Ureteral endometriosis: clinical and radiological follow-up after laparoscopic ureterocystoneostomy.

BACKGROUND: Ureteral endometriosis is a rare entity that may lead to progressive hydroureteronephrosis and renal loss. When the localization of ureteral stenosis is close to the ureterovesical junction, ureterocystoneostomy may be required. The aim of the present study was to evaluate post-operative complication rates and clinical outcomes at 1- and 6-month follow-up after laparoscopic ureterocystoneostomy. METHOD: Twenty patients who underwent ureterocystoneostomy for pelvic endometriosis in our tertiary referral centre for endoscopic surgery during 1 year were studied. A cystography was performed on Day 7 after surgery to verify the integrity of anastomosis and a satisfactory bladder capacity. Follow-up consisted of gynaecological examination and transvaginal ultrasound at 1 and 6 months after surgery. At 6 months, urography and cystography were also performed. Measurements included results of a pre-operative clinical and instrumental assessment, intra- and post-operative complications, post-operative bladder capacity at cystography and improvement of pain, using a visual analogue scale for the main symptoms related to endometriosis and uro-specific pain. RESULTS: Neither a case of ureteral fistula nor other complications requiring re-intervention were reported. Post-operative transient deficit of bladder voiding occurred in five cases (25%), urinary infection in one and post-operative pyrexia in four (20%) patients. The median time to resuming voiding function was 3 days (range 1-20 days). In six cases, a mild vesico-ureteral reflux at the operated side was observed at 7-day cystography. Post-operative symptomatology was improved significantly (P<0.05) for all symptoms. Urography and cystography performed at 6 months confirmed good post-operative reconstructions in all cases. CONCLUSIONS: The objective of surgical treatment of ureteral endometriosis is to remove the stenotic tract and to preserve renal function. In cases of intrinsic ureteral endometriosis, the procedure of laparoscopic ureterocystoneostomy is feasible and has good outcomes at short- and medium-term follow-up.

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.

Barium enema evaluation of colonic involvement in endometriosis.

OBJECTIVE: The purpose of our study was to define the role of double-contrast barium enema (DCBE) compared with laparoscopy in the diagnosis and local staging of intestinal endometriosis. MATERIALS AND METHODS: A search of our radiology database revealed the cases of 234 women who underwent surgical resection for pelvic endometriosis with associated intestinal surgery for intestinal endometriosis. We retrospectively evaluated all preoperative DCBE images for the presence of bowel endometriosis and the number, site (rectum, sigmoid, cecum), and size of the lesions. The radiographic findings at DCBE were retrospectively correlated with those at surgical pathologic examination. RESULTS: DCBE revealed 211 intestinal lesions of bowel endometriosis in 168 (71.8%) of 234 patients with pelvic endometriosis clinically enrolled. Forty (23.8%) of the 168 women had more than one endometriotic bowel nodule (two nodules in 37 cases, three in three cases). Laparoscopy revealed 233 intestinal lesions in 174 (74.3%) of the patients. Fifty-four (31.0%) of 174 women had more than one endometriotic bowel nodule (two nodules in 49 cases, three in five cases). There was 100% correlation between the DCBE and histologic findings as far as site and size of the lesions were concerned. DCBE had a sensitivity of 88.4%, specificity of 93.0%, positive predictive value of 97.5%, negative predictive of 71.0%, and accuracy of 89.5% in the identification of bowel endometriosis. CONCLUSION: DCBE is helpful in discerning bowel wall involvement in endometriosis, enabling proper surgical planning. DCBE also appears to have a role in the management of endometriosis.

Bronchial reacutization and gastroesophageal reflux: is there a potential clinical correlation?

BACKGROUND: Pepsin plays a role in gastroesophageal reflux (GER). Aims of this study were to verify if pepsin could be the cause of frequent bronchial exacerbations and to check if the persistence of chronic respiratory symptoms were correlated with pre-existing respiratory diseases. METHODS: From January to May 2016, 42 patients underwent a diagnostic bronchoscopy. All patients had a history of at least one bronchial exacerbation during the previous year. Bronchial lavage fluid specimens were obtained. A semiquantitative assessment of pepsin in the samples was carried out based on the intensity of the test sample. RESULTS: Pepsin was present in 37 patients (88%), but in patients with bronchial asthma and chronic obstructive pulmonary disease (COPD), the finding of pepsin in the bronchoalveolar fluid was 100%. There was a strong positive statistical correlation between pepsin detection and radiological signs of GER (ρ=0.662), and between pepsin detection and diagnosis (ρ=0.682). No correlation was found between the bacteriology and the presence of pepsin in the airways (ρ=0.006). CONCLUSIONS: The presence of pepsin in the airways shows the occurrence of reflux. The persistence of respiratory symptoms by at least 2 months suggest an endoscopic bronchial examination. This straightforward test confirms the cause possible irritation of the airways and may prevent further diagnostic tests, such as an EGD or pH monitoring esophageal.

Profile of Trypanosoma cruzi infection in a tropical medicine reference center, Northern Italy.

BACKGROUND: Chagas disease (CD) is endemic in Central and South America, Mexico and even in some areas of the United States. However, cases have been increasingly recorded also in non-endemic countries. The estimated number of infected people in Europe is in a wide range of 14000 to 181000 subjects, mostly resident in Spain, Italy and the United Kingdom. METHODOLOGY/PRINCIPAL FINDINGS: Retrospective, observational study describing the characteristics of patients with CD who attended the Centre for Tropical Diseases (Negrar, Verona, Italy) between 2005 and 2013. All the patients affected by CD underwent chest X-ray, ECG, echocardiography, barium X-ray of the oesophagus and colonic enema. They were classified in the indeterminate, cardiac, digestive or mixed category according to the results of the screening tests. Treatment with benznidazole (or nifurtimox in case of intolerance to the first line therapy) was offered to all patients, excluding the ones with advanced cardiomiopathy, pregnant and lactating women. Patients included were 332 (73.9% women). We classified 68.1% of patients as having Indeterminate Chagas, 11.1% Cardiac Chagas, 18.7% as Digestive Chagas and 2.1% as Mixed Form. Three hundred and twenty-one patients (96.7%) were treated with benznidazole, and most of them (83.2%) completed the treatment. At least one adverse effect was reported by 27.7% of patients, but they were mostly mild. Only a couple of patients received nifurtimox as second line treatment. CONCLUSIONS/SIGNIFICANCE: Our case series represents the largest cohort of T. cruzi infected patients diagnosed and treated in Italy. An improvement of the access to diagnosis and cure is still needed, considering that about 9200 infected people are estimated to live in Italy. In general, there is an urgent need of common guidelines to better classify and manage patients with CD in non-endemic countries.

Defecography: a practical approach.

The purpose of this pictorial essay is to describe the main morpho- functional imaging features, physiological and pathological, of the recto-anal region and pelvic floor as depicted with conventional video defecography. Defecography has dramatically improved our knowledge of dysfunctions of evacuation. The most frequent indications and related disorders are presented from a database of more than 2500 examinations conducted in two radiology departments over a period of 15 years. Imaging features of the common recto-anal and pelvic floor disorders are described: rectal prolapse, rectocele, intussusception, descending pelvic floor syndrome, puborectalis muscle syndrome, enterocele, and sigmoidocele. Conventional video defecography still represents the gold standard examination for the identification and staging of morphological and functional disorders of the recto-anal region and pelvic floor in evacuation dysfunctions.

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

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

Diagnostic accuracy of MRCP in choledocholithiasis.

PURPOSE: To evaluate the accuracy of MRCP in diagnosing choledocholithiasis considering Endoscopic Retrograde Cholangiopancreatography (ERCP) as the gold standard. To compare the results achieved during the first two years of use (1999-2000) of Magnetic Resonance Cholangiopancreatography (MRCP) in patients with suspected choledocholithiasis with those achieved during the following two years (2001-2002) in order to establish the repeatability and objectivity of MRCP results. MATERIALS AND METHODS: One hundred and seventy consecutive patients underwent MRCP followed by ERCP within 72 h. In 22/170 (13%) patients ERCP was unsuccessful for different reasons. MRCP was performed using a 1.5 T magnet with both multi-slice HASTE sequences and thick-slice projection technique. Choledocholithiasis was diagnosed in the presence of signal void images in the dependent portion of the duct surrounded by hyperintense bile and detected at least in two projections. The MRCP results, read independently from the ERCP results, were compared in two different and subsequent periods. RESULTS: ERCP confirmed choledocholithiasis in 87 patients. In these cases the results of MRCP were the following: 78 true positives, 53 true negatives, 7 false positives, and 9 false negatives. The sensitivity, specificity and accuracy were 90%, 88% and 89% respectively. After the exclusion of stones with diameters smaller than 6 mm, the sensitivity, specificity and accuracy were 100%, 99% and 99%, respectively. MRCP accuracy was related to the size of the stones. There was no significant statistical difference between the results obtained in the first two-year period and those obtained in the second period. CONCLUSIONS: MRCP is sufficiently accurate to replace ERCP in patients with suspected choledocholithiasis. The results are related to the size of stones. The use of well-defined radiological signs allows good diagnostic accuracy independent of the learning curve.

Preoperative double-contrast barium enema in patients with suspected intestinal endometriosis.

STUDY OBJECTIVES: To assess the usefulness of double-contrast barium enema (DCBE) in the diagnosis of endometriotic lesions of the bowel and to define its potential value in preoperative decision making for intestinal surgery. DESIGN: Retrospective study (Canadian Task Force classification II-2). SETTING: General hospital with a specialized endometriosis unit. PATIENTS: One hundred and eight women with symptoms suggestive of intestinal endometriosis who underwent DCBE before laparoscopic surgery. INTERVENTION: Laparoscopic complete excision of endometriosis. MEASUREMENTS AND MAIN RESULTS: Fifty-five patients were found to have an entirely normal colon on DCBE studies. Twenty-eight of these were found to have adhesions of the bowel at laparoscopy. Radiographic abnormalities suggestive of endometriosis were detected in 53 patients; 20 of these underwent laparoscopic bowel segmental resection, 10 laparoscopic full-thickness disc excision, 4 laparoscopic mucosal skinning, and 4 total laparoscopic hysterectomy with bilateral salpingo-oophorectomies. Fourteen patients refused intestinal surgery. One patient had no endometriosis but severe adhesions. In all cases but one, the radiographic findings on DCBE were confirmed by surgery and with histopathologic examination of the resected specimens (accuracy 99%). In these same cases, the preoperative choice of intestinal surgery remained unchanged during the procedure. CONCLUSION: Our data show that, in expert hands, DCBE correlated with a patient's clinical history and clinical findings is capable of diagnosing bowel wall involvement due to endometriosis, which could require intestinal surgery. This allows for proper preoperative planning of surgical procedures and a thorough informed consent.