Pre-op hormonal treatment of endometriosis found to be protective against post-op complications
Casarin J, Ghezzi F, Mueller M, et al. Surgical outcomes and complications of laparoscopic hysterectomy for endometriosis: a multicentric cohort study. J Minim Invasive Gynecol. 2023;30:587-592. doi:1016/j.jmig.2023.03.018
In a large European multicenter retrospective cohort study, Casarin and colleagues evaluated perioperative complications during laparoscopic hysterectomy for endometriosis or adenomyosis in 995 patients treated from 2010 to 2020.2
Reported intraoperative data included the frequency of ureterolysis (26.8%), deep nodule resection (30%) and posterior adhesiolysis (38.9%), unilateral salpingo-oophorectomy (15.1%), bilateral salpingo-oophorectomy (26.8%), estimated blood loss (mean, 100 mL), and adverse events. Intraoperative complications occurred in 3% of cases (including bladder/bowel injury or need for transfusion).
Postoperative complications occurred in 13.8% of cases, and 9.3% had a major event, including vaginal cuff dehiscence, fever, abscess, and fistula.
Factors associated with postoperative complications
In a multivariate analysis, the authors found that increased operative time, younger age at surgery, previous surgery for endometriosis, and occurrence of intraoperative complications were associated with Clavien-Dindo score grade 2 or greater postoperative complications.
Medical treatment for endometriosis with estro-progestin or progestin medications, however, was found to be protective, with an odds ratio of 0.50 (95% confidence interval, 0.31–0.81).
WHAT THIS EVIDENCE MEANS FOR PRACTICE
It is well known that endometriosis is a risk factor for surgical complications. The reported complication rates in this cohort were relatively high, with nearly 10% of patients sustaining a major event postoperatively. While surgical risk is multifactorial and includes factors that are difficult to capture, including surgeon experience and patient population baseline risk, the relatively high incidence reported should be cause for pause and be incorporated in patient counseling. Of note, this cohort did undergo a large number of higher order dissections and a high number of bilateral salpingo-oophorectomies (26.8%), which suggests a high-risk population.
What we found most interesting, however, was the positive finding that medication administration was protective against complications. The authors suggested that the antiinflammatory effects of hormone suppressive medications may be the key. Although this was a retrospective cohort study, the significant risk reduction seen is extremely compelling. A randomized clinical trial corroborating these findings would be instrumental. Endometriosis acts similarly to cancer in its progressive spread and destruction of surrounding tissues. As is increasingly supported in the oncologic literature, perhaps neoadjuvant therapy should be the standard for our “benign” high-risk endometriosis surgeries, with hormonal suppression serving as our chemotherapy. In our own practices, we may be more likely to encourage preoperative medication management, citing this added benefit to patients.
Diaphragmatic endometriosis prevalence higher than previously reported
Pagano F, Schwander A, Vaineau C, et al. True prevalence of diaphragmatic endometriosis and its association with severe endometriosis: a call for awareness and investigation. J Minim Invasive Gynecol. 2023;30:329-334. doi:10.1016/j.jmig.2023.01.006
Pagano and colleagues conducted an impressive large prospective cohort study that included more than 1,300 patients with histologically proven endometriosis.1 Each patient underwent a systematic evaluation and reporting of intraoperative findings, including bilateral evaluation for diaphragmatic endometriosis (DE).
Patients with DE had high rates of infertility and high-stage disease
In this cohort, 4.7% of patients were found to have diaphragmatic disease; 92.3% of these cases had DE involving the right diaphragm. Patients with DE had a higher rate of infertility than those without DE (nearly 50%), but otherwise they had no difference in typical endometriosis symptoms (dysmenorrhea, dyspareunia, dyschezia, dysuria). In this cohort, 27.4% had diaphragmatic symptoms (right shoulder pain, cough, cyclic dyspnea).
Patients found to have DE had higher rates of stage III/IV disease (78.4%), and the left pelvis was affected in more patients (73.8%).
WHAT THIS EVIDENCE MEANS FOR PRACTICE
The prevalence of DE in this large cohort evaluated by endometriosis surgeons was far higher than previously reported rates of DE (0.19%–1.5% for abdominal endometriosis cases).17,18 Although admittedly this center cares for a larger portion of women with high-stage disease than many nonspecialty centers do, it still begs the question: Are we as a specialty underdiagnosing diaphragmatic endometriosis, especially in our patients with more severe endometriosis? Because nearly 5% of endometriosis patients could have DE, a thoughtful and systematic approach to the abdominal survey and diaphragm should be performed for each case. Adding questions about diaphragmatic symptoms to our preoperative evaluation may help to identify about one-quarter of these complicated patients preoperatively to aid in counseling and surgical planning. Patients to be specifically mindful about include those with high-stage disease, especially left-sided disease, and those with infertility (although this could be a secondary association given the larger proportion of patients with stage III/IV disease with infertility, and no multivariate analysis was performed). This study serves as a thoughtful reminder of this important subject.
The prevalence of DE in this large cohort evaluated by endometriosis surgeons was far higher than previously reported rates of DE (0.19%–1.5% for abdominal endometriosis cases).17,18 Although admittedly this center cares for a larger portion of women with high-stage disease than many nonspecialty centers do, it still begs the question: Are we as a specialty underdiagnosing diaphragmatic endometriosis, especially in our patients with more severe endometriosis? Because nearly 5% of endometriosis patients could have DE, a thoughtful and systematic approach to the abdominal survey and diaphragm should be performed for each case. Adding questions about diaphragmatic symptoms to our preoperative evaluation may help to identify about one-quarter of these complicated patients preoperatively to aid in counseling and surgical planning. Patients to be specifically mindful about include those with high-stage disease, especially left-sided disease, and those with infertility (although this could be a secondary association given the larger proportion of patients with stage III/IV disease with infertility, and no multivariate analysis was performed). This study serves as a thoughtful reminder of this important subject.
A word on fertility-sparing treatments for adenomyosis
Several interesting and thoughtful studies were published on the fertility-sparing management of adenomyosis.6-8 These included a comparison of fertility outcomes following excisional and nonexcisional therapies,6 a systematic review of the literature that compared recurrence rates following procedural and surgical treatments,8 and outcomes after use of a novel therapy (percutaneous microwave ablation) for the treatment of adenomyosis.7
Although our critical evaluation of these studies found that they are not robust enough to yet change our practice, we want to applaud the authors on their discerning questions and on taking the initial steps to answer critical questions, including:
- What is the best uterine-sparing method for treatment of diffuse adenomyosis?
- Are radiofrequency or microwave ablation procedures the future of adenomyosis care?
- How do we counsel patients about fertility potential following procedural treatments?