Saturday, April 12, 2014
Case for excision and regional centres
"No drug has yet been shown to eradicate endometriosis and none has yet been shown to effect a long term cure, particularly for those women with deeply invasive disease. Discontinuation of medication usually results in the recurrence of pain within 12 months. Superficial removal of endometriosis with various ablative techniques has been shown in randomised trials to produce long term symptomatic improvement in women with mild and moderate disease. Surgical ablation has not yet been shown to be effective in the treatment of advanced deeply invasive endometriosis; in addition, the use of high powered energy sources adjacent to the bowel and bladder is potentially dangerous and limits the possibility of deep ablation in these areas.
After the unsuccessful use of medications and ablation techniques the gynaecologist may consider hysterectomy usually combined with bilateral oophorectomy. There undoubtedly is a place for hysterectomy and oophorectomy in the treatment of advanced endometriosis but this should only be considered if there are other indications for hysterectomy or where surgical excision of endometriotic deposits has failed.
The early resort to hysterectomy for the treatment of any stage of endometriosis is to be deplored. Endometriosis is an extra-uterine disease, and the aim of treatment should be to remove all the extra-uterine disease while retaining all the healthy tissue including the uterus and ovaries. This approach is particularly important for younger women. Unfortunately, it is still too common for young women to have a hysterectomy performed before adequate attempts to remove foci of extra-uterine endometriosis have been made. This view is firmly entrenched in gynaecological teaching, as a quotation from a standard textbook for postgraduates shows: “However, if her family is complete and she is young, radical pelvic clearance is absolutely necessary to cure the disease”. The italics are mine and I profoundly disagree with this recommendation.
If all the endometriotic tissue can be removed, excellent long term results without the need for hysterectomy or oophorectomy can be obtained. There is also clear evidence that failure to remove all the endometriotic tissue may result in persistent symptoms even when the uterus and ovaries have been removed, and that these symptoms are cured by excising residual endometriotic tissue.
The best long term results for the management of advanced endometriosis come from those centres using careful excisional techniques aimed at removing as much as possible of the endometriotic disease. Excision using either the carbon dioxide laser or scissors has been shown to be highly effective using both laparotomy and laparoscopy. The laparoscopic approach is preferred in most situations because it affords better visualisation of the anatomy and pathology, and thereby permits more precise surgery. The laparoscopic approach also allows major abdominal wall incisions to be avoided with a consequent reduction in post-operative pain, reduction in hospital stay and reduction in post-operative recovery times. Laparoscopic excision of endometriosis has been shown in long term studies to be highly effective in reducing or eradicating endometriosis. The five-year risk of a diagnosis of new endometriosis following laparoscopic excision has been shown to be 19%. Redwine and Perez have recently reported a remarkable long term study using pre- and post-operative pain scores to evaluate the effectiveness of conservative excision of endometriosis. This study is of more than 500 consecutive cases treated by the authors and followed for up to four years, and showed significant and sustained improvements in pelvic pain, dyspareunia and painful bowel movements after extensive laparoscopic excision. Excellent long term results have been obtained with laparoscopic excision of endometriosis even when the lower bowel has been involved. Reich8 has reported the first 100 cases of a series of over 400 cases of laparoscopic dissections of deep fibrotic endometriosis in the cul de sac with very favourable long term results. In this study 89% of the women presenting with severe pain as a major symptom achieved complete or partial relief and 74% of those wishing to conceive did so. No laparotomies were necessary but the average operating time was more than 3 hours with a range of 1 to 9 hours.
Endometriosis is an enigmatic disorder which is frequently under-diagnosed and inadequately treated. Deeply invasive endometriosis involving the utero- sacral ligament, the ovary, the rectovaginal septum and cul de sac or the rectosigmoid colon requires surgical excision. Usually this can best be performed laparoscopically, although some cases may still require laparotomy.
Gynaecologists should ask themselves a number of fundamental questions concerning the treatment of deeply invasive endometriosis. Why do we so often use drugs for advanced endometriosis when there is no evidence that they are effective? Endometriosis is a disease of ectopic endometrium located outside the uterus; why does removal of the healthy uterus remain a cornerstone of its management? Why do we continue to use multiple ineffective therapies when more effective ones are available?
Deeply invasive endometriosis is a common and benign disease. Health services naturally look towards providing the simplest, quickest and cheapest form of treatment for such conditions. The available evidence suggests that the most effective form of treatment is complete surgical excision of endometriosis, an operation which is neither quick nor simple. Surgical excision of endometriosis is both demanding and difficult. Even by laparotomy, and especially by laparoscopy, the surgical procedures are time consuming, often taking more than three hours. How many health services allow a gynaecologist to take a whole morning's operating time to treat just one patient with a benign disease? The procedures are often judged by health care systems, private insurance companies and individual gynaecologists to be not cost effective.
Difficult, challenging surgery with potential complications and inadequate financial reward may partly explain the lack of suitable treatment centres for this common condition. A few skilled and determined pioneering gynaecologists have demonstrated the technical possibilities of laparoscopic excision of endometriosis, but to date this service is available to only a tiny fraction of the women who might benefit from this treatment.
What can be done to improve this situation? I believe there is now sufficient evidence to justify the setting up of regional centres interested in the management of advanced endometriosis, which would function much as regional oncology centres. These centres for the treatment of endometriosis would need to be adequately staffed and equipped to ensure that a suitable number of these long operations can be undertaken. These endometriosis centres would need to work in close association with other groups such as colorectal and urological surgeons, reproductive medical specialists, basic scientists and counselling and support services.
These centres would be expensive, but their cost could be offset by replacing the considerable number of ineffective approaches currently being used with more complex but more effective treatments. Policy makers will only be convinced by randomised comparisons of laparoscopic excision of endometriosis performed by suitably trained, skilled gynaecological surgeons and standard treatments, where outcome measures include not only women's perception of improvement and rates of pregnancy, but also an economic analysis."