference existed in the incidence of the recurrence detected by ultrasound. The overall number of pregnancies after surgery was significantly lower in the group with adenomyosis (p=.03). CONCLUSION Complete excision of deep endometriosis is not always feasible because of adenomyosis. For this reason, preoperative imaging screening for adenomyosis could be included in the preoperative workup when extensive disease is clinically suspected.

Laparoscopic Disk Resection for Bowel Endometriosis Using a Circular Stapler and a New Endoscopic Method to Control Postoperative Bleeding from the Stapler Line

BACKGROUND Complete laparoscopic excision of endometriosis offers good longterm symptomatic relief, especially for those with severe or debilitating symptoms. Intestinal endometriosis affect between 3% and 36% of women with endometriosis and 50% of women with disease severe enough that intestinal surgery, with or without intestinal segmental resection, may be required. STUDY DESIGN Between January 2003 and September 2006, we performed 35 laparoscopic complete excisions of endometriosis with full thickness disk resections of bowel endometriosis using the CEEA stapler (US Surgical) inserted transanally. RESULTS The endometriotic nodule of the bowel was completely removed in all patients. No major or minor surgical complications occurred during the primary surgical procedure. One patient underwent a diverting temporary ileostomy because of air loss after insufflation of the rectosigmoid colon, which was closed successfully 1 month after surgery. In three of seven cases of rectal bleeding from the stapler line, for the first time, we successfully used conservative endoscopic management. CONCLUSIONS In properly selected patients, full thickness disk excision using a circular stapler is a feasible procedure that avoids the potential morbidities of a low anastomosis. We suggest conservative management by endoscopic hemostasis before referring patients for a new operation in cases of rectal bleeding from the anastomotic site.

A multicenter study comparing surgical outcomes and ultrasonographic evaluation of scarring after laparoscopic myomectomy with conventional versus barbed sutures

To compare clinical outcomes after laparoscopic myomectomy using traditional interrupted sutures (TIS) versus continuous barbed suture (CBS) for treatment of symptomatic uterine myomas.

Caesarean scar pregnancy complicated by placenta percreta followed by suppurative appendicitis after conservative management with methotrexate

node chain or area and often asymptomatic. The histological examination is usually of hyaline vascular variant. UCD is usually curable by surgical excision of the mass and the prognosis is good. The systemic or multicentric variant of CD (MCD) is a less common and more aggressive form. Its corresponding histological pattern is the plasma cell variant, and rarely the plasmablastic type. It is frequently accompanied by systemic manifestations, such as fever and night sweats. Patients with MCD require systemic treatment and their prognosis is unfavourable (El-Osta and Kurzrock 2011; Ye et al. 2010; Talat and Schulte 2011). UCD is most commonly found in the mediastinum. However, it can develop anywhere lymphoid tissue is found. The distribution of localised Castleman ’ s disease has been reported as 65% in the mediastinum, 16% in the neck, 12% in the abdomen and 3% in the axilla (Bucher et al. 2005). The pelvic cavity is an unusual site for Castleman ’ s disease. The diagnosis of CD was still mostly dependent on the postoperative histological examination. For this patient, complaints, symptoms, physical examination and accessory examination were all nonspecific. Because of the relatively high incidence of adnexal masses in the female population, the preoperative diagnosis of the patient was gynaecological adnexal mass. But during the operation, we found the mass was localised behind the peritoneum. The diagnosis of the CD was according to the postoperative histological examination. For this kind of the solitary mass, exploratory laparoscopic operation is suitable. In this case, the laparoscopic operation has the advantage of good surgical fi elds and an easier to perform operation, compared with laparotomy. Laparoscopy off ers multiple advantages over traditional laparotomy, including smaller incisions, less blood loss, reduction in the need for analgesics, decreased morbidity and a more rapid recovery (Demir and Marchand 2012). The aetiology of CD is still not clear. The chronic inflammation, immunodeficiency state and autoimmune disorders (such as viral infection involving the human herpes virus 8, the Epstein – Barr virus or autoimmune haemolytic anaemia) are considered to be the possible causal factors of CD (Oksenhendler 2009). Although this patient was not examined for infection of the human herpes virus 8 or the Epstein – Barr virus, she did not have any manifestation of chronic inflammation, immunodeficiency state or autoimmune disorders. The possible susceptibility for her could be her family history of tumour. In conclusion, Castleman ’ s disease should be considered as a rare differential diagnosis in patients with a gynaecological adnexal mass. Preoperative and intraoperative differential diagnosis of CD is important. Exploratory laparoscopic operation is a suitable surgical choice.

Pivotal points in interstitial pregnancy: New insights in conservative medical treatment of non-ruptured interstitial pregnancy

We report the efficacy of a minimally invasive approach of the multidose protocol with methotrexate (MTX) in the management of three cases of interstitial pregnancy (IP), with elevated serum β-hCG in two cases. New considerations and management strategies are discussed. Successful termination of IP and in one case, a subsequent successful pregnancy, was achieved. The process led to the development of an enhanced understanding of diagnostic modalities and their limitations, with regard to the particular entities under discussion. We also focused attention on pivotal points and anatomical features in the management of this dangerous occurrence. Long-term results with careful follow-up were analysed by instrumental procedure. This hazardous type of ectopic pregnancy can be managed with systemic administration of MTX, also in patients with elevated β-hCG values. The present report underlines that an integrated approach in early diagnosis, multidose treatment and close follow-up, are essential forms of medical management.