The above link will take you to a very important study. For those of us providing excision surgery, we have known this for a long time. Most published studies on pain only have a follow up period of 6 mos to 1 year with occasional studies looking at 18 mos to 2 years. For the shorter duration studies, the pain relief is better with even ablation surgery, but in the longer follow up periods, the general consensus is the pain returns nearly to baseline with ablation. This is why there have been so many drug studies, and now a loss of interest in surgical treatment for endometriosis. This and the few other studies out there that support long term improvement (seven years in this case) with the proper excisional surgical technique are critically important for the evolution of thought treatment of endometriosis. This study is very exciting and hopefully will advance the treatment process for endometriosis. This on the heels of the FDA’s approval of “oral lupron” therapies, e.g. Egalix, which sets the stage to thrust us back into the late 1980’s era of thinking and will doom many women to a long miserable struggle with endometriosis. This, just as lupron was fading away as a common treatment for endometriosis.
With excision on the rise and becoming more popular, there are many doctors who label their surgery as excision, yet either don’t treat disease in “critical areas” or use ablation there. As popularity increases, more surgeons will be trying to get into this area but without proper instruction, may not be pursuing a complete excisional approach. Patients should proceed with caution. Also, many don’t realize that there are two schools of thought in excision surgery: Individual spot excision vs regional or segmental excision. We believe that the more comprehensive segmental excision is much preferred due to the inclusion of microscopic disease in the resection with this technique. In this technique the pelvis is divided into 4 quadrants: anterior cul de sac, posterior cul de sac, and both right and left ovarian fossa areas. If there is any disease or hint of disease in a quadrant, that entire quadrant is removed. These areas represent the most common sites of endo. Additionally, in teenagers and early twenties patients, where endometriosis is very subtle, we pursue a 4 quadrant resection with the finding of any disease anywhere in the pelvis. Based on the slow progression to more visible lesions, we would assume that there is a great deal of microscopic endometriosis in these young patients.
Michael D. Fox, MD