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Background:
Endometriosis affects 1 in 10 women in the childbearing age. It causes period pain which can be disabilitating and can cause infertility. Severe endometriosis found in 5 – 37% of women. Severe endometriosis diagnosis established in the presence of DIE involving uterus, rectovaginal septum, ureters and bowels.
Laparoscopic surgery is associated with a high risk of complications requiring specialist multidisciplinary team approach, compromising of expert gynaecologist, colorectal surgeon, urologist and radiologist. In the United Kingdom the British Society of Gynaecology Endoscopy (BSGE) accredits and monitors recognised centres of care.
In 2018 we established a BSGE accredited centre in Dubai following the BSGE guidelines. We introduced MRI ENZIAN classification to assess the location, size and depth of DIE prior to surgery.
Methods and population:
In total 43 women had Laparoscopic surgery for stage 4 endometriosis. All performed by the same specialist surgical team. 51 cases were operated between October 2018 and March 2020.
MRI ENZIAN classification was used as part of preoperative assessment to decide on extent of endometriosis and need for bowel resection. All women completed BSGE pelvic pain questionnaire prior to surgery. Second analysis performed to correlate MRI ENZIAN classification with surgical ENZIAN classifications. We analysed the data of 51 patients between October 2018 and March 2020. MRI reported by one radiologist, all cases managed laparoscopic ally by one Gynaecologist and Colorectal surgeon. Age range of patients 22 – 48 years (mean 36.4 years, SD 9.7 years).
Results
43 women completed their pre-operative BSGE pain questionnaire. Length of follow up depends on date of surgery. At 3, 6, 12 and 24 months post-operatively, women reported no symptoms of pre-menstrual pain, dyspareunia or dyschezia. All women reported significant improvement in their pain symptoms at 6, 12 and 24 hours post-operatively. There were no conversions to laparotomy. There were no major complications; minor complications were infection in 1 case requiring repeat Laparoscopy and pelvic lavage.
CA125 was measured in 29 women and 22 (75.8%) had elevated CA125. Total Laparoscopic Hysterectomy as completed in 6 out of 43 as they completed their family and had extensive adenomyosis not suitable for resection. Bowel resection with end to end anastomosis was performed in 6 women. None required colostomy.
For the 2ry analysis, there was statistically significant correlation between MRI ENZIAN classification and surgical findings (P 0.01). MRI identified 92 lesions; 86 of these were confirmed and excised laparoscopically (95%). Histology confirmed endometriosis in all 86 lesions. Excellent radio-surgical correlation for recto-sigmoid DIE, identifying all cases allowing pre-operative counceling and planning of bowel resection. MRI identified all the recto-vaginal lesions and most of uterosacral lesions (90%).
Conclusion
Management of DIE is complex requiring a multidisciplinary team approach, surgical management of DIE should be considered in women who experience symptoms associated with DIE as it has been shown to significantly improve endometriosis-associated pain and improve quality of life. Our data shows good outcome and low complication rate.
