子宫内膜异位症生育指数与相关不孕患者腹腔镜术后妊娠的相关性

目的 评价子宫内膜异位症(内异症)生育指数与内异症不孕患者腹腔镜术后妊娠的相关性.方法 回顾性分析2005年1月至2010年1月350例行腹腔镜手术治疗的内异症相关不孕患者的病史及手术资料,电话随访其术后的妊娠情况.按照内异症生育指数的评分标准计算生育指数,利用Kaplan-Meier生存分析法计算不同分值患者的累积妊娠率,并进行比较.结果 内异症生育指数8、9、10分患者术后36个月的累积妊娠率分别为62.5％、69.8％、81.1％,3者间比较,差异无统计学意义(P=0.24);5、6、7分患者术后36个月累积妊娠率分别为49.8％、43.9％、41.6％,3者间比较,差异也无统计学意义(P=0.83).但8～10分患者术后36个月的总累积妊娠率为71.8％,5～7分患者为44.4％,两者比较,差异具有统计学意义(P=0.000).0～4分患者例数较少(共33例),其中15例妊娠.结论 内异症生育指数与内异症相关不孕患者腹腔镜术后的妊娠率相关.内异症生育指数对指导术后处理的选择且有重要的临床意义.     

Feasibility and clinical outcome of laparoscopic colorectal resection for endometriosis

OBJECTIVE: This study was undertaken to evaluate the feasibility and complications of laparoscopic segmental colorectal resection for endometriosis and its efficacy on gynecologic and digestive symptoms. STUDY DESIGN: After magnetic resonance imaging and rectal endoscopic sonographic evaluation of symptomatic colorectal endometriosis, 40 consecutive women requiring colorectal resection were included in this study. Symptom questionnaires were completed before and after the procedure. Perioperative complications and linear intensity scores for several gynecologic and digestive symptoms were recorded. RESULTS: Thirty-six women (90%) underwent laparoscopic segmental colorectal resection and 4 required laparoconversion. Major complications occurred in 4 cases (10%), including 3 rectovaginal fistulae and 1 pelvic abscess. Transient urinary dysfunction occurred in 7 women (17.5%). Median follow-up after colorectal resection was 15 months (3-22 months). Median overall preoperative and postoperative pain scores were 8 +/- 1 (range 4-10) and 2 +/- 2 (0-10), respectively ( P < .0001). Nonmenstrual pelvic pain ( P = .0001), dysmenorrhea ( P < .0001), dyspareunia ( P = .0001), and pain on defecation ( P < .0005) were improved by colorectal resection. Lower back pain and asthenia were not improved. CONCLUSION: Our results suggest that laparoscopic segmental colorectal resection for endometriosis is feasible but carries a risk of major postoperative complications. Colorectal resection improved gynecologic and digestive symptoms, and the overall pain score.     

Expression of apoptosis-related proteins in peritoneal, ovarian and colorectal endometriosis

Endometriosis is defined as the presence of endometrial glands and stroma outside the uterus. Apoptosis, a physiological process by which multicellular organisms eliminate superfluous cells, is altered in tumor tissue. Here we studied the expression of the apoptosis-related proteins p53, bcl-2, bax, p21 and fas in proliferative (n = 9) and secretory (n = 9) endometrium, and in peritoneal (n = 11), ovarian (n = 20) and colorectal (n = 20) endometriosis, by qualitative and semi-quantitative immunohistochemical methods using the percentage of positive cells and HSCORE analysis.

In endometrium, p53, p21 and fas expression was low, whereas bax and bcl-2 expression was elevated. Using HSCORE analysis, only bcl-2 expression varied during the menstrual cycle (48.9 ± 34.2% in the proliferative phase, 11.5 ± 24.7% in the secretory phase, p = 0.01).

Using HSCORE analysis, p53 expression was higher in ovarian endometriosis than in peritoneal (p < 0.0001) and colorectal endometriosis (p = 0.03). P21 expression was higher in ovarian endometriosis than in peritoneal (p = 0.01) and colorectal endometriosis (p = 0.01). Bcl-2 expression was lower in ovarian endometriosis than in peritoneal (p = 0.0002) and colorectal endometriosis (p < 0.0001). Fas expression was higher in peritoneal endometriosis than in ovarian (p = 0.02) and colorectal endometriosis (p = 0.008).

In conclusion, these results confirm the involvement of apoptosis in the pathogenesis of endometriosis. Moreover, expression of apoptosis-related proteins varies according to the location of endometriosis suggesting the involvement of different apoptotic pathways.     

Fertility and pain outcomes following laparoscopic segmental bowel resection for colorectal endometriosis: a review

Intestinal involvement in endometriosis is thought to occur in up to 12% of all endometriosis cases. While colorectal resection is being increasingly advocated as a feasible management option in patients with severe disease, there still remains significant resistance towards this surgery. This article aims to review the current literature to determine the pain and fertility outcomes following segmental bowel resection for colorectal endometriosis.     

子宫内膜异位症生育指数(EFI)对EMs相关不孕妇女腹腔镜术后自然妊娠的预测价值

目的:探讨子宫内膜异位症生育指数(EFI)对EMs相关不孕患者腹腔镜术后自然妊娠率的预测价值。方法:回顾分析2008年1月至2012年3月于我院行腹腔镜治疗的730例EMs相关不孕患者,根据手术发现进行EFI评分,并随访其妊娠情况和妊娠结局。比较不同EFI分值患者的自然妊娠率,Kaplan-Meier生存分析法计算累积妊娠率,采用Log-rank检验进行比较。结果:完成随访的548例患者的总妊娠率为43.43%(238/548)。EFI评分8~10分者的总妊娠率为54.55%(168/308),8、9、10分的妊娠率分别为53.66%(66/123)、51.75%(74/143)和66.67%(28/42),各分值间比较差异无统计学意义(P=0.225)。EFI 7分者的妊娠率为42.27%(41/97),低于8~10分者,差异有统计学意义(P=0.035);EFI 4~6分的妊娠率为21.71%(28/129),4、5、6分的妊娠率分别为17.86%、19.05%和25.42%,各分值间比较差异无统计学意义(P=0.638),显著低于7分者(P=0.000)。EFI 0~3分的妊娠率为7.14%(1/14)。术后不同时间的妊娠率有统计学差异(P=0.000)。r-AFS分期I~IV期的妊娠率分别为45.23%(57/126)、47.33%(71/150)、44.08%(67/152)和44.17%(53/120),无统计学差异(P=0.939)。结论:EFI能较好地预测接受腹腔镜手术的EMs相关不孕患者的术后生育力。     

Bowel resection for intestinal endometriosis

Over the last twenty years, segmental resection (SR) has been the technique most frequently used to treat bowel endometriosis. Nowadays, it is most commonly performed by laparoscopy; however, there is evidence that it can be safely performed by robotic-assisted laparoscopic surgery. Rectovaginal fistula and anastomotic leakage are the two major complications of SR; other complications include pelvic abscess, postoperative bleeding, ureteral damage, and anastomotic stricture. Several studies showed that SR causes improvement in pain and intestinal symptoms; nerve-sparing SR may improve the functional outcomes. The rates of postoperative recurrence of bowel endometriosis vary across the studies, possibly because of the different definitions of recurrence.     

Surgical outcome and long-term follow up after laparoscopic rectosigmoid resection in women with deep infiltrating endometriosis

The aim of this study was to assess the long-term outcome of treating severely symptomatic women with deep infiltrating intestinal endometriosis by laparoscopic segmental rectosigmoid resection. Detailed intraoperative and postoperative records and questionnaires (preoperatively, 1 month postoperatively and every 6 months for 3 years) were collected from 22 women. The estimated blood loss during surgery was 290 ± 162 ml (range 180–600), and average hospital stay was 8 days (range 6–19). One woman required blood transfusion after surgery. Two cases were converted to laparotomy. One woman had early dehiscence of the anastomosis. Six months after surgery, there was a significant reduction of symptom scores (greater than 50% for most types of pain) related to intestinal localisation of endometriosis ( P < 0.05). Score improvements were maintained during the whole period of follow up. Noncyclic pelvic pain scores showed significant reductions ( P < 0.05) after 6 and 12 months, but there was a high recurrence rate later. Dysmenorrhoea and dyspareunia improved in 18/21 and 14/18 women with preoperative symptoms, respectively. Constipation, diarrhoea and rectal bleeding improved in all affected women for the whole period of follow up. Laparoscopic segmental rectosigmoid resection seems safe and effective in women with deep infiltrating colorectal endometriosis resulting in significant reductions in painful and dysfunctional symptoms associated with deep bowel involvement.     

A prospective multi-centre study of major complications experienced during excisional laparoscopic surgery for endometriosis

OBJECTIVE: To clarify the rate of major intra-operative and post-operative complications experienced during excisional surgery for endometriosis. DESIGN: Prospective multi-centre observational study set in two University teaching hospitals and three private hospitals in Sydney, Australia. All consecutive subjects undergoing laparoscopic excisional surgery for minimal to severe endometriosis were recruited (790 subjects). Complications were recorded intra-operatively or post-operatively on a secure computerised patient database. Major intra- and post-operative complications i.e. inadvertent visceral or vascular injury or other complications directly related to surgery that either significantly prolonged the operating time, delayed discharge or necessitated re-admission. RESULTS: Seven hundred and ninety subjects were recruited over a 3-year period. Seven major complications were experienced (8.8/1000); four bowel injuries, one cystotomy, one ureteric transection, and one major vascular injury. All visceral or vascular injuries were diagnosed prior to completion of the surgery. No significant longterm sequelae were experienced. CONCLUSION: The incidence of major complications in this study of 8.8/1000 compares favourably with other similar reports. In view of the potential symptom relief obtained, the authors continue to believe the benefits of such surgery significantly outweigh the risks of subsequent operative-related morbidity.     

The impact of deep disease on surgical treatment of endometriosis

Objective

To compare the difficulty of surgery in patients with and without deeply infiltrating endometriosis.

Study design

Prospective cohort study performed in one hospital specialized in the surgical treatment of endometriosis. 193 consecutive patients undergoing excision of all visible endometriosis by laparoscopy (176 patients, 91.2%) or by laparotomy (17 patients, 8.2%). The duration of surgery, the number of operations, the number of day-surgery operations, the need to operate with a surgeon, the ability to perform complete excision during one operation, and the ability to perform operation by laparoscopy were compared in patients with and without deep lesions.

Results

The mean duration of surgery was 192 (SD 96), and 76 (SD 41) min in patients with and without deep lesions (p < 0.001). Ureterolysis (66% vs. 20%, p < 0.001), division of adhesions (92% vs. 69%, p < 0.001), and hysterectomy (32% vs., 8%, p < 0.001), were more often performed on patients with deep lesions. 41 patients (42%) with deep lesions, and 1 patient (1%) without deep lesions were operated with a surgeon (p < 0.001). Day-surgery was less often performed on patients with deep lesions (11% vs. 45%, p < 0.001). Complete excision during one operation was performed on 95% and on 97% of the patients with and without deep lesions (p = 1.0). Complete excision was less often performed by laparoscopy in patients with deep lesions (79% vs. 95%, p < 0.001).

Conclusions

Surgical treatment of deep lesions is more demanding and time-consuming than surgical treatment of other types of endometriosis, and collaboration with a surgeon is often necessary. Complete excision during one operation is a realistic goal for endometriosis surgery, but it is significantly less often achievable by laparoscopy in patients with deep lesions than in patients without deep lesions.     

Diagnosis and laparoscopic treatment of an unusual case of advanced extragenital endometriosis

Endometriosis is considered to be a benign gynaecological disorder, although several pathophysiological aspects of endometrial lesions resemble the behaviour of malignant tissue: similar to carcinomas, endometriotic cells are able to invade and destroy surrounding anatomical structures. Although the medical treatment of endometriotic lesions, including the use of GnRH analogues or gestagens, show temporary effectiveness and have been reported to cause a regression of disease, they rarely provide long-term relief of symptoms in advanced stages of endometriosis involving extragenital organs, such as the rectum or the urinary system. We here describe the diagnosis and minimally invasive surgical treatment of an unusually advanced case of endometriosis involving the rectosigmoid, the urinary bladder and the ureter, leading to secondary hydronephrosis and loss of renal function.     

Pelvic adhesion formation at second-look surgery after laparoscopic partial and total peritoneal excision for women with endometriosis

The purpose of this study was to determine the incidence of pelvic adhesion formation at second-look surgery after laparoscopic excision of the pelvic peritoneum for pelvic endometriosis. The setting was a district hospital in the UK with a specialised unit for laparoscopic surgical treatment of endometriosis; this was a retrospective study. We used data from the hospital computer database to identify patients who had undergone laparoscopic excision of pelvic endometriosis from April 1998 to March 2004. All subsequent admissions for surgery (laparoscopic or open) were reviewed for the presence of pelvic adhesions as documented in the records and collaborated with photographs from surgery. Forty-eight cases were identified from a cohort of 236 patients who initially had laparoscopic excision of pelvic peritoneum affected with endometriosis. Forty-six had laparoscopic surgery and two had open surgery. At second look surgery, 44 patients (91.7%) had no de-novo pelvic adhesions in the areas where the initial excision was performed. Four patients (8.3%) had filmy adhesions in the pelvis; these patients had other surgical procedures (two had LAVH) or on-going disease (one with recto-vaginal endometriosis nodule and the other with ovarian endometrioma at initial surgery). There were no dense or significant pelvic adhesions. Laparoscopic excision of the pelvic peritoneum as a treatment for pelvic peritoneal endometriosis is not associated with significant pelvic adhesion formation.     

盆腔子宫内膜异位症病灶分布特点及其腹腔镜诊断准确性的评价

目的 探讨盆腔子宫内膜异位症（内异症）病灶的分布特点以及腹腔镜用于诊断不同部位、不同类型内异症病灶的准确率及其与病理诊断的符合率。方法 对62例腹腔镜诊断的内异症病灶行切除术,对肉眼正常的腹膜随机进行活检,并均送病理检查。以病理诊断为标准,计算腹腔镜诊断不同类型、不同部位以及不同颜色内异症病灶的阳性预测值、阴性预测值及敏感度、特异度。结果 62例患者中,55例有卵巢子宫内膜异位囊肿。取得219份内异症腹膜病灶组织、54份肉眼正常腹膜组织以及71个卵巢子宫内膜异位囊肿;盆腔后半部腹膜内异症病灶占80．8％（177／219）,左侧（58．0％,127／219）多于右侧（42．0％,92／219）。盆腔腹膜内异症病灶中蓝色病灶最常见,占39．3％（86／219）。腹腔镜诊断腹膜内异症与病理诊断比较,阳性预测值为67．6％,敏感度为93．7％,阴性预测值为81．4％,特异度为38．3％。其中以蓝色病灶和左侧宫骶韧带处病灶的病理诊断阳性率最高,分别为94．2％及84．7％。卵巢子宫内膜异位囊肿中,左侧占43．6％（24／55）,右侧占27．3％（15／55）,双侧占29．1％（16／55）,其中80．3％（57／71）的卵巢子宫内膜异位囊肿被病理诊断证实。肉眼正常腹膜活检54份标本中,10例（18．5％）病理检查阳性。结论 盆腔内异症病灶的分布呈非对称性,盆腔后部多于前部,左侧多于右侧;腹腔镜下所见的蓝色病灶及宫骶韧带病灶的病理诊断阳性率较高。