Improvement of the quality of life after surgery for deep infiltrating endometriosis.

Deep rectovaginal surgery done by accredited centers improves the quality of life.

Key Points

Importance:

• To stop smoking and requiring referral to a specialist centre in women with deep rectovaginal endometriosis are important to achieve a better postoperative quality of life.

Highlights:

• Quality of life can be improved and restored after surgery for deeply infiltrated endometriosis, when performed in a skilled and accredited endometriosis center.

What's done here:

• Authors wanted to examine the factors that influence quality of life after laparoscopic deep rectovaginal excision surgery for endometriosis.
• A multicentre prospective cohort study involving 63 hospitals accredited as British Society for Gynaecological Endoscopy(BSGE) specialist endometriosis centres was planned.
• More than 8300 consecutive women underwent laparoscopic surgical excision of deep rectovaginal endometriosis by pararectal space dissection were included.
• The mean quality of life assessed by a standard questionnaire prior to, 6 and 24 months after surgery was compared to potential prognostic factors:
  • Age, smoking, BMI, previous treatments, concomitant bowel surgery, surgical complications. 

Key results:

• The mean "prior to surgery" quality of life score (mVAS) increased at 6 months and was found to be mantained at 24 month' evaluation.
• Out of the 16 predefined factors, only 5  (age, smoking, BMI, bowel surgery, and previous surgery for endometriosis) showed relative differences concerning improvement of quality of life.
• Women who underwent segmental bowel resection had a significantly better postoperative quality of life compared to those who did not have bowel surgery.
• Women aged under 45, smokers, and those who had previous surgery for endometriosis had poorer postoperative outcome compared to others.
• Especially women older than 45 years and those receiving preoperative GnRH analogs showed better clinical improvement.
• Peri- or post-operative serious complications were around 4%, which is an acceptable considering the complexity of the surgery.

Limitations:

• The results may not be generalisable due to the high standards of BSGE Endometriosis Centres.
• Large sample size, prospective data collection, the evaluation of patient characteristics and previous medical history, are strengths.
• Although the reduced loss to follow up by 6 and 24 months may be a limitation, still the number of patients with follow-up are high for statistical power.
• Randomized controlled studies are necessary.

Lay Summary

Deeply infiltrating endometriosis is the most severe form among the endometriosis types. The required laparoscopic approach is the appropriate excision of endometriotic foci from pelvis, by consideration of failure and side effects of the medical treatments. The specialist endometriosis centers showed good evidence of the safety and effectiveness of laparoscopic surgery for deep infiltrating endometriosis patients. Improved the quality of life at 6 months after surgery could be achieved and be maintained at 2 years in these specialized endometriosis  centers. Factors related to the individual patient characteristics, and miscellaneous complications after surgical excision still remain to impact the outcome of surgery and the quality of life. 

The clinician may determine the medium and long-term quality of life independent of the surgery if there is clear and statistical evidence when counseling the patient preoperatively.

Bryne et al, from Royal Cornwall Hospitals, Cornwall, United Kingdom, set up this multicentre prospective cohort study involving 63 hospitals accredited as British Society for Gynaecological Endoscopy(BSGE) specialist endometriosis centres, and 8368 laparoscopically operated consecutive women iwere evaluated. The results recently published in the journal named "European Journal of Obstetrics Gynecology and Reproductive Biology". 

The authors wanted to assess "the quality of life" in comparison to 16 potential prognostic factors that chosen by the BSGE scientific advisory group, including age, BMI, smoking, previous endometriosis treatments, the presence of concomitant bowel surgery, and surgical complications.

The mean quality of life assessed by a standard questionnaire prior to, 6 and 24 months after surgery was compared to potential prognostic factors, and evaluated with 95% confidence intervals were used to assess the quality of life scores. A pair-wise comparison for the short and long term term were made between preoperative, 6 and 24 months after the operation. 

Statistical analyses clearly showed an improved overall quality of life. The subgroups of smokers, patients younger than 45 years, theose who were surgically treated preoperatively, and patients with BMI more than 35 showed statistically significant poorer outcome.

The results of the study indicate the efficacy of appropriate laparoscopic surgery for deep rectovaginal endometriosis when performed by a specialized accredited endometriosis center.

Research Source: https://pubmed.ncbi.nlm.nih.gov/33873083/