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Endometriosis Talk

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Talk for GYN practitioners on Endometriosis

Talk for GYN practitioners on Endometriosis

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    • 1.  
    • 2. Endometriosis Surgery and Adhesion Prevention Nicholas Leyland, BASc , MD,MHCM, FRCSC Chief of OB/GYN St Joseph’s Health Centre, Medical Director of Women’s, Children’s and Family Health Program. Associate Professor OB/GYN, University of Toronto. Left Ureterolysis
    • 3. *Trademark ©ETHICON, INC. 2007
    • 4. Interceed:
      • Years of proven efficacy in a wide variety of procedures:
      • Adhesiolysis Myomectomy Ovarian Surgery Tubal Surgery Surgical Treatment for Endometriosis
      • Excellent safety profile Over 10 years of clinical experience
    • 5.  
    • 6. Surgical Approach: Objectives
      • Is Surgery Even Necessary: Indications
      • What to do: Burn or Cut?
      • Special Situations:
        • Endometriomas
        • Deep Infiltrating Endometriosis
      • Adjunctive Surgical Techniques and Prevention of Adhesions
    • 7. Is Surgery Even Necessary?
      • Risks – 0.2-3% overall complication rate
      • Requires additional expertise and training
      • Reimbursement limitations/OR resources limited
      • Excellent medical options exist for pain
      • GnRH Agonists, Aromatase Inhibitors,
      • Mirena IUS
    • 8. Indication for Surgical Management of Endometriosis
      • Diagnosis
      • Acute, chronic pain
      • Significant impact on quality of life
      • Failure of medical therapy
      • Infertility investigation and treatment
      • Endometrioma
      • Secondary organ involvement (bowel, bladder, ureter, nerve)
    • 9. Surgery Pros and Cons
      • Diagnosis and Treatment
      • Prolonged therapeutic effect
      • Fecundity Improvement
      • (EndoCAN)
      • Risk of injury to organs
      • Greater adhesions
      • Limited resources
      • Limited expertise
      • Negative Laparoscopy
      • Advantages
      • Disadvantages
    • 10. Macroscopic appearance of endometriosis black, red, vesicular POD obliteration Marked distorted anatomy Endometriotic cysts Adhesions Bowel endometriosis
    • 11. Additional Limitations of Surgery
      • Missed lesions: false negative laparoscopy
      • Required Expertise –
        • Most grads not comfortable with advanced
        • and many basic endoscopic techniques
        • Ob/Gyn Endoscopy Survey, Raymond,Ternamian,Leyland JMIG 2004
    • 12. SURGICAL OPTIONS: EXCISION OR ABLATION? For Endometriosis
    • 13. Surgical Options: Excision vs. Ablation
      • Excision
        • Multiple energy modalities (Laser, Scissors, Harmonic)
      • Ablation
        • Laser, electrosurgery
    • 14. Surgical Options: “to cut or not to cut”
      • Histologic diagnosis
      • Greater depth of treatment
      • Requires greater skill
      • Injury to adjacent organs
      • Faster
      • Less skill required
      • Unable to determine full extent
      • Thermal damage risk
      • Excision
      • Ablation
    • 15. DOES SURGERY HELP? Endometriosis Related Pain
    • 16. Does Surgery Help Pain?
      • Sutton et al Fertil Steril 1994 (n=63)
        • Laser ablation + LUNA improves pain at 6 months versus expectant management (63 vs. 23%)
        • At 73 months, 55% of follow up (n=38) pain free (JSLS 2001)
      • Abbot J et al. Fertil Steril 2004 (n=39)
        • Lap excision improved pain at 6 months compared with diagnostic laparoscopy (80% vs. 32 %)
    • 17. Does Surgery Help Pain?
      • Cochrane Library:
      • “ Laparoscopic surgery reduces pelvic pain caused by endometriosis”
      Laparoscopic surgery for pelvic pain associated with endometriosis (Cochrane Review 2008) Jacobson TZ, Barlow DH, Garry R, Koninckx P
    • 18. Ablation versus Excision
      • Limited evidence*
      • Wright et al JMIG 2005 (n=24)
        • Mild disease, 6 month follow up
        • ALL lesions treated
        • Equally effective BUT did not include
          • Deeply infiltrating disease
      • Both likely effective to some degree for MILD disease but more involved disease requires wide excision for pain relief
      • *Consensus statement for the management of chronic pelvic pain and endometriosis: proceedings of an expert-panel consensus process
      • Chronic Pelvic Pain/Endometriosis Working Group, GAMBONE et al.
    • 19. Additional Surgical Skills for Advanced Endometriosis Surgery
      • Ureterolysis
      • Appendectomy
      • Suturing
      • Bowel lesions
      • Cystoscopy
      • Rigid Sigmoidscopy
    • 20. Deeply infiltrating endometriosis
      • May be responsible for “failed surgical treatment”
      • Identification is difficult
        • Deep Dyspaurenia
        • Rectovaginal exam
        • Rectal Ultrasound
        • MRI
    • 21. Deep Versus Superficial Endometriosis: What do you see?
    • 22. Ovarian Endometriomas
    • 23. Ovarian Endometriomas
      • Laparoscopic ovarian cystectomy
          • confirm the diagnosis histologically
          • reduces risk of recurrence over fulguration
          • reduce the risk of infection at IVF
          • Improves access to follicles and possibly improve ovarian response
          • May impair ovarian reserve
    • 24. Endometriomas
      • Tissue specimen
      • Decrease recurrence
      • Post op adhesions
      • Risk of decreasing number of follicles
        • (Ragni et al AmJOG 2004)
      • Simpler technique
      • ? Preserve greater ovarian tissue
      • Risk of Recurrence
      • Excision
      • Fulguration
    • 25. Endometriomas
      • Excision versus Fulguration
        • Recurrence of pain (19 mos vs. 9.5 mos)
          • Berretta et al Fertil Steril 1998
        • Recurrence of symtoms at 2 years(15.8% vs. 56.7%)
        • Re-operation rate (5.8% vs. 22.9%)
          • Alborzi et al. Fertil Steril 2004
      • Overall: EXCISION OF CYST preferable for PAIN
    • 26. Ablation versus Excision of Cysts
          • Cochrane Review 2008:
          • Authors' Conclusions: There is good evidence that excisional surgery for endometriomata provides for a more favourable outcome than drainage and ablation with regard to the recurrence of the endometrioma, recurrence of pain symptoms, and in women who were previously subfertile, subsequent spontaneous pregnancy rates
          • Caveat: ART
      • Excisional surgery versus ablative surgery for ovarian endometriomata R J Hart, et al The Cochrane Library 2008
    • 27. ADJUNCTIVE SURGICAL TECHNIQUES
    • 28. Additional Surgical Options
        • 1.-Adhesion Prevention
      • 2.- Presacral Neurectomy Significant benefit in select cases but duration unknown ( Zullo , Am J Obstet Gynecol, 2003)
      • 3.- Appendectomy
        • Up to 20% diseased in endometriosis/pain patients
    • 29. Appendectomy: “The Hockey Stick” Sign
    • 30. Adhesions:
      • Despite even the best surgical techniques, post-surgical adhesions form in the majority of patients undergoing gynecologic pelvic surgery
      • Adhesions following some gynecologic surgery are a major cause of post-operative pelvic pain, infertility, bowel obstruction and the need for repeat surgery .
      • Adhesion barriers are a method of enhancing good surgical technique in reducing post-surgical adhesions
    • 31. Arrhythmia Management Arrhythmia Management **Circulatory_Disease_Management** **Circulatory_Disease_Management** General Surgery General Surgery **Laboratory_Medicine** **Laboratory_Medicine** Neurosurgery Neurosurgery Nursing Nursing **Ob_Gyn** **Ob_Gyn** Orthopaedics Orthopaedics                                                 HOME    REGISTER    LOGIN    HELP    PRIVACY POLICY                             Advanced Search     Product Information        Professional Resources        Product Ordering        Contact Us                                                More Information GYNECARE INTERCEED (TC7) Absorbable Adhesion Barrier Essential Product Information     GYNECARE INTERCEED (TC7) Absorbable Adhesion Barrier Clinical Information     Clinical Bibliography     Incidence of Post-Surgical Adhesions Features and Benefits     Proven Effective and Safe Order Information     Order GYNECARE INTERCEED (TC7) Absorbable Adhesion Barrier Company Home Page     ETHICON Women's Health & Urology, a division of ETHICON, INC. Related Product Information     GYNECARE INTERCEED (TC7) Absorbable Adhesion Barrier                                                                                                                                                                                                                                                                        Post-surgical Adhesions—A common & costly outcome                                                                                                                                                      Despite even the best surgical techniques, post-surgical adhesions form in the majority of patients undergoing gynecologic pelvic surgery          Adhesions following some gynecologic surgery are a major cause of post-operative pelvic pain, infertility, bowel obstruction and the need for repeat surgery 6          It is impossible to predict who will develop adhesions or where they will occur          In addition to the emotional cost to the patient, post-surgical adhesions cost the U.S. healthcare system $1.6 billion annually 7          Adhesion barriers are a proven method of enhancing good surgical technique in reducing post-surgical adhesions        *Trademark ©ETHICON, INC. 2007 All contents copyright © Johnson & Johnson Gateway, LLC 2000-2009 unless otherwise noted. This site was written for U.S. healthcare professionals only. Click here for our Privacy Policy and Legal Notice . If you have chosen this country and/or language view in error and need to return to the main menu click here . Capitalized product names are trademarks of Johnson & Johnson or its affiliated companies. Prescription products or in vitro diagnostics only unless otherwise noted in our non-prescription product list .  
    • 32. Interceed:
      • Years of proven efficacy in a wide variety of procedures:
      • Adhesiolysis Myomectomy Ovarian Surgery Tubal Surgery Surgical Treatment for Endometriosis
      • Excellent safety profile Over 10 years of clinical experience
    • 33.  
    • 34.  
    • 35.  
    • 36.  
    • 37.  
    • 38. TAKE HOME MESSAGES
    • 39. Take Home Messages:
      • Ideal practice: diagnose and remove endometriosis surgically at same time
      • Laparoscopic excision and ablation of endometriosis provides pain relief
      • Pain can be reduced by removing the entire lesions in severe and deeply infiltrating disease
      • Role for adjunctive procedures is evidence beased
      • Adhesion barriers have a role
    • 40. Take Home Messages
      • Consider Adjunctive Surgical Procedures:
        • Presacral Neurectomy
        • Appendectomy
        • Adhesiolysis and Adhesion Prevention
    • 41. Approach to Managing Endometriosis:
      • Available expertise
      • Accurate diagnosis
      • Surgical skills
        • Anatomy knowledge
        • Dissection skills
        • Knowledge of energy
        • Suturing skills
      • Specialized team
      • Multi-disciplinary approach
        • Nurse educator
        • Family physician
        • Bowel surgeon
        • Urologist
        • Pain Specialists
    • 42. Surgical Approach: Objectives
      • Is Surgery Even Necessary: Indications
      • What to do: Burn or Cut?
      • Special Situations:
        • Endometriomas
        • Deep Infiltrating Endometriosis
      • Adjunctive Surgical Techniques
    • 43. THANK YOU!
    • 44.  

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