{"paper_id":"38bdf067-644e-436f-8c53-976e881de665","body_text":"New Zealand Medical Journal \nTe ara tika o te hauora hapori\n2024 Mar 8; 137(1591). ISSN 1175-8716\nhttps://www.nzmj.org.nz/ ©PMA \narticle\n49\nEmergency department attendances \nfor persistent pelvic pain are not \nreduced following laparoscopic \nsurgery for women with or without \nendometriosis \nKaren Joseph\nabstract\naim: To explore the change in emergency department (ED) attendances for persistent pelvic pain (PPP) following laparoscopic treatment \nof endometriosis.\nmethods: A retrospective service evaluation was conducted on a convenience sample of 1 calendar year of elective gynaecological  \nlaparoscopies for PPP . Data were collected on ED visits for surgical complications, and for PPP in the 12 months prior to and following surgery.\nresults: Of the 195 women undergoing laparoscopy, 30 had attended the ED owing to their PPP in the preceding year. Endometriosis \nwas found and treated in 51% of the cohort and no cause for pain was found in the other 96 women. Eighteen women suffered post-  \noperative complications. In the subsequent 12 months, 31 of the cohort attended the ED for PPP . Likelihood of unscheduled hospital \nvisits for post-operative complications and for exacerbations of pain in the year prior to and following surgery was independent of the \npresence of endometriosis lesions. \nconclusions: In a cohort of women living with PPP , laparoscopic surgery failed to reduce the need to attend the ED owing to their pain. \nFurther investigation into interventions that can reduce the burden of pain on these women and the healthcare system is required.\nP\nersistent pain perceived in structures \nrelated to the pelvis affects around one in \nfour women, and is commonly associated \nwith negative cognitive, behavioural, sexual and \nemotional consequences.1 \nPersistent pelvic pain (PPP) is recognised inter-\nnationally as posing a high burden on health \nservices.2,3 Women living with PPP commonly \nexperience flare-ups of pain and these may lead to \npresentation to acute hospital services. Abdominal \npain is the presenting concern for around half of \nhigh frequency users of emergency departments \n(ED) and approximately 40% of acute hospital \ngynaecological presentations are for pelvic pain \nfor which no cause is found during the visit.4–6 \nEDs are specialist services for those with acute \nillness or injury, and the complex difficulties  \nassociated with chronic pain are not well  \nmanaged in this setting. 7,8 Women attending ED \nfor PPP often undergo numerous investigations \nwith high cost and low probability of finding any \nabnormality, and report dissatisfaction with their \ncare.6,9\nInitiatives such as Choosing Wisely encourage \nconsideration of healthcare resources in clinical \ndecision making. 10 There is, however, a paucity \nof evidence on cost effectiveness to guide these \ndecisions.11\nSurgery to diagnose and treat presumed  \nendometriosis lesions is often seen as the mainstay \nof management for PPP. Such surgery is widely \nanticipated to reduce acute healthcare use—\neither by removing the “pain generator” or, in the \ncase of a negative laparoscopy, providing reassurance \nand allowing engagement with persistent pain \nservices. This hypothesis, however, has not been \nproven, with some evidence that healthcare costs \nincrease following surgical intervention.12,13\nThis study aimed to explore the change in use \nof acute hospital services by women with PPP \nin the year prior to and following a laparoscopy \nintended to treat their pain.\nPopulation\nThe Christchurch Women’s Hospital (CWH) \nprovides services to a population of 288,000 \nfemales within north and central Canterbury, \n\nNew Zealand Medical Journal \nTe ara tika o te hauora hapori\n2024 Mar 8; 137(1591). ISSN 1175-8716\nhttps://www.nzmj.org.nz/ ©PMA \narticle\n50\nNew Zealand. This includes 134,000 women in \nthe reproductive age group (15–49) who are most \ncommonly affected by pelvic pain. New Zealand \ndata indicate a PPP prevalence of 25%; therefore, \napproximately 33,000 women live with PPP in this \nregion.14\nAs the COVID-19 pandemic has had substantial \ninfluence on surgical waiting lists since 2020, \nthe calendar year 2019 was selected to provide a  \nconvenience sample.\nMethods\nElective operation booking records were \nobtained from the CWH surgical waiting list office \nfor all planned surgical procedures between 1  \nJanuary and 31 December 2019. Procedures listed \nas laparoscopy for the investigation or treatment \nof PPP without abnormality on pre-operative \nimaging were identified. \nA hand search of the electronic patient records \nwas undertaken for each individual identified.  \nVariables collected included: indication for proce-\ndure; surgical findings and intervention including  \nhistopathology; post-operative complications \nrequiring hospital treatment; and ED visits for PPP \nin the 12 months prior to and following surgery.\nA Chi-squared test of association was  \nperformed using MedCalc Software (MedCalc \nSoftware, Ostend, Belgium) to determine whether \nthere was a difference in ED attendances. A \np-value of 0.05 was considered significant.\nOn application to Health and Disability Ethics \nCommittee, it was deemed that as an audit this \nstudy was out of scope for needing review.\nResults\nTwo hundred and three elective laparoscopies \nwere performed for the investigation or treat -\nment of pelvic pain in 2019. Eight were removed \nfrom data analysis, leaving a dataset of 195.  \nReasons for exclusion were: the procedures were \npart of a planned staged operation (4), listed  \nindication also included infertility (3), and missing \noperative note (1). \nEndometriosis was visually identified (E+) and \ntreated in 99 cases (51%). The lesions were histo -\nTable 1: Presentation to ED by endometriosis lesion status.\nE+ (n=99) E- (n=96) P-value\nUnplanned admission \nfor post-operative \ncomplications\n12 (12%) 6 (6.3%)  p=.16\nPresented to ED in 1 year \nprior to operation 15 (15%) 15 (16%) p=.93\nPresented to ED in 1 year \npost-operation 13 (13%) 18 (19%) p=.28\nED = emergency department; E+ = endometriosis identified and treated at laparoscopy; E- = no endometriosis identified; X2, \np-value of 0.05 considered significant.\nTable 2: Presentation to ED in the year prior to and following surgery.\nPre-operation year ED \nattendance for PPP\nPost-operation year ED \nattendance for PPP P-value\nE+ 15 (15%) 13 (13%) p=.17\nE- 15 (16%) 18 (19%) p=.57\nWhole cohort 30 (15%) 31 (16%) p=.89\nED = emergency department; PPP = persistent pelvic pain; E+ = endometriosis identified and treated at laparoscopy; E- = no \nendometriosis identified; X2, p-value of 0.05 considered significant.\n\nNew Zealand Medical Journal \nTe ara tika o te hauora hapori\n2024 Mar 8; 137(1591). ISSN 1175-8716\nhttps://www.nzmj.org.nz/ ©PMA \narticle\n51\nlogically confirmed in 86, not confirmed in 5, and \nin 7 cases ablation only was performed with no \nhistology taken. In 96 cases (49% of the cohort), no \nendometriosis was found (E-). \nOne hundred and sixty-four women were  \ndischarged on the day of surgery and 31 women \nrequired an inpatient stay post-operatively (total \n33 bed-nights). Costings provided by the hospital \nestimate a total of NZ$2.3 million for surgery and \npost-surgical stay for this cohort. \nEighteen women suffered surgical complications \nrequiring unscheduled hospital care: 12 who had \nreceived treatment for endometriosis and six who \nhad a normal pelvis at laparoscopy. Complications \nwere all minor and included uncontrolled pain \n(10), wound infection (4), bleeding (3), urinary \nretention (1), and port site endometrioma (1). \nThere was no difference in likelihood of complica-\ntion requiring hospital care by lesion status, X2 (1 \nN=195) = 2.0, p=.16\nThere was no change in number of women \nfrom the study cohort presenting to the ED for \ntheir PPP between the 12 months pre-operatively \n(30 women, 15 E+, 15 E-; totalling 44 visits) and the \n12 months following their surgical intervention \n(31 women, 13E+ and 18E-; totalling 42 visits) X2 (1 \nN=195) = 0.02, p=.89.\nThe proportion of women who attended the \nED for their PPP did not differ by endometriosis \nlesion status at surgery during the pre-operative \nyear X2 (1 N=195)=0.01, p=.93; or post-operative \nyear X2 (1 N=195)=1.2, p=.28.\nDiscussion\nThis study aimed to explore the impact of lapa-\nroscopic surgical intervention on the requirement \nto attend the ED for PPP. The results identified that \nNZ$2.3 million (excluding management of compli-\ncations) invested into elective laparoscopic surgical \nintervention did not reduce this healthcare burden \non the acute hospital services in the following 12 \nmonths. This finding is consistent with a study \nin the United Kingdom, which found that reduced \naccess to surgery for PPP during the pandemic lock-\ndowns did not result in increased ED attendance for \nexacerbations of pain.6 \nEndometriosis was identified in 51% of the women, \nwhich is concordant with published literature that \nstates endometriosis lesions are found in 40–60% of \nthose with PPP.15 A growing volume of evidence \nsupports that, for women with PPP, the presence \nof endometriosis lesions does not predict the \namount of pain or suffering experienced. 16,17 In \nthis study, the presence of lesions did not predict \nlikelihood of attending ED for PPP either pre- or \npost-operatively. This is consistent with a British \nstudy, which found that half of women presenting \nto the ED with a flare-up of PPP have a diagnosis \nof endometriosis.6 \nAs need for ED attendance for PPP in the year \npre-operatively was independent of lesion status \nit is perhaps unsurprising that surgical removal \nof these lesions did not alter this in the subse -\nquent year for the E+ cohort. The evidence base  \nsupporting surgical management of PPP or \npain attributed to endometriosis is limited, and  \ntypically utilises reduction in pain intensity scores \nas outcomes.18,19 Pain by definition has both sensory \nand emotional components not captured in such \nunidimensional outcome measures. Change in \npain intensity alone has been shown to be a poor \npredictor of future disability and quality of life in \npersistent pain conditions.20\nThe impact of pain on functioning and the \ndecision to attend acute services is, however,  \npredicted by psychosocial factors. Those with \nhigh levels of symptom-related anxiety and worry \nare more likely to attend healthcare.21 \nAn audit of attendees to the CWH gynaecology \nclinic with pelvic pain found a strikingly high \nlevel of catastrophic worry about pain and other \npsychosocial yellow flags. 22 Surgical intervention \nis unlikely to improve these factors. There is, how-\never, evidence that multidisciplinary (MDT) pain  \nclinics where interventions address such psycho -\nsocial domains improve quality of life and reduce \nhealthcare costs by over 90% for those living with \nmusculoskeletal pain.23 Specialist MDT interventions \nfor women living with PPP have shown comparable \noutcomes across a range of domains including \nreduction in pain-related worry,24–26 and have also \nbeen shown to reduce subsequent attendances \nat the ED. 25,27,28 Currently, however, there is very \nlimited access to such MDT pain services in New \nZealand.29\nLimitations \nThis retrospective study has limitations. It was \nnot possible to establish if there was any change in \nattendance at non-hospital healthcare including  \ncommunity or private sector services, or to \nexplore the decision making behind the ED atten-\ndances. The data also lack detail on differences \nbetween ED attenders and non-attenders, aside \nfrom endometriosis lesion status. As patient-  \nreported outcome or experience measures are \n\nNew Zealand Medical Journal \nTe ara tika o te hauora hapori\n2024 Mar 8; 137(1591). ISSN 1175-8716\nhttps://www.nzmj.org.nz/ ©PMA \narticle\n52\nnot obtained following surgery at CWH it was not  \npossible to determine if there were any changes in \npain experience or other outcome measures such \nas quality of life. \nThe follow-up period of this study includes \nMarch–May 2020 when New Zealand was under \nCOVID-19 “lockdown” restrictions. It is possible \nthat this event influenced decision making behind \nED attendances during this time. \nConclusions and future directions\nWhile the data have limitations, this study adds \nfurther information on the costs and implications \nof current healthcare for PPP. Further prospec -\ntive research is required to explore the efficacy \nand cost effectiveness of current management \napproaches, including systematic collection \nof patient-reported outcome measures across \na number of domains including quality of life \nmeasures. Such information would allow individ-\nuals and funders to make informed treatment decisions, \nand also provide baseline data to compare with \nalternative models of care.\nA move from the current high-cost biomedical- \nfocussed model of care to a wider socio-  \npsycho-biomedical approach via MDT services \ncarries potential for benefits to both those living \nwith PPP and the health services that provide \nthem with care.\n\nNew Zealand Medical Journal \nTe ara tika o te hauora hapori\n2024 Mar 8; 137(1591). ISSN 1175-8716\nhttps://www.nzmj.org.nz/ ©PMA \narticle\n53\ncompeting interests\nI received no funding for this work and have no conflicts \nof interest to declare.\nacknowledgements\nI would like to thank Dr Isabelle Lewis for her assistance \nwith the data collection.\ncorresponding author information\nKaren Joseph: Gynaecologist & Specialist Pain \nMedicine Physician, Christchurch Women’s Hospital, \nChristchurch, New Zealand.  \nE: Karen.joseph@cdhb.health.nz\nurl\nhttps://www.nzmj.org.nz/journal/vol-137-no-1591/\nemergency-department-attendances-for-persistent-\npelvic-pain-are-not-reduced-following-laparoscopic-\nsurgery-for-women-with-or-without-endometriosis\nreferences\n1. Engeler DB, Bananowski AP , Berghmans B, \net al. EAU Guidelines on Chronic Pelvic Pain \n[Internet]. European Association of Urology; \n2019 [cited 2023 Nov 17]. 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