Rectal surgery for endometriosis--should we be aggressive?

STUDY OBJECTIVE: To assess the outcome of aggressive but conservative laparoscopic surgery in the treatment of severe endometriosis involving the rectum. DESIGN: Retrospective study (Canadian Task Force classification III). SETTING: Endosurgery unit of a tertiary referral center. PATIENTS: One hundred sixty-nine women. INTERVENTION: Laparoscopy or laparotomy. MEASUREMENTS AND MAIN RESULTS: The procedure was completed successfully laparoscopically in 145 (86%) and by laparotomy in 24 women (14%). The rate of preoperative symptoms was higher in 25 women who underwent bowel resection compared with those who had other bowel surgery. In addition to bowel surgery, excision of uterosacral ligaments, adhesiolysis, excision of endometrioma, and oophorectomy were the four most commonly performed procedures. At 35-month follow-up 61 patients (36%) required further surgery for pain. The average time between primary and repeat surgery was 16 months. This second operation was performed by laparoscopy in over three-fourths of the women. Overall recurrent endometriosis was found in 26 patients (15%). Overall morbidity associated with all surgery was 12.4%. CONCLUSION: Surgery for endometriosis of the cul-de-sac and bowel involves some of the most difficult dissections encountered, but it can be accomplished successfully with the low postoperative morbidity typical of laparoscopy.

Laparoscopic diagnosis of endometriosis.

OBJECTIVE: To consider and explain the possibility of difficulties in diagnosis of endometriosis at previous laparoscopy DESIGN: Retrospective patient record review. SETTING: The Endometriosis Care Centre of Australia and the private practices of authors. SAMPLE: Two hundred and fifteen patients with clinical evidence of endometriosis examined laparoscopically between March 1999 and May 2001. MAIN OUTCOME MEASURES: Confirmation of endometriosis by histological biopsy. RESULTS: Endometriosis was confirmed in 168 of the 215 women. Of these women 38 had a previous negative laparoscopy within 12 months of the current laparoscopy. CONCLUSIONS: It is possible that in some of the patients, who previously had a negative laparoscopy, endometriosis was not recognised. Possible reasons for difficulty in diagnosis have been identified and techniques to improve diagnosis suggested. This retrospective study was performed to consider and explain the possibility of difficulties in diagnosis of endometriosis at previous laparoscopy.

Glucose metabolism of human morula and blastocyst-stage embryos and its relationship to viability after transfer.

The pregnancy rate and implantation rate following blastocyst transfer in the human have been reported to be high; however, it has remained necessary to transfer 2-3 blastocysts to achieve these rates. Morphological criteria are currently used to select blastocysts for transfer and have some limited correlation with ongoing viability. Glucose metabolism of 189 human morula to blastocyst stage embryos was analysed using a non-invasive ultramicrofluorescence technique to determine if this could be used to predict viability. There was a linear trend to increased glucose uptake with progression from the morula to the hatching/hatched blastocyst stage of development, whereas glycolytic activity did not vary. There was no consistent difference in glucose uptake or glycolytic activity for embryos at the various morphological stages on day 5 compared to day 6 in vitro. Glucose uptake and glycolytic activity of the nine embryos positively identified as having implanted following transfer varied and were apparently not different from the values for embryos that failed to implant. In addition, viability was demonstrated to be compatible with high glycolytic activity, with four of nine implanted embryos having a glycolytic activity in the highest 15% of the population of embryos studied. Glucose uptake and glycolytic activity of male and female embryos did not appear to be different. Glucose metabolism cannot be used prospectively to select viable human morula or blastocyst stage embryos for transfer and it is also unlikely to be a useful tool to predict the sex of the embryo.