Linee guida per la Chirurgia - Tutti i chirurghi e gli esperti sono invitati a contribuire
below a non exhaustive list of suggested topics ; the highlighted titles are written today
- Medical therapy before and after surgery for endometriosis
- Diagnosis and treatment of typical lesions”
- diagnosis and surgery of cystic ovarian endometriosis
- diagnosis and surgery of deep endometriosis
Reproductive surgery
- Hydrosalpinx and tubal occlusion
- Trans-hydroculdoscopy
- Good surgical practice (GSP)
- Adhesion and pain prevention
- Antibiotics before and after surgery
- Electrosurgery
Hysterectomy indications and technique
Pelvic floor surgery
Oncologic surgery
Hysteroscopic surgery
ESHRE endometriosis guidelines
Rationale : RCT by established surgeons means that the results of RCTs during the learning curve are not accepted eg a RCT on laparoscopic hysterectomy with durations of surgery longer than 180 min. Established surgeons are those with an international or at least national visibility as evidenced by live surgery, congress presentations and the appreciation of their peers.
are more complete since they
reflect expert surgeons knowledge
together with evidence
Other EBM Guidelines
reflect only published and/or RCT evidence
or if you have additions/updates or if you wrote a new guideline
send to pkoninckx@gmail.com your approval, update or guideline
together with your name,eventually your affiliation and
eventually an hyperlink to your/hospital website.
The list and authority of those who approve is the strength of the guideline
Guidelines by surgeons reflect the available evidence together with surgical experience. In the absence of evidence the surgical experience remains valid until proven otherwise. Existing EBM guidelines for endometriosis as the ESHRE guidelines (1) emphasize the evidence of RCT (A, B, or C grade) and dismiss what is not ‘proven’. Their recommendations based on expert opinion are weak, which is not surprising since only 3 Of the 14 authors can be considered endometriosis surgeons. For clinicians and surgeons these guidelines are biased and not very useful for clinical decision making.
The randomised controlled trial is poorly suited for surgery since the variability in disease and in the skill of the surgeons requires prohibitively large series. They moreover do not reflect rare events as complications. A 1% complication rate would require a RCT of some 6000 interventions for meaningful conclusions. (30 ‘cases’ mean 3000 surgeries in each arm)
Important aspects of surgery are practically impossible to demonstrate. It is impossible to demonstrate that lesions were missed during surgery, unless a repeat laparoscopy is performed which is not possible for ethical reasons. It is impossible to judge quality of surgery unless video-registration of the entire surgery is available. It is close to impossible to organise blinding in surgery. Many trials would be unethical to perform.
Therefore guidelines by surgeons with a large expertise in laparoscopic surgery are needed. To the available evidence surgical experience, rare events as prevention of complications and surgical strategy will be added.
The model is based upon our experience in reviewing the diagnosis and treatment of deep endometriosis (Fertil Steril 2012) and for the article on epidemiology of endometriosis in press in Gynaecological Surgery. It moreover will permit the valorisation by a much larger list of surgeons which in publications are limited to some 5 authors plus the acknowledgements.
We expect that one day Societies as ESGE, AAGL and Society for Reproductive surgeons will publish these guidelines.
References
1. Dunselman GA, Vermeulen N, Becker C, Calhaz-Jorge C, D’Hooghe T, De BB et al. ESHRE guideline: management of women with endometriosis. Hum Reprod. 2014;29:400-412.