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

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

Endometriosis • L 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)

Total Pelvic Peritoneal Excision Suggested by Trehan, 2001 • T o 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)

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 o impro ve pa in a nd q ua lity o f life • T o 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 • I 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

Objective: • T o de te rmine the lo ng te rm e ffe c tive ne ss o f T o 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 o de te rmine sa fe ty, ra te o f furthe r surg e ry, a nd ho spita l sta y

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 • wo : 2-8 ye a r fo llo w-up Study T q ue stio nna ire s me a suring pa in & QOL (E HP-5)

Complicated Stage IV Endometriosis cases included in this study

Main results Total Study Group Women who had laparoscopic excision of endometriosis 207 Further Surgery 47 (22.7%) Questionnaire Questionnaire Respondents Non ‐ Respondents 117 (56.5%) 90 (43.5%)

Histogram showing the age of all women with endometriosis Histogram showing the age of all women with endometriosis Indications 30 30 4% 17% 20 20 Frequency Frequency Pain Infertility 79% Pain & Infertility 10 10 Mean =34.27� Mean =34.27� Std. Dev. =6.606� Std. Dev. =6.606� N =207 N =207 0 0 10 10 20 20 30 30 40 40 50 50 60 60 Age at the time of excision Age at the time of excision

Concomitant procedures (alone or in combination) during 207 excisions: Procedure n % Laparoscopic Assisted vaginal Hysterectomy 46 22.2% Oophorectomy 11 5.3% Bilateral 7 (3.4%) Unilateral 4 (1.9%) 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%

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

Re ‐ operation: 47 (22.7%) Reoperation Cases Characteristics n= 47 Histological Diagnosis of endometriosis Yes 17 No 30 Of the 17 women with endometriosis: Pelvic endometriosis 13 (Uterovesical fold & outside margin) Pelvic Endometriosis and Adenomyosis 1 Chocolate cyst 1 Chocolate cyst and Fallopian tube endometriosis 1 Fallopian tube endometriosis 1

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%)

Main Results of study 1: Length of Hospital stay (207 ) Total no. Total no. of nights Percentage of of 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

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

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

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)

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)

Global and Non ‐ menstrual global pain score pre and post op : 28 30 25 20 18 13 15 Before 10 9 After 5 0 Global pain score Non ‐ menstrual (Median change in pain Global pain score score p =0.001)

Patient’s view of the procedure • Que stion Ye s(no% ) No(no% ) T ota 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?

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

Conclusion: T ota l L a pa rosc opic Pe lvic Pe ritone a l E xc ision Justifie d : • E ffe c tive a t improving pa in & QOL Sig nific a nt impro ve me nt (p<0.001) o • Sa fe No ma jo r c o mplic a tio n o • Re - ope ra tion Ma inly due to o va ria n a dhe sio ns a nd hyste re c to my o • Hospita l Sta y 89.45% o ve r nig ht sta y o • Re c urre nc e L o 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 . o • 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. o

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