Belgium faces a problem to perform deep endometriosis surgery without bowel resection.

Summary of presentations on 10/9/12 in Ircad Straatsburg, on 12/9/12 as a debate with Prof Keckstein at the yearly ESGE meeting and on 20-9-12 in Brussels when prof Donnez became emeritus.

History

In 1990 I started the surgical resection of deep endometriosis together with Prof em Penninckx ie after our first publication on this subject.
In 1995, following a few bowel resections for deep endometriosis we made the practical arrangement that sigmoid-resections would be performed by the bowel surgeons to keep up with the work load and since technically easier. Indeed at that moment the surgeons just started with endoscopic surgery.
Around 2000 several hospitals had started deep endometriosis surgery and most of them were performing almost routinely bowel resections. The reason for this was that it was technically easier, that the responsibility was shared with the surgeon. Moreover it should be noticed that reimbursement of a bowel resection is at least 5 times higher than for a discoid excision. As a result, Prod konincks (KULeuven) and Prof Donnez (UCL) in Belgium, and a few groups in the US (eg Charles Koh Milwaukee, Camran Nezhat Atlanta, David Redwine Oregon) ) became an absolute minority.
From 2005 onwards more data became available and it became clear that a bowel resection can be avoided, that the results of a bowel resection are not superior, while low bowel resections are associated. This trend is obvious in the presentation of Prof Arnaud Wattiez (Staatsburg) and Prof Paulo Ribeiro (Sao Paulo) stating that with increasing expertise their prevalence of bowel resections had decreased from 30% to less than 10%.

A bowel low resection is generally avoidable

It can be argued whether for a low rectovaginale endometriosis nodule 1% of less than 10% bowel resections should be performed. It is clear however that more than 60% bowel resections constitute a problem. The reality however is that surgeons either decide during surgery and perform few bowel resections ; those who decide before surgery mostly end by performing over 60% of bowel resections.
Discoid excision without a bowel resection has become technically standardized as evidenced by the many presentations.

Why this large variation in percentage of bowel resections ?

The indication is not the reason since highly variable for bowel resections as demonstrated in a systematic review.
The conclusion was that the main reason for bowel resections is either because decisions are made before surgery, or that skill to perform discoid resections is insufficient.

Why should low bowel resections be avoided

Results are not better
Complications are higher than after discoid excisions ; especially the long term complications ie a life long bladder problems in 30%, bowel problems in 30% and sexual problems as anorganismia in 40%.
Bowel resections are clearly not indicated and useless when by pathology afterwards no endometriosis is found or the endometriosis is only outside the bowel.
And notwithstanding all this, most bowel resections are low bowel resections

High sigmoid nodules : conservative surgery is more difficult and complications of bowel resections are low.

We perform 10% bowel resections for sigmoid nodules but our advice to those with less experience is to be more liberal in bowel resections. W

And the patient ?

Patient rarely receives information on the alternative to avoid a bowel resection. If after surgery no endometriosis is found, this is rarely shared with the patient.
We therefore strongly suggest that decisions are taken during surgery. If at laparoscopy the nodule or the intervention is judged too difficult for the skills of the surgeon, the patient should be referred. If during surgery the intervention reveals to be too difficult a bowel resection can be performed.
Key thus is to avoid too many errors in judgment. The only way for the patient to judge this is a videoregistration.

Why is the problem in Belgium ( and probably shortly in the US) ?

Since Prof Koninckx en Prof Donnez became emeritus at KULeuven and UCL respectively, both strong promotors of conservative surgery left both universities. Those remaining often perform very liberally bowel resections, which risks to become a problem for the patients with a deep endometriosis.

What are the solutions ?

Mandatory video-registration of all interventions for deep endometriosis is considered as important since the indication for bowel resections would become controllable afterwards.
Video-registration could be used as a condition for reimbursement. Video-registration thus has the potentiality to decrease costs for society while enhancing quality for the patient

Prof Koninckx en Dr Ussia
Gruppo Italo Belga voor endometriose chirurgie.