Enhanced peroperative imaging of endometriosis and peritoneal carcinomatosis
Authors:   , Vlek Stijn Lukas 
Published: July 2024

This thesis explores new methods to improve the diagnosis and staging of endometriosis and peritoneal carcinomatosis from colorectal cancer. The studies focus on preoperative planning, laparoscopic fluorescence techniques, and a novel surgical procedure for rectal resection in endometriosis patients, aiming to enhance patient outcomes.

Preoperative Techniques
An existing preoperative technique for measuring the depth of endometriosis infiltration in the bowel wall was re-evaluated. Analysis of a prospective database showed an 89% sensitivity and 97% positive predictive value correlation between MRI and histopathology. This helps in selecting the surgical strategy and patient counseling.

Health Technology Assessment
A health technology assessment evaluated the potential benefits of haptic feedback in laparoscopic instruments for deep endometriosis. The analysis suggested a potential cost saving of €687 per patient, indicating that haptic feedback could be cost-effective.

Enhanced Laparoscopic Imaging
Endometriosis lesions are difficult to identify, and recurrence rates are high. A systematic review examined the potential of narrow-band imaging (NBI), autofluorescence imaging (AFI), and 5-ALA fluorescence imaging. All techniques improved sensitivity for detecting peritoneal endometriosis compared to conventional white light laparoscopy. The LITE-study directly compared NBI, near-infrared imaging with ICG, and 3D imaging with conventional white light laparoscopy. 3D imaging showed improved sensitivity of 83.5% compared to 75.8% for white light laparoscopy. Combining 3D imaging and NBI resulted in a sensitivity of 91.2%. A more complete resection of endometriosis might be achieved by combining 3D imaging with NBI, though further studies are needed to evaluate clinical benefits.

Detection of Peritoneal Metastases
A prospective trial similar to the LITE-study evaluated the best detection technique for peritoneal metastases from colorectal carcinoma. NBI showed a significantly increased sensitivity of 96.0% compared to 80.0% for white light imaging. This suggests NBI could be a safe and effective method for assessing the need for HIPEC treatment and the extent of cytoreduction.

Near-Infrared Imaging with ICG
Near-infrared imaging with ICG did not show improved sensitivity for detecting endometriosis and peritoneal carcinomatosis. Different phases of ICG administration were evaluated, including the direct post-administration phase and the prolonged phase up to 24 hours after administration, with no significant improvements in detection.

Biliary Structure Identification
A systematic review and meta-analysis evaluated the visualization of biliary structures using near-infrared imaging with ICG during laparoscopic cholecystectomy. Visualization was 86.5% before dissection of Calot's triangle and 96.5% after, comparable to intraoperative cholangiography but less invasive.

Transanal Minimally Invasive Surgery (TAMIS)
Transanal total mesorectal excision has gained significant interest over the past decade. For rectal resection in endometriosis, mesorectal excision is not needed, but the anterior approach can be complicated by adhesions in stage IV endometriosis. The TAMIS technique, described here for the first time in international literature for endometriosis, appears safe and feasible. In selected patients, this technique can avoid open surgery and create an anastomosis in difficult low lesions, which would be more challenging with conventional low anterior resection.

In summary, this thesis provides valuable insights and improvements in the diagnosis and surgical treatment of endometriosis and peritoneal carcinomatosis, focusing on preoperative planning, enhanced imaging, and new surgical techniques to improve patient outcomes.