Laparoscopic excision of endometriosis: a randomized, placebo-controlled trial

Pelvic pain in women and men: recent findings

PURPOSE OF REVIEW

All Pubmed-listed articles generated by the search terms 'pelvic' and 'pain' from the year 2004 (plus or minus 6 months) were examined for relevance to pain management therapeutics. An emphasis was given to clinical studies related to chronic pain disorders.

RECENT FINDINGS

Use of the descriptive diagnosis 'pelvic pain', traditionally limited to gynecological pains, has now been generalized to include male populations with similar symptom complexes arising from organs of reproduction and other pelvic organ systems such as the gastrointestinal tract and urological structures. Clinical studies have sought to refine or test existing 'standard' therapies for current pain groupings, and have frequently obtained frustrating results because many therapies appear to be effective in only a subset of patients. Notably, the same therapeutics appear to be effective in similar subsets of patients with other protean disorders.

SUMMARY

A commonality of symptoms suggests a commonality of pathophysiology, although this has not proved to be globally true. The success of therapeutic options appears to depend upon a stratification of previous pain groupings into overlapping subsets each with their effective treatment. Current studies are still defining these subsets and finding monotherapies to be inadequate for whole populations.

Le coaching de l'endométriose

Coaching is a well-known terminology and an approach currently used, particularly in the worlds of company management and sport, but its use in the medical field appeared only recently. In the latter field, coaching bears behavioral and psychological aspects. It can not only be intended to a medical team, but also the practionner himself, for a better management of any disease, his patient for a better treatment effect and compliance and an optimal coping with the disease. In the case of endometriosis, a chronic disease, two key aspects are briefly reviewed to illustrate the benefits of coaching and to sensitize health providers to this approach. Thus, an appropriate diagnostic strategy should allow to reduce the delay in the diagnosis, so frequently blamed, and to identify other associated painful diseases. Also, management should be improved as well, not only by applying appropriate therapeutic recommandations, and alternative measures, but also by a better multidisciplinary support towards patient expectations with long-term guidance.

The value of virtual reality–simulator training in the development of laparoscopic surgical skills

OBJECTIVE

To determine the effectiveness of virtual reality (VR) training in improving the surgical skills of medical students and gynecologic trainees.

DESIGN

A prospective observational study to assess the changes observed in objectively measured surgical performance after VR training.

SETTING AND POPULATION

University teaching hospital and the laboratories of the University of Western Australia.

PARTICIPANTS

Fifteen 5th-year medical students, six junior-doctor trainees (years 1-3), and eight senior trainees (years 4-6).

INTERVENTIONS

Standard gynecologic procedures before and after VR training were undertaken on sheep. The procedures were video-recorded and edited to blind the scorer as to identity and seniority of the operator. The procedures were scored using a combination of operative time and penalties for surgical errors. The surgical scores were correlated with the VR scores.

MEASUREMENTS AND MAIN RESULTS

Operative skills were assessed using a combination score compiled from scores obtained while undertaking salpingectomy, salpingotomy, and tubal clipping. Virtual reality scores were also a combination score derived from summation of various computer-calculated measures of time and accuracy in undertaking two standardized exercises.

RESULTS

The baseline VR scores were significantly related to the overall pre-training scores (salpingectomy p = .032). A better initial VR score was also predictive of better surgical performance. The initial VR score was also predictive of improvement observed between baseline and post-training (p = .004).

CONCLUSION

Virtual reality training is of value in improving surgical skills in the clinical environment. It appears to be of most value in the earliest stages of training. These data suggest that serious consideration should be given to incorporating VR training into the training program of obstetricians and gynecologists at an early stage.

Efficacy of laparoscopic excision of visually diagnosed peritoneal endometriosis in the treatment of chronic pelvic pain

OBJECTIVE

To determine the efficacy of laparoscopic excision of visually diagnosed endometriosis in the treatment of chronic pelvic pain.

STUDY DESIGN

Sixty-two women with chronic pelvic pain and who underwent laparoscopic excision of visually diagnosed peritoneal lesions suggestive of endometriosis returned postal questionnaires. The main outcomes measures were change in pelvic pain symptoms measured on a continuous and ordinal scale and patient satisfaction following treatment. Secondary outcomes were quality of life, time off work and use of health service resources.

RESULTS

42/62 (68%) women with an average follow up time of 13 months (range 6-38 months) returned completed outcome questionnaires. The mean amount of pelvic pain was reduced following surgery compared to immediately prior to treatment, regardless of the nature of the pain (P<0.05). Overall, 67% (95% CI 50-80%) of women reported improvement in pain symptoms and 71% (95% CI 55-84%) were satisfied with the results of treatment. Satisfaction with treatment was comparable whether the visual diagnosis of peritoneal endometriosis was confirmed histologically or not (62% versus 64%, P=1.0).

CONCLUSION

Laparoscopic excision of visually diagnosed endometriosis appears to be efficacious in the treatment of women with chronic pelvic pain. The launch of a long-term randomised controlled trial to confirm these provisional results is now required.

Thoracic Endometriosis: Current Knowledge

Thoracic endometriosis syndrome includes four well-recognized clinical entities, namely catamenial pneumothorax, catamenial hemothorax, catamenial hemoptysis and lung nodules, as well as some exceptional presentations. The etiological mechanisms of this syndrome are not well understood, and different theories have been proposed. Controversies exist about optimal management, as experience has been drawn from case reports and small clinical series. Surgery, hormonal treatments and combined approaches have all been proposed, with variable results in terms of short and long term outcome.

Quality of life after laparoscopic colorectal resection for endometriosis

BACKGROUND

Indications of colorectal resection for endometriosis remain controversial because of the risk of major complications. Therefore, the aims of the current study were to evaluate the efficacy of laparoscopic segmental colorectal resection for endometriosis on quality of life and gynaecologic and digestive symptoms, and its complications.

METHODS

After magnetic resonance imaging and rectal endoscopic sonographic evaluation of symptomatic colorectal endometriosis, 58 consecutive women requiring colorectal resection were included in this study. Symptom questionnaires and the short-form (SF)-36 Health Status and the quality of life score were completed. Linear intensity scores for several gynaecologic and digestive symptoms and perioperative complications were also recorded.

RESULTS

Fifty-one women (88%) underwent laparoscopic segmental colorectal resection and seven required laparoconversion. Major complications occurred in nine cases (15.5%), including six rectovaginal fistulae (10.3%), and the three remaining complications corresponded to a haemoperitoneum, a uroperitoneum and a pelvic abscess. Median follow-up after colorectal resection was 22.5 months (2-55 months). A significant improvement in dysmenorrhoea (P < 0.0001), dysparaeunia (P < 0.0001), bowel movement pain or cramping (P < 0.0001), pain on defecation (P < 0.0001), diarrhoea (P < 0.016), lower back pain (P < 0.0001) and asthaenia (P < 0.0002) was observed. Tenesmus, rectorrhagia and constipation were not improved. All the items of the SF-36 Health Status and the quality of life score were improved after colorectal resection for endometriosis.

CONCLUSION

Laparoscopic segmental colorectal resection for endometriosis significantly improves quality of life and gynaecologic and digestive symptoms. However, women have to be informed on the risk of complications including rectovaginal fistula.

Advances in the management of endometriosis: an update for clinicians

Endometriosis is a chronic and recurrent disease characterized by the presence and proliferation of endometrial tissue outside the uterine cavity, which occurs in approximately 10% of women of reproductive age. In this estrogen-dependent disorder, lesions become inactive and gradually undergo regression during states of ovarian down-regulation, such as amenorrhoea or menopause. The impact of endometriosis includes impaired fertility potential, as well as symptoms of dysmenorrhoea, dyspareunia and chronic non-menstrual pain, all of which adversely affect quality of life. Management of endometriosis focuses on pain relief and includes medical and surgical treatment. Pharmacologic therapies currently in use include combination oral contraceptives (COCs), danazol, GnRH analogues and progestins. Although some agents show efficacy in relieving pain, all differ in their side effects, making it difficult to achieve a balance between efficacy and safety. Efficacy has been demonstrated with danazol or GnRH analogues; however, treatment is limited to 6 months because of significant metabolic side effects. Alternatives for longer-term management of symptoms include add-back therapy with GnRH analogues, COCs or progestins. Newer options for treatment of endometriosis include depot medroxyprogesterone acetate subcutaneous injection, as well as several agents under investigation that may prove to have therapeutic potential.

Laparoscopy for abdominal emergencies

BACKGROUND

Emergency laparoscopic exploration can be used to identify the causative pathology of acute abdominal pain. Laparoscopic surgery also allows treatment of many intraabdominal disorders. This report was prepared to describe the effectiveness of laparoscopic surgery compared to laparotomy or nonoperative treatment.

METHODS

A panel of European experts in abdominal and gynecological surgery was assembled and participated in a consensus conference using Delphi methods. The aim was to develop evidence-based recommendations for the most common diseases that may cause acute abdominal pain.

RECOMMENDATIONS

Laparoscopic surgery was found to be clearly superior for patients with a presumable diagnosis of perforated peptic ulcer, acute cholecystitis, appendicitis, or pelvic inflammatory disease. In the emergency setting, laparoscopy is of unclear or limited value if adhesive bowel obstruction, acute diverticulitis, nonbiliary pancreatitis, hernia incarceration, or mesenteric ischemia are suspected. In stable patients with acute abdominal pain, noninvasive diagnostics should be fully exhausted before considering explorative surgery. However, diagnostic laparoscopy may be useful if no diagnosis can be found by conventional diagnostics. More clinical data are needed on the use of laparoscopy after blunt or penetrating trauma of the abdomen.

CONCLUSIONS

Due to diagnostic and therapeutic advantages, laparoscopic surgery is useful for the majority of conditions underlying acute abdominal pain, but noninvasive diagnostic aids should be exhausted first. Depending on symptom severity, laparoscopy should be advocated if routine diagnostic procedures have failed to yield results.

Fertility after laparoscopic colorectal resection for endometriosis: preliminary results

OBJECTIVE

To examine fertility, reproductive outcomes, and determinants of fertility after laparoscopic segmental colorectal resection for endometriosis.

DESIGN

Retrospective longitudinal study.

SETTING

Tertiary university gynecology unit.

PATIENT(S)

The study population consisted of 34 women with colorectal endometriosis, of whom 22 wished to conceive. Demographic, surgical, and histological characteristics of 10 women who conceived were compared with those of 12 women who failed to conceive.

INTERVENTION(S)

Laparoscopic colorectal resection for endometriosis.

MAIN OUTCOME MEASURE(S)

Rates of pregnancy and live birth.

RESULT(S)

Mean follow-up after segmental colorectal resection was 24 months (range 6-42 months), and the pregnancy rate was 45.5%. The median time to conceive was 8 months (range 3-13 months). Twelve pregnancies occurred in 10 women, comprising nine spontaneous singleton pregnancies (7 vaginal deliveries, 1 cesarean section, and 1 ongoing pregnancy), and three pregnancies obtained by IVF (one miscarriage, one ongoing twin pregnancy, and one triplet pregnancy necessitating cesarean section at 29 weeks for premature rupture of the membranes, with two surviving infants). The live birth rate was 82%. The women who did and did not conceive did not differ in terms of mean follow-up, mean age, body mass index (BMI), parity, smoking, use and duration of oral contraception (OC), duration of infertility, or the length of the resected colorectal segment. Uterine adenomyosis was the main determinant of pregnancy after colorectal resection.

CONCLUSION(S)

These preliminary results suggest that extensive laparoscopic segmental colorectal resection for endometriosis can enhance fertility, with high rates of spontaneous pregnancy and live birth.

Endometriosis and pelvic pain: epidemiological evidence of the relationship and implications

The relationship between chronic pelvic pain symptoms and endometriosis is unclear because painful symptoms are frequent in women without this pathology, and because asymptomatic forms of endometriosis exist. Our comprehensive review attempts to clarify the links between the characteristics of lesions and the semiology of chronic pelvic pain symptoms. Based on randomized trials against placebo, endometriosis appears to be responsible for chronic pelvic pain symptoms in more than half of confirmed cases. A causal association between severe dysmenorrhoea and endometriosis is very probable. This association is independent of the macroscopic type of the lesions or their anatomical locations and may be related to recurrent cyclic micro-bleeding in the implants. Endometriosis-related adhesions may also cause severe dysmenorrhoea. There are histological and physiopathological arguments for the responsibility of deeply infiltrating endometriosis (DIE) in severe chronic pelvic pain symptoms. DIE-related pain may be in relation with compression or infiltration of nerves in the sub-peritoneal pelvic space by the implants. The painful symptoms caused by DIE present particular characteristics, being specific to involvement of precise anatomical locations (severe deep dyspareunia, painful defecation) or organs (functional urinary tract signs, bowel signs). They can thus be described as location indicating pain. A precise semiological analysis of the chronic pelvic pain symptoms characteristics is useful for the diagnosis and therapeutic management of endometriosis in a context of pain.

Laparoscopy and reported pain among patients with endometriosis

OBJECTIVE

To compare the effectiveness of sharp excision of endometriosis with sham surgical excision in alleviating endometriosis-associated pain for up to 1 year following surgery.

METHODS

Patients requiring a laparoscopy for severe pelvic pain were eligible. If endometriosis was visually identified at laparoscopy, a biopsy of a representative lesion was taken. The women were then randomized either to have all remaining endometriosis excised with laparoscopic scissors (the excision group) or to have no further surgical treatment (the control group). Patients were asked to complete daily pain scales for 1 month preoperatively and quarterly for 1 year postoperatively. Subjects were blinded to their treatment allocation for 1 year.

RESULTS

Twenty-nine women underwent laparoscopy and biopsy and were randomized to have excision or no treatment of endometriosis. The excision and control groups were similar in age, parity, and revised American Society for Reproductive Medicine stage of disease. Sixteen women completed the full year of follow-up: 9 in the excision group, and 7 in the control group. Overall, recorded pain was significantly reduced at 1 year (P < 0.05), with no significant difference between the excision and control groups.

CONCLUSION

Laparoscopy with diagnostic biopsy alone is associated with a significant reduction in pain for up to 1 year postoperatively. Although the study lacked sufficient statistical power to exclude an effect of excision, pain relief in each group was similar. These results indicate a potential benefit of sham surgical procedures in assessing novel surgical interventions.

Medication and transference in psychoanalytically oriented psychotherapy of the borderline patient

The regressive potential of the borderline patient has been recognized ever since the term was first introduced by Adolph Stern in 1938. He believed these patients were "too ill for classical psychoanalysis," and indeed almost all who have written on this subject have supported Stern's view, recognizing the severe regressive potential of a borderline patient in unmodified psychoanalysis. Taking medication is not generally considered to be a particularly regressive experience. It should be remembered, however, that for many patients and especially for patients with borderline personality disorder, medication can be both an overvalued hope and a terrifying assault. Thus, although the pharmacologic action of the medication may help to integrate the patient's ego functioning, the very taking of the medication may at the same time initiate subtle and unanticipated regressive drives. Two forces are then set in motion with potentially different effects. In a treatment where the same physician is prescribing medication and doing psychotherapy, the common pathway of these forces is transference. Thus, pharmacologic action may modify transference. And more importantly, because it is less easily recognized, transference issues may affect the patient's subjective experience of the action of the medication. For this reason, it is particularly important that not only diagnostic issues but also transference issues be understood before medication is prescribed.(ABSTRACT TRUNCATED AT 250 WORDS)