Endometriosis Is Associated With Higher Healthcare Utilization and Upper Gastrointestinal Symptoms.

Endometriosis is a chronic inflammatory disease affecting 10%-15% of women, with symptoms including abdominopelvic pain, dysmenorrhea, and menorrhagia. Up to 90% experience gastrointestinal (GI) symptoms including constipation, bloating, and nausea/vomiting.1 Females with endometriosis are at 3-5 times greater risk of developing IBS than healthy women,2,3 with rates of IBS as high as 52%.4 Another study demonstrated 37% of those with IBS also had endometriosis, much higher than the typical prevalence of endometriosis.5 Patients with IBS and endometriosis experience lower pain thresholds and more painful menstrual cycles than those with either condition alone. This amplification of pain experiences can increase health care utilization and decrease quality of life.

Radiology State-of-the-art Review: Endometriosis Imaging Interpretation and Reporting.

Endometriosis is a common condition impacting approximately 190 million individuals and up to 50% of women with infertility globally. The disease is characterized by endometrial-like tissue located outside of the uterine corpus, which causes cyclical hemorrhage, inflammation, and fibrosis. Based on clinical suspicion or findings at routine transvaginal pelvic US or other prior imaging, dedicated imaging for endometriosis may be warranted with MRI or advanced transvaginal US. Deep endometriosis (DE) in the pelvis includes evaluation for stromal and fibrotic components and architectural distortion resulting from fibrosis and tethering. It is a disease requiring a compartment-based, pattern-recognition approach. MRI has the benefit of global assessment of the pelvis and is effective in assessing for features of malignancy and for evaluating extrapelvic locations. Transvaginal US has the advantage of dynamic maneuvers to assess for adhesions and may achieve higher spatial resolution for assessing the depth of bowel wall invasion. T1-weighted MRI evaluation increases the specificity of diagnosis by identifying hemorrhagic components, but the presence of T1 signal hyperintensity is not essential for diagnosing DE. Endometriosis is a disease with a broad spectrum; understanding the mild through advanced manifestations, including malignancy evaluation, is within the scope and breadth of radiologists' interpretation.

Surgical Considerations in the Management of Adolescent Endometriosis-An Expert Commentary.

Given the complexities and controversies that exist in diagnosing adult endometriosis, as well as optimizing medical and surgical management, it is not surprising that there is even more ambiguity and inconsistency in the optimal surgical care of endometriosis in the adolescent. This collaborative commentary aimed to provide evidence-based recommendations optimizing the role of surgical interventions for endometriosis in the adolescent patient with input from experts in minimally invasive gynecologic surgery, pediatric and adolescent gynecology, and infertility/reproductive medicine.

Endometriosis with colonic and rectal involvement: surgical approach and outcomes in 142 patients.

PURPOSE: Endometriosis involving the colon and/or rectum (CRE) is operatively managed using various methods. We aimed to determine if a more limited excision is associated with 30-day complications, symptom improvement, and/or recurrence. METHODS: This is a retrospective review of consecutive cases of patients who underwent surgical management of CRE between 2010 and 2018. Primary outcomes were the associations between risk factors and symptom improvement, 30-day complications, and time to recurrence. Multivariable logistic regression assessed the independent risk factors. RESULTS: Of 2681 endometriosis cases, 142 [5.3% of total, mean age 35.4 (31.0; 39.0) years, 73.9% stage IV] underwent CRE excision (superficial partial = 66.9%, segmental = 27.5%, full thickness = 1.41%). Minor complications (14.8%) were associated with blood loss [150 (112; 288) vs. 100 (50.0; 200) mls, p = 0.046], Sigmoid involvement [45.5% vs. 12.2%, HR 5.89 (1.4; 22.5), p = 0.01], stoma formation [52.6% vs. 8.9%, HR 10.9 (3.65; 34.1), p < 0.001], and segmental resection [38.5% vs. 5.8%, HR 9.75 (3.54; 30.4), p < 0.001]. Superficial, partial-thickness resections were associated with decreased risk [(4.2% vs. 36.2%), HR 0.08 (0.02; 0.24), p < 0.001]. Factors associated with major complications (8.5%) were blood loss [250 (100; 400) vs. 100 (50.0; 200) mls, p = 0.03], open surgery [31.6% vs. 4.9%, HR 8.74 (2.36; 32.9), p = 0.001], stoma formation [42% vs. 3.3%, HR 20.3 (5.41; 90.0), p < 0.001], and segmental colectomy [28.2% vs. 0.9%, HR 34.6 (6.25; 876), p < 0.001]. Partial-thickness resection was associated with decreased risk ([.05% vs. 23.4%, HR 8.74 (2.36; 32.9), p < 0.001]. 19.1% experienced recurrence. Open surgery [5.2% vs. 21.3%, HR 0.14 (0.02; 1.05), p = 0.027] and superficial partial thickness excision [23.4% vs. 10.6%, HR 2.86 (1.08; 7.59), p = 0.027] were associated. Segmental resection was associated with decreased recurrence risk [7.6% vs. 23.5%, HR 0.27 (0.08; 0.91), p = 0.024]. CONCLUSION: Limiting resection to partial-thickness or full-thickness disc excision compared to bowel resection may improve complications but increase recurrence risk.

Bilateral Cornual Resection for Uterine-sparing Removal of Tubal Sterilization Devices.

STUDY OBJECTIVE: To describe a uterine-sparing minimally invasive surgical technique for laparoscopic resection of tubal occlusion devices using bilateral cornuectomy. DESIGN: This video reviews the background of the tubal occlusion device known as Essure and the indications and methods for surgical removal with a stepwise demonstration of a minimally invasive technique with narrated video footage. SETTING: The most cited reason for patients' desire for removal of the Essure device is pelvic pain. Both hysteroscopic and laparoscopic methods have been used for removal of these devices. Laparoscopy is indicated if it has been >3 months since insertion, if a coil is noted to be malpositioned, or if the patient desires continued permanent sterilization. Techniques for removal include salpingostomy, salpingectomy, and cornuectomy. Removal of the entire device is essential, given that any remaining coil or polyethylene terephthalate fibers may continue to cause symptoms. The coils of the device can easily be fractured; therefore, in our practice we perform a bilateral cornuectomy when uterine retention is desired Supplemental Videos 1 and 2, because fracture rates are higher with salpingectomy than cornuectomy. We demonstrate the steps of this method and highlight the critical aspects for surgeons to consider during the procedure. INTERVENTIONS: Laparoscopic bilateral cornuectomy approach to a uterine-sparing excision of Essure tubal occlusion devices to reduce the risk of coil retention and fracture: 1) Injection of dilute vasopressin at the uterine cornua for vasoconstriction and hemostasis 2) Circumferential dissection of the uterine cornua using monopolar energy 3) Confirmation of endometrial cavity entry using methylene blue 4) Excision of fallopian tube along mesosalpinx to include the fimbriated end 5) Closure of the myometrial layers using a unidirectional barbed suture in a running fashion CONCLUSION: In patients who desire uterine preservation, we recommend a minimally invasive technique of bilateral cornual resection for removal of tubal sterilization devices to avoid device fracture and inadvertent retention of coils.

Surgical coaching in obstetrics and gynecology: an evidence-based strategy to elevate surgical education and promote lifelong learning.

The American Board of Medical Specialties, of which the American Board of Obstetrics and Gynecology is a member, released recommendations in 2019 reimagining specialty certification and highlighting the importance of individualized feedback and data-driven advances in clinical practice throughout the physicians' careers. In this article, we presented surgical coaching as an evidence-based strategy for achieving lifelong learning and practice improvement that can help to fulfill the vision of the American Board of Medical Specialties. Surgical coaching involves the development of a partnership between 2 surgeons in which 1 surgeon (the coach) guides the other (the participant) in identifying goals, providing feedback, and facilitating action planning. Previous literature has demonstrated that surgical coaching is viewed as valuable by both coaches and participants. In particular, video-based coaching involves reviewing recorded surgical cases and can be integrated into the physicians' busy schedules as a means of acquiring and advancing both technical and nontechnical skills. Establishing surgical coaching as an option for continuous learning and improvement in practice has the potential to elevate surgical performance and patient care.

Racial and ethnic disparities in surgical care for endometriosis across the United States.

BACKGROUND: Despite an estimated 10% prevalence of endometriosis among reproductive-age women, surgical population-based data are limited. OBJECTIVE: We sought to investigate racial and ethnic disparities in surgical interventions and complications among patients undergoing endometriosis surgery across the United States. STUDY DESIGN: We performed a retrospective cohort study of American College of Surgeons National Surgical Quality Improvement Program data from 2010 to 2018 identifying International Classification of Diseases, Ninth/Tenth Revision codes for endometriosis We compared procedures, surgical routes (laparoscopy vs laparotomy), and 30-day postoperative complications by race and ethnicity. RESULTS: We identified 11,936 patients who underwent surgery for endometriosis (65% White, 8.2% Hispanic, 7.3% Black or African American, 6.2% Asian, 1.0% Native Hawaiian or Pacific Islander, 0.6% American Indian or Alaska Native, and 11.5% of unknown race). Perioperative complications occurred in 9.6% of cases. After adjusting for confounders, being Hispanic (adjusted odds ratio, 1.31; 95% confidence interval, 1.06-1.64), Black or African American (adjusted odds ratio, 1.71; confidence interval, 1.39-2.10), Native Hawaiian or Pacific Islander (adjusted odds ratio, 2.08; confidence interval, 1.28-3.37), or American Indian or Alaska Native (adjusted odds ratio, 2.34; confidence interval, 1.32-4.17) was associated with surgical complications. Hysterectomies among Hispanic (adjusted odds ratio, 1.68; confidence interval, 1.38-2.06), Black or African American (adjusted odds ratio, 1.77; confidence interval, 1.43-2.18), Asian (adjusted odds ratio, 1.87; confidence interval, 1.43-2.46), Native Hawaiian or Pacific Islander (adjusted odds ratio, 4.16; confidence interval, 2.14-8.10), and patients of unknown race or ethnicity (adjusted odds ratio, 2.07; confidence interval, 1.75-2.47) were more likely to be open. Being Hispanic (adjusted odds ratio, 1.64; confidence interval, 1.16-2.30) or Black or African American (adjusted odds ratio, 2.64; confidence interval, 1.95-3.58) was also associated with receipt of laparotomy for nonhysterectomy procedures. The likelihood of undergoing oophorectomy was increased for Hispanic and Black women (adjusted odds ratio, 2.57; confidence interval, 1.96-3.37 and adjusted odds ratio, 2.06; confidence interval, 1.51-2.80, respectively), especially at younger ages. CONCLUSION: Race and ethnicity were independently associated with surgical care for endometriosis, with elevated complication rates experienced by Hispanic, Black or African American, Native Hawaiian or Pacific Islander, and American Indian or Alaska Native patients.

Fertility-Preserving Surgical Management of a Cesarean Section Scar Ectopic Pregnancy.

STUDY OBJECTIVE: To demonstrate techniques used for fertility-preserving surgical management of a cesarean scar ectopic pregnancy. DESIGN: A narrated video case report demonstrating techniques and surgical approach. SETTING: With the increasing number of cesarean deliveries being performed, cesarean scar ectopic pregnancies (CSEP) have an increasing incidence affecting approximately 1 in 2000 pregnancies. CSEP can be associated with serious complications, which include maternal hemorrhage, uterine rupture, and even maternal death. This video highlights a case presentation of a 28-year-old G6P4014 with a history of 4 previous cesarean deliveries who presented with a persistent cesarean scar ectopic pregnancy that had failed previous medical management. INTERVENTIONS: This video highlights the techniques that allow for fertility-preservation with restoration of normal anatomy as well as minimizing blood loss with a potentially morbid procedure. Techniques used to allow for fertility preservation with restoration of normal anatomy: 1. Utilization of avascular spaces and identification of critical structures to restore anatomy that is often distorted by the CSEP. 2. Limited use of electrosurgery to allow for adequate postoperative healing. 3. Identification of the endometrial cavity to allow for complete removal of the CSEP and isthmocele repair. Techniques used to minimize blood loss: 1. Intracervical injection of dilute vasopressin. 2. Intrauterine injection of dilute vasopressin (20U in 60 cc of injectable saline). 3. Temporary occlusion of bilateral gonadal vessels using surgical clips. CONCLUSION: The surgical techniques highlighted in this video allow for the surgical removal of a cesarean scar ectopic pregnancy with concurrent repair of the uterine defect, allowing for restoration of normal anatomy. This is a safe and feasible fertility-preserving option that can be performed using a minimally-invasive approach.

Brentuximab vedotin in combination with rituximab, cyclophosphamide, doxorubicin, and prednisone as frontline treatment for patients with CD30-positive B-cell lymphomas.

We conducted a phase I/II multicenter trial using 6 cycles of brentuximab vedotin (BV) in combination with rituximab, cyclophosphamide, doxorubicin, and prednisone (R-CHP) for treatment of patients with CD30-positive (+) B-cell lymphomas. Thirty-one patients were evaluable for toxicity and 29 for efficacy including 22 with primary mediastinal B-cell lymphoma (PMBCL), 5 with diffuse large B-cell lymphoma (DLBCL), and 2 with gray zone lymphoma (GZL). There were no treatment-related deaths; 32% of patients had non-hematological grade 3/4 toxicities. The overall response rate was 100% (95% CI: 88-100) with 86% (95% CI: 68-96) of patients achieving complete response at the end of systemic treatment. Consolidative radiation following end of treatment response assessment was permissible and used in 52% of all patients including 59% of patients with PMBCL. With a median follow-up of 30 months, the 2-year progression-free survival (PFS) and overall survival (OS) were 85% (95% CI: 66-94) and 100%, respectively. In the PMBCL cohort, 2-year PFS was 86% (95% CI: 62-95). In summary, BV-R-CHP with or without consolidative radiation is a feasible and active frontline regimen for CD30+ B-cell lymphomas (NCT01994850).

Considerations for the Surgical Management of Diaphragmatic Endometriosis.

STUDY OBJECTIVE: The objective of this video is to review relevant surgical anatomy, resection and ablation methods, and techniques to optimize management of diaphragmatic endometriosis. DESIGN: Video footage of surgical anatomy and surgical technique. Institutional review board approval was not required. SETTING: Thoracic endometriosis lesions can involve the pleura, the lung, and the diaphragm. The prevalence of thoracic endometriosis is unknown, but most cases involve the diaphragm. A large percentage of patients are asymptomatic. Those who are symptomatic can present with cyclic shoulder pain, right upper quadrant pain, or catamenial pneumothorax. Symptomatic cases refractory to medical management or recurrence require surgical management [1,2]. Safe and efficient management of these cases depends on an experienced multidisciplinary team. In this video, the experiences and management tools used by our team are described. INTERVENTIONS: Laparoscopic management of primary and recurrent symptomatic diaphragmatic endometriosis. CONCLUSION: A multidisciplinary skilled team approach to the surgical management of diaphragmatic endometriosis to optimize outcomes is preferred.

Diagnostic work-up in paediatric and adolescent patients with adnexal masses: an evidence-based approach.

Adnexal masses are rare in the young female population. The differential diagnosis includes ovarian masses, tubal/paratubal masses, masses related to the gastrointestinal tract (colon), infectious lesions, or pregnancy. Acute abdominal pain, and less commonly, precocious puberty or vaginal bleeding, are typical symptoms in these cases. The majority of adnexal masses in the paediatric and adolescent population are benign; however, a thorough preoperative assessment is essential to guide surgical intervention and optimise patient outcomes. The proper diagnosis of an adnexal mass, correct management (surgical or nonsurgical), and necessary referrals are of paramount importance. In the light of these cornerstones, this review describes the aetiologies, presenting symptoms, and appropriate diagnostic work-up for paediatric and adolescent patients affected by adnexal masses.

Intravenous acetaminophen vs saline in perioperative analgesia with laparoscopic hysterectomy.

BACKGROUND: Opioids are effective for the treatment of postoperative pain but can cause nausea and are associated with dependency with long-term use. Nonopioid medications such as acetaminophen offer the promise of decreasing these nondesirable effects while still providing patient comfort. OBJECTIVE: The purpose of this study was to compare intravenous acetaminophen with placebo and to evaluate postoperative pain control and opioid usage after laparoscopic hysterectomy. STUDY DESIGN: We conducted a prospective double-blind randomized study with 183 patients who were assigned randomly (1:1) to receive acetaminophen or placebo (Canadian Task Force Design Classification I). Patients received either 1000 mg of acetaminophen (n=91) or a placebo of saline solution (n=92) at the time of induction of anesthesia and a repeat dose 6 hours later. Both groups self-reported pain and nausea levels preoperatively and at 2, 4, 6, 12, and 24 hours after extubation with the use of a visual analog scale with a score of 0 for no pain to 10 for highest level of pain. Patients self-reported pain, nausea, and postoperative oral opiates that were taken after discharge. All opiates were converted to milligram equivalents of oral morphine for standardization. RESULTS: There were no significant differences in generalized abdominal pain at any time point postoperatively that included 2 hours (placebo 3.6±2.5 vs acetaminophen 4.4±2.5; P=.07) and up to 24 hours (placebo 3.3±2.4 vs acetaminophen 3.6±2.5; P=.28). Similar results were observed for nausea scores. There were no differences in opioid consumption at any time point including intraoperatively (placebo 4.4±3.9 vs acetaminophen 3.3±4.0; P=.06), post anesthesia care unit (placebo 10.5±10.3 vs acetaminophen 9.7±10.3; P=.59), and up to 24 hours after surgery (placebo 1.4±2.0 vs acetaminophen 1.6±2.1; P=.61). There were no differences in demographics or surgical data between groups. CONCLUSION: There was no difference between acetaminophen and placebo groups in postoperative pain, satisfaction scores, or opioid requirements. Given the relatively high cost ($23.20 per dose in our study), lack of benefit, and available oral alternatives, our results do not support routine use during hysterectomy.

Techniques in minimally invasive surgery for advanced endometriosis.

PURPOSE OF REVIEW: Surgery can be an important treatment option for women with symptomatic endometriosis. This review summarizes the recommended preoperative work up and techniques in minimally invasive surgery for treatment of deeply infiltrating endometriosis (DIE) involving the obliterated posterior cul-de-sac, bowel, urinary tract, and extrapelvic locations. RECENT FINDINGS: Surgical management of DIE can pose a challenge to the gynecologic surgeon given that an extensive dissection is usually necessary. Given the high risk of recurrence, it is vital that an adequate excision is performed. With improved imaging modalities, preoperative counseling and surgical planning can be optimized. It is essential to execute meticulous surgical technique and include a multidisciplinary surgical team when indicated for optimal results. SUMMARY: Advanced laparoscopic skills are often necessary to completely excise DIE. A thorough preoperative work up is essential to provide correct patient counseling and incorporation of the preferred surgical team to decrease complications and optimize surgical outcomes. Surgical management of endometriosis is aimed at ameliorating symptoms and preventing recurrence.

The use of barbed suture for bladder and bowel repair.

STUDY OBJECTIVE: To describe the laparoscopic repair of bladder and bowel injuries using barbed suture and review postoperative outcomes. DESIGN: Retrospective medical chart review (Canadian Task Force classification II-3). SETTING: Large academic medical institution. PATIENTS: Thirty-three women who underwent laparoscopic repair of the bladder and/or bowel wall using barbed suture between January 2009 and July 2013. INTERVENTION: Not applicable. MEASUREMENT AND MAIN RESULTS: The patients underwent a total of 9 cystotomies (27.3%), 7 enterotomies (21.2%), 4 bladder seromuscular injuries (12.1%), 12 bowel seromuscular injuries (36.4%), and 1 bladder and bowel seromuscular injury (3.0%). Of the 33 injuries, 17 (51.5%) were intentional in the setting of bladder or bowel endometriosis nodule excision, whereas the other 16 (48.5%) were accidental and occurred at the time of lysis of adhesions. Thirteen of 14 bladder injuries (92.9%) were at the dome, and 1 injury (7.1%) was at the trigone. Fifteen of 20 bowel injuries (75%) were rectal, 3 (15%) were on the colon, and 2 (10%) were on the small intestine. Cystotomies ranged in length from 1 to 5 cm, and enterotomies ranged from 1.5 to 6 cm. All bladder and bowel seromuscular injuries were repaired using a single layer of barbed suture. Twelve full-thickness bladder or bowel wall defects (75%) were repaired using 2 layers of barbed suture, and 4 defects (25%) were repaired using a layer of barbed suture and a layer of a running or interrupted smooth delayed absorbable suture. Duration of follow-up ranged from 1 month to 15 months. There were no major complications. Only 1 patient who had undergone a large enterotomy repair developed constipation secondary to a mild rectal stricture diagnosed 3 months postoperatively. Symptoms of constipation since resolved spontaneously in that patient. CONCLUSION: Barbed suture provides adequate tension-free bladder and bowel repair. No major complications have been encountered; therefore, the use of barbed suture for the repair of bladder or bowel defects seems feasible and safe.

Development and validation of a laparoscopic sacrocolpopexy simulation model for surgical training.

STUDY OBJECTIVE: To develop a valid laparoscopic sacrocolpopexy simulation model for use as an assessment and learning tool for performing this procedure. DESIGN: Simulation study (Canadian Task Force classification II-2). SETTING: Two tertiary academic centers. INTERVENTION: A training model was developed to simulate performance of a laparoscopic sacrocolpopexy. Construct validity was measured by comparing observed masked performances on the model between experienced Female Pelvic Medicine and Reconstructive Surgeons (experts) and upper level trainees. All videotaped performances were scored by 2 surgeons who were masked to subject identity and using the valid and reliable Global Operative Assessment of Laparoscopic Skills scale. MEASUREMENTS AND MAIN RESULTS: The expert group included Female Pelvic Medicine and Reconstructive Surgeons (n = 5) experienced in laparoscopic sacrocolpopexy, and the trainee group (n = 15) included fourth-year gynecology residents (n = 5) and fellows in Female Pelvic Medicine and Reconstructive Surgery and in Minimally Invasive Gynecologic Surgery (n = 10). The experts performed significantly better than the trainees in total score and in every domain of the Global Operative Assessment of Laparoscopic Skills scale (median [range] score: expert group, 33 [30.5-39] vs. trainee group, 20.5 [13.5-30.5]; p = .002). Previous surgical experience had a strong association with performance on the model (rho > 0.75). Most subjects "agreed" or "strongly agreed" that the model was authentic to the live procedure and a useful training tool. There was strong agreement between masked raters (interclass correlation coefficient 0.84). CONCLUSION: This simulation model is valid and reliable for assessing performance of laparoscopic sacrocolpopexy and may be used for practicing key steps of the procedure.

Laparoscopic Vecchietti procedure: pearls for success.

OBJECTIVE: To present an effective strategy for optimizing the care of patients with Müllerian agenesis who desire surgical management for the creation of a neovagina with the laparoscopic Vecchietti procedure. DESIGN: This video provides a framework for patient evaluation and selection, surgical strategy, and postoperative care regimen to provide optimal postprocedural outcomes. SETTING: Academic Hospital. PATIENT(S): This is a 22-year-old patient with Müllerian agenesis who was unsuccessful with conservative strategies for vaginal lengthening and sought care for neovagina creation. INTERVENTION(S): The patient underwent preoperative pelvic floor physical therapy and vaginal dilation, both of which were ineffective in producing adequate vaginal lengthening. We then performed a laparoscopic Vecchietti procedure. The procedure occurred at a large academic institution with two obstetrics-gynecology subspecialty surgeons providing perioperative care. MAIN OUTCOME MEASURE(S): A vaginal length of 7 cm was achieved, which was sustained at >12 months. RESULT(S): The patient was managed by a multidisciplinary team using our established care regimen, with follow-up demonstrating a sustained positive treatment outcome. The vaginal length at more than 1 year after the procedure measured 7 cm. CONCLUSION(S): Using a methodological, patient-focused approach and an experienced multidisciplinary team can optimize immediate- and long-term surgical outcomes for patients with Müllerian anomalies who do not have acceptable success with conservative methods.

Evaluation and Management of Endometriosis in the Adolescent.

Endometriosis is a chronic condition, with debilitating symptoms affecting all ages. Dysmenorrhea and pelvic pain often begin in adolescence, affecting school, daily activities, and relationships. Despite the profound burden of endometriosis, many adolescents experience suboptimal management and significant delay in diagnosis. The symptomatology and laparoscopic findings of endometriosis in adolescents are often different than in adults, and the medical and surgical treatments for adolescents may differ from those for adults as well. This Narrative Review summarizes the diagnosis, evaluation, and management of endometriosis in adolescents. Given the unique challenges and complexities associated with diagnosing endometriosis in this age group, it is crucial to maintain a heightened level of suspicion and to remain vigilant for signs and symptoms. By maintaining this lower threshold for consideration, we can ensure timely and accurate diagnosis, enabling early intervention and improved management in our adolescent patients.