Conservative Surgery of Deep Bowel Endometriosis

Koninckx, Philippe; Ussia, Anastasia; Адамян, Л В; Al-Suwaidi, Shaima; Amro, Bedayah; Gharbi, Hanan; Tahlak, Muna; Wattiez, Arnaud

doi:10.1007/978-3-030-50446-5_11

Cited by 7 publications

(5 citation statements)

References 42 publications

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“…As endometriosis lesions can originate from endometrial cells, from coelomic fibroblasts or epithelium and even from bone Please cite this article as: Koninckx PR et al, The epidemiology of endometriosis is poorly known as the pathophysiology and diagnosis are unclear, Best Practice & Research Clinical Obstetrics and Gynaecology, https://doi.org/10.1016/j.bpobgyn.2020.08.005 marrow cells, endometriosis cells might return to normal endometrium or even to normal coelomic epithelium/mesothelium when the driving forces inducing epigenetic changes disappear. This could explain why microscopical endometriosis has not yet been linked to any clinical pathology and why conservative excision of deep endometriosis which is obviously incomplete is not associated with a higher recurrence risk than a large bowel resection [47]. These observations suggest that some histologically endometrium-like cells with only reversible epigenetic changes can return to normal when the driving motor is removed such as following the excision of a deep endometriosis nodule.…”

Section: Pathophysiology and Natural History Of Endometriosismentioning

confidence: 99%

The epidemiology of endometriosis is poorly known as the pathophysiology and diagnosis are unclear

Koninckx

Ussia

Adamyan

et al. 2021

Best Practice & Research Clinical Obstetrics & Gynaecol

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and recognition of subtle lesions is problematic. Reliable surgical data are small series not permitting multivariate analysis. Endometriosis is a hereditary disease. The oxidative stress of heavy menstrual bleeding with retrograde menstruation and an altered pelvic microbiome are probably associated with increasingly severe endometriosis. Whether the prevalence is increasing, or whether endometriosis is associated with fat intake or an increased risk of cardiovascular disease is unclear.

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Section: Pathophysiology and Natural History Of Endometriosismentioning

confidence: 99%

The epidemiology of endometriosis is poorly known as the pathophysiology and diagnosis are unclear

Koninckx

Ussia

Adamyan

et al. 2021

Best Practice & Research Clinical Obstetrics & Gynaecol

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“…Since this is unlikely to change, it seems important to use a Bayesian approach to establish the value of the collective experience of surgeons in technique, results and complications and the importance of granular intra-operative details ( Kanters et al, 2018 ). This is not contradicted by the decision of doing a bowel resection or a conservative excision or a discoid excision being based to a large extent on personal preferences ( Koninckx et al, 2020b ) since results and complications vary with surgical skills and experience. To convert this collective opinion based on repetitive surgical interventions with the outcome as measurement, into a degree of evidence will be a methodological and statistical challenge.…”

Section: Discussionmentioning

confidence: 99%

Reconsidering evidence-based management of endometriosis

Koninckx¹,

Ussia²,

Al-Suwaidi³

et al. 2022

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Background: Without an adequate animal model permitting experiments the pathophysiology of endometriosis remains unclear and without a non-invasive diagnosis, information is limited to symptomatic women. Lesions are macroscopically and biochemically variable. Hormonal medical therapy cannot be blinded since recognised by the patient and the evidence of extensive surgery is limited because of the combination of low numbers of interventions of variable difficulty with variable surgical skills. Experience is spread among specialists in imaging, medical therapy, infertility, pain and surgery. In addition, the limitations of traditional statistics and p-values to interpret results and the complementarity of Bayesian inference should be realised. Objectives: To review and discuss evidence in endometriosis management Materials and Methods: A PubMed search for blinded randomised controlled trials in endometriosis. Results: Good-quality evidence is limited in endometriosis. Conclusions: Clinical experience remains undervalued especially for surgery. What is new? Evidence-based medicine should integrate traditional statistical analysis and the limitations of P-values, with the complementary Bayesian inference which is predictive and sequential and more like clinical medicine. Since clinical experience is important for grading evidence, specific experience in the different disciplines of endometriosis should be used to judge trial designs and results. Finally, clinical medicine can be considered as a series of experiments controlled by the outcome. Therefore, the clinical opinion of many has more value than an opinion.

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“…For deep endometriosis, surgical excision is the method of choice. As described in recent reviews (81,82), for rectum lesions a conservative excision without a bowel resection is almost always feasible but at the cost of eventually a lengthy muscularis suture. A less complete excision, finished by a wedge resection using a circular stapler, seems the way forward (83,84) as suggested by clinical observation.…”

Section: Surgery Of Endometriosismentioning

confidence: 99%

Pathogenesis Based Diagnosis and Treatment of Endometriosis

et al. 2021

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Understanding the pathophysiology of endometriosis is changing our diagnosis and treatment. Endometriosis lesions are clones of specific cells, with variable characteristics as aromatase activity and progesterone resistance. Therefore the GE theory postulates GE incidents to start endometriosis, which thus is different from implanted endometrium. The subsequent growth in the specific environment of the peritoneal cavity is associated with angiogenesis, inflammation, immunologic changes and bleeding in the lesions causing fibrosis. Fibrosis will stop the growth and lesions look burnt out. The pain caused by endometriosis lesions is variable: some lesions are not painful while other lesions cause neuroinflammation at distance up to 28 mm. Diagnosis of endometriosis is made by laparoscopy, following an experience guided clinical decision, based on history, symptoms, clinical exam and imaging. Biochemical markers are not useful. For deep endometriosis, imaging is important before surgery, notwithstanding rather poor predictive values when confidence limits, the prevalence of the disease and the absence of stratification of lesions by size, localization and depth of infiltration, are considered. Surgery of endometriosis is based on recognition and excision. Since the surrounding fibrosis belongs to the body with limited infiltration by endometriosis, a rim of fibrosis can be left without safety margins. For deep endometriosis, this results in a conservative excision eventually with discoid excision or short bowel resections. For cystic ovarian endometriosis superficial destruction, if complete, should be sufficient. Understanding pathophysiology is important for the discussion of early intervention during adolescence. Considering neuroinflammation at distance, the indication to explore large somatic nerves should be reconsidered. Also, medical therapy of endometriosis has to be reconsidered since the variability of lesions results in a variable response, some lesions not requiring estrogens for growth and some being progesterone resistant. If the onset of endometriosis is driven by oxidative stress from retrograde menstruation and the peritoneal microbiome, medical therapy could prevent new lesions and becomes indicated after surgery.

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Conservative Surgery of Deep Bowel Endometriosis

Cited by 7 publications

References 42 publications

The epidemiology of endometriosis is poorly known as the pathophysiology and diagnosis are unclear

The epidemiology of endometriosis is poorly known as the pathophysiology and diagnosis are unclear

Reconsidering evidence-based management of endometriosis

Pathogenesis Based Diagnosis and Treatment of Endometriosis

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