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A Comparison of Examination and Surgical Findings in Women With Endometriosis
Abstracts / Journal of Minimally Invasive Gynecology 22 (2015) S1–S253
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incidence of complications, It can release the symptoms obviously, improve the quality of life up to the level of normal female population.
137 Correlation Between Magnetic Resonance Imaging Results and Findings at Surgery for Cases of Severe Endometriosis Ma K,1 Majumder K,1 Clayton R,1 Rajashanker B,2 Ed-Osagie E.1 1 Obstetrics and Gynaecology, St. Mary’s Hospital, Manchester, Greater Manchester, United Kingdom; 2Clinical Radiology, St. Mary’s Hospital, Manchester, Greater Manchester, United Kingdom
Design: A clinical observational study. Setting: A teaching hospital of Sun yat-sen university. Patients: 63 patient with deep infiltrating endometriosis involve bowel. Intervention: Laparoscopic bowl segmental resection were used to resect the endometriotic lesions during surgery for patient with bowel endometriosis. visual analog scale (VAS) was used to score the severity of pain symptoms before and after surgery. The SF-36 questionnaire was applied to all patients to evaluate the quality of life before and after surgery. Measurements and Main Results: 62 patients have laparoscopic bowel segmental resection.The mean of operative time was 31297min, Mean blood loss was 230182ml, Intraoperative complications occurred in 6 cases, of which 4 were excessive blood loss up to at least 500ml and 2 were bladder injury. Postoperative complications developed in 28 cases (45.2%), including 18 urinary retention (29%), 4 rectovaginal fistula (6.5%), 2 vaginal dehiscence (3.2%) and 1 thrombogenesis, pelvic abscess, general peritonitis, incomplete intestinal obstruction, respectively. All this complications were managed eventfully. The pre-operative VAS scores of dysmenorrhea, dyspareunia, pain on defecation and chronic pelvic pain was 52.9, 4.32.2, 7.31.9 and 3.83.0, respectively, while the post-operative VAS scores was 2.92.2, 0.720.50, 1.60.70 and 2.12.0. The improvement in dysmenorrhea, dyspareunia and pain on defecation was statistically significant (P\0.05). The improvement of post-operative quality of life was statistically significant (P\0.05) in all 8 domains. While compared with the standardized data of Chinese female population, post-operative mean score of the 8 domains of SF-36 had no statistically significant difference(P\0.05). Conclusion: Laparoscopic Bowel segmental resection is a safe and effective procedure for bowel endometriosis. Although it have a high
Study Objective: To determine whether preoperative staging of patients with suspected stage IV endometriosis with magnetic resonance imaging(MRI) is consistent with findings at laparoscopy, cystoscopy and sigmoidoscopy. Design: Retrospective cohort study. Setting: Tertiary referral endometriosis centre. Patients: All patients with severe endometriosis discussed at multidisciplinary level between August 2014 to March 2015. Intervention: All patients with suspected severe endometriosis are staged pre-operatively by MRI and results discussed between a team of gynaecologist, radiologist, colorectal and urological surgeons and endometriosis specialist nurses. Findings are then compared with surgical staging by diagnostic laparoscopy, cystoscopy and sigmoidoscopy. Measurements and Main Results: 30 patients were identified with suspected severe endometriosis and staged pre-operatively with MRI. 6 patients underwent staging laparoscopy, cystoscopy and sigmoidoscopy, 3 patients underwent radical excision of rectovaginal endometriosis and 2 patients underwent total laparoscopic hysterectomy and radical excision of rectovaginal endometriosis. 10 patients are awaiting surgical management and remaining 9 patients opted for continued medical management. Ovarian pathology was seen in 72% of cases (8 of 11 cases with unilateral/bilateral endometriomas) and was consistent with laparoscopic findings in 8 of 8 cases. Adenomyosis was seen in 7 of 11 cases and this was confirmed in 2 of 2 cases who underwent hysterectomy. Rectovaginal nodules were identified in 7 of 11 cases and both were confirmed at laparoscopy. 3 cases showed polypoid infiltration into rectal mucosa on MRI and all cases were confirmed at sigmoidoscopy or anterior resection. Urological abnormalities were found in 2 of 11 cases with unilateral hydroureter and both cases were confirmed at laparoscopy. Conclusion: Pre-operative staging of patients with suspected severe endometriosis with magnetic resonance imaging appears to correlate with surgical findings in the identification of rectovaginal disease, urological abnormality and adnexal pathology. This facilitates counselling of patients regarding future medical or surgical management and allows optimisation of their care by involving the appropriate specialties early on. 138 A Comparison of Examination and Surgical Findings in Women With Endometriosis Bhatti M,1,2 Arnold A,1,2 Ketheeswaran A,1,2 Nesbitt-Hawes E,1,2,3 Deans R,1,2,3 Abbott J.1,2,3 1University of New South Wales, Sydney, NSW, Australia; 2Royal Hospital for Women, Sydney, NSW, Australia; 3Prince of Wales Private Hospital, Sydney, NSW, Australia Study Objective: To investigate the accuracy of bimanual examination in predicting operative times for laparoscopic excision of endometriosis and comparing to clinical experience. Design: Prospective observational study. Setting: Academic affiliated hospital. Patients: Women with suspected endometriosis scheduled for laparoscopy. Intervention: History and examination were used to estimate operative time. This was repeated under general anesthesia. Examining clinicians
S56
Abstracts / Journal of Minimally Invasive Gynecology 22 (2015) S1–S253
included students-[N]; trainees-[T]; experts-[E]; and masters-[M]. Intraoperatively, surgical staging and operative time were recorded. Measurements and Main Results: 121 women were recruited. Clinical estimations of operating time exceeded surgical times by a median of 16 minutes, with 80% of cases completed in less time than predicted. Estimations under anesthetic, immediately pre-operatively exceeded surgical times by 1 minute with 90% of cases completed within 33 minutes of their predicted time. Students and trainees underestimated time by 3 and 1 minutes respectively; experts and masters overestimated by 1 and 4 minutes respectively, although differences were not statistically significant (p=0.496). Increasing experience resulted in stronger associations between examination and surgical findings for the uterosacral ligaments ([N]p=0.6, [T]p=0.007, [E] p=0.004, [M]p =0.002), pouch-of-Douglas ([N]p=0.02, [M]p=0.004), rectum ([N]p=0.53, [T]p=0.49, [M]p=0.19) and adnexae ([T]p=0.1, [E] p\0.001, [M]p\0.001). Sensitivities increased with experience for examination of the pouch-of-Douglas ([T]-27%, [E]-33%, [M]-63%), adnexae ([T]–10%, [E]–28%, [M]-35%), uterosacral ligaments ([N]28%, [T]-31%, [E]-61%, [M]-78%) and rectovaginal septum ([T]-46%, [E]-33%, [M]-63%). Overall pre-operative clinical examination was a poor predictor of disease with sensitivities of 15%-65% across all disease sites. Conclusion: Physical examination is an essential tool that provides useful and accurate reflections of surgical time with experienced examiners estimating surgical time more accurately; it is amenable to training and provides useful information to healthcare providers. Exact localization and staging of disease is poor with clinical examination given the difficulty in accessing and assessing all pelvic areas, with better results obtained in an anaesthetized patient. Examination findings are dependent on clinician experience and can be trained.
Stroma
139 Needle Based Confocal Endomicroscopy (nCLE) Performed Through Transrectal Ultrasound (TRUS): The First Experience in Intestinal Endometriosis Rossini LG,1 Meirelles LR,2 Reimao SM,1 Paccos JL,2 Filippi SS,1 Ribeiro CM,2 Valenciano J,2 Martins FP,2 Cassab JC,2 Coudry R.2 1 Endoscopy, Irmandade da Santa Casa de S~ao Paulo, Sao Paulo, SP, Brazil; 2Endoscopy, Hospital Sirio-Liban^es, Sao Paulo, SP, Brazil Study Objective: Up to 95% of intestinal endometriotic lesions are found in sigmoid colon and rectum. It is the most common extra genital disease that affects between 3% and 37% of women with endometriosis (EDT). Intestinal EDT is difficult to diagnose and should be considered a severe disease. An adequate diagnosis of deep endometriotic lesions remains a challenge and usually occurs around seven years after the onset of symptoms. Even for cases showing signs, symptoms, and/or tests suggestive of EDT, other intestinal diseases, such as intestinal malignant neoplasm, should be ruled out to avoid delay or wrong medical treatment. Diagnostic tools, including transrectal ultrasound (TRUS), magnetic resonance imaging, transvaginal ultrasound, barium enema, and colonoscopy, play significant roles in determining a precise preoperative diagnosis and staging of the disease. Design: Our group has started using a new diagnostic tool for intestinal EDT, which is needle based Confocal Laser Endomicroscopy (nCLE), performed through TRUS a fine needle aspiration (FNA). As far as we know, it is the first experience of nCLE in EDT. Setting: This study was conducted in a tertiary care hospital. Patients: We report five cases of patients with deep pelvic EDT, which we performed TRUS followed by nCLE and FNA of the lesion. Intervention: See in patients section. Measurements and Main Results: Results of nCLE and histology were compared. There are common findings, between nCLE and histology as endometrial glands without globet cells with variable size, presence of stromal elements, fibrous tissue and tortuous neovascularization.
glands Conclusion: More studies with higher samples are needed to confirm our findings. We believe that with this approach it will be possible to differentiate intestinal EDT from other tumors, classify in vivo different types of EDT (glandular, stromal and mixed) and maybe distinguish different degrees of differentiation. In the future, these findings can help to individualize the treatment as well as improve its response. 140 Analysis of Risk Factors for Post-Operative Rectovaginal Fistula in Deep Endometriosis Yi X, Zheng Y, Hua K. Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China Study Objective: To identify risk factors for post-operative rectovaginal fistula (PRF) in patients with deep endometriosis.
S55
incidence of complications, It can release the symptoms obviously, improve the quality of life up to the level of normal female population.
137 Correlation Between Magnetic Resonance Imaging Results and Findings at Surgery for Cases of Severe Endometriosis Ma K,1 Majumder K,1 Clayton R,1 Rajashanker B,2 Ed-Osagie E.1 1 Obstetrics and Gynaecology, St. Mary’s Hospital, Manchester, Greater Manchester, United Kingdom; 2Clinical Radiology, St. Mary’s Hospital, Manchester, Greater Manchester, United Kingdom
Design: A clinical observational study. Setting: A teaching hospital of Sun yat-sen university. Patients: 63 patient with deep infiltrating endometriosis involve bowel. Intervention: Laparoscopic bowl segmental resection were used to resect the endometriotic lesions during surgery for patient with bowel endometriosis. visual analog scale (VAS) was used to score the severity of pain symptoms before and after surgery. The SF-36 questionnaire was applied to all patients to evaluate the quality of life before and after surgery. Measurements and Main Results: 62 patients have laparoscopic bowel segmental resection.The mean of operative time was 31297min, Mean blood loss was 230182ml, Intraoperative complications occurred in 6 cases, of which 4 were excessive blood loss up to at least 500ml and 2 were bladder injury. Postoperative complications developed in 28 cases (45.2%), including 18 urinary retention (29%), 4 rectovaginal fistula (6.5%), 2 vaginal dehiscence (3.2%) and 1 thrombogenesis, pelvic abscess, general peritonitis, incomplete intestinal obstruction, respectively. All this complications were managed eventfully. The pre-operative VAS scores of dysmenorrhea, dyspareunia, pain on defecation and chronic pelvic pain was 52.9, 4.32.2, 7.31.9 and 3.83.0, respectively, while the post-operative VAS scores was 2.92.2, 0.720.50, 1.60.70 and 2.12.0. The improvement in dysmenorrhea, dyspareunia and pain on defecation was statistically significant (P\0.05). The improvement of post-operative quality of life was statistically significant (P\0.05) in all 8 domains. While compared with the standardized data of Chinese female population, post-operative mean score of the 8 domains of SF-36 had no statistically significant difference(P\0.05). Conclusion: Laparoscopic Bowel segmental resection is a safe and effective procedure for bowel endometriosis. Although it have a high
Study Objective: To determine whether preoperative staging of patients with suspected stage IV endometriosis with magnetic resonance imaging(MRI) is consistent with findings at laparoscopy, cystoscopy and sigmoidoscopy. Design: Retrospective cohort study. Setting: Tertiary referral endometriosis centre. Patients: All patients with severe endometriosis discussed at multidisciplinary level between August 2014 to March 2015. Intervention: All patients with suspected severe endometriosis are staged pre-operatively by MRI and results discussed between a team of gynaecologist, radiologist, colorectal and urological surgeons and endometriosis specialist nurses. Findings are then compared with surgical staging by diagnostic laparoscopy, cystoscopy and sigmoidoscopy. Measurements and Main Results: 30 patients were identified with suspected severe endometriosis and staged pre-operatively with MRI. 6 patients underwent staging laparoscopy, cystoscopy and sigmoidoscopy, 3 patients underwent radical excision of rectovaginal endometriosis and 2 patients underwent total laparoscopic hysterectomy and radical excision of rectovaginal endometriosis. 10 patients are awaiting surgical management and remaining 9 patients opted for continued medical management. Ovarian pathology was seen in 72% of cases (8 of 11 cases with unilateral/bilateral endometriomas) and was consistent with laparoscopic findings in 8 of 8 cases. Adenomyosis was seen in 7 of 11 cases and this was confirmed in 2 of 2 cases who underwent hysterectomy. Rectovaginal nodules were identified in 7 of 11 cases and both were confirmed at laparoscopy. 3 cases showed polypoid infiltration into rectal mucosa on MRI and all cases were confirmed at sigmoidoscopy or anterior resection. Urological abnormalities were found in 2 of 11 cases with unilateral hydroureter and both cases were confirmed at laparoscopy. Conclusion: Pre-operative staging of patients with suspected severe endometriosis with magnetic resonance imaging appears to correlate with surgical findings in the identification of rectovaginal disease, urological abnormality and adnexal pathology. This facilitates counselling of patients regarding future medical or surgical management and allows optimisation of their care by involving the appropriate specialties early on. 138 A Comparison of Examination and Surgical Findings in Women With Endometriosis Bhatti M,1,2 Arnold A,1,2 Ketheeswaran A,1,2 Nesbitt-Hawes E,1,2,3 Deans R,1,2,3 Abbott J.1,2,3 1University of New South Wales, Sydney, NSW, Australia; 2Royal Hospital for Women, Sydney, NSW, Australia; 3Prince of Wales Private Hospital, Sydney, NSW, Australia Study Objective: To investigate the accuracy of bimanual examination in predicting operative times for laparoscopic excision of endometriosis and comparing to clinical experience. Design: Prospective observational study. Setting: Academic affiliated hospital. Patients: Women with suspected endometriosis scheduled for laparoscopy. Intervention: History and examination were used to estimate operative time. This was repeated under general anesthesia. Examining clinicians
S56
Abstracts / Journal of Minimally Invasive Gynecology 22 (2015) S1–S253
included students-[N]; trainees-[T]; experts-[E]; and masters-[M]. Intraoperatively, surgical staging and operative time were recorded. Measurements and Main Results: 121 women were recruited. Clinical estimations of operating time exceeded surgical times by a median of 16 minutes, with 80% of cases completed in less time than predicted. Estimations under anesthetic, immediately pre-operatively exceeded surgical times by 1 minute with 90% of cases completed within 33 minutes of their predicted time. Students and trainees underestimated time by 3 and 1 minutes respectively; experts and masters overestimated by 1 and 4 minutes respectively, although differences were not statistically significant (p=0.496). Increasing experience resulted in stronger associations between examination and surgical findings for the uterosacral ligaments ([N]p=0.6, [T]p=0.007, [E] p=0.004, [M]p =0.002), pouch-of-Douglas ([N]p=0.02, [M]p=0.004), rectum ([N]p=0.53, [T]p=0.49, [M]p=0.19) and adnexae ([T]p=0.1, [E] p\0.001, [M]p\0.001). Sensitivities increased with experience for examination of the pouch-of-Douglas ([T]-27%, [E]-33%, [M]-63%), adnexae ([T]–10%, [E]–28%, [M]-35%), uterosacral ligaments ([N]28%, [T]-31%, [E]-61%, [M]-78%) and rectovaginal septum ([T]-46%, [E]-33%, [M]-63%). Overall pre-operative clinical examination was a poor predictor of disease with sensitivities of 15%-65% across all disease sites. Conclusion: Physical examination is an essential tool that provides useful and accurate reflections of surgical time with experienced examiners estimating surgical time more accurately; it is amenable to training and provides useful information to healthcare providers. Exact localization and staging of disease is poor with clinical examination given the difficulty in accessing and assessing all pelvic areas, with better results obtained in an anaesthetized patient. Examination findings are dependent on clinician experience and can be trained.
Stroma
139 Needle Based Confocal Endomicroscopy (nCLE) Performed Through Transrectal Ultrasound (TRUS): The First Experience in Intestinal Endometriosis Rossini LG,1 Meirelles LR,2 Reimao SM,1 Paccos JL,2 Filippi SS,1 Ribeiro CM,2 Valenciano J,2 Martins FP,2 Cassab JC,2 Coudry R.2 1 Endoscopy, Irmandade da Santa Casa de S~ao Paulo, Sao Paulo, SP, Brazil; 2Endoscopy, Hospital Sirio-Liban^es, Sao Paulo, SP, Brazil Study Objective: Up to 95% of intestinal endometriotic lesions are found in sigmoid colon and rectum. It is the most common extra genital disease that affects between 3% and 37% of women with endometriosis (EDT). Intestinal EDT is difficult to diagnose and should be considered a severe disease. An adequate diagnosis of deep endometriotic lesions remains a challenge and usually occurs around seven years after the onset of symptoms. Even for cases showing signs, symptoms, and/or tests suggestive of EDT, other intestinal diseases, such as intestinal malignant neoplasm, should be ruled out to avoid delay or wrong medical treatment. Diagnostic tools, including transrectal ultrasound (TRUS), magnetic resonance imaging, transvaginal ultrasound, barium enema, and colonoscopy, play significant roles in determining a precise preoperative diagnosis and staging of the disease. Design: Our group has started using a new diagnostic tool for intestinal EDT, which is needle based Confocal Laser Endomicroscopy (nCLE), performed through TRUS a fine needle aspiration (FNA). As far as we know, it is the first experience of nCLE in EDT. Setting: This study was conducted in a tertiary care hospital. Patients: We report five cases of patients with deep pelvic EDT, which we performed TRUS followed by nCLE and FNA of the lesion. Intervention: See in patients section. Measurements and Main Results: Results of nCLE and histology were compared. There are common findings, between nCLE and histology as endometrial glands without globet cells with variable size, presence of stromal elements, fibrous tissue and tortuous neovascularization.
glands Conclusion: More studies with higher samples are needed to confirm our findings. We believe that with this approach it will be possible to differentiate intestinal EDT from other tumors, classify in vivo different types of EDT (glandular, stromal and mixed) and maybe distinguish different degrees of differentiation. In the future, these findings can help to individualize the treatment as well as improve its response. 140 Analysis of Risk Factors for Post-Operative Rectovaginal Fistula in Deep Endometriosis Yi X, Zheng Y, Hua K. Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China Study Objective: To identify risk factors for post-operative rectovaginal fistula (PRF) in patients with deep endometriosis.