Indocyanine green in deep infiltrating endometriosis: a preliminary feasibility study to examine vascularization after rectal shaving.

OBJECTIVE: To evaluate the feasibility of using indocyanine green (ICG) to estimate the vascularization of the resected zone during a laparoscopic rectal shaving. DESIGN: Indocyanine green can highlight blood vascularization when injected intravenously. There is no relevant, objective, intraoperative method to assess the vascularity of the resected zone during a laparoscopic rectal shaving for deep infiltrating endometriosis (DIE) to prevent fistula. We conducted a registered clinical trial examining the feasibility of the use of ICG to evaluate the bowel vascularization after endometriosis rectal shaving (Institutional Review Board number 2016-002773-35). SETTING: Tertiary university hospital. PATIENT(S): Twenty-one patients underwent laparoscopic surgery for DIE with a rectal shaving. INTERVENTION(S): Patients undergoing laparoscopic surgery for DIE received ICG intravenously at the end of the endometriosis resection. MAIN OUTCOME MEASURE(S): The main evaluation criteria was the fluorescence degree in the operated rectal area and in the vaginal suture. We used a visual assessment with a Likert-type scale from 0 to 4 (0 = no fluorescence; 4 = very good fluorescence). RESULT(S): No adverse reaction was recorded. Most of the patients (81%) showed very good fluorescence levels at the rectal shaving area. The protocol did not increase the operating time. In one patient we changed the surgical strategy making two stitches to bring the rectal muscularis closer together, which improved the degree of fluorescence. There was no case of digestive fistula. CONCLUSION: Indocyanine green fluorescent imaging is feasible in endometriosis surgery and may be considered as a potential candidate to further enhance patient safety in endometriosis bowel surgery. CLINICAL TRIAL REGISTRATION NUMBER: NCT03080558.

Use of indocyanine green in endometriosis surgery.

OBJECTIVE: To report and visually demonstrate the feasibility of using indocyanine green (ICG) in endometriosis surgery and to discuss potential benefits. DESIGN: ICG fluorescent imaging has been validated to assess tissue perfusion with clinical use in many medical fields, including gynecology and digestive surgery, but has not described in endometriosis surgery for bowel assessment. To our knowledge, there is no validated, objective, intraoperative method to assess the vascularity of the operated bowel in endometriosis surgery, a potentially good indicator for postoperative fistula formation. Our center is conducting a registered clinical trial examining the use of ICG to evaluate the bowel vascularization after endometriosis rectal shaving surgery, and the potential role in reducing fistula rates (Institutional Review Board no 2016-002773-35). SETTING: Tertiary university hospital. PATIENT(S): Three patients undergoing laparoscopic surgery for deep infiltrating endometriosis (DIE) with the use of a rectal shaving procedure. INTERVENTIONS(S): Patients undergoing laparoscopic surgery for DIE with a rectal shaving procedure were injected with ICG intravenously at the end of endometriosis resection. MAIN OUTCOME MEASURES: Visual assessment of the rectal shaving area was assessed as fluoresced or not with the use of a Likert-type scale (0 = no fluorescence; 4 = very good fluorescence). RESULT(S): After ICG injection, all three patients have showed very good fluorescence levels at the rectal shaving area with no adverse reactions. Other uses of ICG are demonstrated throughout the video (vaginal cuff, ureter, and ovary assessment). CONCLUSION(S): ICG fluorescent imaging is feasible in endometriosis surgery, and there is an ongoing trial to determine if its use reduces postoperative fistula formation. CLINICAL TRIAL REGISTRATION NUMBER: NCT03080558.

Innovative integrative bedside teaching model improves tutors' self-assessments of teaching skills and attitudes.

INTRODUCTION: Patient bedside is the ideal setting for teaching physical examination, medical interviewing, and interpersonal skills. Herein we describe a novel model for bedside teaching (BST) practiced during tutor training workshop and its resulting effect on practitioners' self assessment of teaching skills and perceptions. METHODS: One-day tutor training workshop included theoretical knowledge supplementation regarding tutors' roles as well as implementing practical tools for clinical education, mainly BST model. The model, which emphasizes simultaneous clinical and communication teaching in a stepwise approach, was practiced by consecutive simulations with a gradual escalation of difficulty and adjusted instruction approaches. Pre- and post-workshop-adjusted questionnaires using a Likert scale of 1 to 4 were completed by participants and compared. RESULTS: Analysis was based on 25 out of 48 participants who completed both questionnaires. Significantly improved teaching skills were demonstrated upon workshop completion (mean 3.3, SD 0.5) compared with pre-training (mean 2.6, SD 0.6; p<0.001) with significant increase in most examined parameters. Significantly improved tutor's roles internalization was demonstrated after training completion (mean 3.7, SD 0.3) compared with pre-workshop (mean 3.5 SD 0.5; p=0.002). DISCUSSION: Successful BST involves combination of clinical and communication skills. BST model practiced during the workshop may contribute to improved teaching skills in this challenging environment.

IFN-gamma acts on T cells to induce NK cell mobilization and accumulation in target organs.

The mechanism(s) that regulates NK cell mobilization and the significance of this process to NK cell activity are unknown. After Con A-induced hepatitis, NK cells are mobilized from the spleen and bone marrow into the periphery in an IFN-gamma-dependent fashion. Intraperitoneal administration of IFN-gamma stimulates the mobilization of NK cells into the circulation, but not their cell death or proliferation. Increased number of circulating NK cells was coupled with their accumulation in the peritoneum, liver, and tumor-bearing lung tissue. Furthermore, increased number of NK cells in the lung reduced metastasis of Lewis lung carcinoma cells (3LL cell line) resulting in significantly extended NK-dependent survival. Mobilization of NK cells was specific and required the presence of T cells. Moreover, mobilization and migration of spleen NK cells in response to IFN-gamma treatment is dependent on the chemokine receptor CXCR3. Mechanistic insights regarding the role of IFN-gamma in the regulation of NK cell mobilization and their accumulation at sites of tumor metastasis may lead to the development of novel immunotherapy for cancer.