Cancer is not cancer, but it looks like cancer when it is not. Endometriosis, a bewildering disease, is increasingly becoming a “modern disease” that endangers women’s health, and since 1986, international academic conferences on endometriosis have been held every two years around the world. This attention to a disease shows the universal importance of the disease.
I. What is endometriosis?
Endometriosis is a condition in which the endometrium, which has a growth function, appears in other parts of the body outside the uterine cavity. Ectopic in the myometrium is called “myometriosis” and ectopic in the ovary is called “ovarian chocolate cyst”. The disease is morphologically benign, but it has malignancy-like behavior such as dissemination, implantation, invasion, or metastasis. The size of the lesion can vary widely and clinical symptoms often do not parallel the extent of the lesion.
Endometriosis has a prevalence of about 10% among women of childbearing age and is on the rise, becoming a “modern disease”. Eighty percent of patients have significant dysmenorrhea and 50% have combined infertility, seriously affecting the health and quality of life of young and middle-aged women.
What are the common locations of endometriosis lesions?
Most endometriosis lesions are located in the ovaries, the uterosacral ligament, the plasma membrane layer of the lower posterior wall of the uterus, as well as the rectal recess, the peritoneal layer of the sigmoid colon and the vaginal rectal diaphragm. Invasion of the ovaries is the most common, accounting for approximately 80% of cases. It can also be seen in the cervix, lateral perineal incision, or surgical incision of the abdominal wall. It can develop in the umbilicus, lungs and extremities, but is very rare. In fact, it can be found in all parts of the body except the spleen.
III. How is endometriosis treated?
There are five “best methods” of treatment for endometriosis: laparoscopic surgery is the best surgical treatment, ovarian suppression is the best pharmacological treatment, surgery → pharmacological treatment → laparoscopic surgery again (three phase therapy) is the best combined treatment, and pregnancy and fertility techniques are the best prospective treatment.
Among these treatments, surgical treatment, especially laparoscopic surgery, is the preferred and best treatment. However, endometriosis is difficult to cure by surgery alone and is prone to recurrence after surgery, therefore, pharmacological treatment still occupies an important place. For endometriosis whose symptoms are not obvious or can be controlled by drugs, surgery can be temporarily dispensed with.
How do you see the value of surgery for endometriosis?
Surgery can remove lesions, separate adhesions and restore the pelvic anatomy, thus achieving symptom relief, promoting fertility and reducing recurrence. Therefore, surgery is the basic treatment for endometriosis. Surgery should be considered if endoheterosis presents with pelvic masses, infertility or pelvic pain that has not been treated with medication. There are three types of surgery: surgery to preserve fertility, surgery to preserve ovarian function and radical surgery, which are mainly decided according to the patient’s age, symptoms, site and extent of the lesion and the requirement for fertility. It has been suggested that anticipatory treatment of intestinal, ureteral, and vaginal-rectal septal endometriosis can in many cases avoid the complications associated with pelvic surgery and the resulting costly procedure.
The choice of surgical modality includes laparoscopic surgery and open surgery, both of which have comparable treatment results. In particular, laparoscopic surgery integrates diagnosis and treatment and is suitable for all stages of endometriosis and has become the gold standard and the preferred surgical procedure for endometriosis diagnosis due to its minimally invasive features, minimal tissue damage, clear visualization, low postoperative adhesion formation, low complications and fast recovery. For infertile patients, tubal lavage or tuboplasty can be performed at the same time to facilitate postoperative conception, which has the advantages that open surgery does not have.
Studies have found that surgery is beneficial in the treatment of early endometriosis infertility. Studies by domestic scholars have found that the mode of surgery also has an effect on pregnancy rates, with laparoscopy generally being superior to open surgery. In infertility due to moderate to severe endometriosis, the 3-year pregnancy rate was 82% with laparoscopy, which was significantly higher than the pregnancy rate of 33.3% after open surgery.
The surgery also had a better effect on pain caused by endometriosis, and the later the stage of endometriosis, the more pronounced the effect. The rate of pain relief at 6 months after surgery was 62.5%. However, the recurrence rate of postoperative symptoms is also high, about 10%-20% per year, so we advocate postoperative supplemental drug therapy to reduce the recurrence rate.
V. What are the ways of surgical treatment for endometriosis?
Surgery can be divided into three types: conservative surgery, semi-radical surgery and radical surgery.
1.Conservative surgery: mainly used for young people with fertility requirements. The uterus and adnexa are preserved (bilateral as much as possible), only the lesions are removed, adhesions are separated, ovaries are reconstructed, and tissues are repaired. In recent years, microsurgery has been applied to remove ectopic lesions, carefully suture the wound, reconstruct the pelvic peritoneum, carefully stop the bleeding, and thoroughly flush it, so as to perfect the surgical results, improve the success rate of pregnancy after surgery, and reduce the recurrence rate. One of the important purposes of conservative surgery is to achieve a full-term pregnancy and delivery, so both partners should be thoroughly examined for infertility before surgery. Post-operative recurrence can still be treated by conservative surgery again, and the results can still be obtained.
(1) Laparoscopic surgery: Through laparoscopic examination, a clear diagnosis can be made, and specially designed knives, scissors and forceps can be used to remove the lesion and separate the adhesions. The lesion can be cauterized with CO2 laser or helium-neon laser under laparoscopy, or the cystic fluid can be aspirated by laparoscopic puncture, then rinsed with saline, then injected with 5-10 ml of anhydrous ethanol, fixed for 5-10 minutes and aspirated, and finally rinsed with saline and aspirated. Tubal lavage is also feasible under laparoscopy.
(2) Ultrasound endometrioid cyst puncture: for recurrent cases after surgical debulking or laparoscopic puncture, ultrasound puncture and drug treatment can be considered.
(3) Conservative dissection: for patients with more severe focal adhesions, especially in medical institutions without laparoscopic equipment or those who are not skilled in laparoscopy, dissection can be performed to separate the adhesions and excavate the ovarian endometrioid cysts, preserving as much normal ovarian tissue as possible, or if the lesion is limited to one side and is heavy and the other side is normal, some advocate removing the diseased side of the adnexa. This has a higher pregnancy rate than that with preservation of the diseased ovary. A simple uterine suspension can also be performed. Whether to do anterior sacral nerve resection is debatable.
2. Semi-radical surgery: in those without fertility requirements and with severe lesions, but at a younger age (<45 years), total excision of the uterus and lesions is feasible, but the normal ovarian tissue on one side is preserved as much as possible to avoid the premature onset of menopausal symptoms. The recurrence rate after semi-radical surgery is generally considered to be low, with few sequelae. Removal of the uterus removes the source of viable endometrial cells for implantation, which may reduce the chance of recurrence. However, there is still a possibility of recurrence because the ovaries are preserved.
3. Radical surgery: If the patient is close to menopause, especially if the disease is severe and has recurred, total hysterectomy and bilateral adnexal resection should be performed. Avoid rupture of the ovarian endometrial cyst as much as possible during surgery. The cystic fluid should be aspirated and flushed as soon as possible when it flows out. For postoperative menopausal syndrome, sedation and Neil estrol are available. If endometriosis occurs at the abdominal wall and perineal incision, it should be completely removed, otherwise it will recur.
VI. How to prevent endometriosis?
Since the etiology of endometriosis is multifaceted, it is controversial whether menstrual reflux itself causes endometriosis, and some preventive opinions are only applicable to a few cases. However, according to the currently recognized etiology, the following points should be noted.
1. Avoid unnecessary, repetitive or overly rough gynecologic double-jobbing near the menstrual period to avoid squeezing the endometrium into the fallopian tubes and causing abdominal implantation.
2. Avoid performing gynecological surgery as close to menstruation as possible. When it is necessary, the operation should be performed gently and avoid squeezing the uterine body with force, otherwise the endometrium may be squeezed into the fallopian tube and abdominal cavity.
3, timely correction of excessive retroflexion of the uterus and cervical canal stenosis, so that the drainage of menstrual blood is smooth, to avoid stagnation, causing backflow.
4. Strictly grasp the operating procedures of tubal patency test (ventilation and fluid) and imaging, and do not perform them just after menstruation or directly during the cycle of curettage to avoid pressing the endometrial fragments into the abdominal cavity via the fallopian tubes.
5. During cesarean delivery and cesarean extraction, care should be taken to prevent the uterine cavity from overflowing into the abdominal cavity. When suturing the uterine incision, do not let the suture pass through the endometrial layer and apply saline flushing before suturing the abdominal wall incision to prevent endometrial implantation.