Nicolas Bourdel

Impact of hospital and surgeon case volume on morbidity in colorectal endometriosis management: a plea to define criteria for expert centers

Summary of background dataNational and international guidelines recommend referring patients with severe forms of endometriosis to expert centers. However, there is a lack of clear criteria to define an expert center. We examined the roles of surgeon and hospital procedure volumes as determinants of morbidity in deep infiltrating endometriosis of the rectum and sigmoid colon (DIERS).MethodsWe conducted a French retrospective multicenter study of hospital facilities performing colorectal surgery for DIERS in 2015. The primary end point was to analyze the relation between case volume and the incidence of complications. We estimated the optimal cut-off (OCO) determined by a minimal p-value approach.ResultsThe study included 56 hospital facilities and collected data of 1135 cases of surgical management of colorectal endometriosis. The mean and median number of procedures per year and per surgeon were 9.17 and 5.58, respectively. The overall rate of grade III–V complication was 7.6% (82/1135). One grade V complication occurred. The rates of rectovaginal fistula, anastomotic leakage, pelvic abscess, and ureteral fistula were: 2.7% (31/1135), 0.79% (9/1135), 3.4% (39/1135), and 0.70% (8/1135), respectively. An OCO of 20 procedures per center and per year (pu2009<u20090.001) was defined. The OCO per surgeon and per year varied between seven (pu2009=u20090.007) and 13 procedures (pu2009=u20090.03). In a multivariate analysis, we found that only the volume of activity was independently correlated to complication outcomes (pu2009=u20090.0013).ConclusionOur results contribute to providing objective morbidity data to determine criteria for defining expert centers for colorectal surgery for endometriosis.

Psychometric properties of the French version of the Endometriosis Health Profile-30, a health-related quality of life instrument

INTRODUCTIONnThe objectives were to evaluate the acceptability, reliability and validity of the cross-cultural adaptation of the Endometriosis Health Profile-30 instrument into French.nnnMETHODSnThis cross-sectional study was conducted between July and October 2015. We created an online link (REDCap platform) with the questionnaires. An endometriosis patients association spread the link on its website and with social networks. The translation and cultural adaptation of the EHP-30 was performed according to guidelines. Psychometric evaluation included data completeness, score distributions, floor and ceiling effects, factor analysis, internal consistency, item-total correlations corrected for overlap, convergent validity and test-retest reliability.nnnRESULTSnThe study included 913 women with endometriosis. In our results, data completeness was excellent. No floor effects were found and one ceiling effect was observed for the Infertility scale. The highest means scores were found for Control and powerlessness and Infertility scales. Factor analysis confirmed the structure of the original EHP-30 questionnaire. Internal consistency was good (Cronbachs α range=0.72-0.96). The correlations of similar scale scores between EHP-30 and SF-36 were all significant (Spearman correlation coefficients ranging from -0.52 to -0.75). Test-retest reliability was good (intraclass correlation coefficients range=0.51-0.98).nnnCONCLUSIONnThe French version of the EHP-30 is an acceptable, reliable and valid instrument for measuring health-related quality of life in women with endometriosis.

Patient Language in Endometriosis Surgery

Endometriosis is a complex disease, and the treatment of each patient must be individualized. Surgery has an important role in the long-term management of these patients. Whenever surgery is indicated, the concept of complete removal of the disease must be kept in mind. In this chapter, the authors discuss some issues about the “patient language” during surgery, important information that is frequently missed by surgeons but that must be well known in order to help in the decision-making process intraoperatively.

Ovarian Cysts: Preoperative Evaluation and Laparoscopic Approach

Benign ovarian tumors remain a common gynecologic problem. The main goal of the preoperative work-up is to exclude malignancy. Laparoscopic approach is the gold standard for the management of ovarian masses because it is safe and has proven advantages compared with laparotomy. However, systematization of the procedure is essential! Oncologic surgical principles must be always followed even in those women whose mass has low suspicion for malignancy. The surgical technique must be adapted to the characteristics of the cyst and the patient. Experts should try to teach young surgeons the proper surgical technique in order to make it easier and reproducible.

Feelings and expectations in endometriosis: Analysis of open comments from a cohort of endometriosis patients

INTRODUCTIONnEndometriosis symptoms may have a negative effect on health-related quality of life (HRQoL). Analyses of open comments are known to be a key source of information and support. The authors aimed to analyse open comments associated with a validation scale study, in order to ascertain whether the questionnaires allowed an adequate exploration of patient preoccupations and in so doing define important quality of life themes not assessed in HRQoL scales.nnnMATERIAL AND METHODSnAnalysis of open comments, following two questionnaires (SF-36 and EHP-30) as part of a national study evaluating the EHP-30, was performed. Questionnaires were distributed online, via a link to the RedCap Internet platform. The association EndoFrance, a support group for endometriosis patients, notified women of the launching of the study. Women were asked to complete the questionnaire and had the opportunity to comment. Comments were gathered, coded systematically, and categorised by theme.nnnRESULTSnOf the 1156 women who responded to the questionnaire, 913 (79.0%) declared having a confirmed surgical diagnosis of endometriosis, and 265 comments were analysed. Comments were classified in 20 themes. Correspondence between the themes and items for both questionnaires and the open comments was investigated for all topics, including those non-addressed by the questionnaires. 8 themes are not mentioned in both questionnaires, 9 themes are covered by EHP-30, two by SF-36 and only one by both.nnnCONCLUSIONnAnonymous data collection and subsequent analysis proves to be an effective and practical way of obtaining patient opinion on their pathology. Analysis of comments may provide additional and useful information to the classical HRQoL Scale.

Evaluation and Selection of Quality Indicators for the Management of Endometrial Cancer

Objective The aim of this study was to evaluate 36 quality indicators (QIs) for monitoring the quality of care of uterine cancer to be implemented in the EFFECT (effectiveness of endometrial cancer treatment) project. Methods The 36 QIs were evaluated in the first 10 patients diagnosed with endometrial cancer and managed in 14 French hospitals in 2011. To assess the status of each QI, a questionnaire detailing the 36 QIs was sent to each hospital, and the information was cross-checked with information from the multidisciplinary staff meeting, surgical reports, and pathological reports. The QIs were evaluated in terms of measurability and improvability. The remaining QIs were evaluated with a multiple correspondence analysis to highlight the interrelationships between qualitative variables describing a population. Results Thirteen of the 14 institutions responded to the survey for a total of 130 patients. Twenty-five of the 36 QIs affected less than 80% of the patients. Thirteen QIs were found not to be improvable because they reached more than 95% of the theoretical target. Finally, 5 QIs concerning more than 80% of the patients were found to be improvable. The multiple correspondence analysis finally identified 3 dimensions—outcome, safety, and perioperative management—that included the 5 QIs. Conclusions In the present study, 5 of the 36 QIs suggested by the EFFECT project seem to be sufficient to report on the quality of endometrial cancer management. Further studies are needed to correlate the information provided by those 5 questions and the relevant outcomes reflecting quality of care in endometrial cancer.

Les adhérences pelviennes : impact et prévention

Les adherences pelviennes sont a la fois une source d’infertilite, d’echecs de la chirurgie de l’infertilite, de douleurs pelviennes chroniques, d’occlusion sur bride et de complication en cas de reintervention. Leur frequence est souvent sous-estimee car leur repercussion clinique est decalee dans le temps. Leur prevention repose d’abord sur une technique chirurgicale appliquant en cœlioscopie les regles de la microchirurgie, incluant une manipulation atraumatique, une hemostase soigneuse – mais une limitation de la coagulation – et une irrigation du champ operatoire. L’insufflation avec du CO2 humidifie et rechauffe est aussi un element important. La prevention par des agents pharmacologiques generaux n’a pas ete prouvee. La prevention par des agents locaux type barrieres solides, liquides ou gel manquent encore de preuve irrefutable de leur efficacite, et celle-la semble de toute facon modeste ; aussi ne doivent-ils venir qu’en complement d’une technique chirurgicale rigoureuse. Il est surtout necessaire que des etudes cliniques plus importantes soient realisees pour evaluer leur niveau d’efficacite.

Total Laparoscopic Hysterectomy: Surgical Technique and Results

Hysterectomy is the most commonly performed major gynecologic procedure around the world. Benign diseases are responsible for more than 70% of the indications for hysterectomy and include menstrual disorders, fibroids, pelvic pain and uterine prolapse (Whiteman et al., 2008). Traditionally, hysterectomy is performed by laparotomy or by vaginal access (Clayton, 2006). In 1989, Reich et al. (1989) described the first totally laparoscopic hysterectomy, which is currently considered an alternative means of access to traditional techniques for hysterectomy. Despite the advantages of the laparoscopic and vaginal routes compared with laparotomy, this remains the most widely used access route for performing hysterectomy worldwide. In Denmark, 80% of hysterectomies for benign disease between 1988 and 1998 were performed by laparotomy (Gimbel et al., 2001). In the period between 1988 and 1990, approximately 1.7 million hysterectomies were performed in the United States and 75% were by the abdominal route (Wilcox et al., 1994). In 2003, 538,722 hysterectomies were performed for benign disease in the United States and the abdominal route was still the most common (66.1%), followed by vaginal (21.8%) and laparoscopic (11.8%). This study demonstrated that there was a statistically significant difference in the average hospital stay among the three types of surgical access (3 ± 0.03 days, 2 ± 0.03 days and 1.7 ± 0.03 days, respectively, p <0.001), for abdominal, vaginal and laparoscopic approaches (Wu et al., 2007). In a multicenter crosssectional study including 23 French university hospitals (Chapron et al, 1999), the rates of laparoscopic, vaginal and laparotomic hysterectomy were 9.6%, 47% and 43.4% respectively. In another study conducted between June and December 2004, including 634 women undergoing hysterectomy for benign disease in 12 French university hospitals, total laparoscopic hysterectomy was performed in 19.1%, laparoscopic assisted vaginal hysterectomy in 8.2%, total abdominal hysterectomy in 24.4% and vaginal hysterectomy in 48.3% (David-Montefiore et al., 2007), showing a significant reduction in the rate of laparotomies for performing hysterectomies. This trend indicates an adaptation to the modern concept of minimally invasive surgery. In some referral centers for gynecological