Sponsored by AAGL Advancing Minimally Invasive Gynecology Worldwide Deep Endometriosis – Diagnosis, Impact of Surgical Treatment, Future Perspectives on Therapies (Didactic) PROGRAM CHAIR Charles E. Miller, MD Charles Chapron, MD Tamer A. Seckin, MD Camran R. Nezhat, MD Jim Tsaltas, MD
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Professional Education Information Target Audience Educational activities are developed to meet the needs of surgical gynecologists in practice and in training, as well as, other allied healthcare professionals in the field of gynecology. Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AAGL designates this live activity for a maximum of 3.75 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS As a provider accredited by the Accreditation Council for Continuing Medical Education, AAGL must ensure balance, independence, and objectivity in all CME activities to promote improvements in health care and not proprietary interests of a commercial interest. The provider controls all decisions related to identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the activity. Course chairs, planning committee members, presenters, authors, moderators, panel members, and others in a position to control the content of this activity are required to disclose relevant financial relationships with commercial interests related to the subject matter of this educational activity. Learners are able to assess the potential for commercial bias in information when complete disclosure, resolution of conflicts of interest, and acknowledgment of commercial support are provided prior to the activity. Informed learners are the final safeguards in assuring that a CME activity is independent from commercial support. We believe this mechanism contributes to the transparency and accountability of CME.
Table of Contents
Course Description ........................................................................................................................................ 1 Disclosure ...................................................................................................................................................... 3 Endometriosis and Hysterectomy C.R. Nezhat ................................................................................................................................................... 5 The Use of Robotic Assistance in the Treatment of Deep Endometriosis C.E. Miller ................................................................................................................................................... 11 The Impact of Surgical Treatment of Endometriosis on Infertility J. Tsaltas ..................................................................................................................................................... 15 Complications T.A. Seckin .................................................................................................................................................. 20 The Impact of Surgical Treatment of Endometriosis on Pelvic Pain C.E. Miller ................................................................................................................................................... 24 Therapeutic Strategies for the Treatment of Extra Pelvic Endometriosis – Diaphragm, Lungs, Pleura C.R. Nezhat ................................................................................................................................................. 33 Perspectives on the Future Treatment of Endometriosis C. Chapron .................................................................................................................................................. 42 Cultural and Linguistics Competency ......................................................................................................... 56
PG 211 Deep Endometriosis – Diagnosis, Impact of Surgical Treatment,
Future Perspectives on Therapies (Didactic)
Charles E. Miller, Chair Faculty: Charles Chapron, Camran R. Nezhat, Tamer A. Seckin, Jim Tsaltas
Course Description
Due to the inexperience in appreciating the diagnosis prior to surgery, the complexity of the surgery itself, and the potential need for a multidisciplinary approach, many women with deep endometriosis are not satisfactorily treated at the time of the initial laparoscopic surgery. This course demystifies the surgical approach to deep endometriosis. This includes hysterectomy and endometriosis, robot-assisted laparoscopy for deep endometriosis, the impact of surgery for endometriosis on pain and infertility, strategies for the treatment of extra pelvic endometriosis, and a discussion on future treatments for endometriosis. Teaching will be enhanced with interactive video session, featuring all faculty members.
Learning Objectives At the conclusion of this course, the participant will be able to: 1) Discuss strategies for laparoscopic hysterectomy in the presence of severe endometriosis; 2) describe how robotic surgery can enhance the treatment of deep endometriosis; 3) discuss the impact of surgical therapy for endometriosis on infertility and pelvic pain; 4) detect extra pelvic endometriosis and discuss surgical treatment; and 5) discuss future treatments for endometriosis.
Course Outline 1:30 Welcome, Introductions and Course Overview C.E. Miller 1:35 Endometriosis and Hysterectomy C.R. Nezhat C.R. Nezhat 2:00 The Use of Robotic Assistance in the Treatment of Deep Endometriosis C.E. Miller 2:20 The Impact of Surgical Treatment of Endometriosis on Infertility J. Tsaltas 2:40 Complications T.A. Seckin 2:55 Video/Interactive Session, Q&A All Faculty 3:25 Break 3:40 The Impact of Surgical Treatment of Endometriosis on Pelvic Pain C.E. Miller 4:05 Therapeutic Strategies for the Treatment of Extra Pelvic Endometriosis – Diaphragm, Lungs, Pleura C.R. Nezhat
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4:30 Perspectives on the Future Treatment of Endometriosis C. Chapron 4:55 Video/Interactive Session, Q&A All Faculty 5:30 Course Evaluation
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PLANNER DISCLOSURE The following members of AAGL have been involved in the educational planning of this workshop and have no conflict of interest to disclose (in alphabetical order by last name). Art Arellano, Professional Education Manager, AAGL* Viviane F. Connor Consultant: Conceptus Incorporated Frank D. Loffer, Executive Vice President/Medical Director, AAGL* Linda Michels, Executive Director, AAGL* Jonathan Solnik Other: Lecturer - Olympus, Lecturer - Karl Storz Endoscopy-America SCIENTIFIC PROGRAM COMMITTEE Arnold P. Advincula Consultant: CooperSurgical, Ethicon Women's Health & Urology, Intuitve Surgical Other: Royalties - CooperSurgical Linda Bradley Grants/Research Support: Elsevier Consultant: Bayer Healthcare Corp., Conceptus Incorporated, Ferring Pharmaceuticals Speaker's Bureau: Bayer Healthcare Corp., Conceptus Incorporated, Ferring Pharm Keith Isaacson Consultant: Karl Storz Endoscopy Rosanne M. Kho Other: Honorarium - Ethicon Endo-Surgery C.Y. Liu* Javier Magrina* Ceana H. Nezhat Consultant: Intuitve Surgical, Lumenis, Karl Storz Endoscopy-America Speaker's Bureau: Conceptus Incorporated, Ethicon Women's Health & Urology William H. Parker Grants/Research Support: Ethicon Women's Health & Urology Consultant: Ethicon Women's Health & Urology Craig J. Sobolewski Consultant: Covidien, CareFusion, TransEnterix Stock Shareholder: TransEnterix Speaker's Bureau: Covidien, Abbott Laboratories Other: Proctor - Intuitve Surgical FACULTY DISCLOSURE The following have agreed to provide verbal disclosure of their relationships prior to their presentations. They have also agreed to support their presentations and clinical recommendations with the “best available evidence” from medical literature (in alphabetical order by last name). Charles E. Miller Grants/Research Support: Covidien, Femasys, Olympus, Novartis, Abbott Laboratories Consultant: Covidien, Femasys, Abbott Laboratories, Ferring Pharm Charles Chapron* Camran R. Nezhat* Tamer A. Seckin*
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Jim Tsaltas Grants/Research Support: Covidien, Merck Serono Scott G. Chudnoff* Asterisk (*) denotes no financial relationships to disclose.
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DisclosureDisclosure
I have no financial relationships to disclose.I have no financial relationships to disclose.
Describe techniques for safe laparoscopic Describe techniques for safe laparoscopic accessaccess
Describe techniques used in difficult Describe techniques used in difficult hysterectomieshysterectomieshysterectomieshysterectomies
Describe techniques used to address difficult Describe techniques used to address difficult adhesions during laparoscopyadhesions during laparoscopy
Describe your Describe your anticipated anticipated procedureprocedure
ParaPara--vesical spacevesical space VesicoVesico--vaginal spacevaginal space VesicoVesico--uterine spaceuterine space RectoRecto--vaginal spacevaginal space
Vascular structuresVascular structuresThe course of inferior epigastric vessels
Obliterated Umbilical Lig.
Urachus
SymphysisPubis
Posterior aspect of anterior abdominal wall
Cervix
The vesicouterine and vesicovaginal spaces
Obturator internus muscle
Right obturator nerveRi ht blit t d
Right Obturator artery
Right external iliac artery and vein
Right obliterated umbilical artery
Right paravesical space and its structures
*Recto-uterine
Space
*
A
Recto-vaginal Space
B
The rectovaginal space is completely developed.The appearance of space A) in a non-hysterectomized patients, and B) in a hysterectomized patients
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A B*
Intraperitoneal view of the sacral promontory and the location of the bifurcation of Aorta (*)
Left common iliac artery
Inferior vena cava
Left common iliac vein
Right common iliac artery
Anatomic relationships of the bifurcation of the Aorta, inferior vena cava and sacral promontory
The middle sacral vessels are in the midline on the sacrum.
Bladder
Rectum
Left ureter Right ureter
The relationship of bladder, ureters and rectum after a radical hysterectomy
The patient is in supine positionThe patient is in supine position The thighs are not flexed so that the suprapubic and The thighs are not flexed so that the suprapubic and
lateral trocars may be maneuveredlateral trocars may be maneuvered Nasogastric tubeNasogastric tube is placed before procedureis placed before procedure
Operative Gynecologic Laparoscopy: Principles and techniques Nezhat 2000. Mc Graw-Hill
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The buttocks are hanging 2-3 inches off the table
Endotracheal tube
Oral‐gastric tube Ensure the patient is completely
relaxed.
Step 3 Step 3 –– Palpation of aortaPalpation of aorta
The aorta and sacral promontory are palpated
Operative Gynecologic Laparoscopy: Principles and techniques Nezhat, 2000. Mc Graw-Hill
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Palpate the abdominal aorta.
Step 4 Step 4 –– Insertion of Veress needleInsertion of Veress needle
Veress needle is grasped by the shaft and directed posteriorly at a 90° angle. Inset shows elevation of skin and subcutaneous tissue by towel clips.
Operative Gynecologic Laparoscopy: Principles and techniques Nezhat, 2000. Mc Graw-Hill
Standard laparoscopyStandard laparoscopy Two to three 5 mm portsTwo to three 5 mm ports
2 lateral2 lateral
1 pr1 pr p bip bi 1 supra1 supra--pubicpubic
RoboticRobotic Three to four 5Three to four 5--8 mm ports8 mm ports
Similar configurationSimilar configuration
Configuration may be altered depending on surgeryConfiguration may be altered depending on surgery
Continuation…..Continuation…..
Before positioning the robotic cart, pressure points Before positioning the robotic cart, pressure points must be carefully paddedmust be carefully padded
In the case of an airway emergency or cardiac In the case of an airway emergency or cardiac arrest resuscitating the patient requires disengagingarrest resuscitating the patient requires disengagingarrest, resuscitating the patient requires disengaging arrest, resuscitating the patient requires disengaging the robotic instruments before backing the cart the robotic instruments before backing the cart away from the OR table away from the OR table
Avoid head docking and use side or between legs Avoid head docking and use side or between legs docking when possible.docking when possible.
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Thank You !Thank You !Thank You !Thank You !
Fellows
Elizabeth Buescher MDJackie Miller, DO
Elizabeth Buescher MD
Chandhu Paka, MDM. Ali Parsa, MD
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The Use of Robotic Assistance in the Treatment of Deep Endometriosis
Charles E. Miller, MD, FACOG
• President, International Society for Gynecologic Endoscopy (ISGE)
• President, AAGL (2007-2008)
• Clinical Associate Professor, Department OB/GYN, University of Illinois at Chicago, Chicago, IL USA
• Director of Minimally Invasive Gynecologic Surgery, Advocate Lutheran General Hospital, Park Ridge, IL USA
• Director, AAGL/SRS Fellowship in Minimally Invasive Gynecologic Surgery, Advocate Lutheran General Hospital, Park Ridge, IL USA
Scope of my talk What evidence supports surgical intervention in the management of
endometriosis-related infertility
Introduction
y
Topics considered in preparation Minimal to Mild Endometriosis Endometriomas DIE (deep infiltrating endometriosis) Inclusive of rectovaginal and colorectal endometriosis
Surgical technique Adhesion prevention Pre and post surgical adjunct medical therapy Repeat surgery Place of surgery for failed IVF No surgery at all
I have taken the starting point that the patient has been diagnosed with endometriosis and they are infertile
In preparation of this talk
Diagnosis modality can include examination, ultrasound, laparoscopy
The infertile population we review are couples with no significant male factor infertility, the female partner is ovulatory and has patent tubes
Intervene at 12 mths of infertility if under age of 35 or at 6 months if 35 or over
The use of laparoscopic surgery in the treatment of subfertility related to minimal and mild endometriosis may improve future fertility
Surgery involving ablation/excision (+/- adhesiolysis) is effective compared
Minimal – Mild Endometriosis
g y g ( y ) pto diagnostic laparoscopy
Evidence is high quality 2 RCTs (Marcoux et al 1997, Gruppo Italiano 1999) Meta analysis of the two Marcoux strong positive effect whereas Gruppo Italiano reported a small negative effect
Jacobson et al – Cochrane review 2010 Limitations of studies discussed by Cochrane and Vercellini etal (2009)
Consensus: On weight and high grade of evidence laparoscopic surgery is recommended for minimal – mild endometriosis to enhance fertility Importance of ongoing laparoscopic skills training Surgery must remain an option – Barri etal 2010
Minimal to Mild: surgical treatment for subfertility
paper population intervention control treatment stats
Marcoux, Canada
Laparoscopic surgery in infertile women with minimal or mild endometriosis NEJM 1997; 337(4):217-22
Diagnostic lap –randomised to resection/ablation or diagnosis only
Follow up 36 weeks or until 20 if i d
29/169 pregnant –17.7%
50/172 pregnant –30.7%
Difference significant p<0.0006
20w if conceived
Gruppo italiano per lo studio dell’endometrioisi
Ablation of lesions or no treatment in minimal-mild endometriosis in infertile women: a randomised trial.
Human reproduction 1999; 14(5): 1332-4
101 <36yo
Infertile >2 years
Lap endo stage I-II AFS
Diagnostic or ablation/excision +/- adhesiolysis
No histology required
Follow up 9m, could have 3m medical treatment
13/47 (28.9%)
12/54 (23.5%)
Longer infertility 40-50% each group had med therapy post op incl GnRHAg
No difference between groups
Powered to detect 2.5 diff in treatment group (based on Hughes metaanalysis & presupposed baseline fecundity in diagnostic group of 25% -probable overestimate, thus underpowered)
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Will break down into endometriomas (ovarian disease) and also rectovaginal /DIE(including colorectal endometriosis) Must remember they are not separate entities and may co
Moderate to severe endometriosis
Must remember they are not separate entities and may co –exist and according to the literature endometriomas are often markers of more severe disease (Banerjee 2008, Chapron 2009) For this discussion I will separate the discussion into: management of Ovarian disease(endometriomas) management of rectovaginal endometriosis/DIE (including colorectal
disease) Need to consider place of surgery, associated symptoms such
as pain, access and costs of both surgery and IVF. Laparoscopic skill acquisition and training are vital.
Many studies have been produced to discuss this topic Guidelines to date – ESHRE(2008), ASRM(2006), NHS(2010) – There may
be a possible benefit
Ovarian endometriomas
p What is the Data? Laparoscopic cystectomy by excisional surgery for endometriomata 4cm or
greater improves fertility(spontaneous pregnancy rates) compared to drainage and coagulation (Beretta 1998, Alborzi 2004). Many other observational studies show an increased pregnancy rate after surgery for endometriomas with a weighted mean of 50% - summarized in Vercellini 2009 and listed in bibliography of this talk
As well as improved fertility rates excision has lower recurrence of endometriomas and symptoms (Hart 2008 and updated 2011 – cochrane review) as compared to drainage and coagulation
High quality as are RCT – limitation not including expectant arm in trial –may downgrade evidence to moderate quality as we do not know true rate of pregnancy with no surgery
Based on the above evidence Weight of other studies
Decisions to treat
Other symptoms attributed to the endometriosis – significant pain, impact on patients QOL, histological diagnosis, reduce risk of cyst complications, improve access for IVF if required and reduce risk of post IVF abscess formation. (Garcia-Velasco 2009 Tubal and Male factor infertility Access to trained surgeons and IVF Must no look at surgery and IVF as competing interests but
rather as complementary therapeutic strategies (Barri 2010, Littman 2005, Adamson 2005)
Early studies suggested minimal if any damage to the ovarian reserve after surgical treatment for endometriomas –
Issues related to treatment
(Loh 1999, Donnez 2001, Canis 2001)
Recent studies however have demonstrated damage to the ovarian reserve Methodology to assess this includes D2 FSH, AFC, Ovarian
reserve, response to gonadotrophins in IVF and AMH
Damage may also relate to size of endometrioma being excised (Roman 2010)
Care with surgical technique Excision is preferred method
Reducing Risks
Care with identification of planes Minimize diathermy and conserve all ovarian tissue possible Recent small randomized clinical trial – shows potential less reduction in
ovarian reserve when suturing is used for haemostasis – AFC outcome measure (Coric 2011)
Combined technique – excisional surgery and also ablative surgery for 10 –20% of endometrioma wall next to hilus (Donnez 2010)
AMH excellent marker Group should consider recommendation of routine AMH testing pre and 3
mths post endometrioma surgery Group should consider egg freezing prior to recurrent endometrioma
surgery in young patient with low AMH not trying to conceive
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Evidence of moderate to high grade exists to recommend excisional surgery for endometriomas 4cm or more to
Ovarian EndometriomasConsensus statement proposal
improve fertility. Appropriate skill and training is required for safe and complete excision. It is important to minimize ovarian damage and further studies are required to ascertain if suturing for haemostasis is superior. Surgeons should consider measurements of ovarian reserve pre and post operative to help counsel patients.
Small study looked at reduction of post operative adhesions by suture to close the ovary for haemostasis compared to
Adhesions
traditional diathermy.(endometriomas) RCT – favored suturing – Pellicano 2008 This is now our practice
2 Cochrane reviews Ahmad 2010 – Barrier agents for adhesion prevention after
gynaecological surgery Do reduce post operative adhesions
No data regarding pregnancy outcome
Metwally 2011 – Fluid and pharmacological agents for adhesion prevention after gynaecological surgery
Adhesions (cont)
There is no evidence of a benefit of using the above agents as an adjunct during pelvic surgery for improving pregnancy outcomes
Consensus:
No data to support the routine use of adhesion barriers to improve pregnancy outcomes
Early studies suggested improvement in fertility rates after management of DIE (Chapron 1999)
Since that time a number of articles have been published discussing this
Surgery for Rectovaginal Lesions
p gissue
Severe endometriosis which infiltrates the posterior vaginal wall and anterior rectal wall is one of the most challenging surgical issues we face as gynaecologists.
There have now been a number of studies on this topic. Studies are either retrospective, observational or prospective.
Surgery may be challenging and the risks of intraoperative and post operative morbidity not negligible
Surgery should only be performed with the appropriate multidisciplinary set up
Pregnancy rates from studies quoted vary from 23 - 57% (recent review Meuleman 2011) These studies vary in quality and the grade of evidence are mostly low quality with occasional moderate quality studies
Ferrero 2009 Pregnancy after bowel resection Surgery Laparoscopy – 57.6%, Laparotomy – 23.6% Surgical technique based on the preference of the colorectal surgeon
Recent Studies of interest
g q p g Laparoscopy superior to laparotomy No Spont Pregn in women over 35 after surgery
Stepniewska A 2009 3 Groups Greater than 1 year infertility (average – 2.5 years) Retrospective cohort study with longitudinal evaluation of clinical outcomes 60 – severe pain request bowel surgery – spont pregn 12/30, IUI 0/5, IVF – 5/13 40 – no consent for bowel surgery(all other endo removed) - Spont Pregn 7/23,
IUI o/3, IVF – 1/13 55 – Stage 3 -4 endo but no bowel endo - spont pregn 24/34, IUI – 4/6, IVF – 4/6 Best outcomes in patients who had stage 3 – 4 endometriosis without bowel
Surgery by laparotomy for severe rectovaginal endometriosis
24 month follow up
Surgery – 44.9%
Expectant management – 46.8%
Bias as stated by authors – patients with more pain and potentially more aggressive disease chose surgery and this may influence pregnancy rates
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Barri 2010 Observational study 825 patients aged 20 – 40 years(mean age 35.3) with infertility and endometriosis –
2001 t 2008
Studies Continued
2001 to 2008 Mean length of infertility – 3.2+/- 2.3 years Diagnosed – stage 3 – 4 AFS Endometriosis Many with endometriomas 483 patients – surgery – 262 spont pregn 58.5% 221 patients – no pregnancy – 144 IVF – 184 Oocyte retrieval and 56 pregnancies IVF chosen by 173 patients who chose no surgery – 68 pregnancies (patients matched) Again age is an issue in both groups (35 yoa) Surgery only - <35 – 229/372, >35 – 33/111 Group 3 – no treatment – 20/69 – 11.8% Good study – favoring surgery If under 35 – Ivf at 12 months, if over 35 – Ivf at 6months
Deep Infiltrating Endometriosis and IVF
IVF only (n=105) Surgery + IVF (n=64) P value
Infertility duration (months) 29 ± 20 35 ± 18 .01
Total dose of FSH (IU) 2380 ± 911 2542 ± 1012 .01
Number of oocytes retreived 10 ± 5 9 ± 5 .04
Fertilisation rate (%) 77.9 78 .76
No. of top quality embryos / patient .59 ± 1 .57 ± 1 .48
No. of embryos transferred 3 ± 1 3 ± 1 1
Implantation rate (%) 19 ± 25.1 32.1 ± 30.6 .03
Pregnancy rate (%) 24 41 .004
(Bianchi et al J Min Invas Gyn 2009)
Debate between the need for bowel resection vs shaving technique only for deep rectovaginal endometriosis
Surgical Technique
Donnez 2010 Prospective analysis of 500 cases 388 patients wished to conceive – 221(57%) spontaneous
pregnancy 167 – needed IVF – failure to conceive after 12 months of trying
or immed IVF due to male factor(25% of this group) 107 conceived
Overall pregnancy rate of 84%
Total Group – 257 patients - colorectal endo (to 30/8/2010
75 Infertility
Our DataTsaltas J, Cooper M, Reid G
5 e t ty 19/75 – 25.3% Infertility, 56/75 – 74.7% pain and infertility
7 lost to follow up, 11 no longer wished to conceive
57 available to follow up still wishing to conceive Pregn rate – 73.6 % 25.9% - spont, 68.5% ART (IVF), 5.6% mode of pregn not recorded
Decision to treat When and how to treat each patient has become much more
individualized Full discussion about options Full discussion about options Place of IVF and/or surgery Consider patients age, male factor, ovarian reserve, ability to
access the ovary safely for OPU, endometriosis pain symptoms and impact on QOL Pre-Operative Ultrasound to assess the size and level of
invasion of the rectal lesion Consent can be appropriately obtained Plan mode of probable surgery – shave, disc, excise Post op – LDR and IVF immed or set time for spont conception
pre IVF
Infertile patients with severe endometriosis including colorectal disease should consider surgery as an alternative t IVF Th RCT t l t th
Severe endometriosis including colorectal disease: Consensus
to IVF. There are no RCT or meta-analyses to answer the question whether the surgical excision of severe endometriosis will enhance pregnancy rates. However recent studies of better quality and larger numbers suggest an improvement in pregnancy rates. Surgery should only be undertaken with appropriate consent and understanding of the risks. Women should be given a full understanding of all available options to help with conception. Surgery for this major disease should be managed by the appropriate multidisciplinary team.
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Cochrane review
Furness 2004
Medical Therapy before or after surgery
Furness 2004 Pre and post-operative medical therapy for endometriosis
surgery
No evidence of benefit to surgery alone
Consensus – no benefit of medical therapy before or after endometriosis surgery for infertility
Limited information is available on the effect of second line surgery for recurrent endometriosis in infertile women.
No RCT: repeat surgery vs expectant management; IVF vs repeat surgery Studies
Repeat Surgery
Studies Fedele 2006 – 1993 to 2002 305 primary surgeries and 54 reoperations for recurrent endometrioma in the same ovary of the primary
cyst Pregnancy rate – Primary – 40.8%, Secondary – 32.4% The surgical Procedure might be technically more challenging and involves a greater risk of further
impairment of function. Vercellini 2009 – review article Analysis of the literature – achieving a pregnancy after repetitive surgery was almost half that observed after
primary surgery 2 cycles of IVF better than repeat surgery
Adamson 2005 Disadvantages of surgery – potential damage to ovarian reserve, morbidity, a potential longer time to conception
compared to IVF and lack of trained surgeons ESHRE 2005 Final decision should consider presence of pain symptoms and large endometriomas. Pain and refusal to proceed
to IVF still constitutes an indication for repeat surgery
No evidence to recommend repeat surgery over IVF
However should consider surgery if increasing pain,
Consensus on repeat surgery
o e e s ou d co s de su ge y c eas g pa ,enlarging endometrioma and no desire for IVF. Surgery can be complex and appropriate consent needs to be obtained.
Grade of Evidence is Low
More studies required
Littman 2005 Study in a tertiary IVF and Endoscopy centre
Failed IVF no previous surgery
Retrospective case series 29 patients with prior IVF failures – 22 conceived after
laparoscopic treatment of endometriosis 15 spontaneous conceptions 7 IVF Pregnancies Authors believe that complete and thorough microsurgical
eradication of endometriosis allows patients to conceive without further IVF therapy and may help optimize success for those who require subsequent IVF cycles
Prospective cohort study – Bianchi 2009 – Previously discussed
Surgery may play a role in patients who have failed IVF treatment and endometriosis. It may be inappropriate to
Consensus – surgery post IVF
continue with repeated IVF cycles without considering surgery to excise the endometriosis. Excision of endometriosis may enhance opportunity to conceive spontaneously and even enhance Ivf outcomes.
Level of evidence - low
ConclusionWe have a responsibility to know the evidence and be able to
present it to our patients in a measured and informed manner
Surgery and IVF should not be seen as competing interests but as an integral part of the treatment equation
The appropriate multidisciplinary team needs to be available to manage many of these complex issues and patients
Must consider the ovarian reserve and its preservation following our intervention
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Preventing Complications of Deep Endometriosis Surgery:
Traps, Tips & Tricks
Tamer A. Seckin, MD, FACOG, ACGEDirector, Park East Gynecology & Surgery
Tamer A. Seckin, MD
Founder & President, Endometriosis Foundation of America
Preceptor, AAGL Minimally Invasive Gynecologic Surgery Fellowship
North Shore LIJ‐Lenox Hill HospitalNew York City, New York
Author has no financial relationships to disclose.
Tamer A. Seckin, MD
Endometriosis is a debilitating, costly disease fraught with diagnosticdelay, high treatment failure and recurrence. True surgical resection andtreatment poses formidable challenges even the hands of experiencedclinicians. In an effort to assist surgeons to provide optimal surgicalintervention for women with endometriosis, this segment will reviewrecognition and impact of procedural complications and identifyappropriate strategies to reduce morbidity and thus optimize patientoutcome
Tamer A. Seckin, MD
outcome.
At the conclusion of this segment, the participant will be able to:1) discuss common complications of surgery for deep disease; and2) describe techniques for reduction, management and prevention.
If we are to achieve significant progress for women with endometriosis, we must
emphasize the single most important step of action:
Improve the quality of surgery
Tamer A. Seckin, MD
Improve the quality of surgery.
~Tamer Seckin, MD, FACOG
Deep Endometriosis• Deep endometriosis together with cystic ovarian
endometriosis represents most severe form of disease1
• Defined as endometriosis infiltrating deeper than 5‐6 mmunder the peritoneum2
• Excision remains treatment of choice for subsequent fertilityand pelvic pain3;
Tamer A. Seckin, MD
• Difficult to treat due to proximity of and common infiltrationin and around bowel, ureter, uterine artery4
• Surgery for deep endometriosis may be “more difficult thansurgery for cancer”5
Video/photo of deep diseaseINSERT HERE
Tamer A. Seckin, MD
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Q: Which surgical procedure is 100% safe?A: The one that is not performed.1
• Laparoscopy largely safe and effective
• Gold standard for endometriosis treatment
• Associated with decreased morbidity andd d 2
Tamer A. Seckin, MD
admission periods2
• However, traumatic complications may stilloccur3 (e.g. bowel, bladder or gastricperforation; large vessel or ureteral injury)
First, Do No Harm…but if complications do occur, timely recognition and
proper management are key• Complications of laparoscopy becoming increasingly less
common; approximately 3.2 per 1000 cases1, 2
• Primarily related to three categories:3
complications of access; physiologic complications of the
Tamer A. Seckin, MD
p f ; p y g p fpneumoperitoneum; complications of operativeprocedure
• Common4 complications related to deep endometriosissurgery:
Intestinal, Bladder, Ureteral
Potential Complications of Deep Endometriosis Surgery• Postoperative urinary retention1
Incidence• May relate to surgeon experience & severity of pathology
present1
• Certain complications are unpreventable2; others may not betrue complications3 (e.g. unintentional entry to bowel incases of severely fibrotic, rectovaginal disease should not beviewed as complication but rather, a necessity for effective
Tamer A. Seckin, MD
treatment)
• Inferior epigastric vessels most common complications,followed by bowel/intestinal4
• Bladder injury rates comparable (0.02%‐8.3%); most commonin LAVH)5
Source N Rate % Description
Koninckx PR 1996 212 3.7 bowel wall had to be resected in 6.3% n=13Complications were one ureter lesion and seven late bowel perforations with peritonitis-onlyCO2-laser endoscopic excision of deep endometriosis
Benbara 2008 40 22.5six digestive fistulas (12.5%), three anastomotic
strictures (6%), one ureterovaginal fistula (2%), and oneureteral stricture (2%
Mohr C, Nezhat FR2005
187 5 One rectovaginal, one uretrovaginal fistula, one anastomotic leak, 2 strictures d38, 23, and 6% for segmental resection,disc excision, and shaving, respectively
Darai E, 2007 71 12.664 segmental resection 9 cases (14% actual comp rate)
six rectovaginalfistula and three pelvic abscesses.
W Kondo, M Canis2010
226 9.324, 17.6, and 6.7% of women who underwent
segmental resection, excision of the nodule and suture, andshaving, respectively
Urinary and colorectal complications following deep endometriosis surgery
Fern, Wattiez 2007 54 3.7 One fistula, one ureter injury -Only ureterolysis
1526 9.57
Despite These Potential Risks…
• Laparoscopic complete excision ofendometriosis offers long‐term relief in mostpatients and should be considered the “GoldStandard.”1
Tamer A. Seckin, MD
Standard.
• Minimally invasive access is generally very welltolerated with reasonable incidence ofcomplication and low recurrence rate.2
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Video/Photo of complication(s)INSERT HERE
Tamer A. Seckin, MD
Precautionary Pearls
• Multidisciplinary approach is imperative1
• Expertise and skill of surgeon should be weighted againstdifficulty of excision and complexity of disease2
• Meticulous post‐operative care3
• Expect complications and be prepared to promptly address
Tamer A. Seckin, MD
• Expect complications and be prepared to promptly addressthem4
• Do not be trapped into delaying effective surgicalintervention, i.e. discoid resection, as primary treatment forwell‐selected patients with deeply infiltrating endometriosisand related debilitating symptoms
Tips & Tricks for Risk Reduction & Management
• Videoregistration & Consent
• Appropriate operator training
• Scrupulous adherence to proper technique
Tamer A. Seckin, MD
• Adequate pre‐operative preparations
e.g. imaging, bowel prep, medical pretreatment, etc.
Videoregistration1
• “Videorecording of procedure is expected to increase quality while decreasing costs” ‐Koninckx
• Increases alertness, slows speed of intervention, leads to improved timely diagnosis and
Tamer A. Seckin, MD
leads to improved timely diagnosis and intervention in complications
• Medicolegal support of surgeon performance
Operator Training• “When in doubt, refer the patient out”
• Complications diminish with increasingexperience
Tamer A. Seckin, MD
• Planning for complete surgicalexcision…should be “ensured by a team ofexperts familiar with endometriosis, itsmultiple manifestations, and itsmanagement.”‐Mereu, et al.1
Scrupulous Adherence to Proper Technique: Ureter
• Ureteral injury can be caused by ligation, ischemia, resection, transection,crushing, or angulation; particularly troublesome sites includesinfundibulopelvic ligament, ovarian fossa and ureteral tunnel (Nezhat)1
• Knowledge of pelvic path key to prevention2
• Retroperitoneal laparoscopic isolation and inspection of both uretershelps diagnose ureteral involvement, which may be silent3
• Appropriate use of preoperative IVP and MRI with contrast in selectpatients may diagnose obstruction and allow surgical planning5
• Preoperative cystoscopy and ureteral stent application
Tamer A. Seckin, MD
• Preoperative cystoscopy and ureteral stent application
• Protect ureter using hydrodistention and resecting affected peritoneum4
• Intraoperative repairs include partial resection and anastomosis, suturing,stenting7
• Do not hesitate to consult urologist (Nezhat et. al.)
22
Scrupulous Adherence to Proper Technique: Bowel• Adequate pre‐operative preparations e.g. bowel prep (though currently
debated), medical pretreatment can facilitate minimal access, reduce riskof infection1 and permit successful management/repair2
• Transrectal MRI and transrectal ultrasonography may be useful in pre‐operative evaluating depth of disease infiltration3
• Avoid Blunt Dissection, as this may result in small bowel obstruction4
• Copious lavage, antibiotic coverage are essential in small colonic wounds5
• Meticulous anatomic recognition and isolation6
Tamer A. Seckin, MD
g
• Team‐oriented approach reduces operator fatigue and potential forimpaired judgment7
• Careful suturing techniques intraoperatively can repair coloniclacterations8
• Resecting part of bowel wall followed by endoscopic suturing may beuneventful; suggesting that opening of rectum during resection of deependometriosis should not be considered a true complication9
Scrupulous Adherence to Proper Technique: Bladder
• Risks include perforation, laceration, thermal damage;bladder injuries are 2 to 3 times more common than ureteralinjuries1
• Care must be taken not to damage intramural part of ureterduring removal of deep disease2
• Ensure complete pre‐operative drainage of bladder3
Tamer A. Seckin, MD
• Continuous monitoring of gaseous distention of urinary bag can aid inearly detection of bladder perforation6
• Laser ablation, adhesiolysis in anterior Douglas Pouch maypredispose to injury if backstop or hydrodissection not used4
• Injuries of >5mm require closure and drainage; lacerationscan be repaired by experienced laparoscopist5
• More significant injuries are managed according to extent,location, and mode of injury6
Summary• Timely referrals to multidisciplinary team (e.g. gynecologic
endoscopist, colorectal surgeon, urologist) can reduce risk andfacilitate effective treatment; advanced surgical skills andanatomical knowledge are required for deep resection and shouldbe primarily performed in tertiary referral centers
• Careful pre‐operative planning, informed consent,videoregistration of benefit to both surgeon and patient
Tamer A. Seckin, MD
• Meticulous adherence to ‘best practice’ techniques is requisite toreduce morbidity and ensure effective management ofcomplications
• Although excision is technically demanding, operativecomplications remain at low risk
• Complete excision of deep disease is essential to improvesymptomatology and reduce recurrence
Koninckx, Timmermans, Meuleman, Penninckx. Complications of CO2-laser endoscopic excision of deep Endometriosis. Human Reproduction vol 11 no 10 pp 2263-2268, 1996.
Reich, 2011. Proceedings of the 2nd Annual Conference on Endometriosis, Endometriosis Foundation of America.
Farr Nezhat, Camran Nezhat, Ceana Nezhat. Averting complications of Laparoscopy: Pearls from 5 patients. OBG Management August 2007 Vol.19 No 8 pages 69-80.
Jae Hee Woo, Guie Yong Lee, Hee Jung Baik. Bladder perforation during laparoscopy detected by gaseous distention of the urinary bag: a report of two cases.Korean J Anesthesiol 2011 April 60(4): 282-284.
Chapron C, Fauconnier A, Goffinet F, Bréart G, Dubuisson JB. Laparoscopic surgery is not inherently dangerous for patients presenting with benign gynaecologicpathology. Results of a meta-analysis. Hum Reprod. 2002;17:1334–1342.
Perugini RA, Callery MP. Complications of laparoscopic surgery. In: Holzheimer RG, Mannick JA, editors. Surgical Treatment: Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001. From: http://www.ncbi.nlm.nih.gov/books/NBK6923. Last accessed 10/1/12.
Seckin ,T. Proceedings of the 2nd Annual Conference on Endometriosis, Endometriosis Foundation of America; 2010 New York
Koninckx, Timmermans, Meuleman, Penninckx. Complications of CO2-laser endoscopic excision of deep Endometriosis. Human Reproduction vol 11 no 10 pp 2263-2268, 1996.
Tamer A. Seckin, MD
Slack A, Child T, Lindsey I, Kennedy S, Cunningham C, Mortensen N, Koninckx P, McVeigh E. Urological and colorectal complications following surgery forrectovaginal endometriosis. BJOG 2007;114:1278–1282.
Camanni et al. Laparoscopic conservative management of ureteral endometriosis: a survey of eighty patients submitted to ureterolysis. Reproductive Biology andEndocrinology 2009, 7:109.
Giudice, Linda, Johannes Leonardus Henricus Evers, and D. L. Healy. Endometriosis: Science and Practice. Chichester, West Sussex: Wiley-Blackwell, 2012. Print.
Koninckx, Ussia, Adamyan, Wattiez, Donnez. Deep Endometriosis: Definition, Diagnosis & Treatment. Fertil Steril Vol. 98, No. 3, September 2012.
Koninckx PR. Videoregistration of surgery should be used as a quality control. J Minim Invasive Gynecol 2008;15:248–53.
Mereu, Gagliardi, Clarizia, Mainardi, Landi, Minelli. Laparoscopic management of ureteral endometriosis in case of moderate-severe hydroureteronephrosis. FertilSteril 2010 Jan;93(1):46-51. Epub 2008 Nov 5.
Seracchioli et al. Importance of Retroperitoneal Ureteric Evaluation in Cases of Deep Infiltrating Endometriosis. Journal of Minimally Invasive Gynecology, Vol 15, No4, July/August 2008.
Makai, Isaacson. Complications of Gynecologic Laparoscopy. Clinical Obstetrics & Gynecology Volume 52, Number 3, 401–411.
• Christel Meuleman1, Carla Tomassetti1, André D'Hoore2, Ben Van Cleynenbreugel3, Freddy Penninckx2, Ignace Vergote1 and Thomas D'Hooghe Surgical treatment of deeply infiltrating endometriosis with colorectal involvement Hum. Reprod. Update (2011) 17 (3): 311‐326 1,*
• W Kondo, N Bourdel, S Tamburro, D Cavoli, K Jardon, B Rabischong, R Botchorishvili, JL Pouly, G Mage, M Canis Complications after surgery for deeply infiltrating pelvic endometriosis BJOG: An International Journal of Obstetrics & Gynecology Volume 118, Issue 3, pages 292–298.
• Slack A, Child T, Lindsey I, Kennedy S, Cunningham C, Mortensen N, Koninckx P, McVeigh E. Urological and colorectal complications following surgery for rectovaginal endometriosis. BJOG 2007;114:1278–1282.
• Emile Darai, MD, PhD,a,
* Isabelle Thomassin, MD,b
Emmanuel Barranger, MD,aRomain Detchev, MD,
a Annie Cortez, MD,
c
Sydney Houry, MD,d
Marc Bazot, MbD. Feasibility and clinical outcome of laparoscopiccolorectal resection for endometriosis American Journal of Obstetrics and Gynecology (2005) 192, 394–400
Arkwright, MD, and Charles Chapron, MD†; Complete Surgery for Low Rectal EndometriosisLong‐term Results of a 100‐Case Prospective Study Annals of Surgery • Volume 251, Number 5, May 2010
• Tamer Seckin, MD Endometriosis Committee: Deep Endometriosis Surgery of Pelvic Sidewalls Proceedings of SLS 20th Anniversary Meeting and Endo Expo2011 GENERAL SESSION: BEST OF LAPAROSCOPY UPDATES Thursday, September 15, 2011 Beverly Hills
• Virginia Frenna, MD, Leonor Santos, MD, Eric Ohana, MD, Charles Bailey, MD, and Arnaud Wattiez, MD. Laparoscopic management of ureteral endometriosis:Our experience. Journal of Minimally Invasive Gynecology (2007) 14, 169–171
23
The Impact of Surgical Treatment of Endometriosis on Pelvic Pain
Charles E. Miller, MD, FACOG
• President, International Society for Gynecologic Endoscopy (ISGE)
• President, AAGL (2007‐2008)
• Clinical Associate Professor, Department OB/GYN, University of Illinois at Chicago, Chicago, IL USA
• Director of Minimally Invasive Gynecologic Surgery, Advocate Lutheran General Hospital, Park Ridge, IL USA
• Director, AAGL/SRS Fellowship in Minimally Invasive Gynecologic Surgery, Advocate Lutheran General Hospital, Park Ridge, IL USA
– Randomized trial (laparoscopic presacral neurectomy and conservative surgery versus conservative surgery)
N 141 ( d t i i t 1 10)
The Impact of Surgical Treatment of Endometriosis on Pelvic Pain
• N = 141 (endometriosis stage 1‐ 10)
• Pain relief at six months
– Laparoscopic presacral neurectomy – 87.3%
– Conservative surgery – 60.3%
• Pain relief at 12 months
– Laparoscopic presacral neurectomy – 85.7%
– Conservative surgery – 57.1%
Zullo F, et al.; Am J Obstet Gynecol 2003; 189:720‐721
27
• Endometriosis infiltrating the vaginal and anterior rectal walls cause symptoms such as deep dyspareunia, dyschezia, and dysmenorrhea 1,2,3
• Rectovaginal endometriosis has limited tendency to progress 4
– 88 women watched for six years
The Impact of Surgical Treatment of Endometriosis on Pelvic PainEffect of surgery for deep infiltrating disease
– Greater than 90% had no endometriosis increase
• Up to 16.7% of patients have deep infiltrating endometriosis in Pouch of Douglas 5,6,7
• 5.3 – 12% of patients with endometriosis have deep infiltrating endometriosis of the bowel
– 73% have rectal involvement 8,9,10
1 Vercellini P, et al.; Fertil Steril 1996; 65: 299‐3042 Vercellini P, et al.; JMIG 2004; 11: 153‐1613 Vercellini P, et al.; Semin Reprod Endocrinol 1997; 15: 251‐2614 Fedele L, et al.; Am J Obstet Gynecol 2004; 191: 1539‐15425 Chapron C , et al.; Obstet Gynecol Scand 2001; 80: 349‐3546 Koninckx PR, et al.; Fertil Steril 1992; 58: 924‐9287 Chapron C, et al.; Ann NY Acad Sci 2001; 943: 276‐2808 Wills HJ, et al.; Aust NZ J Obstet Gynaecol 2008; 48: 292‐2959 Koninckx PR, et al; Hum Reprod 1996; 11: 2263‐226810 Redwine DB, et al.; Fertil Steril 2001; 76: 358‐365
• Surgical Treatment of Deeply Infiltrative Endometriosis with
Deep Colorectal Involvement
– Chapron (2006)
The Impact of Surgical Treatment of Endometriosis on Pelvic Pain
• Intestinal endometriosis often multifocal and multicentric
• N=426 (172 DIE)
Rectum/Rectosigmoid ‐ 65.7%
Sigmoid ‐ 17.4%
Cecum/Ileocecal junction 4.1%
Appendix 6.4%
Small Bowel 4.7%
Omentum 1.7%
WES 2011 Consensus on Endometriosis
Preoperative Diagnosis Using Imaging
• Transvaginal Ultrasonography
• MRIMRI
• Excretory Urography / Uro‐MRI
• Rectal Echoendoscopy
“BETWEEN A ROCK AND A HARD PLACE”
The Impact of Surgical Treatment of Endometriosis on Pelvic Pain
Effect of surgery for deep infiltrating disease
Incomplete resection negatively impacts success; radical interventions increase risk of major complications, such as ureteral and rectal injuries.
Koninckx PR, et al; Hum Reprod 1996; 11: 2263‐2268 Fedele L, et al.; Am J Obstet Gynecol 2004; 191: 1539‐1542Ford J, et al.; BJOG 2004; 111: 353‐356
The Impact of Surgical Treatment of Endometriosis on Pelvic Pain
Effect of surgery for deep infiltrating disease
More than 30 case series published in English peer reviewed journals since 2000 evaluating radical conservative surgery for rectovaginal endometriosis causing pain
• Deficiencies of studies which preclude the ability to make recommendations
– Most studies observational, or retrospective and non comparative– Numbers in studies generally small– Disease extent including depth of penetration often not well described– Surgical access inconsistent– Proportion of women undergoing colorectal surgery highly variable; i.e. aggressive vs. conservative– Colorectal surgery varies (shaving, disk resection, low anterior resection)– Major intra and post operative complications vary – 0% to 13%– Follow up usually short– Dropouts not included– Use of medical treatment post operatively not reported– Surgical outcome is operator dependent– Publications bias (poor results may defer from publishing)– Heterogeneity of patient populations– Incorporation of dropouts
28
The Impact of Surgical Treatment of Endometriosis on Pelvic PainEffect of surgery for deep infiltrating disease
• Vercellini, et al. (2006)
– Single controlled trial – not randomized, rather patient preference
– N = 105 with infertility and painN = 105 with infertility and pain
• 61 expectant
• 44 laparotomy
– 7 low anterior rectal resection
– 6 ureterolysis
– 1 segmental bladder resection
• No severe intra operative complications
• 1 left uteroperitoneal fistula ‐ ureterolysis
Vercellini P, et al.; Am J Obstet Gynecol 2006; 195: 1303‐1310
The Impact of Surgical Treatment of Endometriosis on Pelvic PainEffect of surgery for deep infiltrating disease
• Vercellini, et al. (2006)
Dysmenorrhea * Dyspareunia ** Dyschezia **
Percentage free of moderate – severe symptoms
* Dysmenorrhea most frequent symptom reported
** Most evident advantage to surgery
*** At two years, significant delays with surgery ‐ (dysmenorrhea p = 0.001, dyspareunia p = 0.001, dyschezia p = 0.008)
Vercellini P, et al.; Am J Obstet Gynecol 2006; 195: 1303‐1310
y y p yExpectant12 months 34.6 37.1 65.324 months *** 24.5 48.2 57.4
The Impact of Surgical Treatment of Endometriosis on Pelvic PainEffect of surgery for deep infiltrating diseaseTime to recurrence of symptoms during follow-up of 105 women with rectovaginal endometriosis who had conservative surgery at laparotomy (dashed line) or expectant management (straight line).
Vercellini P; Human Reprod Update 2009; 15(2):177‐88
• Discectomy ‐ 40% show endometriosis @ time of bowel resection
The Impact of Surgical Treatment of Endometriosis on Pelvic Pain
• Recurrence
– Total: resection 5.8% mixed 17.6%
– Visual histology: resection 2.5% mixed 5.7%
• Post op pain ‐ post op hormones, <50% patient based reports (<18% VAS)
• QOL did improve, however only 4% of data was prospective
• N = 41– 25 colorectal resection
– 16 nodule excision
Surgical Management of Deep Infiltrating Endometriosis of the Rectum
The Impact of Surgical Treatment of Endometriosis on Pelvic Pain
• Results– No differences in recurrence
– Symptom free at two years:
Dysmenorrhea Dyspareunia Non‐Cyclic Pain
Colorectal Resection 80% 65% 43%
Nodule Excision 62% 81% 69%
Roman H, Hum Reprod 2011; 26(2): 274‐81
• Deep infiltrating endometriosis of the rectum
– Darai (2010)
• Randomized trial of laparoscopically assisted versus open colorectal resection for endometriosis
– 52 women randomized
The Impact of Surgical Treatment of Endometriosis on Pelvic Pain
– 52 women randomized
– Median follow up – 19 months
– Findings» Each showed significant improvement in digestive symptoms
• Dyschezia – p < 0.0001, diarrhea ‐ p < 0.01, bowel pain and cramping ‐ p < 0.0001, back pain ‐ p = 0.001
» No difference in quality of life between groups» Median blood loss less in laparoscopic group ‐ p < 0.05» Total number of complications higher in open surgery group – p = 0.04)» Pregnancy rate higher in laparoscopic group ‐ p = 0.006
Darai E, Ann Surg 2010; 251: 1018‐1023
29
• 70‐80% short term pain relief
• Success declined with time
– By one year many patients required analgesia or hormonal therapy 1,2,3
The Impact of Surgical Treatment of Endometriosis on Pelvic PainEffect of surgery for deep infiltrating disease
– By one year many patients required analgesia or hormonal therapy , ,
– Medium term recurrence of lesions – 20% 4,5,6
– 25% repeat surgery 7,8,9,10
1 Anaf V, et al.; JAAGL 2001; 8: 55‐602 Thomassin I, et al.; Am J Obstet Gynecol 2004; 190: 1264‐12713 Fleisch MC, et al.; Euro J Obstet Gynecol Reprod Biol 2005; 123: 224‐2294 Fedele L, et al.; Am J Obstet Gynecol 2004; 190: 1020‐10245 Brouwer R, et al.; Anz J Surg 2007; 77: 562‐5716 Kristensen J et al.; Acta Obstet Gynecol Scand 2007; 86: 1467‐14717 Reich H, et al.; J Reprod Med 1991; 36: 516‐5228 Nezhat C, et al.; Br J Obstet Gynaecol 1992; 99: 664‐6679 Mohr C, et al.; JSLS 2005; 9: 16‐2410 Mereu L et al.; JMIG 2007; 14: 463‐469
• Deep infiltrating endometriosis of the rectum
– Roman (2011)
• No evidence to support risk of recurrences less with colorectal resection versus rectal nodule excision 1
The Impact of Surgical Treatment of Endometriosis on Pelvic Pain
– DeCicco (2010)
• In 34 articles describing 1,889 bowel resections, the following was noted:
– Level of bowel resection and size of lesions were poorly reported
– Indicators for bowel resection variable, and rarely accurate
– Surgery duration varied widely
– Endometriosis not always confirmed at pathologic evaluation 2
1 Roman H, et al.; Hum Reprod 2011; 26: 274‐2812 DeCicco C, et al.; BJOG 2011; 118: 285‐291
Post Operative Complications Post Bowel Resection
• Urinary retention ‐most common
– Due to damage to parasympathetic plexus – bladder denervation
– Decreased risk with nerve sparing techniques 1,2,3
The Impact of Surgical Treatment of Endometriosis on Pelvic PainEffect of surgery for deep infiltrating disease
1 Volpi E, et al.; Surg Endosc 2004; 18: 109‐1122 Possover M, et al.; J Am Coll Surg 2005; 21: 913‐9173 Landi S, et al.; Hum Reprod 2006; 21: 774‐7814 Darai E, et al.; Am J Obstet Gynecol 2005; 192: 394‐4005 Dubernard G, et al.; Hum Reprod 2006; 21: 1243‐1247
• Design – Prospective
– SF – 36 health status questionnaire (preoperative and 6 months postoperative)
Quality of life after laparoscopic segmental rectosigmoid resection of nodule shaving for deep infiltrating endometriosis with bowel involvement
The Impact of Surgical Treatment of Endometriosis on Pelvic Pain
postoperative)
– N = 100
• Results– Significant improvement (p < 0.0005) in all pain related symptoms,
physical and mental health
– No difference is post op SF‐36 scores whether treatment via intestinal nodule shaving or segmental intestinal resection (p > 0.005)
Mabrouk, M, et al., Health and Quality of Life Outcomes, 2011, 9:98
Mean (± standard deviation) preoperative and postoperative scores of the scale of SF‐36
Quality of life after laparoscopic segmental rectosigmoid resection of nodule shaving for deep infiltrating endometriosis with bowel involvement
The Impact of Surgical Treatment of Endometriosis on Pelvic Pain
Mabrouk, M, et al., Heath and Quality of Life Outcomes, 2011, 9:98
Mean improvement (± standard deviation) of SF‐36 scores six months after surgery
Quality of life after laparoscopic segmental rectosigmoid resection of nodule shaving for deep infiltrating endometriosis with bowel involvement
The Impact of Surgical Treatment of Endometriosis on Pelvic Pain
Mabrouk, M, et al., Heath and Quality of Life Outcomes, 2011, 9:98
30
Quality of life after segmental resection of the rectosigmoid by laparoscopy in patients with deep infiltrating endometriosis
• Design – Prospective
– SF – 36 health status questionnaire (preoperative and 1 year postoperative)
The Impact of Surgical Treatment of Endometriosis on Pelvic Pain
Bassi MA, et al., JMIG 2011; 18(6): 730‐3
– N = 151
• Results– Significant improvement (p < 0.001) in all pain related symptoms, physical
and mental health
Quality of life after segmental resection of the rectosigmoid by laparoscopy in patients with deep infiltrating endometriosis
Degrees of pain (scale 0‐10) recorded before and after laparoscopic treatment (N = 151)
The Impact of Surgical Treatment of Endometriosis on Pelvic Pain
Bassi MA, et al., JMIG 2011; 18(6): 730‐3
Quality of life after segmental resection of the rectosigmoid by laparoscopy in patients with deep infiltrating endometriosis
Scores of the SF‐36 questionnaire applied before and 1 year after
The Impact of Surgical Treatment of Endometriosis on Pelvic Pain
Bassi MA, et al., JMIG 2011; 18(6): 730‐3
applied before and 1 year after laparoscopic treatment in 151 women with rectosigmoid
endometriosis
• Prospective pathologic analysis of 45 surgical specimens of bowel endometriosis obtained by laparoscopic segmental resection of the sigmoid.
The Impact of Surgical Treatment of Endometriosis on Pelvic Pain
• 89.3% of lesions with effected circumference greater than 40% impacted the submucous mucous layers of the bowel
• Proceed with bowel resection
Abrao MS, et al., JMIG 2008; 15(3): 280‐5. Epub 2008 Mar
Effect of surgery for deep infiltrating bowel diseaseEffect of surgery for deep infiltrating bowel disease
“The choice of the best surgical approach in the
The Impact of Surgical Treatment of Endometriosis on Pelvic Pain
management of deep infiltrating endometriosis of the rectum (DIER) is the subject of a debate that is far
from being closed”
Roman H, et al.; Hum Reprod 2011; 26: 274‐281
ReferencesBallard K, et al., Fertil Steril 2010; 04(1): 20‐7
Fauconnier A, et al., Fertil Steril 2002; 78: 719‐26
Gruppo Italiano per lo Studio dell’Endometriosi, Hum Reprod 2001; 16(12): 2668‐71
Hsu A, Obstet Gynecol 2011; 118(2): 223‐30
Weir E, et al., JMIG 2005; 12(6): 486‐93
Vercellini P, Human Reprod Update 2009; 15(2): 177‐88
Vignali M, et al., JMIG 2005; 12(6): 508‐13
Ferrero S, et al., Hum Reprod 2007; 22(4): 1142‐8
Vercellini P, et. al., Human Reprod 2006; 21(1): 2679‐85
Cheong Y, et al., J Obstet Gynaecol 2008; 28(1): 82‐5
Shakiba K, et al., Obstet Gynecol 2008; 111(6): 1285‐92
Sutton CJ, et al., Fertil Steril 1994; 62(4): 696‐700
Sutton CJ, et al., Fertil Steril 1997; 68(6): 1070‐4
Abbott J, et al., Fertil Steril 2004; 82(4): 878‐84
Jarrell J, et al., J Obstet Gynaecol Can 2005; 27(5): 477‐85
Jarrell J et al., J Obstet Gynaecol Can 2007; 29(12): 988‐91
Wright J, et al., Fertil Steril 2005; 83: 1830‐1836
Chapron C, et al., Human Reprod Update 2002; 8: 591‐97
Vercellini P, et al., Am J Obstet Gynecol 2003; 188: 606‐610
Possover M, et al., J Am Coll Surg 2005; 21: 913‐17
Landi S, et al., Human Reprod 2006; 21: 774‐81
Darai E, et al., Am J Obstet Gynecol 2005; 192: 394‐400
Dubernard G, et al., Hum Reprod 2006; 21: 1243‐1247
Mabrouk M, et al., Health and Quality of Life Outcomes, 2011; 9:98
Bassi MA et al., JMIG 2011; 18(6): 730‐3
Abrao MS, et al., JMIG 2008; 15(3): 280‐5. Epub 2008 Mar
32
Video Assisted Laparoscopy Video Assisted Laparoscopy in Treatment of Extra Pelvic in Treatment of Extra Pelvic
EndometriosisEndometriosisC N h t MDC N h t MDCamran Nezhat, MDCamran Nezhat, MD
Clinical Professor Department of OBGYN UCSFClinical Professor Department of OBGYN UCSFAdjunct Clinical Professor Department of OBGYN & SurgeryAdjunct Clinical Professor Department of OBGYN & Surgery
Stanford University Medical CenterStanford University Medical CenterCenter for Special Minimally Invasive and Robotic SurgeryCenter for Special Minimally Invasive and Robotic Surgery
Discuss the Discuss the concept of concept of extragenitalextragenital endometriosisendometriosis
Review relevant pathophysiology and anatomy of Review relevant pathophysiology and anatomy of extragenitalextragenital endometriosisendometriosis
Review Review surgical principles related to treatment of surgical principles related to treatment of extensiveextensive extragenitalextragenital endometriosisendometriosisextensive extensive extragenitalextragenital endometriosisendometriosis
Occurs in 1Occurs in 1--12% of patients with 12% of patients with endometriosisendometriosisIt can occur in the absence of visible pelvic It can occur in the absence of visible pelvic diseasediseasediseasediseaseEndometriosis has been reported in almost Endometriosis has been reported in almost all body structuresall body structures
Nezhat et al. EndometriosisAdvanced Management & Surgical Techniques.Springer-Verlag, 1995.
SymptomsSymptoms
PainPain
BleedingBleeding
Organ dysfunctionOrgan dysfunction
Di erse and p ling res lting fromDi erse and p ling res lting fromDiverse and puzzling resulting from Diverse and puzzling resulting from functioning endometrial tissue or functioning endometrial tissue or scarring in the affected sitescarring in the affected site
Relation to the menstrual cycle offers a clue to the diagnosis
Presents in about 20% of women with Presents in about 20% of women with endometriosisendometriosis
Symptoms include frequency, urgency, Symptoms include frequency, urgency, dysuria, and hematuriadysuria, and hematuria
Bladder EndometriosisBladder Endometriosis
Most common site of genitourinary Most common site of genitourinary tract endotract endo
Pathological confirmation is crucialPathological confirmation is crucial 11Pathological confirmation is crucial Pathological confirmation is crucial –– 1 1 out of 15 cases of deeply infiltrating out of 15 cases of deeply infiltrating bladder endo was adenosarcomabladder endo was adenosarcoma
Nezhat et al. Fertil Steril Oct 2002;78(4):872Nezhat et al. Fertil Steril Oct 2002;78(4):872--5.5.
35
Ureter Obstruction with Ureter Obstruction with HydroureterHydroureter
Endo of genitourinary tract is Endo of genitourinary tract is common however it causescommon however it causescommon, however, it causes common, however, it causes compression and obstruction in <1%compression and obstruction in <1%
Laparoscopic Treatment Laparoscopic Treatment of Ureteral Endometriosisof Ureteral Endometriosis
UreterolysisUreterolysisVaporization and excision of endometriosisVaporization and excision of endometriosisUreterotomy or segmental ureteral resectionUreterotomy or segmental ureteral resectionRetrograde internal ureteral stentRetrograde internal ureteral stentOne layer repair (4One layer repair (4--0 Polydioxanone)0 Polydioxanone)Postoperative ureterogramPostoperative ureterogram
Study of 28 women with deeply infiltrating Study of 28 women with deeply infiltrating urinary tract endometriosisurinary tract endometriosis–– 7 Bladder endometriosis7 Bladder endometriosis
Nezhat C, Nezhat F, Nezhat CH, Nasserbakhat F, Rosati M, Seidman D. Urinary tract endometriosis treated by laparoscopy. Fertility and Sterility 1996;66(6):920-24.
Technique Technique –– BladderBladder
Full thickness resection and repairFull thickness resection and repair 66
Resection without mucosaResection without mucosa 11
F l th t 10F l th t 10 14 d14 d 77Foley catheter x 10Foley catheter x 10--14 days14 days 77–– Cystogram prior to discontinuing foleyCystogram prior to discontinuing foley
Nezhat C, Nezhat F, Nezhat CH, Nasserbakhat F, Rosati M, Seidman D. Urinary tract endometriosis treated by laparoscopy. Fertility and Sterility 1996;66(6):920-24.
36
Bladder EndometriosisBladder Endometriosis7 women7 women
AgeAge 2929--39 (avg. 30)39 (avg. 30)
Pelvic painPelvic pain 66
MenouriaMenouria 11
Nezhat C, Nezhat F, Nezhat CH, Nasserbakhat F, Rosati M, Seidman D. Urinary tract endometriosis treated by laparoscopy. Fertility and Sterility 1996;66(6):920-24.
Results Results –– BladderBladder
ComplicationsComplications 00
RecurrenceRecurrence 00
Subsequent surgerySubsequent surgery 22–– Recurrence of pelvic painRecurrence of pelvic pain 11
–– EndometriomaEndometrioma 11
Nezhat C, Nezhat F, Nezhat CH, Nasserbakhat F, Rosati M, Seidman D. Urinary tract endometriosis treated by laparoscopy. Fertility and Sterility 1996;66(6):920-24.
Technique Technique –– UreterUreter
Partial obstructionPartial obstruction 1717–– Ureterolysis and excision of endoUreterolysis and excision of endo 1010–– Partial wall resectionPartial wall resection 77
Nezhat C, Nezhat F, Nezhat CH, Nasserbakhat F, Rosati M, Seidman D. Urinary tract endometriosis treated by laparoscopy. Fertility and Sterility 1996;66(6):920-24.
Lung and Lung and DiaphragmDiaphragm
EndometriosisEndometriosis
37
Historical PerspectiveHistorical Perspective
Endometriosis of the lung parenchyma was first Endometriosis of the lung parenchyma was first described by Schwarz in 1938.described by Schwarz in 1938.Spontaneous pneumothorax associated with Spontaneous pneumothorax associated with menstrual cycles (catamenial pneumothorax) was menstrual cycles (catamenial pneumothorax) was described as early as 1958.described as early as 1958.–– Schwarz O. Endometriosis of the Lung.Schwarz O. Endometriosis of the Lung. Am J ObstetAm J ObstetSchwarz O. Endometriosis of the Lung. Schwarz O. Endometriosis of the Lung. Am J Obstet Am J Obstet
Gynecol. Gynecol. 1938;36:8871938;36:887--889.889.–– Maurer ER, Schaal JA, Mendez FL, Jr. Chronic Maurer ER, Schaal JA, Mendez FL, Jr. Chronic
recurring spontaneous pneumothorax due to recurring spontaneous pneumothorax due to endometriosis of the diaphragm. endometriosis of the diaphragm. J Am Med Assoc. J Am Med Assoc. Dec 13 1958;168(15):2013Dec 13 1958;168(15):2013--2014.2014.
Woodruff JD. Pleural and parenchymal Woodruff JD. Pleural and parenchymal pulmonary endometriosis. Obstet Gynecol pulmonary endometriosis. Obstet Gynecol 1981;58:5521981;58:552--6.6.
Catamenial PneumothoraxCatamenial Pneumothorax
2222--37% of those who present with 37% of those who present with catamenial pneumothaces have implants catamenial pneumothaces have implants in the pleura or diaphragm at VATSin the pleura or diaphragm at VATS–– Foster DC, Stern JL, Buscema J, Rock JA, Foster DC, Stern JL, Buscema J, Rock JA,
Woodruff JD. Pleural and parenchymal Woodruff JD. Pleural and parenchymal pulmonary endometriosis. Obstet Gynecol pulmonary endometriosis. Obstet Gynecol 1981;58:5521981;58:552--6.6.
PathophysiologyPathophysiology
RightRight--side predominance (up to 92%)side predominance (up to 92%)–– RoussetRousset--Jablonski C, Alifano M, PluJablonski C, Alifano M, Plu--Bureau Bureau
G, et al. Catamenial pneumothorax and G, et al. Catamenial pneumothorax and endometriosisendometriosis--related pneumothorax: clinical related pneumothorax: clinical ppfeatures and risk factors. Hum Reprod features and risk factors. Hum Reprod 2011;26:23222011;26:2322--9.9.
PathophysiologyPathophysiology
Metastatic model Metastatic model -- Transdiaphragmatic Transdiaphragmatic passage of air from genital tract through passage of air from genital tract through diaphragmatic perforationsdiaphragmatic perforations
Crutcher RR Waltuch TL Blue ME RecurringCrutcher RR Waltuch TL Blue ME Recurring–– Crutcher RR, Waltuch TL, Blue ME. Recurring Crutcher RR, Waltuch TL, Blue ME. Recurring spontaneous pneumothorax associated with spontaneous pneumothorax associated with menstruation. J Thorac Cardiovasc Surg menstruation. J Thorac Cardiovasc Surg 1967;54:5991967;54:599--602.602.
PathophysiologyPathophysiology
Sampson’s theory of retrograde menstruation Sampson’s theory of retrograde menstruation along with understanding of peritoneal along with understanding of peritoneal circulation from pelvis to right paracolic gutter circulation from pelvis to right paracolic gutter allows endometrial cells to reach the right allows endometrial cells to reach the right subdiagphragmatic areasubdiagphragmatic areagp ggp gHepatic ligaments represent barriers Hepatic ligaments represent barriers –– favor favor right sideright side–– Vercellini P, Abbiati A, Vigano P, et al. Vercellini P, Abbiati A, Vigano P, et al.
Asymmetry in distribution of diaphragmatic Asymmetry in distribution of diaphragmatic endometriotic lesions: evidence in favour of the endometriotic lesions: evidence in favour of the menstrual reflux theory. Hum Reprod menstrual reflux theory. Hum Reprod 2007;22:23592007;22:2359--67.67.
38
PathophysiologyPathophysiology
Hormonal model implicates high Hormonal model implicates high prostaglandin Fprostaglandin F22 at ovulation, which may at ovulation, which may result in vasospasm and associated result in vasospasm and associated ischemia in the lungs. This, in turn and in ischemia in the lungs. This, in turn and in combination with prostaglandincombination with prostaglandin--induced induced bronchospasm, may result in alveolar bronchospasm, may result in alveolar rupture and subsequent pneumothoraxrupture and subsequent pneumothorax–– Rossi NP, Goplerud CP. Recurrent Rossi NP, Goplerud CP. Recurrent
catamenial pneumothorax. catamenial pneumothorax. Arch Surg. Arch Surg. Aug Aug 1974;109(2):1731974;109(2):173--176.176.
TreatmentTreatment
MultiMulti--disciplinary approachdisciplinary approachCombined VideoCombined Video--assisted thoracoscopic assisted thoracoscopic surgery (VATS) and LSC surgery (VATS) and LSC -- definitive definitive diagnosis and surgical treatmentdiagnosis and surgical treatment–– Chemical pleurodesis pleurectomy andChemical pleurodesis pleurectomy and–– Chemical pleurodesis, pleurectomy, and Chemical pleurodesis, pleurectomy, and
segmental resection segmental resection –– Treatment of intraTreatment of intra--abdominal and subabdominal and sub--
diaphragmatic endometriosis; BSO in select diaphragmatic endometriosis; BSO in select casescases
Nezhat C, Nicoll LM, Bhagan L, et al. Endometriosis of Nezhat C, Nicoll LM, Bhagan L, et al. Endometriosis of the diaphragm: four cases treated with a combination of the diaphragm: four cases treated with a combination of laparoscopy and thoracoscopy. laparoscopy and thoracoscopy. J Minim Invasive J Minim Invasive Gynecol. Gynecol. SepSep--Oct 2009;16(5):573Oct 2009;16(5):573--580.580.
24 women underwent 24 women underwent laparoscopic treatment of laparoscopic treatment of endometriosis of the diaphragmendometriosis of the diaphragm–– 17 patients had 217 patients had 2--5 lesions of 5 lesions of
endo on the diaphragm <1cmendo on the diaphragm <1cm–– 7 women had numerous lesions 7 women had numerous lesions
scattered across the diaphragmscattered across the diaphragm
Lesions were bilateral in 8 Lesions were bilateral in 8 patients, limited to R patients, limited to R hemidiaphragm in 14, L hemidiaphragm in 14, L hemidiaphragm in 2hemidiaphragm in 2Endo infiltrated the muscular Endo infiltrated the muscular layer of the diaphragm in 7 layer of the diaphragm in 7 patientspatients
Nezhat CH, Seidman D, Nezhat F, Nezhat C. Laparoscopic surgical management of diaphragmatic endometriosis. Fertil Steril 1998;69(6):1048‐1055.
Endometriosis of the LiverEndometriosis of the Liver
• Extremely rare entity • First described in 1986 by Finkel et al• Difficult to diagnose• Often misdiagnosed preoperatively asOften misdiagnosed preoperatively as
echinococcal or amebic cyst, pyogenicabscess, cystadenoma, hematoma, or metastatic disease
Nezhat C, Kazerooni T, Berker B, Lashay N, Fernandez S, Marziali M. Laparoscopic management of hepatic endometriosis: Report of two cases and review of the literature. JMIG. 2005;12:196-200.
PrevalencePrevalenceOnly 17 cases reported in the literatureOnly 17 cases reported in the literatureAge ranges from 21Age ranges from 21--6262Lesion size ranged from 2.7Lesion size ranged from 2.7--24 cm24 cm16/17 patients had symptomatic RUQ pain16/17 patients had symptomatic RUQ painOnly 2/17 patients reported catamenial painOnly 2/17 patients reported catamenial painOnly 5 cases correctly diagnosed Only 5 cases correctly diagnosed preoperativelypreoperativelyyy9/17 patients had their pelvis evaluated for 9/17 patients had their pelvis evaluated for endometrioisendometriois–– 6 had pelvic endometriosis6 had pelvic endometriosis–– 8 did not have pelvis evaluated8 did not have pelvis evaluated
Nezhat C, Kazerooni T, Berker B, Lashay N, Fernandez S, Marziali M. Laparoscopic management of hepatic endometriosis: Report of two cases and review of the literature. JMIG. 2005;12:196‐200.
39
PathophysiologyPathophysiologyMany theories for the origin of hepatic Many theories for the origin of hepatic endometriosis including:endometriosis including:–– implantation theoryimplantation theory–– coelomic theorycoelomic theory–– metaplasia theorymetaplasia theory–– induction theoryinduction theory–– autoimmune theoryautoimmune theory
We believe lymphovascular spread also plays aWe believe lymphovascular spread also plays aWe believe lymphovascular spread also plays a We believe lymphovascular spread also plays a role due to intraparenchymal location in some role due to intraparenchymal location in some patientspatientsRight lobe predominanceRight lobe predominance–– Possibly due to clockwise perioneal fluid flowPossibly due to clockwise perioneal fluid flow
Nezhat C, Kazerooni T, Berker B, Lashay N, Fernandez S, Marziali M. Laparoscopic management of hepatic endometriosis: Report of two cases and review of the literature. JMIG. 2005;12:196‐200.
Endometriosis of the Liver: Endometriosis of the Liver: TreatmentTreatment
14 cases treated with laparotomy14 cases treated with laparotomy
1 case treated with danazol (pt declined 1 case treated with danazol (pt declined surgery)surgery)surgery)surgery)
Nezhat C, Kazerooni T, Berker B, Lashay N, Fernandez S, Marziali M. Laparoscopic management of hepatic endometriosis: Report of two cases and review of the literature. JMIG. 2005;12:196‐200.
Liver EndometriosisLiver Endometriosis
First 15 cases reported in the First 15 cases reported in the literature were treated by literature were treated by laparotomylaparotomy
Report of 2 cases treated Report of 2 cases treated l i lll i lllaparoscopicallylaparoscopicallyNezhat C et al. Laparoscopic management of hepatic Nezhat C et al. Laparoscopic management of hepatic
endometriosis: report of two cases and review of the literature. J endometriosis: report of two cases and review of the literature. J Minim Invasive Gynecol. 2005 MayMinim Invasive Gynecol. 2005 May‐‐Jun;12(3):196Jun;12(3):196‐‐200.200.
CitationsCitations1. Nezhat et al. EndometriosisAdvanced Management & Surgical Techniques.
3. Nezhat et al. Fertil Steril Oct 2002;78(4):872Nezhat et al. Fertil Steril Oct 2002;78(4):872--55
4. 4. Nezhat C, Nezhat F, Nezhat CH, Nasserbakhat F, Rosati M, Seidman D. Urinary tract endometriosis treated by laparoscopy. Fertility and Sterility 1996;66(6):920-24
5. 5. Schwarz O. Endometriosis of the Lung. Schwarz O. Endometriosis of the Lung. Am J Obstet Gynecol. Am J Obstet Gynecol. 1938;36:8871938;36:887--889.889.
6. 6. Maurer ER, Schaal JA, Mendez FL, Jr. Chronic recurring spontaneous pneumothorax due to Maurer ER, Schaal JA, Mendez FL, Jr. Chronic recurring spontaneous pneumothorax due to endometriosis of the diaphragm. endometriosis of the diaphragm. J Am Med Assoc. J Am Med Assoc. Dec 13 1958;168(15):2013Dec 13 1958;168(15):2013--20142014..
8. 8. Foster DC, Stern JL, Buscema J, Rock JA, Woodruff JD. Pleural and parenchymal Foster DC, Stern JL, Buscema J, Rock JA, Woodruff JD. Pleural and parenchymal pulmonary endometriosis. Obstet Gynecol 1981;58:552pulmonary endometriosis. Obstet Gynecol 1981;58:552--6.6.
9. 9. RoussetRousset--Jablonski C, Alifano M, PluJablonski C, Alifano M, Plu--Bureau G, et al. Catamenial pneumothorax and endometriosisBureau G, et al. Catamenial pneumothorax and endometriosis--
related pneumothorax: clinical features and risk factors. Hum Reprod 2011;26:2322related pneumothorax: clinical features and risk factors. Hum Reprod 2011;26:2322--99..10. Crutcher RR, Waltuch TL, Blue ME. Recurring spontaneous pneumothorax associated with Crutcher RR, Waltuch TL, Blue ME. Recurring spontaneous pneumothorax associated with
11. Vercellini P, Abbiati A, Vigano P, et al. Asymmetry in distribution of diaphragmatic 11. Vercellini P, Abbiati A, Vigano P, et al. Asymmetry in distribution of diaphragmatic endometriotic lesions: evidence in favour of the menstrual reflux theory. Hum Reprod endometriotic lesions: evidence in favour of the menstrual reflux theory. Hum Reprod 2007;22:23592007;22:2359--6767
13. Nezhat C, Nicoll LM, Bhagan L, et al. Endometriosis of the diaphragm: four cases 13. Nezhat C, Nicoll LM, Bhagan L, et al. Endometriosis of the diaphragm: four cases treated with a combination of laparoscopy and thoracoscopy. treated with a combination of laparoscopy and thoracoscopy. J Minim Invasive J Minim Invasive Gynecol. Gynecol. SepSep--Oct 2009;16(5):573Oct 2009;16(5):573--580580
1414 N h t CH S id D N h t F N h t C L i i l t f14. 14. Nezhat CH, Seidman D, Nezhat F, Nezhat C. Laparoscopic surgical management of diaphragmatic endometriosis. Fertil Steril 1998;69(6):1048-1055
15. Nezhat C et al. Laparoscopic management of hepatic endometriosis: report of two Nezhat C et al. Laparoscopic management of hepatic endometriosis: report of two cases and review of the literature. J Minim Invasive Gynecol. 2005 Maycases and review of the literature. J Minim Invasive Gynecol. 2005 May--Jun;12(3):196Jun;12(3):196--200200
THANK YOU !THANK YOU !THANK YOU !THANK YOU !
40
Fellows
Elizabeth Buescher MDJackie Miller, DO
Elizabeth Buescher MD
Chandhu Paka, MDM. Ali Parsa, MD
41
Perspectives on
the Future Treatment
of Endometriosis
Professor Charles Chapron, MDHead of Department,
Université Paris Descartes,
Sorbonne Paris Cité
Faculté de Médecine, AP-HP,
GHU Ouest, CHU Cochin, Paris, France
Disclosure Slide
N fi i l l ti hiNo financial relationships to disclose
Learning Objectives Slide
At the conclusion of this activity,th ti i t ill b bl t dithe participant will be able to discuss
the modalities of future medico-surgical therapeutic options in the
management of endometriosis
Gynecology Surgical unit:
C Chapron, B Borghese, P Santulli, H Foulot, MC Lafay-Pillet, A Bourret, G Pierre, A Bititi, C Souza
Medical unit:A Gompel, G Plu-Bureau
Laboratory: GeneticD Vaiman, F Mondon, S Barbaux
Laboratory: ImunulogyB Weill, F Batteux, C Nicco, C Chéreau
Reproductive endocrinology unit:D de Ziegler V Gayet,I Streuli, FX Aubriot
Intestinal surgeryB Dousset, M Leconte.
C cco, C C é eau
Laboratory: Reproducive biologyJP Wolf, V Lange, K Pocate,JM Kuntzman, C Chalas
Statistical unitF Goffinet, de Mouzon J
D de Ziegler, Professor and Head, Reproductive Endocrinology and Infertility unit,A Gompel, Professor and Head, Medical Gynecological unit,
C Chapron, Professor and Chair, Dpt Gynecology Obstetrics II and Reproductive Medicine
Endometriosis: Perspectives on the Future Treatment
ENDOME
Delay for diagnosis
ETRIOSIS
Endometriosis: Diagnosis process
Onset ofthe symptoms
Surgical diagnosisand
treatment
6 to 10 years
42
Endometriosis: Diagnosis process
16 centers10 countriesN = 745 osis
Nnoaham et al., Fertil Steril (2011)
3.3 ± 3.6 years
10.7 ± 9.3 years
Endometriosis: Diagnosis process
Age of 1st pelvic symptoms
Onset of symptoms
Ballweg ML (2004)
Adolescents 67.1%
Adults 39.2%
Greene et al., Fertil Steril (2009)
Endometriosis: Diagnosis process
Age of 1st pelvic symptoms
Onset of Time from seekingsymptoms medical attention
to diagnosis
Ballweg ML (2004)
Adolescents 6.0 ± 0.2 years
Adults 2.0 ± 0.3 years
Greene et al., Fertil Steril (2009)
Endometriosis: Progressive disease ? Age and incidence of endometriotic lesions
SUP
Koninckx et al., Fertil Steril (1991)
SUP
OMADIE
Surgery for intestinal DIEn = 100 patients; Minimum of follow-up: 5 years
Predictive factors for transient neurogenic bladder
Parameters Transient neurogenic bladderYes (n = 16) No (n = 84) pn % n %
Leconte, Dousset, Chapron and Batteux, Am J Pathol (2011)Eutopic E
DIEDIEEutopic E Eutopic E
Epithelial Stromal
on cell proliferation
- 87% - 93% - 95% - 88%
Deep Endometriosis: the mTOR/AKT pathway
Quantitative Quantitative l i
Quantitative l i f
Leconte, Dousset, Chapron and Batteux, Am J Pathol (2011)
analysis of AKT
analysis of pAKT
analysis of phospho-p70S6K
DIE: Effect of mTOR/AKT Inhibitor (Temsirolimus)
Effect of Temsirolimus (selective mTOR/AKT inhibitor +++)
on cell proliferation
Invitro
Leconte, Dousset, Chapron and Batteux, Am J Pathol (2011)
DIE: Effect of mTOR/AKT Inhibitor (Temsirolimus)
Invivo
Untreated
Glands
Stroma
Fibrosis
Treated(3 weeks after)
Leconte, Dousset, Chapron and Batteux, Am J Pathol (2011)p < 0.01
2.44 ± 0.181.19 ± 0.25
53
Take home messages
Management and strategy:Endometriosis
and- Global approach
-Multidisciplinary approach
- New non hormonal treatments
Patients
Global approach
Take home messages
Management and strategy:Endometriosis
and Pelvic pain- Global approach
- Multidisciplinary approach
- New non hormonal treatments
Patients
Pelvic painGlobal approach
Take home messages
Management and strategy:Endometriosis
and Pelvic pain- Global approach
- Multidisciplinary approach
- New non hormonal treatments
Patients
Pelvic pain
Infertility
Global approach
Take home messages
Management and strategy:Endometriosis
and Pelvic pain- Global approach
- Multidisciplinary approach
- New non hormonal treatments
Patients
Pelvic pain
Infertility
Global approach
Surgery
Medical Ttt
ART
Endometriosis: Perspectives on the Future Treatment
ENDOME
Earlier diagnosis
Complete surgicalexeresis
Delay for diagnosis
Risk of recurrences
ETRIOSIS
Multidisciplinaryapproach
Phenotype
Non hormonal treatment
Multifocal disease
Heterogeneous disease
Results of hormonal treatment
PresidentsFelice Petraglia
(Siena, Italy)Charles Chapron (Paris, France)
Hans Rudolf Tinnemberg (Giessen, Germany)
54
References list (1)Nnoham KE, Hummelshoj L, Webster P, d’Hooghe T, de Cicco Nardone F, de Cicco Nardone C,
Jenkinson C, Kennedy S, Zonderevan KT: Impact of endometriosis on quality of life and work productivit: a multicenterstudy across ten countries. Fertil Steril 2011; 96: 366-373.
Koninckx PR, Meuleman C, Demeyere S, Lessafre E, Cornillie FJ: Suggestive evidence that pelvic endometriosis is a progresive disease, whereas deeply infiltrating endometriosis is associated with pelvic pain. Fertil Steril 1991, 55: 759-765.
Dousset B, Leconte M, Borghese B, Millischer AE, Roseau G, Arkwright S, Chapron C: Complete surgery g g p p g yfor low rectal endometriosis : long term results of a 100-case prospective study. Ann Surg. 2010; 251 (5): 887-895.
Vercellini P, Crosignani PG, Abbiati A, Somigliana E, Vigano P, Fedele L: The effect of surgery for symptomatic endometriosis: the other side of the story. Hum Reprod Update 2009; 15: 177-188.
Chapron C, Chopin N, Borghese B, Foulot H, Dousset B, Vacher-Lavenu MC, Vieira M, Hasan W, Bricou A:Deeply infiltrating endometriosis: Pathogenetic implications of the anatomic distribution.Hum Reprod 2006; 21(7): 1839-1845.
Chapron C, Bourret A, Chopin N, Dousset B, Leconte M, Amsellem-Ouazana D, de Ziegler D, Borghese B: Surgery for bladder endometriosis: Long term results and concomitant management of associated posterior deep lesions. Hum Reprod 2010; 25 (4): 884-889.
Associated ovarian endometriomas is a marker for greater severity of the disease.Fertil Steril 2009, 92: 453-457.
Vercellini P, Crosignani PG, Somigliana E, Berlanda N, Barbara G, Fedele L: Medical treatment for rectovaginal endometriosis: what is the evidence? 2009; 24: 2504-2514.
Noel J.C; Chapron C; Bucella D; Buxant F; Peny M.O; Fayt I; Borghese B; Anaf V: Estrogen and progesterone receptors in smooth muscle component of deep infiltrating endometriosis.Fertil Steril. 2010, 93: 1774-1777.
Chapron C, Lafay-Pillet MC, Monceau E, Borghese B, Ngô C, Souza C, de Ziegler D: Questioning patients about their adolescent history can identify markers associated with deepinfiltrating endometriosis. Fertil Steril 2011, 95 (3): 877-881.
Chapron C, Souza C, Borghese B, Lafay-Pillet MC, Santulli P, Bijaoui G, Goffinet F, de Ziegler D: Oral contraceptives and endometriosis : the past use of oral contraceptives for treating severe primary dysmenorrhea is associated with endometriosis, especially deep infiltrating endometriosis.Hum Reprod 2011; 26(8): 2028-2035 .
Lafay-Pillet MC, Schneider A, Borghese B, Santulli P, Souza C, Streulli I, de Ziegler D, Chapron C : Deep infiltrating endometriosis is associated with markedly lower body mass index (BMI) : a 476 case-control study. Hum Reprod 2012; 27(1): 265-272
References list (3)
Chapron C, Borghese B, Streuli I, de Ziegler D: Markers of adult endometriosis detectable in adolescence. J Ped Adol Gynecol 2011; 24: S7-S12.
Meuleman C, Tomasetti C, d’Hoore A, Van Cleynenbreugel B, Penninckx F, Vergote I, d’Hooghe T: Surgical treatment of deeply infiltrating endometriosis with colorectal involvement. Hum Reprod Update 2011, 17: 311-326.
Carmona F, Martinez-Zamora A, Gonzalez X, Gines A, Bunesch L, Balasch J: Does the learning curve of conservative laparoscopic surgery in women with rectovaginal endometriosis impairthe recurrence rate. Fertil Steril 2009; 92: 868-875.
Abrao MS, Podagec S, Dias Jr JA, Averbach M, Garry R, Ferraz Silva LF, Carvalho FM: Deeply infiltrating endometriosis affecting the rectum and lymph nodes. Fertil Steril 2006; 86: 543-547.
Chapron C, Chiodo I, Leconte M, Amsellem-Ouazana D, Chopin N, Borghese B, Dousset B: Severe ureteral endometriosis: the intrinsic type is not so rare after complete surgical exeresis of deep endometriotic lesions. Fertil Steril 2010, 93: 2115-2120.
Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, Borghese B, Chapron C: Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first line imaging examination. Hum Reprod. 2009; 24 (3): 602-607.
References list (4)d’Hooghe T and Hummelshoj L: Multi-disciplinary centers/networks of excellence for endometriosis
management and research: a proposal. Hum Reprod 2006; 21; 2743-2748.
Chapron C, Santulli P, de Ziegler D, Noel JC, Anaf V, Streuli I, Foulot H, Souza C, Borghese B: Ovarian endometrioma : severe pelvic pain is associated with deeply infiltrating endometrisosis.Hum Reprod 2012; 27(3): 702-711.
Borghese B, Barbaux S, Mondon F, Santulli P, Pierre G, Vinci G, Chapron C, Vaiman D: Research resource : Genome-wide profiling of methylated promoters in endometriosis reveals a subtelomeric location of hypermethylation. Mol Endocrinol 2010; 24 (9): 1872-1885.
Borghese B, Chiche JD, Vernerey D, Chenot C, Mir O, Bijaoui G, Bonaiti-Pellié C, Chapron C. : Genetic polymorphisms of matrix metalloproteinase MMP-12 and MMP-13 gene are implicated in endometriosis progression.Hum Reprod 2008, 23(5): 1207-1213.
Borghese B, Mondon F, Noel JC, Fayt I, Mignot MT, Vaiman D, Chapron C: Gene expression profile for ectopic versus eutopic endometrium provides new insights into endometriosis oncogenetic potential. Mol Endocrinol 2008; 22 (11): 2557-2562.
References list (5)Borghese B, Santulli P, Héquet D, Pierre G, de Ziegler D, Vaiman D, Chapron C: Genetic polymorphisms
of DNMT3L involved in hypermethylation of chromosal ends are associated with greater risk of developping ovarian endometriosis. Am J Pathol 2012; 180 (5): 17811-786.
Borghese B, Tost J, de Surville M, Busato F, Le Tourneur F, Mondon F, Vaiman D;,Chapron C: Identification of susceptibility genes for superficial, ovarian and deep infiltrating endometriosis using a pooling-based genome-wide association study. 2012 (submitted for publication).
Streuli I, de Ziegler D, Borghese B, Santulli P, Batteux F, Chapron C: New treatment strategies and emerging drugs in endometriosis Expert Opin Emerging Drugs 2012; 17(1): 83-104emerging drugs in endometriosis. Expert Opin Emerging Drugs 2012; 17(1): 83-104.
Rocha AL, Reis FM, Petraglia F: New trends for the medical treatment of endometriosis. Expert Opin Investig Drugs 2012; 21: 905-919.
Ngo C, Nicco C, Leconte M, Chéreau C, Arkwright S, Vacher-Lavenu MC, Weill B, Chapron C, Batteux F: Protein kinase inhibitors can control the progression of endometriosis in vitro and in vivo. J Pathol 2010; 222 (2): 148-157.
References list (6)
Leconte M, Nicco C, Ngô C, Chéreau C, Chouzenoux S, Marut W, Guibourdenche J, Arkwright S, Weill B, Chapron C, Dousset B, Batteux F: The mTOR/AKT inhibitor temsirolimus prevents deep infiltrating endometriosis in mice. Am J Pathol 2011; 179: 880-889.
Leconte M, Nicco C, Ngô C, Arkwright S, Chéreau C, Guibourdenche J, Weill B, Chapron C, eco e , cco C, gô C, g S, C é eau C, Gu bou de c e J, e , C ap o C,Dousset B, Batteux F: Antiproliferative effect of cannabinoid agonists on deep infiltrating endometriosis. Am J Pathol 2010; 177 (6): 2963-2970.
55
CULTURAL AND LINGUISTIC COMPETENCY Governor Arnold Schwarzenegger signed into law AB 1195 (eff. 7/1/06) requiring local CME providers, such as
the AAGL, to assist in enhancing the cultural and linguistic competency of California’s physicians
(researchers and doctors without patient contact are exempt). This mandate follows the federal Civil Rights Act of 1964, Executive Order 13166 (2000) and the Dymally-Alatorre Bilingual Services Act (1973), all of which
recognize, as confirmed by the US Census Bureau, that substantial numbers of patients possess limited English proficiency (LEP).
California Business & Professions Code §2190.1(c)(3) requires a review and explanation of the laws
identified above so as to fulfill AAGL’s obligations pursuant to California law. Additional guidance is provided by the Institute for Medical Quality at http://www.imq.org
Title VI of the Civil Rights Act of 1964 prohibits recipients of federal financial assistance from
discriminating against or otherwise excluding individuals on the basis of race, color, or national origin in any of their activities. In 1974, the US Supreme Court recognized LEP individuals as potential victims of national
origin discrimination. In all situations, federal agencies are required to assess the number or proportion of LEP individuals in the eligible service population, the frequency with which they come into contact with the
program, the importance of the services, and the resources available to the recipient, including the mix of oral
and written language services. Additional details may be found in the Department of Justice Policy Guidance Document: Enforcement of Title VI of the Civil Rights Act of 1964 http://www.usdoj.gov/crt/cor/pubs.htm.
Executive Order 13166,”Improving Access to Services for Persons with Limited English
Proficiency”, signed by the President on August 11, 2000 http://www.usdoj.gov/crt/cor/13166.htm was the genesis of the Guidance Document mentioned above. The Executive Order requires all federal agencies,
including those which provide federal financial assistance, to examine the services they provide, identify any
need for services to LEP individuals, and develop and implement a system to provide those services so LEP persons can have meaningful access.
Dymally-Alatorre Bilingual Services Act (California Government Code §7290 et seq.) requires every
California state agency which either provides information to, or has contact with, the public to provide bilingual
interpreters as well as translated materials explaining those services whenever the local agency serves LEP members of a group whose numbers exceed 5% of the general population.
~
If you add staff to assist with LEP patients, confirm their translation skills, not just their language skills.
A 2007 Northern California study from Sutter Health confirmed that being bilingual does not guarantee competence as a medical interpreter. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538.
US Population
Language Spoken at Home
English
Spanish
AsianOther
Indo-Euro
California
Language Spoken at Home
Spanish
English
OtherAsianIndo-Euro
19.7% of the US Population speaks a language other than English at home In California, this number is 42.5%