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    The case for surgery for endometriosis


    Medical therapy versus excision

    As has been suggested in the literature, persistent emphasis on medical treatment for endometriosis may be misleading and result in physicians mismanaging their patients.9 Data indicate that little difference exists in effectiveness of the various analogs, all of which last only while the patient is undergoing treatment and most of which have negative side effects. Early disease does not disappear under suppressive treatment yet may also not progress; hence use of oral contraceptives or progestins may be successful in temporary suppression. However, in the interest of patient-centered care, the decision to use medical therapy should be made by a woman after all options have been reviewed.

    All medical therapy, whether administered as first-line treatment or postoperatively, is associated with high rates of disease recurrence.10,11 Surgery, on the other hand, provides symptom reduction for up to 5 years, with studies indicating that excision is more effective than ablation. Moreover, one recent prospective, randomized, double-blind study revealed that more patients in the ablation group continued to receive medical treatment at 5 years.12 While systematic literature reviews report rates of pain recurrence as high as 50% at 1 to 2 years after surgery for symptomatic endometriosis,13 that is likely due to the nature of the surgery and the surgeon’s skill. Incomplete excision is the predominant reason for disease recurrence, with return of pain and symptoms directly correlated to surgical precision and removal of peritoneal and deeply infiltrating disease. The goal should be to eradicate disease completely in order to keep risk of recurrence as low as possible.14

    The assumption that all surgery is performed by surgeons of similar caliber and experience is inaccurate, and such postulation does not address the issue of success in removing all disease at the time of surgery, ignoring the excellent results of truly skilled excisionists with adequate experience in recognition and total resection. The success of treatment indeed depends on ability to eradicate all lesions,15 and endometriosis is most likely to recur close to the original area of involvement as a result of incomplete excision or ablation.16 In experienced hands, laparoscopic surgery helps afford long-term symptomatic relief, improves pregnancy rates, and reduces recurrence of disease while largely avoiding complications.17 Complete excision is essential for improving pain and preventing disease recurrence.18


    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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