Detection and Classification of Hysteroscopic Images Using Deep Learning

BACKGROUND

Although hysteroscopy with endometrial biopsy is the gold standard in the diagnosis of endometrial pathology, the gynecologist experience is crucial for a correct diagnosis. Deep learning (DL), as an artificial intelligence method, might help to overcome this limitation. Unfortunately, only preliminary findings are available, with the absence of studies evaluating the performance of DL models in identifying intrauterine lesions and the possible aid related to the inclusion of clinical factors in the model.

AIM

To develop a DL model as an automated tool for detecting and classifying endometrial pathologies from hysteroscopic images.

METHODS

A monocentric observational retrospective cohort study was performed by reviewing clinical records, electronic databases, and stored videos of hysteroscopies from consecutive patients with pathologically confirmed intrauterine lesions at our Center from January 2021 to May 2021. Retrieved hysteroscopic images were used to build a DL model for the classification and identification of intracavitary uterine lesions with or without the aid of clinical factors. Study outcomes were DL model diagnostic metrics in the classification and identification of intracavitary uterine lesions with and without the aid of clinical factors.

RESULTS

We reviewed 1500 images from 266 patients: 186 patients had benign focal lesions, 25 benign diffuse lesions, and 55 preneoplastic/neoplastic lesions. For both the classification and identification tasks, the best performance was achieved with the aid of clinical factors, with an overall precision of 80.11%, recall of 80.11%, specificity of 90.06%, F1 score of 80.11%, and accuracy of 86.74 for the classification task, and overall detection of 85.82%, precision of 93.12%, recall of 91.63%, and an F1 score of 92.37% for the identification task.

CONCLUSION

Our DL model achieved a low diagnostic performance in the detection and classification of intracavitary uterine lesions from hysteroscopic images. Although the best diagnostic performance was obtained with the aid of clinical data, such an improvement was slight.

Hysteroscopic Transillumination as a Guide for Laparoscopic Excision of Rudimentary Uterine Horn: A Winning Duo

STUDY OBJECTIVE

Anatomic anomalies of the female reproductive genital tract affect approximately 5.5% of women [1]. The hemiuterus or class U4 by the European Society of Human Reproduction and Embryology / European Society for Gynaecological Endoscopy 2013 classification is a rare congenital malformation defined as a unilateral uterine development, with a contralateral part that could be either incompletely formed or absent. This class is divided into 2 subclasses depending on the presence or not of a functional rudimentary cavity (U4a/U4b) [2]. This work aimed to share our experience performing an hysteroscopic and laparoscopic combined technique to surgically manage this uterine malformation exploiting the hysteroscopic transillumination.

DESIGN

A step-by-step explanation of surgical technique with narrated video footage.

SETTING

Tertiary Level Academic Hospital "IRCCS Azienda Ospedaliero - Universitaria di Bologna" Bologna, Italy.

INTERVENTIONS

A 32-year-old woman with a symptomatic (severe dysmenorrhea and chronic pelvic pain) suspected U4a uterine malformation diagnosed at our center was scheduled for laparoscopic removal of the right uterine horn and ipsilateral salpingectomy exploiting the contemporary hysteroscopic transillumination guidance. We selected this approach to avoid possible complications owing to the anatomic anomalies that are very common in these cases [3,4]. After coagulation and section of the right round ligament at the uterine angle and opening of the right broad ligament, access to the retroperitoneum was obtained to directly visualize the entire course of ureter and the uterine artery. The right uterine artery was coagulated and sectioned at the uterus. Then, the hysteroscope was introduced to the uterine fundus and the light source brightness was increased up to 100% to allow an adequate transmural visualization of the uterine defect from the laparoscope. Once the defect edge was well highlighted, the right uterine horn was isolated and removed using a monopolar hook, taking care to preserve an adequate amount of myometrium. A double layer running suture with barbed absorbable thread (V-Loc) for reconstructive purposes was performed. The specimen was retrieved inside an endobag to allow a safe extraction. Right salpingectomy was then performed.

CONCLUSION

Considering the great anatomic variability of this condition, this type of surgery is not always simple. Indeed, the borders between the uterus and the rudimentary uterine horn are often not perfectly recognizable; this can lead to accidental removal of healthy myometrium and increase the risk of perioperative bleeding [5]. In our experience, the combined hysteroscopic and laparoscopic combined technique allows the surgeon to better delimit the borders of the hemiuterus, providing a more conservative and safer surgery. Hysteroscopic transillumination offers the possibility to modulate the radicality in the resection of the rudimentary horn and in the final treatment of dysmorphism. VIDEO ABSTRACT.

Laparoscopic entry techniques: Which should you prefer?

BACKGROUND

Despite a debate spanning two decades, no consensus has been achieved about the safest laparoscopic entry technique.

OBJECTIVES

To update the evidence about the safety of the main different laparoscopic entry techniques.

SEARCH STRATEGY

Six electronic databases were searched from inception to February 2021.

SELECTION CRITERIA

All randomized controlled trials (RCTs) comparing different laparoscopic entry techniques were included.

DATA COLLECTION AND ANALYSIS

Entry-related complications and total time for entry were compared among the different methods of entry calculating pooled odds ratios (ORs) and mean differences, with 95% confidence intervals (CIs); P < 0.05 was considered significant.

MAIN RESULTS

In total, 25 RCTs (6950 patients) were included. Complications considered were vascular, visceral and omental injury, failed entry, extraperitoneal insufflation, bleeding and infection at the trocar site bleeding, and incisional hernia. Compared to direct trocar, the OR for Veress needle was significantly higher for omental injury (OR 3.65, P < 0.001), for failed entry (OR 4.19, P < 0.001), and for extraperitoneal insufflation (OR 5.29, P < 0.001). Compared to the open method, the OR for Veress needle was significantly higher for omental injury (OR 4.93, P = 0.001), for failed entry (OR 2.99, P < 0.001), for extraperitoneal insufflation (OR 4.77; P = 0.04), and for incisional hernia. Compared to the open method, the OR for direct trocar was significantly lower for visceral injury (OR 0.17, P = 0.002) and for trocar site infection (OR 0.27, P = 0.001).

CONCLUSIONS

The direct trocar method may be preferred over Veress needle and open methods as a laparoscopic entry technique since it appears associated to a lower risk of complications.

Is preoperative ultrasound tumor size a prognostic factor in endometrial carcinoma patients?

Objective

We aimed to assess the prognostic value of preoperative ultrasound tumor size in EC through a single center, observational, retrospective, cohort study.

Methods

Medical records and electronic clinical databases were searched for all consecutive patients with EC, preoperative ultrasound scans available to ad hoc estimate tumor size, and a follow-up of at least 2-year, at our Institution from January 2010 to June 2018. Patients were divided into two groups based on different dimensional cut-offs for the maximum tumor diameter: 2, 3 and 4 cm. Differences in overall survival (OS), disease specific survival (DSS) and progression-free survival (PFS) were assessed among the groups by using the Kaplan–Meier estimator and the log-rank test.

Results

108 patients were included in the study. OS, DSS and PFS did not significantly differ between the groups based on the different tumor diameter cut-offs. No significant differences were found among the groups sub-stratified by age, BMI, FIGO stage, FIGO grade, lymphovascular space invasion status, myometrial invasion, lymph nodal involvement, histotype, and adjuvant treatment.

Conclusions

Preoperative ultrasound tumor size does not appear as a prognostic factor in EC women.

Histological Prognostic Factors of Endometrial Cancer in Patients with Adenomyosis: A Systematic Review and Meta-Analysis

BACKGROUND

A better endometrial cancer (EC) prognosis in patients with coexistent adenomyosis has been hypothesized based on a different prevalence of favorable EC histological prognostic factors. However, pooled risk of EC unfavorable histological prognostic factors in patients with adenomyosis has never been calculated.

OBJECTIVES

We aimed to assess the risk of EC unfavorable histological prognostic factors in patients with adenomyosis.

METHODS

All studies with data about histological prognostic factors of EC in patients with and without adenomyosis were included. Relative risk for each unfavorable histological prognostic factor of EC, such as nonendometrioid histotype, FIGO grade 3, FIGO stage II-IV, lymphovascular space invasion (LVSI), and deep myometrial invasion, was calculated in patients with adenomyosis compared to patients without adenomyosis.

RESULTS

Seven studies with 4,439 patients were included in the quantitative analysis. EC patients with adenomyosis showed a pooled RR of 0.77 (p = 0.05) for nonendometrioid histotype, 0.55 (p < 0.00001) for FIGO grade 3, 0.60 (p = 0.005) for FIGO stage II-IV, 0.75 (p = 0.004) for LVSI, and 0.65 (p = 0.001) for deep myometrial invasion.

CONCLUSION

EC patients with adenomyosis have a significantly decreased risk for unfavorable histological prognostic factors of EC compared to EC patients without adenomyosis. Such findings might explain the supposed better EC prognosis in patients with adenomyosis.

Pelvic floor dysfunction at transperineal ultrasound and chronic constipation in women with endometriosis

OBJECTIVE

To assess the association between sonographic findings at transperineal ultrasound (TPU) and chronic constipation (CC) in women with endometriosis.

METHODS

An observational prospective cohort study was performed by enrolling all endometriosis women scheduled for surgery between September 2019 and October 2020. Women underwent TPU at rest and during Valsalva maneuver evaluating levator-hiatal-area (LHA), antero-posterior diameter (APD), levator-ani muscle (LAM)-coactivation. Ultrasound findings were compared between women with and without CC in the whole study population, and subsequently in two subgroups [only ovarian and deep infiltrating endometriosis (DIE)].

RESULTS

87 women were enrolled: 29 (33%) with CC and 58 (67%) without CC. Women with endometriosis and CC showed a smaller LHA during Valsalva, less LHA and APD enlargement from rest to maximum Valsalva, a higher prevalence of LAM-coactivation compared to women without CC. In ovarian-subgroup, women with CC had smaller LHA at Valsalva, less enlargement of LHA and APD from rest to maximum Valsalva and higher prevalence of LAM-coactivation compared to non-CC patients. In DIE-subgroup, TPU did not significantly differ between CC and non-CC patients.

CONCLUSION

TPU signs of pelvic floor muscle hypertone are more frequent in endometriosis patients with CC compared to those without constipation, particularly in women affected by isolated ovarian endometriosis.

Conservative cesarean scar pregnancy treatment: local methotrexate injection followed by hysteroscopic removal with hysteroscopic tissue removal system

OBJECTIVE

To describe a conservative cesarean scar pregnancy (CSP) treatment in a patient with the desire for future pregnancy. To date, there is no gold standard for the management of a viable CSP. There is a wide range of treatment options that include major surgery and minimally invasive procedures. Moreover, after a minimally invasive treatment, the gestational sac may be visible at ultrasound for >6 months. The described technique may be useful to avoid complications related to the use of energy with a large reduction in operative times.

DESIGN

Description of the technique with narrated video footage.

SETTING

Academic tertiary hospital.

PATIENT(S)

A 31-year-old woman with a previous cesarean section was referred to our clinic with lower abdominal pain. Transvaginal ultrasound revealed a gestational sac with a viable embryo located in the anterior isthmic region, suggestive of CSP at 9 weeks of gestation. Appropriate counseling describing the two diametrically opposite clinical management options was performed, and the patient decided to terminate the pregnancy. Informed consent was obtained from the patient.

INTERVENTION(S)

Hysteroscopy was performed under local anesthesia in an outpatient setting, using a 2.9-mm Hopkins II Forward-Oblique Telescope 30° endoscope (Karl Storz, Tuttlingen, Germany) with a 4.3-mm inner sheath and 5F instruments. A 3.7F needle (Deflux metal needle; Oceana Therapeutics, Edison, NJ) was pushed into the myometrial tissue surrounding the implantation site of the gestational sac at four different points. Six additional injections were performed into the gestational sac, and 50-mg methotrexate was injected. The appropriate follow-up was performed to determine the success of the procedure. β-Human chorionic gonadotropin was dosed weekly until negative. After 6 weeks, to remove the avascular trophoblastic remnants found at ultrasound evaluation, the patient underwent hysteroscopic removal with a 6-mm TruClear hysteroscopic tissue removal system (Medtronic Parkway, Minneapolis, MN). A contemporary transabdominal ultrasound was performed to minimize surgical risks.

MAIN OUTCOME MEASURE(S)

Complete and conservative CSP treatment with the absence of surgical complications.

RESULT(S)

Conservative cesarean scar pregnancy treatment was performed successfully with primary local methotrexate injection followed, after 6 weeks, by hysteroscopic removal of the CSP remnants with the TruClear hysteroscopic tissue removal system. The first procedure lasted 6 minutes, whereas hysteroscopic removal of the CSP lasted 5 minutes. Both procedures were performed in an outpatient setting, and no complications were detected during and after the treatments. The patient reported good health at the 1-month follow-up visit, and the ultrasound showed an empty isthmocele (Fig. 1).

CONCLUSION(S)

Primary local methotrexate injection followed by hysteroscopic removal of the CSP remnants with the hysteroscopic tissue removal system may be a valuable treatment for women who desire pregnancy in the near future. This combined technique may avoid potential complications, such as thermal-induced myometrial injuries or uterine perforation. Moreover, the operator has the possibility to perform an under-vision procedure with a lower incidence of intraoperative and postoperative bleeding. Because it does not reduce fertility/pregnancy rate, this technique should be a valid option in patients who desire future pregnancy.

C-reactive Protein for Predicting Early Postoperative Complications in Patients Undergoing Laparoscopic Shaving for Deep Infiltrating Endometriosis

STUDY OBJECTIVE

To assess the accuracy of C-reactive protein (CRP) in predicting early postoperative complications in patients undergoing elective laparoscopic shaving for rectosigmoid deep infiltrating endometriosis (DIE).

DESIGN

A single-center observational retrospective cohort study.

SETTING

Third-level referral center for endometriosis.

PATIENTS

A total of 294 patients were included in the study. All of them underwent elective laparoscopic shaving for rectosigmoid DIE.

INTERVENTIONS

Postoperative CRP levels (assessed from day 3 onward, every 48 hours, until hospital discharge) and early postoperative complications were reviewed to assess CRP as a predictive marker of postoperative complications.

MEASUREMENTS AND MAIN RESULTS

The study outcomes were the association between early postoperative complications and CRP levels, the optimal CRP cutoff, and its predictive accuracy. Twenty-five patients (8.5%) experienced early postoperative complications. Five patients with postoperative complications within 2 days of surgery were excluded from the analysis. On postoperative day 3 the difference in the means of CRP levels between patients with and without complications was 2.5 mg/dL (95% CI, 1.0-4.1), whereas on day 5 the difference was 5.3 mg/dL (95% CI, 3.3-7.5), with a significant increase of 2.8 mg/dL (95% CI, 0.2-5.5). On postoperative day 7 the difference was 11.4 mg/dL (95% CI, 8.2-14.6), with an increase of 6.1 mg/dL (95% CI, 2.2-9.9) from day 5. The mean CRP level in the group with complications showed an increase of 1.2 mg/dL (95% CI, -1.3 to 3.8) from day 3 to day 5 and of 6.2 mg/dL (95% CI, 2.6-9.8) from day 5 to day 7. The optimal cutoff for the CRP level in predicting early postoperative complications was 3.1 mg/dL on postoperative day 3 and 5.2 mg/dL on postoperative day 5, with a sensitivity of 87.5% (95% CI, 52.9-97.8) and 80% (95% CI, 37.6-96.4), a specificity of 62.5% (95% CI, 52.1-71.9) and 91.2% (95% CI, 81.1-96.2), a positive predictive value of 17.5% (95% CI, 8.7-31.9) and 44.4% (95% CI, 18.9-73.3), a negative predictive value of 98.2% (95% CI, 90.6-99.7) and 98.1% (95% CI, 90.1-99.7), and an area under the receiver operating characteristic curve of 75.0% (95% CI, 61.9-80.1) and 85.6% (95% CI, 74.1-96.5), respectively.

CONCLUSION

CRP on postoperative day 5 seemed to be a moderately accurate predictive marker of early postoperative complications in the patients who had undergone elective laparoscopic shaving for rectosigmoid DIE.

Transvaginal ultrasound features of normal uterosacral ligaments

OBJECTIVE

To show a step-by-step technique to assess normal uterosacral ligaments (USLs) during transvaginal ultrasound. Uterosacral ligaments represent the most common location of deep infiltrating endometriosis (DIE) in the posterior compartment and their involvement significantly increases the risk of ureteral lesions. The ultrasonographic diagnosis of DIE involving USLs is characterized by a wide range of accuracies described between studies, probably due to variations in the examination technique, quality of ultrasound equipment, and experience of the operators. Although described as a new classification system of DIE involving USLs, the technique for visualizing normal USLs has not yet been described.

DESIGN

Stepwise demonstration of the technique with narrated video footage.

SETTING

Academic tertiary hospital.

PATIENT(S)

The video shows a 33-year-old nulliparous woman scheduled for laparoscopic removal of a para-ovarian cyst of approximately 6 cm. Procedural steps were repeated and confirmed in another four patients submitted to laparoscopy for benign diseases (Table 1). Moreover, we here show the case of a 29-year-old woman with an isolated DIE nodule of the right USL with a comparison of laparoscopic and ultrasound findings. To better point out the technique applied in a clinical setting we show also cases of infiltrated USLs (Table 2) during the ultrasound scan in women scheduled for endometriosis surgery. Informed consent was obtained from all of the patients. The study protocol was approved by the local institutional Ethics Committee (580/2018/Oss/AOUBo).

INTERVENTION(S)

To understand correctly the right position of USLs we performed an ultrasound during a surgical procedure; in this way it was possible to recognize the area of interest while the surgeon filled the pouch of Douglas with fluid and highlighted the anatomical area with pliers. Uterosacral ligaments can be seen in the mid-sagittal and transverse view of the uterus.

MAIN OUTCOME MEASURE(S)

Description of appearance of normal USLs during transvaginal ultrasound.

RESULT(S)

Uterosacral ligaments, at transvaginal ultrasound, appear as hyperechoic stripes starting from the cervix and pointing laterally in a semi-horizontal direction.

CONCLUSION(S)

We provided a step-by-step technique (Table 3) that may be a useful tool to see accurately both the USLs at transvaginal ultrasound.

Indocyanine Green Fluorescence Angiography after Full-thickness Bowel Resection for Rectosigmoid Endometriosis-A Feasibility Study

STUDY OBJECTIVE

To evaluate feasibility of near-infrared (NIR)-indocyanine green (ICG) imaging for bowel vascularization assessment after full-thickness bowel resection for rectosigmoid endometriosis (RSE).

DESIGN

This is a prospective, single-center, preliminary study on consecutive patients who were symptomatic submitted to discoid or segmental resection for RSE and NIR-ICG evaluation for vascular assessment of the anastomotic line from May 2018 to January 2020.

SETTING

Tertiary university hospital.

PATIENTS

Thirty-two women with RSE meeting eligibility criteria were included for study analysis.

INTERVENTIONS

NIR-ICG evaluation of anastomotic line vascularization after RSE removal.

MEASUREMENTS AND MAIN RESULTS

Fluorescence degree of the anastomotic line was assessed with a 0 to 2 Likert scale, as follows: 0 or "absent" (no fluorescence observed), 1 or "irregular" (not uniform distribution or weak fluorescence), and 2 or "regular" (uniform distribution of fluorescence and similar to the proximal colon). In all the patients included in the study (100%), NIR-ICG imaging allowed the evaluation of fluorescence degree of the anastomotic line. No adverse reaction related to ICG use was recorded. The protocol did not greatly lengthen operating time (median, 4 [range, 3-5] minutes). Excellent interoperator agreement was observed. Most of the patients (31 of 32, 96.9%) showed regular fluorescence on the anastomotic line; in 1 patient with irregular fluorescence at NIR-ICG after discoid excision, the anastomotic suture was reinforced through interrupted stitches. We had 1 case of anastomotic leakage after segmental resection with intraoperative good fluorescence at NIR-ICG evaluation.

CONCLUSION

NIR-ICG imaging for anastomotic perfusion assessment after discoid or segmental resection for RSE seems to be a feasible, safe, and reproducible method.

Adhesion barriers in laparoscopic myomectomy: Evidence from randomized clinical trials

OBJECTIVE

To evaluate the effectiveness of different adhesion barriers in the prevention of de novo adhesion development after laparoscopic myomectomy.

METHODS

A systematic review was performed by searching seven electronic databases for all randomized clinical trials (RCTs) comparing the use of any absorbable adhesion barrier (i.e. intervention group) with either no treatment or placebo (i.e. control group) in the prevention of adhesion development after laparoscopic myomectomy.

RESULTS

Eight RCTs with a total of 748 participants (392 in the intervention group and 356 in the control group) were included. The assessed adhesion barrier methods were: oxidized regenerated cellulose (ORC) in two studies, auto-crosslinked hyaluronic acid (HA) gel in two studies, 4% icodextrin solution in one study, modified HA and carboxy-methylcellulose in one study, polyethylene glycol ester trilysine amine solution plus a borate buffer solution in one study, and polyethylene glycol amine plus dextran aldehyde polymers in another study.

CONCLUSION

Adhesion barrier methods showing the most promising results were: ORC, auto-crosslinked HA gel, and polyethylene glycol amine plus dextran aldehyde polymers.

Transvaginal Ultrasound and Doppler Features of Intraligamental Myomas

OBJECTIVES

To describe the ultrasound (US) features of intraligamental myomas (IMs) using Morphological Uterus Sonographic Assessment group standardized terminology.

METHODS

This was a retrospective monocentric study. A total of 125 consecutive women with a preoperative US diagnosis of a myoma located close to the uterine isthmus (International Federation of Gynecology and Obstetrics stages 5, 6, and 7) from 2016 to 2019 who underwent laparoscopic or laparotomic myomectomy or hysterectomy were included for study analyses. The US data were retrieved from US reports and stored digital images by 2 authors. Ultrasound features of myomas were described according to Morphological Uterus Sonographic Assessment terminology. Clinical data for the study population were retrieved from the patients' records.

RESULTS

Nineteen women with a surgical confirmation of an IM were included in the study group; the remaining population constituted the control group (n = 106). Non-uniform echogenicity was detected in 17 of 19 (89%) of IMs compared to 26 of 106 (25%) fibroids in the control group (P < .001). The presence of shadowing was detected in 12 of 19 (63%) IMs compared to 94 of 106 (89%) cases in the control group (P = .004). Intraligamental myomas were more vascularized tumors compared to myomas in the control group (P = .004). Transvaginal US showed high specificity for the diagnosis of an IM (0.93; 95% confidence interval, 0.87-0.96).

CONCLUSIONS

On US imaging, IMs appear as vascularized solid tumors with nonuniform echogenicity; cones of shadows were less frequent in IMs than the control group, and this finding can help in the differential diagnosis. Knowledge of their specific US features could help sonographers make an accurate diagnosis, allowing them to plan correct surgery and avoid severe complications.

Rectosigmoid Endometriosis Vascular Patterns at Intraoperative Indocyanine Green Angiography and their Correlation with Clinicopathological Data

Introduction. The objective of the study was to evaluate the presence of different rectosigmoid endometriosis (RSE) vascular patterns using intraoperative indocyanine green (ICG) angiography and their correlation with clinicopathological data. Material and Methods. A prospective pilot study on 30 consecutive symptomatic women affected by RSE and scheduled for minimally invasive surgery between May 2018 and January 2019. ICG was used for the intraoperative evaluation of RSE vascularization. Perfusion grade was classified as follows: 0-1 = no or low fluorescence (hypovascular pattern); 2 = regular fluorescence, similar to healthy surrounding rectosigmoid tract (isovascular pattern); and 3-4 = diffuse or abundant fluorescence (hypervascular pattern). Results. Thirty women were intravenously injected with ICG after nodule exposure. No adverse effects related to ICG use were noted. After a 5- to 50-s latency from ICG injection, the real-time direct visualization of RSE perfusion showed diffuse or abundant fluorescence in 12/30 (40%) women, while in the remaining 18/30 (60%), fluorescence was poor or absent. No statistical differences were observed between the 2 groups regarding preoperative, intraoperative, and histological variables analyzed, except for a maximum diameter of bowel lesions and microvessel density (MVD). Hypovascular nodules had a larger maximum diameter (39.5 ± 15.6 mm vs 30.3 ± 11.4 mm, P < .05) and lower MVD (154.6+/43.6 vs 281.1+/-77.4, P < .05) than hypervascular ones. Conclusions. ICG angiography is a feasible and safe technique to intraoperatively assess RSE vascularization. The majority (60%) of endometriotic nodule presented a hypovascular pattern. The hypovascular pattern seems to be associated with a larger nodule size and lower MVD.

Laparoscopic surgery for benign adnexal conditions under spinal anaesthesia: Towards a multidisciplinary minimally invasive approach

•

In general surgery locoregional anaesthesia increased laparoscopy advantages.

•

28 women submitted to gynaecological laparoscopy for benign adnexal conditions.

•

13 patients under spinal anaesthesia, 15 under general anaesthesia.

•

Less postoperative pain and reduced need f opioids in the spinal anaesthesia arm.

•

Earlier mobilization and return of bowel function in the spinal anaesthesia arm.

Background

Laparoscopic gynaecological surgery is commonly performed under general anaesthesia with endotracheal intubation. In general surgery, locoregional anaesthesia was applied to laparoscopic procedures, increasing minimally invasive surgery advantages.

Aims

To assess and compare postoperative pain after laparoscopic adnexal procedures for benign conditions under spinal anaesthesia (SA) versus general anaesthesia (GA). Furthermore, anaesthesiologic, surgical and clinical data were evaluated in both groups.

Materials and Methods

This is a prospective cohort study performed in a tertiary level referral centre for minimally invasive gynaecological surgery (Gynaecology and Human Reproduction Physiopathology, University of Bologna). Women scheduled for adnexal laparoscopic surgery for benign conditions between February and May 2019 were assigned to receive either SA or GA with endotracheal intubation. A sample size of 13 women per group was needed to detect a 2-point difference in pain scores.

Main findings

13 women were enrolled in the SA arm, 15 in the GA arm. In the SA cohort, the most common intraoperative adverse event was shoulder pain, reported by 3/12 women. At 1, 8, 12, 24 and 48 h after surgery pain was significantly lower in the SA arm (p < .05). Patients submitted to SA experienced no need for opioid drugs administration, unlike those receiving GA. Patients’ mobilization and return of bowel function were noted significantly earlier in the SA group (p < .05).

Conclusions

SA is a feasible, safe and effective anaesthesiologic technique for laparoscopic gynaecological procedures for benign conditions, allowing a better control of postoperative pain. Women undergoing SA achieve earlier mobilization and bowel canalization. During the Covid-19 pandemics, SA could be useful in reducing the need for invasive procedures on respiratory tract.

Liver function, tolerability and satisfaction during treatment with ulipristal acetate in women with fibroids: a single center experience

The aim of the study was to evaluate liver function in women treated with ulipristal acetate (UPA) and to assess the tolerability and satisfaction during treatment. This Cross-sectional study included women with symptomatic uterine fibroids subjected to one or more 3-month treatment courses of 5 mg UPA daily. Following European Medical Agency's prescriptions, women were asked about symptoms potentially related to liver damage and had blood tests done, to assess serum levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT). Data on side effects, tolerability and satisfaction with the therapy were obtained during a phone interview. A total of 162 women completed the study with a mean treatment duration of 1.8 ± 0.9 cycles. No increased AST and ALT serum levels were detected and no woman reported symptoms suggestive of liver injury. The majority of women reported improvement of fibroids-related symptoms and a high degree of satisfaction with treatment. More than half of women had side effects, in most cases not as severe as to discontinue therapy. Ulipristal acetate did not worsen liver function or cause severe organ injury and showed high tolerability and satisfaction profiles. Therefore, we believe that it can still be considered a valuable option in the treatment of uterine fibroids.

Universality of galactic surface densities within one dark halo scale-length

It was recently discovered that the mean dark matter surface density within one dark halo scale-length (the radius within which the volume density profile of dark matter remains approximately flat) is constant across a wide range of galaxies. This scaling relation holds for galaxies spanning a luminosity range of 14 magnitudes and the whole Hubble sequence. Here we report that the luminous matter surface density is also constant within one scale-length of the dark halo. This means that the gravitational acceleration generated by the luminous component in galaxies is always the same at this radius. Although the total luminous-to-dark matter ratio is not constant, within one halo scale-length it is constant. Our finding can be interpreted as a close correlation between the enclosed surface densities of luminous and dark matter in galaxies.

Analysis of rotation curves in the framework of the gravitational suppression model

We present an analysis of suitable rotation curves (RCs) of eight galaxies, aimed at checking the consistency and universality of the gravitational suppression (GraS) hypothesis, a phenomenological model for a new interaction between dark matter and baryons. Motivated by the puzzle of the core versus cusp distribution of dark matter in the center of halos, this hypothesis claims to reconcile the predictions from N-body Lambda cold dark matter simulations with kinematic observations. The GraS model improves the kinematic fitting residuals, but the mass parameters are unphysical and put the theory in difficulty.

AEC set-up optimisation with computed radiography imaging

Phototimer set-up is a critical procedure for dose and image quality optimisation in computed radiography (CR) systems. While a conventional radiography automatic exposure control device (AEC) can be calibrated in order to gain a constant optical density on the film independent of beam quality and patient size, CR detectors present a high dynamic range which allows a much larger dose interval, but with different image quality levels. CR leads to a less frequent exam repetition, but may produce quite noisy images if the exposure level on the plate is not correct. The aim of this work is to evaluate the performance of a CR plate (Agfa MD40) in order to optimally calibrate an AEC device. The plate response has been characterised in terms of digital signal, exposure on the plate and signal-to-noise ratio for different beam qualities, in a patient of standard size.

Botulinum toxin with and without casting in ambulant children with spastic diplegia: a clinical and functional assessment

This study compared clinical and functional outcomes after treatment with botulinum toxin A (BTX-A) and BTX-A with casting in children with dynamic equinus foot. Ten children (seven males, three females; mean age 6 years 4 months, SD 2 years 7 months; range 4 to 11 years) with mild spastic diplegia and independent walking were divided into two groups: group 1, BTX-A and group 2, BTX-A plus casting. BTX-A was injected in the triceps surae bilaterally at multiple sites while the children were sedated with mask anaesthesia. Dysport toxin was used, 15 to 20 IU/kg in each muscle. Immediately after injection an ankle-foot orthosis was applied to children in group 1 and a cast to children in group 2. Clinical assessment using the Ashworth scale, Gross Motor Function Measure (GMFM), range of movement measurement, and gait analysis was performed before treatment and 1, 4, and 12 months after treatment. Spasticity decreased significantly at 1-month examination in both groups (p = 0.002), at 4-month examinations (Wilcoxon test p = 0.003), and 12 month (p = 0.052) examinations in group 2. GMFM highlighted a significant improvement in group 2 at the 4-month examination (p = 0.052 for standing,p = 0.007 for walking). Gait analysis showed a significant increase in the walking speed in group 2 (p = 0.04). No change was detected in ankle kinematics and kinetics or in muscular activity during the gait cycle. We confirmed that BTX-A reduces spasticity and improves functional performance in standing and walking; association with casting provides more marked and enduring results.

Food entrapped in papilla of Vater: uncommon cause of vomiting

CASE REPORT

A 20 month old girl was admitted for intractable vomiting over several days, with no other symptoms. Family and personal history were not contributive. Clinical and neurological examination, and routine blood tests and investigations (plain abdominal x ray, upper gastrointestinal tract contrast study, abdominal ultrasonography) were normal. The upper gastrointestinal endoscopy showed a mild antral gastritis and the second portion of duodenum was occupied by a tough, fibrous mass partially embedded into the papilla of Vater. The foreign body was removed and proved to be vegetable fibre (pineapple). Symptoms subsided immediately and the child was discharged with gastroprotective therapy. After two months, on endoscopic examination, the signs of gastropathy had cleared; the papilla of Vater was undamaged, but unchomped food debris was again found in the duodenum.

DISCUSSION

There are sporadic reports of foreign bodies retained into the papilla of Vater, all of them in adults. This child, though her papilla was tiny, had no jaundice or pancreatitis, unlike most of the reported cases. This is the first report of this finding in a child. The cause of the vomiting was not shown on abdominal ultrasonography or contrast study. It should be added to the list of unusual causes of vomiting.

[Osteomas and exostoses of the facial structures: a morphological study and the etiopathogenetic considerations]

The differential diagnosis of the osteocondensing lesions (osteomata and exostoses) is till today a topical issue for the experts. In order to test the reliability of the etiopathogenetic theories advanced up to now, the authors carried out a research on samples of tissue coming from surgical interventions for osteomata and exostoses of the maxillofacial region resortied with optical and polarized-light microscopes (OM-PLM). This research meant to analyze the morphological and structural characteristics of newly formed tissues; a considerable attention has been devoted to the difference between primary and secondary bone and to the quality of cementing lines. Thanks to the data resulted from this study, the authors advanced interesting theories about these pathologies either from an etiological and nosological point of view.

[The late complications and nutritional follow-up in 96 patients who underwent a total gastrectomy]

Clinical and nutritional follow-up was performed in 96 patients who had undergone total gastrectomy. We studied the incidence of clinical complications and alterations of nutritional parameters in those patients who had undergone curative resection and were alive and free of neoplastic disease 1 year (36 patients) and 2 years (26 patients) after operation. We observed a very low incidence of late complications, and nutritional parameters, 1 year and 2 years after operation, were normal in almost all the patients. We obtained these results because we performed a Roux en Y esophagojejunostomy using an at least 60 cm-loop; we also adopted a strict and rigorous follow-up, able to guarantee an adequate daily calorie intake. In fact, a close relationship between calorie intake and the variations of nutritional parameters was observed.