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    The case for surgery for endometriosis

     

    Some patients may benefit from careful surgical assessment and intervention by specialists, but unfortunately, such referrals are often injudiciously withheld (particularly in primary care/generalist settings and or adolescents) due to lack of understanding across all disciplines.

    A 3-mm diagnostic scope, however, could spare a patient who does not have endometriosis from potentially long intervals of expensive, uncomfortable, and hazardous medical treatment(s).4 Medical “diagnosis” and “management” of endometriosis may continue to lead to further diagnostic and definitive treatment delays—and patient dissatisfaction—when a strategy of “treat without seeing” is adopted.

    The LAPEX approach

    LAPEX is a minimally invasive gynecologic surgery strongly associated with symptomatic improvements in general health, sexual function, fertility, and quality of life in those struggling with endometriosis,5 with complete excision preventing persistent disease in many cases.6 Inadequately treated, however, endometriosis may lead to continued pain, infertility, substantial dysfunction and decreased quality of life, costly in-patient stays, postoperative morbidity, reduced productivity and, ultimately, poor outcomes. This contributes to an unnecessary financial burden on the patient, hospital provider, practitioner, and society.

    The high rates of recurrence associated with endometriosis surgery in the literature strongly depend on the completeness of disease removal. LAPEX is a well-established yet under-practiced approach, with the goal at time of surgery to completely resect all disease, restore normal anatomy, and apply measures for adhesion prevention.

    Data suggest that the surgical objective should be complete eradication; therefore, the surgeon must be prepared to excise all lesions suggestive of endometriosis as well as all atypical tissue, because in most anatomic sites, approximately 50% of atypical specimens prove to be endometriosis.4 Despite its proven efficacy, surgical treatment is not without peril, and many surgeons may be unprepared for such an undertaking; hence, timely referral to a center of expertise in endometriosis is warranted. Despite its increased degree of technical difficulty, LAPEX remains the most minimally invasive, cost-effective option.

    Complete resection offers the best reduction and control of symptoms, even in teenagers; results do not depend on postoperative hormonal suppression.7,8 Further reviews have demonstrated that surgical management is effective in treatment of painful symptoms and dysfunction as well as subfertility, and evidence supports laparoscopic intervention as the primary treatment modality for all stages of disease.9

     

    Ken R Sinervo, MD, MSc, FRCSC, ACGE
    Dr Sinervo is Medical Director of the Center for Endometriosis Care, Atlanta, Georgia.

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    • Dr. CHOWE
      Thank you for an important article that reiterates the fact that the more endometriosis is removed surgically the better the results are for reduced recurrence, pain reduction and improved fertility. I would like to add this idea. In general it seems that endometriosis is not however "cured" with surgery. Post suppressive medical therapy in a premenopausal women who is not actively attempting to conceive is critical (especially when uterus and ovaries are left in place). It will result in a longer lasting effect. Otherwise, regardless of the extent of tissue (peritoneal implant) removal there will be recurrence in 2-5 years from either retrograde flow or peritoneal metaplasia. Without treatment you set a younger woman up to have multiple surgeries over the years. After multiple surgeries they can develop adhesive disease and neuropathic pain. This must be avoided. In my mind menopause is the only "cure" and everything else we do is only temporizing, regardless of how complete it is. Thank you again for your time and ideas! They are valuable.

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