Find below a summary of an article published in ‘Gynaecological Surgery’
Philippe R. Koninckx1-2 and Anastasia Ussia2; 1KULeuven, Leuven, Belgium ; Univ of Oxford, Oxford, UK ; Università Cattolica, Rome Italy ; and 2Gruppo Italo Belga, Villa del Rosario, Rome , Italy
Little progress has been made over the last 2 decades in endometriosis treatment. Medical treatment has not made any progress.Lesions become less active after menopause and during therapy but they however, do not disappear. Medical treatment of endometriosis does not enhance fertility and even the effectiveness of medical therapy upon endometriosis associated pain should be considered with caution given the important the placebo effect.
New dogmas were introduced , such as the delay in diagnosis The delay in diagnosis in endometriosis is known but can probably be found for all non life threatening diseases causing chronic pain. The delay in diagnosis depends upon the expertise of the physician who only recognizes what he knows and with his interests. This diagnostic delay of endometriosis obviously causes suffering and impairs a woman’s quality of life but is true for most other chronic pain syndromes. For endometriosis, it is fortunate that this delay in diagnosis does not impair treatment outcome nor that endometriosis becomes worse during this period. Centers of excellence have become “fashionable” in many areas of medicine as infertility and oncology.
Centers of excellence could do more harm than good
and will not decrease delay in diagnosis
Centers of excellence in endometriosis” to reduce the delay and improve treatment has become fashion and proposed overall by those who do not do surgery. We fear that they will do more harm than good. The arguments used to justify such centers of excellence indeed sound as lobbying for personal interests, while lacking evidence that the suggested goals will indeed be achieved. Diagnosis of endometriosis will not be accelerated, since patients are referred after the diagnosis has been made . Referral of endometriosis patients is the difficulty since pain symptoms of endometriosis are not specific. ‘Centers of excellence in Pain’ are not useful accelerate diagnosis . In addition whether centers of excellence improve treatment outcome is equally doubtful since propsed by non-surgeons , they risk to keep the patient unnecessarily long on medical treatment. If we want to improve the care of women with endometriosis we should decrease the diagnostic delay and improve treatment. In order to decrease the delay in diagnosis of endometriosis in women with pelvic pain, we need centers (of excellence) for chronic pelvic pain. Since medical treatment today only reduces pain while never curing the disease, surgical treatment of endometriosis remains the first and most important treatment. The surgical treatment of severe endometriosis has been proven to be so effective that randomized controlled trials comparing surgery with expectant management for larger cystic ovarian endometriosis and for deep endometriosis would be considered unethical in women with severe pain. Since severe endometriosis surgery has been recognized as requiring skill and expertise, it might be preferable to have centers of e excellent endometriosis surgery. Ideally endometriosis surgery should combine the diagnostic laparoscopy with surgery. Moreover, those performing endometriosis surgery should have the expertise and the technical skills to perform the more advanced surgical interventions when necessary. Centers of excellence in endometriosis surgery could be a major step forward in achieving this. Today, unfortunately, women often need a second intervention since the surgery could not be performed during the diagnostic laparoscopy. This however, is considered a minor problem. What is worse is incomplete surgery since the first surgery is the most important while incomplete surgery will make subsequent surgery more difficult impairing outcome. Too often women still undergo a hysterectomy leaving the deep endometriosis nodule untouched. Bowel resections for deep endometriosis are performed too liberally notwithstanding frequent and serious long term consequences of low rectum resections. Some of these bowel resections are even performed for little endometriosis outside the bowel and too often in women without endometriosis (up to 26% as published recently).. Since the most important variable in the outcome of surgery is the surgeon we strongly suggest that some kind of quality control of surgery be implemented, by systematic taping of entire interventions . To become recognized as a center of excellence in endometriosis surgery we therefore strongly suggest that a strict quality control, preferably by systematic taping should become a key criterion.