The cytokine storm and thyroid hormone changes in COVID-19

BACKGROUND

COVID-19 is now a worldwide pandemic. Among the many extra-pulmonary manifestations of COVID-19, recent evidence suggested a possible occurrence of thyroid dysfunction.

PURPOSE

The Aim of the present review is to summarize available studies regarding thyroid function alterations in patients with COVID-19 and to overview the possible physio-pathological explanations.

CONCLUSIONS

The repercussions of the thyroid of COVID-19 seem to be related, in part, with the occurrence of a "cytokine storm" that would, in turn, induce a "non-thyroidal illness". Some specific cytokines and chemokines appear to have a direct role on the hypothalamus-pituitary-thyroid axis. On the other hand, some authors have observed an increased incidence of a destructive thyroiditis, either subacute or painless, in patients with COVID-19. The hypothesis of a direct infection of the thyroid by SARS-Cov-2 stems from the observation that its receptor, ACE2, is strongly expressed in thyroid tissue. Lastly, it is highly probable that some pharmaceutical agents largely used for the treatment of COVID-19 can act as confounding factors in the laboratory evaluation of thyroid function parameters.

Pre-pregnancy body mass index, gestational weight gain and adverse birth outcomes: some evidence from Italy

BACKGROUND

Overweight and obese women present an increased risk of poor maternal and child health outcomes. The aim of this paper is to analyze the joint effects of pre-pregnancy body mass index and inadequate gestational weight gain on birth weight and gestational age in an Italian sample of pregnant women.

METHODS

Data were obtained from a sample of about 2,000 pregnant women at the University Teaching Hospital of Perugia University (Italy) in 2013. We used the revised classification proposed by Institute of Medicine to identify gestational weight gains considered as appropriate. Logistic regression models were used to estimate the adjusted odds-ratios of women belonging to any BMI class different from normal (used as the reference category) and of women who increased their weight by an amount smaller or greater than normal, controlling for a large set of observable confounders.

RESULTS

Higher probability of low birth weight was associated with both obesity (OR = 1.9124, s.e. = 0.526) and less than normal weight gains (OR = 2.3614, s.e. = 0.388). The probability of fetal macrosomia was found to be positively associated with more than normal weight increases (OR = 2.6232, s.e. = 0.465). Pre-term deliveries were associated with less than normal gestational weight gains (OR 1.7338, s.e. = 0.320).

CONCLUSION

Overweight and obesity represent a big issue for public health. In particular, weight management during pregnancy and pre-pregnancy could determine negative health outcomes in newborns. In our study we found that inadequate weight variations during pregnancy, according to the Classification of the Institute of Medicine, negatively influence health conditions at birth. Stronger initiatives, especially in terms of midwifery, nurse training and informative policies should be adopted by policy makers.

Ten-Year Survival and Age at Diagnosis of Women with Breast Cancer from a Population-Based Study in Umbria, Italy

We analyzed the 10-year survival of 1,512 women with breast cancer in relation to age at diagnosis. The incident cases were from an ad hoc investigation in Umbria, a region of central Italy, for the period 1978-1982. The follow-up was carried out by an automatic link with the RENCAM (Nominative register of causes of death) and verified at the Registrar's Offices of the various towns of the region. Observed survival at 1 year was 0.89, at 3 years 0.75, at 5 years 0.64 and at 10 years 0.47. Median survival was 9.0 years. Relative survival at 1, 3, 5, 10 years was respectively 0.91, 0.79, 0.71 and 0.59. Women <35 years of age had a better prognosis both at 5 (0.83) and 10 years (0.69) from diagnosis. Thereafter, survival decreased with increasing age. The exception to this trend was women in the 45-49 and 60-64 year age ranges, for which survival was greater than the previous age range classes by 6% and 13%, respectively, at 5 years from diagnosis and 6% and 14% at 10 years. Comparison of data from Umbria and Italian and European Registries shows that the prognosis for Umbrian women with breast cancer is quite good.

Predictability of hypoadrenalism occurrence and duration after adrenalectomy for ACTH-independent hypercortisolism

OBJECTIVE

To evaluate if the parameters of hypothalamic-pituitary-adrenal (HPA) axis activity could predict the occurrence and duration of post-surgical hypocortisolism (PSH) in patients with Cushing's syndrome (CS) and with adrenal incidentaloma (AI).

METHODS

We studied 80 patients (54 females, age 53.3 ± 11 years), who underwent adrenalectomy for CS (17 patients) or for AI (53 patients). Before surgery, we measured adrenocorticotroph hormone (ACTH), urinary free cortisol (UFC) and serum cortisol after 1 mg dexamethasone suppression test (1 mg-DST) levels. After surgery, all patients were given a steroid replacement therapy, and PSH was searched after 2 months by a low-dose (1 µg, iv) corticotropin stimulation test, that was repeated every 6 months in PSH patients for at least 4 years.

RESULTS

The PSH occurred in 82.4 and 46% of CS and AI patients, respectively. In the whole sample and in AI patients separately considered, the PSH was independently predicted by the preoperative cortisol levels after 1 mg-DST, however, with a low (< 70%) accuracy. In AI patients the PSH occurrence was not ruled out even by the cortisol levels after 1 mg-DST lower than 1.8 μg/dL (50 nmol/L). In the 50% of CS patients and in 31% of AI patients the PSH lasted more than 18 months and in 35.7% of CS patients it persisted for more than 36 months. In AI patients, the PSH duration was not predictable by any parameter. However, a PSH duration of at least 12 months was significantly predicted before adrenalectomy (sensitivity 91.7%, specificity 41.2%, positive predictive value 52.4%, negative predictive value 87.5%, p = 0.05) by the presence of at least 2 out of low ACTH levels, increased UFC levels and cortisol levels after 1 mg-DST ≥ 3.0 µg/dL (83 nmol/L).

CONCLUSION

The PSH occurrence and its duration are hardly predictable before surgery. All patients undergoing unilateral adrenalectomy should receive a steroid substitutive therapy.

Health and income inequalities in Europe: What is the role of circumstances?

Equality of opportunity theories distinguish between inequalities due to individual effort and those due to external circumstances. Recent research has shown that half of the variability in income of World population was determined by country of birth and income distribution. Since health and income are generally strictly related, the aim of this paper is to estimate how much variability in income and health is determined by external circumstances. We use data from the Survey of Health, Ageing and Retirement (SHARE) and the English Longitudinal Survey on Ageing (ELSA), two comparable multidisciplinary surveys that provide micro-level data on health and financial resources among the elderly for a large number of European countries. Our baseline estimation shows that about 20% of the variability in income is explained by current country-specific circumstances, while health outcomes range from 12% using BMI to 19% using self-rated health. By including early-life circumstances, the explained variability increases almost 20 percentage points for income and for self-rated health but less for other health outcomes. Finally, by controlling for endogeneity issues linked with effort, our estimates indicate that circumstances better explain variability in health outcomes. Results are robust to some tests, and the implications of these findings are discussed.

Laparoscopic Radiofrequency Thermal Ablation for Uterine Adenomyosis

BACKGROUND AND OBJECTIVES

Symptomatic uterine adenomyosis, unresponsive to medical therapy, is a challenging condition for patients who desire to preserve their uterus. This study was an evaluation of the feasibility and efficacy of laparoscopic radiofrequency thermal ablation of symptomatic nodular uterine adenomyosis.

METHODS

Fifteen women with symptomatic nodular adenomyosis, who had no plans for pregnancy but declined hysterectomy, underwent radiofrequency thermal ablation. Ultrasonography was performed at baseline and at postoperative follow-ups at 3, 6, 9, and 12 months. The impact of uterine adenomyosis-related symptoms was assessed according to the visual analog scale.

RESULTS

The median number of nodular lesions treated per patient was 1 (range, 1-2). The median baseline volume of the adenomyosis area was 60 cm(3) (range, 18-128). The median reduction in volume was 32, 49.4, 59.6, and 65.4% at 3, 6, 9, and 12 months, respectively. A significant progressive improvement in the symptoms score was observed at the 4 follow-ups.

CONCLUSION

In this study, laparoscopic radiofrequency thermal ablation reduced uterine adenomyosis-related symptoms and volume, with significant relief of symptoms.

Consensus on Recording Deep Endometriosis Surgery: the CORDES statement

STUDY QUESTION

Which essential items should be recorded before, during and after endometriosis surgery and in clinical outcome based surgical trials in patients with deep endometriosis (DE)?

SUMMARY ANSWER

A DE surgical sheet (DESS) was developed for standardized reporting of the surgical treatment of DE and an international expert consensus proposal on relevant items that should be recorded in surgical outcome trials in women with DE.

WHAT IS KNOWN ALREADY

Surgery is an important treatment for symptomatic DE. So far, data have been reported in such a way that comparison of different surgical techniques is impossible. Therefore, we present an international expert proposal for standardized reporting of surgical treatment and surgical outcome trials in women with DE.

STUDY DESIGN, SIZE, DURATION

International expert consensus based on a systematic review of literature.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Taking into account recommendations from Consolidated Standards of Reporting Trials (CONSORT), the Innovation Development Exploration Assessment and Long-term Study (IDEAL), the Initiative on Methods, Measurement and Pain Assessment in Clinical trials (IMMPACT) and the World Endometriosis Research Foundation Phenome and Biobanking Harmonisation Project (WERF EPHect), a systematic literature review on surgical treatment of DE was performed and resulted in a proposal for standardized reporting, adapted by contributions from eight members of the multidisciplinary Leuven University Hospitals Endometriosis Care Program, from 18 international experts and from audience feedback during three international meetings.

MAIN RESULTS AND THE ROLE OF CHANCE

We have developed the DESS to record in detail the surgical procedures for DE, and an international consensus on pre-, intra- and post-operative data that should be recorded in surgical outcome trials on DE.

LIMITATIONS, REASONS FOR CAUTION

The recommendations in this paper represent a consensus among international experts based on a systematic review of the literature. For several items and recommendations, high-quality RCTs were not available. Further research is needed to validate and evaluate the recommendations presented here.

WIDER IMPLICATIONS OF THE FINDINGS

This international expert consensus for standardized reporting of surgical treatment in women with DE, based on a systematic literature review and international consensus, can be used as a guideline to record and report surgical management of patients with DE and as a guideline to design, execute, interpret and compare clinical trials in this patient population.

STUDY FUNDING/COMPETING INTERESTS

None of the authors received funding for the development of this paper. M.A. reports personal fees and non-financial support from Bayer Pharma outside the submitted work; H.T. reports a grant from Pfizer and personal fees for being on the advisory board of Perrigo, Abbvie, Allergan and SPD.

TRIAL REGISTRATION NUMBER

N/A.

Economic Evaluation of the effect of Quitting Smoking on Weight Gains: Evidence from the United Kingdom

OBJECTIVE

This article estimated the causal effect of quitting smoking on body weight gains in the United Kingdom to evaluate whether savings in health costs deriving from smoking prevention and its related diseases are greater than the costs associated with increased obesity.

METHODS

We used a longitudinal data set extracted from two waves (2004-2006) of the British Household Panel Survey, which includes information on smoking and a large number of sociodemographic variables. We modeled the effect of quitting smoking on body weight accounting for heterogeneous responses from individuals belonging to different clinical classes of body mass index (BMI) (i.e., overweight and obese individuals). National Health Service costs associated with smoking were then used to implement a cost-benefit analysis, comparing the advantages of smoking reductions with the costs associated with increased obesity.

RESULTS

The BMI was found to increase by 0.26 points for quitters compared with those who continued to smoke. The estimated BMI increase was larger for overweight (0.49 points) and obese (0.76 points) people. This result does not change when different control groups are examined. From an economic perspective, the National Health Service cost reductions attributable to quitting smoking were £156.81 million whereas the lost benefit for unintended increases in body weight was £24.07 million.

CONCLUSIONS

This article found that the health benefits associated with quitting smoking are greater than the costs associated with increased overweight and obesity.

Rare case of giant cystic adenomyoma mimicking a uterine malformation, diagnosed and treated by hysteroscopy

We describe a case of giant cystic uterine adenomyoma that was diagnosed and treated by hysteroscopy. In a 27-year-old woman with menometrorrhagia, severe dysmenorrhea, and chronic pelvic pain, pelvic ultrasonography revealed an enlarged uterine cavity filled with homogeneous low echogenic fluid content. A large cornual hematometra of 8.0 cm in diameter in a bicornuate uterus was suspected, and this hypothesis was also supported by magnetic resonance imaging findings. On the contrary, hysteroscopy revealed a bilocular huge cystic lesion of the posterior uterine wall that was removed by means of monopolar loop resection. The operative finding and the histopathologic examination confirmed the diagnosis of cystic adenomyoma of the uterus. Hysteroscopy may represent a valid tool for diagnosis and minimally invasive treatment of cystic adenomyoma, including those of large volume. Its use is helpful in differential diagnosis between cystic adenomyoma and uterine malformations as a possible cause of pelvic pain.

Self-perceived health among Eastern European immigrants over 50 living in Western Europe

OBJECTIVES

This paper examines whether Eastern European immigrants aged 50 and over living in Northern and Western Europe face a health disadvantage in terms of self-perceived health, with respect to the native-born. We also examined health changes over time (2004-2006-2010) through the probabilities of transition among self-perceived health states, and how they vary according to nativity status and age group.

METHODS

Data were obtained from the Survey of Health, Ageing and Retirement in Europe (SHARE). Logistic regressions and probabilities of transition were used.

RESULTS

Results emphasise the health disadvantage of Eastern European immigrants living in Germany, France and  Sweden with respect to the native-born, even after controlling for socio-economic status. Probabilities of transition also evidenced that people born in Eastern Europe were more likely to experience worsening health and less likely to recover from sickness.

CONCLUSIONS

This paper suggests that health inequalities do not affect immigrant groups in equal measure and confirm the poorer and more steeply deteriorating health status of Eastern European immigrants.

Transvaginal sonography for preoperative assessment of deep endometriosis

PURPOSE

To determinate transvaginal scan (TVS) accuracy in the preoperative evaluation of deep endometriosis in a large cohort of patients with subsequent laparoscopic assessment.

METHODS

A retrospective study was performed in a tertiary referral center for endometriosis. Transvaginal scan reports were retrieved from an electronic database of all patients who underwent laparoscopy for pelvic pain or infertility in 2009. The accuracy of TVS was assessed for 10 different sites of pelvic endometriosis.

RESULTS

Four hundred twenty women were included in the study. Sensitivity and specificity of TVS were 61% and 99%, respectively, for bladder endometriosis, 52% and 96% for endometriosis of rectovaginal septum, 65% and 99% for rectum endometriosis, and 69% and 98% for endometriosis of the sigmoid colon.

CONCLUSIONS

TVS appears to be useful for the detection of endometriosis located in the bladder and involving the sigmoid colon, the rectovaginal septum, and the rectum.

Randomised clinical trial: low-volume bowel preparation for colonoscopy - a comparison between two different PEG-based formulations

BACKGROUND

Low-volume bowel preparations with polyethylene glycol (PEG) have been shown to provide an equivalent cleansing with improved tolerability as compared with standard PEG bowel preparation for colonoscopy. A new iso-osmotic sulphate-free formulation of PEG-Citrate-Simethicone (PEG-CS) in combination with bisacodyl has been recently developed.

AIM

To compare the quality of bowel cleansing with PEG-CS with bisacodyl vs. PEG-Ascorbate (PEG-ASC) in adult out-patients undergoing colonoscopy.

METHODS

Randomised, observer-blind, parallel group study in adult out-patients undergoing colonoscopy in five Italian centres. Both preparations were taken the evening before the procedure. Subjects were instructed to take 2-4 tablets of 5 mg bisacodyl at 16:00 hours and 2 L of PEG-CS at 20:00 hours or 2 L of PEG-ASC plus 1 L of additional water the day before colonoscopy. Bowel cleansing was evaluated according to the Boston Bowel Preparation Scale (≥6 scores were considered as 'clinical success'), and mucosal visibility according to a 3-point scale. Tolerability, acceptability and compliance were also evaluated.

RESULTS

Four hundred and eight patients were randomly allocated to PEG-CS and bisacodyl (n = 204, male patient 48%, mean age 59.1 years) or PEG-ASC (n = 204, male patient 51%, age 59.4 years). In the planned per-protocol analysis, the rate of successful preparation was 79.1% following PEG-CS with bisacodyl, and 70% following PEG-ASC (P < 0.05). Mucosal visibility was evaluated as optimal in 56.1% in the PEG-CS and bisacodyl and 46.3% in the PEG-ASC group (P < 0.05). There were no serious adverse events (AE) in each of the two experimental groups. Two subjects in the PEG-ASC group discontinued the study because of AE.

CONCLUSIONS

Polyethylene glycol-Citrate-Simethicone in combination with bisacodyl was more effective for bowel cleansing than PEG-ASC for out-patient colonoscopy. Tolerability, safety, acceptability and compliance of the two low-volume bowel preparations were similar.

Nerve-sparing laparoscopic eradication of deep endometriosis with segmental rectal and parametrial resection: the Negrar method. A single-center, prospective, clinical trial

BACKGROUND

The weight of surgical radicality, together with a lack of anatomical theoretical basis for surgery and inappropriate practical skills, can lead to serious impairments to bladder, rectal, and sexual functions after laparoscopic excision of deep infiltrating endometriosis. Although the "classical" laparoscopic technique for endometriosis excision involving segmental bowel resection has proven to relieve symptoms successfully, it is hampered by several postoperative long-term and/or definitive pelvic dysfunctions.

METHODS

In this prospective cohort study, we compare the laparoscopic nerve-sparing approach to the classical laparoscopic procedure in a series of 126 cases. Satisfactory data for bowel, bladder, and sexual function were considered as primary endpoints.

RESULTS

A total of 126 patients were considered for analysis: 61 treated with nerve-sparing radical excision of pelvic endometriosis with segmental bowel resection (group B), and 65 treated with the classical technique (group A). Intraoperative, perioperative, and postoperative complications were similar between the two groups. Mean days of self-catheterization were significantly lower in the nerve-sparing group (39.8 days) compared with the non-nerve-sparing group (121.1 days; p < 0.001). The relapse rate within 12 months after surgery was comparable between the two groups. Patients of group A suffered from urinary retention more frequently between 1 and 6 months (p = 0.035) compared with group B and did not experience any improvement between 6 months and 1 year (p = 0.018). Overall detection of severe bladder/rectal/sexual dysfunctions was significantly different between the two groups, and 56 patients of group A (86.2%) reported a significantly higher rate of severe neurologic pelvic dysfunctions vs. 1 patient (1.6%) of group B (p < 0.001).

CONCLUSIONS

Our technique appears to be feasible and offers good results in terms of reduced bladder morbidity and apparently higher satisfaction than the classical technique. Considering that this kind of surgery requires uncommon surgical skills and anatomical knowledge, we believe that it should be performed only in selected reference centers.

Laparoscopic rectal resection for severe endometriosis of the mid and low rectum: technique and operative results

BACKGROUND

Although several studies have shown that laparoscopic resection is safe and feasible in bowel endometriosis, limited data are available on the specific treatment for endometriosis of the rectum. The aim of this study is to describe operative and postoperative outcomes after laparoscopic resection of the mid/low rectum for endometriosis.

METHODS

Between 2002 and 2010, 750 patients (median age 33 years) underwent laparoscopic resection of the mid/low rectum for deep infiltrating endometriosis at a single institution. All operations were performed with a standardized technique by a single surgeon.

RESULTS

Median operative time was 255 min, and median blood loss 150 ml. Of patients, 7% required blood transfusions. Laparotomic conversion rate was 1.6%. Mechanical low and very low colorectal anastomoses were carried out in 92.5 and 7.5% of patients, respectively. Temporary ileostomy rate was 14.5%. Median length of stay was 8 days. Overall surgical morbidity was 9% with no mortality. Rates of anastomotic leak, rectovaginal fistula, and intraabdominal bleeding were 3, 2, and 1.2%. Forty patients (5.5%) required reoperation.

CONCLUSIONS

Laparoscopic resection of the mid/low rectum for endometriosis can be performed safely with acceptable rates of morbidity/reoperation and with low rates of specific complications, including anastomotic leak and rectovaginal fistula. The very high surgical volume of the operating surgeon is probably one of the most important factors in order to maximize postoperative outcomes.

Symptomatic vaginal bleeding in a postmenopausal woman revealing colon adenocarcinoma metastasizing exclusively to the vagina

Vaginal carcinomas are rare entities, accounting for 2% of all malignant cancers of the female genital tract, and the vast majority are metastatic. Adenocarcinoma of the colon metastasizing to the vagina is extremely rare, only 5 cases have been reported. We present the case of a woman who experienced vaginal bleeding as an isolated symptom of vaginal metastasis of colorectal adenocarcinoma. Vaginal localization of metastasis from colorectal cancer significantly worsens the survival prognosis, and a standard treatment has not yet been proposed. Potential mechanisms of spread of colorectal cancer to the vagina and therapeutic approaches are discussed. In this case, treatment included surgery and chemotherapy.

Proposal for a systematic preoperative assessment of pelvic endometriosis

AIM

Severe endometriosis represents one of the most challenging clinical and surgical cases in gynecology. Preoperative assessment of the extension of the disease is of key relevance to opt for medical or surgical therapy and, sometimes, to plan a multidisciplinary approach.

METHODS

A systematic diagnostic approach is proposed and evaluated in a tertiary referral centre. It is based on an initial clinical evaluation and a second level ultrasound of the pelvis. Further exams, whenever required, have to be aimed at demonstrating specific involvements of organs other than ovaries and peritoneum such as bowel, urinary tract and nerves.

RESULTS

The application of the proposed protocol has led to a reduction of the number of non-radical surgical procedures due to incomplete consent associated with missed diagnosis over the years (P<0.001).

CONCLUSION

Our findings support the efficacy of a systematic diagnostic approach to endometriosis. This allows a correct planning of therapy with a multidisciplinary approach when necessary.

Distribution of endometriotic lesions in endometriosis stage IV supports the menstrual reflux theory and requires specific preoperative assessment and therapy

A detailed picture of the prevalence and distribution of abdomino-pelvic endometriosis in more that 1,500 cases of endometriosis stage IV is presented. A great prevalence of endometriotic localizations in the posterior pelvic compartment compared to the other quadrants with more frequently observed lesions on the left part of the pelvis supports the menstrual reflux theory. The extent of anatomical sites suggests the opportunity to plan a proper preoperative instrumental study for patients with clinical suspect of severe endometriosis possibly to set a multidisciplinary clinical or surgical management.

Laparoscopic ileocecal resection for bowel endometriosis

BACKGROUND

Ileocecal endometriosis is a very rare entity, and its diagnosis is usually made during surgery for other endometriosis sites or, rarely, because of direct complications of ileal involvement. This study was designed to analyze perioperative and long-term outcomes after bowel resection for ileocecal endometriosis.

METHODS

All patients who underwent surgery for ileocecal endometriosis between October 2004 and January 2008 were prospectively collected and analyzed.

RESULTS

Thirty-one women (median age, 34 (range, 25-40) years) were identified. Ileocecal endometriosis was diagnosed during surgery in all patients, and it was associated with colorectal endometriosis in 29 patients (94%). All patients underwent laparoscopic ileocecal resection with no laparotomic conversion. Rectosigmoid or rectal resections was associated in 28 patients (90%) and nodulectomy for sigmoid endometriosis in 1 patient. Median duration of surgery was 301 (range, 90-480) min. Other associated surgical procedures included total hysterectomy (n = 3, 14%), ureterolysis (n = 7, 23%), excision of vesical (n = 4, 13%), vaginal (n = 8, 26%), and parametrial (n = 3, 14%) nodules. There was no mortality. Four patients (13%) required blood transfusions and one a reoperation for bleeding. In a patient who performed ureterolysis, a ureteral fistula occurred. The median hospital stay was 7 (range, 5-18) days. Long-term (>12 months) follow-up data were available for 18 patients. After a median follow-up of 27 months, in 12 of 18 patients (67%) defecation after surgery was normal. Only one patient developed recurrence, which is under medical treatment.

CONCLUSIONS

Laparoscopic ileocecal resection is safe and feasible and should be considered as part of surgery for endometriosis with radical intent.

Colorectal endometriosis: benefits of long-term follow-up in patients who underwent laparoscopic surgery

In this retrospective cohort study, three groups of patients were included: 60 women who underwent endometriosis surgery with colorectal segmental resection, 40 women with surgical evidence of bowel endometriosis who underwent endometriosis removal without bowel resection, and 55 women affected by moderate or severe endometriosis with at least one endometrioma and deep infiltrating endometriosis but without bowel involvement. The results of a long-term ambulatory follow-up showed that if colorectal endometriosis was present, postoperative pain regression was more frequent, and among patients with bowel endometriosis the rate of recurrence was lower if segmental resection was performed.

Laparoscopic nerve-sparing transperitoneal approach for endometriosis infiltrating the pelvic wall and somatic nerves: anatomical considerations and surgical technique

PURPOSE

Endometriotic or fibrotic involvement of sacral plexus and pudendal and sciatic nerves may be quite frequently the endopelvic cause of ano-genital and pelvic pain. Feasibility of a laparoscopic transperitoneal approach to the somatic nerves of the pelvis was determined and showed by Possover et al. for diagnosis and treatment of ano-genital pain caused by pudendal and/or sacral nerve roots lesions and adopted at our institution. In this paper we report our experience and anatomo-surgical consideration regarding this technique.

METHODS

Confidence with this technique was obtained after several laparoscopic and laparotomic dissections on fresh, embalmed and formalin-fixed female cadavers and is now routinely performed at our institution in all cases of extensive endometriosis of the pelvic wall, involving the somatic nerves.

RESULTS

We describe two different laparoscopic transperitoneal approaches to the lateral pelvic wall in case of: (A) deep pelvic endometriosis with rectal and/or parametrial involvement extending to pelvic wall and somatic nerves; (B) isolated endometriosis of pelvic wall and somatic nerves.

CONCLUSIONS

Laparoscopic transperitoneal retroperitoneal nerve-sparing approach to the pelvic wall proved to be a feasible and useful procedure even if limited to referred laparoscopic centers and anatomically experienced and skilled surgeons.

Evaluation of colonic involvement in endometriosis: double-contrast barium enema vs. magnetic resonance imaging

BACKGROUND

The purpose of the study was to compare the accuracy of double-contrast barium enema (DCBE) and magnetic resonance imaging (MRI) in the diagnosis of intestinal endometriosis using the histological examination on resected specimen as comparative standard.

METHODS

Eighty-three consecutive patients with suspected intestinal endometriosis, resected between 2005 and 2007, were prospectively evaluated. All of the women underwent preoperative DCBE and MRI on the same day. We evaluated number, site (rectum, sigmoid, cecum), and size of the lesions. The imaging findings were correlated with those resulting at pathology.

RESULTS

Among the 65 women who underwent surgery, 50/65 (76.9%) were found to have bowel endometriosis, with 9/50 (18%) patients presenting two lesions; DCBE allowed to detect 50/59 (84.7%) lesions. MRI allowed to detect 42/59 (71.1%) lesions. DCBE showed sensibility, specificity, PPV, NPV, and accuracy of respectively 84.7, 93.7, 98.0, 62.5, and 86.6%, MRI of 71.1, 83.3, 93.3, 46.8, and 74.6%.

CONCLUSION

DCBE is more accurate than unenhanced MRI in the diagnosis of bowel endometriosis, and should be preferred in the preoperative management of this disease, since it usually enables a proper surgical planning.

Laparoscopic colorectal resection for deep infiltrating endometriosis: analysis of 436 cases

BACKGROUND

Complete removal of all visible lesions is considered the adequate treatment of pelvic endometriosis in order to reduce recurrence. Laparoscopic colorectal resection of bowel endometriosis is still challenging. A large series is reported.

METHODS

A longitudinal evaluation of surgical and clinical complications of 436 cases of severe endometriosis with colorectal resection was carried out. All procedures were performed laparoscopically in a single center and short-term complications were surveyed.

RESULTS

The overall complication rate was 8.3% with need for laparoconversion in 3.2%. Sixty patients required blood transfusion (13.7%), and rectovaginal fistulae were the most frequent postoperative complication (3.2%).

CONCLUSION

Laparoscopic colorectal resection for endometriosis is a relatively safe procedure in a context of close collaboration between gynecologists and surgeons, although it requires adequate training.

Discoid or segmental rectosigmoid resection for deep infiltrating endometriosis: a case-control study

OBJECTIVE

To evaluate the efficacy of discoid resection for the treatment of deep infiltrating endometriosis and whether it could be considered to be a valid alternative to the rectosigmoid segmental resection.

DESIGN

Case-control study.

SETTING

Departments of Obstetrics and Gynecology, Ospedale Sacro Cuore of Negrar, Verona, and Catholic University of the Sacred Heart, Rome, Italy.

PATIENT(S)

Women with deep infiltrating and intestinal endometriosis divided into study group (48 patients) and control group (88 patients).

INTERVENTION(S)

All patients underwent laparoscopic endometriosis excision plus discoid rectosigmoid resection (study group) or segmental resection (control group).

MAIN OUTCOME MEASURE(S)

Short- and long-term outcomes.

RESULT(S)

In the study group, median operating time was 200 minutes, with a median estimated blood loss of 203 mL. Median ileus was 3 days with a median postoperative hospitalization of 7 days. Early complications were observed in six patients (12.5%), and in two of them (4.16%) a surgical management was necessary. Median follow-up period was 33 months, and five recurrences (10.4%) were registered. In the control group, no significant differences were noticed except for longer operative time, more temporary ileostomy, postoperative fever, and long-term bladder dysfunctions.

CONCLUSION(S)

Laparoscopic mechanical discoid resection is feasible, markedly improved endometriosis related symptoms, and could be considered as a worthy alternative to classic segmental resection in selected patients.

National pathfinder survey on children's oral health in Italy: pattern and severity of caries disease in 4-year-olds

This paper describes the dental health status of Italian 4-year-olds in 2004/2005 and analyzes the association between caries in preschool children and some background characteristics in children and parents. Caries was recorded according to WHO criteria. 5,538 subjects were examined. Information on the children's and their parents' social, behavioral, ethnic and demographic status was obtained through a series of closed questions. Bivariate analysis was performed to investigate the association between caries and background characteristics. The probability of being an extra zero for the dmfs index was estimated via the zero-inflated negative binomial regression model (ZINB). 78.4% (95% CI = 77.2-79.6) of the children were caries-free. The national mean dmfs index was 1.36 (95% CI = 1.15-1.57), ranging from 1.22 (95% CI = 1.03-1.42) in the Italian North-East to 1.73 (95% CI = 0.83-2.63) in the South section. Significant bivariate associations between caries experience and risk factors were observed for parents' nationality (not Italian vs. Italian: p < 0.001), parents' educational levels (low vs. high: p < 0.001), preterm birth (yes vs. no: p = 0.011), prolonged breastfeeding (</=13 months vs. >13 months: p = 0.038) and early tooth eruption (<6 months as reference: p = 0.004). Multivariable analysis (ZINB) showed that children with a low caries risk level had a higher probability of being an extra zero; in particular, children from fathers with a high educational level showed a probability of being an extra zero of 0.22. The results suggest a need to plan preventive programs to reduce oral health disparities among Italian preschool children, based on educational intervention with parents and children concerning oral health and caries prevention.