Specificity of peritoneal blue staining

10 03 2011

To the Editor:

We read with interest and pleasure the technique proposed by Rauh-Hain and Laufer (1) to increase the diagnostic accuracy of laparoscopy in endometriosis. The diagnostis of superficial implants may be difficult, particularly the identification of the limits of the disease. Therefore a staining technique would be useful to identify abnormal peritoneal areas, helping the surgeons to decide the limits of the surgical treatment. We would like to propose three comments to this approach.

First, the idea of staining to identify abnormal peritoneal areas is not new. In 1994 our group proposed identifying abnormal peritoneal areas by staining with methylene blue. We even reported in a non-controlled study that fertility was improved after the laparoscopic treatment, with bipolar coagulation, of all stained areas (2).

Second in our experience, staining of the peritoneum is not specific to endometriosis. As a matter of fact, we observed that all traumatized areas are stained in blue, whatever the cause of the trauma. Indeed, we found that areas traumatized by a 5 mm aspiration lavage cannula are stained when the blue is injected after the trauma. As they use a different dye, we encourage the authors to further explore the potential and the limits of their new technique. If at the end of the laparoscopic treatment they observe peritoneal stained areas whose shape is linear, these are probably the consequence of trauma induced by the instruments. Obviously these areas do not require further treatments.

Third, the staining of traumatized peritoneal area is explained by peritoneal physiology. The peritoneal surface is covered by phospholipids produced by mesothelial cells (3). Because of these phospholipids, the surface of the peritoneum is hydrophobic so that the tissue is not stained by the blue dyes which are hydrophilic, whereas when this surfactant is removed by a trauma or a peritoneal disease, the surface is no longer hydrophobic and the underlying tissue may be stained with blue dyes.

This approach is indeed interesting for identifying traumatized areas; however, it should be adequately understood so as to avoid unnecessary surgical procedures aimed at the possible growth of invisible or poorly visible implants.

Michel Canis, M.D., Ph.D.
Hubert Manhes, M.D.
Gerard Mage, M.D.
Department of Gynecologic Surgery
CHU Estaing
Clermont-Ferrand, France

References
1. Rauh-Hain JA, Laufer MR. Increased diagnostic accuracy of laparoscopy in endometriosis using indigo carmine: a new technique. Fertil Steril. 2011 Jan 11.

2. Manhes H, Shulman A, Haag T, Canis M, Demontmarin JL. Infertility due to diseased pelvic peritoneum: laparoscopic treatment. Gynecol Obstet Invest. 1994;37(3):191-5.

3. Hills BA. Role of surfactant in peritoneal dialysis. Perit Dial Int. 2000;20:503-15.

Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2011.03.037

The Authors Respond:

We thank Drs. Canis, Manhes, and Mage for their interest in our case report (1), and for their comments.

Their series of thirty-one patients with unexplained infertility (2), some with the presumed diagnosis of endometriosis, is of great importance and supports the hypothesis that staining the peritoneum with either concentrated methylene blue or indigo carmine might be a useful technique in the diagnosis and management of endometriosis. Studies in the gastroenterology literature suggest that the indigo carmine is not absorbed by the epithelium in the gastrointestinal tract and pools in crevices between epithelial cells, highlights small or flat lesions and defines irregularities in mucosal architecture (3).

The hypothesis that staining of traumatized peritoneal area is explained by the fact that the surface of the peritoneum is hydrophobic is an interesting idea. We recognized the potential limitations of utilizing indigo carmine for the detection of endometriosis. The accuracy to detect areas of endometriosis is one of the potential weaknesses of this method. Clearly, further research is needed to determine if other entities, such as trauma to the peritoneum, might also stain with indigo carmine. We agree that this approach should be adequately understood to avoid unnecessary surgical procedures.

Marc Reed Laufer, M.D.
Department of Obstetrics and Gynecology
Brigham and Women’s Hospital
and
Division of Gynecology
Department of Surgery
Children’s Hospital Boston
Harvard Medical School
Boston, Massachusetts

References
1. Rauh-Hain JA, Laufer MR. Increased diagnostic accuracy of laparoscopy in endometriosis using indigo carmine: a new technique. Fertil Steril. 2011 Jan 11.

2. Manhes H, Shulman A, Haag T, Canis M, Demontmarin JL. Infertility due to diseased pelvic peritoneum: laparoscopic treatment. Gynecol Obstet Invest. 1994;37(3):191-5.

3. Canto, MI. Staining in gastrointestinal endoscopy: the basics. Endoscopy 1999; 31(6): 479-86.

Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2011.03.036

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