Laparoscopic helium plasma coagulation for the treatment of endometriosis

Evidence-based recommendations on laparoscopic helium plasma coagulation for the treatment of endometriosis. This involves a minimally invasive procedure used to vaporise endometrial deposits.

# Guidance
This guidance replaces the previous guidance on laparoscopic helium plasma coagulation for the treatment of endometriosis (Interventional Procedures Guidance no. 54, March 2004).
Current evidence suggests there are no major safety concerns associated with laparoscopic helium plasma coagulation for the treatment of endometriosis. However, evidence on efficacy does not appear adequate for this procedure to be used without special arrangements for consent and for audit or research.
Clinicians wishing to undertake laparoscopic helium plasma coagulation for the treatment of endometriosis should take the following actions.
Inform the clinical governance leads in their Trusts.
Ensure that patients understand the uncertainty about the efficacy of the procedure and provide them with clear written information. In addition, use of NICE's information for the public is recommended.
Audit and review clinical outcomes of all women undergoing laparoscopic helium plasma coagulation for the treatment of endometriosis.
Clinicians undertaking this procedure should have adequate training before performing the technique. The British Society for Gynaecological Endoscopy has produced standards for training.
Publication of randomised controlled trials on the efficacy of this procedure will be useful. The Institute may review the procedure upon publication of further evidence.# The procedure

# Indications
Women with endometriosis have deposits of endometrial tissue (which is normally confined to the lining of the uterus) outside the uterus. Many women are asymptomatic, but others may experience pelvic pain, dyspareunia, dysmenorrhoea or infertility.
In most women, endometriosis can be treated with analgesics and hormones. Women whose endometriosis does not respond may be offered minimally invasive surgery to excise or destroy the endometrial deposits, most commonly by electrocautery or laser through a laparoscope. Women with very severe symptoms may be offered more radical treatment involving hysterectomy and removal of the ovaries.

# Outline of the procedure
Laparoscopic helium plasma coagulation of endometriosis is a minimally invasive procedure used to vaporise endometrial deposits. A laparoscope is used to direct an ionised beam of helium gas at endometrial deposits to destroy them.

# Efficacy
The method of evaluating symptoms following the procedure varied between studies, making comparison difficult. Across three series, symptomatic relief was achieved in 49% (39/79), 72% (179/250) and 81% (17/21) of women at 3 months' follow-up. In another case series, continuing symptoms were reported in 38% (5/13) of women at 14 months' follow-up.
Only 1 case series of 50 women, which included 9 women who presented with infertility and 15 who were both symptomatic and infertile, reported fertility outcomes: 44% (4/9) of the solely infertile group and 20% (3/15) of the women who were also symptomatic had conceived within 6 months of the procedure.
In 1 case series, none of the 250 procedures had to be converted to open surgery, and there were no re-admissions after 3 months, whereas a repeat procedure was required in 16% (5/31) of women in another case series, in which the mean period to return to normal daily activities was 12 days. There was no long-term follow-up of women beyond 6 months in published case series. For more details, refer to the sources of evidence section.
The Specialist Advisors noted that the procedure may cause less lateral burning than the diathermy technique, and may allow women to be treated on a day-case basis.

# Safety
Three series recorded no side effects or complications related to the procedure in a total of 130 women. After 3 months' follow-up of 250 cases, 1 case series reported no major postoperative complications and no surgical complications. For more details, refer to the sources of evidence section.
The Specialist Advisors noted that theoretical adverse events include damage to normal tissue (as seen when other energy sources are used), bowel injury, haemorrhage, infection and, potentially, helium embolisation.# Further information

# Sources of evidence
The evidence considered by the interventional procedures advisory committee is described in the interventional procedure overview of laparoscopic helium plasma coagulation of endometriosis.

# Information for patients
NICE has produced information for patients and carers on this procedure. It explains the nature of the procedure and the guidance issued by NICE, and has been written with patient consent in mind.