Review on endometriosis surgery

P. Koninckx, A. Ussia, J. Keckstein, M. Malzoni, L. Adamyan, A. Wattiez
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引用次数: 3

Abstract

The indication and technique of endometriosis surgery changed rapidly over the last 50 years since better understanding the disease and an improved diagnosis. This review will therefore include a short discussion of the importance and limits of evidence-based medicine (EBM), the clinical importance and diagnostic value of imaging and the alternative medical treatments. Surgery is the cornerstone of infiltrating and fibrotic endometriosis and useful for minor endometriosis. We suggest redefining the aim of surgery, as the elimination of all endometrium like cells with genetic or epigenetic (G-E) endometriotic changes. Microscopic endometriosis in the peritoneum, in the bowel wall and in lymph nodes at distance from a deep endometriosis nodule does not need surgery since there is no evidence that it causes pain, infertility or progression into more severe forms of endometriosis. Subtle and typical lesions need excision or destruction since some of them might progress because of G-E changes. Excision of cystic ovarian endometriosis is associated with fewer recurrences, probably since more complete, but with more ovarian damage than superficial destruction of the lining of the cyst. However, since endometriotic infiltration in the cyst wall is less than 2 mm deep, the rest of the capsule being fibrosis, chemical superficial destruction might combine completeness with superficial treatment. For the surgery of deep endometriosis, the authors have reached consensus on many aspects. This comprises the prevention of nerve damage, the complete excision from the vaginal fornix, the complete excision from the bladder preserving the intramural ureter, ureter excision and anastomosis for fibrotic stenosis, short instead of large bowel resections when necessary and the liberal use of sigmoid resections. Other aspects remain debated, such as the excision of fibrotic endometriosis surrounding and extending below the ureter risking to damage the inferior hypogastric plexus, the exact indication of rectum resections versus complete excision with eventual suture of muscularis or mucosa versus limited excision completed by discoid excision with a circular stapler. The concept of completeness of excision will be discussed since the outer layers might be metaplastic cells without G-E changes. Also, the treatment of macroscopically fibrotic lesions without endometriosis is not clear.
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子宫内膜异位症手术综述
在过去的50年里,由于对子宫内膜异位症有了更好的了解和更好的诊断,手术的适应症和技术发生了迅速的变化。因此,本文将简要讨论循证医学(EBM)的重要性和局限性、影像学的临床重要性和诊断价值以及替代医学治疗。手术是浸润性和纤维化子宫内膜异位症的基石,对轻度子宫内膜异位症也很有用。我们建议重新定义手术的目的,作为消除所有子宫内膜样细胞的遗传或表观遗传(G-E)子宫内膜异位症的改变。在腹膜、肠壁和淋巴结中发生的显微镜下子宫内膜异位症不需要手术,因为没有证据表明它会导致疼痛、不孕或进展为更严重的子宫内膜异位症。细微和典型的病变需要切除或破坏,因为其中一些病变可能因G-E变化而发展。切除囊肿性卵巢子宫内膜异位症的复发率较低,可能是因为手术更彻底,但与囊肿内膜的表面破坏相比,卵巢损伤更大。然而,由于囊肿壁的子宫内膜异位症浸润深度小于2mm,囊膜的其余部分为纤维化,化学浅表破坏可与浅表治疗相结合。对于深部子宫内膜异位症的手术治疗,笔者在许多方面达成了共识。这包括预防神经损伤,阴道穹窿的完全切除,膀胱的完全切除,保留壁内输尿管,输尿管切除和吻合纤维化狭窄,必要时短时间代替大肠切除和乙状结肠切除术的自由使用。其他方面仍有争议,如切除输尿管周围和延伸到胃下神经丛的纤维化子宫内膜异位症,直肠切除术的确切指征是完全切除并最终缝合肌层或粘膜,还是用圆形吻合器完成盘状切除的有限切除。由于外层可能是化生细胞而没有G-E变化,因此将讨论切除的完整性的概念。此外,无子宫内膜异位症的宏观纤维化病变的治疗尚不清楚。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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