The role of the multidisciplinary team in the management of deep infiltrating endometriosis

Recommendations for the implementation and conduct of multidisciplinary team meetings for those providing endometriosis and adenomyosis care - a Delphi consensus of the European Endometriosis League (EEL)

Background

The treatment of endometriosis and adenomyosis requires a complex, multidisciplinary approach. Some centres have established multidisciplinary teams (MDT) and regular meetings. There are currently no international data or recommendations.

Objectives

To examine existing MDT meetings and define consensus recommendations to support implementation and conduct.

Materials and Methods

Online questionnaires were sent through the European Endometriosis League (EEL) based on a Delphi protocol. After a literature review and assessment of existing MDT meetings, essential aspects for consensus statements were identified. The consensus statements were evaluated using a 5-point Likert scale with the possibility to modify them. Results were analysed between rounds and reported to the respondents. Consensus, defined as ≥70% agreement, concluded the Delphi process when achieved in the majority of statements.

Main outcome measures

Prevalence and type of existing MDT meetings and recommendations.

Results

In round 1, 69 respondents participated, with 49.3% (34) having an MDT meeting at their institutions, of which 97% are multidisciplinary. 50 % meet once a month and 64.7% indicated that less than 25% of their patients are discussed. Throughout the three rounds, 47 respondents from 21 countries participated. During the process, 82 statements were defined, with an agreement of 92.7% on the statements.

Conclusions

This study assessed existing MDT meetings for endometriosis and adenomyosis and developed recommendations for their implementation and conduct. The consensus group supports the strengths of MDT meetings, highlighting their role in offering guideline-based, multidisciplinary, and personalised care.

What is new?

This study presents the first international data and recommendations on MDT meetings for endometriosis and adenomyosis.

Robotic surgery for bowel endometriosis: a multidisciplinary management of a complex entity

BACKGROUND

Bowel endometriosis impacts quality of life. Treatment requires complex surgical procedures with associated morbidity. Precision approach with robotic surgery leads to organ preservation. Bowel endometriosis requires a multidisciplinary management to improve patient outcomes. This study evaluates perioperative outcomes of bowel endometriosis undergoing multidisciplinary planning and robotic surgery.

METHODS

Consecutive cases of multidisciplinary robotic bowel endometriosis procedures (January 2021-December 2022) were evaluated from a prospectively maintained database in a national endometriosis accredited centre. Patients were managed through a multidisciplinary setting including gynaecologists, colorectal robotic surgeons, and other specialists. Dyschezia (menstrual and non-cyclical) and quality of life were assessed pre- and postoperatively (6 months) through validated questionnaires.

RESULTS

Sixty-eight consecutive cases of robotic bowel endometriosis were included. Median age was 35.0 (30.2-42.0) years. Median body mass index was 24.0 (21.0-26.7) kg/m2. Procedures performed were 48 (70.6%) shavings, 11 (16.2%) deep shavings, 3 (4.4%) disc excisions, and 6 (8.8%) segmental resections. One (1.5%) patient required temporary stoma. Median operating time was 150 (120-180) min. There were no conversions/return to theatre postoperatively. Median endometriotic nodule size was 25.0 (15.5-40.0) mm. Two (2.9%) patients developed postoperative complications. Median length of postoperative stay was 2 (2-4) days. Median follow-up was 12 (7-17) months. One (1.5%) patient recurred. Median menstrual dyschezia score improved from 5.0 (2.0-8.0) to 1.0 (0.0-5.7). Median non-cyclical dyschezia significantly improved (p < 0.001) from 1.0 (0.0-5.7) to 0.0 (0.0-2.0). Median quality of life score improved from 52.5 (35.0-70.0) to 74.5 (60.0-80.0).

CONCLUSIONS

Robotic multidisciplinary approach to bowel endometriosis provides good perioperative outcomes with improvement of dyschezia and quality of life.

Comprehensive endometriosis care: a modern multimodal approach for the treatment of pelvic pain and endometriosis

Endometriosis is a prevalent gynecological disease, leading to chronic pain and inflammation, affecting 1 in 10 individuals presumed female at birth. The diagnostic journey is often arduous, marked by neglect of the right diagnosis and prolonged wait times, significantly compromising the quality of life among those affected. This review provides a nuanced exploration of endometriosis-associated pain management, encompassing medical, surgical, and holistic approaches, all guided by accurate and refined diagnostics. Our paramount goal is to empower physicians as key figures in confronting this intricate challenge with a patient-centric approach, ultimately aiming to improve treatment and quality of life. Acknowledging each patient's unique needs, we emphasize the importance of tailoring a spectrum of options informed by current literature and insights gleaned from our experience in a high-volume tertiary endometriosis center. It is imperative to recognize endometriosis as a complex and chronic disease, often occurring with co-morbid conditions and nuanced complexities, necessitating a long-term personalized multimodal approach for each case. In addition, incorporating principles such as patient autonomy, profound respect for diverse experiences, and practical education on treatment choices is pivotal in enhancing treatment outcomes and overall patient satisfaction.

Does Sexual Function and Quality of Life Improve after Medical Therapy in Women with Endometriosis? A Single-Institution Retrospective Analysis

BACKGROUND

Endometriosis is a gynecological condition affecting up to 10% of women of reproductive age and characterized by chronic pain. Pain is the major cause of the impairment of quality of life in all aspects of these patients. Previous studies have shown that endometriosis treatment, hormonal or surgical, has proven effective not only in controlling the disease but also in improving symptoms, and we can assume also effective in improving quality of life.

METHODS

This study evaluates quality of life and sexual function in patients with endometriosis at the time of diagnosis and after 6 months of medical therapy, to assess the impact of treatment on these aspects. We evaluated retrospectively patients with a diagnosis of endometriosis between 2018 and 2020. All patients underwent gynecological examination and transvaginal ultrasound and filled in three questionnaires. The same evaluation was provided after taking medical hormonal therapy.

RESULTS

The improvement of dysmenorrhea, chronic pelvic pain, and dyspareunia after medical treatment were statistically significant. Instead, items concerning arousal, lubrication, and sexual satisfaction showed a statistically significant worsening after therapy.

CONCLUSIONS

We can state that hormone therapy alone is not sufficient to achieve an improvement in the patient's quality of life and sexual function. Emerging evidence suggests that most of these patients showed a central sensibilization phenomenon characterized by an amplification of the response to a peripheral and/or neuropathic nociceptive trigger, which is expressed by hyperalgesia and allodynia. For this reason, in these patients, it is better to adopt a multimodal and multidisciplinary approach, including other professional figures, that acts on pain and also intervenes in all those conditions that contribute to worsening quality of life.

Validation of a multidisciplinary virtual reality (VR) robotic surgical curriculum

The objective is to identify whether trainees demonstrate improvement in a standardized knot-tying task as assessed by Global Evaluative Assessment of Robotic Skills (GEARS) score after completion of a virtual reality (VR) robotic curriculum. An IRB-exempt prospective study was conducted with surgical trainees from August 2021 to February 2023. Participants initially performed a baseline robotic suturing task in which they were instructed to tie interrupted square knots in 10 min. Participants then completed a virtual reality simulation curriculum involving 23 exercises until they achieved 90% proficiency on all tasks. Participants then repeated the suturing task. Pre- and post-curriculum suturing tasks were recorded, de-identified, and scored by expert graders using a GEARS score. Trainees from three academic centers were invited to participate. Medical students (MS1-MS3) and surgical residents from gynecology, urology, and general surgery were invited to participate. Twenty-five trainees completed the pre-curriculum suturing task, the VR curriculum, and the post-curriculum suturing task. Trainees demonstrated significant improvement in their post-test GEARS score by 2.43 points (p < 0.05) and were able to tie three additional knots within 10 min after completion of the curriculum (p < 0.05). Trainees also demonstrated a faster time to complete first knot (114 s improvement, p < 0.05) after completion of the curriculum. All participants agreed or strongly agreed that completion of the robotic curriculum helped them feel more comfortable using the robotic console, and improved their robotic surgical skills. Surgical trainees and medical students with limited prior robotic surgical experience demonstrated objective improvement after completion of a standardized VR curriculum.

The value of pre-operative outpatient flexible sigmoidoscopy in patients with deep infiltrating endometriosis

BACKGROUND

Deep infiltrating endometriosis (DE) is a particularly severe disease which affects 10-20% of women with endometriosis. 90% of DE is rectovaginal and when suspected, some clinicians have suggested the routine use of flexible sigmoidoscopy to identify intraluminal disease. We aimed to assess the value of sigmoidoscopy prior to surgery for rectovaginal DE, both in terms of diagnosis and planning management.

OBJECTIVES

We aimed to assess the value of sigmoidoscopy prior to surgery for rectovaginal DE.

MATERIALS AND METHODS

A retrospective case series study was performed from a consecutive cohort of patients with DE referred for outpatient flexible sigmoidoscopy between January 2010 and January 2020. All patients were under the care of a specialist endometriosis multidisciplinary team.

MAIN OUTCOME MEASURES

The primary outcome measure was the incidence of luminal disease.

RESULTS

102 consecutive cases were analysed with no cases confirming intraluminal disease. Non-specific evidence of endometriosis such as tight angulation of the bowel was found in 36.3%. Following sigmoidoscopy 100 patients proceeded to surgery and the risk of bowel resection during surgery was 4%.

CONCLUSIONS

Due to the low incidence of luminal endometriosis, performing sigmoidoscopy routinely is of limited benefit. We recommend the selective use of sigmoidoscopy where serious pathology such as colorectal neoplasia is considered or to determine the location of endometriosis lesions which aids subsequent resectional surgery planning.

WHAT IS NEW?

This large case series details a very low incidence of intraluminal disease and makes recommendations for the specific scenarios where flexible sigmoidoscopy should be used.

Study of postoperative complications after the implementation of a multidisciplinary care pathway for patients with digestive endometriosis

PURPOSE

To assess the quality of care following the establishment of a multidisciplinary care pathway for patient operated on for deep pelvic endometriosis with digestive impairment.

METHODS

We conducted a retrospective monocentric study of patients suffering from deep infiltrating endometriosis, treated in Gynaecological Department at Toulouse University Hospital from January 2018 to December 2020. We compared our results to those of our previous study, Gornes et al. which showed a postoperative complication occurred in 37.8% of the cases and a postoperative severe complication according to the Clavien-Dindo classification (grades 3b) rate of 18.3%.

RESULTS

98 patients were included. Our study shows a clear decrease in postoperative complications with an overall complication rate of 19.4% and severe complications (grades 3b) of 4.1%. The rate of complication appeared to be significantly less frequent in the case of shaving in relation to other digestive procedures (p = 0.008) and in the case of a lesion of < 20 mm by MRI (p = 0.01). The use of multidisciplinary surgical care was more frequent in the case of multiple locations (66.7% vs. 41.8%, p = 0.07) and was more frequent in the case of transmural damage with echo endoscopy (and to a lesser degree in the case of damage of the muscularis or mucous membrane) (p = 0.05).

CONCLUSIONS

Multidisciplinary care of endometriosis with digestive damage appears to be indispensable. The intraoperative intervention of a skilled digestive surgeon of bowel endometriosis helps create the best balance between effectiveness-complications-functional prognosis, with a reduction of severe postoperative complications.

NUF2 overexpression contributes to epithelial ovarian cancer progression via ERBB3-mediated PI3K-AKT and MAPK signaling axes

Introduction

NDC80 kinetochore complex component (NUF2) is upregulated and plays an important role in various human cancers. However, the function and mechanism of NUF2 in epithelial ovarian cancer (EOC) remain unclear.

Methods

NUF2 expression was detected in EOC tissues and cell lines. The effects of NUF2 downregulation on cell proliferation, migration and invasion in EOC were analyzed by CCK-8 and Transwell assays. Meanwhile, the effect of NUF2 downregulation on tumor growth in vivo was determined by xenograft tumor models. The mechanisms by which NUF2 regulates EOC progression were detected by RNA sequencing and a series of in vitro assays.

Results

We showed that NUF2 was significantly upregulated in EOC tissues and cell lines, and high NUF2 expression was associated with FIGO stage, pathological grade and poor EOC prognosis. NUF2 downregulation decreased cell proliferation, migration, invasion and tumor growth in nude mice. RNA sequencing studies showed that NUF2 knockdown inhibited several genes enriched in the phosphatidylinositol-4,5-bisphosphate 3-kinase (PI3K)-AKT serine/threonine kinase (AKT) and mitogen-activated protein kinase (MAPK) signaling pathways. Erb-B2 receptor tyrosine kinase 3 (ERBB3) was the key factor involved in both of the above pathways. We found that ERBB3 silencing could inhibit EOC progression and repress activation of the PI3K-AKT and MAPK signaling pathways. Furthermore, the exogenous overexpression of ERBB3 partially reversed the inhibitory effects on EOC progression induced by NUF2 downregulation, while LY294002 and PD98059 partially reversed the effects of ERBB3 upregulation.

Conclusion

These results showed that NUF2 promotes EOC progression through ERBB3-induced activation of the PI3K-AKT and MAPK signaling axes. These findings suggest that NUF2 might be a potential therapeutic target for EOC.

Serbian National Training Programme for minimally invasive colorectal surgery (LapSerb): short-term clinical outcomes of over 1400 colorectal resections

INTRODUCTION

The Serbian National Training Programme for minimally invasive colorectal surgery (LapSerb) was introduced to implement laparoscopic colorectal surgery across Serbia. The programme aimed to accelerate training of established colorectal surgeons through a competency-based programme. This involved knowledge assessment, workshops, live operating, and competency-based assessment of unedited videos. The aim of this study is to report the outcomes of laparoscopic colorectal resection performed by LapSerb certified surgeons.

METHODS

LapSerb prospectively maintained multicentred database was analysed for laparoscopic colorectal resections from January 2015 to February 2021. Data collected included patient demographics, indications for surgery, perioperative data, and 30-day outcomes.

RESULTS

A total of 1456 laparoscopic colectomies by 24 certified surgeons were included in the final analysis. Mean age was 67 (± 12) years old and male to female ratio was 1:1.5. 83.1% of the colectomies were malignant, mainly due to adenocarcinoma. Anterior resection was the most common procedure with 699 (48%) cases, followed by right and left colectomies with 357 (24.5%) and 303 (21%) procedure respectively. 4.8% of patients required conversion to open surgery. Thirty-day readmission and reoperation rates were 2.3% and 4.7%, respectively. Overall mortality in all cases was 1.1% and R0 resections were achieved in 97.8% of malignant colectomies.

CONCLUSION

The LapSerb programme successfully and safely established laparoscopic colorectal surgery across the country with comparable and acceptable short-term clinical outcomes.

ATAD2 Upregulation Promotes Tumor Growth and Angiogenesis in Endometrial Cancer and Is Associated with Its Immune Infiltration

Background

Endometrial cancer is one of the three major gynecologic malignancies, and its incidence continues to rise. ATPase family AAA structural domain-containing protein 2 (ATAD2) is an ATPase protein, which is an independent factor for poor prognosis in endometrial cancer. However, its role in the disease is yet to be determined.

Methods

The Tumor IMmune Estimation Resource (TIMER) database was used to assess ATAD2 expression in pan-cancer, and the relevance of ATAD2 expression in Uterine Corpus Endometrial Carcinoma (UCEC) in clinical settings was obtained using Gene Expression Profiling Interactive Analysis (GEPIA) and UALCAN analysis. In addition, the Human Protein Atlas database was used to assess ATAD2 protein expression in UCEC. Furthermore, in vitro molecular biology and in vivo functional experiments were employed to ascertain the effect of ATAD2 expression on tumor angiogenesis and tumor growth. UALCAN was used to screen for ATAD2 coexpressed genes, and Sangerbox was utilized to perform Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analyses of these coexpressed genes. Finally, the TIMER, Tumor Immune System Interaction and Drug Bank (TISIDB), and GEPIA databases were used to analyze the relationship between ATAD2 and immune infiltration.

Results

ATAD2 is highly expressed in a variety of tumors, and in UCEC, it plays the role of a protooncogene. Basic experiments revealed that ATAD2 promotes vascular endothelial growth factor expression in endometrial cancer and affects tumor growth and angiogenesis. In addition, GO and KEGG enrichment analyses showed that ATAD2-associated genes were chiefly enriched in certain signaling pathways, such as herpes simplex virus 1 infection and that ATAD2 was associated with immune infiltration in UCEC.

Conclusion

Our findings suggest that ATAD2 promotes tumor growth and angiogenesis in endometrial cancer. Furthermore, ATAD2 is associated with immune infiltration and is a potential diagnostic and therapeutic target.

The experiences of endometriosis patients with diagnosis and treatment in New Zealand

Endometriosis is a chronically painful, invasive, inflammatory disease, with limited treatment options and long delays to diagnosis, which impacts 10% of females in New Zealand.

Introduction

As part of a larger group discussion study, this paper covers three themes associated with endometriosis patient experiences: intensity of pain, diagnostic tool shortcomings and perspectives of treatment options.

Materials and methods

The goal of this research was the inclusion of patient voices to guide research priorities. In early 2022, 50 New Zealand endometriosis patients participated in anonymous, asynchronous, text-based group discussions on the VisionsLive platform. The patients ranged in age from 18-48. The patients answered 50 questions, 23 text-based and 27 quantitative, and then took part in online group discussions.

Results and discussion

The average age of symptom onset was 15.3 years, while the average delay from symptom onset to a working or surgically confirmed diagnosis was 7.91 years. The top five reported symptoms within the cohort were pain-based, and the participants discussed the many impacts of this pain on their work and education. The four main diagnostic tools employed on this cohort were abdominal ultrasound (72%), transvaginal ultrasound (68%), laparoscopy (82%) and sharing their symptom history with a medical practitioner (88%). The most common emotions patients experienced following receiving a diagnosis of endometriosis were relief (86%), feeling overwhelmed (54%), and anger (32%). The main treatments offered to this cohort were pain relief (96%), laparoscopic surgery (84%) and the combined oral contraceptive pill (80%). Of these three treatments, only laparoscopic surgery was viewed positively by the majority of users, with 67% considering laparoscopy an effective treatment, compared to 46% of users for pain relief, and 25% of users for the combined oral contraceptive pill.

Conclusions

Gathering the voice of patients revealed that long delays to diagnosis and dismissal by medical practitioners frequently manifests as a reaction of relief by patients once diagnosed. Results also showed treatment options such as pain relief and hormonal medications were often considered ineffective, but were routinely offered as the first, or only, options for patients. It is therefore important that both quicker routes to diagnosis and more effective treatment options be developed.

Construction of a miRNA-Based Nomogram Model to Predict the Prognosis of Endometrial Cancer

Objective: To investigate the differential expression of microRNA (miRNA) in patients with endometrial cancer and its relationship with prognosis and survival. Method: We used The Cancer Genome Atlas (TCGA) database to analyze differentially expressed miRNAs in endometrial cancer tissues and adjacent normal tissues. In addition, we successfully screened out key microRNAs to build nomogram models for predicting prognosis and we performed survival analysis on the key miRNAs as well. Result: We identified 187 differentially expressed miRNAs, which includes 134 up-regulated miRNAs and 53 down-regulated miRNAs. Further univariate Cox regression analysis screened out 47 significantly differentially expressed miRNAs and selected 12 miRNAs from which the prognostic nomogram model for ECA patients by LASSO analysis was constructed. Survival analysis showed that high expression of hsa-mir-138-2, hsa-mir-548f-1, hsa-mir-934, hsa-mir-940, and hsa-mir-4758 as well as low-expression of hsa-mir-146a, hsa-mir-3170, hsa-mir-3614, hsa-mir-3616, and hsa-mir-4687 are associated with poor prognosis in EC patients. However, significant correlations between the expressions levels of has-mir-876 and hsa-mir-1269a and patients' prognosis are not found. Conclusion: Our study found that 12 significantly differentially expressed miRNAs might promote the proliferation, invasion, and metastasis of cancer cells by regulating the expression of upstream target genes, thereby affecting the prognosis of patients with endometrial cancer.

Impact of endometriosis on women's life decisions and goal attainment: a cross-sectional survey of members of an online patient community

OBJECTIVES

To examine women's perceptions of endometriosis-associated disease burden and its impact on life decisions and goal attainment.

DESIGN

An anonymous online survey was distributed in October 2018 through the social media network MyEndometriosisTeam.com.

PARTICIPANTS

Women aged 19 years and older living in several English-speaking countries who self-identified as having endometriosis.

OUTCOME MEASURES

Patients' perspectives on how endometriosis has affected their work, education, relationships, overall life decisions and attainment of goals. Subanalyses were performed for women who identified as 'less positive about the future' (LPAF) or had 'not reached their full potential' (NRFP) due to endometriosis.

RESULTS

743 women completed the survey. Women reported high levels of pain when pain was at its worst (mean score, 8.9 on severity scale of 0 (no pain) to 10 (worst imaginable pain)) and most (56%, n=415) experienced pain daily. Women reported other negative experiences attributed to endometriosis, including emergency department visits (66%, n=485), multiple surgeries (55%, n=406) and prescription treatments for symptoms of endometriosis (72%, n=529). Women indicated that they believed endometriosis had a negative impact on their educational and professional achievements, social lives/relationships and overall physical health. Most women 'somewhat agreed'/'strongly agreed' that endometriosis caused them to lose time in life (81%, n=601), feel LPAF (80%, n=589) and feel they had NRFP (75%, n=556). Women who identified as LPAF or NRFP generally reported more negative experiences than those who were non-LPAF or non-NRFP.

CONCLUSIONS

Women who completed this survey reported pain and negative experiences related to endometriosis that were perceived to negatively impact major life-course decisions and attainment of goals. Greater practitioner awareness of the impact that endometriosis has on a woman's life course and the importance of meaningful dialogue with patients may be important for improving long-term management of the disease and help identify women who are most vulnerable.

Challenging cases in oncofertility: insights from a national specialized e-meeting for fertility preservation specialists

Purpose

To determine the use of a new specialized E-Meeting for Complex Cases in Oncofertility by fertility preservation specialists (FPSs)

Material and methods

We present 3 years of activity of the E-Meeting for Complex Cases in Oncofertility, a new tool created in September 2016 which allows national oncofertility experts to share viewpoints about challenging cases for which they do not have experience or sufficient data in order to provide them an emergency advice within 48 h. Second, a survey was conducted to evaluate the use of this e-meeting for participating FPSs.

Results

One hundred and four experts have joined the e-meeting since its set-up, and 109 challenging cases have been submitted. The mean age of the patients was 22.4 ± 8.9 years, and 87.0% were female. Each submitted case received on average of 1.8 ± 1.1 different strategies for FP and the opinions of 7.1 ± 3.4 experts. Among the FPSs who submitted cases, seeking opinions from other FPSs allowed them to confirm their care plan (N = 49, 84.4%), to offer different options to their patients (N = 34, 58.6%), and to compare their practices with those of other specialists (N = 23, 39.6%). All respondents reported a self-perceived improvement in their practice of oncologic FP (n = 80, 100.0%).

Conclusion

Specific attention should be paid to challenging cases for which the experiences of only a few individuals exist. Enhancing communication between FPSs through oncofertility networks, pooling experiences, and collecting the most complex cases is required to improve the management of these patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10815-021-02275-1.

A Non-Infectious Uveitis Multidisciplinary Clinic in a Tertiary Referral Center: Clinical Impact and Added Value

Non-infectious uveitis (NIU) is a group of sight-threatening diseases that generates significant burden for the healthcare systems due to its adverse outcomes, irreversible structural complications in the eye with loss of visual function, limited clinical expertise and low-grade evidence for best practice. The usefulness of multidisciplinary care, specifically close collaboration between Rheumatologists and Ophthalmologists in NIU, has been emphasized in the literature. In this paper, the assessment tools and protocols used in our clinic are depicted and an overview of our activity with a brief description of the patients included in our registry, between 2018 and 2020 is provided. The cohort of 290 patients assessed in our NIU clinic, their demographics, sources of referral, details about immunosuppression treatment, and internal and external collaborations is described. This experience-based manuscript aims to describe the general functioning of our multidisciplinary NIU clinic, highlighting the benefits and drawbacks of multidisciplinary team management in patients with NIU, ultimately initiating a dialogue on what an NIU clinic should be and providing information for newly NIU clinics start-up. In conclusion, establishing a standardized and multidisciplinary clinic in NIU allows to systematically observe and follow-up this infrequent disease at a tertiary hospital level, thus improving quality of care delivery and research avenues.

MRI for the diagnosis and staging of deeply infiltrating endometriosis: a national survey of BSGE accredited endometriosis centres and review of the literature

OBJECTIVES

Our objective was to establish the primary mode of imaging and MR protocols utilised in the preoperative staging of deeply infiltrating endometriosis in centres accredited by the British Society of Gynaecological Endoscopy (BSGE).

METHODS

The lead consultant radiologist in each centre was invited to complete an online survey detailing their protocols.

RESULTS

Out of 49 centres, 32 (65%) responded to the survey. Two centres performed transvaginal ultrasound as the primary method for preoperative staging of deeply infiltrating endometriosis and the remainder performed MRI. 21/25 centres did not recommend a period of fasting prior to MRI and 22/25 administered hyoscine butylbromide. None of the centres routinely offered bowel preparation or recommended a specific pre-procedure diet. 21/25 centres did not time imaging according to the woman's menstrual cycle, and instructions regarding bladder filling were varied. Rectal and vaginal opacification methods were infrequently utilised. All centres preferentially performed MRI in the supine position - six used an abdominal strap and four could facilitate prone imaging. Just under half of centres used pelvic-phased array coils and three centres used gadolinium contrast agents routinely. All centres performed T1W with fat-suppression and T2W without fat-suppression sequences. There was significant variation relating to other MR sequences depending on the unit.

CONCLUSIONS

There was significant inconsistency between centres in terms of MR protocols, patient preparation and the sequences performed. Many practices were out of line with current published evidence.

ADVANCES IN KNOWLEDGE

Our survey demonstrates a need for evidence-based standardisation of imaging in BSGE accredited endometriosis centres.

The multidisciplinary management of rectal cancer

Rectal cancer treatment has evolved during the past 40 years with the use of a standardized surgical technique for tumour resection: total mesorectal excision. A dramatic reduction in local recurrence rates and improved survival outcomes have been achieved as consequences of a better understanding of the surgical oncology of rectal cancer, and the advent of adjuvant and neoadjuvant treatments to compliment surgery have paved the way for a multidisciplinary approach to disease management. Further improvements in imaging techniques and the ability to identify prognostic factors such as tumour regression, extramural venous invasion and threatened margins have introduced the concept of decision-making based on preoperative staging information. Modern treatment strategies are underpinned by accurate high-resolution imaging guiding both neoadjuvant therapy and precision surgery, followed by meticulous pathological scrutiny identifying the important prognostic factors for adjuvant chemotherapy. Included in these strategies are organ-sparing approaches and watch-and-wait strategies in selected patients. These pathways rely on the close working of interlinked disciplines within a multidisciplinary team. Such multidisciplinary forums are becoming standard in the treatment of rectal cancer across the UK, Europe and, more recently, the USA. This Review examines the essential components of modern-day management of rectal cancer through a multidisciplinary team approach, providing information that is essential for any practising colorectal surgeon to guide the best patient care.

Pathophysiological Basis of Endometriosis-Linked Stress Associated with Pain and Infertility: A Conceptual Review

Women with endometriosis are often under stress due to the associated pain, infertility, inflammation-related and other comorbidities including cancer. Additionally, these women are also under stress due to taboos, myths, inter-personal troubles surrounding infertility and pain of the disease as well as due to frequent incidences of missed diagnosis and treatment recurrence. Often these women suffer from frustration and loss of valuable time in the prime phase of life. All these complexities integral to endometriosis posit a hyperstructure of integrative stress physiology with overt differentials in effective allostatic state in women with disease compared with disease-free women. In the present review, we aim to critically examine various aspects of pathophysiological basis of stress surrounding endometriosis with special emphasis on pain and subfertility that are known to affect the overall health and quality of life of women with the disease and promising pathophysiological basis for its effective management.

The Exeter Knee Infection Multi Disciplinary Team approach to managing prosthetic knee infections: A qualitative analysis

Background

A Knee Infection Multi-Disciplinary Team meeting was established in Exeter. This study was designed to qualitatively evaluate the impact of the MDT on those involved.

Materials and methods

Semi-structured interviews of all members of the MDT at Exeter were undertaken and analysed using Nvivo software. Data was coded to identify common patterns and trends.

Results

The common themes identified were improved communication and standardisation of care. The main challenges identified were the timing of the meetings and funding.

Conclusion

This study has used established qualitative techniques to evaluate the impact of the Exeter Knee Infection MDT.