{"paper_id":"7314b538-fb1a-49e6-968c-a0a34ab0d6c1","body_text":"ORIGINAL ARTICLE\nTeenagers, adolescents, endometriosis and recurrence:\na retrospective analysis of recurrence following primary\noperative laparoscopy\nEmmanuel Kalu & William McAuley &\nRobert Richardson\nReceived: 3 January 2008 / Accepted: 7 February 2008 / Published online: 21 March 2008\n# Springer-V erlag 2008\nAbstract In this paper, we aim to describe the clinical\nfeatures and treatment outcome following the laparoscopic\ntreatment of endometriosis in teenagers and adolescents.\nThis is a retrospective review of girls aged 21 and below\nwho underwent operative laparoscopy for endometriosis.\nWe identified two groups: (1) the EMA T group, being those\nwho underwent their primary laparoscopic surgery under\nthe Endometriosis and Minimal Access Therapy team\n(EMA T), and (2) the non-EMA T group, consisting of those\nreferred to the EMA T team with recurrent symptoms\nfollowing primary operative laparoscopy by other gynaecol-\nogists. Symptom recurrence and the need for re-operation\nwas compared between the two groups. Twenty-eight girls,\nage range 15 –21 years, were identified. All had pelvic pain\nunresponsive to the pill and non-steroidal anti-inflammatory\ndrugs (NSAIDs). Most disease was atypical, with the\nuterosacral ligaments and ovarian fossae being the most\ncommon sites. The re-operation rate per surgical team at\n24 months was 14.2% for the EMA T group vs. 42.8% for the\nnon-EMA T group. All recurrences in the non-EMA T group\ncoincided with the location of primary disease. Disease\nrecurrence occurred most commonly in the uterosacral\nligaments. Endometriosis in teenagers is mainly atypical\nand, in our series, commonly affects the uterosacral\nligaments. Disease in this location is deeply infiltrating and\nis usually not amenable to electrocoagulation. We advocate\ndisease resection to minimise recurrence.\nKeywords Teenagers . Adolescents . Endometriosis .\nOperative laparoscopy . Recurrence\nIntroduction\nEndometriosis (the presenc e of functional endometrial\nglands and stroma outside the uterine cavity) can strike at\nany age. The true incidence of this disease among teenagers\nand adolescents remains unknown. It has been identified in\nover 50% of teenagers with chronic pelvic pain and\ndyspareunia [ 1, 2] and in about 70% of teenagers with\npelvic pain not responding to non-steroidal anti-inflamma-\ntory drugs (NSAIDs) and oral contraceptive pills [ 3].\nSevere dysmenorrhoea and pelvic pain, two major symp-\ntoms of endometriosis, remain the single most frequent\ncauses of absenteeism from school [ 4] and account for the\nloss of over 140 million work hours yearly [ 5]. The\ntreatment of this often chronic and debilitating disease\nwhen found is, therefore, of prime importance in young\npeople. Although various authors have characterised endo-\nmetriosis in teenagers and adolescents [ 1–3], information\non treatment outcome in this age group is limited. In this\nretrospective cohort study, we describe the clinical features\nand treatment outcome of teenagers and adolescents who\nunderwent the laparoscopic treatment of endometriosis at\nthe Chelsea and Westminster Hospital, London.\nMethods\nTeenagers and adolescents, defined as those patients aged\n21 years or less at the time of primary surgery, who had had\noperative laparoscopy were identified from the hospital\ndatabase. Patients were divided into two groups: (1) the\nGynecol Surg (2008) 5:209 –212\nDOI 10.1007/s10397-008-0379-9\nE. Kalu ( *) : W. McAuley : R. Richardson\nGynaecology, Chelsea and Westminster Hospital,\n369 Fulham Road,\nLondon SW10 9NH, UK\ne-mail: ekalu@doctors.org.uk\n\nEMA T group, being those who underwent their primary\nlaparoscopic surgery under the (specialist) Endometriosis\nand Minimal Access Therapy team (EMA T), and (2) the\nnon-EMA T group, consisting of those referred to the EMA T\nteam with recurrent symptoms following primary operative\nlaparoscopy by other gynaecologists. Follow up to\n24 months was completed. Treatment outcome was\nassessed on the basis of symptom recurrence and the need\nfor second operative laparoscopy. All of the patients were\nseen in the EMA T clinic following referral by the non-\nEMA T team or as routine follow up after primary surgery\nby the EMA T team, during which, assessment for the need\nfor further surgery was made. The decision for re-operation\nwas based on the presence of persistent symptoms, high\npain score, previous non-response to medical therapy and\npatients’ consent. All second surgeries were performed by\nthe EMA T team. During repeat laparoscopy, the index\ndisease location was compared to the disease location at the\ntime of primary surgery. Disease recurrence, as well as the\nsite of recurrence, was compared between the two groups.\nThe results were analysed using the Statistical Package for\nthe Social Sciences (SPSS, Surrey, UK). With an alpha\nvalue of 0.05, the power of the study (type 2 error) to detect\na significant difference in disease recurrence between the\ntwo groups would be 85.3%.\nResults\nUsing the hospital coding system, we identified 570 women\nwho underwent laparoscopic treatment of endometriosis at\nthe Chelsea and Westminster Hospital, London, between\n2000 and 2005. A total of 4.9% (28/570) were teenagers\nand adolescents, age range 15 –21 years. All had pelvic pain\nunresponsive to the pill and NSAIDs. The nature of the\npelvic pain was cyclical in 78% and non-cyclical in 21% of\nthe cases. Other presenting symptoms and their frequencies\nare shown in Table 1. Fifty percent of the primary\nlaparoscopic procedures (14/28) were performed by the\nEMA T team, and the other half by non-EMAT consultants,\nincluding referrals from secondary care. Disease severity\nwas equally distributed between the two groups. In the non-\nEMA T group, treatment was exclusively by electrocoagu-\nlation/ablation. In contrast, in the EMA T group, treatment\nwas predominantly by lesion resection. The uterosacral\nligaments (USL) and ovarian fossae were the most common\nsites affected (Fig. 1). Atypical endometriosis constituted\nthe most common lesions in this age group (Fig. 2 and\nPicture 1). The re-operation rate at 2 years was 14.2%\n(2/14) for the EMA T group vs. 42.8% (6/14) for the non-\nEMA T group (p=0.023) (Figs. 3 and 4).\nDisease recurrence occurred most commonly in the\nuterosacral ligaments (Fig. 3). All recurrences in the non-\nEMA T group coincided with the location of primary disease.\nDiscussion\nAbout 5% of women who underwent surgery for endome-\ntriosis in the 5-year period were teenagers/adolescents. This\nequates to about five young women per annum, a small but\nsignificant number. The chronic debilitation associated with\nthis disease makes its management in these young people of\nprime importance. Although laparoscopy has been shown\nto be safe, minimally invasive and enables a definitive\ndiagnosis and treatment of endometriosis in adolescents [ 6],\nthe decision to subject these young people to surgery is\noften delayed and preceded by a prolonged period of\nunsuccessful symptomatic treatment. Surgical treatment,\nTable 1 Presenting symptoms in teenagers and adolescents with\nendometriosis\nSymptoms Total number Percentage a\nPelvic pain 28/28 100%\n-Cyclical 22/28 78.57%\n-Non-cyclical 6/28 21.42%\nDyspareunia\nb 17/23 73.39%\nIrregular periods 13/28 46.45%\nV aginal discharge 3/28 10.71%\nBowel symptoms 3/28 10.71%\nUrinary symptoms 1/28 3.57%\na The percentages do not add up to 100% because the patients often\nhad more than one symptom\nb Five teenagers were not sexually active\n0\n0.1\n0.2\n0.3\n0.4\n0.5\n0.6\n0.7\nuterosacral ligament\nPOD\nOvarian fossaovari\nan surf\nace\nBroad lig\nEndometrioma\nUterovesical pouch\nFa\nllopia\nn tube\nColumn 1\nFig. 1 Disease location\n210 Gynecol Surg (2008) 5:209 –212\n\nhowever, is associated with recurrence, and this seems to\ndepend on who operates.\nIn our series, girls who were operated by generalist\ngynaecologists had a three-fold increase in symptom recur-\nrence and the need for re-operation, compared to their counter-\nparts, who were operated by an endometriosis specialist team.\nThis difference in treatment outcome may be related to the\nmode of surgical treatment. While the treatment was\nexclusively by electrocoagulation/ablation in the non-EMA T\ngroup, in the EMA T group, treatment was predominantly by\nlesion resection. This is important, since the most common\nlocation of endometriosis in this series were the uterosacral\nligaments. Disease in this location is usually deeply infiltrat-\ning and not amenable to electrocoagulation [ 7]. The high\nrecurrence in the non-EMA T group may, therefore, be related\nto the incomplete ablation of deeply infiltrating disease. The\nfact that there was always recurrence in the areas of previous\nablation in the non-EMA T group cases also points to in-\nsufficient primary treatment in this group.\nFollowing disease resection by the specialist EMA T\nteam, symptom recurrence after 2 years was 14%. This is\nsimilar to other published series following the resection of\nteenage endometriosis by a specialist team [ 8, 9]. In their\nseries, Stavroulis et al. [ 8] reported that eight of 11\nteenagers diagnosed with endometriosis were completely\npain-free or greatly improved and a further two reported\npartial improvement following laparoscopic resection.\nLike other researchers [ 2, 10], we found red endometri-\nosis with neovascularisation to be the most frequent type of\nlesion in these young women. Red lesions include at least\nthree morphologic forms, red polyps, red vesicles and red\nflame-like lesions [ 11], and they are thought to be more\nbiologically active than their brown/black counterparts and\nmore strongly associated with dysmenorrhoea [ 12]. The\ntypical blue –black (powder burn) implants common in\nadult women were present in only 18% of our cases. Other\nsubtle appearances of endometriosis that may easily go\nunrecognised during surgery in young women include\nvesicular lesions and lesions in peritoneal pockets. The\nrole that atypical disease plays in the recurrence/persistence\nof symptoms in this age group remains uncertain. It is\npossible that failure to recognise and treat atypical disease\nmay also contribute to the non-resolution of symptoms.\nPicture 1 Red endometriosis in the uterosacral ligament\n0\n5\n10\n15\n20\n25\n30\nuterosacral\nligs\novarian fossa pelvic side\nwall\nPOD\n%\nColumn 1\nFig. 3 Site of disease recurrence\n0.00%\n10.00%\n20.00%\n30.00%\n40.00%\n50.00%\n60.00%\n70.00%\n80.00%\n90.00%\nRed\nNeovascularisation\nVesicu\nlar\nBlu\ne-black\nRectov\nag\ninal nodule\nBrow\nn\nAll\nen\n Masters\n Pou\nch\nFig. 2 Types of lesions found\nin teenagers/adolescents\nGynecol Surg (2008) 5:209 –212 211\n\nHowever, because there was a 100% recurrence in the areas\nof previous ablation in our series, the persistence of\nsymptoms in the non-EMA T group is more likely due to\nincomplete treatment by ablation.\nConclusion\nEndometriosis in teenagers is mainly atypical, and, in our\nseries, commonly affects the uterosacral ligaments. As\ndisease in this area is usually not amenable to electro-\ncoagulation/ablation, we recommend disease resection to\nminimise recurrence. Since resection may impose greater\nsurgical risks, we suggest that primary surgery in these\npatients should be within a centre where disease resection\ncan be performed.\nReferences\n1. Goldstein DP , deCholnoky C, Emans SJ, Leventhal JM (1980)\nLaparoscopy in the diagnosis and management of pelvic pain in\nadolescents. J Reprod Med 24:251 –256\n2. Reese KA, Reddy S, Rock JA (1996) Endometriosis in an\nadolescent population: the Emory experience. J Pediatr Adolesc\nGynecol 9:125 –128\n3. Laufer MR, Goltein L, Bush M, Cramer DW, Emans SJ (1997)\nPrevalence of endometriosis in adolescent girls with chronic\npelvic pain not responding to conventional therapy. J Pediatr\nAdolesc Gynecol 10:199 –202\n4. Lamb EJ (1981) Clinical features of primary dysmenorrhea. In:\nDawood MY (ed) Dysmenorrhea. Williams & Wilkins, Baltimore, pp\n107–129\n5. Ylikorkala O, Dawood MY (1978) New concepts in dysmenor-\nrhea. Am J Obstet Gynecol 130:833 –847\n6. Wolfman W, Kreutner K (1984) Laparoscopy in children and\nadolescents. J Adolesc Health Care 5:261 –265\n7. Hasson HM (1979) Electrocoagulation of pelvic endometriotic\nlesions with laparoscopic control. Am J Obstet Gynecol 135:115–121\n8. Stavroulis AI, Saridogan E, Creighton SM, Cutner AS (2006)\nLaparoscopic treatment of endometriosis in teenagers. Eur J\nObstet Gynecol Reprod Biol 125:248 –250\n9. Marsh EE, Laufer MR (2005) Endometriosis in premenarcheal\ngirls who do not have an associated obstructive anomaly. Fertil\nSteril 83:758 –760\n10. Laufer MR, Sanfilippo J, Rose G (2003) Adolescent endometri-\nosis: diagnosis and treatment approaches. J Pediatr Adolesc\nGynecol 1693(3 Suppl):S3 –S11\n11. Jensen RPS, Russell P (1986) Nonpigmented endometriosis:\nclinical, laparoscopic, and pathologic definition. Am J Obstet\nGynecol 155:1154–1159\n12. V ernon MW, Beard JS, Graves K, Wilson EA (1986) Classification\nof endometriotic implants by morphologic appearance and capacity\nto synthesize prostaglandin F. Fertil Steril 46:801 –806\n0\n2\n4\n6\n8\n10\n12\n14\n0 6 12 18 24 30 36 42 48\nPatients remaining\nsymptom Free\ntime (months)\nEMAT\n(Disease \nResection)\nNon-EMAT\n(Disease \nAblation)\nRecurrence-free interval after primary\nSurgery for endometriosis in young adults graph\nP = 0.023\nAt 24 Months\nFig. 4 Recurrence-free interval after primarysurgery for endometri-\nosis in young adults\n212 Gynecol Surg (2008) 5:209 –212","source_license":"CC0","license_restricted":false}