{"paper_id":"5b5fb399-6884-4083-82a4-bd9781b4858e","body_text":"Gynecol Surg (2004) 1:67–68\nDOI 10.1007/s10397-004-0023-2\nEDITORIAL\nJeremy T. Wright · David B. Redwine\nTreatment of endometriosis—a special skills module only?\nPublished online: 23 March 2004\n/C23 Springer-Verlag Berlin / Heidelberg 2004\nEndometriosis probably affects 6% of the UK female pop-\nulation [1]. It can be identified on over 240,000 websites\nand appears in over 10,000 articles on a Medline search.\nDespite this, its aetiology remains uncertain, its pathology\ndisputed [2, 3] and its treatment poor. Most medical\ntreatments are based on ovulation suppression and induc-\ning amenorrhoea. The treatment regimens are usually of\nshort duration and have a high drop-out rate because of\nintolerable side effects.\nThe recurrence rate of symptoms is high, particularly\nof chronic pain and dyspareunia [4]. This in itself leads to\nsignificant changes in quality of life scores, which do not\nseem to improve despite some relief of symptoms as\nmeasured by structured questionnaires [5]. There is some\nevidence to suggest that the greater the extent of the\ndisease, the more symptomatic women are, although\nequally there are reports of patients who are severely\nsymptomatic despite appearing to have laparoscopically\ntrivial disease [4].\nAn appalling statistic collected by the National Endo-\nmetriosis Society is the length of time from the first\nsymptom to diagnosis—15 years. An invariable finding in\npatients with severe endometriosis is that symptoms start\nshortly after the menarche, probably when ovulation is\nestablished, and the symptoms are ignored or treated\nmedically without a diagnosis for many years. Nodular\ninfiltrating endometriosis can in fact be clinically diag-\nnosed with some certainty by palpation of the utero-sacral\nligaments and Pouch of Douglas and the posterior cul de\nsac, which is not something that is routinely undertaken\nby gynaecologists, who may be more concerned with\nadnexal tenderness or uterine enlargement [6]. Reluctance\nto be examined because of pain may be interpreted as\nevidence of psychosexual problems and a referral made\nfor abdominal ultrasound scanning, which will almost\ninevitably be negative, further delaying the diagnosis. By\nand large, imaging techniques are unhelpful in the di-\nagnosis in endometriosis except in the case of ovarian\nendometriomas. The finding of ovarian fixity and tender-\nness on vaginal scan may raise suspicion of endometri-\nosis, but these findings may be apparent simply by\nconducting an accurate pelvic examination.\nEven if a laparoscopy is eventually carried out, this\nmay well be undertaken by an unsupervised gynaecologist\nin training, with inadequate instrumentation and a poorly\npositioned patient. Disease that is obvious at subsequent\nlaparoscopy is thus missed, and the woman may be\nwrongly labelled as having unexplained pain, psychosex-\nual problems or as a victim of child abuse. While accurate\nvisual inspection of the peritoneal surfaces is important,\nthe invasiveness of the disease will not always be initially\napparent [7]. What appears to be a small superficial lesion\ncan frequently be the head of a severe nodular or in-\nfiltrating area of endometriosis that can remain undetect-\ned beneath the surface. Laparoscopy should therefore\ninclude careful palpation of any suspect lesion with a\nblunt probe to check for possible infiltration or nodularity.\nIt is unfortunately rare, but should be routine, for any\nlesion to be confirmed by excision and histological ex-\namination. The diagnosis of endometriosis is all too\nfrequently made, if at all, by visual inspection only.\nHistologic confirmation of endometriosis is rarely\ndone at surgery because of concerns about potential\nmorbidity, but a firm diagnosis is always helpful. This is\nvital in patients with recurrent symptoms following\noperative treatment, as it may be difficult to distinguish\ncarbonisation following some ablative techniques from\npigmented lesions of endometriosis. An error in diagnosis\nmay lead to patients receiving further medical therapy in\nthe absence of disease.\nSurgical treatment remains predominantly laparoscop-\nic with a myriad of energy sources being recommended\non the basis of very little hard evidence or common sense.\nExcision of disease is uncommonly performed, although\nJ. T. Wright ( ))\nSt Peter’s Hospital,\nGuildford Road,\nChertsey, KT16 OPZ, UK\ne-mail: jwrighta@cix.co.uk\nTel.: +44-1483-715699\nD. B. Redwine\n2190 NE Professional Ct, Bend, OR 97701, USA\n\nit is the only technique that provides histologic confir-\nmation and that can treat all superficial or deep disease\nanywhere in the body. For the relatively small proportion\nof women with infiltrating nodular disease of the recto-\nvaginal septum, the muscularis of the rectum and the\nutero-sacral ligaments, treatment options are more haz-\nardous and the treatment results are worse because very\nfew gynaecologists have the expertise to undertake the\nradical laparoscopic surgery required to dissect the\nendometriotic tissue away from the great vessels and\nureter on the sidewall and to enter the rectovaginal sep-\ntum.\nThe possibility of a rectal perforation or a minor\nresection of the anterior rectal wall is sufficient to make\nmany surgeons unwilling to undertake this surgery,\ndespite a simple primary repair being entirely adequate.\nA colorectal surgeon may be capable of performing an\nanterior resection although they have little understanding\nof the disease or of modern treatment options. There is\nthus an inevitability that they will advise surgery through\na midline incision, often with a covering ileostomy and\nremoval of much larger portions of the bowel than is\nnecessary [8]. This is despite the existence of good case\nseries demonstrating that laparoscopically assisted seg-\nmental resection or anterior wall resection produces good\nresults with very low morbidity [9]. In some patients, it is\npossible to remove endometriotic disease from the bowel\nwall without rupturing the mucosa and with a simple\nseromuscular repair. A diverting ileostomy or colostomy\nis never necessary for treating colorectal endometriosis\nand would represent a significant departure from the\nstandard of care for this disease. Although the patients are\nyoung and the initial operative morbidity low, the use of a\nmidline scar and ileostomy is cosmetically objectionable\nto most women who become aware of simpler minimally\ninvasive forms of treatment and condemns the patient to\ntwo unnecessary major surgical procedures: the initial\ndiversion procedure and the follow-up procedure to\nreverse it. Adhesions resulting from unnecessary laparot-\nomy can make subsequent surgery more hazardous and\ncould compromise fertility and increase the hazard of egg\ncollection in assisted reproduction techniques.\nIt can thus be seen that endometriosis is one of the\nmost common human diseases, more prevalent even than\nconditions such as breast cancer, cervical cancer, sexually\ntransmitted diseases and diabetes. It is poorly managed,\nand there is an overwhelming need to address this.\nPlanned and radical excisional therapy with a view to\nexcising all the identified lesions will cure 50% of\npatients and lead to good long-term symptom relief for up\nto 75% of patients with severe lesions and appropriate\nsurgical management [6, 7]. However, this treatment\nshould be carried out by appropriately trained surgeons\nand subject to scrupulous audit, neither of which exists\noutside of a very few specialist units.\nThese surgical training needs should be addressed with\nsome urgency, with attention directed toward all the\nspecialties—gynaecology, general surgery and urology—\ninvolved in the multi-specialty approach that is common-\nly necessary in the surgical treatment of this disease.\nEndometriosis as a disease has an abysmally low\nprofile in health care circles despite the obvious morbid-\nity, and it is time that it was much better placed on the\nagenda of women’s health care needs. Women should be\nable to received skilled advice and help with appropriate\nsupport to help them deal with this debilitating condition.\nThe need for specialist centres dealing with endometriosis\nis every bit as real and perhaps more pressing than cancer\nservices, since the morbidity of endometriosis lasts much\nlonger than that of cancer, and endometriosis is much\nmore common than cancer.\nThe surgery is specialist, as specialist as that of on-\ncology or gynaecological urology, and deserves to be\nrecognised as such with similar proper training—it is\ninappropriate to regard it as a special skills module only,\nas is currently planned by the RCOG.\nThe BSGE and the ESGE are realising that laparo-\nscopic surgery requires special training, and there is\nfinally the possibility of developing proper training on a\nEurope-wide basis. This, together with an appropriate\naudit of results, may be the beginning of the recognition\nof this type of surgery as a speciality in its own right, as it\nrichly deserves to be.\nReferences\n1. Higgs H, Noronha F, Ramos Dias JL (1995) Intestinal endo-\nmetriosis (Portuguese). Acta Med Port 8:635–638\n2. Nisolle M, Donnez J. Peritoneal endometriosis, ovarian endo-\nmetriosis and adenomyotic nodules of the rectovaginal septum\nare three different entities (see comments). Fertil Steril 68:585–\n596\n3. Redwine DB (1987) Mulleriosis instead of endometriosis\n(letter). Am J Obstet Gynecol 156:761\n4. Redwine DB (1986) Endometriosis. JAMA 256:1296\n5. Garry R, Clayton R, Hawe J (2000) The effect of endometriosis\nand its radical laparoscopic excision on quality of life indica-\ntors. BJOG (Int J Obstetr Gynaecol) 107:44–54\n6. Redwine DB, Wright JT (2001) Laparoscopic treatment of\ncomplete obliteration of the cul-de-sac associated with endo-\nmetriosis: long-term follow-up of en bloc resection. Fertil Steril\n76:358–365\n7. Wright JT (2000) The diagnosis and management of infiltrating\nnodular recto-vaginal endometriosis. Curr Opin Obstet Gynecol\n12:283–287\n8. Redwine DB (1990) The visual appearance of endometriosis\nand its impact on our concepts of disease. Prog Clin Biol Res\n323:393–412\n9. Weed JC, Ray JE (1987) Endometriosis of the bowel. Obstet\nGynecol 69:727–730\n68","source_license":"CC0","license_restricted":false}