Clinicalobservation Of Laparoscopic Management Of Deep Infiltrating Endometriosis

ObjectiveDeep infiltrating endometriosis(DIE)is a benign disease associated with pelvic pain and infertility,which is severely impairing the physical and mental health of patients in childbearing age.The laparoscopic surgery is increasingly accepted as a routine for the diagnosis and treatment of DIE because it can offer more advantages when compared with open interventions.However,the standard surgical procedures for DIE have remained controversial and challenging.Through retrospective analysis of 15 patients having underwent the laparoscopic surgery,we discussed the operation program,perioperative and postoperative managements,thus providing a reference for individualized treatment of DIE.Materials and MethodsPatients with deep infiltrating endometriosis underwent laparoscopic procedures in Shandong Provincial Qianfoshan Hospital and Jinan Central Hospital from January 2011 to December 2015 were included in this study.The revised American Society for Reproductive Medicine classification(ASRM)provided a numerical score of severity based on visual findings at laparoscopy.Before surgery and at three postoperative followup(3rd month,6th month and 1st year),patients were always asked to evaluate their severity of pain by the visual analog scale(VAS).Other recorded data were also collected from the computerized database including: age,body mass index,parity,gynecological examination,operating time,amount of blood loss,length of hospital stay,postoperative management and so on.The statistics were analyzed with ANOVA of repeated measurement data in SPSS 20.0.ResultsFifteen patients met the requirement and were enrolled in the study.There was no complication or conversion to laparotomy registered during laparoscopic surgery.The intraoperative ASRM staging results were stage III(6/15)and stage IV(9/15).Pathological reports confirmed there were evidences of deep endometriosis(endometrial glands and stroma of >5 mm)in the specimens of all cases.Other characteristics of these cases about the surgery treatment were as follows: the mean blood loss was(118±96)ml(n=15,20ml~400ml),the average time of operation was(168.9±42)min(range,97min~273min)and the mean length of hospital stay was(6.0±1.7)d(range,4d~11d).After an average follow-up time of(26.1±15.0)mouths,we found 80% of the patients accepted GnRHa therapy for 3 to 4 cycles and their mean visual analog scale(VAS)score of 3rd month,6th month and 1st year following drug treatment were(1.0±1.7),(2.5±2.3),(2.5±2.3),respectively.However,at the same follow-up time point,the mean VAS score of other three patients who did not use GnRHa after surgery were(1.0±1.7),(2.5±2.3),(2.5±2.3).Compared with the mean VAS score before treatment,there was an obvious improvement at each fellow-up after laparoscopy combined with GnRHa therapy(7.4±3.6 VS 0.8±0.9,7.4±3.6 VS1.3±0.9,7.4±3.6 VS 1.6±1.3,P=0.001),whereas there was no statistically significant difference among the three time points(P>0.05).The pain was also relieved in the non-GnRHa group but their data could not carry on the statistical analysis because of too few cases.In addition,it was showed in the study that a patient was diagnosed as endometrioma again at 24 th month after surgery combined with 4 cycles GnRHa therapy and another one begun to suffer from dysmenorrheal again at 6th month after surgery alone.Meanwhile no evidence of DIE relapse was found in the rest.Conclusion1.Laparoscopic excision of endometriosisis proved feasible,safe and effective wherever its nodes are in uterosacral ligament or rectouterine pouch orvaginal rectal septum.2.Our study supports laparoscopic management of completely lesion removal followed by subcutaneous injection of GnRHa can significantly relieve symptoms,improveequality of life and reduce the recurrence of DIE.The treatment strategy above may be a choice for women with DIE in reproductive age.