[Intestinal endometriosis. Current status]

Surgeons' workload assessment during indocyanine-assisted deep endometriosis surgery using the surgery task load index: The impact of the learning curve

Objective

Assess the surgeons' workload during deep endometriosis surgery after ureteral ICG

Design

Prospective, consecutive, comparative, single-center study

Population

41 patients enrolled to deep endometriosis surgery with ureteral ICG from January 2019 to July 2021 at La Paz University Hospital

Methods

Patients were divided into 2 groups: patients operated during the learning curve of ureteral ICG instillation and patients operated after the technique was implemented and routinely performed. After surgery, the SURG-TLX form was completed by the surgeons. We evaluated whether a workload reduction occurred.

Main outcomes measures

Surgeon's workload was measured using the SURG-TLX form, obtaining the total workload and 6 different dimensions (distractions, temporal demands, task complexity, mental demands, situational stress and physical demands)

Results

A significant positive correlation was found between surgical complexity and situational stress (p = 0.04). Mental demands (p = 0.021), physical demands (p = 0.03), and total workload (p = 0.025) were significantly lower when the technique was routinely performed. The mental demand, physical demands, and total workload perceived by the surgeons at the beginning of the implementation was higher (68 [39–72], 27 [11–46.5], 229 [163–240], respectively) than in the latter ones (40 [9–63], 11.5 [0–32.8], 152 [133.3–213.8], respectively). Distractions appeared to be higher in the latter surgeries (8.5 [0–27.8]) than in the first surgeries (0 [0–7]; p = 0.057).

Conclusions

Ureter ICG instillation prior to DE surgery significantly reduces the mental and physical demands and total workload of the surgeons in DE surgeries after overcoming the learning curve. Distractions appear to increase as surgical stress decreases.

Deep Learning to Measure the Intensity of Indocyanine Green in Endometriosis Surgeries with Intestinal Resection

Endometriosis is a gynecological pathology that affects between 6 and 15% of women of childbearing age. One of the manifestations is intestinal deep infiltrating endometriosis. This condition may force patients to resort to surgical treatment, often ending in resection. The level of blood perfusion at the anastomosis is crucial for its outcome, for this reason, indocyanine green (ICG), a fluorochrome that green stains the structures where it is present, is injected during surgery. This study proposes a novel method based on deep learning algorithms for quantifying the level of blood perfusion in anastomosis. Firstly, with a deep learning algorithm based on the U-Net, models capable of automatically segmenting the intestine from the surgical videos were generated. Secondly, blood perfusion level, from the already segmented video frames, was quantified. The frames were characterized using textures, precisely nine first- and second-order statistics, and then two experiments were carried out. In the first experiment, the differences in the perfusion between the two-anastomosis parts were determined, and in the second, it was verified that the ICG variation could be captured through the textures. The best model when segmenting has an accuracy of 0.92 and a dice coefficient of 0.96. It is concluded that segmentation of the bowel using the U-Net was successful, and the textures are appropriate descriptors for characterization of the blood perfusion in the images where ICG is present. This might help to predict whether postoperative complications will occur during surgery, enabling clinicians to act on this information.

Imaging of gastrointestinal endometriosis: what the radiologist should know

Deep invasive gastrointestinal endometriosis (DIGIE) is a frequent and severe presentation of endometriosis. Although most cases invade the rectosigmoid colon, DIGIE can involve any portion of the gastrointestinal tract from the stomach to the rectum, and is commonly multifocal and multicentric. Although histopathologic confirmation with surgery remains the gold standard for diagnosis, ultrasound (US) and magnetic resonance imaging (MRI) are the key non-invasive imaging modalities for initial assessment. US may be preferred as a screening study because of its easy availability and low-cost. Pelvic MRI and magnetic resonance enterography (MRE) provide substantial advantages for disease mapping in the pre-operative period, particularly in extensive bowel endometriosis. Although medical management of DIGIE with hormonal therapy can help control symptoms, disease course can be relentless and require surgical intervention. Surgical options depend on, the location; length; depth; circumference; multicentric or multifocal disease. With procedures including simple excision, fulguration of superficial lesions, shaving, disc excision, and segmental resection. A successful treatment outcome is largely dependent on good communication between the treating surgeon and the radiologist, who can provide vital information for effective surgical planning by reporting the key elements that we elaborate upon in this paper.

Endometriosis of the appendix causing small bowel obstruction in a virgin abdomen

A 29-year-old, otherwise well, nulligravid woman presented to the emergency department with 1-day history of generalised abdominal pain and vomiting. She had similar symptoms 6 months prior following recent menstruations, which resolved conservatively. She had no prior history of abdominal surgery or endometriosis. CT scan demonstrated distal small bowel obstruction. A congenital band adhesion was suspected, and she underwent prompt surgical intervention. During laparoscopy, a thickened appendix was adhered to a segment of distal ileum. There was blood in the pelvis. Laparoscopic adhesiolysis and appendicectomy were performed. Histopathology demonstrated multiple foci of endometriosis of the appendix with endometrial glands surrounded by endometrial stroma. Oestrogen receptor and CD10 immunostains highlighted the endometriotic foci. The patient made a good recovery and was referred to a gynaecologist for further management.

A new reported case of ileocecal infiltrative endometriosis, a disease which is probably underdiagnosed

We have read the recent publications by Guerra et al. and Ávila et al. of two clinical cases of ileocecal infiltrative endometriosis. We present a new case and wonder if this disease is more frequent than previously thought.

Intestinal endometriosis. Our experience

Intestinal endometriosis is defined as a bowel infiltration by ectopic endometrial tissue. The prevalence is 3-37% of all women affected by endometriosis. Rectosigmoid colon is the most frequent location (70-93%), followed to ileocecal region, appendix and other colon and small bowel segments. Intestinal endometriosis usually is asymptomatic. Often it is only diagnosed during surgery for other reasons. The symptoms frequently are nonspecific, although it may appear as an acute abdominal pain. Clinical history, physical examination and image techniques are necessary for the diagnosis. The choice of the operative technique depends on the clinical presentation and on the fertility wishes of the patient. Laparotomy and laparoscopy are equally effective, but laparoscopic approach is preferred. We present 17 cases of patients from our Hospital diagnosed with intestinal endometriosis, from 2006 to 2015.

Endometriosis and Crohn's Disease Side by Side: A Case Report

Endometriosis is the presence of ectopic endometrial tissue at extrauterine sites. Symptoms vary greatly and depend on the extent of the disease, ranging from an asymptomatic state to a miscellaneous group of symptoms. The correct diagnosis of intestinal endometriosis is often delayed because it may clinically masquerade as a wide spectrum of diseases, mainly Crohn's disease.

We describe the case of a 42-year-old woman who presented to our hospital with subacute bowel obstruction. She had been suffering from strong abdominal disorders for over ten years with recurrent abdominal pain and chronic diarrhea, sometimes with gross bleeding, resulting in impaired nutrition, weight loss, and several hospital admissions. She had been diagnosed with Crohn's Disease ten years earlier, which was established by imaging, endoscopic and histologic criteria. The gastrointestinal symptoms were recurrent despite the medication for inflammatory bowel disease (IBD). The patient underwent a laparotomy, which identified a large bowel wall thickening with severe mucosal edema and luminal stricture in the proximal ileum. An ileocecal resection and appendectomy with latero-lateral ileocolic anastomosis was performed. Histopathological examination reported a diagnosis of ileocecal endometriosis. After a three-year follow-up period, she has no gynecologic symptoms but still maintains chronic diarrhea and imaging and endoscopic criteria are suggestive of IBD.

Intestinal endometriosis should be borne in mind when a woman of reproductive age presents with episodic gastrointestinal symptoms. Multidisciplinary care should be encouraged.

Acute small bowel obstruction secondary to intestinal endometriosis, an elusive condition: a case report

Background

Endometriosis is a benign condition affecting females of reproductive age. Although intestinal endometriosis is common it is rare for the condition to manifest as an acute bowel obstruction secondary to ileocaecal and appendicular endometriosis. This case is important to report as it highlights the diagnostic difficulty this particular condition presents to an emergency surgeon.

Case presentation

We present the case of a 33 year old female of Asian origin who presented with symptoms and signs of an acute small bowel obstruction. A right hemicolectomy for suspected malignancy was performed with an ileocolic anastomosis. Histological examination demonstrated extensive endometriosis of the appendix and ileocaecal junction.

Conclusion

Enteric endometriosis should be considered as a differential diagnosis when assessing females of reproductive age with acute small bowel obstruction. A high index of suspicion is required to arrive at a diagnosis of this elusive condition.

[Retrospective analysis of the use of the Spanish words severo and severidad in CIRUGIA ESPANOLA during 2007]

INTRODUCTION

The Spanish words severo (severe) and severidad (severity) are usually used as a synonyms of grave (serious) and gravedad (seriousness), although the Spanish Royal Academy of Language (Real Academia Española [RAE]) specifically recommends not to use them in this sense. A retrospective analysis to evaluate the use of the words severo and severidad in Cirugía Española during 2007 was performed.

MATERIAL AND METHOD

All the articles published in Cirugía Española during 2007 were reviewed. The articles in which severo and/or severidad were present were selected. For each article, the month of publication, the type of article, the geographic origin and the exact sentence containing these words were analyzed. Correctness and incorrectness of their use was studied according to the RAE normative.

RESULTS

A total of 33 articles were selected. Every month (except for January) had, at least, 2 articles. Thirty-one of the articles were from Spain whereas 2 were from Hispano-America. Eleven cases were original articles, 7 reviews, 6 case reports, 3 editorials, 3 special articles and 3 letters to the editor.

CONCLUSIONS

The Spanish words severo and severidad are inadequately used too often in scientific texts. It must be avoided using them as a synonym of grave, importante or serio, incorrect translations of the English word severe.