Radical resection of invasive endometriosis with bowel or bladder involvement—Long-term results

Laparoscopic colorectal resections with transvaginal specimen extraction for severe endometriosis

INTRODUCTION

Bowel resection is now considered the "gold standard" treatment for severe endometriosis infiltrating the bowel. Laparoscopic colorectal resection can be considered a safe option in order to reduce surgical trauma and complications as well as to improve cosmetics. Transvaginal approach, used for several years to remove large specimens, can be an interesting approach also in case of colorectal resections.

AIM OF THE STUDY

To present our experience on laparoscopic colorectal resection and transvaginal specimen extraction as treatment of severe endometriosis.

RESULTS

Eleven patients (mean age 45+/-12 years) have been operated by a combined team of gynecologist and colorectal surgeons. There were no intra- or post-operative complications. In all cases, the transvaginal route was used to remove the specimen and prepare the bowel for anastomosis. Patients were allowed to free light diet on post-operative day 3+/-1 and discharged on day 5+/-2. The mean follow-up was 4+/-2 months and all patients are well with normal bowel function and symptoms free.

CONCLUSIONS

Our preliminary experience demonstrates such approach is safe and feasible with excellent results in term of post-operative course.

Targeting mast cells in endometriosis with janus kinase 3 inhibitor, JANEX-1

Endometriosis (EMS) is a chronic inflammatory disease of multifactorial etiology characterized by implantation and growth of endometrial glands and stroma outside the uterine cavity. EMS is a significant public health issue as it affects 15-20% of women in their reproductive age. Clinical symptoms may include pelvic pain, dysmenorrhea, dyspareunia, pelvic/abdominal masses, and infertility. Symptomatic treatments such as surgical resection and/or hormonal suppression of ovarian function and analgesics are not as effective as desired. Consequently, there is an enormous unmet need to develop effective medical therapy capable of preventing the occurrence and recurrence of EMS without undesirable side-effects. EMS-associated intra-abdominal bleeding episodes, local inflammation, adhesions, and i.p. immunologic dysfunction leads to pelvic nociception and pelvic pain. Increasing evidence supports the involvement of allergic-type inflammation in EMS. Invasion of mast cells, degranulation, and proliferation of interstitial component are observed in endometriotic lesions. Presence of activated and degranulating mast cells within the nerve structures can contribute to the development of pain and hyperalgesia by direct effects on primary nociceptive neurons. Therefore, treatments targeting endometrial mast cells may prove effective in preventing or alleviating EMS-associated symptoms. The Janus kinase 3 (JAK3) is abundantly expressed in mast cells and is required for the full expression of high-affinity IgE receptor-mediated mast cell inflammatory sequelae. JANEX-1/WHI-P131 is a rationally designed novel JAK3 inhibitor with potent anti-inflammatory activity in several cellular and in vivo animal models of inflammation, including mouse models of peritonitis, colitis, cellulitis, sunburn, and airway inflammation with favorable toxicity and pharmacokinetic profile. We hypothesize that JAK3 inhibitors, especially JANEX-1, may prove useful to prevent or alleviate the symptoms of EMS.

Laparoscopic treatment of deep endometriosis with segmental colorectal resection: short-term morbidity

STUDY OBJECTIVE

Adequate surgical treatment of severe deep endometriosis requires complete excision of all implants, but the modality of bowel resection is still debated. We describe the results of our experience as a tertiary care endometriosis referral center in complete laparoscopic management of deep pelvic endometriosis with bowel involvement.

DESIGN

A prospective single-center study (Canadian Task Force classification II-1).

SETTING

In Sacro Cuore General Hospital of Negrar, Italy.

PATIENTS

One hundred ninety-two women treated with laparoscopic excision of deep endometriosis and segmental colorectal resections were evaluated.

INTERVENTION

From January 2003 through December 2005 we registered all consecutive patients laparoscopically treated for deep endometriosis who also were having segmental bowel resection.

MEASUREMENTS AND MAIN RESULTS

Data analysis included age, weight, body mass index, history of endometriosis, preoperative symptoms, parity, infertility, operative procedures, operating time, conversion, intraoperative and postoperative morbidity, recovery of bladder and bowel function, and discharge from hospital. We report our results in terms of feasibility and short-term morbidity. Radicality was achieved in 91.5% of patients. Laparoconversion occurred in 5 cases (2.6%). Major complications that required repeat operation occurred in 20 cases (10.4%): Nine anastomosis leakages (4.7%), 3 uroperitoneum (1.6%), 4 hemoperitoneum (2.1%), 1 pelvic abscess (0.5%), 1 bowel perforation, 1 intestinal obstruction, and 1 sepsis. Minor complications occurred in 50 patients (26%).

CONCLUSION

Laparoscopic segmental colorectal resection for endometriosis is feasible and, in hospitals with necessary experience, can be proposed to selected patients who are informed of the risk of complications.

RECTAL ENDOMETRIOSIS: RESULTS OF RADICAL EXCISION AND REVIEW OF PUBLISHED WORK

BACKGROUND

The aim of this paper is to review the results of surgical excision of rectal endometriosis and review the published work on this challenging condition.

METHODS

All cases of endometriosis involving the rectum treated by a single colorectal surgeon were identified from a prospective database and the results reviewed.

RESULTS

Between 1995 and 2005, 213 rectal procedures were carried out on 203 patients together with an endogynaecologist. Eighteen cases involved dissection of endometriosis off the rectal wall, 58 involved full-thickness excision of the anterior rectal wall and 137 segmental excisions of the rectum were carried out. A loop ileostomy was required in 7 (5%) of the segmental resections. Seventy-five per cent of the cases were either laparoscopic or laparoscopically assisted. Infertility was significantly more common in the group requiring a segmental resection (P=0.026) and a history of rectal pain during defecation more common in patients having dissection of endometriosis off the rectal wall (P=0.031). There were no other significant differences between the different types of rectal surgery. The morbidity for all rectal procedures was 7% and there was one anastomotic leak in the segmental resection group. The actuarial rectal recurrence rate of endometriosis was 22.2% 95% confidence interval (CI) (2.5, 42.0) for dissection off the rectal wall and this was significantly different from the recurrence of 5.17% 95%CI (0.0, 10.9) for anterior rectal wall excision and 2.19% 95%CI (0.0, 4.6) for segmental rectal resection (P=0.007). The overall rectal recurrence for all cases was 4.69% 95%CI (1.8, 7.5).

CONCLUSION

Endometriosis of the rectum can be successfully treated with low morbidity and low recurrence rates by excising the disease as completely as possible using full-thickness excision of the anterior rectal wall or segmental resection of the rectum.

[Ileal perforation secondary to intestinal endometriosis]

Endometriosis is defined as the presence of endometrial tissue outside the uterus. The bowel is not often affected. There are no specific clinical findings for intestinal endometriosis. It is typically asymptomatic, but sometimes can present with abdominal pain, diarrhoea, constipation or intestinal obstruction. Ileal perforation is a rare complication of intestinal endometriosis and only a few cases have been reported in the literature. Intestinal endometriosis can mimic many gastrointestinal diseases, such as irritable bowel syndrome, inflammatory bowel disease, infections and neoplasms. The diagnosis is made by laparoscopy or laparotomy. We present a case of a woman with intermittent abdominal pain and ileal perforation secondary to intestinal endometriosis.

Laparoscopic resection of intestinal endometriosis: A 5-year experience

STUDY OBJECTIVE

To describe the clinical manifestations, surgical techniques, and complications observed in patients undergoing laparoscopic resection of intestinal deeply infiltrating endometriosis (DIE).

DESIGN

Prospective nonrandomized (Canadian Task Force Classification II-3).

SETTING

University hospital and private practice.

PATIENTS

We evaluated 125 patients with intestinal DIE treated from February 2000 through September 2005.

INTERVENTIONS

Laparoscopic radical excision of DIE followed by resection of the rectosigmoid colon.

MEASUREMENTS AND MAIN RESULTS

The clinical examination of our patients demonstrated that 66.4% of patients had tenderness, whereas 80.8% had nodules on the pouch of Douglas. In 95.2% we observed pain caused by cervical mobilization, and all the patients had pain during the pouch of Douglas mobilization. Regarding bowel infiltration, preoperative investigation with rectal endoscopic ultrasonography was positive in all cases. Endoscopic rectal ultrasonography demonstrated the depth of intestinal infiltration. Superficial lesions were observed in 9.6% of patients and muscularis involvement in 71.2%. The segmental resection was performed in most of the patients (92%) and the linear resection in 6.4% of them. Median surgical time was 110 minutes, and the median hospital stay was 7 days after the surgery; the patients continued fasting for 3 to 7 days. The return to normal activity was achieved in a median 15 days after the surgery. The surgical procedure and the postoperative follow-up demonstrated no complications in 90.4% of the patients. Minor complications were observed in 4% of the cases. Major complications occurred in 5.6% of the patients, including 2 cases of intestinal fistulas (1.6%) and 3 cases of long-lasting urinary retention (2.4%).

CONCLUSION

Clinical symptoms of patients with intestinal endometriosis are not specific. Operative laparoscopy is a safe and effective method to treat intestinal endometriosis. To avoid major complications, special attention must be paid to the intestinal anastomosis and to the nerve preservation.

Clinical Aspects and Surgical Treatment of Urinary Tract Endometriosis: Our Experience with 31 Cases

OBJECTIVES

To present and discuss clinical and surgical management of urologic endometriosis.

METHODS

Retrospective review of a database on surgical patients with endometriosis.

RESULTS

Thirty-one patients (incidence, 2.6%; mean age, 33.1 yr) were affected by urologic endometriosis (bladder, 12; ureter, 15; both, 4). Bladder endometriosis was revealed by symptoms related to menses and showed a typical endoscopic picture, whereas ureteral involvement had a nonspecific or silent symptomatology. All patients affected by bladder endometriosis and undergoing transurethral resection (2 cases) developed a bladder recurrence; a ureteral recurrence was observed in two of six patients submitted to laparoscopic ureterolysis and in one of two patients submitted to ureterectomy with ureteroureterostomy. Conversely, no relapses were observed among the 14 patients who had partial cystectomy or the 9 who had ureterectomy and ureterocystoneostomy. Finally, two patients underwent nephrectomy due to end-stage renal atrophy.

CONCLUSIONS

Cystoscopy is advisable in women with pelvic endometriosis with lower urinary tract symptoms; the upper urinary tract should be evaluated in all patients with pelvic endometriosis to exclude asymptomatic ureteral involvement. Partial cystectomy gives the best results when used to treat bladder endometriosis. Ureterolysis can be successful only in case of limited ureteral involvement with no urinary obstruction, whereas terminal ureterectomy and ureterocystoneostomy should be preferred in case of obstructive ureteral endometriosis.