published on AAGL Listserv  Date:    Mon, 19 Oct 2009 20:07:01 -0400    From:    “Philippe R. Koninckx , Carlo de Cicco and Anastasia Ussia”
<Gary_Frishman@BROWN.EDU>       Subject: True incidence bowel endometriosis

Reading the comment by David Redwine we are really concerned. The  arguments used are purely authority based without any evidence that the  statements are correct or unbiased.

*” I don’t get any scans, imaging, colonoscopy, or barium studies on any  patient, ever. I diagnose bowel endometriosis in the most accurate way possible: by looking at the bowel”*.  It sounds like God, but I fear that this is not the best treatment of the patient. It is wise to have at least a contrast enema and an ultrasound before surgery and an assessment of hydronefrosis. This is necessary in order to decide

- whether a bowel preparation should be given. To give a bowel preparation to all patients would be overtreatment for some patients.
- whether a ureter stent should be placed before surgery. As we published recently (De Cicco et al, Fertil steril 2009) ureterolysis of an hydroneophrosis should not be done without a stent whereas systematic stenting is overtreatment and potentially damaging to the ureter.
- whether an elective sigmoid resection should be done.  We plan an elective sigmoid resection for sigmoid nodules giving more than 50% occlusion over more than 3 cm. whether a ureter stent should be placed

“*operating on it if I find it, whether it requires a superficial disc resection, full thickness disc resection, or segmental resection”.* ‘We recently made a systematic review of the 1600 bowel resections published (submitted), and found no data relating the indication for bowel resection to size.  Unless data are provided permitting to judge the ratio of bowel resections to discoid resections according to size, or unless a systematic videorecording is performed permitting some evaluation afterwards how can we trust that the judgment during surgery is correct, and that bowel resections are not performed too liberally.

*“In over 800 bowel resections for apparent endometriosis, the incidence of a negative path report in my hands is less than 0.05%.”*  It is always nice to give the impression to do much better than the others : in a recent report - RBMonline, 2009- 8/50 on whom a bowel resection for endometriosis was performed, no endometriosis was found whereas in other 6 endometriosis was situated outside the bowel. We do not know whether this is the tip of the iceberg because of underreporting or whether this reflects reality. Moreover the statement is misleading since we do not want to know whether endometriosis is confirmed but in which percentage the endometriosis did not or only superficially infiltrate the muscularis (thus making a resection overtreatment).

Philippe R. Koninckx1-2 , Carlo de Cicco1 and Anastasia Ussia2
1 University of Leuven, Leuven Belgium and 2 Gruppo Italo Belga, Roma, Italy