Predictors of complications for laparoscopic treatment of endometriosis

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Postoperative complications from laparoscopic treatment for suspected endometriosis could not be predicted by preoperative patient characteristics or surgical findings of advanced endometriosis, according to a retrospective cohort study.

However, the study in Acta Obstetricia et Gynecologica Scandinavica did find that adhesiolysis, ureterolysis and an increased number of total procedures were predictive of perioperative complications.

“Laparoscopic treatment of endometriosis is highly variable, depending on the goals of the patient, the extent of disease and the skills of the surgeon,” said principal investigator Nisse Clark, MD, MPH, a minimally invasive gynecologic surgeon at Massachusetts General Hospital in Boston. “For instance, a simple procedure may only require a laparoscopic survey and a peritoneal biopsy, whereas a more complex procedure may entail a radical excision of all deep-infiltrating lesions, paralleling an oncologic debulk.”

Dr. Clark pointed out that it would be helpful to understand what factors increase surgical complexity and increase a patient’s risk of a complication. “We undertook this study in hopes of identifying preoperative or intraoperative factors that would predict a complication,” she told Contemporary OB/GYN.

Methods
The cohort of 397 women underwent laparoscopic treatment of suspected endometriosis at Brigham and Women’s Hospital in Boston between 2009 and 2016. Predictors of major perioperative complications were assessed by comparing the characteristics of women who had any major intraoperative or postoperative complications to women who had no complications.

The procedures were excision of superficial endometriosis (55.4% of women), excision of deep‐infiltrating endometriosis (24.9%), fulguration of endometriosis (38.3%), hysterectomy (23.2%), ovarian cystectomy (35.5%), salpingectomy (18.6%), oophorectomy (15.1%) and bowel resection (1.0%). The women, many of whom had multiple procedures, were followed for 60 days following each surgery, during which time 4.5% (n = 18) developed a major perioperative complication.

Findings
Women with advanced endometriosis (defined as stage III or IV endometriosis, rectovaginal endometriosis or deep-infiltrating endometriosis) were more likely to have a complication, though not a statistical significant difference. In total, 77.8% of women with a complication versus 56.7% of women without a complication had advanced endometriosis (P = 0.077).

On the other hand, women with a complication were significantly more likely to have undergone adhesiolysis or ureterolysis: 88.9% with a complication versus 52.5% without a complication for adhesiolysis (P = 0.002) and 61.1% of women with a complication versus 28.8% without a complication for ureterolysis (P = 0.003). The total number of procedures was also greater for women who had a complication: 4.3 vs. 3.2 (P = 0.003). All other procedure characteristics were comparable between women with and without complications.

Conclusions
“We were surprised to find that advanced endometriosis did not increase the risk of a complication with statistical significance,” Dr. Clark said. “Instead, we found that certain intraoperative procedures, such as ureterolysis and adhesiolysis, and the total number of procedures performed increased the risk of a complication.”

These procedural factors are surrogates for surgical complexity that more reliably predict complications than disease classification, according to the study. “Our study suggests that intraoperative events are the main driver of postoperative surgical outcomes,” Dr. Clark said. “One could conclude, therefore, that patients who undergo extensive laparoscopic dissection are most at risk of a complication, and thus surgeons should have heightened awareness for potential complications during or after surgery in these women.”

However, because the study did not find any preoperative patient characteristics that predicted a complication, “this limits the ability to apply these findings to patient counseling prior to surgery,” she said.

Future improvements in radiologic imaging, like assessment for deep-infiltrating disease with pelvic ultrasound and magnetic resonance imaging (MRI), “will hopefully improve our ability to identify patients at risk of requiring significant dissection and its associated risks,” he said.

Disclosures:

Dr. Clark reports no relevant financial disclosures.