A meta-analysis of the use of 4 % icodextrin solution to prevent adhesion formation after gynaecological surgery

Post-surgical adhesions are common and can cause substantial co-morbidity. The aim of this review was to investigate the efficacy of 4 % icodextrin solution, a widely used adhesion prevention agent, in gynaecological surgery. Randomised-controlled trials comparing the use of 4 % icodextrin solution vs. Ringer’s-lactated saline (control) in women of any age undergoing fertility-conserving surgery either by laparoscopy or laparotomy were searched and meta-analysis performed. Compared to Ringer’s-lactated saline, there was no significant difference in the number of patients free from de novo adhesions at second-look laparoscopy (SLL) (odds ratio, 1.21 [0.76, 1.93]), the adhesion score reduction at SLL (mean difference (MD), 0.71 [?0.66, 2.08]), the percentage reduction in adhesion extent (MD, 5.47 [?4.18, 15.12]) or severity (MD, 13.49 [?23.78, 50.75]). The included studies reported the effect of 4 % icodextrin in different ways thus limiting meta-analysis. This is the first meta-analysis of icodextrin and the lack of evidence found to support the use of icodextrin suggests further research is required which should be presented in a uniform manner.     

Laparoscopic nerve-sparing surgery of deep infiltrating endometriosis: description of the technique and patients’ outcome

Introduction  

The radical surgery of the deep infiltrating endometriosis of the rectovaginal septum and the uterosacral ligaments with or without bowel resection can cause a serious damage of the pelvic autonomic nerves with urinary retention and the need of self-catheterization.     

Are symptoms after a colorectal segmental resection in deep endometriosis really improved? The point of view of women before and after surgery

Introduction: Bowel endometriosis can cause debilitating symptoms. Surgical colorectal resection is often required for symptomatic relief. Aim of our study was to evaluate quality of life over a one-year follow-up period in patients submitted to a colorectal resection for the treatment of deep endometriosis. Change in intestinal and extra-intestinal symptoms, and reproductive outcome were also evaluated.

Methods: A prospective observational study was conducted on a cohort of 20 women affected by intestinal endometriosis and submitted to a laparoscopic colorectal resection. The subjects completed a questionnaire about quality of life (SF-36), and they scored in a 100-point rank questionnaire gynecological, urinary and gastrointestinal symptoms, pre-operatively and one-?year postoperatively.

Results: Significant improvements were observed in all domains of the SF-36 throughout the study period. Dysmenorrhea, dyspareunia and not menstrual pelvic pain showed a significant decrease 1?year after surgery. There was also a decrease in abdominal pain, rectal bleeding and constipation but not of nausea, abdominal pain, defecation pain, tenesmus, diarrhea, mucorrhea. Also some urinary symptoms did not improve.

Conclusions: The radical surgical approach has a positive impact on quality of life, although it does not improve all the symptoms complained before surgery. Clear pre-surgical counseling and careful patient selection is suggested.     

94 months follow-up after laparoscopic assisted vaginal resection of septum rectovaginale and rectosigmoid in women with deep infiltrating endometriosis

Background  

Endometriosis with bowel involvement is the most invasive form and can cause infertility, chronic pelvic pain and bowel symptoms. Effective surgical treatment of endometriosis requires complete excision of endometriosis and in same case may require segmental rectosigmoid resection.     

Feasibility and long-term efficacy of hysteroscopic myomectomy for myomas with intramural development by the use of non-electrical “cold” loops

This study aimed to assess the feasibility and the short- and long-term efficacy of hysteroscopic myomectomy for submucous myomas with intramural development [grade 1 (G1) and grade 2 (G2)] by using non-electrical “cold” loops and to verify the role of preoperative variables on surgical outcomes. Symptomatic (bleeding and infertility) premenopausal patients with the diagnosis of submucous myoma at transvaginal sonography, and with G1 and G2 grading at sonohysterography, were included in this prospective study. Hysteroscopic myomectomy was performed by the combined monopolar electrical slicing and traction-and-leverage manoeuvres by non-electrical “cold” loops. One hundred fifty-nine patients were recruited, and 169 procedures were performed. Operating time, fluid deficit, complications and complete resection at first procedure (perioperative outcomes) and persisting symptoms and additional surgery for persisting symptoms (long-term outcomes) were not significantly different for G1 vs. G2 myomas. Perioperative outcomes were significantly different when comparing myoma mean diameter <3.0 vs. ≥3.0 cm (75th percentile). Multivariate analysis and multiple regression analysis proved that myoma mean diameter was the only significant variable for surgical outcomes. Hysteroscopic myomectomy by non-electrical “cold” loops is an effective and efficient treatment for submucous myomas with intramural development. Myoma mean diameter is the only significant preoperative variable for perioperative outcome, while myoma grading loses its role as a prognostic factor.     

Recommendations for the surgical treatment of endometriosis—part 1: ovarian endometrioma

Study question

What does this document on the surgical treatment of endometriosis jointly prepared by the European Society for Gynaecological Endoscopy (ESGE), ESHRE, and the World Endometriosis Society (WES) provide?

Summary answer

This document provides recommendations covering technical aspects of different methods of surgery for endometriomas in women of reproductive age.

What is already known

Endometriomas (ovarian endometriotic cysts) are a commonly diagnosed form of endometriosis, owing to the relative ease and accuracy of ultrasound diagnosis. They frequently present a clinical dilemma as to whether and how to treat them when found during imaging or incidentally during surgery. Previously published guidelines have provided recommendations based on the best available evidence, but without technical details on the management of endometriosis.

Study design, size and duration

A working group of ESGE, ESHRE and WES collaborated on writing recommendations on the practical aspects of endometrioma surgery.

Participants/materials, setting and methods

This document focused on endometrioma surgery. Further documents in this series will provide recommendations for surgery of deep and peritoneal endometriosis.

Main results and the role of chance

The document presents general recommendations for surgery of endometrioma and specific recommendations for cystectomy, ablation by laser or by plasma energy, electrocoagulation and a combination of these techniques applied together or with an interval between them.

Limitations and reasons for caution

Owing to the limited evidence available, recommendations are mostly based on clinical expertise.

Wider implications of the findings

These recommendations complement previous guidelines on the management of endometriosis.

Study funding/competing interests

The meetings of the working group were funded by ESGE, ESHRE and WES. CB declares to be a member of the independent data monitoring committee for a clinical study by ObsEva and receiving research grants from Bayer, Roche Diagnostics, MDNA Life Sciences and Volition. ES received honoraria for provision of training to healthcare professionals from Ethicon, Olympus and Gedeon Richter. The other authors declare that they have no conflict of interest.

     

Twenty-five years after the FIGO guidelines for the use of fetal monitoring: Time for a simplified approach?

Twenty-five years after the FIGO Workshop that produced the “Guidelines for the use of fetal monitoring,” these remain the only broad international consensus effort in this field. Documents of a similar nature have been produced by national institutions, with subsequent updates of the initial concepts. The 3-class classification system has now been adopted by all the major guidelines, and while there are numerous similar features, and indeed many ideas were inspired by the FIGO guidelines, many key aspects still lack consensus. Making guidelines simpler and more objective may be an important step to guarantee a wide application and assimilation of the recommendations, as well as an enhanced reproducibility and increased memory retention.     

“Centers of excellence in endometriosis surgery” or “centers of excellence in endometriosis”

Centers of excellent endometriosis surgery could improve the care of women with endometriosis, especially if combined with control of the quality of the surgery performed, e.g., through systematic taping of entire interventions. Centers of excellence in endometriosis without emphasis on providing excellent surgery seem of little value and could do more harm than good.