{"paper_id":"c1b78370-8d39-4b81-bd85-a575298dbc9c","body_text":"Review Article Open Access\nJournal of Surgery \n[Jurnalul de Chirurgie]\nJournal of Surgery [Jurnalul de Chirurgie]\nISSN: 1584-9341\nJ Surgery\nISSN: 1584-9341 JOS, an open access journal \n Volume 11 • Issue 4 • 4\nKeywords: Deep infiltrating endometriosis; DIE; Quality of life; \nQOL; Preoperative evaluation\nBackground\nEndometriosis is a painful and chronic gynecologic disorder, \ncharacterized by the presence of ectopic endometrium outside \nthe endometrial cavity. Under this situation endometrial cells are \nimplanted ectopically, that lead to retrograde menstruation via the \nfallopian tubes into the pelvis\n [1]. Endometriosis affects at least 6.3 \nmillion women and girls predominantly of reproductive age in the \nUnited States, 1 million in Canada, and millions more worldwide. It is \nassociated with pelvic pain and infertility\n [2]. Peritoneal endometriosis, \novarian endometriosis and DIE are the three clinical presentations \nof endometriosis that have been described before\n [3]. Furthermore, \nseveral classifications of DIE have been proposed. In one classification, \nthree different types of DIE are distinguished\n [4]: \n(I) A large lesion in the peritoneal cavity, infiltrating conically with the \ndeeper parts becoming progressively smaller is designated as type-1;\n(II) In type-2, the bowel is being retracted over the lesion, and becomes \ndeeply situated in the rectovaginal septum without infiltrating it;\n(III) Spherically shaped lesions, situated deep in the rectovaginal \nseptum, and are often only visible as a small typical lesion at laparoscopy \nor often not visible at all. In the year 1995, Donnez and Nisolle have \nproposed only two types of DIE, first being caused by the invasion of a \nvery active peritoneal lesion deep in the retroperitoneal space. In cases \nof lateral peritoneal invasion, utero-sacral ligaments can be involved as \nwell as the anterior wall of the recto-sigmoid bowel junction resulting \nin a retraction, adhesions and secondary obliteration of the cul-de-\nsac. A second type is pseudo-DIE where the lesion originates from the \nrectovaginal septum tissue and consists essentially of smooth muscle \nwith active glandular epithelium and scanty stroma\n [5].\nToday it is believed that endometriotic lesions can penetrate deep \neither into the retroperitoneal space or into the walls of the pelvic \norgans\n [6]. However, the mechanism is not clear and little is known \nabout the impact of the different types of surgery in the treatment of \nDIE on complications, pain, patients’ quality of life (QOL), recurrence \nrate and pregnancy rate or fertility. The aim of this review is therefore \nto evaluate the quality of life improvement after the different surgical \nmodalities for management of DIE based on the above-mentioned \nparameters. \nMaterial and Method\nIn this review we have searched The PUBMED (March 2005 \nto July 2015) for relevant articles. Heading terms “deep infiltrating \nendometriosis, quality of life” (n1=33) and “deep infiltrating \nendometriosis” (n2=402) were used. All pertinent articles were \nretrieved without any language restriction. To ensure the relevance of \nthe publications, additional inclusion criteria were applied. We have \nincluded only those studies that contained a clear explanation of the \nsurgical technique, an effectual evaluation of pain and an explicit \ndescription of post-operative QOL. To ensure a complete review of the \npreoperative evaluation of DIE, we have also included some of the most \nrelevant studies regarding this subject, without any restriction. \nSpecific Symptoms of DIE\nDIE exhibits a broad spectrum of clinical manifestations. DIE can \nbe completely asymptomatic, or can become a disorder where quality \nof live is heavily compromised, as DIE is defined by the presence of \nendometrial implants, fibrosis and muscular hyperplasia under the \n*Corresponding author: Margan Mădălin-Marius, Assistant Lecturer, Department \nof Obstetrics and Gynecology, “Victor Babeș” University of Medicine and Pharmacy \nTimișoara, University Clinic of Obstetrics and Gynecology “Bega”, Victor Babeș \nBlvd. No 12, 300226, Timiș oara, Romania, Tel: +40 (0) 726 27 73 54; E-mail:  \nlmarganmm@gmail.com\nReceived November 18, 2014; Accepted December 15, 2015 ; Published \nDecember 20, 2015\nCitation: Simedrea M, Margan MM, Cioroianu I, Pătrașcu R, Mărginean A, et al. \nCQuality of Life Improvement after Surgery for Deep Infiltrating Endometriosis \n(DIE). Journal of Surgery [Jurnalul de chirurgie]. 2015; 11(4): 137-142 DOI: \n10.7438/1584-9341-11-4-4\nCopyright: © 2015 Simedrea M, et al. This is an open-access article distributed \nunder the terms of the Creative Commons Attribution License, which permits \nunrestricted use, distribution, and reproduction in any medium, provided the \noriginal author and source are credited.\nAbstract\nEndometriosis is categorized as one of the chronic benign gynecologic diseases, which causes pelvic pain and \ninfertility, affecting almost 10% of reproductive-age women. Deeply infiltrating endometriosis (DIE) is a specific entity of \nendometriosis, responsible for painful symptoms, which are related to the anatomic location of the lesions. In this paper, \nwe aim to review the current literature regarding the post-surgery quality of life improvement for DIE. Irrespective of \nits low sensitivity and specificity, vaginal examination and evaluation of specific symptoms should be emphasized as a \nbasic diagnostic tool in detecting endometriosis. This will help in planning further DIE related therapeutic interventions. \nOut of several, transvaginal ultrasound (TVUS) has been reported as one of the widely used and excellent tools to \ndiagnose DIE lesions in different locations (rectovaginal septum, retrocervical and paracervical areas, rectum and \nsigmoid and vesical wall).\nQuality of Life Improvement after Surgery for Deep Infiltrating \nEndometriosis (DIE)\nVoicu Simedrea1, Mădălin-Marius Margan2,3, Iris Cioroianu4, Raul Pătrașcu4, Andrei Mărginean5 and Roxana Nicolescu3\n1Premiere Hospital Timișoara, Romania\n2Department of Obstetrics and Gynecology, “Victor Babeș” University of Medicine and Pharmacy, Timișoara, Romania\n3Timişoara County Emergency Clinical Hospital, “Bega” University Clinic of Obstetrics and Gynecology, Timișoara, Romania \n4“Victor Babeș” University of Medicine and Pharmacy, Timișoara, Romania\n5“Dr. Victor Popescu” Emergency Military Clinical Hospital, Timișoara, Romania\n\nJ Surgery\nISSN: 1584-9341 JOS, an open access journal \nSimedrea V, et al.\n138\nVolume 11 • Issue 4 • 4\ndyschezia, gastrointestinal symptoms, and noncyclical pelvic pain and \nthe anatomic locations of deep infiltrating endometriosis. They found \na direct correlation between symptoms and location of DIE, as painful \ndefecation was associated with vagina involvement and dyspareunia \nwith uterosacral ligament localization. Other manifestations such as: \nGI symptomatology and lower urinary tract symptoms were correlated \nwith bowel, respectively with bladder extension. It was also noticed that \nsevere dysmenorrhea was more frequent in patients with adhesions in \nthe Douglas pouch [16]. In a study by Chapron et al., 300 women were \nevaluated in order to assess the type and severity of pain symptoms and \ncorrelate them with intraoperatory findings. Endometrioma associated \nto severe pelvic pain strongly correlates with the presence of DIE, thus \nmaking preoperative extensive evaluation of endometriotic lesions \nmandatory for planning the surgical intraoperative strategy [17]. As \na consequence, it is crucial to conduct additional investigations in \norder to map out DIE lesions accurately before surgery. The best time \nto conduct additional investigation is either during menstruation or \njust before/after the menstruation. Pelvic exam should always be \nassociated with transvaginal ultrasound (TVUS), which is definitely the \nmost important and widely available tool in evaluating endometriosis. \nExisting preliminary results need to be confirmed, but is a common \nview that TVUS should be conducted systematically at first intention \n[18]. Transrectal ultrasonography (TRUS) is one of the most reliable \nand widely accepted methods of diagnosing for infiltration of the bowel \nwall [15,19-22]. Infiltration of the bowel wall is an essential point of \npreoperative investigation as it affects the way the surgery is performed. \nOne must consider following factors while opting for TRUS: (1) pre-\nexistence of rectal bleeding (2) possible bowel infiltration (3) possibilities \nof painful menstrual bowel functional symptoms in the absence of \nrectal bleeding and (4) possibility of a large posterior lesion. Among \nother methods, few clinicians also adopt cystoscopy and ureteroscopy \nin order to determine urinary tract mucosal infiltration, especially when \nbladder endometriosis is suspected [23-25]. This method allows the \nposition of the lesion relative to the ureteral meatuses to be established. \nThis is an important factor to consider especially when deciding on the \nsurgical technique.\nRegarding preoperative staging, the revised American Society \nfor Reproductive Medicine (rASRM) score is the most widely used \nclassification of endometriosis. The Enzian classification, also revised \nin 2011 and mainly used in the German-speaking countries, was \ndeveloped as a supplement to the rASRM score, in order to provide \na morphologically descriptive classification of deeply infiltrating \nendometriosis [26].\nMagnetic resonance imaging (MRI) is another means of \npreoperative evaluation that provides complete and simultaneous \ndescriptions of the anterior and posterior compartments of the pelvis \n[27]. Complete and simultaneous preoperative evaluation is important, \nas DIE lesions are most often located in the posterior compartment of \nthe pelvis\n [10,28]. Posterior compartment of the pelvis is an area that \ntransvaginal ultrasonography does not explore well. One drawback of \nMRI is that it is less sensitive for the diagnosis of bowel infiltration \n[29,30]. \nVirtual modified colonoscopy is a single investigation that \ncan visualize all affected organ systems in the pelvis and abdomen \n(multifocal bowel lesions, urinary tract lesions, reproductive organ \nlesions, and distant organ lesions such as liver involvement). The LSD/\nMURO Scale is a new preoperative classification designed specifically \nfor this method in an attempt to quantify the severity of rectogenital \ndisease and disseminated endometriosis [31]. Further studies are \nessential to establish novel way of diagnosing bowel infiltration and \nto define the respective places of the various additional means of \ninvestigation. If the intestinal infiltration is known or suspected to \nexist, the bowel must be prepared preoperatively.\nperitoneum [7]. It may also involve, in descending order of frequency, \nthe uterosacral ligaments, the rectosigmoid colon, the vagina and the \nbladder. DIE may cause severe dysmenorrhoea. However, pelvic pain \nmay be more common in women with deep, infiltrating implants post-\nsurgery. It is reported that, DIE induced pain is due to compression or \ninfiltration of nerves in the sub-peritoneal pelvic space by the implants\n \n[8]. However, the intensity of pain in woman with DIE correlates well \nwith the depth and volume of infiltration  [9]. DIE induced painful \nsymptoms is very organ specific, being present in precise anatomical \nlocations. However, multifocality is also a major characteristic of DIE \nLesions [9]. DIE induced pain can thus be described as organ and \nlocation specific pain. Rectovaginal endometriosis accounts for 5% \nto 10% of women with DIE\n [9]. It is characterized by the presence of \npalpable endometriotic nodules deep in the connective tissue of the \npelvis. This shows profound fibrosis and fibromuscular hyperplasia [9]. \nSurgical versus Conservative Management\nSurgery is the primary mode of treatment in most of the infiltrating \ndiseases. Surgical treatment is very effective in relieving painful \ndefecation, pelvic pain and dyspareunia  [10]. In principle, deep \nendometriotic lesions should be ignored some time and should not \nbe always treated because of its passive impact (and effect). However, \nintestinal and ureteral foci that cause progressive stenosis constitute \nindisputable reasons for operating. Otherwise, it is not necessary \nto opt for asymptomatic DIE surgery and should not be considered \nmandatory in all cases. In case there is no response to medical therapies \nor there is a symptom, which requires urgent surgical procedure, \nsurgery should be the primary mode of DIE treatment. In addition, \nthe location of the DIE lesions must dictate the choice of operating \ntechnique. Since endometriosis is located primarily on the pelvic \norgans, laparoscopy should be the preferred technique for diagnosis, \nespecially in multifocal cases. It is ideal to obtain consent for surgical \nresection of DIE, if surgery is performed for diagnosis.\nNormally, the mean number of lesions is significantly correlated \nwith the location of the main lesion, as the percentage of isolated DIE \nlesions that is located on a single, varies between 29 and 83% [10]. \nDuring speculum observation, a bluish lesion is observed which is \nnormally located in the upper third corner of posterior vaginal wall. \nThese are normally pathognomonic for DIE diagnosis. Under such \nsituation, a detailed medical investigation in the posterior vaginal fornix \nshould be made for irregular appearance or for a stiff and thickened \narea. During this process, existence of a nodule must be sought during \nthe vaginal touch. Even though, most clinicians sought for nodular \nlesion (a most standard form observed), it is not a must-to-follow rule\n \n[11,12]. It is also true that the outcome of clinical examination varies \nper the physical location of the lesion. However, signs like lateral \ndeviation of the cervix [13] or asymmetry of the uterosacral ligaments \ninstead of a nodule are also evident [14,15]. With a close examination \nwith the speculum that finds lesions evocative of endometriosis, \nthe upper third of the posterior surface of the vagina is infiltrated. \nNevertheless, this proportion is significantly far lower in cases where \nthe bowel or uterosacral ligaments are involved\n [11]. On the same note, \nlesions affecting vagina results in more frequent palpation of a nodule \nor painful infiltration during the vaginal touch\n [11]. So, the surgical \npractice must systematically include a rectal touch.\nPreoperative Evaluation\nPelvic exam still represents an important step in the initial \nevaluation of DIE, as it offers the first perspective of preoperative \nassessment. Studies have demonstrated that results vary depending on \nDIE involvement, having low sensitivity and specificity, especially when \nreferring to multiple localizations: ovaries, bladder, rectum, ureters etc. \nFauconnier et al. in a study on 255 women evaluated the correlation \nbetween specific symptoms such as: dysmenorrhea, dyspareunia, \n\nJ Surgery\nISSN: 1584-9341 JOS, an open access journal \nQuality of Life Improvement after DIE 139\nVolume 11 • Issue 4 • 4\nIn conclusion, TVUS / TRUS provide accurate information about \nthe presence and extent of the lesions. Moreover, TVUS with or without \nprior preparation of the colon, can be alone an accurate non-invasive \nmethod for preoperative detection of deep-infiltrating endometriosis \n(DIE) involving the rectosigmoid. Ultrasound evaluation of DIE lesions \nis very similar to that performed laparoscopically in concordance \nwith Enzian classification. However, involvement of the USL, pelvic \nand vaginal wall is difficult to assess by ultrasound only. MRI proves \nits worth in the correct classification of doubtful cases, in case of \nextrapelvic localization and abdominal adhesions. Both ultrasound and \nMRI are accurate diagnostic methods, with no differences in terms of \ndisease staging. Transvaginal ultrasound is the first choice investigation \nif clinical suspicion is present and for rectovaginal septum evaluation. \nEnzian classification and rASRM score supplement each other in \nterms of morphological description and have common potential for \nclassifying endometriosis. Preoperative staging permits the creation of \na treatment plan and provides an early stage prognosis [26,32-35].\nChoosing the Best Surgical Approach\nThe overall goal behind designing the best surgical approach is \nto achieve complete resection of all symptomatic DIE lesions during \na one-step surgical intervention. To accomplish this, several surgical \nprocedures must be associated. Operative laparoscopy based partial \ncystectomy is a standard method for bladder DIE. For vaginal DIE, \nnumerous authors have demonstrated that operative laparoscopy using \nvarious techniques like electrosurgery, sharp dissection or laser CO\n2; \nexclusively laparoscopic procedure or laparoscopically assisted vaginal \nsurgery is highly efficient. For DIE infiltrating the uterosacral ligaments, \nit has been shown that laparoscopic surgical resection is efficient. \nIn principle, the location of the endometriosis governs the choice of \noperating technique. Despite a huge number of available publications, \nthere is no definitive answer available for a best possible surgical \nprocedure that is recommended for women presenting with DIE. \nPrevious studies show at least two widely used (and accepted) surgical \napproaches that are employed: (1) colorectal resection removing the \nrectal segment affected by the disease, and (2) nodule excision. Nodule \nexcision may be performed by shaving the rectum. Alternatively, \nnodule excision is performed by removing the nodule along with \nthe surrounding rectal wall. Again, the best surgical procedures to \ntreat DIE lesions can be further divided into two concepts of surgery: \nconservative and radical. Conservative surgery is otherwise known as \n“nodulectomy” where intestinal DIE implant is resected. Nodulectomy \nis accomplished by rectal shaving [36-39] or mucosal skinning\n [40]. \nRectal shaving allows an incomplete excision of microscopic implants, \nand lead to cyclic pain or digestive complaints. However, as cyclic \npain may be controlled by post-operative hormonal treatment, they \nshould not lend support to an argument for a more aggressive surgical \napproach. In case of bladder endometriosis, partial cystectomy is the \nsurgical treatment of reference. This operation has been conducted \nby operative laparoscopy as described elsewhere [41,42]. Moreover, \nclinicians use laparoscopic surgical resection in cases of deep \nendometriosis infiltrating the uterosacral ligaments\n [43-47]. In this \ncase, it is necessary to conduct ureterolysis to be able to execute the \nuterosacral ligament (USL) nodule completely without any risk of \nureter injury. Decision on laparoscopic surgery is totally dependent \nupon the nature of USL. A bilateral surgery is conducted if a nodule \naffects both USLs. However, a healthy contralateral ligament should \nnot be resected if the USL lesion is unilateral.\nApproaching an advanced stage of endometriosis disease can be \na real challenge, as it should take into consideration the real extent of \ninfiltration and all possible complications that may appear. Angioni \net al. demonstrated that incomplete surgery of DIE can eventually \nlead to higher rates of pain recurrences and even to repeated surgery \naccompanied by medical therapies [48].\nDetermining Quality of Life Improvement after Surgery \nfor DIE\nQuality of life (QOL) and health-related satisfaction of DIE patients \ncan be assessed with the Medical Outcomes Survey Short Form 36 \n(MOS-SF-36). Available in several languages, MOS-SF-36 is the most \nwidely used generic instrument to evaluate health-related quality of life\n \nand offers a simple tool to help clinicians select and inform patients \nwho might benefit from DIE surgery [49]. Previous study shows \nthat preoperative assessment of QOL with the SF-36 questionnaire \ncan predict the QOL improvement after laparoscopic resection for \nendometriosis\n [50]. It is very important to emphasize patient’s pain \nduring the preoperative examination, which normally has a higher \nimpact on the other components of QOL\n [51]. However, conservative \nsurgeries in young women have a higher rate of pain recurrence  [52]. \nSame study has demonstrated that in the absence of bowel resection in \nwomen with DIE, intestinal endometriosis is the factor most strongly \nassociated with the actuarial recurrence rate [52].\nOne flip side of this questionnaire is that, SF-36 contains 36 items \nand thus places a considerable burden on both patients and investigators \n[53]. To overcome this issue, Ware and colleagues, therefore, decided \nto develop a substantially shorter questionnaire-the SF-12—reducing \nthe number of items from 36 to 12 [54]. Clinicians found that the SF-\n12 summary measures are highly correlated with the SF-36 summary \nmeasures. In addition, SF-12 items explained about maximum \nvariation of the SF-36 summary measures. SF-12 also reproduces eight-\nscale profile with fewer levels than SF-36 scales and yields less precise \nscores, as would be expected for single-item and two-item scales\n [50]. \nHowever, for large group of studies, confidence intervals are largely \ndetermined by sample size and hence these differences are not as \nimportant.\nPrevious studies have evaluated the impact of surgery on quality \nof life using visual analogue scale (VAS)\n [55,56]. From a group of \npatients with endometriosis, a significant negative correlation between \nVAS rating and quality of life has been evaluated by using MOS SF-36 \nquestionnaire\n [57]. In addition, the same group has found a relation \nbetween hyperalgesia to pressure pain threshold measured and the \nimpairment of SF-36 physical function as well as mental health \nparameters. All these interesting facts emphasize the systematic use \nof MOS SF-36 questionnaire as a tool, especially to identify patients \nwho may have a benefit of surgery. On the same note, Abbott et al. \n(2004) have demonstrated a placebo effect of surgery on quality of \nlife in 30% of patients with DIE\n [58]. Using qualitative and semi-\nquantitative evaluations of symptoms, Redwine and Wright (2001) has \nconvincingly demonstrated that women with predominant low back \npain or asthenias are less likely candidates for extensive surgery\n [59]. \nHowever, we observed these data are partly in contrast with a previous \nreport\n [60] with no reduction in medium- or long-term frequency \nand severity of recurrent dysmenorrhea after laparoscopic uterosacral \nligament resection. \nA study published by Mabrouk et.al (2011) on 100 patients who \nunderwent laparoscopic surgery for DIE evaluated quality of life \nthrough the QOL questionnaire, the short form 36 (SF-36), which \nwas completed preoperatively and postoperatively at 6-months. \nLaparoscopic excision of DIE lesions performed either by intestinal \nsegmental resection or by nodule shaving, significantly improved the \ngeneral symptomatology in DIE, with an increase in patient’s general \nstatus and even psycho-emotional condition. The authors encourage \nclinicians to use this questionnaire when assessing women's health-\nrelated quality of life outcome after surgery for DIE [61]. Dae Gy \nHong et al. evaluated the outcomes on health-related quality of life \n(HRQOL) of radical excision of DIE in Douglas cul-de-sac among \n390 patients who underwent laparoscopic surgery. They evaluated the \npreoperative and postoperative visual analog scale (VAS) pain scores \n\nJ Surgery\nISSN: 1584-9341 JOS, an open access journal \nSimedrea V, et al.\n140\nVolume 11 • Issue 4 • 4\nand HRQOL data from the 36-item Short Form (SF-36) questionnaire \nand concluded that radical excision of DIE is safe and is associated \nwith significant improvement in QOL, especially in terms of pain [62]. \nAnother study by Angioni et al. demonstrated that complete surgical \nexcision of deep endometriosis is associated with better long-lasting \nimprovement in quality of life. They encouraged surgeons to completely \nexcise DIE implants when possible, as administration of GnRHa is \nfollowed by only a temporary improvement of symptomatology when \nincomplete surgery is performed [48]. In a study published by Ruffo et \nal., long-term outcome after laparoscopic bowel resections for DIE was \nevaluated on a number of 900 cases. Bowel resection for endometriosis \nis associated with an acceptable postoperative complication rate and \nsignificant improvement in symptoms (except for rectal bleeding and \ndysuria). Unfortunately, the median follow-up was just 54 months, \nwhich can be considered as a bias, so further studies need to be done in \norder to confirm the results [63]. \nThe study published by Lukic et al. showed significant improvement \nin women with endometriosis and deep dyspareunia who underwent \nlaparoscopic interventions. After a six-month follow-up, there was a \nsignificant improvement either in painful symptoms, but also in the \nquality of sexual and social lifes [64]. Unfortunately, there are a few \nstudies evaluating the quality of sex life in women with dyspareunia \nand endometriosis before and after surgical treatment. Abbott et \nal. evaluated the surgical outcomes in 135 women, demonstrating \nimprovement in dyspareunia and sexual pleasure using the Sexual \nActive Questionnaire (SAQ), with a 2-5 year follow-up [65]. Ferrero \net al. also showed an increase in the number of coituses and more \nsatisfactory orgasm among 68 women who underwent surgical \nintervention for endometriosis [66]. \nA pilot study on 20 patients with DIE and colorectal infiltration \nwho benefited from osteopathic manipulative therapy, showed an \nimprovement of the quality of life evaluated by the SF-36 questionnaire. \nFurther randomized studies are required to correctly evaluate the \nbenefits and outcomes of this technique [67]. \nIdentifying Patients Most Likely to Benefit from Surgery\nThe latest review on the subject clearly concludes that surgery \nshould be indicated only in the following situations: patients who \npresent with significant dyspareunia and dyschezia that results in \nmajor impairment of quality of life (evaluated by VAS . 7), patients \nwho present with signs of bowel obstruction, and patients who have \nfailed previous in vitro fertilization (IVF) cycles [68].\nTherefore, a thorough preoperative diagnostic investigation and \ncareful detailed counseling are of major importance to understand \nwhich patients are most likely to benefit from DIE surgery. A good \nunderstanding of family history and physical examination of the \npatients helps predicting clinicians to evaluate the risks and benefits \nof surgery on an individual basis. Patients with prior information of \nthe intestinal and urologic systems are the good candidates to schedule \nintraoperative consultation. Laparoscopic visualization remains \nthe gold standard for diagnosis of endometriosis and preoperative \nimaging may also help guide therapeutic approaches, enabling patient \ncounseling prior to surgery. Patients with pain should undergo a trial \nof empiric hormonal treatment, especially those who fail to benefit \nfrom laparoscopy. Patients with unsatisfactory preoperative function \nare most likely to improve, especially those with worse preoperative \nimagery. However, patients with a previous family history of DIE are \nless likely to gain functional improvement. Previous studies report a \nworse preoperative physical function as a strong predictor of functional \nimprovement. This is true for patients who especially fall under upper \nquartile of the change in SF-36 function score\n [69]. One must consider \npredictive variables and operationalize into a clinical scoring tool to \nidentify patients who are most likely to benefit from DIE surgery in \nterms of a clinically meaningful improvement in SF-36 function score.\nConclusion\nA delay between onset of symptoms and diagnosis of DIE is mainly \nattributed to insensitivity of specific signs and available diagnostic \ntests. There is a clear need for a comprehensive preoperative evaluation \nof the disease with precise description of the morphologic extension. \nThis mandatory step can provide the necessary surgical planning and \npredict possible future quality of life improvements. Patients should \nbe precisely informed and counseled about treatment options and \nexpected results.\nConflict of interest\nThe authors have no conflict of interest to report.\nReferences\n1. Sampson JA (1927) Peritoneal endometriosis due to menstrual dissemination \nof endometrial tissue into the pelvic cavity. Am J Obstet Gynecol 14: 422-469.\n2. Kennedy S, Bergqvist A, Chapron C, D’Hooghe T, Dunselman G, et al. (2005) \nESHRE guideline for the diagnosis and treatment of endometriosis. Hum \nReprod 20:2698-2704.\n3. Donnez J, Nisolle M, Grandjean P, Gillerot S, Clerckx F (1992) The place of \nGnRH agonists in the treatment of endometriosis and fibroids by advanced \nendoscopic techniques. Br J Obstet Gynaecol 99: 31-33.\n4. Koninckx PR, Martin D (1994) Treatment of deeply infiltrating endometriosis. \nCurr Opin Obstet Gynecol 6: 231-241.\n5. Donnez J, Nisolle M (1995) Advanced laparoscopic surgery for the removal \nof rectovaginal septum endometriotic or adenomyotic nodules. 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Arch Gynecol Obstet.\n63. Abbott JA, Hawe J, Clayton RD, Garry R (2003) The effects and effectiveness \nof laparoscopic excision of endometriosis: a prospective study with 2-5 year \nfollow-up. Hum Reprod 18: 1922-1927.\n64. Ferrero S, Abbamonte LH, Giordano M, Ragni N, Remorgida V (2007) Deep \ndyspareunia and sex life after laparoscopic excision of endometriosis. Hum \nReprod 22: 1142-1148.\n65. Daraï C, Deboute O, Zacharopoulou C, Laas E, Canlorbe G, et al. (2015) \nImpact of osteopathic manipulative therapy on quality of life of patients with \ndeep infiltrating endometriosis with colorectal involvement: results of a pilot \nstudy. Eur J Obstet Gynecol Reprod Biol 188: 70-73. \n\nJ Surgery\nISSN: 1584-9341 JOS, an open access journal \nSimedrea V, et al.\n142\nVolume 11 • Issue 4 • 4\n66. Abrão MS, Petraglia F, Falcone T, Keckstein J, Osuga Y, et al. (2015) Deep \nendometriosis infiltrating the recto-sigmoid: critical factors to consider before \nmanagement. Human Reproduction Update 21: 329-339. \n67.  Quintana JM, Escobar A, Aguirre U, Lafuente I, Arenaza JC (2009) Predictors \nof health-related quality-of-life change after total hip arthroplasty. Clin Orthop \nRelat Res 467: 2886-2894.","source_license":"CC0","license_restricted":false}