When is Endometriosis Surgery an Emergency?
Endometriosis is a chronic estrogen-dependent disease where endometrial glandular and stromal cells occur outside the uterine cavity. Lifelong management of the disease should aim to maximize the use of medical treatment and avoiding repeated or emergency surgical procedures.
Treatment of endometriosis
Therapies for endometriosis-related symptoms including dysmenorrhea, dyspareunia, chronic pelvic pain, and infertility are mainly a combined approach of analgesics, hormonal treatments, and surgical intervention.
The surgical management of endometriosis is usually not the first choice in clinical practice. There are many reasons for this. They include complications and disadvantages of surgery. For example, the risk of organ damage, possible reduction of ovarian reserve, adhesion formation, possible lack of improvements in pain or recurrence of disease/pain, the necessity for the use of postoperative medical treatment, and standard surgical risks are all drawbacks of surgery.
However, non-surgical management of ovarian endometrioma may have some potential drawbacks and risks too. These include pelvic inflammatory disease or tubo-ovarian abscesses through rupture or infection, the risk of malignant transformation later in life, and the negative impact of ovarian endometrioma on the ovarian reserve.
Furthermore, surgical intervention has some advantages over medical treatments. For example, it provides a histologic diagnosis, allows assessment of pelvic cysts in terms of malignancy, and reduces pain by destroying all endometriotic implants.
There are also some specific cases where surgical intervention is better. These include:
- need for tissue diagnosis of endometriosis
- contraindications to/or refusal of medical therapy
- persistent pain despite medical therapy
- obstruction of the bowel or urinary tract
- endometrioma rupture
Determining whether surgery is necessary
Prior to ascribing a patient’s abdominal or pelvic pain to endometriosis, the clinician should consider other common causes of pain. These could include ectopic pregnancy, pelvic infection, and ovarian torsion. Patients may also have concomitant endometriosis and inflammatory bowel disease (Crohn’s disease). Endometriosis may be a cause for acute abdomen in women, and it should be considered in the differential diagnosis.
The first step in such emergency cases is taking a careful anamnesis and performing a detailed physical and pelvic examination. Then hemogram and a pregnancy test can differentiate the presence of pregnancy and pregnancy-related adverse conditions. Imaging modalities such as ultrasonography, Doppler ultrasonography, and magnetic resonance imaging (MRI) can aid in the differential diagnosis. Other departments such as general surgery and urology should be consulted to rule out the presence of an emergency related to the environmental organs including appendicitis, nephrolithiasis, or acute pyelonephritis.
Especially in the case of endometrioma rupture, emergency surgical intervention can reduce the dissemination of endometriotic cyst fluid spread. It can also prevent adhesions, and preserve fertility. If obstruction of the bowel or urinary tract occurs due to infiltration of endometriosis, urgent surgical management plays a vital role in minimalizing the loss of organ function.
Blood tests such as serum CA125 level are not sensitive and specific for endometriosis. However, increased blood values of these markers during follow-up, changes in the ultrasonographic appearance of endometriomas, and aggravation of patient symptoms may also require emergency surgical intervention.
The case of deep infiltrating endometriosis
Deep infiltrating endometriosis is the most severe manifestation of endometriosis, affecting 20% of patients. It is when ectopic endometrial tissue infiltrates under the peritoneum, pelvic structures, and the organ walls such as the uterosacral ligaments, colon, vagina, bladder, ureter, rectovaginal septum, and the lateral parametrium. The lateral parametrium covers the retroperitoneal connective tissue from the uterus to the lateral pelvic wall.
If endometriosis spreads to the parametrium, surgical intervention plays a major role in management. However, preoperative clinical treatment can reduce tissue injury and the need for aggressive surgical intervention. Surgeons usually perform disc excision for single lesions. They prefer segmental resection for larger lesions or when neoplasia is a concern.
Types of endometriosis surgery
Surgical resection can be conservative (treatment of endometriosis by ablation or resection) or definitive (removal of all visible implants). The main objective should be therapeutic and effective surgical intervention. The potential benefits and complications should be discussed with the patient. These are based on age, obstetric history, desire for pregnancy, symptoms, and the characteristics and localization of the endometriotic lesions.
Ablation aims to completely destroy the endometrial epithelium surrounded by stroma. Excisional surgery results in a more favorable outcome than drainage and ablation in terms of disease and symptom recurrence and obstetric outcomes.
Ovarian cystectomy using stripping or combined excision/ablation technique is better than ablation in terms of endometrioma recurrence, pain symptoms, and increased spontaneous conception rate among subfertile patients.
In the case of ovarian torsion due to the presence of endometrioma, detorsion of the ovary and cystectomy of the endometrioma is the most appropriate approach. Clinicians can consider hysterectomy with oophorectomy and removal of all visible endometriosis lesions in women who do not have fertility desires and do not respond to other conservative therapies.
Surgeons should explain to patients that hysterectomy is not a definitive treatment for endometriosis. Laparotomy and laparoscopy are equally effective in the treatment of endometriosis. However, laparoscopic surgery appears to be superior to laparotomy. This is because it leads to less postoperative pain, a shorter hospital stay, a quicker recovery, and a better cosmetic outcome.
In the case of emergency surgery for endometriosis, if the vital signs of the patient are stable, laparoscopy may be preferable. Patients who do not desire to become pregnant immediately after surgery should use hormonal therapy postoperatively.
The optimal management of endometriosis
Despite extensive research, the optimal management of endometriosis still remains unclear. The decision for treatment should be patient-centered. Factors such as her clinical presentation and age, symptom severity, disease extent and location, reproductive desires, and other comorbidities should be considered. The side effects and complications of medical treatment and surgery and cost should are also factors to consider.
Pain relief, amelioration of fertility, prevention of progression of the disease, restoration of normal anatomy, and delay of recurrence should be a priority in the management of endometriosis. This is the case even in emergency situations. Therefore, all women with endometriosis should receive an evaluation by a multidisciplinary approach considering all possibilities in the differential diagnosis. Surgeons should make the final decision for the treatment of urgent cases in a short time. This should be based on tolerability, therapeutic effectiveness, the physician’s experience, the patient’s preferences and needs, and cost.
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