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Endometriosis: surgical perspectives Dr. med Thomas Gyr Dr. med. Christian Polli Chairman of Gynecology and Obstetrics Chief of service of Gynecology and Obstetrics Endometriosis center, Ospedale Civico di Lugano SEF/EEL certification since 2014 Endometriosis: surgical perspectives Endometriosis center, Ospedale Civico di Lugano SEF/EEL certification since 2014 Dr. med Thomas Gyr Dr. med. Christian Polli Chairman of Gynecology and Obstetrics Chief of service of Gynecology and Obstetrics Role of surgery in Endometriosis 1. Diagnosis 2. Treatement Titolo presentazione / Data / Pag. 3 Role of surgery in Endometriosis 1. Diagnosis 2. Treatement Pain Titolo presentazione / Data / Pag. 4 Role of surgery in Endometriosis 1. Diagnosis 2. Treatement Pain Infertility Titolo presentazione / Data / Pag. 5 Role of surgery in Endometriosis: Diagnosis LAPAROSCOPY can confirm the presence and the localisation of the disease: I. II. III. IV. Peritoneal wall Ovaries (Endometriomas) Rectovaginal space Other (Bladder, Abdominal wall, Ombilic….) Titolo presentazione / Data / Pag. 6 Role of surgery in Endometriosis: Diagnosis Peritoneal: Titolo presentazione / Data / Pag. 7 Role of surgery in Endometriosis: Diagnosis Ovaries (ENDOMETRIOMAS): Titolo presentazione / Data / Pag. 8 Role of surgery in Endometriosis: Diagnosis Rectovaginal: Titolo presentazione / Data / Pag. 9 Role of surgery in Endometriosis: Diagnosis Bladder: Titolo presentazione / Data / Pag. 10 Role of surgery in Endometriosis: Diagnosis Titolo presentazione / Data / Pag. 11 Surgical techniques in Endometriosis: SCORES Ezian Titolo presentazione / Data / Pag. 12 rASRM Role of surgery in Endometriosis: Diagnosis Titolo presentazione / Data / Pag. 13 Role of surgery in Endometriosis: See and Treat/Discuss AIMS - Remove all visible lesions - Re-establish normal anatomy - Preserve the ovarian function Laparoscopy should be the standard approach Titolo presentazione / Data / Pag. 14 Role of surgery in Endometriosis: See and Refer - Beyond surgery for diagnostic purpose and removal for early stage disease, it is recognized that complex endometriosis is not for every gynecologist and can be the most challenging and difficult type of pelvic surgery with potential for significant risks and complications. Multidisciplinary counseling, expertise and support in certified centers. Titolo presentazione / Data / Pag. 15 Role of surgery in Endometriosis: Titolo presentazione / Data / Pag. 16 Role of surgery in Endometriosis: Titolo presentazione / Data / Pag. 17 Center of endometriosis ORL: Organization chart Direzione Generale EOC Giorgio Pellanda Ospedale Regionale di Lugano Luca Jelmoni* Qualità Adriana Degiorgi Responsabile Centro Endometriosi Dr. med. Thomas Gyr Dr. med. Christian Polli Titolo presentazione / Data / Pag. 18 Centro ProCrea - Dr. med. Michael Jemec ENDOHELP - Francesca Gaia Centro Terapia del Dolore - Dr. med. Sergio Castelanelli Partners Dr. med. Valerio Vitale Dr. med. Filippo Del Grande Segretariato Federico Milva Radiologia Prof. Luca Mazzucchelli Reparto Annalisa Ruzzitu Patologia Dr. med Fernando Jermini Dr. med. Giordano Venzi Urologia Prof. Raffaelle Rosso Dr. med Dimitri Christoforidis Chirurgia Ambulatorio Dr. med Thomas Gyr Dr. med. Christian Polli Irene Schärli – aiuto medico Incoming patients General practitioners Population External gynaecologists Associate residents Unit’s Partners ProCrea Endohelp Titolo presentazione / Data / Pag. 19 The endometriosis center ORL in numbers: Type of procedures Bowel resection 1 3 1 Abdominal wall resection 1 2 Bladder lesions resection 2 3 Hysterectomy 3 1 4 13 Endomertriomas resection 16 Rectovaginal endometriosis resection Titolo presentazione / Data / Pag. 20 8 13 0 2010 6 9 10 2011 2012 1 7 8 10 20 2013 3 30 40 50 The endometriosis center ORL: Details Min. Average Max. Age 22 y 35 y 56 y Operation time 0h40’ 2h27’ 5h00’ Hospitalization time (days) 1 4.96 18 Preoperative Pig-tail insertion Complications 8% (N=8) 15% (N=16) Complains 1% (N=1) Referred patient to University centre 6% (N=6) Titolo presentazione / Data / Pag. 21 Complications Type Data Acute depression 1% (N=1) Urinary infections 5% (N=5) Bladder disorders 2% (N=2) Ureteral lesions (stenosis, fistula, etc.) 3% (N=3) Peripheral nerve lesions 1% (N=1) Post operative hematoma 2% (N=2) Allergic skin reaction 1% (N=1) Intra-operative skin lesion 1% (N=1) Meta analysis of CHAPRON and al. Rates of major and minor surgical complication associated with laparoscopy range from 1.4% to 7.5% Titolo presentazione / Data / Pag. 22 Surgical techniques in Endometriosis: Pain treatement Peritoneal endometriotic lesions - EXCISION within 2-3 mm of clear surgical margins (avoid thermocoagulation) - ATTENTION must be paid to the underlying structures as i.e. ureter/vessels/nerves Titolo presentazione / Data / Pag. 23 Surgical techniques in Endometriosis Peritoneal endometriotic lesions Titolo presentazione / Data / Pag. 24 Surgical techniques in Endometriosis: Pain treatement Endometriomas - Every attempt should be made to remove endometriosis cyst completely. Sharp careful dissection with scissors and punctual hemostasis is by far considered better than the stripping technique. - Always consider complete aspiration of the «chocolate» content Titolo presentazione / Data / Pag. 25 Surgical techniques in Endometriosis: Pain treatement Endometriomas - Ovarian defect will close spontaneously (if less than 5cm).Sometimes it is necessary to close the cortex of the ovary with some 3-0 absorbable sutures (Hemostasis +++) Titolo presentazione / Data / Pag. 26 Surgical techniques in Endometriosis: Pain treatement Endometriomas Titolo presentazione / Data / Pag. 27 Surgical techniques in Endometriosis: Pain treatement Rectovaginal Endometriosis Surgery to face only in the case of adequate counseling, planning and availability of trained surgical team. TECHNIQUE - Mobilization of the uterus and Suspension of the ovaries. - Pararectal space opening/Ureterolysis - Dissection/Mobilization of the nodule from the posterior wall of the vagina Rectal shaving vs. Disk/Segmental bowel resection Titolo presentazione / Data / Pag. 28 Surgical techniques in Endometriosis: Pain treatement Rectovaginal Endometriosis Titolo presentazione / Data / Pag. 29 Surgical techniques in Endometriosis: PAIN treatement - Clinicians should not perform laparoscopic uterosacral nerve ablation (LUNA) as an additional procedure to conservative surgery to reduce endometriosis-associated pain (Proctor, et al., 2005). - Clinicians should be aware that presacral neurectomy (PSN) is effective as an additional procedure to conservative surgery to reduce endometriosis-associated midline pain, but it requires a high degree of skill and is a potentially hazardous procedure (Proctor, et al., 2005). Titolo presentazione / Data / Pag. 30 Surgical techniques in Endometriosis: PAIN treatement - Sometimes clinicians must consider hysterectomy with removal of the ovaries and all visible endometriosis lesions, in women who have completed their family and failed to respond to more conservative treatments. Women should be informed that hysterectomy will not necessarily cure the symptoms or the disease. Titolo presentazione / Data / Pag. 31 Role of surgery in Endometriosis: INFERTILITY Based on the guidelines of: - Royal College of Obstetricians and Gynecologists French College of Obstetricians and Gynecologists European Society of Human Reproduction and Embryology (ESHRE 2013) American Society for Reproductive Medecine (ASRM 2012) The following conclusions on recommendations can be given Titolo presentazione / Data / Pag. 32 Role of surgery in Endometriosis: INFERTILITY A) Factors that determine the need for surgical interventions include: 1. 2. 3. 4. AGE (>35 y) Previous therapies Nature and severity of symptoms Location and severity of disease Titolo presentazione / Data / Pag. 33 Role of surgery in Endometriosis: INFERTILITY B) Surgical treatment of stage ASRM I/II of endometriosis in infertile patients prior to assisted reproductive technologies (ART) leads to improved live birth. C) For infertile patients with stage ASRM III/IV endometriosis, conservative laparoscopic surgery is indicated particular when significant symptoms are present. The effectiveness of surgical excision of deep nodular lesions before treatment with ART in women with endometriosis-associated infertility is not well established with regard to reproductive outcome. Titolo presentazione / Data / Pag. 34 Role of surgery in Endometriosis: INFERTILITY However more recent findings suggest that women with ASRM stage III/IV have a good chance of spontaneous pregnancy following laparoscopic resection of the disease. 73% chace to conceive within 12 month Erin M. and al. - Jan 2015 University of New South Whales – Australia Titolo presentazione / Data / Pag. 35 Role of surgery in Endometriosis: ENDOMETRIOMAS: TREATEMENT DILEMMA The most recent evidence suggest to avoid surgical treatement and proceed to IVF if: - Infertile patient is asymptomatic Older patients Diminuished ovarian reserve (low AMH) Bilateral endometriomas Prior surgical treatement Titolo presentazione / Data / Pag. 36 Role of surgery in Endometriosis: ENDOMETRIOMAS: TREATEMENT DILEMMA The most recent evidence suggest to proceed to surgery if: - Unilateral cyst more than 4 cm Invalidant pain symptoms Intact ovarian reserve (AMH) Sonografic features for malignancies (NB incidence less than 1%) - IVF not planned Titolo presentazione / Data / Pag. 37 Role of surgery in Endometriosis: CONCLUSIONS Proceeding directly to FIVET may reduce the time to conceive, avoid potential surgical complications and limit cost. Surgery should always be considered when patients have concomitant pain, symptoms refractory to medical management and when malignancy cannot be ruled out. Titolo presentazione / Data / Pag. 38 Role of surgery in Endometriosis: INFERTILITY (references) - - - - - Opøien HK, Fedorcsak P, Byholm T and Tanbo T. Complete surgical removal of minimal and mild endometriosis improves outcome of subsequent IVF/ICSI treatment. Reprod Biomed Online 2011; 23:389–395. Benschop L, Farquhar C, van der Poel N and Heineman MJ. Interventions for women with endometrioma prior to assisted reproductive technology. Cochrane Database Syst Rev 2010:CD008571. Donnez J, Wyns C and Nisolle M. Does ovarian surgery for endometriomas impair the ovarian response to gonadotropin? Fertil Steril 2001; 76:662-665. Hart RJ, Hickey M, Maouris P and Buckett W. Excisional surgery versus ablative surgery for ovarian endometriomata. Cochrane Database Syst Rev 2008:CD004992. [Edited (no change to conclusions), published in Issue 5, 2011.] Bianchi PH, Pereira RM, Zanatta A, Alegretti JR, Motta EL and Serafini PC. Extensive excision of deep infiltrative endometriosis before in vitro fertilization significantly improves pregnancy rates. J Minim Invasive Gynecol 2009; 16:174–180. Papaleo E, Ottolina J, Viganò P, Brigante C, Marsiglio E, De Michele F and Candiani M. Deep pelvic endometriosis negatively affects ovarian reserve and the number of oocytes retrieved for in vitro fertilization. Acta Obstet Gynecol Scand 2011; 90:878–884. Titolo presentazione / Data / Pag. 39 Role of surgery in Endometriosis: INFERTILITY (references) - - - Marcoux S, Maheux R, Berube S. Laparoscopic surgery in infertile women with minimal or mild endometriosis. Canadian Collaborative Group on Endometriosis. N Engl J Med 1997;337:217–22. Parazzini F. Ablation of lesions or no treatment in minimal-mild endometri- osis in infertile women: a randomized trial. Gruppo Italiano per lo Studio dell' Endometriosi. Hum Reprod 1999;14:1332–4. Chapron C, Vercellini P, Barakat H, Vieira M, Dubuisson JB. Management of ovarian endometriomas. Hum Reprod Update 2002;8:591–7. Schenken RS. Modern concepts of endometriosis. Classification and its consequences for therapy. J Reprod Med 1998;43:269–75. Donnez J, Nisolle M, Gillet N, Smets M, Bassil S, Casanas-Roux F. Large ovarian endometriomas. Hum Reprod 1996;11:641–6. Titolo presentazione / Data / Pag. 40 THANK YOU
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