Anastasia Ussia

Bowel resection for deep endometriosis: a systematic review

Please cite this paper as: De Cicco C, Corona R, Schonman R, Mailova K, Ussia A, Koninckx P. Bowel resection for deep endometriosis: a systematic review. BJOG 2011;118:285–291.

Laparoscopic management of ureteral lesions in gynecology

OBJECTIVE To investigate the outcome of laparoscopic repair of ureteral injury in laparoscopic gynecologic surgery. DESIGN Prospective trial. SETTING University hospital. PATIENT(S) Forty patients with a ureteral lesion in laparoscopic surgery between 1991 and 2007. INTERVENTION(S) Laparoscopic ureteral repair, laparoscopic-assisted or blind stent insertion. MAIN OUTCOME MEASURE(S) Treatment outcome of ureteral lesion analyzed by type of injury, time of diagnosis, and management. RESULT(S) In 4,350 consecutive laparoscopic gynecologic interventions, 42 lesions occurred, 5 during hysterectomy, 1 during adnexectomy, and 36 during deep endometriosis surgery. In the latter group (n = 1,427), the incidence was 1.5% and 21% in women without and with hydronephrosis, respectively. In eight women in whom a stent was inserted after surgery without laparoscopic guidance, five were uneventful and three needed a second intervention. In all 34 women in whom a laparoscopic repair over a stent was performed, the outcome was uneventful, whether diagnosed and treated during surgery (n = 25) or after surgery (n = 9). CONCLUSION(S) Laparoscopic repair over a stent was uneventful for all lacerations, transections, and fistulas, whether performed during or after surgery, and was superior to blind stent insertion. In women with hydronephrosis and deep endometriosis, a preoperative stent insertion seems to be mandatory.

Pathophysiology of Cyclic Hemorrhagic Ascites and Endometriosis

Massive hemorrhagic ascites (4470 mL, range 1-10 L) in women with endometriosis is a rare condition occurring predominantly in black women. Of the 43 case reports published, 42 are compatible with the hypothesis that the hemorrhagic ascites is predominantly a consequence of excessive ovarian transudation similar to a Meigs syndrome. Indeed, bilateral ovariectomy cures the condition without recurrences, whereas after unilateral ovariectomy or cystectomy recurrence rate is more than 50%; during ovarian suppression by luteinizing hormone-releasing hormone agonist ascites disappears, but reappears after treatment. Superficial pelvic endometriosis also contributes to the ascites because after superficial endometriosis destruction the recurrence rate is only 4 in 14. Based on these data, it is suggested, to scrutinize the ovaries for tumors given the analogy with Meigs syndrome. In women desiring fertility, conservative treatment with destruction of endometriosis only can be attempted given the cure rate of some 20%. It is unknown what the effect of ovulation induction would be.

Tension-free Vaginal Tapes and Pelvic Nerve Neuropathy.

Obturator nerve neuropathies after tension-free vaginal tape or transobturator tape are considered to be caused by nerve trauma, although it is unclear whether these are accidents or whether these injuries are inherent to the procedure of tape insertion. Two cases show that obturator nerve neuropathy can occur after tension-free vaginal tape without direct trauma to the obturator nerve possibly as a consequence of excessive fibrotic reaction or persisting low-grade inflammation. PubMed Entrez, Cochrane Library, and up-to-date databases were searched for obturator and pudendal neuropathy and for neuropathies associated with tension-free vaginal tape-transobturator tape and the symptoms, diagnosis, and therapy of the pudendal and obturator nerve neuropathies are reviewed. Based on data, our experience, and data available in literature, we can conclude that, if conservative obturator nerve block confirms the diagnosis of obturator nerve neuropathy and symptoms recur shortly thereafter, a laparoscopic neurolysis can be proposed as therapy.

An endometriosis classification, designed to be validated

Several endometriosis classifications were proposed, based on the assumption that endometriosis is a progressive disease, and designed to score severity of visible lesions. In addition, several specific classifications, e.g., for deep endometriosis, were proposed. None of these classifications however, have been validated to be predictive for diagnosis, treatment prognosis, recurrence, progression or for the associated infertility or pain. The difficulties derive from the fact that pathophysiology and the natural history are still uncertain. A classification should avoid assumptions. It seems established beyond reasonable doubt that endometriosis presents as subtle, typical, cystic, and deep lesions and that severity of each lesion is related to size or volume. By pathology, these four lesions present as active, burnt-out, inactive, and active lesions, respectively. Besides this, there are many uncertainties. It is unclear whether endometriosis is one disease progressing ultimately into severe endometriosis or whether typical, cystic, and deep endometriosis represents three different diseases, each being an end stage. It is unclear whether endometriotic cells are different from endometrial cells or whether only the environment is different. It is unclear how adenomyosis, Müllerianosis, and peritoneal pockets should be considered. We therefore suggest a descriptive classification with the severity of Subtle, Typical, Cystic, Deep, Adenomyotic, and peritoneal pocket lesions, estimated by their area or volume. This classification should permit to evaluate the actual uncertainties in order to build subsequently a validated classification. The similarity of the classes for superficial and cystic lesions with the rAFS classification is considered an advantage. It is discussed why adhesions need not to be scored. In conclusion, a simple classification scoring separately severity of subtle, typical, cystic, deep, adenomyotic, and peritoneal pocket lesions is suggested. This will permit to confirm or reject statistically many of the actual uncertainties on endometriosis and to evaluate what the predictive power of the severity of each type of lesion is, both essential elements for a validated endometriosis classification.

The role of the peritoneal cavity in adhesion formation

The article by Barcz et al. (1) deserves a comment since it should make us think. Differences in peritoneal fluid constituents between women with and without endometriosis have been studied repetitively since the late 1970s in order to gain insight into the pathophysiology of endometriosis and associated infertility. Endometriosis is associated with a low-grade inflammation with more and more activated macrophages in peritoneal fluid. Despite the huge amount of data available, as this article also contributes to the data of cytokine concentrations, a comprehensive conclusion was never reached. More specifically, for most factors it remains speculative which are contributing to the development of endometriosis and which are a consequence of endometriosis (2). Peritoneal adhesions following surgery remain a major problem leading to chronic pelvic pain, infertility, and occasional bowel obstructions. The use of barriers to prevent adhesion formation was based on the prevailing concept that peritoneal healing and adhesion formation is decided in a few days, resulting from a local inflammatory process between opposing lesions. In this process, fibrin deposition and fibrinolysis play a major role. Efficacy of a barrier, however, rarely exceeded 50%. Recent evidence has demonstrated the importance of the entire peritoneal cavity and of factors in peritoneal fluid to enhance adhesion formation. While peritoneal lesions and the associated local inflammatory reaction remain essential to start the process, factors from the peritoneal cavity are quantitatively much more important for the severity and extend of adhesion formation. That slight manipulation of bowels in the upper abdomen can increase adhesions at a surgical lesion in the lower abdomen unequivocally points to factors from the upper abdomen reaching the lower abdomen through the peritoneal fluid (3). A series of experiments in a laparoscopic mouse model pointed to an acute inflammation of the entire peritoneal cavity as the driving mechanism (4). This acute inflammatory reaction is caused by the cumulative mesothelial trauma either mechanically or bymesothelial hypoxia (CO2 pneumoperitoneum) (5) or hyperoxia (exposure to air, as in open surgery), or desiccation. Prevention thus should aim at a mesothelial partial oxygen pressure between 10 and 70 mmHg (achieved by adding a few percent of oxygen to the CO2 pneumoperitoneum), while preventing any desiccation. Slight cooling of the peritoneal cavity is beneficial, since the mesothelial cell becomes more resistant to trauma. It should be realized that in order to combine absence of desiccation and cooling, the latter should be performed independently (e.g. by sprinkling saline at room temperature). If the temperature of the incoming humidified gas is slightly higher condensation will occur. If the temperature of the incoming gas is lower than the peritoneal temperature it will be heated and desiccation will occur. Since bothmechanisms of adhesion formation are complementary (local inflammatory process enhanced by factors from the peritoneal cavity), prevention should address both mechanisms. In animal models (6) and in the human (in preparation) the sequential minimalization of mesenchymal damage during

The digital operating room and the surgeon

The “word digital operating room” aims to integrate the images, information, and work flow available in the hospital and in the operating theater. In addition, it can distribute and record information while adding intelligence. The understanding of a digital operating room thus is highly variable. Whereas digital operating rooms are rapidly being incorporated in the hospitals, the clinical validation of improved quality of surgery is limited. The proven and expected usefulness of image distribution in one OR (routing and switching) or outside the OR (broadcasting), of integrating information, of image and video registration, and of intelligence, is reviewed with the perspective of quality and safety of surgery. It is expected that the digital OR will contribute to the learning and teaching and to the quality of surgery. Especially, the introduction of intelligence will be a major step forward. It remains important however that we, endoscopic surgeons, remain closely involved in shaping and orienting this future.

“Centers of excellence in endometriosis surgery” or “centers of excellence in endometriosis”

Centers of excellent endometriosis surgery could improve the care of women with endometriosis, especially if combined with control of the quality of the surgery performed, e.g., through systematic taping of entire interventions. Centers of excellence in endometriosis without emphasis on providing excellent surgery seem of little value and could do more harm than good.

Evidence-Based Medicine in Endometriosis Surgery: Double-Blind Randomized Controlled Trial Versus the Consensus Opinion of Experts

Medicine used to be an empirical set of methods and nonempirical principles acquired by observation and research to prevent, diagnose, and treat or palliate the disease and help the patient. Medicine is considered an art because the interpretation of complaints and symptoms and the choice of treatment require special skills and individualization. The state of the art progressively evolves and improves by trial and error guided by the available scientific and observational knowledge. This knowledge is shared freely. Research has progressively added knowledge and evidence. We tend to forget that available proven evidence constitutes only a small part of decision-making and of selecting medical treatment or surgery in daily practice. Taking hysterectomy as an example, let us consider all the variables that occur: determining the indication for surgery, selection of the surgical access route and technique, selection of sutures and energy, and the many other parameters that vary within the operating theater environment and with the skill and experience of the surgeon. This plethora of variables and the absence of unanimous agreement on many aspects of this process highlight the problem. Nevertheless, in the absence of concrete evidence, the surgeon must use the available knowledge and make decisions based on experience, the practice of the institution, and the regulations of the jurisdiction in which he or she works. Knowledge of anatomy and understanding the mechanisms involved, as established by research, guides the progressive development of surgery and of the choices involved. Most have become basic surgical principles: preservation of anatomy and function, use of proper dissection planes, and meticulous hemostasis and nerve sparing. The latter was empirically introduced in oncologic surgery; however, it is only over the last decade that we began to understand the anatomy of the pelvic nerves and started to incorporate nerve sparing into reproductive and endometriosis surgery. As surgeons, we almost

The Association of Endometriosis and Adenomyosis: Vast Literature but Scant Conclusive Data.

Despite the presence of more than 15 000 articles with “endometriosis” or “‘adenomyosis” on their titles published in peer-reviewed journals, our understanding of these 2 entities remains limited and is thus subject to much controversy. As discussed previously in this journal, the elephant in the room is the number of publications and the quality control of the data [1]. The exponentially increasing flow of information also includes publications in journals that review poorly and on websites and social media. The information overload necessitates selective reading of properly reviewed good studies, often only of the abstract or conclusions. However, the huge volume of manuscripts submitted hampers the quality of peer review. This vicious circle is moreover fueled by the pressure to publish that stimulates slicing complex data into several partial reports. Slicing of data into simple questions multiplies the number of publications, accelerates publication, and facilitates reviewing. Slicing of data, moreover, becomes necessary when the length of publications is limited (e.g., to 2500 words), but this makes the understanding of more complex problems more difficult. In the absence of an animal model to test a hypothesis, endometriosis and adenomyosis are limited to observational data with specific statistical pitfalls. First, the quality and completeness of data collection need a clear description of methods and definitions used. Second, it is obvious that a significant association of p = .05 also means a probability of 5% that the association is not true. Less obvious is the risk of 1 spurious or false-positive significant result when multiple comparisons are performed. When performing 10, 20, 40, or 60 comparisons, the risk of a false-positive result increases from 40% to 64%, 87%, and 95%, respectively [2,3]. To avoid this trap, it is important that the hypothesis or the aim of a study is clearly formulated before analysis, instead of analyzing data sets without a hypothesis, which some consider “torturing data until they confess” [2,4]. The article, “Anterior Focal Adenomyosis and Bladder Deep Infiltrative: Is There a Link?” [5], in the current issue of the journal provides good and clear data and suggests a common pathophysiologic mechanism. However, after reading the article several times in detail, the many emerging questions prompted us to comment to stimulate discussion on the association of endometriosis and adenomyosis, on their pathophysiology, and on the pitfalls of statistical evaluation of observational data.