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.
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