A Systematic Review of the Efficacy and Availability of Targeted Treatments for Central Sensitization in Women With Endometriosis.

OBJECTIVES: Central sensitization (CS) contributes to patient variability when treating pain in endometriosis. Targeting this process may alleviate hyperalgesia and allodynia in women refractory to current treatments. Currently, there has been no review of targeted treatments for central sensitization in women with endometriosis. Therefore, this review aims to identify and summarize the findings of studies regarding the availability and efficacy of targeted treatments for CS in women with endometriosis. MATERIALS AND METHODS: A systematic review was conducted searching MEDLINE, Embase and CINAHL. Inclusion criteria: primary research articles, women with endometriosis and CS features, and description of treatments for CS, or its effects on hyperalgesia and allodynia. Exclusion criteria: review articles, letters to the editor, commentaries, editorials, protocols, or women with endometriosis infiltrating nerves. Risk of bias analysis was conducted. Data was reviewed and summarized by treatment method. RESULTS: Eight studies met inclusion criteria, demonstrating limited research in this area. Four treatment options were addressed: surgical approaches, nerve stimulation approaches, injection-based therapies, and hormonal therapies. Surgery and nerve stimulation appear the most promising treatments for CS. Injections have limited and mixed evidence of efficacy. Limited evidence suggests hormonal therapies may be ineffective. DISCUSSION: Given the lack of evidence for any treatment, all require further research to determine treatment efficacy before options will be available clinically. There is a clear need for consistency in defining and identifying CS in study populations. This review identifies areas of interest, particularly surgery and nerve stimulation, from which future research must stem.

POMMS: Pre-operative misoprostol in myomectomy surgery: A randomised controlled pilot study.

OBJECTIVE: To assess the effect of pre-operative sublingual misoprostol on intra-operative blood loss in abdominal myomectomy as compared to placebo. STUDY DESIGN: Double-blind randomised controlled pilot study. A single tertiary Gynaecology Unit in Melbourne, Australia. Women ≥ 18 years old undergoing laparoscopic or open myomectomy. Women undergoing laparoscopic or open myomectomy for symptomatic uterine leiomyomas were randomised to pre-operative sublingual 400mcg misoprostol or placebo. Intra-operative blood loss was measured via accurate record keeping of the post-operative volume in the suction canister and weighed packs, minus any irrigation fluid used. RESULTS: Intraoperative blood loss in the misoprostol treatment group was 306 ml ± 281 ml, compared to 325 ± 352 ml in the placebo group; P = 0.83. Fibroid volume was a consistent predictor of intra-operative blood loss. For each 1 ml increase in fibroid volume there is an increase in blood loss by 0.26 ml (95 % CI: 0.07 - 0.46). CONCLUSIONS: In this study, we found that there was no significant difference in blood loss between women who received and did not receive sublingual misoprostol before abdominal myomectomy. This is an exploratory study laying the foundation for further randomised clinical trials.

Evolution of Bowel Complaints after Laparoscopic Endometriosis Surgery: A 1497 Women Comparative Study.

STUDY OBJECTIVE: To assess to what degree can digestive symptoms improve after endometriosis surgery for different localizations. DESIGN: A comparative retrospective study employing data prospectively recorded in the North-West Inter-Regional Female Cohort for Patients with Endometriosis (CIRENDO) from June 2009 to November 2018. SETTING: Two referral centers. PATIENTS: A total of 1497 women undergoing surgery because of pelvic endometriosis were divided into 3 groups: superficial endometriosis (Group 1, n = 396), deep endometriosis sparing the bowel (Group 2, n = 337), and deep endometriosis involving the bowel (Group 3, n = 764). INTERVENTIONS: Surgery for endometriosis. MEASUREMENTS AND MAIN RESULTS: Preoperative and postoperative gastrointestinal symptoms were evaluated with standardized questionnaires, including the Gastrointestinal Quality of Life Index (GIQLI) and Knowles-Eccersley-Scott-Symptom questionnaire (KESS). The degree of postoperative improvement in digestive symptoms was compared between the groups. The women in Group 3 were significantly symptomatic in terms of cycle-related gastrointestinal symptoms and scores of standardized questionnaires GIQLI and KESS. According to the 1-year postoperative evaluation, women in Group 3 experienced the most significant improvement in their gastrointestinal symptoms. CONCLUSION: Women with severe bowel symptoms and deep endometriosis infiltrating the bowel should be informed about the high probability of symptom improvement after the removal of bowel nodules. Conversely, in women without deep endometriosis, postoperatively, there is less improvement in baseline digestive complaints.

Effect of Surgical Skin Antisepsis on Surgical Site Infections in Patients Undergoing Gynecological Laparoscopic Surgery: A Double-Blind Randomized Clinical Trial.

Importance: Gynecological laparoscopies are one of the most common surgical procedures worldwide. Limited evidence exists on rates of surgical site infections in patients undergoing gynecological laparoscopies and strategies to prevent these infections. Objective: To compare rates of port-site infections, organ or space infections, and any type of surgical site infections among patients who underwent gynecological laparoscopies and received 1 of 3 types of skin preparation solutions. Design, Setting, and Participants: A double-blind randomized clinical trial was conducted between February 28, 2017, and November 26, 2018, at a tertiary university-affiliated referral center. A total of 661 patients 18 years or older who underwent an elective operative laparoscopy for treatment of nonmalignant gynecological disorders were randomly assigned in a 1:1:1 ratio to have their skin cleaned before surgery with alcohol-based chlorhexidine, alcohol-based povidone-iodine, or water-based povidone-iodine. Statistical analysis was performed from February 28, 2017, to November 26, 2018. Analyses were performed on a modified intention-to-treat basis. Interventions: A total of 221 patients were randomized to have their skin prepared preoperatively with water-based povidone-iodine, 220 were randomized to alcohol-based povidone-iodine, and 220 were randomized to alcohol-based chlorhexidine. The patients were blinded to the solution used to clean their skin. Patients were followed up 1 and 4 weeks after surgery by a physician who was blinded to the skin preparation solution used at surgery. Evidence of infection according to Centers for Disease Control and Prevention criteria were documented. Main Outcomes and Measures: The primary outcome of this study was port-site infection 30 days after surgery. Secondary outcomes were organ or space infections and any type of surgical site infections; the study also aimed to prospectively describe rates of surgical site infections in gynecological laparoscopies. Results: Of the 661 patients, 640 (96.8%; mean [SD] age, 36.2 [10.6] years) were examined after surgery by a physician at the study site and were included in the modified intention-to-treat analysis. The overall rate of port-site infection was 10.2% (65 of 640), rate of organ or space infection was 6.6% (42 of 640), and rate of any surgical site infection was 16.3% (104 of 640). The odds ratio for port-site infection for alcohol-based chlorhexidine vs water-based povidone-iodine was 1.13 (95% CI, 0.61-2.08), for alcohol-based chlorhexidine vs alcohol-based povidone-iodine was 1.34 (95% CI, 0.71-2.52), and for water-based povidone-iodine vs alcohol-based povidone-iodine was 1.19 (95% 0.62-2.27). Conclusions and Relevance: Surgical site infections were more common than expected among patients who underwent gynecological laparoscopies. No skin preparation solution provided an advantage compared with the other solutions in reducing infection rates. Trial Registration: http://anzctr.org.au Identifier: ACTRN12617000475347.

Double Disk Excision of Large Deep Endometriosis Nodules Infiltrating the Low and Mid Rectum: A Pilot Study of 20 Cases.

STUDY OBJECTIVE: To report the technique of double disk excision of deep endometriosis nodules infiltrating the mid or low rectum and surgical outcomes. DESIGN: A retrospective case series using data prospectively recorded in the North-West Inter Regional Female Cohort for Patients with Endometriosis database. SETTING: University tertiary referral center. PATIENTS: Twenty women managed for large deep endometriosis nodules infiltrating the mid or low rectum. INTERVENTIONS: Double disk excision using transanal end-to-end anastomosis circular stapler. MEASUREMENTS AND MAIN RESULTS: Twenty women managed by double disk excision from May 2016 to September 2019 were included in the study. The mean time of intervention was 149 ± 74 minutes. The cumulated mean diameter of the excised rectal disks was 53.4 ± 19.1 mm, whereas in 85% of the women, it was ≥50 mm. The mean distance between the lowest margin of the disk and the anal verge was 66 mm. Vaginal infiltration was removed in 15 patients (75%), and in 6 patients (30%) it exceeded 30 mm in diameter. Owing to the presence of sigmoid colon nodules, 2 patients (10%) underwent concomitant segmental sigmoid resection of 4 cm and 6 cm in length, respectively. Transitory stoma was performed in 8 patients (40%) owing to concomitant vaginal excision >3 cm in size. After a follow-up varying from 3 months to 42 months, no digestive fistula was recorded. The rate of Clavien-Dindo 3 complications was 15%. CONCLUSION: Double disk excision is suitable for excising large deep endometriosis nodules infiltrating the mid or low rectum and is associated with a low severe complication rate with good functional outcomes in women. Further studies are required to assess the improvement of functional outcomes in deep endometriosis nodules infiltrating the mid or low rectum in comparison with colorectal resection.

Intramural Ectopic Pregnancy Following Myomectomy.

Intramural pregnancy is a rare form of ectopic pregnancy with early diagnosis essential for prevention of severe hemorrhage and uterine rupture. We report a rare case of an intramural ectopic pregnancy at 12 weeks gestation in a woman 1 year post open myomectomy. Both transvaginal ultrasound and magnetic resonance imaging were utilized as diagnostic aids in this case. The rare nature of this clinical scenario and lack of guidelines for management made clinical decision making difficult. Due to the size and location of the gestational sac, hysterectomy was deemed to be the safest modality, and a midline laparotomy, total abdominal hysterectomy, and bilateral salpingectomy was performed.