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28/31-10-2009 Congresso ESGE (European society Gynaecological Endoscopy )

The Gruppo Italo Belga made 4 presentations
28-10 : Drssa A Ussia & Prof P Koninckx Severe deep endometriosis should be operated by experts
An extremely difficult surgery for endometriosis in a woman with a previous hysterectomie was explained.  Without experience the deep endometriosis would not have been noticed and the patient would stillhave pain.
28-10 C De Cicco, A. Ussia, P. Koninckx : Bowel resections for endometriosis : a review.

28-10 : Prof P koninckx & Drssa A Ussia . Animal models for adhesion formation and prevention

29-10 : Prof P koninckx & Drssa A Ussia . Ureteral endometriosis : resection or ureterolysis ?

29-10 : M.M Binda , P. koninckx : Adhesion prevention : lessons friom pathophysiology.
A review was made concerning the new methods of ureter treatment in endometriosis, as explained in this website

20-8-2009  Since 2 days we have a a series of comments concerning the observation that women with (mild and superficial endometriosis have more nerve fibers in the endometrium. A lot of speculation of a new diagnostic test followed

Our Comments

This is another example (as I discussed in http://www.gynsurgery.be and http://www.mondoginecologico.it) that interpretation of research data should be done carefully and that conclusions by researchers often are overstretched and/or biased.
The observation of higher incidences of nerve fibers in the endometrium of women with endometriosis is nice research. To suggest this as a non invasive diagnostic test however is way premature.
1. First, an association does not permit to conclude about cause and effect. We know ( more than 50 articles) since 20 years that the endometrium of women with endometriosis is slightly different from the endometrium of women without endometriosis. It is unclear whether these differences are a consequence of the endometriosis or whether these differences merely signal an ‘endometrioitic’ constitution (as suggested in the endometriotic disease theory). Knowing what happens after surgical excision of endometriosis could give a hint. We previously demonstrated that the decrease in natural killer cells in endometriosis women is not affected by surgical excision of endometriosis whereas CA125 decreases tremendously therafter.
2. Second the article knowingly and willingly disregard subtle endometriosis which is present intermittently in many women and which -I and others think- should not be considered a disease, as discussed in the literature since more than 10 years.
My guess considering the pain symptoms, is that the increased nerve endings is a sign besides many others, that a women will have more retrograde menstruation and also more frequently subtle endometriosis etc, something I am considering since many years as irrelevant findings at laparoscopy since subtle endometriosis does not cause pain or infertility.
The key problem of not recognising or not referring severe endometriosis or doing an incomplete excision or doing unnecessary bowel resections will remain.

28-2-2009 :The debate concerning rectosigmoid endometriosis on AAGL-ENDO-EXCHANGE automatic digest system;LISTSERV@listserv.brown.edu

We Wrote :

Our overall approach to these patients is as follows
1. If less than 50% bowel occlusion on contrast enema
- if asymptomatic and no desire to become pregnancy : do nothing (most I saw are not evolutive ; evolutivity anyway is not proven)
- if symptomatic : indication depends on the severity of pain
- if a pregnancy is planned I would be prudent since these nodules become bigger and might occasionally cause occlusion during pregnancy or ovulation induction.
2. If more than 50% bowel occlusion on contrast enema
I would be prudent since a bowel obstruction means urgent surgery in less than good circumstances.  If a pregnancy is planned, I would definitively do surgery.

This however is a partial academic discussion, since more than 50% occlusion at the level of the rectosigmoid or rectum is extremely rare and all of them can be treated by discoid/full thickness excision. For the sigmoid however 50% occlusion occurs in some 10-20% and we prefer to have a sigmoid resection done.
Philippe R. Koninckx*,**  and Anastasia Ussia**
*Dpt obstetrics and gynaecology, KULeuven Belgium, Univ Cattolica, Rome, Univ Oxford, UK
** Gruppo Italo-Belga, Villa del Rosario and l’Anunciatella, Rome, Italy