Peritoneal stripping in  endometriosis ?

“Peritoneal stripping of large areas of normal looking peritoneum” as a treatment for endometriosis is circulating on the web. It was recently debated in newspapers and is being discussed on patient forums. It even is advocated by some gynaecologists. Since in the literature as pubmed no publications are found, some comments seem to be useful.

Subtle endometriosis or non pigmented endometriosis.

As discussed on this site, it remains scientifically debated whether subtle endometriosis should be considered a pathology. If endometriosis is defined by the definition of 100 years ago ie ‘endometrial cells and stroma outside the uterus’ subtle endometriosis fulfills the criteria of endometriosis. Until today however, we do not have any data that subtle endometriosis causes pain or infertility. Typical endometriosis seems to be associated with pain and probably with infertility. It is beyond the scope of this blog to discuss this in detail : for those interested I recommend reading my article of over 10 years ago “biases in endometriosis research” demonstrating that after 1986 ie after non pigmented lesions were recognized as ‘endometriosis’ , the prevalence of endometriosis increased tremendously (in up to 85 % of women in Leuven), which means that many women who previously were considered normal , now became considered as having endometriosis. Before 1986 a consistent association between superficial –typical- endometriosis with the LUF syndrome was found ; after 1986 this association disappeared. This we interpreted as being caused by the fact that many normal women before 1995 were considered as having endometriosis after 1986.

Non pigmented or subtle lesions became a hype during the mid-eighties and the search started for smaller and smaller lesions leading to the concept of microscopical endometriosis ie invisible by the naked eye. Several authors tried to demonstrate this concept ; some small lesions were found but the data never were very convincing.

That excision of typical lesions could reduce pain was rather convincingly demonstrated in the RCT of Sutton. That this also increased fertility remains until today, much less clear.

That treatment of subtle lesions is helpful has to the best of my knowledge never been demonstrated, neither for pain, not for infertility, and not in order to prevent progression of the disease.

Placebo effect, psychology and laparoscopy.

The LUF syndrome –still the best explanation of the associated infertility in typical endometriosis- is strongly trait anxiety related.
The treatment of pelvic pain has a placebo effect of 30%, or as we wrote a placebo effect of 80% in about half of women with very severe deep endometriosis.
Indirect evidence strongly suggests that laparoscopy by itself decreases pain and even increases fertility. It is speculative to consider this a placebo effect or psychotherapy or something else. Indeed our recent work on adhesion formation clearly demonstrated that a CO2 pneumoperitoneum induced an acute inflammatory reaction in the entire pelvis. Whether this inflammatory reaction might affect pain and fertility today is pure speculation, but cannot be excluded.

Surgery for endometriosis

To discuss pathophysiology and our uncertainties and to formulate hypotheses is intellectually nice and anyway innocent. A treatment on the contrary should at least be proven not to be harmful, and preferentially be demonstrated to be effective. Is often seems forgotten that the absence of any quality control in surgery, does permit us to introduce new types of surgery. We seem to agree to excise typical lesions and maybe a peritoneal area when several typical lesions are found as being almost confluent. Peritoneal stripping of large areas of normal looking pelvis as a treatment of endometriosis, however should be juged severely.

Stripping of large areas of normal peritoneum probably is harmful l since these large denuded areas probably will increase adhesion formation afterwards.
Stripping of large areas of normal peritoneum does not have a sound scientific basis.
Stripping of large areas of normal peritoneum is not useful as far as demonstrated today.
Endometriosis is not a cancer and the concepts of ovarian debulking where stripping is being done, cannot be applied to endometriosis

In conclusion stripping of large areas of normal peritoneum today should be considered as unproven, possibly harmful and mutilating surgery which as least should be evaluated in some trials. I sincerely doubt however that any IRB would give permission for such experimental surgery based upon speculation.

Prof P.R. Koninckx and Drssa A. Ussia
KULeuven Belgium and Gruppo Italo-Belga, Rome, Italy

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