Karolina Afors

Adolescent Endometriosis: Report of a Series of 55 Cases With a Focus on Clinical Presentation and Long-Term Issues.

STUDY OBJECTIVE To report the clinical presentation and long-term issues of adolescent endometriosis. DESIGN Retrospective cohort study. SETTING Single private clinical center, Bordeaux, France. PATIENTS Adolescents with a confirmed diagnosis of endometriosis. INTERVENTIONS Surgical excision or ablation or lesions performed at laparoscopy. MEASUREMENTS AND MAIN RESULTS Fifty-five adolescents, ages from 12 to 19 years (mean age 17.8), who were diagnosed with endometriosis from March 1998 to April 2013 were included in the study. Pain of various types was the leading symptom in all patients, except 2. Twenty-three patients had an adnexal mass identified preoperatively, and 5 had an associated infertility issue at the time of diagnostic laparoscopy. Four patients had an associated genital malformation. Fifty-one percent of the patients had a history of appendectomy. A familial history of endometriosis was reported by 19 patients (34.5%), with a first-degree relative affected in 14 cases (25.45%), and 47.3% of patients were smoking at least 5 cigarettes a day. Superficial implants was encountered in 31 cases (56.4%), endometriomas in 18 cases (32.72%), and deep infiltrating endometriosis (DIE) in 6 cases (10.90%). Sixty percent of patients were scored as stages I to II and 40% as stages III to IV. Five patients were lost to follow-up, and 37 had a follow-up ranging from 36 to 315 months (mean follow-up 125.5 months). Among the 50 patients not lost to follow-up, 13 (26%) had either no pain, or improved and had acceptable pain with medical treatment. Seventeen patients of the 50 adolescents not lost to follow-up (34%) underwent a repeat laparoscopy. A subsequent laparoscopic and/or magnetic resonance imaging scan was performed in 35 patients because of persistent pain. Among these, there was 12 endometriomas (7 recurrences) and 12 DIEs (3 recurrences), giving recurrence rates for endometriomas and DIEs of 36.84% and 50%, respectively. During the study, 18 patients wished to have a child. Thirteen had a delivery (72.2%), and 9 pregnancies occurred in patients who initially presented with stage I to II endometriosis. Of the 11 patients who had subfertility, 6 successfully conceived (54.5%). CONCLUSIONS Adolescent endometriosis is not a rare condition. In our study a familial history was reported in more than one-third of patients. Among those patients treated for DIE, there was a trend for higher rates of recurrences (symptoms or lesions) that required repeat laparoscopy. However, the impact on subsequent fertility appeared to have been limited.

Obesity in laparoscopic surgery

Since the 1980s, minimally invasive techniques have been applied to an increasing number and variety of surgical procedures with a gradual increase in the complexity of procedures being successfully performed laparoscopically. In the past, obesity was considered a contraindication to laparoscopy due to the higher risk of co-morbid conditions such as diabetes, hypertension, coronary artery disease and venous thromboembolism. Performing laparoscopic gynaecological procedures in morbidly obese patients is no longer a rare phenomenon; however, it does necessitate changes in clinical practice patterns. Understanding of the physiological changes induced by laparoscopy, particularly in obese patients, is important so that these may be counteracted and adverse outcomes avoided. Laparoscopy in obese patients confers certain advantages such as shorter hospital stay, less post-operative pain and fewer wound infections. In addition to these benefits, minimal-access surgery has been demonstrated as safe and effective in obese patients; however, specific surgical strategies and operative techniques may need to be adopted.

Hysteroscopic Endometrial Resection Versus Laparoscopic Supracervical Hysterectomy for Abnormal Uterine Bleeding: Long-term Follow-up of a Randomized Trial.

STUDY OBJECTIVE To compare long-term efficacy of laparoscopic supracervical hysterectomy (LSH) and hysteroscopic endometrial ablation (HEA) in treating persistent abnormal uterine bleeding. DESIGN Canadian Task Force II-2. SETTING University hospital. PATIENTS One hundred fifty-three women treated for abnormal uterine bleeding by LSH or HEA. INTERVENTION Long-term follow-up assessment of reintervention rate and quality of life (QoL) using the Quality Metrics Health Survey Short Form 12. MEASUREMENT AND MAIN RESULTS This study is the long-term follow-up of a randomized control trial conducted in 2003 comparing LSH and HEA in terms of reoperation rate and QoL. Starting from November 2010 all patients included in the first trial were invited to participate in this study and clinically evaluated through vaginal examination and transvaginal ultrasound. After a mean follow-up of 14.4 years, 29% of patients (20/71) treated with HEA underwent further surgery, whereas no patients after LSH had symptom recurrence. The reintervention rate was significantly higher in the HEA group (p < .0001), with a relative risk of 1.39 (95% confidence interval, 1.20-1.61). The assessment of QoL demonstrated a higher score, in both physical and mental components, in the LSH group (p < .0001). CONCLUSION The lower reintervention rate and the better physical and mental health scores make LSH a more suitable procedure to treat recurrent abnormal uterine bleeding when compared with HEA.

Totally Laparoscopic Intracorporeal Anastomosis With Natural Orifice Specimen Extraction (NOSE) Techniques, Particularly Suitable for Bowel Endometriosis

The objective of this retrospective study was to evaluate the feasibility of natural orifice specimen extraction (NOSE) techniques in 41 patients undergoing bowel resection for treatment of deep infiltrating endometriosis. In all patients laparoscopic treatment of rectovaginal endometriosis with bowel resection had been performed. In 32 patients the classic approach was adopted (group 1), and in 9 a NOSE technique was performed (group 2). Demographic, operative, and postoperative data were compared. Statistical analyses were performed using SPSS software, version 16.0. When needed, qualitative variables were compared using the χ(2) test or the Fisher exact test. Quantitative variables using the t-test were used. The threshold of statistical significance was set at p = .05. No statistically significant difference was observed between the 2 groups. Eight complications (19.5%) were observed, 2 minor (4.8%) and 6 major (14.6%). Of major complications, 2 were observed in the NOSE group (n = 2; 22.2%). It was concluded that the NOSE technique is a feasible approach in patients undergoing bowel resection for treatment of deep infiltrating endometriosis.

Does the Number of Neoadjuvant Chemotherapy Cycles before Interval Debulking Surgery Influence Survival in Advanced Ovarian Cancer

Objective: To evaluate the overall survival (OS) of patients with initially inoperable advanced ovarian cancer, tubal carcinoma, or primary peritoneal carcinoma of stages III or IV undergoing neoadjuvant chemotherapy (NAC) followed by cytoreductive surgery, according to the number of cycles performed. Methods: This retrospective study was conducted in three main oncology centres in the east of France, reviewing the charts of all patients who underwent NAC between January 1, 1998 and October 31, 2012. We performed an OS analysis using multivariate Cox regression models adjusted for potential confounders. We also analysed progression-free survival (PFS) as well as chemotherapy- and surgery-related morbidity. Results: Of the 204 patients included, 75 (36.8%) underwent ≤4 NAC cycles and 129 (63.2%) ≥5 NAC cycles. Characteristic data were similar in the two groups. Five-year OS was 35.0 and 25.8%, respectively. This difference was non-significant [HR = 1.06 (0.70-1.59), p = 0.79]. We also found no differences in PFS or morbidity between the two groups. Conclusions: The number of NAC cycles does not seem to play a role in the OS of patients with advanced ovarian cancer. Further evidence and prospective data are needed to assess the value of a high/low number of NAC cycles among these patients.

Step-by-step Type C Laparoscopic Radical Hysterectomy With Nerve-sparing Approach

STUDY OBJECTIVE To show the laparoscopic technique to perform type C radical hysterectomy with a nerve-sparing approach and pelvic lymphadenectomy. DESIGN Educational video with step-by-step explanation of the technique using videos and pictures to highlight the anatomic landmark that guides the procedure. SETTING The goal of this procedure is to enlarge the resection of the paracervix at the junction with internal iliac vascular system, leaving the neural part of the structure under the deep uterine vein untouched. Type C consists in the resection of the uterosacral ligament at the rectum level and the vesicouterine ligament at the bladder level. The ureter is mobilized completely, and 15 to 20 mm of the vagina from the tumor or cervix is resected. Performing such an enlarged hysterectomy, the preservation of the nerve supply to the bladder is crucial, leading to the creation of the subclasses. Type C1 conserves a nerve-sparing approach remaining above the deep uterine vein, whereas in type C2 a resection beyond this landmark including the neural part of the paracervix is performed. INTERVENTIONS Total laparoscopic type C1 radical hysterectomy with pelvic lymphadenectomy. CONCLUSION This video shows the feasibility of type C radical hysterectomy through a minimally invasive approach. The possibility to perform this type of procedure laparoscopically matches with the more conservative approach to cervical cancer, bringing all the advantages of this technique into this field of gynecologic surgery.

Hysterectomy in the Surgical Management of Endometriosis

While the role of hysterectomy in the management of chronic pelvic pain is subject to debate, it is considered a viable option for the treatment of endometriosis. It is performed in patients severely debilitated by symptoms who no longer wish to retain reproductive function. There is evidence to support its rationale as well as its efficiency in treating endometriosis related pelvic pain. It yields a high level of satisfaction in patients despite their young age and the presence of residual pain in a significant number of cases. It should be part of a radical approach, nevertheless the role of concomittant salpingo-oophorectomy is still subject to debate. Performing a hysterectomy in a context of endometriosis entails the application of a general strategy that aims to restore the anatomy and identify important landmarks. A preparatory operative step is thus often necessary before the usual key surgical steps of hysterectomy can be performed.

Contents Vol. 91, 2016

A.B. Benson, Chicago, Ill. A. Chang, Singapore A.L. Cheng, Taipei J.F. Cleary, Madison, Wis. M. Dietel, Berlin P. Dufour, Strasbourg M.S. Ernstoff, Buffalo, N.Y. M.G. Fakih, Duarte, Calif. J.J. Grau, Barcelona H. Gronemeyer, Illkirch D.F. Hayes, Ann Arbor, Mich. C.S. Johnson, Buffalo, N.Y. M.J. Kelley, Durham, N.C. L. Kumar, New Delhi P.J. Loehrer, Indianapolis, Ind. J.R. Marshall, Buffalo, N.Y. S. Monfardini, Milan R. Nagler, Haifa R. Ohno, Nagoya B. Pestalozzi, Zurich H.M. Pinedo, Amsterdam E.A. Repasky, Buffalo, N.Y. A. Semczuk, Lublin E.F. Smit, Amsterdam C.N. Sternberg, Rome R. Stupp, Zurich M.S. Tallman, New York, N.Y. S. Tanaka, Hiroshima M. Tian, Houston, Tex. D.L. Trump, Buffalo, N.Y. T. Wiegel, Ulm W. Yasui, Hiroshima H. Zhang, Hangzhou City Editor-in-Chief