Novel Technology to Capture Objective Data from Patients' Recovery from Laparoscopic Endometriosis Surgery.

STUDY OBJECTIVE: To assess the feasibility of a noncontact radio sensor as an objective measurement tool to study postoperative recovery from endometriosis surgery. DESIGN: Prospective cohort pilot study. SETTING: Center for minimally invasive gynecologic surgery at an academically affiliated community hospital in conjunction with in-home monitoring. PATIENTS: Patients aged above 18 years who sleep independently and were scheduled to have laparoscopy for the diagnosis and treatment of suspected endometriosis. INTERVENTIONS: A wireless, noncontact sensor, Emerald, was installed in the subjects' home and used to capture physiologic signals without body contact. The device captured objective data about the patients' movement and sleep in their home for 5 weeks before surgery and approximately 5 weeks postoperatively. The subjects were concurrently asked to complete a daily pain assessment using a numeric rating scale and a free text survey about their daily symptoms. MEASUREMENTS AND MAIN RESULTS: Three women aged 23 years to 39 years and with mild to moderate endometriosis participated in the study. Emerald-derived sleep and wake times were contextualized and corroborated by select participant comments from retrospective surveys. In addition, self-reported pain levels and 1 sleep variable, sleep onset to deep sleep time, showed a significant (p <.01), positive correlation with next-day-pain scores in all 3 subjects: r = 0.45, 0.50, and 0.55. In other words, the longer it took the subject to go from sleep onset to deep sleep, the higher their pain score the following day. CONCLUSION: A patient's experience with pain is challenging to meaningfully quantify. This study highlights Emerald's unique ability to capture objective data in both preoperative functioning and postoperative recovery in an endometriosis population. The utility of this uniquely objective data for the clinician-patient relationship is just beginning to be explored.

[The role of the combined balneotherapeutic treatment as the 'add-back therapy' against the background of the anti-hormonal effects of the agonists of gonadotropin-releasing hormone in the women suffering from endometriosis genitalis externa]. / Kompleksnoe bal'neolechenie v kachestve terapii prikrytiia na fone antigormonal'nogo vozdeistviia agonistami gonadotropin-rilizing gormona u zhenshchin s naruzhnym éndometriozom.

BACKGROUND: The use of agonists of gonadotropin-releasing hormone (GnRH) for the rehabilitation treatment of the patients presenting with endometriosis genitalis externa is known to significantly enhance the risk of development of hypoestrogenism. The so-called 'add-back-therapy' is carried out as a preventive measure to eliminate hypoestrogenism caused by the intake of GnRH agonists without detriment to the effectiveness of anti-hormonal therapy. AIM: The objective of the present study was to estimate the effectiveness of the new method ('add-back hormone replacement therapy') in comparison with anti-hormonal therapy with the use of GRH agonists at the stage of the early postoperative medical rehabilitation based on the drinking of mineral waters (MW) and radon therapy (RT) in the patients who had undergone the laparoscopic interventions for the treatment of endometrioid heterotopies of the ovaries (1-3 months post-operatively). MATERIAL AND METHODS: To evaluate the effectiveness of the spa and health resort-based rehabilitation measures, the long-term effects of GnRH agonists have been studied in 2 groups of the patients formed by the of simple randomization method. The main group (MG) was comprised of 45 women received medical rehabilitation under conditions of a spa and health resort setting with the application of medium-salt water from the Pyatigorsk spring and radon therapy in the combination with triptorelin. The group of comparison (CG) was composed of 44 women given the treatment with the use of triptorelin under the out-patient conditions. The assessment of the results of the study included: the estimation of the intensity of pelvic pain syndrome, indicators of the hormonal status and the quality of life (QL), ultrasonic examination of the pelvic organs, and the occurrence of adverse effects of triptorelin. The duration of the study was 3 years (2014-2016). RESULTS: The analysis of the long-term results of the rehabilitative treatment has demonstrated that the rehabilitation activities under the spa and health resort conditions within 1-3 months after the surgical intervention including the application of MW and RT in the combination with an agonist of gonadotropin-releasing hormone (triptorelin) greatly contributed to the stability of the results of the treatment: specifically, only 2.5% of the patients suffered the recurrence of cystic ovarian endometriosis whereas 24.5% (p<0.001) reported the restoration of the reproductive function. The patients comprising the control group experienced the recurrence of the pathologic process in 7.5% of the cases and the restoration of the reproductive function in 15.8% of the cases (p<0.001). Simultaneously, the quality of life in the patients in the main group improved 3.4 times on the average in comparison with the initial level (p<0.001). The 2.2-fold improvement of the quality of life was documented in the control patients (p<0.001). At the same time, the frequency of adverse reactions to the treatment with triptorelin in the control patients was higher than in the main group including pain in the epigastric area, headache, irritability, hyperhidrosis, and instability of arterial blood pressure (ABP) that significantly deteriorated the life quality in these women. CONCLUSION: The comparative analysis of the results of the follow-up observations has demonstrated that the application of drinking mineral water and radon therapy for the treatment of the women suffering from endometriosis genitalis externa can be recommended as 'add-back therapy' against the background of anti-hormonal effects of agonists of gonadotropin-releasing hormone.

The long-term effects of endometrioma surgery on ovarian reserve: a prospective case-control study.

The objective of this study was to evaluate the long-term effects of endometrioma excision on ovarian reserve. This study evaluated the long-term effects of endometrioma excision on ovarian reserve. A total of 63 women were enrolled in this prospective case-control study; 21 women had histories of endometrioma surgery (study group), 21 women had diagnoses of endometrioma, and 21 healthy age-matched women served as controls. Participants were recruited from the Department of Obstetrics and Gynecology, Inonu University Faculty of Medicine, between January 2007 and January 2016. The mean follow-up duration after endometrioma surgery was 30.4 ± 18.0 months for the study group. The mean follicle-stimulating hormone, luteinizing hormone and estradiol levels were similar among groups, but the anti-Müllerian hormone (AMH) level was significantly lower in the surgery group than in the control group (p < .001). The mean AMH level was 42% lower in the endometrioma surgery group than in the endometrioma group and 30% lower in the endometrioma group than in the control group (p = .080 and p = .160, respectively). Endometrioma has a detrimental effect on ovarian reserve, and decreased ovarian reserve compared with that in healthy fertile subjects without endometrioma is evident shortly after endometrioma excision. However, the endometrioma excision procedure does not significantly decrease the ovarian reserve in the long term.

[The application of low-frequency ultrasound for the comprehensive treatment and rehabilitation of the patients presenting with chronic endometritis]. / Primenenie nizkochastotnogo ul'trazvuka v kompleksnoi terapii i reabilitatsii patsientok s khronicheskim éndometritom.

The incidence of chronic endometritis remains rather high despite considerable progress in reproductive medicine including the advent of the new methods for assisted reproduction; the pregnancy rate after the treatment of this condition is still unacceptably low. It implies the necessity of the careful preparation of endometrium for the implantation of the embryo especially in women with a history of unsuccessful outcomes of the IVF treatment. It calls for the development of the efficient therapeutic modalities for the management of chronic endometritis and restoration of the normal reproductive function; their introduction into the therapeutic algorithm remains equally relevant. The characteristic features of chronic endometritis include blood circulatory disorders in the vessels of the uterus and in the pelvic vascular basin, changes of local immunity in the endometrium concomitant with the activation of cellular and humoral responses of inflammation in the form of enhanced leukocyte infiltration and increased production of cytokines. The long duration of such a process results in the development of fibrosis that, in its turn, leads to chronic tissue hypoxia, potentiation of inflammation, and disruption of decidualization that hampers successful implantation. The article shows the possibility of using low-intensity ultrasound for the treatment and rehabilitation of the patients presenting with chronic endometritis. The data concerning the primary biophysical processes developing in the tissues under the influence of ultrasound are discussed. The therapeutic effects and their underlying mechanisms and described. The physiotherapeutic treatment considerably improved vascular hemodynamics in the pelvic basin and produced trophotropic, defibrosing, and anti-inflammatory effects. The clinical data giving evidence of the high effectiveness of the application of intrauterine ultrasound cavitation provide a basis for the recommendation to include this physical factor in the existing algorithms for the pre-gravid preparation of the women presenting with disorders of the reproductive function and chronic endometritis.

SF-36 preoperative interest of predicting improvement of quality of life after laparoscopic management of minimal endometriosis.

THE PURPOSE OF THE STUDY: To study preoperative thresholds of the SF-36 components above which we can predict a high risk of failure in order to improve the quality of life after surgery for patients with minimal endometriosis. MATERIAL AND METHODS: Design: prospective and multicenter observational study between February 2004 and 2011. PATIENTS: 167 patients with operated minimal endometriosis. SETTING: for the Physical Component Summary (PCS) or the Mental Component Summary (MCS) subscales of the SF-36 questionnaire, an improvement defined by an increase of 5 points. INTERVENTION: evaluation by the SF-36 questionnaire the week before and one year after surgery. MEASUREMENT AND MAIN RESULTS: Success of surgery measured by an improvement in both components. We found significantly different initial variables between patients with improvement and those without: initial MCS score (P=0.0003), initial PCS score (P<0.0001) and dyspareunia (P=0.004). Multivariate analysis revealed only two significant variables. Initial MCS higher than 40 (OR=4.6) and initial PCS higher than 50 (OR=10.6) are risk factors for failure of improvement after surgery. CONCLUSION: Surgery is seldom a good treatment for improving QOL in minimal endometriosis. We set two thresholds for SF-36, 50 for PCS and 40 for MCS: above there is a very high risk of failure (86% of failure in our population). Under, the risk of failure remains high (54.3%). CANADIAN TASK FORCE CLASSIFICATION OF STUDY DESIGN: Evidence obtained from well-designed cohort or case-control studies, preferably from more than one center or research group.

Tratamentos na Endometriose: Uma revisão sistemática / Treatments in Endometriosis: A systematic review

Introdução: O tratamento da endometriose permanece em discussão e tem como objetivo primário a redução da dor e melhora da qualidade de vida. Objetivos: analisar quais tratamentos vem sendo utilizados até então para endometriose e qual seu grau de evidência. Métodos: a pesquisa foi realizada na base de dados pubmed, Science direct e medline, seguindo as orientações PRISMA. Resultados: Para dor pélvica, são descritos os tratamentos empíricos baseados em orientações físicas e aconselhamentos, progestágenos, anticoncepcionais, antiinflamatórios e SIU-LNG (dispositivo de liberação hormonal intra-útero). Já os tratamentos citados para infertilidade são, ablação cirúrgica das lesões, cirurgias mais complexas que envolvem outros sistemas além do reprodutor, tratamento hormonal pós cirúrgico e inseminação intra-útero e fertilização in vitro. Conclusão: Atualmente o tratamento padrão é a laparoscopia nos casos mais graves, com dores mais intensas ou infertilidade e a terapia conservadora sobretudo, os tratamentos hormonais em casos considerados mais brandos.

Introduction: The treatment of endometriosis remains under discussion and its primary objective the reduction of pain and improvement in quality of life. Objectives: To analyze which treatment has been previously used for endometriosis and what their level of evidence. Methods: The survey was conducted in Pubmed database, Science direct and medline, following the PRISMA guidelines. Results: For pelvic pain are described empirical treatment based on physical guidance and counseling, progestogen contraceptives, anti-inflammatory and LNG-IUS (intrauterine hormonal release device). Already mentioned treatments for infertility are surgical removal of the lesions, more complex operations involving other systems besides the player, hormone treatment and post surgical intrauterine insemination and IVF. Conclusion: Currently the standard treatment is laparoscopic in severe cases with more severe pain or infertility and conservative therapy especially hormonal treatments in cases considered milder.

[Rehabilitation goals in discharge reports and in patient questionnaires--on the example of endometriosis patients]. / Rehabilitationsziele in ärztlichen Entlassungsberichten und in Patientenfragebogen--am Beispiel von Endometriose-Patientinnen.

BACKGROUND: [corrected] The goal orientation of rehabilitation has increasingly found its way in research and practice. Though, shortcomings were ascertained for the implementation into the clinical routine furthermore. An empirical analysis of goal setting in clinical practice should complement the available evidence. METHODS: The study is based on a cross-sectional survey of all endometriosis patients, who had been treated at a rehabilitation center in 2008 or 2009. Data stemmed from the uniform medical rehabilitation discharge reports, and a patient questionnaire, which was sent to the registered women by the clinic routinely before the beginning of the rehabilitation. Data about rehabilita­tion goals were available as free text information for both the discharge reports as well as the pa­tient questionnaires. A category system oriented at the ICF system (International Classification of Functioning, Disability and Health), was developed to structure the goals. RESULTS: 293 patients had provided information concerning their rehabilitation goals, while 69 patients didn't reply to the question of their rehabilitation goals. The latter were excluded to the analysis. In the discharge reports, altogether, more goals were documented than in the patient questionnaires (5.98 compared to 4.97 goals per patient). In 35% of the numbers of rehabilitation goals clear congruence was found between the data in the discharge reports and the patient questionnaires. CONCLUSION: The results support the assump­tion that the included patients had difficulties in goal-setting. In addition it is obvious that the goals in the discharge reports had little relation to the goals framed by the patients, in language and content. A goal-setting process less oriented towards the medical and clinical needs but more towards the patients needs and expectation would be desirable particularly with regard to a more intensive patient orientation. The implementation of a prepared list of possible rehabilitation goals could serve for the shared goal-setting process in the context of anamnesis.

One-year follow-up of serum antimüllerian hormone levels in patients with cystectomy: are different sequential changes due to different mechanisms causing damage to the ovarian reserve?

OBJECTIVE: To investigate whether the serum antimüllerian hormone (AMH) levels recover within 1 year after cystectomy for endometriomas, and to analyze the pattern of sequential changes in the serum AMH levels. DESIGN: Prospective study. SETTING: University hospital. PATIENT(S): Thirty-nine patients undergoing cystectomy for unilateral endometrioma (n = 22) and bilateral endometriomas (n = 17). INTERVENTION(S): Serum samples collected 2 weeks before, and 1 month and 1 year after surgery were assayed for AMH levels. MAIN OUTCOME MEASURE(S): Assessment of the ovarian reserve damage based on alterations in the serum AMH levels and the association with parameters of endometriosis and surgery for endometriomas. RESULT(S): The median AMH levels were 3.56, 1.90, and 2.10 ng/mL before, 1 month after, and 1 year after surgery, respectively. Twenty patients showed higher AMH levels 1 year after surgery than 1 month after surgery (increase group); 19 patients showed lower AMH levels (decrease group). We found a statistically significant difference in the number of follicles removed by surgery between the two groups. CONCLUSION(S): The decrease in the serum AMH levels caused by cystectomy can recover. Our results suggest that removal of ovarian cortex might be involved in the decrease of the ovarian reserve just after surgery, and that a continuous decrease of the ovarian reserve after cystectomy might be attributed to other mechanisms.

[The use of restorative medicine technologies for the rehabilitation of the patients presenting with endometriosis of external genitalia].

This paper reports the results of analysis of the psycho-emotional status and pain syndrome in the women presenting with endometriosis of external genitalia treated with a combination of hormonal preparations and balneotherapy. A total of 216 infertile patients were involved in the study. The duration of the infertility period varied from 1.5 to 19 years. All the patients underwent surgical intervention. The influence of rehabilitative therapy on the quantitative vital indices (psycho-emotional adaptation to the social environment and pain intensity) was estimated before and after the treatment. The patients were divided into 3 groups. Those of group 1 received an oral contraceptive (30 mcg of ethinylestradiol plus 2 mg dienogest) as a continuous three-cycle course (63 tablets) followed by its discontinuation for the 7 day menstrual period and the final three-cycle course (total duration of therapy 6 months). The patients of group 2 were treated with injections of agonists of gonadotropin releasing hormone (GnRH) at a dose of 3.75 mg once every 4 weeks (total duration 6 months). In group 3, the injections of GnRH agonists (3.75 mg once every 4 weeks, total duration 6 months) were combined with a course of balneotherapy using radon. All the three rehabilitative modalities produced a well-apparent positive effect. Chronic pelvic pain before treatment was reported by 90,3% of the patients. After the treatment, the number of such women in groups 1, 2, and 3 decreased to 20,8%, 12,5%, and 30,6% respectively Dyspareunia in the pre-treatment period was diagnosed in 66,7% of the patients. After treatment, this pathology persisted only in 23,6%, 18,1%, and 31,9% of the patients in groups 1, 2, and 3 respectively. Psycho-emotional disorders before treatment were documented in 90,3% of the patients compared with 27,8%, 25%, and 30,6% after therapy. It is concluded that all the three therapeutic modalities markedly improved health conditions of the patients presenting with endometriosis of external genitalia, but the combination of GnRH agonists with radon therapy produced the most pronounced clinical effect.

Effect of patient selection on estimate of reproductive success after surgery for rectovaginal endometriosis: literature review.

The effect of rectovaginal endometriosis on fertility is unclear. Several authors foster radical surgery, including colorectal resection, as a fertility-enhancing procedure. However, interpretation of data is difficult, as the baseline fertility status is often undefined and it is not always possible to discriminate between spontaneous conceptions and those resulting from IVF. A systematic literature review was performed with the aim of defining the pregnancy rate specifically in patients who were infertile before surgery and who sought spontaneous pregnancy. A PubMed search was conducted to identify English language studies published between 2005 and 2011 evaluating reproductive performance after surgery for rectovaginal and rectosigmoid endometriosis. According to the results of the 11 selected studies, the mean post-operative conception rate in all women seeking pregnancy independently of preoperative fertility status and IVF performance was 39% (95% CI 35-43%; 223/571), but dropped to 24% (95% CI 20-28%; 123/510) in infertile patients who sought spontaneous conception (odds ratio 0.50, 95% CI 0.38-0.65%). Patients' selection significantly influences the estimate of the effect of rectovaginal endometriosis excision on infertility. This should be carefully taken into consideration at preoperative counselling. Rectovaginal endometriosis usually is associated with pain symptoms, but the effect of this disease form on fertility is uncertain, as burial of foci beneath rectouterine adhesions with exclusion of the deepest part of the pelvis may limit interference with fertilization processes. Several authors foster radical surgery, including colorectal resection, as a fertility-enhancing procedure. However, interpretation of data is difficult, as the baseline fertility status is often undefined and it is not always possible to discriminate between spontaneous conceptions and those resulting from IVF. A systematic literature review was performed with the aim of defining the pregnancy rate specifically in patients who were infertile before surgery and who sought pregnancy spontaneously. A PubMed search was conducted to identify English language studies published between 2005 and 2011 evaluating reproductive performance after surgery for rectovaginal and rectosigmoid endometriosis. According to the results of the 11 selected studies, the mean post-operative conception rate in all women seeking pregnancy independently of preoperative fertility status and IVF performance was 39% (223/571), but dropped to 24% (123/510) in infertile patients who sought conception spontaneously. The 15% difference is statistically significant. Infertile patients with rectovaginal endometriosis considering surgery, should be carefully informed of the real probability of post-operative conception avoiding generic overestimations.

A pilot study of the prevalence of leg pain among women with endometriosis.

Radiating leg pain is a common symptom presenting in manual therapy practices. Although this symptom has been reported as a complication of endometriosis, its prevalence and characteristics have not been studied. We surveyed members of a national endometriosis support group with endometriosis using a self-administered, mailed questionnaire. The main outcome measures were the prevalence and characteristics of leg pain. Of 94 respondents, leg pain was reported by 48 women (51%), and was bilateral in 59% of these symptomatic women. The likelihood of experiencing leg pain was related to weight gain since age 18, age, and height. The most common treatments tried included exercise, over-the-counter medications, and massage therapy, all with variable results. These data support leg pain as a prevalent complication of endometriosis, and that the disease may affect multiple peripheral nerves. Manual therapists should remain aware to this possible etiology for radiating pain.

[General conditions concerning the implementation of an outpatient education programme--characteristics and distinctions from an inpatient training programme]. / Rahmenbedingungen für die Umsetzung eines ambulanten Schulungsprogramms--Besonderheiten und Abgrenzung zu einer stationären Schulung.

INTRODUCTION: The aim of the EVA study was to develop an outpatient education programme for women with endometriosis with a view to permanent transfer into routine care. Implementation of the programme generated several problems and obstacles that are not, or not to this extent, present in the inpatient setting of a rehabilitation clinic. METHODS: The patient education programme was developed in line with an existing inpatient programme, taking into account the criteria for evaluating such training programmes. Several adjustments to process, structure and content level had to be made to achieve the conditions of the outpatient setting. RESULTS: Since May 2008, 17 training courses took place in various outpatient and acute inpatient settings, and a total of 156 women with diagnosed endometriosis participated. The problems and obstacles that emerged affected similarly the process, structure and content of the training programme. DISCUSSION: On the structural level, especially problems with availability of rooms, technical equipment and trainers occurred, leading to significant time pressures. The main problem on the procedural level was the recruitment of participants, since--in contrast to the inpatient setting and to disease management programmes--no assignment by physicians or insurers takes place. Furthermore, gainful activity of the participants and the resulting shift of the training beyond the usual working and opening hours are important barriers for implementation. The unavailability of trainers in these settings requires creative solutions. Regarding the contents of the training it has to be taken into consideration that--unlike the inpatient setting--no aftercare intervention and no individual psychological consultation are possible. The training programme has to be designed in such a way that all problems that have occurred could be dealt with appropriately. CONCLUSION: In summary, the permanent implementation of an outpatient training programme is possible but is more time-consuming than inpatient trainings due to unfavourable conditions concerning recruitment, organization and procedure. It seems that "soft" factors such as motivation, integration into the clinic concept, well-defined acceptance of responsibility and experience in dealing with the disease and with patient groups are the critical success factors. Until now cost carriage by the health insurance funds has not been realized--except for disease management programmes; so there is still a need for action here.

Fertility after colorectal resection for endometriosis: results of a prospective study comparing laparoscopy with open surgery.

OBJECTIVE: To determine whether the surgical route of colorectal resection for endometriosis is a determinant factor for fertility. DESIGN: Prospective study. SETTING: Tertiary-care university hospital. PATIENT(S): Fifty-two patients with endometriosis were randomly assigned to laparoscopic or open surgery. INTERVENTION(S): Laparoscopically assisted vs. open colorectal resection. MAIN OUTCOME MEASURE(S): Evaluation of fertility outcomes spontaneously and after assisted reproductive therapy. RESULT(S): The mean follow-up was 29 months. Among the 28 patients wishing to conceive, 11 (39.3%) became pregnant. Overall cumulative pregnancy rate at 52 months for these patients was 45.1%. For patients with or without infertility, the cumulative pregnancy rate was 37.6% and 55.6%, respectively, and the cumulative spontaneous pregnancy rate 13.3% and 36.5%, respectively. All the spontaneous pregnancies were observed in the laparoscopy group. CONCLUSION(S): This study demonstrates that spontaneous pregnancy is more frequent after laparoscopy compared with open surgery for colorectal endometriosis.

Quality of life in endometriosis: evaluation of the Dutch-version Endometriosis Health Profile-30 (EHP-30).

The Dutch version of the Endometriosis Health Profile-30 (EHP-30) showed a high return rate and data completeness, low floor and ceiling effects, as well as good internal consistency, test-retest reliability and construct validity. The questionnaire is a reliable and valid instrument for the measurement of health-related quality of life in women with endometriosis.

Robotic versus standard laparoscopy for the treatment of endometriosis.

OBJECTIVE: To compare robot assisted laparoscopic platform to standard laparoscopy for the treatment of endometriosis. DESIGN: A retrospective cohort controlled study. SETTING: Tertiary referral center. PATIENT(S): Seventy-eight reproductive aged women. INTERVENTION(S): Robot assisted or standard laparoscopy for the treatment of endometriosis between January 2008 and January 2009. MAIN OUTCOME MEASURE(S): Operative time, estimated blood loss, hospitalization time, intraoperative and postoperative complications. RESULT(S): Seventy-eight patients underwent treatment of endometriosis, 40 by robot assisted laparoscopy and 38 by standard laparoscopy. The two groups were matched for age, body mass index (BMI), stage of endometriosis, and previous abdominal surgery. Mean operative time with the robot was 191 minutes (range 135-295 minutes) compared with 159 minutes (range 85-320 minutes) during standard laparoscopy. There were no significant differences in blood loss, hospitalization, intraoperative or postoperative complications. There were no conversions to laparotomy. CONCLUSION(S): Both robot assisted laparoscopic and standard laparoscopic treatment of endometriosis have excellent outcomes. The robotic technique required significantly longer surgical and anesthesia time, as well as larger trocars.

Are we underutilizing Palmer's point entry in gynecologic laparoscopy?

OBJECTIVE: To report our experience using Palmer's point entry in women undergoing gynecologic laparoscopic surgery. DESIGN: Retrospective observational study. SETTING: University teaching hospital, London, United Kingdom. PATIENT(S): We reviewed all patients who underwent laparoscopic gynecologic surgery under the care of the senior author between January 1, 2005, and December 31, 2008. INTERVENTION(S): Gynecologic laparoscopic surgery. MAIN OUTCOME MEASURE(S): Indications, incidence, success, and complications of using Palmer's entry. RESULT(S): Three hundred eighty-five patients underwent laparoscopic surgery. We used umbilical entry in 249 (64.6%) and Palmer's entry in 136 (35.4%). In almost three fourths of cases, the indications for using Palmer's point were previous laparotomy or the presence of large uterine fibroids. The next most common reasons for choosing Palmer's point were known documentation of intra-abdominal adhesions from prior laparoscopies, large ovarian cysts, and hernias or hernia repairs. Entry via Palmer's point was successful in all but two cases (98.5%), and there were no entry-related complications. CONCLUSION(S): Our experience shows that laparoscopic entry using the left upper quadrant is safe with a low failure rate. Because the vast majority of gynecologic laparoscopies are done using subumbilical entry, it seems that Palmer's entry is underused by many gynecologists, despite it being safer in patients at risk of underlying adhesions and more appropriate in the presence of a large pelvic mass or a nearby hernia.

Colorectal endometriosis: benefits of long-term follow-up in patients who underwent laparoscopic surgery.

In this retrospective cohort study, three groups of patients were included: 60 women who underwent endometriosis surgery with colorectal segmental resection, 40 women with surgical evidence of bowel endometriosis who underwent endometriosis removal without bowel resection, and 55 women affected by moderate or severe endometriosis with at least one endometrioma and deep infiltrating endometriosis but without bowel involvement. The results of a long-term ambulatory follow-up showed that if colorectal endometriosis was present, postoperative pain regression was more frequent, and among patients with bowel endometriosis the rate of recurrence was lower if segmental resection was performed.

Laparoscopic conservative surgery for stage IV symptomatic endometriosis: short-term surgical complications.

OBJECTIVE: To study severe endometriosis as a cause of pelvic pain, which represents one of the most challenging disorders in gynecology. DESIGN: Retrospective study. SETTING: Teaching hospital. PATIENT(S): A total of 1,363 women with severe endometriosis (revised American Society for Reproductive Medicine [rASRM] stage IV). INTERVENTIONS: A detailed survey of all patients with severe endometriosis (rASRM stage IV) who underwent laparoscopy at our center between January 2004 and December 2007 was carried out. MAIN OUTCOME MEASURE(S): Clinical and surgical data were retrieved and assessed according to the extent of surgery performed. Intraoperative, ultra-short, and short-term clinical complications were assessed. RESULTS: A total of 1,201 women underwent laparoscopic radical surgery with excision of all visible endometriotic lesions, with a significant improvement of symptoms at 1-month follow-up evaluation. The overall intraoperative complication rate was 2.0%. The morbidity was significantly increased when bowel surgery was performed, with a risk of intraoperative complications that was threefold higher. Of the patients who had bowel surgery, 18 (4.1%) required reintervention within the first week after surgery. CONCLUSION(S): We report on the safety and efficacy of laparoscopic eradication of all visible implants in cases of rASRM stage IV endometriosis when surgery is performed in a referral center.

Reconstrução de umbigo após ressecção de foco de endometriose / Umbilicus reconstruction after endometriosis scar

Várias técnicas têm sido utilizadas para reconstruir a cicatriz umbilical, mas nenhuma tem mostrado ser a ideal para todos os casos. Os autores apresen- tam um caso de reconstrução imediata de umbigo, utilizando uma técnica de simples execução, realizada após ressecção de foco de endometriose.

Various techniques have been used to reconstruct umbilical scar, however none have appeared to be the ideal for all cases. The authors present a case of imediat reconstruction of umbilicus making use of an simple technique wich was done after resection if umbilical endometriosis.

Measuring health-related quality of life outcomes in women with endometriosis--results of the Gynaecology Audit Project in Scotland.

The clinical management of endometriosis was addressed within the recent Gynaecology Audit Project in Scotland. The impact of endometriosis and its treatment on women's health-related quality of life was examined using a condition-specific measure and a general measure, the Short Form 36 health survey (SF-36). Postal questionnaires containing the health-related quality of life measures were sent to 273 women at diagnosis and six months later. The measurement properties, including the reliability, validity and responsiveness, of the measures were examined. The condition-specific questions and the SF-36 had a high level of reliability. The validity of the condition-specific scores was demonstrated by their high correlation with the SF-36 which is a well-validated measure. Furthermore, the condition-specific scores were related to clinicians' assessment of disease severity and the need for further treatment. At the six month follow-up, changes in scores conformed to expected hypotheses, demonstrating the responsiveness of both measures. As a general measure, the SF-36 appeared to reflect the effects of both the condition of interest (i.e. endometriosis) and other conditions affecting health at the time of measurement (i.e. treatment side effects). The condition-specific measure was more responsive than the SF-36 to the changes in pain symptoms which resulted from active treatment. A condition-specific questionnaire, together with a general measure such as the SF-36 health survey, can provide a reliable, valid and responsive package of measures for assessing health-related quality of life in women with endometriosis. Such measures should be used alongside clinical measures of outcome to assess the effectiveness of different treatment strategies for endometriosis. A similar approach combining general and specific instruments would be useful in medical audits of other conditions.