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Wednesday, 3 July 2013

June Roundup in July



Unfortunately I’ve been a bit behind this month, but I always keep my eye on what going on in the world of endo research.

So with that in mind let’s have a look at what’s been going on

Firstly, a study into surgical treatment for endometriosis of the bladder. This form of the disease isn’t particularly common, but it does add another layer of misery to the sufferer so knowing the optimal treatment is important. This study took sixty nine patients with bladder endometriosis and recorded what surgical procedures they had and how this affected their symptoms afterward. After follow up period of between 4 and 92 months, 92.7% of the women either had no symptoms, or a reduction in symptoms. What this study highlighted was the need for surgeons with specialist training in different types of endo (i.e. bladder, bowel etc) as they may require a different surgical approach.

Speaking of bladder and bowel surgery, up next is a report on the use of robotic assisted surgery for the treatment of just those conditions. This study included 19 cases of bowel surgery and 5 cases of bladder surgery, all of which occurred without complications. Now, robot-assisted surgery is a hot topic at the moment because it is a new and growing technique. But we are also stuck in a catch-22 situation with robotic surgery. You see, people are reluctant to support robotic surgery until there are more studies into its effectiveness, but you can’t have more studies until you support wider use of robotic surgery. Either way it looks like robotic surgery is here to stay and it is a safe and effective tool with a skilled surgeon at the helm.

Speaking of robot-assisted surgery, there are many different types of surgical procedure the robot can be utilised for in the treatment of endometriosis. In severe cases of the disease, doctors may opt for hysterectomy and our next study examines the safety and effectiveness of using the robot for such a procedure. In summary this study looked at 43 cases of women with severe endo (19 with stage III and 24 with stage IV). The results of which were -  operating times averaged at 145 minutes (with a variation of 67-325 mins); 41 out of 43 women only had a 1day hospital stay, with one woman needing to stay for 5days due to needing a laparotomy and one woman staying 3days because of a bowel obstruction that cleared. There were no reported complications during surgery though after surgery one woman had to be readmitted with a vaginal cuff abscess which was treated with antibiotics and drained. The authors of this study make some good points about the pros and cons of robotic surgery, namely – “The robotic platform improves the depth of perception and facilitates the resection of deep infiltrating lesions. In addition, the robotic system improves dexterity, filters the surgeon’s tremor, and improves intuitive movements”; however they also say “Robotic surgery has several disadvantages compared with traditional laparotomy. These include increased cost; the lack of tactile feedback to the surgeon [i.e the ‘feel’ of the toughness or resistance of tissues]; the presence of bulky robotic arms, as well as long and thick cords; the inability to move the surgical table once the robot arms are attached; and a limited range of motion with respect to operating in different quadrants in the same case”.

Sticking with a surgical theme is a study from the US looking at the effectiveness of surgical excision of endometriosis across five different medical centre’s. All the women included in this study were suffering endometriosis associated pain, of which 90 had operative information. Once these women were operated on, 65 were confirmed to have endometriosis and 25 had no confirmation of endo. Interestingly, of all the patients who had endometriosis confirmed at these centres, 84.6% had previously been given hormonal therapy or ablation (burning away of endo) surgery, indicating that these treatments are not very effective at reducing endo pain symptoms.  After their surgeries, all of the women in the different centres noticed a significant reduction in all but bowel symptoms (bowel symptoms were reduced though, but the amount of reduction wasn’t considered statistically significant). Interestingly the authors of this study found there was no significant difference in the pain and quality of life scores between women who were given hormonal therapy after excision surgery and those who weren’t. However, the post-operative information was collected 6 months after surgery, so long term effectiveness couldn’t be gauged. In any case this study shows that excision of endometriosis is still the preferred method of treatment for the disease where possible.

It is rapidly becoming apparent that endometriosis is a disease that begins to present itself in adolescence. This is extremely important to know because it means general practitioners need to be able to spot the signs of endometriosis in young girls and make sure they get treatment as soon as possible. But what are the major signs of endo? A new study looking at diagnosis of endo in adolescent girls found that 75% of girls with chronic pelvic pain (which is any pain in the pelvic area that lasts more than six months) that did not respond to medical treatment and 70% of girls with dysmenorrhoea (excessively painful/heavy periods) were later diagnosed with endometriosis. All doctors need to be aware of these ‘red flags’ and act on them quickly.

Next up is copper, which is great for electrical wiring and making cheap jewellery, but also may be important for endometriosis. Our bodies need miniscule amount of copper to function properly, but as with so very many things in this world, there is fine balance to be kept. In your body copper can float around by itself, but is also carried around by a protein called ceruplasmin and this latest study looked at the levels of both of these in the blood of women with advanced stage endometriosis compared to disease free women. What they found was that levels of copper and ceruplasmin were much higher in the blood of women with endo, but what does this mean? That’s a tricky question to answer because we’re still not sure what role copper might play in endo. Excess levels of copper are known to be a marker for oxidative stress and oxidative stress certainly seems to be elevated in women with endo. Oxidative stress, as the name suggests, is not something you want happening to excess in your body; prolonged exposure to oxidative stress can make you run down and generally feel like crap, in addition localised oxidative stress can actually promote the survival of endometriosis. Further study is needed to find out if copper is a cause or effect of oxidative stress, but as an interesting aside, elevated levels of copper in the blood could possibly be used as an indicator of advanced stage endometriosis.

Finally is a study from Denmark about the risk of endometriosis and fertility problems in the daughters of women with the disease. This was quite a large study, including information from 12,389 women with endometriosis and 52,371 without. Overall daughters of women with endometriosis were just over two times more likely to be diagnosed with endo. However, daughters of women with endo had no difference in the rate of deliveries, risk of miscarriage and ectopic pregnancy compared to the daughters of women without endo.  

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