Deep Endometriosis

Transcription

Deep Endometriosis

Deep Endometriosis – Diagnosis, Impact
of Surgical Treatment, Future Perspectives
on Therapies (Didactic)
PROGRAM CHAIR
Charles E. Miller, MD
Charles Chapron, MD
Camran R. Nezhat, MD
Tamer A. Seckin, MD
Jim Tsaltas, MD
Sponsored by
AAGL
Advancing Minimally Invasive Gynecology Worldwide
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
2:00
The Use of Robotic Assistance in the Treatment of Deep Endometriosis
2:20
The Impact of Surgical Treatment of Endometriosis on Infertility
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
4:05
Therapeutic Strategies for the Treatment of Extra Pelvic Endometriosis –
Diaphragm, Lungs, Pleura
C.R. Nezhat
1
C.E. Miller
J. Tsaltas
C.E. Miller
C.R. Nezhat
4:30
Perspectives on the Future Treatment of Endometriosis
4:55
Video/Interactive Session, Q&A
5:30
Course Evaluation
C. Chapron
All Faculty
2
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*
3
Jim Tsaltas
Grants/Research Support: Covidien, Merck Serono
Scott G. Chudnoff*
Asterisk (*) denotes no financial relationships to disclose.
4
Disclosure




Describe techniques for safe laparoscopic
access
Describe techniques used in difficult
hysterectomies
Describe techniques used to address difficult
adhesions during laparoscopy




I have no financial relationships to disclose.
Describe your
anticipated
procedure
Estimated blood
loss
Estimated duration
Preoperative
antibiotics
Test your equipment prior to the patient entering the operating room
Review normal anatomy
 How to develop retroperitoneal dissection
 Discuss preoperative planning
 Examine proper instrumentation and techniques for
dissection
 Review possible complications and management

5
Step 1 – Know the Anatomy



Abdominal wall
Ligaments
Avascular spaces
Para-vesical space
ParaVesico
Vesico--vaginal space
 Vesico
Vesico--uterine space
 Recto
Recto--vaginal space



Vascular structures
The course of inferior epigastric vessels
Obliterated
Umbilical Lig.
Urachus
Symphysis
Pubis
Cervix
Posterior aspect of anterior abdominal wall
The vesicouterine and vesicovaginal spaces
*
Obturator
internus muscle
Right
Ri
ht obliterated
blit t d
umbilical artery
Recto-uterine
Space
Right obturator
nerve
*
Right Obturator
artery
Recto-vaginal
Space
A
Right external iliac
artery and vein
B
The rectovaginal space is completely developed.The appearance of space
A) in a non-hysterectomized patients, and B) in a hysterectomized patients
Right paravesical space and its structures
6
Left
common
iliac artery
Inferior vena
cava
Right
common
iliac artery
*
B
A
Left
common
iliac vein
Intraperitoneal view of the sacral promontory and the location of the bifurcation of Aorta (*)
Anatomic relationships of the bifurcation of the Aorta, inferior vena cava and sacral promontory
Bladder
Left ureter
Right ureter
Rectum
The middle sacral vessels are in the midline on the sacrum.
The relationship of bladder, ureters and rectum after a radical hysterectomy
Step 2 - Patient Positioning
Ureter
Common iliac
artery


The ureter cross over the common iliac artery

The patient is in supine position
The thighs are not flexed so that the suprapubic and
lateral trocars may be maneuvered
Nasogastric tube is placed before procedure
Operative Gynecologic Laparoscopy: Principles and techniques
Nezhat 2000. Mc Graw-Hill
7
The buttocks are hanging
2-3 inches off the table
Endotracheal tube
Oral‐gastric tube
Ensure the patient is completely relaxed.
Step 3 – Palpation of aorta
The aorta and sacral promontory are palpated
Nezhat, 2000. Mc Graw-Hill
8
Step 4 – Insertion of Veress needle
Palpate the abdominal aorta.
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.
Nezhat, 2000. Mc Graw-Hill

Standard laparoscopy
Two to three 5 mm ports
2 lateral
 1 suprasupra
pr -pubic
p bi



Robotic
Three to four 55--8 mm ports
Similar configuration
 Configuration may be altered depending on surgery


Continuation…..
 Before
positioning the robotic cart, pressure points
must be carefully padded
 In the case of an airway emergency or cardiac
arrest resuscitating the patient requires disengaging
arrest,
the robotic instruments before backing the cart
away from the OR table
 Avoid head docking and use side or between legs
docking when possible.
9
Fellows
Thank You !
Jackie Miller, DO
Elizabeth Buescher MD
M. Ali Parsa, MD
10
Chandhu Paka, MD
Disclosure
The Use of Robotic Assistance in the
Treatment of Deep Endometriosis
• Grants/Research Support: Covidien,
Femasys, Olympus, Novartis, Abbott
Laboratories
• Consultant: Covidien
Covidien, Femasys,
Femasys Abbott
Laboratories, Ferring Pharm
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
2
Objectives
1. List two advantages of robotic assisted surgery.
ROBOTIC SURGERY HAS PROVEN TO BE A
VIABLE ALTERNATIVE FOR MULTIPLE
PROCEDURES IN MINIMALLY INVASIVE
GYNECOLOGIC SURGERY
2. List two areas where robotics positively assists minimally
invasive gynecologic surgery.
3. Discuss the impact of robotic surgery on the treatment of
superficial and deep endometriosis.
3
4
Disadvantages of Robotic Assistance in Minimally Invasive
Gynecologic Surgery
• Advantages of robotic assistance in minimally invasive
gynecologic surgery
• Cost
–
–
–
–
–
–
Eliminates tremor (filters movement)
Scales down hand movement (more precise)
Stereoscopic viewer at console
Enables 3D imaging
Steady image
Advanced ergonomics – instrument articulation provides seven
degrees of movement (mimics human wrist movement and
eliminates fulcrum effect)
– Reduces physician fatigue
– Robot $1.5 - $1.75 million
– Reposable instruments (10 time use) - $250 (average cost per use)
• Lack of tactile feedback (visual haptics)
• Need for well qualified assistant
• Learning curve (albeit short)
• Potential loss of laparoscopic (suturing) skills
5
6
11
Robotic Assisted Radical Hysterectomy for Cervical Cancer
Robotic Assisted Laparoscopic Hysterectomy
Payne TN, et al., JMIG 2008; 15(3): 286-91
Payne TN, et al., Obstet Gynecol 2010; 115(3): 535-42
Payne TN, et al., J Robotic Surg 2010; 4: 11-17
Boggess JF, Obstet Gynecol 2009; 114: 585-593
Scandola M, JMIG 2011; 18(6): 705-15
Lowe MP, Gynecol Oncol 2009; 113:191-4
Cantrell LA, Gynecol Oncol 2010; 117: 260-5
7
Robotic Assisted Hysterectomy for Endometrial Cancer
Gaia G, Obstet Gynecol 2010; 116: 1422-31
Mok ZW, Int J Gynecol Cancer 2012; 22(5): 819-25
Paley PJ, Am J Obstet Gynecol 2011; 204: 551.e1-9
Lau S, Obstet Gynecol 2012; 119(4): 717-24
Leitao MM, Gynecol Oncol 2012; 125(2): 394-9. Epub 2012 Feb 1
Lim PC, JMIG 2010; 17(6): 739-48
Gehrig PA, Gynecol Oncol 2008; 111: 41-5
8
Robotic Assisted Hysterectomy Sacrocolpopexy
Siddiqui NY, Am J Obstet Gynecol 2012; 206(5): 435.e1-5. Epub 2012 Feb 1
Seror J, World J Urol 2012; 30(3): 393-8. Epub 2011 Aug 20
9
10
Robotic Assisted Myomectomy
The Last Frontier
Robot Assisted Endometriosis Surgery for
Deep Infiltrative Surgery
Currently, literature is comprised of only feasibility
studies, no large case series and certainly no
randomized controlled reports.
Advincula A, et al., JMIG 2007; 14(6):698-705
Barakat E, Obstet Gynecol 2011; 117: 256-65
11
12
12
Robotic Assisted Endometriosis Surgery for Deep
Infiltrative Disease
N =1
• 22 consecutive robot assisted complete laparoscopic excisions of deep
infiltrative endometriosis with colorectal involvement 3/10 to 5/11
N=7 stage III, 2 stage IV
– Segmental resection
• N=12
• Median nodule 35mm
– Shaving
N=2
• N=10
• Median nodule 30mm
N=80 stage IV (2 parametrium, 6 rectovaginal
septum, 10 sigmoid serosa, 4 cecum)
– Surgical technique
N=2
• Umbilical access vs. right periumbilical (bowel resection)
– Instrumentation
N=26 stage IV
Averbach M, Arq Gastroenterol 2010; 47(1):116-118
Nezhat C, Fertil Steril 2010; 94(7): 2758-60
Frick AC, JSLS 2011; 15: 396-99
Brudie LA, J Robotic Surgery, published on-line October 2011
Tan SJ, Taiwanese J Obstet Gynecol 2012; 51:18-25
Dulemba J, J Robotic Surg, published on-line June 2012
Ercoli A, Hum Reprod 2012; 27(3):722-26
•
•
•
•
N=12
Monopolar scissors
Monopolar hook
Bipolar forceps
Large needle holder
13
14
Surgical and Anatomopathologic Findings
Six Month Follow Up
Post Operative Findings
Pre and post operative symptoms on VAS analogue scale
(19 patients)
15
16
• Median operative time and hospitalization comparable to
historical conventional laparoscopy data 1,2,3
Despite the recognized advantage of increased
precision in robotic assisted surgery, deep
infiltrative endometriosis creates increased
challenges for the robotic surgeon
• Median blood loss and blood transfusion rate improved
over historical conventional laparoscopy data 1,2
• Rectovaginal fistula in 13 patients undergoing vaginal
resection (major risk at conventional laparoscopy) 1,4
1
2
3
4
Ruffio G, Surg Endosc 2010; 24: 63-67
Fanifani F, Fertil Steril 2010; 94: 444-49
Darai E, Surg Endosc 2007; 21: 1572-77
17
18
13
References
IS1200 P/N IS2000 P/N
400189
420189
400208
420208
400177
420177
400278
420278
400139
420139
400143
420143
400176
420176
400207
420207
400145
420145
400203
420203
400173
420173
400174
420174
400227
420227
400048
420048
400049
420049
400190
420190
400146
420146
400121
420121
400205
420205
400141
420141
400110
420110
400172
420172
400171
420171
400033
420033
400117
420117
400178
420178
400181
420181
400036
420036
400179
420179
400093
420093
400001
420001
400007
420007
400006
420006
400209
420209
400194
420194
Cannula
Size
8MM
8MM
5MM
8MM
5MM
5MM
5MM
8MM
5MM
8MM
5MM
8MM
8mm
8MM
8MM
8MM
5MM
8MM
8MM
5MM
8MM
8MM
8MM
8MM
5MM
8MM
8MM
8MM
8MM
8MM
8MM
8MM
8MM
8MM
8MM
Instrument Name
DOUBLE FENESTRATED GRASPER
THORACIC GRASPER
BOWEL GRASPER
GRASPING RETRACTOR
SCHERTEL GRASPER
MARYLAND DISSECTOR
BULLET NOSE DISSECTOR
TENACULUM FORCEPS
DeBAKEY FORCEPS
PERICARDIAL DISSECTOR
HARMONIC CURVED SHEARS
HARMONIC CURVED SHEARS
PK DISSECTING FORCEPS
LONG TIP FORCEPS
CADIERE FORCEPS
COBRA GRASPER
CURVED SCISSORS
FINE TISSUE FORCEPS
FENESTRATED BIPOLAR FORCEPS
ROUND TIP SCISSORS
PRECISE BIPOLAR FORCEPS
MARYLAND BIPOLAR FORCEPS
MICRO BIPOLAR FORCEPS
BLACK DIAMOND MICRO FORCEPS
NEEDLE DRIVER
CURVED SCISSORS
RESANO FORCEPS
DeBAKEY FORCEPS
MONOPOLAR CURVED SCISSORS
PROGRASP FORCEPS
POTTS SCISSORS
ROUND TIP SCISSORS
LARGE NEEDLE DRIVER
SUTURECUT NEEDLE DRIVER
MEGA NEEDLE DRIVER
Jaw
Closing
Force At
Tip (N)
3.00
3.00
3.50
4.00
5.00
5.00
5.00
6.00
6.00
6.00
6.50
6.50
6.50
6.50
7.00
7.00
7.50
8.50
8.50
9.00
9.00
9.00
9.50
9.50
9.50
10.00
10.00
11.50
12.00
12.00
12.50
12.50
16.00
17.00
19.00
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Rank
Very Low
Low
Medium
High
Payne TN, et al., JMIG 2008; 15(3): 286-91
Payne TN, et al., Obstet Gynecol 2010; 115(3): 535-42
Payne TN, et al., J Robotic Surg 2010; 4: 11-17
Boggess JF, Obstet Gynecol 2009; 114: 585-93
Scandola M, JMIG 2011; 18(6): 705-15
Lowe MP, Gynecol Oncol 2009; 113: 191-4
Cantrell LA, Gynecol Oncol 2010; 117: 260-5
Gaia G, Obstet Gynecol 2010; 116: 1422-31
Mok ZW, Int J Gynecol Cancer 2012; 22(5): 819-25
Paley PJ, Am J Obstet Gynecol 2011; 204: 551.e1-9
Lau S, Obstet Gynecol 2012; 119(4): 717-24
Leitao MM, Gynecol Oncol 2012; 125(2): 394-9. Epub 2012 Feb 1
Lim PC, JMIG 2010; 17(6): 739-48
Gehrig PA,
PA Gynecol Oncol 2008; 111: 41
41-5
5
Siddiqui NY, Am J Obstet Gynecol 2012; 206(5): 435.e1-5. Epub 2012 Feb 1
Seror J, World J Urol 2012; 30(3): 393-8. Epub 2011 Aug 20
Advincula A, JMIG 2007; 14(6): 698-705
Barakat E, Obstet Gynecol 2011; 117: 256-65
Averbach M, Arq Gastroenterol 2010; 47(1): 116-118
Nezhat C, Fertil Steril 2010; 94(7): 2758-60
Frick AC, JSLS 2011; 15: 396-99
Brudie LA, J Robotic Surgery, pub online Oct 2011
Tan SJ, Taiwanese J Obstet Gynecol 2012; 51: 18-25
Dulemba J, J Robot Surg, pub online Jun 2012
Ercoli A, Hum Reprod 2012; 27(3): 722-26
Ruffio G, Surg Endosc 2010; 24: 63-67
Fanifani F, Fertil Steril 2010; 94: 444-49
Darai E, Surg Endosc 2007; 21: 1572-77
Very High
19
20
14
What evidence supports
surgical interventions in the
management of endometriosisrelated infertility
AAGL - 2012
Disclosures
 Grants/Research Support: Covidien, Merck Serono
Dr Jim Tsaltas
President AGES
Head Of Gynaecolgical Endoscopy
Southern Health & Monash Medical Centre
Monash University
Senior Infertility Specialist Melbourne IVF
Introduction
In preparation of this talk
 Scope of my talk
 I have taken the starting point that the patient has been
diagnosed with endometriosis and they are infertile
 What evidence supports surgical intervention in the management of
endometriosis-related infertility
y
 Diagnosis modality can include examination, ultrasound,
laparoscopy
 Topics considered in preparation
 Minimal to Mild Endometriosis
 Endometriomas
 DIE (deep infiltrating endometriosis)
 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
 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
Minimal to Mild: surgical treatment for
subfertility
Minimal – Mild Endometriosis
 The use of laparoscopic surgery in the treatment of subfertility related to
minimal and mild endometriosis may improve future fertility
 Surgery
g y involving
g ablation/excision (+/( adhesiolysis)
y ) is effective compared
p
to diagnostic laparoscopy
 Evidence is high quality
paper
population
intervention
control
treatment
stats
Marcoux, Canada
Laparoscopic surgery in
infertile women with minimal
or mild endometriosis NEJM
1997; 337(4):217-22
341 infertile
women, 2039yo, infertile
>12m (median
31m)
Diagnostic lap –
randomised to
resection/ablatio
n or diagnosis
only
29/169
pregnant –
17.7%
50/172
pregnant –
30.7%
Difference
significant
p<0.0006
13/47
(28.9%)
12/54
(23.5%)
Follow up 36
weeks or until
20w if conceived
20
i d
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
 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
15
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
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)
Moderate to severe endometriosis
Ovarian endometriomas
 Will break down into endometriomas (ovarian disease) and also
rectovaginal /DIE(including colorectal 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:
 Many studies have been produced to discuss this topic
 Guidelines to date – ESHRE(2008), ASRM(2006), NHS(2010) – There may
be a p
possible benefit
 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
 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.
Decisions to treat
Issues related to treatment
 Based on the above evidence
 Weight of other studies
 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 –
(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
 (Somigliani 2003, Somigliani 2006, Chang 2010, Benaglia 2010,
Hirokawa 2011)
 Damage may also relate to size of endometrioma being excised
(Roman 2010)
Reducing Risks
 Care with surgical technique
 Excision is preferred method
 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
16
Ovarian Endometriomas
Consensus statement proposal
Adhesions
 Evidence of moderate to high grade exists to recommend
excisional surgery for endometriomas 4cm or more to
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
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
Adhesions (cont)
Surgery for Rectovaginal Lesions
 Early studies suggested improvement in fertility rates after management of
DIE (Chapron 1999)
 Since that time a number of articles have been p
published discussing
g this
issue
 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
 Metwally 2011 – Fluid and pharmacological agents for adhesion
prevention after gynaecological surgery
 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
Recent Studies of interest
Studies Continued
 Ferrero 2009 Pregnancy after bowel resection
 Vercellini 2006
 Surgery
Laparoscopy – 57.6%, Laparotomy – 23.6%







 Surgical
g
technique
q based on the p
preference of the colorectal surgeon
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
involvement
17
105 women – 44 chose surgery,
g y, 61 expectant
p
management
g
Patients self selected
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
Deep Infiltrating Endometriosis and
IVF
Studies Continued
Infertility duration (months)
 Barri 2010
 Observational study
 825 patients aged 20 – 40 years(mean age 35.3) with infertility and endometriosis –
2001 tto 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
Total dose of FSH (IU)
Number of oocytes retreived
Fertilisation rate (%)
No. of top quality embryos / patient
No. of embryos transferred
Implantation rate (%)
Pregnancy rate (%)
IVF only (n=105)
Surgery + IVF (n=64)
P value
29 ± 20
35 ± 18
.01
2380 ± 911
2542 ± 1012
.01
10 ± 5
9±5
.04
77.9
78
.76
.59 ± 1
.57 ± 1
.48
3±1
3±1
1
19 ± 25.1
32.1 ± 30.6
.03
24
41
.004
(Bianchi et al J Min Invas Gyn 2009)
Surgical Technique
Our Data
Tsaltas J, Cooper M, Reid G
 Debate between the need for bowel resection vs shaving
technique only for deep rectovaginal endometriosis
 Total Group – 257 patients - colorectal endo (to 30/8/2010
5 Infertility
e t ty
 75
 19/75 – 25.3% Infertility, 56/75 – 74.7% pain and infertility
 Donnez 2010
 43 segmental resection, 28 disc excision, 4 multiple
procedures
 7 lost to follow up, 11 no longer wished to conceive
 57 available to follow up still wishing to conceive
 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)
 Pregn rate – 73.6 %
 107 conceived
 25.9% - spont, 68.5% ART (IVF), 5.6% mode of pregn not recorded
 Overall pregnancy rate of 84%
Severe endometriosis including
colorectal disease: Consensus
Decision to treat
 When and how to treat each patient has become much more
individualized
 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.
to
IVF There
Th
are no RCT or meta-analyses
t
l
tto answer th
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.
18
Medical Therapy before or after
surgery
Repeat Surgery
 Cochrane review
 Furness 2004
 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
 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
 Pre and post-operative medical therapy for endometriosis
surgery
 No evidence of benefit to surgery alone
 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
 Consensus – no benefit of medical therapy before or
after endometriosis surgery for infertility
 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
Consensus on repeat surgery
Failed IVF no previous surgery
 No evidence to recommend repeat surgery over IVF
o e e sshould
ou d co
consider
s de su
surgery
ge y if increasing
c eas g pa
pain,,
 However
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
 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
Consensus – surgery post IVF
Conclusion
 Surgery may play a role in patients who have failed IVF
treatment and endometriosis. It may be inappropriate to
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
 We 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
19
Preventing Complications of Deep Endometriosis Surgery:
Traps, Tips & Tricks
Author has no financial relationships to disclose.
Tamer A. Seckin, MD, FACOG, ACGE
Director, Park East Gynecology & Surgery
Founder & President, Endometriosis Foundation of America
Preceptor, AAGL Minimally Invasive Gynecologic Surgery Fellowship
North Shore LIJ‐Lenox Hill Hospital
New York City, New York
Tamer A. Seckin, MD
Tamer A. Seckin, MD
If we are to achieve significant progress
for women with endometriosis, we must
emphasize the single most important
step of action:
Endometriosis is a debilitating, costly disease fraught with diagnostic
delay, high treatment failure and recurrence. True surgical resection and
treatment poses formidable challenges even the hands of experienced
clinicians. In an effort to assist surgeons to provide optimal surgical
intervention for women with endometriosis, this segment will review
recognition and impact of procedural complications and identify
appropriate strategies to reduce morbidity and thus optimize patient
outcome
outcome.
Improve the quality of surgery
surgery.
At the conclusion of this segment, the participant will be able to:
1) discuss common complications of surgery for deep disease; and
2) describe techniques for reduction, management and prevention.
~Tamer Seckin, MD, FACOG
Tamer A. Seckin, MD
Tamer A. Seckin, MD
Deep Endometriosis
Video/photo of deep disease
INSERT HERE
• Deep endometriosis together with cystic ovarian
endometriosis represents most severe form of disease1
• Defined as endometriosis infiltrating deeper than 5‐6 mm
under the peritoneum2
• Excision remains treatment of choice for subsequent fertility
and pelvic pain3;
• Difficult to treat due to proximity of and common infiltration
in and around bowel, ureter, uterine artery4
• Surgery for deep endometriosis may be “more difficult than
surgery for cancer”5
Tamer A. Seckin, MD
Tamer A. Seckin, MD
20
First, Do No Harm…
Q: Which surgical procedure is 100% safe?
but if complications do occur, timely recognition and
proper management are key
A: The one that is not performed.1
• Complications of laparoscopy becoming increasingly less
common; approximately 3.2 per 1000 cases1, 2
• Laparoscopy largely safe and effective
• Gold standard for endometriosis treatment
• Associated with decreased morbidity and
admission
d
periods
d2
• However, traumatic complications may still
occur3 (e.g. bowel, bladder or gastric
perforation; large vessel or ureteral injury)
• Primarily related to three categories:3
complications
p
off access;; p
physiologic
y
g complications
p
off the
pneumoperitoneum;
complications
of
operative
procedure
• Common4 complications related to deep endometriosis
surgery:
Intestinal, Bladder, Ureteral
Tamer A. Seckin, MD
Tamer A. Seckin, MD
Potential Complications of Deep Endometriosis Surgery
Incidence
• May relate to surgeon experience & severity of pathology
present1
• Postoperative urinary retention1
• Rectovaginal fistula2
• Ureterovaginal fistula3
• Ureteric damage requiring radiological stenting4
• Ureter injury7
• Colonic/Bowel
C l i /B
l8
• Nerve injury9
• Anastomotic Leak
• Rectovesical Fistula
• Ureterorectal Fistula
• Certain complications are unpreventable2; others may not be
true complications3 (e.g. unintentional entry to bowel in
cases of severely fibrotic, rectovaginal disease should not be
viewed as complication but rather, a necessity for effective
treatment)
• Inferior epigastric vessels most common complications,
followed by bowel/intestinal4
• Bladder injury rates comparable (0.02%‐8.3%); most common
in LAVH)5
Tamer A. Seckin, MD
Tamer A. Seckin, MD
Urinary and colorectal complications following deep endometriosis surgery
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
22.5
six digestive fistulas (12.5%), three anastomotic
strictures (6%), one ureterovaginal fistula (2%), and one
ureteral stricture (2%
Mohr C, Nezhat FR
2005
187
5
One rectovaginal, one uretrovaginal fistula, one anastomotic leak, 2 strictures d
38, 23, and 6% for segmental resection,disc excision, and shaving, respectively
Darai E, 2007
71
12.6
64 segmental resection 9 cases (14% actual comp rate)
six rectovaginal
fistula and three pelvic abscesses.
W Kondo, M Canis
2010
226
9.3
24, 17.6, and 6.7% of women who underwent
segmental resection, excision of the nodule and suture, and
shaving, respectively
Minelli 2009
436
8.7
16 recto vaginal, 5 Leak, 2 vesicovagianal, 4 ureter Fistulas
100
6-8
6 (2 anastomosis leak and 4 rectovaginal fistula)
2 Urinary Leak OPEN cases
124
4.3
0 segmental resection,
96 disc excision, and shaving,
4 Rectovaginal Fistula, 2 Ureter fistulas
Dousset , Chapron
2010
Slack, McVeigh, Koninckx
2007
Kovoor, Wattiez,
2010
21
14.7
2 vesicovaginal fistula
Only Bladder resections
Cavalries 2011
55
9
4 complication 2 anastomotic leak, one bleeding, one bowel injury
transanal circular stapler anastomosis ( 52 patients)
54
3.7
One fistula, one ureter injury -Only ureterolysis
1526
9.57
Fern, Wattiez
2007
Despite These Potential Risks…
• Laparoscopic
complete
excision
of
endometriosis offers long‐term relief in most
patients and should be considered the “Gold
Standard.”1
Standard.
• Minimally invasive access is generally very well
tolerated with reasonable incidence of
complication and low recurrence rate.2
Tamer A. Seckin, MD
11
Tamer A. Seckin, MD
21
Video/Photo of complication(s)
INSERT HERE
Precautionary Pearls
• Multidisciplinary approach is imperative1
• Expertise and skill of surgeon should be weighted against
difficulty of excision and complexity of disease2
• Meticulous post‐operative care3
• Expect complications and be prepared to promptly address
them4
• Do not be trapped into delaying effective surgical
intervention, i.e. discoid resection, as primary treatment for
well‐selected patients with deeply infiltrating endometriosis
and related debilitating symptoms
Tamer A. Seckin, MD
Tamer A. Seckin, MD
Tips & Tricks for Risk Reduction & Management
•
•
•
•
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
leads to improved timely diagnosis and intervention in complications
• Medicolegal support of surgeon performance
Videoregistration & Consent
Appropriate operator training
Scrupulous adherence to proper technique
Adequate pre‐operative preparations
e.g. imaging, bowel prep, medical pretreatment, etc.
Tamer A. Seckin, MD
Tamer A. Seckin, MD
Scrupulous Adherence to Proper Technique: Ureter
Operator Training
• Ureteral injury can be caused by ligation, ischemia, resection, transection,
crushing, or angulation; particularly troublesome sites includes
infundibulopelvic ligament, ovarian fossa and ureteral tunnel (Nezhat)1
• Knowledge of pelvic path key to prevention2
• Retroperitoneal laparoscopic isolation and inspection of both ureters
helps diagnose ureteral involvement, which may be silent3
• Appropriate use of preoperative IVP and MRI with contrast in select
patients may diagnose obstruction and allow surgical planning5
• Preoperative cystoscopy and ureteral stent application
• Protect ureter using hydrodistention and resecting affected peritoneum4
• “When in doubt, refer the patient out”
• Complications diminish with increasing
experience
• Planning
for
complete
surgical
excision…should be “ensured by a team of
experts familiar with endometriosis, its
multiple
manifestations,
and
its
management.”‐Mereu, et al.1
• Intraoperative repairs include partial resection and anastomosis, suturing,
stenting7
• Do not hesitate to consult urologist (Nezhat et. al.)
Tamer A. Seckin, MD
Tamer A. Seckin, MD
22
Scrupulous Adherence to Proper Technique: Bowel
Scrupulous Adherence to Proper Technique: Bladder
• Adequate pre‐operative preparations e.g. bowel prep (though currently
debated), medical pretreatment can facilitate minimal access, reduce risk
of 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
g
and isolation6
• Team‐oriented approach reduces operator fatigue and potential for
impaired judgment7
• Careful suturing techniques intraoperatively can repair colonic
lacterations8
• Resecting part of bowel wall followed by endoscopic suturing may be
uneventful; suggesting that opening of rectum during resection of deep
endometriosis should not be considered a true complication9
• Risks include perforation, laceration, thermal damage;
bladder injuries are 2 to 3 times more common than ureteral
injuries1
• Care must be taken not to damage intramural part of ureter
during removal of deep disease2
• Ensure complete pre‐operative drainage of bladder3
• Continuous monitoring of gaseous distention of urinary bag can aid in
early detection of bladder perforation6
• Laser ablation, adhesiolysis in anterior Douglas Pouch may
predispose to injury if backstop or hydrodissection not used4
• Injuries of >5mm require closure and drainage; lacerations
can be repaired by experienced laparoscopist5
• More significant injuries are managed according to extent,
location, and mode of injury6
Tamer A. Seckin, MD
Tamer A. Seckin, MD
Summary
Koninckx, Timmermans, Meuleman, Penninckx. Complications of CO2-laser endoscopic excision of deep Endometriosis. Human Reproduction vol 11 no 10 pp 22632268, 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 6980.
• Timely referrals to multidisciplinary team (e.g. gynecologic
endoscopist, colorectal surgeon, urologist) can reduce risk and
facilitate effective treatment; advanced surgical skills and
anatomical knowledge are required for deep resection and should
be primarily performed in tertiary referral centers
• Careful
pre‐operative
planning,
informed
consent,
videoregistration of benefit to both surgeon and patient
• Meticulous adherence to ‘best practice’ techniques is requisite to
reduce morbidity and ensure effective management of
complications
• Although excision is technically demanding, operative
complications remain at low risk
• Complete excision of deep disease is essential to improve
symptomatology and reduce recurrence
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.
Nezhat C, Berger GS, Nezhat FR, Buttram, VC, Nezhat C, eds. Operative laparoscopy: preventing and managing complications. In: Nezhat CR, ed. Endometriosis:
Advanced Management and Surgical Techniques. Springer-Verlag; 1995. Print.
Chapron C, Fauconnier A, Goffinet F, Bréart G, Dubuisson JB. Laparoscopic surgery is not inherently dangerous for patients presenting with benign gynaecologic
pathology. 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 ProblemOriented. 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 22632268, 1996.
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.
Camanni et al. Laparoscopic conservative management of ureteral endometriosis: a survey of eighty patients submitted to ureterolysis. Reproductive Biology and
Endocrinology 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. Fertil
Steril 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, No
4, July/August 2008.
Makai, Isaacson. Complications of Gynecologic Laparoscopy. Clinical Obstetrics & Gynecology Volume 52, Number 3, 401–411.
Tamer A. Seckin, MD
•
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.
•
•
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 for rectovaginal endometriosis. BJOG 2007;114:1278–1282. a
c
a,
b
a
* Isabelle Thomassin, MD, Emmanuel Barranger, MD, Romain Detchev, MD, Annie Cortez, MD,
Emile Darai, MD, PhD,
d
Sydney Houry, MD, Marc Bazot, MbD. Feasibility and clinical outcome of laparoscopic
colorectal resection for endometriosis American Journal of Obstetrics and Gynecology (2005) 192, 394–400
•
Bertrand Dousset, MD,* Mahaut Leconte, MD,* Bruno Borghese, MD,† Anne‐Elodie Millischer, MD,‡Gilles Roseau, MD,§ Sylviane 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
Tamer A. Seckin, MD
23
Disclosures:
Grants/Research Support: Covidien, Femasys, Olympus, Novartis, Abbott Laboratories
Consultant: Covidien, Femasys, Abbott Laboratories, Ferring Pharm
• 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
Pain descriptions reported by 113 women with endometriosis and 36 women with an apparently normal pelvis
Objectives
1. List three different methods for the treatment of deep infiltrative endometriosis involving the rectum.
2. List three reasons why literature related to deep infiltrative endometriosis is difficult to interrupt.
3. Discuss the quality of life following bowel resection.
Ballard K, et al., Fertil Steril 2010; 94(1): 20‐7
Pain descriptions reported by 41 women with a diagnosis of superficial endometriosis and 72 women with deep endometriosis
Associations between pain area and site of endometriosis in 113 women with endometriosis
24
•
Fauconnier (2002)
–
Retrospective study 225 women with symptomatic deep infiltrating endometriosis • Relationship between stage, site and morphological characteristics of pelvic endometriosis and pain • Frequency
– Severe dysmenorrhea
» Increased adhesions of Pouch of Douglas
» Decreased parity
– Gruppo Italiano per lo Studio dell’Endometriosi (2001)
– Dyspareunia
» Increased uterosacral ligament deep infiltrating endometriosis
» Decreased bladder deep infiltrating endometriosis
• Multi center cross sectional observational study
• N = 469
• First laparoscopy or laparotomy for endometriosis and pain of ≥ 6 months duration
– No clear cut association with either
– Non‐cyclic pelvic pain
» Increased bowel deep infiltrating endometrioses
» Decreased in infertile women
– Dyschezia during menstruation » Increased deep infiltrating endometriosis of vagina
– Lower urinary symptoms
» Increased deep infiltrating endometriosis of bladder
» Decreased in women with lower BMI
– GI Symptoms
» Increased bowel or vaginal deep infiltrating endometriosis
Gruppo Italiano per lo Studio dell’Endometriosi, Hum Reprod 2001; 16(12): 2668‐71
Fauconnier A, et al.; Fertil Steril 2002; 78: 719‐26
Relating Pelvic Pain Location to Surgical Findings of Endometriosis
• N = 133
• Weir, E (2005)
– 96 patients with endometriosis and pain
– 37 patients with pelvic pain and no endometriosis
– 7,993 patients ≥ 15 years who underwent “minor” or “intermediate” conservative surgery for early disease in Ontario, Canada
g y
y
,
• Results Results – women with endometriosis
women with endometriosis
–
–
–
–
–
–
Lower body mass indexes
More likely Caucasian
More previous surgeries
More frequent dysmenorrhea
More frequent dysmenorrhea with incapacitation
Dysuria associated with superficial bladder endometriosis
• Follow up 4 years
• Additional surgical treatment 27%, hysterectomy 12%
• Other lesions, including endometriomas, not associated with pain in the same location
– Lesion depth, disease burden, lesion number, or endometriomas not associated with pain
Weir E, et al.; JMIG 2005; 12(6): 486‐93
Hsu A, Obstet Gynecol 2011; 118(2): 223‐30
Effect of surgery for stage I – IV disease
Pain recurrence or re‐operation rates reported after first‐line conservative surgery for symptomatic endometriosis
• Effect of surgery for stage I – IV disease: non comparative studies
– Vignali (2005)
• Pain recurrence 24% (greater in younger patients)
• Lesion recurrence 13% (greater with cul‐de‐sac obliteration)
– Vercellini (2006)
• 24% recurrence at 3 years
– Stage I – 33%, Stage II – 24%, Stage III – 21%, Stage IV – 19%
• Only significant covariate – age (seen also by Cheong, 2008)
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.; Hum Reprod 2006; 21(1): 2679‐85
Cheong Y, et al.; J Obstet Gynaecol 2008; 28(1): 82‐5
Vercellini P; Human Reprod Update 2009; 15(2): 177‐88
25
• Effect of surgery for stage I – IV disease: non comparative studies
• Effect of surgery for stage I – IV disease: controlled studies
– Shakiba (2008)
– 3 randomized controlled studies
1. Sutton et al., 1994
Sutton et al., 1997
• Relative risk of repeat surgery
– Age 19‐28: 1.75 – 4.76
– Age 30‐39: 1
2. Abbott et al., 2004
Surgery Free at:
19‐29
30 ‐39
> 40
2 years
63.9
88.0
85.7
5 years
33.3
58.0
76.2
7 years
27.8
43.3
76.2
3. Jarrell et al., 2005
Jarrell et al., 2007
Sutton CJ, et al.; Fertil Steril 1994; 62(4): 696‐700
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
Shakiba K, et al.; Obstet Gynecol 2008; 111(6): 1285‐92
– Sutton (1994)
•
•
•
•
•
•
– Abbott (2004)
Double blind study
63 women with minimal/moderate endometriosis
Laparoscopy for pelvic pain
Laparoscopy for pelvic pain
32 laser vaporization of endometriosis plus uterosacral nerve ablation
31 expectant management
At 6 months – 63% improved in laser group, 23% improved in expectant group
• 39 women laparoscopy – minimal to severe endometriosis
– 20 excision
– 19 expectant
• Subsequent laparoscopy at six months to excise all lesions
• Symptom improvement at six months – excision 80%, no treatment 0%
• 33 women with second look – 15 excision group, 18 expectant
– Sutton (1997)
•
•
•
•
One year follow up
Per Sutton, pain relief in 90%
Per intention to treat: success is 56% in laser group, 23% in control group
Absolute benefit of surgery at one year – 33%
Pain improvement 6 months after second look ‐ Original excision – 53%
‐ Expectant – 83%
Second line surgery less effective
– Jarrell (2005)
– Jarrell (2007)
• 29 women – mild to moderate endometriosis and severe symptoms
• Long term follow up
– 15 laparoscopic excision
l
– 14 observational laparoscopy
• 12 – 14 years overall repeat surgery
–
–
–
–
• Pain diaries at baseline 3, 6, 12 months
– No significant difference in visual analogue pain score
– 45% reduction excision
– 33% reduction observation
» Similar to dropouts – 42% excision, 33% observation
48% observational group
52% excision group
Correlated to original pain
No correlation with age, stage or excision
Jarrell J, et al.; J Obstet Gynaecol Can 2007; 29(12): 988‐91
26
• Impact of modality on treatment of ovarian endometrioma
• Excision versus ablation
– Systematic literature reviews
– Wright (2005)
• Chapron (2002) 1
• Vercellini (2003) 2
• Hart (2005) (
)3
• Randomized trial
• N = 141 (mild endometriosis)
– Laparoscopic excision of pseudocyst versus drainage and electrocoagulation of pseudocyst
– Follow up at six months
• Excision
» Average difference in pain score and pre and post surgery
• Excision ‐ 11.2
• Ablation – 8.7
–
–
–
–
–
NS
1
Wright J., et al.; Fertil Steril 2005; 83: 1830‐1836
2
3
Reduced rate of recurrence (OR 0.41; 95% CI 0.18 – 0.93)
Reduced rate of reoperation (OR 0.21; 95% CI 0.05 – 0.79)
Reduced rate of dysmenorrhea (OR 0.15; 95% CI 0.06 – 0.38)
Reduced rate of dyspareunia (OR 0.08; 95% CI 0.01 – 0.51)
Reduce rate of non‐menstrual pelvic pain (OR 0.10; 95% CI 0.02 – 0.56)
Chapron C, et al.; Human Reprod Update 2002; 8: 591‐597
Vercellini P, et al.; Am J Obstet Gynecol 2003; 188: 606‐610
Hart RJ, et al.; Cochrane Database Syst Rev 2005; 5: CD004992
• Endometrioma surgery
• Endometrioma surgery
– Beretta (1998)
– Alborzi (2007)
• 64 patients randomized, cystectomy versus fenestration/coagulation • 100 patients randomized, cystectomy versus fenestration/coagulation • Endometrioma > 3 cm
• Recurrence of symptoms at two years
Significant
• Recurrence of symptoms (months)
Significant
– Excision – 19
– Fenestration/coagulation – 9.5
– Excision – 15.8%
– Fenestration/coagulation – 56.7%
• Rate of repeat Surgery
– Excision – 5.8%
– Fenestration/coagulation – 22.9%
Beretta P, et al.; Fertil Steril 1998; 70: 1176 ‐ 1180
Alborzi S, et al.; Fertil Steril 2007; 88: 507 ‐ 509
• Zullo (2003)
• According to Cochrane meta‐analysis:
– Randomized trial (laparoscopic presacral neurectomy and conservative surgery versus conservative surgery)
– Uterosacral ligament ablation does not improve relief due to dysmenorrhea (OR 0.77; 95% CI 0.43 – 1.39)
• N = 141 (endometriosis stage 1‐
N 141 ( d
ti i t
1 10)
– Presacral neurectomy does improve relief due to dysmenorrhea (OR 3.14; 95% CI 1.59 – 6.21)
• 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%
Latthe PM, et al.; Acta Obstet Gynecol Scand 2007; 86: 4‐15
Zullo F, et al.; Am J Obstet Gynecol 2003; 189:720‐721
27
Effect of surgery for deep infiltrating disease
•
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
–
–
– Chapron (2006)
88 women watched for six years
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
–
1
2
• Surgical Treatment of Deeply Infiltrative Endometriosis with
Deep Colorectal Involvement
• 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%
73% have rectal involvement 8,9,10
Vercellini P, et al.; Fertil Steril 1996; 65: 299‐304
Vercellini P, et al.; JMIG 2004; 11: 153‐161
3 Vercellini P, et al.; Semin Reprod Endocrinol 1997; 15: 251‐261
4
Fedele L, et al.; Am J Obstet Gynecol 2004; 191: 1539‐1542
Chapron C , et al.; Obstet Gynecol Scand 2001; 80: 349‐354
Koninckx PR, et al.; Fertil Steril 1992; 58: 924‐928
Chapron C, et al.; Ann NY Acad Sci 2001; 943: 276‐280
8 Wills HJ, et al.; Aust NZ J Obstet Gynaecol 2008; 48: 292‐295
9 Koninckx PR, et al; Hum Reprod 1996; 11: 2263‐2268
10 Redwine DB, et al.; Fertil Steril 2001; 76: 358‐365
5
6
7
Preoperative Diagnosis Using Imaging
• Transvaginal Ultrasonography
• MRI
• Excretory Urography / Uro‐MRI
• Rectal Echoendoscopy
WES 2011 Consensus on Endometriosis
More than 30 case series published in English peer reviewed journals since 2000 evaluating radical conservative surgery for rectovaginal endometriosis causing pain
“BETWEEN A ROCK AND A HARD PLACE” •
Deficiencies of studies which preclude the ability to make recommendations
–
–
–
–
–
–
–
–
–
–
–
–
–
–
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: 1539‐1542
Ford J, et al.; BJOG 2004; 111: 353‐356
28
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
• Vercellini, et al. (2006)
• Vercellini, et al. (2006)
– Single controlled trial – not randomized, rather patient preference
Percentage free of moderate – severe symptoms
– N = 105 with infertility and pain
N = 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
Dysmenorrhea *
y
Dyspareunia **
yp
Dyschezia **
y
Expectant
12 months
24 months ***
34.6
24.5
37.1
48.2
65.3
57.4
Surgery
12 months
24 months ***
59.8
38.9
86.2
72.9
86.3
78.1
* 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)
Time 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).
• Muelemann (2011)
– 49 studies, 3,894 patients (72.7% resection, 9.8% discs, 17.4% shaving) • 2‐3 cm does not insure free margins • Discectomy ‐ 40% show endometriosis @ time of bowel resection • 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 Vercellini P; Human Reprod Update 2009; 15(2):177‐88
Surgical Management of Deep Infiltrating Endometriosis of the Rectum
• Deep infiltrating endometriosis of the rectum • N = 41
– Darai (2010)
– 25 colorectal resection
– 16 nodule excision
• Randomized trial of laparoscopically assisted versus open colorectal resection for endometriosis
– 52 women randomized
52 women randomized
• Results
– Median follow up – 19 months
– No differences in recurrence
– 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
– Symptom free at two years:
Colorectal Resection Nodule Excision
Dysmenorrhea
80%
62% Dyspareunia
65%
81%
Non‐Cyclic Pain
43%
69%
Darai E, Ann Surg 2010; 251: 1018‐1023
Roman H, Hum Reprod 2011; 26(2): 274‐81
29
• Deep infiltrating endometriosis of the rectum • 70‐80% short term pain relief
– Roman (2011)
• No evidence to support risk of recurrences less with colorectal resection versus rectal nodule excision 1
• Success declined with time
, ,
– By one year many patients required analgesia or hormonal therapy By one year many patients required analgesia or hormonal therapy 1,2,3
– Medium term recurrence of lesions – 20% 4,5,6
– 25% repeat surgery 7,8,9,10
– DeCicco (2010)
• In 34 articles describing 1,889 bowel resections, the following was noted:
–
–
–
–
1
Anaf V, et al.; JAAGL 2001; 8: 55‐60
2 Thomassin I, et al.; Am J Obstet Gynecol 2004; 190: 1264‐1271
3 Fleisch MC, et al.; Euro J Obstet Gynecol Reprod Biol 2005; 123: 224‐229
4 Fedele L, et al.; Am J Obstet Gynecol 2004; 190: 1020‐1024
5 Brouwer R, et al.; Anz J Surg 2007; 77: 562‐571
6 Kristensen J et al.; Acta Obstet Gynecol Scand 2007; 86: 1467‐1471
7 Reich H, et al.; J Reprod Med 1991; 36: 516‐522
8 Nezhat C, et al.; Br J Obstet Gynaecol 1992; 99: 664‐667
9 Mohr C, et al.; JSLS 2005; 9: 16‐24
10 Mereu L et al.; JMIG 2007; 14: 463‐469
1
2
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
Roman H, et al.; Hum Reprod 2011; 26: 274‐281
DeCicco C, et al.; BJOG 2011; 118: 285‐291
Quality of life after laparoscopic segmental rectosigmoid resection of nodule shaving for deep infiltrating endometriosis with bowel involvement
Post Operative Complications Post Bowel Resection
• Design – Prospective
Urinary retention ‐ most common
•
–
–
– SF – 36 health status questionnaire (preoperative and 6 months postoperative)
– N = 100
Due to damage to parasympathetic plexus – bladder denervation
1,2,3
Decreased risk with nerve sparing techniques p
g
q
Rectovaginal Fistula – second most common
•
–
–
–
1
2
Risk as high as 10%
Lowered risk if rectal tumor not opened 4,5
Hemoperitoneum, anastomotic leaks, ureteral fistula/uroperitoneum, bowel perforation, pelvic abscess, temporary ileostomy, post‐op bowel or ureteral stenosis
• 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)
Volpi E, et al.; Surg Endosc 2004; 18: 109‐112
Possover M, et al.; J Am Coll Surg 2005; 21: 913‐917
3 Landi S, et al.; Hum Reprod 2006; 21: 774‐781
4
5
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
Mean (± standard deviation) preoperative and postoperative scores of the scale of SF‐36
Mean improvement (± standard deviation) of SF‐36 scores six months after surgery
Mabrouk, M, et al., Heath and Quality of Life Outcomes, 2011, 9:98
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
Degrees of pain (scale 0‐10) recorded before and after laparoscopic treatment (N = 151)
– SF – 36 health status questionnaire (preoperative and 1 year postoperative)
– N = 151
• Results
– Significant improvement (p < 0.001) in all pain related symptoms, physical and mental health
Bassi MA, et al., JMIG 2011; 18(6): 730‐3
• Prospective pathologic analysis of 45 surgical specimens of bowel endometriosis obtained by laparoscopic segmental resection of the sigmoid.
Scores of the SF‐36 questionnaire applied before and 1 year after
applied before and 1 year after laparoscopic treatment in 151 women with rectosigmoid endometriosis
• 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
References
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
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
Hart RJ, et al., Cochrane Database Syst Rev 2005; 5: CD004992
Beretta P, et al, Fertil Steril 1998; 70: 1176‐80
Alborzi S, et al., Fertil Steril 2007; 88: 507‐9
Latthe PM et al., Acta Obstet Gynecol Scand 2007; 86: 4‐15
Zullo F, et al., Am J Obstet Gynecol 2003; 189: 720‐721
Vercellini P, et al., Fertil Steril 1996; 65: 299‐304
Vercellini P. et al., JMIG 2004; 11: 153‐61
Fedele L, et al., Am J Obstet Gynecol 2004; 191: 1539‐42
Chapron C, et al., Obstet Gynecol Scand 2001; 80: 349‐54
Koninckx PR, et al., Fertil Steril 1992; 58: 924‐28
Chapron C, et al., Ann NY Acad Sci 2001; 943: 276‐80
Willis HJ, et al., Aust NZ J Obstet Gynaecol 2008; 48: 292‐95
Abrao MS, Miller CE, Ob.Gyn. News – Master Class in Gynecologic Surgery, Aug 2011
Koninckx PR, et al., Hum Reprod 1996; 11: 2263‐2268
Effect of surgery for deep infiltrating bowel disease
“The choice of the best surgical approach in the 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
31
References Cont’d
Redwine DB, et al., Fertil Steril 2001; 76: 358‐65
Ford J, et al., BJOG 2004; 111: 353‐56
Vercellini P, et al., Am J Obstet Gynecol 2006; 195: 1303‐10
Roman H, Hum Reprod 2011; 26(2): 274‐81
Darai E, Ann Surg 2010; 251: 1018‐23
Anaf V, et al., JAAGL 2001; 8: 55‐60
Thomassin I, et al., Am J Obstet Gynecol 2004; 190: 1264‐71
Fleisch MC et al., Euro J Obstet Gynecol Reprod Biol 2005; 123: 224‐29
Fedele L, et al., Am J Obstet Gynecol 2004; 190: 1020‐24
Brouwer R, et al., Anz J Surg 2007; 77: 562‐71
Kristensen J, et al., Acta Obstet Gynecol Scand 2007; 86: 1467‐71
Reich H et al J Reprod Med 1991; 36: 516‐22
Reich H, et al., J Reprod Med 1991; 36: 516‐22
Nezhat C, et al., Br J Obstet Gynaecol 1992; 99: 664‐67
Mohr C, et al., JSLS 2005; 9: 16‐24
Mereu L, et al., JMIG 2007; 14: 463‐69
DeCicco C, et al., BJOG 2011; 118: 285‐91
Volpi E, et al., Surg Endosc 2004; 18: 109‐112
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
Objectives
Video Assisted Laparoscopy
in Treatment of Extra Pelvic
Endometriosis
Discuss the concept of extragenital endometriosis
Review relevant pathophysiology and anatomy of
extragenital endometriosis
Review surgical principles related to treatment of
extensive extragenital endometriosis
C
Camran
N
Nezhat,
h t MD
Clinical Professor Department of OBGYN UCSF
Adjunct Clinical Professor Department of OBGYN & Surgery
Stanford University Medical Center
Center for Special Minimally Invasive and Robotic Surgery
Palo Alto, CA
www.Nezhat.org
Extragenital Endometriosis
Extragenital Endometriosis
Most common sites
Occurs in 11-12% of patients with
endometriosis
It can occur in the absence of visible pelvic
disease
Endometriosis has been reported in almost
all body structures
– GI tract
– Urinary tract
Remote sites
–
–
–
–
–
Lungs
Skin
Nervous system
Retina
Adrenal gland
Nezhat et al. Endometriosis
Advanced Management & Surgical Techniques.
Springer-Verlag, 1995.
Symptoms
Bowel Endometriosis
Incidence
Rectum and sigmoid 76%
Appendix
18%
Cecum
5%
Pain
Bleeding
Organ dysfunction
Di erse and p
Diverse
puzzling
ling res
resulting
lting from
functioning endometrial tissue or
scarring in the affected site
Relation to the menstrual cycle offers a clue to the diagnosis
33
Incidence of
Bowel Endometriosis
Incidence of
Bowel Endometriosis
Redwine et al.
415/1545
(26%)
Jerby et al.
30/509
(5.9%)
Nezhat
187/3201
(5.8%)
Study of 1,573 Women treated
for endometriosis
– 5.4% gastrointestinal involvement
– 65% rectum or rectosigmoid
involvement
Prystowsky et al., 1988
Suspect Bowel Endometriosis
in the presence of:
Bowel Endometriosis
Palpable tumor in the rectovaginal septum
Rectal bleeding with menses
Constipation with menses
Diarrhea with menses
Pain after surgical removal of all
recognizable lesions
Treatments:
– Segmental resection
– Disk excision
– Shaving
– Rectal wall excision
– Appendectomy
Bowel Endometriosis
Bowel Endometriosis
Gynecologists are often uncomfortable
operating on the bowel.
Treatment dependent on:
– Depth of lesion
– Location
– Experience of surgeon
G
General
l surgeons may b
be unfamiliar
f ili with
ith
endometriosis.
34
Bowel Endometriosis:
Preop Considerations
Laparoscopic Treatment
of Bowel Endometriosis
Consider bowel prep in all nonnonemergent patients
With fixed mucosa, full thickness
penetration must be anticipated
Deep rectosigmoid resection and
anastomosis should be anticipated
No
Superficial/
Shaving
Disc
Excision
Excision
Resection
Jerby
30
23 (77%)
5 (17%)
7 (23%)
Nezhat
187
102 (54.5%)
47 (25%)
38 (20.3%)
No
Average
Age
Symptoms
Previous
Surgeries
JJerby
b
30
34 (22
(22--49)
Pain
P i (100%)
(0--6)
(0
Nezhat
187
35 (21
(21--56)
Pain (99%)
(1
(1--6)
Jerby BL, Kessler H, Falcone T, Milsom JW. Laparoscopic management of colorectal
endometriosis. Surg Endosc 1999;13:1125-8.
Mohr C, Nezhat FR, Nezhat CH, Seidman DS, Nezhat CR. Fertility considerations in
laparoscopic treatment of infiltrative bowel endometriosis. JSLS 2005;9:16-24.
Authors
Authors
Authors
Small
Bowel
Cecum
Appendix
Recto
Recto-sigmoid
Rectum
Jerby
0
2 (7%)
2 (7%)
10 (33%)
29 (93%)
Nezhat
7 (3.7%)
3 (1.6%)
4 (2%)
74
(39.5%)
128 (68%)
Urinary Tract Endometriosis
Bladder Endometriosis
Most common site of genitourinary
tract endo
Pathological confirmation is crucial – 1
out of 15 cases of deeply infiltrating
bladder endo was adenosarcoma
Presents in about 20% of women with
endometriosis
Symptoms include frequency, urgency,
dysuria, and hematuria
Nezhat et al. Fertil Steril Oct 2002;78(4):8722002;78(4):872-5.
35
Ureter Obstruction with
Hydroureter
of Ureteral Endometriosis
Ureterolysis
Vaporization and excision of endometriosis
Ureterotomy or segmental ureteral resection
Retrograde internal ureteral stent
One layer repair (4(4-0 Polydioxanone)
Postoperative ureterogram
Endo of genitourinary tract is
common however
common,
however, it causes
compression and obstruction in <1%
Urinary Tract Endo:
Urinary Tract Endometriosis
Preop Considerations
Urinalysis
Preoperative cystoscopy
IVP – if ureter involvement is suspected
Consultation with urology
Study of 28 women with deeply infiltrating
urinary tract endometriosis
– 7 Bladder endometriosis
– 21 Ureter endometriosis
Incidence
– October 1989 – September 1994
28 (1.3%) in 2,226 women
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.
Inclusion Criteria
Technique – Bladder
Bladder
Full thickness resection and repair
Resection without mucosa
Foley
10-14 d
days
F l catheter
th t x 10-
– Full thickness or deep musclaris involvement
Ureter
– Complete
C
l t or partial
ti l ureteral
t l obstruction
b t ti
– Ureteral wall involvement
6
1
7
– Cystogram prior to discontinuing foley
36
Results – Bladder
Bladder Endometriosis
Age
Pelvic pain
Menouria
7 women
29--39 (avg. 30)
29
6
1
Complications
Recurrence
Subsequent surgery
0
0
2
– Recurrence of pelvic pain
– Endometrioma
Ureter Endometriosis
21 women
Technique – Ureter
Partial obstruction
17
Age
Pelvic pain
Localized pain
Back Pain
Follow--up
Follow
– Ureterolysis and excision of endo 10
– Partial wall resection
7
Repair
2
No repair
5
 Internal stent x 2
2--8 weeks
13
 Pelvic Drain
4
Complete resection and
reanastomosis
1
1
24-46 (avg. 35)
2421
14
11
– 5-33 months
4
Results – Ureter
Hospital stay
Complication
Lung and
Diaphragm
Endometriosis
1-6 days (avg 1.8)
1
– Pleural effusion
Pain relief
Ureteral patency
Functioning kidney
Subsequent surgery
– Mesothelioma
– Ovarian remnant
20 (95%)
21
20
2
1
1
37
Incidence Endometriosis
Lung/Diaghragm
Historical Perspective
Endometriosis of the lung parenchyma was first
described by Schwarz in 1938.
Spontaneous pneumothorax associated with
menstrual cycles (catamenial pneumothorax) was
described as early as 1958.
38.8% Diaphragm affected
29.6% Pleura affected
– Schwarz O. Endometriosis of the Lung. Am J Obstet
Gynecol. 1938;36:887
1938;36:887--889.
– Maurer ER, Schaal JA, Mendez FL, Jr. Chronic
recurring spontaneous pneumothorax due to
endometriosis of the diaphragm. J Am Med Assoc.
Dec 13 1958;168(15):20131958;168(15):2013-2014.
– Lillington GA, Mitchell SP, Wood GA. Catamenial
pneumothorax. JAMA. Mar 6 1972;219(10):13281972;219(10):13281332.
– Foster DC, Stern JL, Buscema J, Rock JA,
Woodruff JD. Pleural and parenchymal
pulmonary endometriosis. Obstet Gynecol
1981;58:552--6.
1981;58:552
Catamenial Pneumothorax
Pathophysiology
Right--side predominance (up to 92%)
Right
22
22--37% of those who present with
catamenial pneumothaces have implants
in the pleura or diaphragm at VATS
– Rousset
Rousset--Jablonski C, Alifano M, Plu
Plu--Bureau
G, et al. Catamenial pneumothorax and
endometriosis--related p
endometriosis
pneumothorax: clinical
features and risk factors. Hum Reprod
2011;26:2322--9.
2011;26:2322
– Foster DC, Stern JL, Buscema J, Rock JA,
Woodruff JD. Pleural and parenchymal
pulmonary endometriosis. Obstet Gynecol
1981;58:552--6.
1981;58:552
Pathophysiology
Pathophysiology
Sampson’s theory of retrograde menstruation
along with understanding of peritoneal
circulation from pelvis to right paracolic gutter
allows endometrial cells to reach the right
subdiagphragmatic
gp g
area
Hepatic ligaments represent barriers – favor
right side
Metastatic model - Transdiaphragmatic
passage of air from genital tract through
diaphragmatic perforations
– Crutcher RR
RR, Waltuch TL
TL, Blue ME
ME. Recurring
spontaneous pneumothorax associated with
menstruation. J Thorac Cardiovasc Surg
1967;54:599--602.
1967;54:599
– 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
2007;22:2359--67.
2007;22:2359
38
Pathophysiology
Treatment
Multi-disciplinary approach
MultiCombined VideoVideo-assisted thoracoscopic
surgery (VATS) and LSC - definitive
diagnosis and surgical treatment
Hormonal model implicates high
prostaglandin F2 at ovulation, which may
result in vasospasm and associated
ischemia in the lungs. This, in turn and in
combination with prostaglandinprostaglandin-induced
bronchospasm, may result in alveolar
rupture and subsequent pneumothorax
– Chemical pleurodesis,
pleurodesis pleurectomy
pleurectomy, and
segmental resection
– Treatment of intra
intra--abdominal and sub
sub-diaphragmatic endometriosis; BSO in select
cases
– Rossi NP, Goplerud CP. Recurrent
catamenial pneumothorax. Arch Surg. Aug
1974;109(2):173--176.
1974;109(2):173
Nezhat C, Nicoll LM, Bhagan L, et al. Endometriosis of
the diaphragm: four cases treated with a combination of
laparoscopy and thoracoscopy. J Minim Invasive
Gynecol. Sep
Sep--Oct 2009;16(5):573
2009;16(5):573--580.
Diaphragmatic Endometriosis
24 women underwent
laparoscopic treatment of
endometriosis of the diaphragm
Liver
Endometriosis
– 17 patients had 2
2--5 lesions of
endo on the diaphragm <1cm
– 7 women had numerous lesions
scattered across the diaphragm
Lesions were bilateral in 8
patients, limited to R
hemidiaphragm in 14, L
hemidiaphragm in 2
Endo infiltrated the muscular
layer of the diaphragm in 7
patients
Nezhat CH, Seidman D, Nezhat F, Nezhat C. Laparoscopic surgical management of diaphragmatic endometriosis. Fertil Steril 1998;69(6):1048‐1055. Prevalence
Endometriosis of the Liver
•
•
•
•
Only 17 cases reported in the literature
Age ranges from 2121-62
Lesion size ranged from 2.7
2.7--24 cm
16/17 patients had symptomatic RUQ pain
Only 2/17 patients reported catamenial pain
Only 5 cases correctly diagnosed
y
preoperatively
9/17 patients had their pelvis evaluated for
endometriois
Extremely rare entity
First described in 1986 by Finkel et al
Difficult to diagnose
Often misdiagnosed preoperatively as
echinococcal or amebic cyst, pyogenic
abscess, cystadenoma, hematoma, or
metastatic disease
– 6 had pelvic endometriosis
– 8 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.
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
Endometriosis of the Liver:
Treatment
Pathophysiology
Many theories for the origin of hepatic
endometriosis including:
–
–
–
–
–
implantation theory
coelomic theory
metaplasia theory
induction theory
autoimmune theory
14 cases treated with laparotomy
1 case treated with danazol (pt declined
surgery)
2 cases treated laparoscopically
We believe lymphovascular spread also plays a
role due to intraparenchymal location in some
patients
Right lobe predominance
– Possibly due to clockwise perioneal fluid flow
Citations
Liver Endometriosis


1. Nezhat et al. EndometriosisAdvanced Management & Surgical Techniques.
Springer-Verlag, 1995
2. Jerby BL, Kessler H, Falcone T, Milsom JW. Laparoscopic management of colorectal endometriosis. Surg
Endosc 1999;13:1125-8.Mohr C, Nezhat FR, Nezhat CH, Seidman DS, Nezhat CR. Fertility
considerations in laparoscopic treatment of infiltrative bowel endometriosis. JSLS 2005;9:16-24
3. Nezhat et al. Fertil Steril Oct 2002;78(4):8722002;78(4):872-5
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
First 15 cases reported in the literature were treated by laparotomy
Report of 2 cases treated l
laparoscopically
i ll
5. Schwarz O. Endometriosis of the Lung. Am J Obstet Gynecol. 1938;36:887
1938;36:887--889.
6. Maurer ER, Schaal JA, Mendez FL, Jr. Chronic recurring spontaneous pneumothorax due to
endometriosis of the diaphragm. J Am Med Assoc. Dec 13 1958;168(15):20131958;168(15):2013-2014.
Nezhat C et al. Laparoscopic management of hepatic endometriosis: report of two cases and review of the literature. J Minim Invasive Gynecol. 2005 May‐‐Jun;12(3):196
Minim Invasive Gynecol. 2005 May
Jun;12(3):196‐‐200.
7. Lillington GA, Mitchell SP, Wood GA. Catamenial pneumothorax. JAMA. Mar 6 1972;219(10):13281972;219(10):1328-1332.
8. Foster DC, Stern JL, Buscema J, Rock JA, Woodruff JD. Pleural and parenchymal
pulmonary endometriosis. Obstet Gynecol 1981;58:5521981;58:552-6.
9. Rousset
Rousset--Jablonski C, Alifano M, Plu
Plu--Bureau G, et al. Catamenial pneumothorax and endometriosis
endometriosis-related pneumothorax: clinical features and risk factors. Hum Reprod 2011;26:23222011;26:2322-9.
10. Crutcher RR, Waltuch TL, Blue ME. Recurring spontaneous pneumothorax associated with
menstruation. J Thorac Cardiovasc Surg 1967;54:599
1967;54:599--602
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
2007;22:2359--67
2007;22:2359
12. Rossi NP, Goplerud CP. Recurrent catamenial pneumothorax. Arch Surg. Aug
1974;109(2):173--176
1974;109(2):173
13. Nezhat C, Nicoll LM, Bhagan L, et al. Endometriosis of the diaphragm: four cases
treated with a combination of laparoscopy and thoracoscopy. J Minim Invasive
Gynecol. Sep
Sep--Oct 2009;16(5):573
2009;16(5):573--580
14
14. Nezhat
N h t CH
CH, S
Seidman
id
D
D, N
Nezhat
h tF
F, N
Nezhat
h tC
C. L
Laparoscopic
i surgical
i l managementt off
diaphragmatic endometriosis. Fertil Steril 1998;69(6):1048-1055
15. Nezhat C et al. Laparoscopic management of hepatic endometriosis: report of two
cases and review of the literature. J Minim Invasive Gynecol. 2005 MayMayJun;12(3):196--200
Jun;12(3):196
.
THANK YOU !
40
Fellows
Jackie Miller, DO
Elizabeth Buescher MD
M. Ali Parsa, MD
Chandhu Paka, MD
41
Perspectives on
the Future Treatment
of Endometriosis
Disclosure Slide
N fifinancial
No
i l relationships
l ti
hi
to disclose
Professor Charles Chapron, MD
Head of Department,
Université Paris Descartes,
Sorbonne Paris Cité
Faculté de Médecine, AP-HP,
GHU Ouest, CHU Cochin, Paris, France
Learning Objectives Slide
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
Reproductive endocrinology unit:
D de Ziegler V Gayet,
I Streuli, FX Aubriot
At the conclusion of this activity,
th participant
the
ti i
t will
ill b
be able
bl tto di
discuss
the modalities of future medicosurgical therapeutic options in the
management of endometriosis
Endometriosis:
Delay for diagnosis
Intestinal surgery
B Dousset, M Leconte.
Laboratory: Genetic
D Vaiman, F Mondon, S Barbaux
Laboratory: Imunulogy
B Weill, F Batteux,
C Nicco,
cco, C Chéreau
C é eau
Laboratory: Reproducive biology
JP Wolf, V Lange, K Pocate,
JM Kuntzman, C Chalas
Statistical unit
F 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: Diagnosis process
Perspectives on the Future Treatment
E
N
D
O
M
E
T
R
I
O
S
I
S
Onset of
the symptoms
Surgical diagnosis
and
treatment
6 to 10 years
42
Age of
1st pelvic symptoms
16 centers
10 countries
N = 745 osis
Onset of symptoms
3.3 ± 3.6 years
Adolescents
67.1%
Adults
39.2%
10.7 ± 9.3 years
Age of
1st pelvic symptoms
Onset of
symptoms
Greene et al., Fertil Steril (2009)
Ballweg ML (2004)
Nnoaham et al., Fertil Steril (2011)
Endometriosis: Progressive disease ?
Age and incidence of endometriotic lesions
Time from seeking
medical attention
to diagnosis
SUP
Adolescents
6.0 ± 0.2 years
Adults
2.0 ± 0.3 years
OMA
DIE
Greene et al., Fertil Steril (2009)
Ballweg ML (2004)
Koninckx et al., Fertil Steril (1991)
Surgery for intestinal DIE
Severe ureteral
endometriosis
n = 100 patients; Minimum of follow-up: 5 years
Predictive factors for transient neurogenic bladder
Parameters
Age ≥ 35
A
BMI > 25
Multiple previous surgery
Additional intestinal resction
Coloanal anastomosis
Associated hysterectomy
N DIE lesions ≥ 4
Delay for diagnosis
(n = 52 patients)
Transient neurogenic bladder
Yes (n = 16)
n
%
No (n = 84)
n
%
p
6
4
10
2
9
4
11
28
16
38
7
7
4
44
NS
NS
NS
NS
< 0.001
< 0.01
< 0.05
37
25
62
12
56
25
69
33
19
45
8
8
5
52
Patients
Nephrectomy
N
%
11
21.1
!!!!!!!
Chapron – Dousset (2011)
Dousset and Chapron Ann Surg (2010)
43
Endometriosis:
Recurrences after surgical treatment
E
N
D
O
M
E
T
R
I
O
S
I
S
Risk of recurrences
Endometriosis:
I
53%
II
III
IV
Vercellini et al., Hum Reprod Update (2009)
DEEPLY INFILTRATING ENDOMETRIOSIS:
LOCATION (n = 877 patients)
E
N
D
O
M
E
T
R
I
O
S
I
S
Intestinal
endometriosis
Cumulative 36- month probability
of moderate to severe dysmenorrhea
Pain recurrence or
re-operation rate (%)
Multifocal disease
MRI: intestinal DIE
Deep endometrisois:
Main
lesion
N
R
BLADDER
USL
VAGINA
INTESTINE
URETER
66
340
102
313
56
877
Associated lesions
USL
Va
Bl
In
L B
2
9
88 170
15 20
56 40
5
10
166 249
6
164
40
186
44
440
Multifocality +++
5
66
102
177
34
318
33
10
109
Total
Ur
594
94
688
63
63
88
422
177
1088
260
2035
Chapron (September 2011)
Deep endometriosis
Global approach
Bifocal intestinal DIE
Anatomic distribution
(n = 360 patients)
Main characteristics
N
%
- Unique without other DIE lesions
35
9.7
- Multifocal intestinal DIE lesions
175 48.6
- Associated left/ right lesions
67
Chapron et al.,
Hum Reprod (2006)
DIE is not
« an organ pathology »
18.6
Vaginal DIE
Chapron - Dousset (September 2011)
44
Endometriosis:
Deep Endometriosis: Clinical symptoms
E
N
D
O
M
E
T
R
I
O
S
I
S
Heterogeneous disease
Endometriosis
Pelvic pain
Pelvic pain
Endometriosis: Heterogeneity
Infertility
Infertility
Deep endometriosis: Definitions
JC Noel (2010)
Left
OMA
Hum Reprod (2010)
Superficial
endometriosis
Ovarian
endometriomas
Endometriosis
Deep infiltrating
endometriosis
Invasion of
the muscularis propria
Bilateral
Kissing
OMAs
Vaginal
DIE
Bladder
DIE
JC Noel (2010)
Right OMA with adhesions
Endometriosis: Associations
Deep endometriosis:
Frequency of associated
ovarian endometriomas
Bilateral Omas:
« Kissing ovaries »
(n = 636 patients)
Main lesion
OMA
OMAs
SUP
Pelvic pain
BLADDER
USL
VAGINA
URETER
INTESTINE
Total
Infertility
DIE
45
N
Associated OMAs
n
%
51
279
93
29
184
636
8
49
19
13
86
175
15.7
17.6
20.4
44.8
46.7
27.5
Right OMA
Chapron unpublished,
(2010)
Deeply infiltrating endometriosis
and ovarian endometriomas
Deeply infiltrating endometriosis
(n = 500 patients).
Results according to the presence of OMA
Mean number of DIE lesions
OMA -
OMA +
P-value
1.64 ± 1.0
2.51 ± 1.72
< 0.0001
a
rAFS score
Implants
a
6.7 ± 4.9
28.1 ± 10.1
Fertil Steril (2009)
< 0.0001
Adhesions
16.5 ± 23.7
36.2 ± 28.7
< 0.0001
Total
23.6 ± 25.7
65.6 ± 33.1
< 0.0001
Pearsons’ Chi-square test
Main DIE lesion
R
OR
95% CI
P-value
USL
Vagina
Bladder
Intestine
Ureter
0.118
5.98
0.137
34.5
8.6
1.70
3.59
3.91
1.1-2.6
2.3-5.6
1.4-10.4
NS
0.014
NS
< 0.0001
0.003
Chapron et al., Fertil Steril (2009)
OR, odds-ratio; CI: confidence interval
Endometriosis:
Deep endometriosis: Medical treatments
E
N
D
O
M
E
T
R
I
O
S
I
S
Results of
hormonal treatment
Hum Reprod, 2009
Deep endometriosis:
Endometriosis:
E and P receptors in the smooth muscle component
Delay for diagnosis
Risk of recurrences
Bladder DIE: ER
Bladder DIE: PR
Multifocal disease
RVS DIE: ER
Heterogeneous disease
Results of
hormonal treatment
RVS DIE: PR
Noel - Chapron et al, Fertil Steril (2010)
46
E
N
D
O
M
E
T
R
I
O
S
I
S
Endometriosis:
Endometriosis: Management
E
N
D
O
M
E
T
R
I
O
S
I
S
Delay for
diagnosis
options
Earlier
diagnosis
Future:
Importance of questionning ?
Endometriosis
Endometriosis: Body Mass Index
Endometriosis: Body Mass Index
Association between BMI and Osis
Lafay Pillet, Chapron et al., Hum Reprod (2012)
DIE: Importance of questionning
Parameters
Group A
No DIE
(n = 131)
Group B
DIE
(n = 98)
p
OR 95%CI
Family history of Osis
6 (4.6%)
13 (13.3)
0.02
3.2 (1.2 - 8.8)
DIE
Lafay Pillet, Chapron et al., Hum Reprod (2012)
Parameters
Group A
No DIE
((n = 131))
Group B
DIE
((n = 98))
p
OR 95%CI
Absenteeism
from school
during menstruation 33 (25.2%) 37 (37.7%) 0.04 1.7 (1 - 3)
47
Parameters
Group A
No DIE
(n = 131)
Prescription of OCPs
because of severe
primary dysmenorrhea
Age
(years)
Duration of use (years)
Group B
DIE
(n = 98)
p
OR 95%CI
15 (25.9%)
29 (58.0%)
0.001
18.1 ± 3.2
16.5 ± 2.4
0.07
5.1± 3.8
8.4 ± 4.7
0.02
4.5 (1.9 – 10.4)
Endometriosis and
oral contraceptives
Endometriosis: Risk factors
Oral
contraceptives
Endometriosis
DIE +++
Two conclusions
Chapron et al., J Ped Adol Gynecol (2011)
Endometriosis:
Risk of
recurrences
Deep intestinal endometriosis:
E
N
D
O
M
E
T
R
I
O
S
I
S
Previous surgical history for endometriosis
Ann Surg
(2010)
Complete surgical
exeresis
48
Previous surgery for Osis
82%
Operative laparoscopy
Open surgery
Multiples procedures
Hysterectomy
59%
29%
48%
5%
Deep endometriosis:
DIE with colorectal involvement
Prevention of recurrences after surgical treatment
Complete surgical exeresis
Multifocality
Preop work-up
Bowel surgery performed
n
%
Bowel resection anastomosis
737
39 9
39.9
Full-thickness disc excision
375
20.3
Shave / superficial excision
679
36.8
Carmona,
Surgeon’s
experience
Op procedure:
Resection >>> Shaving
Abrao et al., Fertil Steril (2006)
CI for sigmoid location: 30%
Intestinal Multifocality: 50%
% of circumference affected
Lymphatic dissemination
Meuleman et al., Hum Reprod Update (2011)
DIE with colorectal involvement
Deep endometriosis: preoperative diagnosis
Postoperative recurrence
Proven osis recurrence
Bowel resection anastomosis
N
n
%
812
20
2 46
2.46
865
49
5.66
Hum Reprod
(2009)
Full-thickness disc excision
Shave / superficial excision
Meuleman et al., Hum Reprod Update (2011)
Endometriosis:
Multifocal
disease
Endometriosis: Centers of excellence
E
N
D
O
M
E
T
R
I
O
S
I
S
Multidisciplinary
approach
d’Hooghe and Hummelshoj (Hum Reprod, 2006)
49
Deep endometriosis: Multidisciplinary approach
Painful OMAs
Necessity to reconsider
the management
OMAs
VAS
Pain
Questioning
Clinical
examination
DIE
≥7
« Isolated »
OMAs
Infertility
Epidemiology
Environment
« Severe » OMAs
Instestine
Ureter
Earlier +++
endometriosis
diagnosis
Ovarian reserve
USL
Vagina
Bladder
Endocrinology
Endometrial biopsies
Imaging
Referral center
Preoperative work-up:
Endometriosis:
Heterogeneous
disease
Gynecologists
Radiologists Imaging
Sonographers
Chapron – Santulli et al.,
Hum Reprod (2012)
Anatomo - pathology
Specific consultations
for adolescents
DIE: Biomarkers
E
N
D
O
M
E
T
R
I
O
S
I
S
Referral center for Osis
Preoperative serum IL-33 levels
VAS Dysmenorrhea
Phenotype
Total number
of DIE lesions
VAS GI symptoms
Worst
DIE lesion
Santulli, Batteux and Chapron (Hum Reprod, 2012)
Endometriosis: Epigenetic changes
Endometriosis: Epigenetic changes
Chromosal distribution of
methylated and demethylated promoter regions
Borghese, Vaiman, Chapron
Promoter regions
Demethylated:
uniformly distributed
Methylated:
Subtelomeric
DNMT3L
B Borghese, C Chapron, D Vaiman Mol Endocrinol (2010)
50
Am J Pathol (2012)
GWAS in endometriosis
19
11
8
5
15
20
MMPs genetic
polymorphysms
10
22
16
12
6
1
3
9
21
17
13
7
4
18
2
X
14
Precise endometriosis lesions’ phenotype
Case control study :
Genetic polymorphisms of matrix metalloproteinases (MMPs) 12 and 13
SUP
Haplotype protector
MMP12‐MMP13
Borghese, Chapron et al., Mol Endocrinol 2008
Borghese, Chapron et al., Hum Reprod 2008
Results of
hormonal treatment
Endometriosis:
Borghese, Vaiman and Chapron Am J Hum Genet 2012
Endometriosis:
E
N
D
O
M
E
T
R
I
O
S
I
S
DIE
OR = 2.09
Association avec DIE OR = 2.09
Association avec SUP: OR 27.6
Endometriosis:
OMA
OR = 2.22
New non hormonal medical options
Expert Opin Emerging Drugs (2012)
Mitogen-activated
protein kinase
inhibitors
Matrix metalloproteinases
inhibitors
Anti-angiogenetic
agents
Statins
Perossisome proliferator
f
activated receptor-Ƴ
Nuclear factor
Kappa β inhibitors
Deep endometriosis
Immunomodulators
Non hormonal
treatment
TNF blockers
Histone deacetylase
inhibitors
Aromatase
inhibitors
COX-2
inhibitors
Antioxydants
Ovarian endometrioma: Oxidative stress
New non hormonal medical options
X 7.75
+ 50%
+ 65%
Cellular
proliferation
X 2.5
Hydrogen peroxyde
production
Effect of NAC on
H2O2 production
Effect of NAC on
cellular proliferation
Rocha, Reis and Petraglia Expert Opin Investig Drugs (2012)
Ngô, Chapron, Batteux
51
Am J Pathol (2009)
Ovarian endometrioma: Oxidative stress
Ovarian endoetrioma:
In
vivo
Oxidative stress
Control
Contrôle
Control
E-trial
cells
E-trotic
cells
Control
NAC
E-trial
cells
E-trotic
cells
Histological score:
2.0 ± 0.25
NAC
Quantitative analysis:
Optic density ratio pERK / ERK
The rate of proliferation of endometriotic cells
is increased through the activation of the
ERK pathway as a consequence of high
constitutive endogenous oxidative stress
Histological score:
1.19 ± 0.13
p < 0.05
Am J Pathol (2009)
Am J Pathol (2009)
Endometriosis: Role of protein kinase inhibitors
Endometriosis: Oxidative stress
Future
ROS
Proliferation
Proliferation
Proliferation
Optic density
ratio pERK / ERK
Activation
de pERK
pERK
inhibitor
N-acetylcysteine
NAC
***: p < 0.001
X
Untreated
Untreated
Prolifération
Ngô, Chapron, Batteux J Pathol (2010)
Endometriosis: Role of protein kinase inhibitors
Deep endometriosis:
O2.-
Oxidative stress
DIE cells
proliferation
H2O2
39%
In vivo with mouse model:
Pathology score
39%
***: p < 0.01
68%
NO
Cellular production of ROS:
basal levels
Ngô, Chapron, Batteux J Pathol (2010)
Leconte, Dousset, Chapron and Batteux, Am J Pathol (2011)
52
Deep Endometriosis: Oxidative stress
Endometriotic cell
proliferation
Proliferative rate
control
Eutopic E
Epithelial
p
DIE
control
Eutopic E
DIE
Stromal
Optic density ratio pERK / ERK
****
DIE cells proliferation is increased through
the activation of the ERK pathway,
as a consequence of high
constitutive endogenous ROS production
****
Effects on N- Acetyl-L-Cysteine:
Antioxydant molecule
Leconte, Dousset, Chapron and Batteux,
Am J Pathol (2011)
Es
Deep Endometriosis: the mTOR/AKT pathway
Future +++
ROS
Effect of protein tyrosine
kinase inhibitor A77-1726
(selective ERK inhibitor +++)
on cell proliferation
Activation
de pERK
pERK
inhibitor
X
- 87% - 93%
Eutopic E
DIE
Epithelial
Prolifération
Quantitative
l i
analysis
of pAKT
Quantitative
analysis
of AKT
- 95%
- 88%
Eutopic E
DIE
Stromal
Eutopic E
DIE: Effect of mTOR/AKT Inhibitor (Temsirolimus)
DIE: Effect of mTOR/AKT Inhibitor (Temsirolimus)
In
vivo
Effect of Temsirolimus
(selective mTOR/AKT inhibitor +++)
on cell proliferation
Quantitative
analysis
l i off
phospho-p70S6K
In
vitro
Glands
Stroma
2.44 ± 0.18
Fibrosis
Untreated
1.19 ± 0.25
Treated
(3 weeks after)
p < 0.01
53
Take home
messages
Take home
messages
Management and strategy:
Endometriosis
- Global approach
Endometriosis
- Global approach
and
Patients
and
Pelvic pain
Patients
-Multidisciplinary approach
- Multidisciplinary approach
- New non hormonal treatments
Take home
messages
Take home
messages
Endometriosis
- Global approach
and
Endometriosis
- Global approach
Pelvic pain
Patients
and
Pelvic pain
Patients
Infertility
Infertility
Surgery
Medical Ttt
Endometriosis:
Delay for
diagnosis
Risk of
recurrences
Multifocal
disease
Heterogeneous
disease
Results of
hormonal treatment
E
N
D
O
M
E
T
R
I
O
S
I
S
Earlier
diagnosis
Complete surgical
exeresis
Multidisciplinary
approach
Presidents
Felice Petraglia
(Siena, Italy)
Charles Chapron
(Paris, France)
Hans Rudolf Tinnemberg
(Giessen, Germany)
Phenotype
Non hormonal
treatment
54
ART
References list (1)
References list (2)
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.
Chapron C, Piétin-Vialle C, Borghese B, Davy C, Foulot H, Chopin N: Deeply infiltrating endometriosis:
Associated ovarian endometriomas is a marker for greater severity of the disease.
Fertil Steril 2009, 92: 453-457.
Greene R, Stratton P, Cleary SD, Ballweg ML, Sinaï N: Diagnostic experience among 4,334 women
reporting surgically diagnosed endometriosis. Fertil Steril 2009; 91: 32-39.
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.
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.
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.
Dousset B, Leconte M, Borghese
g
B, Millischer AE, Roseau G, Arkwright
g S, Chapron
p
C: Complete
p
surgery
g y
for low rectal endometriosis : long term results of a 100-case prospective study.
Ann Surg. 2010; 251 (5): 887-895.
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 deep
infiltrating endometriosis. Fertil Steril 2011, 95 (3): 877-881.
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, 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 .
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.
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
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.
References list (3)
References list (4)
Chapron C, Borghese B, Streuli I, de Ziegler D: Markers of adult endometriosis detectable in adolescence.
J Ped Adol Gynecol 2011; 24: S7-S12.
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.
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.
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.
Santulli P, Borghese B, Chouzenoux S, Vaiman D, Borderie D, Streuli I, Goffinet F, de Ziegler D, Weill B,
Batteux F, Chapron C: Serum and peritoneal IL-33 levels areelevated in deeply infiltrating
endometriosis. Hum Reprod 2012 ; 27 (7) 2001-2009.
2001 2009.
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.
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.
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.
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.
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.
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.
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 (6)
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.
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.
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
endometriosis. Expert Opin Emerging Drugs 2012; 17(1): 83-104
83-104.
Leconte
eco e M,, Nicco
cco C, Ngô
gô C, Arkwright
g S, Chéreau
C é eau C, Gu
Guibourdenche
bou de c e J, Weill
e B,, C
Chapron
ap o C,
Dousset B, Batteux F: Antiproliferative effect of cannabinoid agonists on deep infiltrating
endometriosis. Am J Pathol 2010; 177 (6): 2963-2970.
Rocha AL, Reis FM, Petraglia F: New trends for the medical treatment of endometriosis. Expert Opin
Investig Drugs 2012; 21: 905-919.
Ngô C, Chéreau C, Nicco C, Weill B, Chapron C; Batteux F: Reactive oxygen species controls
endometriosis progression. Am J Pathol 2009; 175 (1): 225-234.
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.
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).
US Population
Language Spoken at Home
California
Language Spoken at Home
Spanish
English
Spanish
Indo-Euro
Asian
Other
Indo-Euro
English
Asian
Other
19.7% of the US Population speaks a
language other than English at home
In California, this number is 42.5%
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.
56

Deep Endometriosis

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