Effectiveness of Total Pelvic Peritoneal Excision for the management - - PowerPoint PPT Presentation

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Apr 28, 2023 486 likes •742 views

Effectiveness of Total Pelvic Peritoneal Excision for the management of endometriosis Mr A K T re ha n , Co nsulta nt Minima l Ac c e ss Gyna e c o lo g ist with spe c ia l inte re st in e ndo me trio sis Dr F Sa nua ulla h , Po st CCT fe llo w

SLIDE 1

Effectiveness of Total Pelvic Peritoneal Excision for the management of endometriosis

Mr A K T re ha n, Co nsulta nt Minima l Ac c e ss Gyna e c o lo g ist with spe c ia l inte re st in e ndo me trio sis Dr F Sa nua ulla h, Po st CCT fe llo w in Minima l Ac c e ss Surg e ry Dr K Ba lla rd , Se nio r L e c ture r in Wo me n’ s He a lth & pro g ra mme dire c to r fo r MSc in Adva nc e d Gyna e c o lo g ic a l e ndo sc o py-Unive rsity o f Surre y

De wsb ury a nd Distric t ho spita l Ha lifa x ro a d, De wsb ury UK

SLIDE 2

Endometriosis

a pa ro sc o pic ra dic a l e xc isio n o f e ndo me trio sis is a we ll e sta b lishe d, sa fe a nd e ffe c tive tre a tme nt

Ho we ve r, re c urre nc e ra te = 21.5% a t 2 ye a rs 40-50%

a t 5 ye a rs (Guo , Hum Re pro d Upda te 2009)

SLIDE 3

Total Pelvic Peritoneal Excision

Suggested by Trehan, 2001

T
e xc ise pe lvic pe rito ne um c o ve ring b o th o va ria n

fo ssa e , pe lvic side wa lls, ute ro sa c ra l lig a me nt a nd Po uc h o f Do ug la s so a s to re mo ve a ll o b vio us a nd sub tle e ndo me trio sis (T

re ha n 2001, 2003)

SLIDE 4

Aim of total Pelvic peritoneum excision

Re duc e dise a se re c urre nc e
E

ndo me trio sis is unlike ly to re c ur in the ne w pe rito ne um e xc ise d pre vio usly

T
impro ve pa in a nd q ua lity o f life
T
a vo id re mo ving o va rie s
I

t ma y b e po ssib le to pre se rve the o va rie s if a ll pe rito ne a l e ndo me trio sis is re mo ve d

mpro ve sa fe ty

Sta rting disse c tio n fro m re la tive ly unsc a rre d pe rito ne um ma y le a d to

fe we r c o mplic a tio ns

SLIDE 5

Objective:

T
de te rmine the lo ng te rm e ffe c tive ne ss o f T
ta l

Pe lvic Pe rito ne a l e xc isio n o f e ndo me trio sis o n pa in a nd he a lth re la te d Qua lity Of L ife (QOL )

T
de te rmine sa fe ty, ra te o f furthe r surg e ry, a nd

ho spita l sta y

SLIDE 6

Methods:

207 c o nse c utive wo me n with

e ndo me trio sis (a ll sta g e s) who ha d to ta l pe lvic pe rito ne a l e xc isio n b e twe e n 1999 a nd 2006.

Ana lysis unde rta ke n in 2008
Study one : A re tro spe c tive study o f

me dic a l c a se no te s

Study T

wo: 2-8 ye a r fo llo w-up

q ue stio nna ire s me a suring pa in & QOL (E HP-5)

SLIDE 7

Complicated Stage IV Endometriosis cases included in this study

SLIDE 8

Main results

Total Study Group Women who had laparoscopic excision

f endometriosis

207 Questionnaire Respondents 117 (56.5%) Questionnaire Non‐Respondents 90 (43.5%) Further Surgery 47 (22.7%)

SLIDE 9

Age at the time of excision

60 50 40 30 20 10

Frequency

30 20 10

Histogram showing the age of all women with endometriosis

Mean =34.27

Std. Dev. =6.606

N =207

Age at the time of excision

60 50 40 30 20 10

Frequency

30 20 10

Histogram showing the age of all women with endometriosis

Mean =34.27

Std. Dev. =6.606

N =207

79% 17% 4%

Indications

Pain Infertility Pain & Infertility

SLIDE 10

Concomitant procedures (alone or in combination) during 207 excisions:

Procedure n % Laparoscopic Assisted vaginal Hysterectomy 46 22.2% Oophorectomy Bilateral 7 (3.4%) Unilateral 4 (1.9%) 11 5.3% Adhesiolysis 101 48.8% Uterine surface coagulation 45 21.7% Ovarian surface coagulation 75 36.2% Ovarian cystectomy 43 20.8% Temporary Ovarian suspension 13 6.3% Ventrosuspension 39 18.8% Creation of pararectal space 54 26.2% Rectal Shaving 57 27.5% Opening and stitching of vagina 9 4.3%

SLIDE 11

Re‐operation: 47 (22.7%)

Procedure n % Laparoscopic Assisted Vaginal Hysterectomy 21 44.6% Ovarian Adhesiolysis 23 50% Unilateral Oophorectomy 3 6.4% Bilateral Oophorectomy (premenopausal‐early part

f study)

1 2% Temporary Ovarian suspension 4 8.5% Ovarian Cystectomy 3 6.5% Excision of vaginal Vault 1 2%

SLIDE 12

Re‐operation: 47 (22.7%)

Reoperation Cases Characteristics n= 47 Histological Diagnosis of endometriosis Yes No 17 30 Of the 17 women with endometriosis: Pelvic endometriosis (Uterovesical fold & outside margin) Pelvic Endometriosis and Adenomyosis Chocolate cyst Chocolate cyst and Fallopian tube endometriosis Fallopian tube endometriosis 13 1 1 1 1

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Main Results of study 1: Complications (207)

Visceral injury 0/103 (0%)

( Bowel, bladder and ureter injury)

Vascular injury 0/103 (0%)
conversion to laparotomy 0/103‐ (0%)

SLIDE 14

Main Results of study 1: Length of Hospital stay (207)

Total no. Total no. of nights Percentage of

f patients overnight stay

207 232 89.4% 185 (89.4% )of patients could be discharged home after overnight stay 21(10.6 %) of patients had 2 days stay 1 (0.5%) of patients stayed for 5days (Bowel shaving and repair ‐

conservative management –not for complication)

Reasons for 2 days stay: pain, social reasons, patient choice and long distance

to travel

SLIDE 15

Main Results of study 1:(207)

Oophorectomy

11/207(5.3%) Oophorectomy
4/11(1.9%) Unilateral Oophorectomy
7/11 (3.4%) Bilateral oophorectomy

(perimenopausal‐early part of study)

Oophorectomy‐ not required for the management of endometriosis

SLIDE 16

Second look appearance of the pelvis after Total Pelvic Peritoneal Excision

T he ne w pe rito ne um whic h g ro ws a ppe ars no rma l witho ut a dhe sio ns, e ndo me trio sis

After Excision Second Look Laparoscopy Patient 1 Patient 2

SLIDE 17

Questionnaire study: 117 (56.5%)

1‐5 scale (scale 1 = never; scale 5 = always)

Sig nific a nt impro ve me nt in pa in (p<0.001)

SLIDE 18

Questionnaire study: 117 (56.5%)

1‐5 scale (scale 1 = never; scale 5 = always)

Sig nific a nt impro ve me nt in QOL

(p<0.001)

SLIDE 19

Global and Non‐menstrual global pain score pre

and post op:

5 10 15 20 25 30 Global pain score Non‐menstrual Global pain score 28 18 13 9 Before After

(Median change in pain score p=0.001)

SLIDE 20

Patient’s view of the procedure

Que stion Ye s(no% ) No(no% ) T
ta l
Ha s the o pe ra tio n impro ve d 103(89.6%) 12(10.2%) 115

yo ur sympto ms?

Wo uld yo u re c o mme nd this to a 111(98.2%) 2(1,8%) 113

frie nd who ha s the sa me c o nditio n?

SLIDE 21

L imita tio ns:

Re tro spe c tive
No n-re spo nde nts 45.3%
Only o ne surg e o n’ s da ta

F uture :

Cha lle ng e s fo r de a ling with wo me n who c o ntinue to

ha ve pa in

Co nside r me a sure s to pre ve nt o va ria n a dhe sio ns
Co nside r whe the r Oo pho re c to my is ne c e ssa ry

SLIDE 22

Conclusion:

T

ta l L

a pa rosc opic Pe lvic Pe ritone a l E xc ision Justifie d :

ffe c tive a t improving pa in & QOL

Sig nific a nt impro ve me nt (p<0.001)
Sa fe
No ma jo r c o mplic a tio n
Re - ope ra tion
Ma inly due to o va ria n a dhe sio ns a nd hyste re c to my
Hospita l Sta y
89.45% o ve r nig ht sta y
Re c urre nc e
L
w -ma inly in the ute ro ve sic a l fo ld a nd o utside the e xc ise d a re a .
Bila te ra l/ unila te ra l oophore c tomy
No t ne c e ssa ry fo r the ma na g e me nt o f e ndo me trio sis.

SLIDE 23

Acknowledgement:

Christine Ro o ke - c linic a l Audit fa c ilita to r

De wsb ury a nd Distric t ho spita l, UK

SLIDE 24