Publications

Surgical management of deeply infiltrating endometriosis: an update.

Deeply infiltrating endometriosis (DIE) manifests itself mainly in the form of pain, predominantly deep dyspareunia, and painful functional symptoms that are aggravated monthly during menstruation, with the semiology being directly correlated with the location of the lesions (bladder, rectum). A workup to assess the extent of the disease is necessary to establish an accurate map of the DIE lesions, which is the essential condition to perform complete exeresis. The treatment of first intention is surgical, because medical treatments are only palliative in the majority of cases. Successful treatment depends on achieving radical surgical exeresis. Analysis of the anatomical distribution of the DIE lesions allows a -'surgical classification-' to be proposed to standardize the modalities of surgical treatment. Further studies are needed to specify the place and modalities of medical treatments preoperatively and postoperatively.

Evidence for asymmetric distribution of lower intestinal tract endometriosis.

Ureteral endometriosis: the role of magnetic resonance imaging.

In six women out of 792 who underwent magnetic resonance imaging (MRI) for management of deep infiltrating endometriosis (DIE), ureteral involvement was suspected. Ureteral endometriosis was identified as a hypointense nodule on T2- weighted images and hyperintense foci on T1-weighted images. Magnetic resonance urography detected obstruction and hydronephrosis in half the women. Detection with MRI of periureteral involvement (extrinsic endometriosis) in four women rather than ureteral wall lesions (intrinsic endometriosis) in two women is an original finding from this series. Magnetic resonance imaging features were correlated and matched with intraoperative and pathologic findings. Magnetic resonance imaging is a useful preoperative tool for the diagnosis and assessment of ureteral endometriosis in rare cases when such lesions have been suspected.

Accuracy of rectal endoscopic ultrasonography and magnetic resonance imaging in the diagnosis of rectal involvement for patients presenting with deeply infiltrating endometriosis.

OBJECTIVE: To compare the accuracy of rectal endoscopic ultrasonography (REU) and magnetic resonance imaging (MRI) for predicting rectal wall involvement in patients presenting histologically proven deeply infiltrating endometriosis (DIE). METHODS: This was a retrospective study of a continuous series of 81 patients presenting histologically proven DIE who underwent preoperative investigations using both REU and MRI. The sonographer and the radiologist, who were unaware of the clinical findings and patient history, but knew that DIE was suspected, were asked whether there was involvement of the digestive wall. RESULTS: Rectal DIE was confirmed histologically in 34 of the 81 (42%) patients. For the diagnosis of rectal involvement, sensitivity, specificity and positive and negative predictive value for REU were 97.1%, 89.4%, 86.8% and 97.7% and for MRI they were 76.5%, 97.9%, 96.3% and 85.2%. CONCLUSION: The sensitivity and negative predictive value of REU were higher than those of MRI suggesting that REU performs better than MRI in the diagnosis of rectal involvement for patients presenting with DIE. Prospective studies with a large number of patients are needed in order to validate these preliminary results.

Deeply infiltrating endometriosis originates from the retrocervical area.

300. J Am Assoc Gynecol Laparosc. 2004 Aug;11(3):440; author reply 440-1. doi: 10.1016/s1074-3804(05)60066-7. Deeply infiltrating endometriosis originates from the retrocervical area. Chapron C, Chopin N, Borghese B, Foulot H.

Prospective evaluation of the learning curve of laparoscopic-assisted vaginal hysterectomy in a university hospital.

STUDY OBJECTIVE: To prospectively analyze the learning curve of laparoscopic-assisted vaginal hysterectomy (LAVH) in a surgical team and evaluate if length of surgery can be reduced safely. DESIGN: Prospective observational study (Canadian Task Force classification II-2). SETTING: Department of obstetrics and gynecology in a university-affiliated hospital. PATIENTS: One hundred and sixty consecutive women undergoing LAVH performed between January 1, 1998 and April 30, 2001. INTERVENTION: LAVH (AAGL Classification System for Laparoscopic Hysterectomy III-B-3). MEASUREMENTS AND MAIN RESULTS: The primary parameter evaluated was length of surgery. Patients were grouped in cohorts of 10, in order to perform a time curve that would assist us in evaluation of the learning process. Once the plateau was reached, we evaluated the process before and after this plateau (groups 1 [learning stage] and 2 [second stage], respectively). Average length of surgery was 126 minutes (range, 60-260). Length of surgery was 138 minutes (range, 75-260) in the learning stage (first 80 cases) and 112 minutes (range, 60-225) in the second stage (p <.0001). Total rate of complications was 11.6%. There were three major complications, and they occurred before the plateau. There were 15 minor complications (9.67%), 8 during the first stage and 7 in the second stage, (p =.9; NS). A second learning curve excluding LAVH with associated surgeries was obtained. The average length of surgery for the first stage was 133 minutes (range, 75-205) and 102 minutes for the second stage (range, 60-130) (p >.0001). CONCLUSION: Analysis of the learning curve demonstrated that the length of surgery in LAVH could be reduced without increasing the number of complications.

[Chronic pelvic pain and endometriosis].

Chronic pelvic pain and endometriosis remain two of the most perplexing problems in gynaecology. In some women, the problem is to determine whether or not endometriosis causes the pain they are consulting for. Deep pelvic endometriosis presents essentially in the form of a painful syndrome dominated by deep dyspareunia and painful functional symptoms that recur according to the menstrual cycle. The semiology is directly correlated with the location of the lesions (bladder, rectum). Lesions of the utero-sacral ligaments are the most frequent deeply infiltrating endometriosis lesions. The following variables are related to the severity of dysmenorrhoea: number of previous surgical procedures for endometriosis, score in the revised American Fertility Society classification, extensiveness of adnexal adhesion, Douglas obliteration, size of the posterior deeply infiltrating endometriosis implant, extent of the sub-peritoneal infiltration by the posterior deeply infiltrating endometriosis. It is essential to investigate (clinically and with magnetic resonance imaging) these deep endometriosis lesions and to draw up a precise map, which is the only way to be sure that exeresis will be complete. Surgery remains the first intention treatment, whereas medical treatment is only palliative in the majority of cases. Success of treatment depends on how radical surgical exeresis is. Operative laparoscopy is efficient for bladder, utero-sacral ligaments and vaginal deeply infiltrating endometriosis. However, indications for laparotomy still exist, notably for bowel lesions. Based on analysis of the anatomical distribution of deep pelvic endometriosis lesions, a -'surgical classification-' is proposed with the aim of establishing standard modes for surgical treatment. Further studies are required to clarify the place and modes for pre- and postoperative medical treatment.

Complications during set-up procedures for laparoscopy in gynecology: open laparoscopy does not reduce the risk of major complications.

OBJECTIVE: To compare the risk of major complications during the set-up procedures for laparoscopy according to whether the classic technique (creation of the pneumoperitoneum followed by introduction of the optics trocar) or open laparoscopy is used. METHODS: Comparison was made of two retrospective series each carried out in a department promoting one of the two techniques. The setting was a university-affiliated hospital. Two groups of patients were compared: group A, classic laparoscopy, n = 8324; group B, open laparoscopy, n = 1562. We investigated the set-up procedures of operative laparoscopy according to the rules of classic or open laparoscopy. RESULTS: The risk of failure requiring conversion to laparotomy is significantly higher in the group of patients who underwent open laparoscopy [three cases (0.19%) vs. 0 case (0.0%); p = 0.004]. The risk of major complications is comparable in the two groups [group A, four cases (0.05%) vs. group B, three cases (0.19%); p = 0.08]. In the classic laparoscopy group there were four major complications: one injury to the aorta and three bowel injuries. In the open laparoscopy group there were three major complications: two bowel injuries and one postoperative occlusion. CONCLUSIONS: Open laparoscopy does not reduce the risk of major complications during the set-up procedures for laparoscopy. Randomized prospective trials are indispensable for comparing the risks involved with the classic technique and those of open laparoscopy.

[Traumatic dissection of the internal carotid artery: malignant supratentorial infarction and decompressive treatment].

We present a case report of a thirty-six-year-old right-handed female. She suffered with a malignant space-occupying supratentorial ischemic stroke caused by a traumatic cervical internal carotid artery dissection. She had a car accident and, initially, presented with a normal examination. In two days, she became comatose (Glasgow Coma Scale score was 5) with complete left hemiplegia, right mydriasis and required respiratory assistance despite the medical treatment. It was decided to perform a large right frontotemporoparietal bone flap with large dural plasty. Eighteen months later, with intensive rehabilitation, the results of neuropsychological testing were normal, and the Barthel Index score was 90. The indications for decompressive surgery in malignant space-occupying supratentorial ischemic stroke remains controversial. The age, general condition, neurological examination (consciousness, pupils, deficit), extent of parenchymal hypodensity and attenuated corticomedullary contrast on the brain CT, degree of midline shift, presence of uncal hernation, disparition of the visibility of the mesencephalic cisterns and third ventricle, high level of the intracranial pressure, and perhaps the results of the perfusion-and diffusion-weighted MRI, are the elements to decide (or not decide) decompressive surgery.

Evidence for asymmetric distribution of sciatic nerve endometriosis.

OBJECTIVE: To investigate if a lateral asymmetry exists in the distribution of endometriotic lesions of the sciatic nerve. DATA SOURCES: All articles on sciatic nerve endometriosis identified by MEDLINE and EMBASE database searches were retrieved, and additional reports were collected by systematically reviewing all references. Monographs on endometriosis published in the last 15 years were consulted. METHODS OF STUDY SELECTION: We considered articles in which the presence of an endometriotic lesion of the sciatic nerve and the affected side were assessed. We also included reports lacking histological examination of sciatic nerve specimens but with a surgical diagnosis of pelvic endometriosis. Two authors abstracted data independently on standardized forms. The number of women and the side of the lesion were obtained from individual studies, and the combined frequency of left- and right-side sciatic nerve endometriosis in published reports was computed. TABULATION, INTEGRATION, AND RESULTS: Thirty-two reports including 63 subjects were selected. Endometriosis of the sciatic nerve was on the right side in 41 patients, on the left in 20, and bilateral in two. Considering only patients with unilateral sciatic nerve endometriosis, the observed proportion of right-side lesions (41 of 61 [67.2%]; 95% confidence interval 54.0%, 78.7%) significantly differed from the expected proportion of 50% (chi(2)(1) 7.23, P =.007). Among the 16 cases of histological demonstration of endometriosis infiltrating sciatic nerve roots or fibers, ten had it on the right side (62.5%) and six on the left. Twenty-six of the 38 subjects (68.4%) with surgical demonstration of pelvic endometriosis but without histopathologic evidence of direct sciatic nerve involvement were affected by right cyclic sciatica. CONCLUSION: The finding that two thirds of patients with sciatic nerve endometriosis had right-side lesions constitutes further evidence against the coelomic metaplasia theory. The interposition of the sigmoid colon between the regurgitated endometrial cells implanted on the left posterolateral pelvic peritoneum seems to protect the left lumbosacral plexus and sciatic nerve.