Quality of life assessment in patients after surgical treatment for deep infiltrating endometriosis in the early postoperative period

Deep infiltrative endometriosis (DIE) is known to be the most severe form of endometriosis. DIE causes significant loss in the patients’ quality of life due to the pain syndrome, infertility and excessive menstrual bleeding until the disablement [1]. The most effective method of serious forms of endometriosis treatment is a surgical removal of the focus of the disease [2]. In this case the most preferable way of treatment is laparoscopy performed by a multidisciplinary team and followed by a non-recurrent therapy. The main drawback of this method is a high frequency of surgical complications; the need for a prolonged rehabilitation [3] results in a significant increase of the therapy cost [4]. The implication of the rapid post-surgical recovery protocols is considered to be the most beneficial way to reduce complications and boost the efficiency of a surgical intervention. These protocols sum up the collection of multidisciplinary methods performed during a perioperative period in order to accelerate the recovery, bring down the frequency of the complications, minimize the period of the inpatient stay without any rehospitalizations and reduce the costs without affecting the patient’s safety [5]. Despite a large number of the global empirical data on the possibility of an early hospital discharge, there is still no general consensus about the criteria for the discharge. Typically, the possibility for the hospital discharge depends fully on the doctor’s personal opinion, which on the one hand may result in an unreasonably early discharge, and on the other hand – in an improperly long inpatient stay. The development of a personified approach to making a decision on the most preferable period for the hospital discharge, based on the certain objective criteria will enable us to optimize the period of the inpatient stay. One of the ways to elaborate this approach is the quality of life assessment which may be applied in the early postoperative period [6].

Materials and Methods

The investigation enrolled data on 62 women with deep infiltrating endometriosis who had been operated on for deep infiltrative endometriosis at the Surgery Department, V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology, in 2017 and 2018. The patients were divided into three groups according to the length of hospital stay: group 1 (n=12) consisted of the patients, who stayed in hospital during the postoperative period less than 4 days, group 2 (n=40) – from 5 to 7 days, group 3 (n=10) – more than 7 days. QoL was assessed in the patients during their stay in hospital using a modified QoL questionnaire for surgical patients during 6–8 hours after surgery and on days 1, 3, 5 and 7 after surgery. The day before surgery the patients were given the QoL questionnaire, as well as oral and written instructions on how to fill in the questionnaire form. The patients filled in the blank sheets all by themselves and then gave them back to the researcher on the day of their hospital discharge. The questionnaire form completion took no more than 5 minutes a day and was easy for the patients. The following questionnaire survey was not conducted after the hospital discharge. The estimation of the questionnaire total results was performed by summing up the answer points for each multiple answer questions.

Results

Each patient underwent a laparoscopic removal of endometriosis foci. The volume of the operative intervention depended on the spread of endometriosis and included retrocervical endometriosis and sacrouterine ligaments ablation together with ureterolysis, shaving and a large bowel resection, vaginal resection, bladder and ovarian resection. The average postoperative length of stay in Group 1 was 3.9 days, in Group 2 – 5.8 days, in Group 3 – 8.8 days. The average age of the patients included in Group 1 was 38.6 years, in Group 2 – 34.6 years, in Group 3 – 29.8 years. The average length of operation was minimal in Group 1 and it took 59 minutes, maximum – in Group 3 (197 minutes). The average length of operation in Group 2 comprised 135.2 minutes. By the same token, the average intraoperative blood loss was minimal in patients from Group 1 (88 ml) in comparison with Groups 2 and 3 (153.1 ml and 240 ml, respectively). Two cases of abnormality during the postoperative period, that did not require any surgical treatment, were identified in Group 3.

The overall early postoperative QoL score are demonstrated in Figure 1.

On the basis of the analysis of Figure 1 we may conclude that the overall early postoperative QoL score is increasing, starting from 53.3 points in Group 1, 54.2 – in Group 2 and 59.5 – in Group 3 during the first 6-8 hours after surgery, reaching 75 to 80 points on the day of the hospital discharge. However, patients of Group 1 achieved this result by the 3rd day of the postoperative period, whereas the patients from Groups 2 and 3 – by the 5th and 7th day, respectively.

Analysis of the physical component of the QoL demonstrated the same trend in the early postoperative period. The patients from Group 1 reached 35 out of 40 points by the 2nd day of the postoperative period, whereas the patients from Groups 2 and 3 achieved the same results only by the 5th day. The time course of changes in the social component of QoL and the overall assessment of one’s health could not allow us to reveal significant trends and patterns. The value of the emotional component throughout the postoperative period increased in all the groups starting from 10.5 and 11.3 during the first 6–8 hours after surgery and reaching 13.6 and 12.0 on the day of discharge in Groups 1 and 2, respectively; Group 3 demonstrated the greatest change in the value of the emotional component over time, starting from 10.5 during the first 6-8 hours after surgery and reaching 11.92 by the 7th day of the stay.

Overall assessment of one’s health was growing during the whole postoperative period. However, the decline of this indicator was noticed on the 2nd day of the inpatient stay in all the groups.

Conclusion

The length of the postoperative period in this research study is in direct proportion to the length of the surgery and intraoperative blood loss, whereas it is in inverse proportion to the age of the patients. The modified early postoperative QoL questionnaire can be used in patients after surgical treatment for DIE. It is an effective method to assess the patient’s state and is easy to fill in as well. The physical component is of the greatest importance in assessing QoL in the early postoperative period, due to which there is a need to improve this questionnaire in order to exclude any meaningless questions. The QoL assessment during the first 6-8 hours after surgery may be significant for the prediction of the period of an early rehabilitation. A systemic QoL assessment used in the postoperative period can become the basis for discharge decision-making. Reaching more than 75 points may be assessed as the criterion for the hospital discharge.