Endometriosis Talk

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Talk for GYN practitioners on Endometriosis

Transcript of Endometriosis Talk

  • 1.

2. Endometriosis Surgery and Adhesion Prevention Nicholas Leyland,BASc , MD,MHCM, FRCSC Chief of OB/GYN St Josephs Health Centre, Medical Director of Womens, Childrens andFamily Health Program. Associate Professor OB/GYN, University of Toronto. LeftUreterolysis 3. *Trademark ETHICON, INC. 2007 4. Interceed:

  • Years of proven efficacy in a wide variety of procedures:
  • AdhesiolysisMyomectomyOvarian SurgeryTubal SurgerySurgical Treatment for Endometriosis
  • Excellent safety profile Over 10 years of clinical experience

5. 6. Surgical Approach: Objectives

  • Is Surgery Even Necessary: Indications
  • What to do: Burn or Cut?
  • Special Situations:
    • Endometriomas
    • Deep Infiltrating Endometriosis
  • Adjunctive Surgical Techniques and Prevention of Adhesions

7. Is Surgery Even Necessary?

  • Risks 0.2-3% overall complication rate
  • Requires additional expertise and training
  • Reimbursement limitations/OR resources limited
  • Excellent medical options exist for pain
  • GnRH Agonists, Aromatase Inhibitors,
  • MirenaIUS

8. Indication for Surgical Management of Endometriosis

  • Diagnosis
  • Acute, chronic pain
  • Significant impact on quality of life
  • Failure of medical therapy
  • Infertility investigation and treatment
  • Endometrioma
  • Secondary organ involvement (bowel, bladder, ureter, nerve)

9. Surgery Pros and Cons

  • Diagnosis and Treatment
  • Prolonged therapeutic effect
  • Fecundity Improvement
  • (EndoCAN)
  • Risk of injury to organs
  • Greater adhesions
  • Limited resources
  • Limited expertise
  • Negative Laparoscopy
  • Advantages
  • Disadvantages

10. Macroscopic appearance of endometriosis black, red, vesicularPOD obliterationMarked distorted anatomy Endometriotic cysts Adhesions Bowel endometriosis 11. Additional Limitations of Surgery

  • Missed lesions: false negative laparoscopy
  • Required Expertise
    • Most grads not comfortable with advanced
    • and many basic endoscopic techniques
    • Ob/Gyn Endoscopy Survey, Raymond,Ternamian,Leyland JMIG 2004

12. SURGICAL OPTIONS: EXCISION OR ABLATION? For Endometriosis 13. Surgical Options: Excision vs. Ablation

  • Excision
    • Multiple energy modalities (Laser, Scissors, Harmonic)
  • Ablation
    • Laser, electrosurgery

14. Surgical Options:to cut or not to cut

  • Histologic diagnosis
  • Greater depth of treatment
  • Requires greater skill
  • Injury to adjacent organs
  • Faster
  • Less skill required
  • Unable to determine full extent
  • Thermal damage risk
  • Excision
  • Ablation

15. DOES SURGERY HELP? Endometriosis Related Pain 16. Does Surgery Help Pain?

  • Sutton et al Fertil Steril 1994 (n=63)
    • Laser ablation + LUNA improves pain at 6 months versus expectant management(63 vs. 23%)
    • At 73 months, 55% of follow up (n=38) pain free (JSLS 2001)
  • Abbot J et al. Fertil Steril 2004 (n=39)
    • Lap excision improved pain at 6 months compared with diagnostic laparoscopy(80% vs. 32 %)

17. Does Surgery Help Pain?

  • Cochrane Library:
  • Laparoscopic surgery reduces pelvicpain caused by endometriosis

Laparoscopic surgery for pelvic pain associated with endometriosis (Cochrane Review 2008) Jacobson TZ, Barlow DH, Garry R, Koninckx P 18. Ablation versus Excision

  • Limited evidence*
  • Wright et al JMIG 2005 (n=24)
    • Mild disease, 6 month follow up
    • ALL lesions treated
    • Equally effective BUTdid not include
      • Deeply infiltrating disease
  • Both likely effective to some degree for MILD disease but more involved disease requires wide excision for pain relief
  • *Consensus statement for the management of chronic pelvic pain and endometriosis: proceedings of an expert-panel consensus process
  • Chronic Pelvic Pain/Endometriosis Working Group,GAMBONEet al.

19. Additional Surgical Skills for Advanced Endometriosis Surgery

  • Ureterolysis
  • Appendectomy
  • Suturing
  • Bowel lesions
  • Cystoscopy
  • Rigid Sigmoidscopy

20. Deeply infiltrating endometriosis

  • May be responsible for failed surgical treatment
  • Identification is difficult
    • Deep Dyspaurenia
    • Rectovaginal exam
    • Rectal Ultrasound
    • MRI

21. Deep Versus Superficial Endometriosis: What do you see? 22. Ovarian Endometriomas 23. Ovarian Endometriomas

  • Laparoscopic ovarian cystectomy
      • confirm the diagnosis histologically
      • reduces risk of recurrence over fulguration
      • reduce the risk of infection at IVF
      • Improves access to follicles and possibly improve ovarian response
      • May impair ovarian reserve

24. Endometriomas

  • Tissue specimen
  • Decrease recurrence
  • Post op adhesions
  • Risk of decreasing number of follicles
    • (Ragni et al AmJOG 2004)
  • Simpler technique
  • ? Preserve greater ovarian tissue
  • Risk of Recurrence
  • Excision
  • Fulguration

25. Endometriomas

  • Excision versus Fulguration
    • Recurrence of pain (19 mos vs. 9.5 mos)
      • Berretta et al Fertil Steril 1998
    • Recurrence of symtoms at 2 years(15.8% vs. 56.7%)
    • Re-operation rate (5.8% vs. 22.9%)
      • Alborzi et al. Fertil Steril 2004
  • Overall: EXCISION OF CYST preferable for PAIN

26. Ablation versus Excision of Cysts

      • Cochrane Review 2008:
      • Authors' Conclusions: There is good evidence that excisional surgery for endometriomata provides for a more favourable outcome than drainage and ablation with regard to the recurrence of the endometrioma, recurrence of pain symptoms, and in women who were previously subfertile, subsequent spontaneous pregnancy rates
      • Caveat: ART
  • Excisional surgery versus ablative surgery for ovarian endometriomata R J Hart, et al The Cochrane Library 2008

27. ADJUNCTIVE SURGICAL TECHNIQUES 28. Additional Surgical Options

    • 1.-Adhesion Prevention
  • 2.-Presacral NeurectomySignificant benefit in select cases but duration unknown ( Zullo , Am J Obstet Gynecol, 2003)
  • 3.- Appendectomy
    • Up to 20% diseased in endometriosis/pain patients

29. Appendectomy:The Hockey Stick Sign 30. Adhesions:

  • Despite even the best surgical techniques, post-surgical adhesions form in the majority of patients undergoing gynecologic pelvic surgery
  • Adhesions following some gynecologic surgery are a major cause of post-operative pelvic pain, infertility, bowel obstruction and the need for repeat surgery .
  • Adhesion barriers are a method of enhancing good surgical technique in reducing post-surgical adhesions

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