Recammente, nella stampa Italiana, il bisfenolo a considerata come la causa dell’endometriosi.
1. La relazione tra endometriosi e ‘endocrine disrupters’ ha inizio nel 1994 con un articolo di Koninckx seguito dall’articolo di Rier. Fino a oggi non è chiaro  se  vi è o meno questa  relazione . Suppratutto e inutile fare paura alle donne.
2.. Anche la storia del bisfenolo – un altro endocrine disrupter della  stessa famiglia- è gia vecchia e inizia con un bell’ articolo di Tsutsumi. e l’articolo di Newbold et al, 2005 . Come demonstrato prima per tanti altre estrogeni (stilbestrol e estogeno-like ) una dose forte supranormale puo creare problemi nel sviluppo genitali. Come dimostrato precedentemente  per tanti altre estrogeni (stilbestrol ed estogeno-like ) una  fortissima  dose può creare problemi nel sviluppo genitali. Il primo articolo nelle donne con endometriosi è di 2009 dimostrando che le donne con endometriosi hanno una  concentrazione di bisfenolo piu alto nel sangue. Non era chiaro se le concentrazioni erano sufficiente per far sviluppare un’endometriosi.
3. I dati recenti Signorile et al 2009 trovano ‘endometriosis-like lesions’ nelle topi.  Dal momento che non è chiaro  se queste lesiooni siano endometriosi, abbiamo (Ronald E. Batt, University at Buffalo, State University of New York, USA ,Lone Hummelshoj, Endometriosis.org, London, England,Charles Chapron, Université Paris Descartes, CHU Cochin, Paris, France ,Dan C. Martin, University of Tennessee Health Science Center, Memphis, USA, Glenna C. Bett, University at Buffalo, State University of New York, USA, John Yeh, University at Buffalo, State University of New York, USA, Philippe R. Koninckx, KULeuven Belgium; University of Oxford, UK; and Università Cattolica, Roma, Italy) gia scritto un  commento per esprimere  i nostri dubbi .  Un altro articolo “The elephant in the room” è adesso ‘in press’.
4. Cosi l’articolo pubblicato recentemente sulla rivista “Visto” dovrebbe  essere considerato con prudenza. Non sono d’accordo soprattutto con la fine dell’articolo, dove il trattamento chirurgico è discusso. L’endometriosi microscopica è un opinione di 25 anni fa e non è mai stato provato. Come è discusso  in questo sito, il problema fondamentale della chirurgia è la chirurgia incompleta che probabilmente è la causa piu importante delle ricorrenze.
Prof P.R. Koninckx e Drssa A. Ussia

Sarà tradotto in breve tempo

Endometriosis is apparently a hot topic with many scientifical controversies. In addition to the numerous and well organised patient organisations, political action and lobbying has become more prominent over the last years. As a consequence of this Endometriosis has been recognised as a social disease in Italy, while also in the EU endometriosis has been put on the political agenda. Recently the monthly newsletter of the WES had an editoreal criticising amonst other things, quality control in surgery. I quote ” You may have noticed a vicious war is raging. Between surgeons. About excellence………………………. It has even been suggested that there should be a camera in every OR and mandatory video registration to prevent abuse and permit quality control………………”.

To understand this comment insight in the medical politics of endometriosis is necessary.

First endometriosis is a misnomer and not always a disease.. Endometriosis was defined 100 years ago as endometrial cells outside the uterus. which is a microscopical description The real questions remains whether this is a disease, something abnormal. Although this sounds like a scientific discussion concerning pathophysiology, the medico polical background is important to understand .

If typical cystic and deep endometriotic lesions are considered 3 different pathologies and 3 endpoints of a disease, without progress from one to the other the specific symptoms of each entity are straightforward. Endometriosis hence becomes a not recurrent disease, as other benign tumors as myoma’s, if surgery was complete. As for most benign tumors, a medical cure is not very realistic. The technical difficulty of complete laparoscopic excision of deep endometriosis has generated the concepts of the Pelvic Surgeon and of quality control in surgery eg through videorecording.
Considering endometriosis as one disease is based upon the hypothesis of Sampson with important consequences. First subtle lesions are considered (erroneously) a pathology and endometriosis becomes a progressive and recurrent disease. Yet the impression exists that the large majority of gynaecologists supports this concept. Besides the fact that this is the traditional vision since 100 years, we should be aware of the a background of medical politics.

The background of the medical politics of endometriosis

Endometriosis is a ‘billion dollar business’ . It is a frequent pathology, with a central role in gynaecology since it is a frequent cause of pain and infertility. Besides the obvious stakeholders as patients, gynaecologists, the farmaceutical industry and the insurances other less well known stakeholders play a role, such as surgery for endometriosis. The development of endoscopic surgery, and the recognition of the technical difficulty of laparoscopic deep endometriosis surgery is changing the organisation of surgery : whereas endometriosis surgery by laparotomy used to be performed by all gynaecologists, deep endometriosis surgery was recognised as level III -the most demanding- surgery in gynaecology. Simultaneously the emphasis of infertility centers has changed away from microsurgery toward IVF.
IVF centers also emphasising excellent surgery have become rare and gynaecologists who are authorities in both surgery and IVF have become almost inxistent. Therefore referrals became moere important. In the absence of this, IVF with a deep nodule in the rectovaginal septum, or incomplete surgery, or liberal use bowel resections might occur.
Quality control of surgery through (mandatory) videoregistration meets strong opposition for several reasons. Besides Medico-legale concerns many are opposed to big brother scenarios. In addition everybody realises that auditing surgery might be used for many other aspects, one of them being that not all specialist should be allowed to perform any kind of surgery.
The DRG, the cost of a surgical intervention, is less publicly known and few realise the direct relationship with quality control. All endometriosis surgery in eg Belgium, also the resection of a deep nodule, is reimbursed a few hundred euro. If however a bowel resection is performed the cost is some 1000 euro, and this nothwithstanding the fact that a nodular resection is more difficult and takes longer. The WES editoreal raised the problem writing “Some of them seem to fear that if bowel resection is paid better than a selective resection of lesions, while being faster and easier, their fellow surgeons would go for an unnecessary bowel resection rather than take the trouble of removing just the invasive process.” Reality is that this important price difference induces a psychological bias, since we all often have the impression that “more expensive must be better”, and that whenever the options are not that clear, bowel resections are favorised, especially when discoid resections mean a referral often to another hospital. More important is that it is impossible the increase the reimbursement of all endometriosis surgery, while the selective increase of the reimbursement of severe endometriosis surgery requires some relationship between cost and severity, something that is difficult without some control of the intervention. In Italy and in the UK discussions are being held to align the reimbursement of severe deep endometriosis nodules (infiltrating the muscle of the bowel) whether performed by bowel resection or nudule excision. This obviously requires videoregistration in order to prevent that a too liberal use of this DRG . Registration would moreover also be important to judge the error in judgment when after a bowel resection, endometriosis is not confirmed by pathology.
Research in endometriosis obviously is important. But research implies grants and money. Again the concept whether endometriosis is a benign tumor (with subtle probably occurring intermittently in all women) or whether implantation is the key initiating factor remains important. Indeed this concepts make research in implantation irrelevant or very important. The same holds true for prevention of implantation to prevent endometriosis. Thus funding risks to shift from implantation to benign tumors. And who decides : the majority .

The pelvic Surgeons are a very small minority in the large group of endometriosis specialists. Also the discussion that we need centers of excellent surgery, not centers of excellence in endometriosis, which risk to do more harm than good, reflects this concept.

Those who promote the pelvic surgeon concept and who try to avoid bowel resections are a small group. Indeed since deep endometriosis is a relative rare disease not that many surgeons are necessary to deal with the pathology, while not that many can have a large eperience.
The large majority is opposed to this concept albeit for various reasons.

The bodies involved in education and accreditation The concept of pelvic surgeon indeed does not fit with the actual subspecialties in gynaecology.
Referrals of deep endometriosis. If bowel resections are the recommended treatment, this type of surgery can be done in every hospital since all surgeons are able to do bowel resections. Although it is unclear what role the high reimbursement of bowel resections play, the local relationship between the gynaecologist and the surgeon are influenced by the alternative of referring patient to another hospital instead of doing together a bowel resection.
Most gynaecologists are opposed to a quality control in surgery
The Infertility lobby. Good surgery indeed is a prevention of IVF . An IVF baby is more expensive than a surgery baby. Mundially we are witnessing a shift away from surgery towards IVF that some call a medico industrial complex.
Oncologist are opposed to the concept where oncology would be less a subspeciality including surgery.
Many scientist do not like the concept that subtle endometriosis and implantation are less important, albeit because of their background.

Prof P. R. Koninckx and Drssa Anastasia Ussia

Habiamo avuto una discussione e-mail internazionale sulle problemi del diagnosi dell’endometriosi (in completo click qui)

Following an international e-mail debate concerning research in endometriosis and political lobbying for endometriosis some comments are important.

1. The discussion and comments clearly demonstrated that the professional world of endometriosis remains divided between a few advanced surgeons (dealing with severe and deep endometriosis), infertility specialists dealing predominantly with superficial endometriosis, gynaecologists involved mainly in medical treatment and researchers.
This already was addressed by discussing why “centers of excellence of endometriosis” could do more harm than good and why “centers of excellent surgery with quality control are needed”.

2. The delay in diagnosis remains a major issue and is caused by a series of factors such as lack of awareness, medical treatment given for longer periods without a diagnosis and lack of adequate referral.
The solution of a simple non invasive diagnostic test, as proposed mainly by the non surgeons and the infertility/IVF/minor surgery specialist might however do more harm than good.
A non invasive diagnostic test, unless 100% sensitive and 100% specific could cause problems as we are living today with MRI and ultrasound. Even for cystic ovarian endometriosis and even performed by experts sensitivity and specificity rarely exceeds 85%. If we really trust this diagnostic test this means that 15% of women will have surgery without a reason and that 15% will not have surgery although needed. When performed by non experts and for deep endometriosis it is much worse. A non invasive diagnostic test risks to meet the same problems of inducing unnecessary overtreatment and delaying necessary surgery.

3. As a surgeon, I personally do not need so much a non invasive diagnostic test for a series of reasons
* pain, certainly severe pain is an the indication for laparoscopy during which the diagnosis will be made. Treatment will be done at the same time or the patient can be referred.
* I do not consider it good clinical practice not doing a laparoscopy or refraining from doing a laparoscopy because the pain is slightly better with medical therapy. (as is often done by non surgeons)
* unexplained infertility for more than 2 years or longer needs a laparoscopy.
* if there is no pain or infertility I have no need to know whether somebody has endometriosis since anyway it is doubtful whether it should be treated..

3. Surgery today is the only really effective treatment for cystic and deep endometriosis. Yet for deep endometriosis, the availability and the quality of surgery is limited and bowel resections are performed increasingly more frequent. For bowel resection instead of discoid resection, I have not seen any justification until today. What is obvious however is that the side effects are much more important than generally acknowledged and that many bowel resections at least are not necessary ( eg when after bowel resection endometriosis was not confirmed by pathology, or when endometriosis was outside the bowel muscle). As unspoken underlying reasons I only can consider the fact that it is faster and easier (all bowel surgeons can do a bowel resection) or resistance to referral of the patient. In addition the fact that in many countries the reimbursement of a bowel resection is 5 times higher than of a discoid resection also might influence policy making. For this discrepancy to be corrected a quality control of surgery through mandatory videoregistration is necessary in order to remain within a reasonable health care budget.

Philippe Koninckx and Anastasia Ussia
Gruppo Italo Belga.

Publicato : 2010 World Endometriosis Society World Endometriosis Society e-Journal Volume 12 No 1, 2010 8

Dear Editor, per l’informazione completa visita il web site inglese

Negli ultimi anni  ci sono state diverse pubblicazioni  nelle quali si ipotizza sempre di più una associazione tra cancro ed endometriosi.Noi riteniamo che ciò non è vero.Dal nostro punto di vista i dati pubblicati sono insufficenti e  spesso incompleti , per cui, essendo tali  articoli  potenzialmente dannosi, in quanto potrebbetro creare falsi allarmismi nelle donne affette da endometriosi, meritano quanto meno una  appropriata discussione.

Innanzitutto,la patofisiologia dell’endometriosi ,ancora oggi,non è ben chiara .L’ipotesi etiopatogentica proposta da Koninckx ed altri nel 1997, Endometriotic disease theory, considera le lesioni sottili superficiali come una normale e fisiologica condizione che  in maniera intermittente si verifica  in tutte le donne in età fertile,  mentre le lesioni tipiche, le cistiche e le profonde  sono da considerare come un tumore benigno e quindi causate da una alterazione del genoma determinata da diversi fattori inclusi quelli ambientali, ciò spiega anche l’ereditarietà, gli effetti della diossina e delle radiazioni, ed anche le mutazioni dell’endometrio delle donne affette da endometriosi .Sebbene l’Ipotesi di Sampson(impianto di cellule endometriali che affluiscono con la mestruazione retrogada attraverso le tube)  vista la presenza di  viable cells  nel liquido peritoneale   e la loro potenzialità di impianto,è molto attraente , non spiega  la progressione e mai , tra l’altro, è stata provata la progressione da un tipo all’altro di endometriosi .  consideriamo l’endometriosi come tumore benigno,  secondo la teoria di Koninckx  è normale che vi siano delle similitudini con tutti gli altri tumori benigni.

 Brinton et al (1997)  hanno pubblicato  una odds ratio di 1.9 e 4 for developing ovarian cancer in women with endometriosis or ovarian endometriosis respectively, a conclusion based upon a Swedish hospital discharge diagnosis of endometriosis. The study of Melin et al (2006) finds an odds ratio of 1.2 equally based on a hospital discharge diagnosis of endometriosis. It can be anticipated that this group of women, in comparison with women without a diagnosis of endometriosis, had had more interventions, more pelvic pain, more medical treatments of endometriosis and probably more infertility treatments. Having been diagnosed with ovarian endometriosis means probable surgery of the ovary, very often focal coagulation leaving behind at least carbon deposits. It also means more adhesion formation etc. It is intellectually unfair to pick one aspect only –endometriosis– for the comparison of two groups of women who differ in many other aspects. This indeed is a fundamental problem of correlation and association statistics. Logistic regression and statistical model building were developed to find out which are independent and which are important factors. This obviously has not been done for the association of endometriosis and cancer. A second bias might have been introduced when analysing national discharge statistics. In most women ovarian endometriosis is diagnosed by ultrasound; and in a recent IOTA review (Van Holsbeke, in press) of over 2500 cysts, a risk of an (borderline) ovarian cancer was found in 1%. This could seem to support the argument, but analysing the data in detail, this is true only for women after menopause, a period of life that seems hardly associated with endometriosis. It would not be surprising if many women who did not have ovarian endometriosis by pathology ended up with a primary hospital discharge diagnosis of endometriosis. Tubal ligation Tubal ligation is associated with a decreased risk of ovarian cancer, a lower incidence of PID, and absence of retrograde menstruation. Tubal ligation, however, also influences in some women ovarian function and blood supply at least as evidenced by irregular cycles. Today we do not know how to explain exactly the decreased incidence of ovarian cancer in these women. The absence of retrograde menstruation does not seem logical as an explanation; indeed women with severe cystic ovarian endometriosis will have a higher incidence of infertility and thus a lower probability of undergoing tubal sterilisation. Accuracy of diagnosis It is surprising that the diagnosis of endometriosis is so easily accepted in the articles using hospital discharge records, knowing that the diagnosis of endometriosis is bound to have biases. Whereas for typical and deep lesions the probability of histological confirmation is very high, the rate of histological confirmation of subtle lesions is low, mainly dependent upon the expertise of the surgeon and the pathologist. Also for cystic ovarian endometriosis the histological confirmation of endometriosis, defined as stroma and glands, is not that well established and often pathology returns as ‘compatible with endometriosis’; most of these women, however, will be discharged as having endometriosis. Especially after menopause the diagnosis of endometriosis risks to be erroneous. Indeed, the occurrence of ‘cystic ovarian endometriosis’ or ‘large cystic ovarian endometriosis’ in women who did not have an existing cystic ovarian endometriosis before menopause is something rare and suspicious by definition. From the available data it is difficult to judge how strict the diagnosis of endometriosis was. Anyway, it would not be surprising, that many of these women were erroneously diagnosed as having had endometriosis. For recent prospective studies where women were followed by serial ultrasound Kobayashi et al (2009, 2008) the bias is obvious given that the ultrasound diagnosis of endometriosis has a specificity of 88% only. Moreover in the group of the 12% false positives the ovarian cancer incidence was 18% after menopause versus 0.6% before menopause (Van Holsbeke, in press). It is moreover questionable not to perform surgery in menopausal women with an ultrasound diagnosis of endometriosis. Menopause Unopposed oestrogen administration following menopause is associated with an increased risk of endometrial hyperplasia and adenocarcinoma. Following menopause, existing endometriosis will become inactive but will not disappear. Considering the prevalence of endometriosis in women before menopause it is very surprising that oestrogen-only therapy following menopause (in women without an endometrium) is not associated with an epidemic of adenocarcinomas originating from the endometriosis. This even looks as if endometriotic cells, although hormonally responsive, are pretty resistant to malignant transformation. Metastatic behaviour Especially deep endometriosis has invasive and „metastatic‟ behavior because of the positive lymph nodes. In our series of over 2000 deep nodules, only one however has turned out to be malignant, and this in a postmenopausal woman (unpublished data). In conclusion, the data describing an association between endometriosis, in particular cystic ovarian endometriosis, and ovarian cancer can be interpreted in many different ways. Today we do not consider the data sufficient to consider women with endometriosis or cystic endometriosis at risk for developing ovarian cancer, a conclusion already reached by others (Somigliana et al, 2006). It reminds us of the fact that so many ovaries have been removed prophylactically after age 50 to find out recently that women with ovaries live longer than women without ovaries (Parker et al, 2009)

„It ain’t so much the things we don’t know that gets us into trouble. It’s the things we do know that just ain’t so‟ Josh Billings

Philippe R Koninckx and Anastasia Ussia

KULeuven, Belgie en Gruppo Italo Belgo, Roma Italia

REFERENCES Brinton LA, Gridley G, Persson I, Baron J, Bergqvist A. Cancer risk after a hospital discharge diagnosis of endometriosis. Am J Obstet Gynecol 1997; 176(3):572-579. Kobayashi H, Sumimoto K, Kitanaka T, Yamada Y, Sado T, Sakata M et al. Ovarian endometrioma–risks factors of ovarian cancer development. Eur J Obstet Gynecol Reprod Biol 2008; 138(2):187-193. Kobayashi H. Ovarian cancer in endometriosis: epidemiology, natural history, and clinical diagnosis. Int J Clin Oncol 2009; 14(5):378-382. Koninckx PR, Barlow D, Kennedy S. Implantation versus infiltration: the Sampson versus the endometriotic disease theory. Gynecol Obstet Invest 1999; 47 Suppl 1:3-9. Mandai M, Yamaguchi K, Matsumura N, Baba T, Konishi I. Ovarian cancer in endometriosis: molecular biology, pathology, and clinical management. Int J Clin Oncol 2009; 14(5):383-391. Melin A, Sparen P, Persson I, Bergqvist A. Endometriosis and the risk of cancer with special emphasis on ovarian cancer. Hum Reprod 2006; 21(5):1237-1242. Parker WH, Broder MS, Chang E, Feskanich D, Farquhar C, Liu Z et al. Ovarian conservation at the time of hysterectomy and long-term health outcomes in the nurses’ health study. Obstet Gynecol 2009; 113(5):1027-1037. Prowse AH, Manek S, Varma R, Liu J, Godwin AK, Maher ER et al. Molecular genetic evidence that endometriosis is a precursor of ovarian cancer. Int J Cancer 2006; 119(3):556-562. Somigliana E, Vigano P, Parazzini F, Stoppelli S, Giambattista E, Vercellini P. Association between endometriosis and cancer: a comprehensive review and a critical analysis of clinical and epidemiological evidence. Gynecol Oncol 2006; 101(2):331-341. Vanholsbeke C, Van Calster B, Guerrierro S, Savelli L, Leone F, Fischerova D, Czekierdowski A, Fruscio R, Veldman J, Van De Putte G, Testa AC, Bourne T, Valentin L, Timmerman D. Imaging in gynaecology: How good are we in identifying endometriomas? F, V & V in ObGyn, 2009, 1 (1): in press.

Questo messagio è publicato in  ‘Gynaecological Surgery’ “Centers of Excellence in Endometriosis surgery” or “Centers of excellence in Endometriosis” Philippe R. Koninckx1-2 and Anastasia Ussia2; 1KULeuven, Leuven, Belgium ; Univ of Oxford, Oxford, UK ; Università Cattolica, Rome Italy ; and 2Gruppo Italo Belga, Villa del Rosario, Rome , Italy

Per commenti e discussione vedere MDlinx
Scarsi progressi sono stati compiuti negli ultimi 2 decenni nel trattamento medico dell’endometriosi. Nessun importante passo in avanti si è fatto nel trattamento medico. Le lesioni endometriosiche diventano meno attive dopo la menopausa o sotto trattamento medico senza però scomparire. Il trattamento medico dell’endometriosi non migliora la fertilità e anche l’efficacia della terapia medica sul dolore associato a endometriosi deve essere considerata con cautela dato l’importante effetto placebo.
Nuovi dogmi sull’endometriosi sono stati introdotti, come il ritardo nella diagnosi di 7 anni (l 7 anni tra i primi sintomi e il diagnosi). ,Ma probabilmente lo stesso ritardo si riscontra per tutte le malattie non mortali che causano dolore cronico.  . Il ritardo nella diagnosi dipende dalla competenza del medico che riconosce solo ciò che conosce e rientra nella sua specialità. Questo ritardo nella diagnosi della malattia, ovviamente, provoca sofferenza e altera la qualità della vita della donna, così come per tutte le altre sindromi da dolore cronico. Fortunatamente però, per quanto riguarda l’endometriosi, questo ritardo nella diagnosi non altera l’esito del trattamento, né l’endometriosi peggiora durante questo periodo.
Centri di eccellenza sono diventati “di moda” in molti settori della medicina, come la sterilità e l’oncologia.
“Centri di eccellenza per l’endometriosi” per ridurre il ritardo nella diagnosi e migliorare il trattamento sono ormai di “tendenza” e vengono proposti nella maggior parte dei casi da coloro che non praticano il trattamento chirurgico. Temiamo che questo possa fare più male che bene. Gli argomenti usati per giustificare tali centri di eccellenza in effetti suonano un po’ come di lobbying per interessi personali, mentre manca la prova che gli obiettivi suggeriti vengano effettivamente raggiunti. La diagnosi di endometriosi non viene accelerata, poiché i pazienti vengono inviate a questi centri solo dopo che la diagnosi (tardiva o meno) è stata fatta. Quanto questi centri migliorino il risultato del trattamento è altrettanto dubbio e si rischia, inoltre, di sottoporre inutilmente la paziente a lunghe cure mediche. Se vogliamo migliorare la cura delle donne con endometriosi dovremo ridurre il ritardo di diagnosi e migliorare il trattamento. Al fine di ridurre il ritardo della diagnosi nelle donne con dolore pelvico, abbiamo bisogno di centri (di eccellenza) per il dolore pelvico cronico. Dal momento che, ad oggi,  le terapie mediche riducono il dolore senza però mai guarire la malattia, il trattamento chirurgico della endometriosi resta il primo ed il più importante.
Il trattamento chirurgico della endometriosi severa è stato dimostrato essere così efficace che fare degli studi clinici nelle donne con dolore severo, mettendo a confronto la chirurgia contro una gestione di attesa, per grandi cisti endometriosiche ovariche e per endometriosi profonda, verrebbe considerato non etico. Dal momento che la chirurgia per l’endometriosi severa richiede grande abilità e competenze, sarebbe preferibile disporre di centri di eccellenza per la chirurgia dell’endometriosi. Idealmente la chirurgia per l’endometriosi dovrebbe combinare la laparoscopia diagnostica con la chirurgia. Inoltre, chi pratica questa chirurgia, dovrebbe avere la competenza e le capacità tecniche per eseguire gli interventi chirurgici più avanzati, se necessario. La creazione di centri di eccellenza per la chirurgia dell’endometriosi sarebbe un importante passo in avanti nel raggiungimento di questo obbiettivo. Oggi, purtroppo, spesso le donne hanno bisogno di un secondo intervento in quanto il trattamento chirurgico non poteva essere eseguito nel corso della laparoscopia diagnostica. Questo, tuttavia, è considerato un problema minore. Quel che è peggio è l’intervento chirurgico incompleto, in quanto il primo intervento è il più importante, mentre la chirurgia incompleta renderà più difficile la seconda operazione peggiorando il risultato finale. Troppo spesso le donne vengono ancora sottoposte ad inutile intervento di isterectomia senza ricevere il trattamento sul nodulo di endometriosi profonda. Le resezione intestinale per endometriosi profonda viene praticata troppo liberamente, nonostante le frequenti e gravi conseguenze a lungo termine che ne derivano, soprattutto per le resezioni del retto.Alcune di queste resezioni intestinali vengono addirittura praticate per lesioni endometriosiche dell’intestino superficiali e, purtroppo troppo spesso, in donne senza endometriosi intestinale (fino al 26%, come pubblicato di recente).
Dal momento che la variabile più importante per l’esito della chirurgia è il chirurgo, noi suggeriamo fortemente che un qualche tipo di controllo di qualità dell’ intervento venga attuato, come la video-registrazione sistematica per intero di tutti gli interventi.Il controllo della qualià dovrebbe essere mandatorio per poter avere il riconoscimento di centro di eccellenza e la video-registrazione dovrebbe essere un criterio di valutazione fondamentale.

<strong>The question </strong> After one year my wife (who has endometriosis) got pregnant.  We are looking for information on the effect of pregnancy upon endometriosis : is there a risk that endometriosis can grow. .

<span style=”color: #ff0000;”><strong>The answer </strong></span>

<strong><span style=”color: #000000;”>effect of a pregnancy upon endometriosis</span>.</strong>
<p style=”padding-left: 30px;”>Pregnancy makes endometriosis and the endometrium decidualise ie both become less active, and endometriosis cause less pain.
Deep endometriosis can increase slightly in size since decidualised cells are slightly bigger. Only when there is a very big nodule with over 90% occlusion of the bowel, there is some risk of a complete occlusion. Therefore these women should be operated before pregnancy. All the others can be happy to be pregnant and forget temperarily about endometriosis.
After the pregnancy, endometriosis reactivates
Most important is to know that a pregnancy does not increase endometriosis ; it however also does not cure endometriosis.

<strong>effect of endometriosis upon the  pregnancy </strong>:  None

Prof P.R. Koninckx

A lady asked : I have a cystic ovarian endometriosis ; do I have an increased riks of ivarian cancer ?

The association between cystic ovarian endometriosis and ovarian cancer remains problematic and disturbing. Too often this soo called association is highlighted ; it creates fear in many patients and is often an alibi not to perform laparoscopic surgery but a laparotomy instead.

Fact 1 In large series there is some statistical association demonstrating that ovarian cancer is slightly more frequent in women with cystic ovarian endometriosis dan in women without. The association however is so weak that it can be considered as clinically irrelevant. Then there is a lot of speculation to explain this.
Fact 2 In large series of ultrasound diagnosis of cystic ovarian endometriosis ovarian cancer is found in some 3% of women, almost all of them in women after menopause though.

Comments

Statistical associations cannot demonstrate a cause and effect relationship and should be interpreted carefully.

Most important is the strength of the association. The association of cystic ovarian endometriosis and ovarian cancer is much weaker than the association between the use of oral contraception and tubal sterilisation and a decrease in ovarian cancer. The latter has been used to suggest that some ascending viral infections might be related to the onset of ovarian cancer, but has never been used as an argument to perform mass sterilisations or for the use of oral contraception.

Associations should be interpreted clinically. With the data we have today, it is important for the patients to know that

If you have a cystic ovarian endometriosis and are less than 45 years

there is almost no (never say never in medecine) real risk of cancer, and a cystectomie can safely be performed.
this will not increase your risk of developing ovarian cancer later.

If you have a cystic ovarian endometriosis and are older than 45 years or after menopause

normally the ovary will be removed, since this is technically easier and out of prudence in a bad so there is no spilling
In addition an larger ovarian cyst many years after menopause is alwyas suspect since endometriosis becomes rare.
This definitively is not an indication for a systematic laparotomy. If you are over 50 and the ovarian cyst is large, making the removal in a bag difficult the surgeon should have the skills to do this without spilling, otherwise it is better to perform a laparotomy.

This is an example of the statement on the home age that scientific data can be difficult to translate to the patient. Too often data are overstretched or misused to induce fear and/or to jsutify a laparotomy, especially by those non familiar with laparoscopic surgery.

Prof P.R. Koninckx e Drssa A. Ussia

Nella discussione sulla chirurgia laparoscopica per l’isterectomia in uteri molto voluminosi e nella discussione sulla utilità della chirurgia robotica abbiamo fatto un commento completo in inglese In breve…….

Date: Tue, 10 Nov 2009 19:45:30 -0500 From: “Philippe R. Koninckx and Anastasia Ussia” Subject: Laparoscopic hysterectomy on the large fibroid uterus
Find below some comments to the discussion on large uteri and on robotic surgery on the AAGL listserv.
1. The first and single most important instrument for a large uterus is a decent manipulator. The uterine rotator, which I patented back in 1991, and which only recently has been finalised into a strong manipulator, permits in addition to other movements as push/pull, ante/retroflexion, rotation of the uterus. The bigger the uterus the more important this is. (This manipulator is actually distributed by Storz ; for videos of its use
2. Ligation of the uterine artery at the origin is a technique which is mandatory to master when really big uteri are tackled. Occasionally, the uterine artery at the level of the uterus can be very difficult to reach, especially when a myoma in the broad ligament makes its access difficult
3. We do appreciate and want to endorse John’s comments on robotic surgery (see below). I have a robot in Leuven and still have not found out what I could use it for, except eventually for tubal reanastomosis. Considering the results (eg of Charles Koh and ours) of laparoscopic reanastomosis it will be very hard to prove superiority of the robot. I do not need it for ureter reanastomosis, and also for endometriosis or myoma’s I do not see its utility. The major problem in Belgium is that the Da Vinci robot is used without proof of superiority and without any economic principle. If the cost of the robot and of the equipment would not been paid by the community , I do not think any gynecologist would pay for a robot. If established endoscopists do not need a robot, its use by non-endoscopists is a step backwards since for every complication they will have to do a laparotomy.

Philippe R. Koninckx and Anastasia Ussia
Uiversity of Leuven, Belgium and Gruppo Italo-Belga, Roma Italia

*** below the comment of John Steege
Date: Mon, 9 Nov 2009 22:59:16 -0500 From: John Steege Subject: Laparoscopic hysterectomy on the large fibroid uterus

Initially, I joined the enthusiasm for the robot, but after doing about 100 cases, I’ve come to feel that in benign gynecology, with a modicum of
experience, there really are no advantages to using the robot. Taking them one by one:
1) 3-D: Maybe it’s a little easier to learn laparoscopy with the robot, but the experienced operator doesn’t need it. My cerebellum has been used to
the “conventional laparoscopy” approach for so long that I don’t even see the 3-D.
2) wristed instruments: Yes, easier to sew, but now with the Quill suture available, it’s quite feasible to do most myomectomies with straight sticks, and
closing the cuff after laparscopic hysterectomy is quite easy. (Our second year residents learn it in about 2-3 cases.)
3) Speed?: Size of uterus, complexity of the sidewalls, and teaching time are the real rate-limiting steps, not the robot or lack thereof.
4) Less pain after surgery?: Hinted at in the marketing, but no data.
5) Less scarring after surgery?: Same as #4.
For the larger uterus (over about 16 weeks), I now use two 5 mm ports on each side, and find this allows a very rapid and low blood loss procedure, even
with a relatively less experienced resident assisting. Choice of tissue-dividing instrument matters little, as there are no data to support a clinically
meaningful difference in healing or safety.
The current pressure to get labeled as a “robotic surgeon” worries me. I think we will see surgeons attempting difficult surgeries they are really not qualified to do, thinking that the robot will make it easier. In fact, the lack of tactile feedback will make it more difficult to successfully deal with advanced
endometriosis, difficult pelvic sidewalls, and the like. More, not fewer, complications are the likely result.
So far, the fact remains that there is nothing special that the robot does for the gyn surgeon with a modicum of experience, who is doing benign
gynecology. I would leave the discussion of gyn cancer surgery and urologic surgery to others, although the issues are far from settled in those areas as
well.
We need to be fair and honest in the information we advance to the public. We need to not let competition among providers distort the data. Advantage
of the robot? The emperor has no clothes.

John Steege, MD

La malformazione congenita dell’utero con ematometra è stata discussa all’ AAGL-ENDO-EXCHANGE Digest, listserv.
Per vedere la discussione completa in Inglese
Philippe R. Koninckx and Anastasia Ussia
University of Leuven, Leuven, Belgium and Gruppo Italo Belga, Rome Italy

Abbiamo visto molte pazienti che  hanno subito una resezione intestinale per endometriosi profonda retto-vaginale, nelle quali non è stata confermata istologicamente l’endometriosi nel segmento resecato. Vedere qui sotto il testo in inglese.

I asked at listserv of AAGL the question how frequently endometriosis was not confirmed after a segmental bowel resection. In the literature the incidence ranges from 0 to 15% and it would not be surprising that we only see the tip of the iceberg since not everyone will report these mistakes.

Sun, 18 Oct 2009 06 David Redwine answered
I’m not sure I understand your question. I don’t get any scans, imaging, colonoscopy, or barium studies on any patient, ever. I diagnose bowel endometriosis in the most accurate way possible: by looking at the bowel during surgery and then operating on it if I find it, whether it requires a superficial disc resection, full thickness disc resection, or segmental resection.
In over 800 bowel resections for apparent endometriosis, the incidence of a negative path report in my hands is less than 0.05%. I’m certain that the results of imaging will never approach the accuracy of this approach, which is also the least expensive approach since surgery need not be preceded by any tests at all.
Are you concerned that preop imaging may be misleading and could result in excessive surgery being done (such as a segmental resection when nothing is
present?). Or are you concerned that surgery itself is being done improperly too often? Or are you concerned that segmental resections are being done when a disc resection might suffice?
David Redwine, M.D.
Bend, Oregon

Comment

Reading the comment by David Redwine we are really concerned. The arguments used are purely authority based without any evidence that the statements are correct or unbiased.
” II don’t get any scans, imaging, colonoscopy, or barium studies on any patient, ever. I diagnose bowel endometriosis in the most accurate way possible: by looking at the bowel” . It sounds like God, but I fear that this is not the best treatment of the patient. It is wise to have at least a contrast enema and an ultrasound before surgery and an assessment of hydronefrosis. This is necessary in order to decide
- whether a bowel preparation should be given. To give a bowel preparation to all patients would be overtreatment for some patients.
- whether a ureter stent should be placed before surgery. As we published recently (De Cicco et all, Fertil steril 2009) ureterolysis of an hydronefrosis should not be done without a stent whereas systematic stenting is overtreatment and potentially damaging to the ureter.
- whether an elective sigmoid resection should be done. We plan an elective sigmoidr esection for sigmoid nodules giving more than 50% occlusion over more than 3 cm.
- whether a ureter stent should be placed
“operating on it if I find it, whether it requires a superficial disc resection, full thickness disc resection, or segmental resection”.
‘We recently made a systematic review of the 1600 bowel resections published (submitted), and found no data relating the indication for bowel resection to size. Unless data are provided permitting to judge the ratio of bowel resections to discoid resections according to size, or unless a systematic videorecording is performed permitting some evaluation afterwards how can we trust that the judgment during surgery is correct, and that bowel resections are not performed too liberally.
“In over 800 bowel resections for apparent endometriosis, the incidence of a negative path report in my hands is less than 0.05%.” It is always nice to give the impression to do much better than the others : in a recent report -RBMonline, 2009- 8/50 on whom a bowel resection for endometriosis was performed, no endometriosis was found whereas in other 6 endometriosis was situated outside the bowel. We do not know whether this is the tip of the iceberg because of underrreporting or whether this reflect reality. Moreover the statement is misleading since we do not want to know whether endometriosis is confirmed but in which percentage the endometriosis did not or only superficially infiltrate the muscularis (thus making a resection overtreatment)

Philippe R. Koninckx1-2 , Carlo de Cicco1 and Anastasia Ussia2
1 University of Leuven, Leuven Belgium and 2 Gruppo Italo Belga, Roma, Italy