Our Recent Question Contest ~ Answer to Lynne Bruton : Can deep infilterating endo in the ovaries be removed? Can diaphragm endo be removed? The simple answer is “yes”. Deep endometriosis of the ovaries presents as endometrioma cysts, also referred to as “chocolate cysts” owing to the chocolate-like appearance of the fluid contained within (it is in fact hemosiderin or old blood). Endometriomas can be excised just like other areas of deep disease can be excised. The process of excising an endometrioma consists of first creating a window cyst wall (cyst wall fenestration), draining the content and then carefully stripping the cyst wall from the surrounding ovarian tissue, while minimizing damage to the ovary (cystectomy). If bleeding occurs during this process then coagulation is used to control it. Some endometriomas peel out easier than others. Complete excision of the endometrioma is the procedure with the lowest recurrence rate (other techniques to treat endometriomas carry a greater risk of recurrence and in turn a greater likelihood of reoperation further down the line). The ovaries have been found to be the site in the pelvis with the highest rate of recurrence following excision surgery. This could be because in some cases small focal areas of disease may be harbored deep within the ovarian tissue and therefore undetectable during surgery and only later do these foci develop into detectable endometriomas. Several studies have been conducted into the benefits of post-operative hormone therapy to reduce the risk of recurrence of ovarian endometriomas but the results have been mixed and it is unclear whether ovarian suppression really offers any benefit in this regard. Fortunately, most patients who have their endometrioms excised do not experience recurrence. Sometimes, if a patient has an extremely large endometrioma (>10cm) it may be impossible to excise it without compromising the ovary. After excision, insufficient healthy ovarian tissue may be left over to reconstruct the ovary and it may be best to simply remove that ovary. This is a rare situation, however, given most endometriomas do not exceed 5cm in diameter and very few exceed 10cm. Another situation where excision of an endometrioma may be futile is when the patient’s ovarian reserve is already very low and the ovary is no longer functioning. This could be due to the patient’s age (there is a natural decline in ovarian reserve with age) or damage from previous ovarian surgery. In such situations, a decision should be made as to whether to perform conservative excision (removing the cyst but not the ovary) or rather whether radical surgery (removing the ovary) is the best option in providing ongoing relief and reducing need for more surgery in the patient’s future. As you can see, decisions need to be tailored to the individual patient’s circumstances and wishes. As for the diaphragm, endometriosis of the diaphragm can be superficial or invasive. If the disease is superficial, most surgeons will opt to treat it by laser vaporization, to carefully vaporize the diseased tissue layer by layer. Thoughts on this vary, however, and some surgeons excise diaphragmatic disease regardless of how invasive it is. If disease is invasive, in which case it will typically involve the full-thickness of the diaphragm (the diaphragm is not very thick) then excision is ideal as it enables the surgeon to safely remove the affected area of diaphragm without damaging the lung. The hole that is created during excision is then suture repaired. Clinical studies show that diaphragmatic disease can be successfully and safely removed with good outcomes. If you suspect diaphragmatic disease, the key is finding a surgeon who will fully visualize the diaphragm, including the space behind the liver and, if disease is found, has the confidence and skill to then remove it. Failure to visualize the entirety of the diaphragm can result in disease in this area being missed and incompletely treated. Sometimes it is necessary to introduce an extra surgical port just under the ribs on the right side in order to get a good view of the area of diaphragm that is usually obscured by the liver on that side. This is the area of diaphragm that is most commonly affected by diaphragmatic disease. Thanks for your question !
Posted on: Tue, 20 May 2014 03:36:05 +0000
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