European accreditation of endometriosis centers of expertise?

Temporal and regional differences in the incidence of hospital-diagnosed endometriosis: a Danish population-based study

INTRODUCTION

Due to diagnostic challenges, normalization of symptoms and an overall lack of awareness among both patients and physicians, endometriosis is an underdiagnosed disease. This can result in delayed treatment and potentially worsening of the disease. Despite initiatives, such as patients' support organizations and specialized endometriosis referral centers, differences in awareness, socioeconomic factors and lifestyle, combined with varying distances to specialized referral centers, could result in regional differences in the degree of underdiagnosing. This study aims to explore temporal and regional variations in the incidence of endometriosis based on the Danish hospital discharge register, and shed light on the degree of underdiagnosing of endometriosis in Denmark.

MATERIAL AND METHODS

This registry-based cohort study included all women aged 15-55 living in Denmark from 1990-2017. Participants were identified through the Danish Civil Registration system and endometriosis diagnoses received at a hospital were obtained from the Danish National Patient Registry. Incidence rates of diagnosed endometriosis were calculated for each year of the study period and for each municipality in Denmark. A Cox regression analysis, stratified by calendar time and adjusted for ethnic origin, household composition, highest educational level and family socioeconomic status, was performed to estimate the association between residence and likelihood of receiving a hospital-based diagnosis of endometriosis.

RESULTS

The nationwide incidence rate of hospital-diagnosed endometriosis was 7.89 (95% confidence interval [CI] 7.80-7.99) per 10 000 person-years and the prevalence in 2017 was 1.63%. The results showed an overall increase in the incidence of diagnosed endometriosis of 46.8% (95% CI 32.9-62.2) during the study period and also displayed significant regional differences. After adjustments, women living in northern Jutland had the highest probability of receiving a hospital-based diagnosis of endometriosis (hazard ratio 1.13, 95% CI 1.09-1.18), whereas women living in northern Zealand had the lowest probability (hazard ratio 0.63, 95% CI 0.60-0.67) compared with eastern Jutland. These regional differences have become more evident over time.

CONCLUSIONS

Our results reveal significant regional differences in the incidence of hospital-diagnosed endometriosis, suggesting that a significant number of women may be left behind without a diagnosis. Further studies are needed to assess the underlying reasons for the significant regional differences.

Crude complication rate is not an accurate marker of a surgeon's skill: A single surgeon retrospective series of 1060 procedures for colorectal endometriosis

OBJECTIVE

To assess the relationship between the rate of postoperative bowel fistula and surgeon experience.

DESIGN

Retrospective study.

SETTING

Two referral centers.

PATIENTS

1060 women managed for colorectal deep endometriosis by one gynecologist surgeon from January 2005 to March 2020.

INTERVENTIONS

Shaving, disc excision and segmental colorectal resection.

MAIN OUTCOME MEASURES

Rate of bowel fistula stratified according to 4 time periods: P1 from 2005 to 2009, P2 from 2010 to 2014, P3 from 2015 to June 2018 and P4 from September 2018 to March 2020.

RESULTS

68 patients (6.4%) were managed during P1, 299 patients (28.2%) during P2, 422 patients (39.8%) during P3 and 271 patients (25.6%) during P4. Both diameter of rectal infiltration and rate of complex surgical procedures progressively increased from P1 to P4. Bowel fistula rate was comparable between all 4 time periods, respectively 2.9, 3.3, 4 and 4.4%. Logistic regression model revealed that risk of fistula decreased when shaving was performed when compared to segmental resection (adj OR 0.1, 95% CI 0-0.5) and increased when deep endometriosis nodules also involved sacral roots (adjOR 4.9, 95%CI 1.8-13.3) and infiltration of the vagina (adj OR 3, 95%CI 1.3-7). No statistically significant relationship was found between surgery time period and risk of fistula.

CONCLUSION

Crude rates of bowel fistula following surgical management of deep endometriosis infiltrating the colon and the rectum are not an accurate marker of surgeon expertise and should be considered in conjunction with expected higher risks related to challenging procedures performed by experienced surgeons.

[Early postoperative complications in a multidisciplinary surgical center exclusively dedicated to endometriosis: A 491-patients series]

OBJECTIVE

The objective of our study is to present the activity volume and postoperative complications in a center exclusively destined to endometriosis surgery.

METHODS

Retrospective mono-centric study analyzing data collected prospectively in patients surgically managed for endometriosis from September 2018 to August 2019.

RESULTS

Four hundred and ninety-one patients underwent surgery for endometriosis during 12 consecutive months: 268 for colorectal localizations (54.6%), 51 for endometriosis of the urinary tract (10.4%), 17 for nodules of ileum and right colon (3.5%), 43 for nodules of parametriums (8.8%), 12 for nodules of sacral roots and sciatic nerves (2.4%), 7 for diaphragmatic localizations (1.4%). Among 268 patients with colorectal endometrioses, of which 48.1% concerned the low and mid rectum, shaving was performed in 102 cases, disc excision in 96 cases and colorectal resection in 100 cases. Stoma was performed in 13.1% of the cases. Patients could have 2 different procedures for multiple colorectal nodules. One hundred and ninety-nine ovarian endometriomas were managed by plasma energy ablation in 64.8%, sclerotherapy in 11.1%, cystectomy in 13.1%, oophorectomy in 11.1%. Major postoperative complications included 12 rectovaginal fistulas, while 18 other surgical procedures were carried out for various complications. In all, 38.1% of procedures involved a general surgeon and 5.3% an urologist.

CONCLUSION

The creation of centers exclusively destined to endometriosis surgery allows the multidisciplinary management of a high number of patients, with an over-representation of severe forms and rare locations of the disease, followed by satisfactory complication rates.

Association between matrix metalloproteinase-2 and matrix metalloproteinase-9 polymorphisms and endometriosis: A systematic review and meta-analysis

Matrix metalloproteinase-2 (MMP-2)-735C/T and MMP-9-1562C/T polymorphisms have been indicated in the predisposition to endometriosis. However, due to the small sample sizes of previous studies, the results remain inconclusive. The present meta-analysis was conducted to detect the association between the two genetic polymorphisms and the risk of endometriosis by pooling all the available data. Electronic databases, including PubMed, Embase, Web of Science and CNKI, were searched comprehensively for studies examining a link between MMP-2 and MMP-9 polymorphisms and endometriosis. The strength of the association was assessed based on the pooled odds ratio with a 95% confidence interval, which was calculated using either the fixed- or random-effect model. Following the inclusion criteria, 6 case-control studies were included. The total number of participants was 2,486 (558 cases and 797 controls concerning the MMP-9-1562C/T polymorphism, and 525 cases and 606 controls concerning the MMP-2-735C/T polymorphism). No significant association was identified between the MMP-2-735C/T or MMP-9-1562C/T polymorphism and endometriosis. In further stratified analysis, no significant association was identified between the MMP-9-1562C/T polymorphism and endometriosis. The present meta-analysis revealed no association between the MMP-2-735C/T and MMP-9-1562C/T polymorphisms and the risk of developing endometriosis. Considering the limitations of the meta-analysis, well-designed studies with larger sample sizes are required.

The patient-centeredness of endometriosis care and targets for improvement: a systematic review

BACKGROUND

Endometriosis is a prevalent condition compromising physical and psychosocial health and thus requiring patient-centered care, which is guided by patients' values. This study aimed to find out what the patient's perspective on endometriosis care is and how the patient-centeredness of endometriosis care can be improved.

METHODS

Electronic databases were searched systematically, and study selection was based on eligibility and quality. Study methodology was examined. Specific care aspects valued by patients were organized according to 10 dimensions of patient-centered endometriosis care. Based on patients' assessments of service quality, patient-centered improvement targets and strengths were identified.

RESULTS

Twelve of 20 eligible studies had sufficient quality to be included. Endometriosis patients valued all 10 dimensions of patient-centered endometriosis care. Problematic service quality was reported for all dimensions but 'coordination and integration' and 'involvement of significant others'. Two patient-centered strengths and 29 patient-centered improvement targets were identified. The most frequently reported improvement targets on which studies agreed were 'timely diagnosis' and 'being believed and respected by staff'.

CONCLUSION

Endometriosis patients value patient-centeredness in addition to effectiveness and safety of care, and its 10 dimensions require attention in clinical practice. Research into the assessment and improvement of patient-centered endometriosis care is required.