A pilot feasibility multicenter study of patients after excision of endometriosis.

OBJECTIVE: To serve as a pilot feasibility study for a randomized study of excision versus ablation in the treatment of endometriosis by (1) estimating the magnitude of change in symptoms after excision only at multiple referral centers and (2) determining the proportion of women willing to participate in a randomized trial. METHODS: We performed a multicenter prospective study of women undergoing excision for endometriosis (Canadian Task Force class II-3) at Duke University Center for Endometriosis Research & Treatment (currently the Saint Louis University Center for Endometriosis), Center for Endometriosis Care, Northshore University Health System, Memorial University (Canada), and Florida Hospital. The study comprised 100 female patients, aged 18 to 55 years, with endometriosis-suspected pelvic pain. The intervention was laparoscopic excision only of the abnormal peritoneum suspicious for endometriosis. The main outcome measures were quality of life, pelvic pain, dysmenorrhea, dyspareunia, and bowel and bladder symptoms. RESULTS: The mean follow-up period was 8.5 months. Excision of endometriosis showed a significant reduction in all pain scores except bowel symptoms, as well as significant improvement in quality of life. Of the patients, 84% were willing to participate in a randomized study. CONCLUSIONS: Quality of life is a needed primary outcome for any randomized study comparing excision versus ablation. A multicenter comparative trial is feasible, although quality assurance would have to be addressed. Patients were willing to be randomized even at surgical referral centers.

Complete laparoscopic excision of endometriosis in teenagers: is postoperative hormonal suppression necessary?

OBJECTIVE: To determine long-term outcomes after complete laparoscopic excision done at a tertiary referral center in a teenager population, who were not specifically advised to take postoperative hormonal suppression. DESIGN: Prospective observational case series (Canadian Task Force II-3). SETTING: A tertiary referral center that specializes in the laparoscopic treatment of endometriosis. PATIENT(S): Teenagers with symptoms suspicious for endometriosis who consented and were prospectively recruited to participate in the study. INTERVENTION(S): All patients underwent diagnostic laparoscopy and complete excision of all areas of abnormal peritoneum with typical and atypical endometriosis. Patients were not specifically advised to take postoperative hormonal suppression. MAIN OUTCOME MEASURE(S): Rate of recurrent (or persistent) endometriosis. RESULT(S): Twenty teenagers underwent complete laparoscopic excision of all areas of abnormal peritoneum with typical and atypical endometriosis. Seventeen patients had endometriosis confirmed by histology at initial surgery. Follow-up was up to 66 months (average 23.1 months). There was a statistically significant improvement in most pain symptoms, including bowel-related symptoms, during this time period. The rate of repeat surgery was 8 of 17 patients (47.1%), but the rate of endometriosis (diagnosed visually or histologically) found at surgery was zero. Only one-third of patients took postoperative hormonal suppression for any length of time. CONCLUSION(S): Complete laparoscopic excision of endometriosis in teenagers--including areas of typical and atypical endometriosis--has the potential to eradicate disease. These results do not depend on postoperative hormonal suppression. These data have important implications in the overall care of teenagers, regarding pain management, but also potentially for fertility. Further large comparative trials are needed to verify these results.

Laparoscopic excision of lesions suggestive of endometriosis or otherwise atypical in appearance: relationship between visual findings and final histologic diagnosis.

STUDY OBJECTIVE: We sought to assess accuracy of visual diagnosis of laparoscopically excised visceral and peritoneal abnormalities suggestive of endometriosis by comparison with final histologic diagnosis. DESIGN: Prospective study of 2005 tissue specimens from 512 patients undergoing laparoscopy for evaluation of pelvic pain was conducted (Canadian Task Force classification II-2). SETTING: A private practice referral center for treatment of endometriosis. PATIENTS: From February 1992 through December 1998, 512 patients underwent laparoscopic excision of endometriosis. In all patients, the primary indication for surgery was pelvic pain with either prior surgical diagnosis or clinical history consistent with endometriosis. INTERVENTIONS: All areas of viscera and peritoneum either with typical appearance suggestive of endometriosis or atypical appearance were completely excised and examined histologically. At laparoscopy, all excised lesions were documented in a diagram by the primary surgeon according to anatomic site and visual description and were labeled as either suggestive of endometriosis or otherwise atypical in appearance. The hospital pathology department received entire lesions fixed in formalin and evaluated specimens for presence or absence of endometriosis. Pathologists, who were blinded to the surgeon's suspicion of endometriosis, were provided only the anatomic site of excised tissue. By definition, diagnosis of endometriosis was made when histologic evidence existed of both endometrial glands and stroma. MEASUREMENTS AND MAIN RESULTS: Diagrams detailing appearance, anatomic site, and surgeon's suspicion of endometriosis versus atypical lesions were compared with final histologic diagnosis. The greatest number of patient lesions were excised from cul-de-sac (n = 309). For this site, using visual criteria for diagnosis of endometriosis, positive predictive value was 93.9%, sensitivity was 69.3%, negative predictive value was 41.9%, and specificity was 83.1%. Prevalence was noted to be 79.0% and accuracy was 72.2%. In addition, atypical-appearing tissue not presumed to be endometriosis was confirmed to be endometriosis histologically in 24.3%. In examining tissue specimens from multiple anatomic sites, laparoscopic visual diagnosis of typical endometriosis generally had high positive predictive value. However, both sensitivity and negative predictive value were lower than expected because of atypical lesions subsequently diagnosed as endometriosis. CONCLUSIONS: These data suggest that when the surgical objective is complete eradication of endometriosis, the surgeon must be prepared to excise all lesions suggestive of endometriosis and tissue atypical in appearance as in most anatomic sites approximately 25% of atypical specimens proved to be endometriosis.