Chirurgia per l’endometriosi profonda senza resezione intestinale sarà difficile in Belgio.

Relazioni il 10/9/12 a Ircad Strasburgo, il 12/9/12 la discussione con il Prof Keckstein durante il congresso dell’ ESGE meeting a Parigi e il 20-9-12 a Bruxelles quando il prof Donnez è diventato emeritus.


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La relazione e l’articolo completo sono a destra

La storia

1990 Prof Koninckx ha iniziato la chirurgia per l’endometriosi profonda con il Prof em Penninckx ie poco dopo la prima pubblicazione.
1995 dopo alcune resezioni intestinali per l’endometriosi profonda , a Leuven noi siamo giunti all’accordo che la resezione del sigma sarebbe stata eseguita dai chirurghi colon/rettali, in parte per ridurre il nostro carico di lavoro ed inoltre non era un intervento estremamente difficile.Per capire ciò bisogna sapere che a quel momento i chirurghi generali erano all’inizio della loro esperienza in chirurgia laparoscopica e Koninckx insegnava la laparoscopia ai chirurghi.
2000 tanti ginecologi hanno iniziato la chirurgia per l’endometriosi profonda, ma quasi tutti fanno sempre la resezione intestinale, perché meno difficile e per motivi medico legali. Inoltre il rimborso del DRG della resezione intestinale è 5 volte più alto che quello della resezione discoide o della chirurgia consrvativa. Cosi il Prof koninckx (KULeuven) e Prof Donnez (UCL) in Belgio, e qualche gruppi in Stati Uniti (eg Charles Koh Milwaukee, Camran Nezhat Atlanta, David Redwine Oregon) ) erano una minoranza
2005 progressivamente con piu dati è divenuto chiaro che la resezione intestinale non è sempre necessaria, che i risultati della resezione intestinale non sono superiori, ed inoltre la resezione del retto bassa è associata a molte complicanze a lungo termine.Questo è stato moto chiaro nelle relazioni del Prof Arnaud Wattiez (Strasburg) e del Prof Paulo Ribeiro (Sao Paulo) : con l’esperienza il tasso delle loro resezioni intestinali è diminuito dal 30% a meno di 10%.

Una resezione del retto bassa si deve generalmente evitare.

It can be argued whether for a low rectovaginale endometriosis nodule 1% of less than 10% bowel resections should be performed. It is clear however that more than 60% bowel resections constitute a problem. The reality however is that surgeons either decide during surgery and perform few bowel resections ; those who decide before surgery mostly end by performing over 60% of bowel resections.
Discoid excision without a bowel resection has become technically standardized as evidenced by the many presentations.

Why this large variation in percentage of bowel resections ?

The indication is not the reason since highly variable for bowel resections as demonstrated in a systematic review.
The conclusion was that the main reason for bowel resections is either because decisions are made before surgery, or that skill to perform discoid resections is insufficient.

Why should low bowel resections be avoided

Results are not better
Complications are higher than after discoid excisions ; especially the long term complications ie a life long bladder problems in 30%, bowel problems in 30% and sexual problems as anorganismia in 40%.
Bowel resections are clearly not indicated and useless when by pathology afterwards no endometriosis is found or the endometriosis is only outside the bowel.
And notwithstanding all this, most bowel resections are low bowel resections

High sigmoid nodules : conservative surgery is more difficult and complications of bowel resections are low.

We perform 10% bowel resections for sigmoid nodules but our advice to those with less experience is to be more liberal in bowel resections. W

And the patient ?

Patient rarely receives information on the alternative to avoid a bowel resection. If after surgery no endometriosis is found, this is rarely shared with the patient.
We therefore strongly suggest that decisions are taken during surgery. If at laparoscopy the nodule or the intervention is judged too difficult for the skills of the surgeon, the patient should be referred. If during surgery the intervention reveals to be too difficult a bowel resection can be performed.
Key thus is to avoid too many errors in judgment. The only way for the patient to judge this is a videoregistration.

Why is the problem in Belgium ( and probably shortly in the US) ?

Since Prof Koninckx en Prof Donnez became emeritus at KULeuven and UCL respectively, both strong promotors of conservative surgery left both universities. Those remaining often perform very liberally bowel resections, which risks to become a problem for the patients with a deep endometriosis.

What are the solutions ?

Mandatory video-registration of all interventions for deep endometriosis is considered as important since the indication for bowel resections would become controllable afterwards.
Video-registration could be used as a condition for reimbursement. Video-registration thus has the potentiality to decrease costs for society while enhancing quality for the patient

Prof Koninckx en Dr Ussia
Gruppo Italo Belga per la chirurgia dell’endometriosi.

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