{"paper_id":"52394349-4fd3-4946-bdcc-e6ec5621fcc0","body_text":"PERSPECTIVE\n“Centers of excellence in endometriosis surgery ” or “centers\nof excellence in endometriosis ”\nPhilippe R. Koninckx & Anastasia Ussia\nReceived: 7 December 2009 / Accepted: 17 December 2009 / Published online: 4 February 2010\n# Springer-V erlag 2010\nAbstract Centers of excellent endometriosis surgery could\nimprove the care of women with endometriosis, especially\nif combined with control of the quality of the surgery\nperformed, e.g., through systematic taping of entire inter-\nventions. Centers of excellence in endometriosis without\nemphasis on providing excellent surgery seem of little\nvalue and could do more harm than good.\nKeywords Endometriosis . Center of excellence . Surgery .\nDeep endometriosis . Videoregistration . Quality control\nIt is amazing how little progress has been made over the\nlast two decades in understanding the pathophysiology of\nendometriosis and of the associated pain or infertility.\nFundamental questions that existed more than 15 years ago\nremain unanswered. First, whether subtle lesions are a\n“natural condition occurring intermittently in most women ”\nor whether we should consider them active and important\nendometriosis lesions continues to be debated [ 1]. Secondly,\nthere still is no explanation why severe lesions develop in\nsome women only. Medical treatment has not made much\nprogress. We have known for more than 30 years that\nendometriotic lesions are hormone responsive, that they\nbecome inactive or less active after menopause, and that they\ncan decidualize during pregnancy. It is, thus, not surprising\nthat during medical therapy with ovarian suppression, or oral\ncontraceptives or progestagen, only therapy endometriotic\nlesions become less inactive; they, however, do not disap-\npear. Medical treatments do not enhance fertility [ 2].\nAlthough widely accepted as a treatment of endometriosis-\nassociated pain, we recently suggested [ 3] that the evidence\nof effectiveness of medical therapy upon endometriosis-\nassociated pain should be considered with caution. Indeed,\nnone of the trials we reviewed fulfilled the randomized\ncontrolled trial (RCT) criteria of sufficient blinding of the\nclinician and/or the patient; full blinding indeed is practically\nimpossible to achieve for hormonal drugs abolishing the\nmenstrual cycle. Moreover, dysmenorrhea disappears by\ndefinition in all women when menstruation is abolished,\nthus, always reducing total pain scores; in addition, the\nabsence of dysmenorrhea will have important carry-over\neffects decreasing the rating of all other pain symptoms.\nFinally, an important placebo effect exists for all pain\nsymptoms; even for very severe deep endometriosis-\nassociated pain [ 3] (women that had 13 to 15/15 on a\nBiberoglu–Behrman scale), an overall 30% placebo effect\nexists. In half of the women, the placebo effect even reduces\npain rating by 80%.\nNew dogmas, such as the delay in diagnosis [4] and centers\nof excellence [ 5] have been introduced. The delay in\ndiagnosis in endometriosis is important and seems well\nestablished. It is questionable, however, whether the political\nuse is not slightly inappropriate [6] since a delay in diagnosis\nprobably is not specific for endometriosis and since the same\nP . R. Koninckx (*)\nKULeuven,\nLeuven, Belgium\ne-mail: PKoninckx@gmail.com\nP . R. Koninckx\nUniversity of Oxford,\nOxford, UK\nP . R. Koninckx\nUniversità Cattolica,\nRome, Italy\nA. Ussia\nGruppo Italo Belga,\nVilla del Rosario,\nRome, Italy\nGynecol Surg (2010) 7:109 –111\nDOI 10.1007/s10397-009-0549-4\n\ndelay can probably be found for all nonlife-threatening\ndiseases causing chronic pain such as, e.g., interstitial cystitis.\nThe delay in diagnosis varies with the expertise and the\neducation of the physician. We indeed only recognize what\nwe know. This has been demonstrated many years ago for the\nlaparoscopic recognition of subtle endometriosis; it also\nexplains the apparently “increasing” incidence of the diagno-\nsis of deep endometriosis in comparison with the period\nbefore 1990 when this was a rare diagnosis. Recognition of a\ndisease also varies with the special interests of the physician\nwhether this is endometriosis or early cancer or anything else.\nThis diagnostic delay of endometriosis obviously causes\nsuffering and impairs a woman ’s quality of life. This,\nhowever, holds true for most other chronic pain syndromes.\nFor endometriosis, it is fortunate that there is no evidence that\nthis delay in diagnosis impairs treatment outcome nor that\nendometriosis becomes worse during this period. Centers of\nexcellence have become “fashionable” in many areas of\nmedicine as infertility and oncology. Centers of excellence in\nendometriosis [5] have been suggested in order to reduce the\ndelay in diagnosis and improve quality of treatment. Many of\nthe arguments used to justify such centers of excellence\nsound—possibly unconsciously—as lobbying for personal\ninterests, while lacking evidence that the suggested goals will\nindeed be achieved. Indeed, it is doubtful whether the\nexistence of centers of excellence will accelerate diagnosis\nsince endometriosis patients normally will be referred after\nthe diagnosis has been made. In contrast with oncology and\ninfertility with a straightforward referral basis, the referral of\nendometriosis patients is much less clear since the pain\nsymptoms of endometriosis are much less specific. To\naccelerate diagnosis centers for chronic pelvic pain might be\nmore useful than centers of excellence in endometriosis. In\naddition, whether centers of excellence improve treatment\noutcome is not that obvious. Infertility diagnosis and\ntreatment have over the last decades largely been centralized\nin in vitro fertilization (IVF) centers at least partially as a\nconsequence either of restrictive regulation of the number of\nIVF centers or as a consequence of organizational and\nindustrial imperatives stimulating larger units. Simultaneous-\nly, we witnessed a decrease of the focus on fertility surgery\nand possibly a decrease in its quality [7]. It is unclear whether\nthe emphasis on IVF while often disregarding surgery [8]h a s\nbeen an advantage for infertility patients.\nIf we want to improve the care of women with endome-\ntriosis, we should decrease the diagnostic delay and improve\ntreatment. In order to decrease the delay in diagnosis of\nendometriosis in women with pelvic pain, we need centers (of\nexcellence) for chronic pelvic pain. Since medical treatment\ntoday only reduces pain while never curing the disease,\nsurgical treatment of endometriosis remains the first and most\nimportant treatment. The surgical treatment of severe endo-\nmetriosis has been proven to be so effective that randomized\ncontrolled trials comparing surgery with expectant manage-\nment for larger cystic ovarian endometriosis and for deep\nendometriosis would be considered unethical in women with\nsevere pain. For typical superficial lesions, RCT ’s have\nproven efficacy [9]. Since, in addition, severe endometriosis\nsurgery has been recognized as requiring skill and expertise,\nit might be preferable to have centers of excellence in\nendometriosis surgery or centers of excellent endometriosis\nsurgery. Those reporting on surgery, furthermore, published\nlow recurrence rates of less than 10% and less than 5% for\ncystic and deep endometriosis.\nIdeally, endometriosis surgery should combine the diagnos-\ntic laparoscopy with surgery if required and should be\nperformed by a surgeon trained not only in the recognition of\nendometriosis but also in other causes of pelvic pain.\nMoreover, those performing endometriosis surgery should\nhave the expertise and the technical skills to perform the more\nadvanced surgical interventions when necessary. Centers of\nexcellence in endometriosis surgery could be a major step\nforward in achieving this. Today, unfortunately, women often\nneed a second intervention since the surgery could not be\nperformed during the diagnostic laparoscopy. This, however, is\nconsidered a minor problem which is difficult to solve. What is\nworse is incomplete surgery since it seems —although never\nformally proven and unethical to prove—that the first surgery\nis the most important one and that inadequate or incomplete\nsurgery will make subsequent surgery more difficult impairing\noutcome. Too often women still undergo a hysterectomy\nleaving the deep endometriosis nodule untouched. Bowel\nresections for deep endometriosis are performed liberally\nnotwithstanding frequent and serious long-term consequences\nof low rectum resections [ 10]. Some of these bowel\nresections are even performed for little endometriosis outside\nthe bowel and occasionally in women without endometriosis\nas demonstrated later by pathology. Centers of excellence in\nendometriosis surgery might help to raise the standard of\ncare. Since, beside the circumstances, the most important\nvariable in the outcome of surgery is the surgeon, we\nstrongly suggest that some kind of quality control of surgery\nbe implemented. This can be done by a regular audit of the\nresults and complications and even better by systematic\ntaping of entire interventions [ 11]. To become recognized as\na center of excellence in endometriosis surgery, we,\ntherefore, strongly suggest that a strict quality control,\npreferably by systematic taping, should become a key\ncriterion.\nIn conclusion, centers of excellence in endometriosis\nsurgery could improve the care of women with endometriosis,\nespecially if combined with control of the quality of the\nsurgery performed, e.g., through systematic taping of entire\ninterventions. Centers of excellence in endometriosis without\nemphasis on providing excellent surgery seem of little value\nand could do more harm than good [ 5].\n110 Gynecol Surg (2010) 7:109 –111\n\nReferences\n1. Koninckx PR (1994) Is mild endometriosis a condition occurring\nintermittently in all women? Hum Reprod 9(12):2202 –2205\n2. Hughes E, Fedorkow D, Collins J, V andekerckhove P (2000)\nOvulation suppression for endometriosis. Cochrane Database Syst\nRev 2:CD000155\n3. Koninckx PR, Craessaerts M, Timmerman D, Cornillie F,\nKennedy S (2008) Anti-TNF- alpha treatment for deep\nendometriosis-associated pain: a randomized placebo-controlled\ntrial. Hum Reprod 23(9):2017 –2023\n4. Stratton P (2006) The tangled web of reasons for the delay in\ndiagnosis of endometriosis in women with chronic pelvic pain:\nwill the suffering end? Fertil Steril 86(5):1302 –1304\n5. D'Hooghe T, Hummelshoj L (2006) Multi-disciplinary centres/\nnetworks of excellence for endometriosis management and\nresearch: a proposal. Hum Reprod 21(11):2743 –2748\n6. Bianconi L, Hummelshoj L, Coccia ME, Vigano P , Vittori G, V eit\nJ et al (2007) Recognizing endometriosis as a social disease: the\nEuropean Union-encouraged Italian Senate approach. Fertil Steril\n88(5):1285–1287\n7. Gomel V , Wang I (1994) Laparoscopic surgery for infertility\ntherapy. Curr Opin Obstet Gynecol 6(2):141 –148\n8. Feinberg EC, Levens ED, DeCherney AH (2008) Infertility surgery\nis dead: only the obituary remains? Fertil Steril 89(1):232–236\n9. Sutton CJ, Ewen SP , Whitelaw N, Haines P (1994) Prospective,\nrandomized, double-blind, controlled trial of laser laparoscopy in\nthe treatment of pelvic pain associated with minimal, mild, and\nmoderate endometriosis. Fertil Steril 62(4):696 –700\n10. Ret Davalos ML, De CC, D'Hoore A, De DB, Koninckx PR\n(2007) Outcome after rectum or sigmoid resection: a review for\ngynecologists. J Minim Invasive Gynecol 14(1):33 –38\n11. Koninckx PR (2008) Videoregistration of surgery should be\nused as a quality control. J Minim Invasive Gynecol 15(2):248 –\n253\nGynecol Surg (2010) 7:109 –111 111","source_license":"CC0","license_restricted":false}