Christopher Sutton

Follow-up report on a randomized controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal to moderate endometriosis

OBJECTIVE To assess the longer term efficacy of laparoscopic laser surgery in the treatment of painful pelvic endometriosis and to observe the natural history of the disease at second-look laparoscopy in a control group. DESIGN One-year follow-up of a prospective, randomized, double-blind controlled trial. SETTING A referral center for the laparoscopic laser treatment of endometriosis. PATIENT(S) Sixty-three patients with pelvic pain and minimal to moderate endometriosis. INTERVENTION(S) After the 6-month follow-up visit, the randomization code was broken, and follow-up was continued to 1 year. Symptomatic patients were offered second-look laser laparoscopy. MAIN OUTCOME MEASURE(S) Continued symptom relief at 1 year after treatment and findings at second-look laparoscopy in symptomatic controls. RESULT(S) Symptom relief continued at 1 year in 90% of those who initially responded. All symptomatic controls had a second-look procedure, with 7 (29%) showing disease progression, 7 (29%) showing disease regression, and 10 (42%) having static disease. CONCLUSION(S) The benefits of laser laparoscopy for painful pelvic endometriosis are continued in the majority of patients at 1 year. Untreated painful endometriosis will progress or remain static in the majority of patients but will spontaneously improve in others.

Laser laparoscopic surgery in the treatment of ovarian endometriomas.

STUDY OBJECTIVE To assess the efficacy of laser laparoscopic photocoagulation of endometriomas (2-18 cm) in patients with pain, infertility, or a combination of the two. DESIGN Retrospective review of all patients with endometriomas from June 1, 1983, to December 31, 1993. SETTING Department of gynecology and obstetrics at a district general hospital and national training center in minimal access surgery. PATIENTS One hundred sixty-five women with large endometriomas present at the time of laser laparoscopy. INTERVENTIONS Carbon dioxide laser or potassium-titanyl-phosphate laser laparoscopic surgery. MEASUREMENTS AND MAIN RESULTS Ninety (74%) of 122 patients reported improvement or resolution of pain; and 30 of 66 achieved a pregnancy, for a cumulative conception rate of 45%. CONCLUSION Laser laparoscopy is a practical, safe, and effective technique for the management of large ovarian endometriomas.

A psychological profile of endometriosis patients in comparison to patients with pelvic pain of other origins

In order to investigate the possibility of a specific psychological profile associated with endometriosis, 81 women with pelvic pain were studied, of whom 40 were diagnosed as having endometriosis and 41 other gynaecological problems. Each patient completed six standardized psychometric tests to assess personality, psychopathology, marital state and pain. Endometriosis patients obtained higher psychoticism, introversion and anxiety scores in comparison to the other pain patients, although the two groups did not differ on pain ratings. Both groups obtained neuroticism, anxiety and psychiatric morbidity scores which were elevated relative to normative data. The possibility that there are certain psychological characteristics which make some women vulnerable to endometriosis is discussed.

Laparoscopic management of ovarian endometriomas: a critical review of current practice.

Endometriomas are a common cause of gynaecological morbidity, but their aetiology and management remain controversial This review focuses on identifying the evidence from published literature for the laparoscopic management of ovarian endometriomas. A critical appraisal shows that laparoscopic surgery is equivalent to laparotomy. There is no evidence to suggest that one minimal access surgical technique is clearly superior to another. However, this may be related to the inconsistencies in study design. In view of this we describe and justify our own management strategy for dealing with endometriomas.

Bilateral uterine artery embolisation for myomata: Results, complications and failures

SummaryUterine artery embolisation (UAE) was carried out on 200 patients who were followed-up by US, MRI, questionnaires and blood tests. Questionnaire data is available from 111 patients and fibroid/uterine volume reduction data from 88 followed-up for a mean of 5/12 months (range 3/12-1 year). The average fibroidhterine volume reduction at 1 year was 69%. US and MRI results were comparable. Menorrhagia improved in 79% of patients; 96% were pleased with the outcome and would recommend it to others. Two serious complications have so far occurred in the 200 patients embolised; in these two patients, infection led to hysterectomy.

Past, Present, and Future of Hysterectomy

Until the late 1930s, the standard type of abdominal hysterectomy was subtotal, leaving the cervix behind to decrease the risk of peritonitis with its attendant high mortality. With the discovery of antibiotics, careful attention to antisepsis, and other medical and surgical advances, this method was gradually replaced by total abdominal hysterectomy in the United States and the United Kingdom, although the subtotal approach still remained popular, in particular in Scandinavian countries. With the advent of laparoscopic hysterectomy, many surgeons, wanting a simpler approach and for a variety of other reasons, have returned to performance of subtotal hysterectomy. The objectives of the present article is to review the development of the operation from a historical perspective, and to attempt to answer some of the dilemmas posed when choosing between a total and subtotal procedure, using results from evidence-based research when possible.

Initial experience with supracervical laparoscopic hysterectomy and removal of the cervical transformation zone.

Objective To assess the feasibility and outcome of laparoscopic supracervical hysterectomy with removal of the cervical transformation zone.

Recurrence of chocolate cysts after laparoscopic ablation.

STUDY OBJECTIVE To estimate the recurrence rate of chocolate cysts 3 to 12 months after ablative laparoscopic surgery. The secondary outcome measure was the need for a repeat surgical procedure. DESIGN Prospective cohort study (Canadian Task Force classification II-2). SETTING Tertiary referral center for laparoscopic treatment of endometriosis. PATIENTS Seventy-three consecutive women with chocolate cysts larger than 2 cm. INTERVENTION Laparoscopy at which cyst capsules were vaporized or coagulated with the potassium-titanyl-phosphate (KTP) laser or Bicap bipolar diathermy. MEASUREMENTS AND MAIN RESULTS There were 96 cysts (23 bilateral) in 73 women (1 patient underwent a two-stage procedure). Their mean diameter was 4.79 cm (range 2-25 cm). The median r-AFS score was 56 (range 22-128), and 55 patients (75.3%) had stage 4 disease. The KTP laser was used in 50 women (68.5%) and bipolar diathermy in 23 (31.5%). At 12 months, 5 patients (6.9%) were lost to follow-up, and 12 had a recurrent cyst. Therefore, the cyst recurrence rate/patient was 16.4% (12/73) and the rate/cyst was 12.5% (12/96). Women who had recurrences were significantly more likely to have bilateral cysts, 7/12 (58.3%), than those with single cysts, 16/61 (26.2%, p =0.032). Bicap bipolar diathermy was associated with a recurrence rate of 20.8% (5/24). The rate in women who had KTP laser ablation was 14.3% (7/49, NS). Eighteen patients had repeat operations (including on recurrent cysts). Therefore the reoperation rate was 24.6% (18/73). No major surgical complications occurred. One woman had a postoperative wound infection after a second procedure to remove an ovary with a recurrent cyst. CONCLUSION Laparoscopic cyst fenestration followed by capsule ablation is safe and effective treatment for preventing recurrence of chocolate cysts.

Use of icodextrin 4% solution in the reduction of adhesion formation after gynaecological surgery

Our objective was to use Adept Registry for clinical evaluation (ARIEL) to monitor ease of use, acceptability and safety of icodextrin 4% solution during routine gynaecological surgery. Surgeons from six European countries were asked to complete anonymised data collection forms for patients undergoing gynaecological laparoscopy or laparotomy procedures with an associated risk of adhesion formation. Gynaecological surgeons from 150 centres recorded patient demographics, use of icodextrin 4% solution and adverse events, and made subjective assessments of ease of use and patient acceptability with the agent. The gynaecological surgery registry included 2,882 patients; 72% (n=2,069) underwent laparoscopies. Most surgeons rated the ease of use (viewing of surgical field and handling of tissues) of icodextrin 4% solution as ‘excellent’ or ‘good’ and leakage from the surgical site as ‘normal’ (approximately 60% of laparoscopies and laparotomies) or ‘less than normal’ (30% and 23%, respectively). Abdominal discomfort was rated by surgeons as ‘as expected’ in 68% of laparoscopy patients and 67% of laparotomy patients and ‘less than expected’ in 24% and 26%. Abdominal distension values were comparable. The incidence of adverse events (laparoscopy 7.5%; laparotomy 13.9%) reflected expected rates in gynaecological surgery. ARIEL data indicate that icodextrin 4% solution was well tolerated and easy to use for the reduction of adhesion formation following gynaecological surgery.

Adhesions and their prevention

Adhesions are a common and unfortunate consequence of most abdominal surgical operations, which start to form within three hours of surgery. Some patients form extensive permanent adhesions that can cause abdominal or pelvic pain, infertility and bowel obstruction. Epidemiological studies have highlighted the extent of this problem and the cost to the Health Service, and although there are numerous approaches to prevent adhesion formation by careful laparoscopic or microsurgical techniques or the use of various adhesion barriers, no method so far has proved completely efficacious in randomised controlled trials. This article reviews the pathogenesis of adhesions, the epidemiological data and the various methods used to try to prevent their formation.