Diagnosis and management of endometriosis of the colon and rectum

Preoperative Diagnosis of Intestinal Endometriosis by Magnifying Colonoscopy and Target Biopsy

Endometriosis can affect any portion of the gastrointestinal tract. A preoperative definitive diagnosis of intestinal endometriosis is difficult, because there is no characteristic endoscopic finding and the endoscopic biopsies usually sample insufficient endometrial tissue for pathologic diagnosis. To our knowledge, the magnifying endoscopic features of intestinal mucosal endometriosis have not been well documented. In this study, we report a case of intestinal endometriosis diagnosed preoperatively by magnifying image-enhanced colonoscopy and target biopsy. A 45-year-old woman was referred to our hospital with abdominal pain in the left lower quadrant. Colonoscopy showed a submucosal tumor-like lesion of approximately 30 mm in diameter exhibiting surface reddening and granular changes in the sigmoid colon. Magnifying endoscopy revealed sparsely distributed round pits in the granules. The mucosal biopsy specimen from the granule provided the diagnosis of intestinal endometriosis. Segmental sigmoidectomy was performed, and pathological examination revealed that the surface colonic mucosa was partially replaced by endometrial tissue, which accounted for the granular change detected in the colonoscopy. It can be speculated that the round pit might reflect the endometrial glands surrounded by endometrial stroma. This case illustrated the characteristic finding and utility of magnifying endoscopy for mucosal intestinal endometriosis.

Role of colonoscopy in the diagnostic work-up of bowel endometriosis

AIM: To evaluate the accuracy of colonoscopy for the prediction of intestinal involvement in deep pelvic endometriosis.

METHODS: This prospective observational study was performed between September 2011 and July 2014. Only women with both a clinical and imaging diagnosis of deep pelvic endometriosis were included. The study was approved by the local ethics committee and written informed consent was obtained in all cases. Both colonoscopy and laparoscopy were performed by expert surgeons with a high level of expertise with these techniques. Laparoscopy was performed within 4 wk of colonoscopic examination. All hypothetical colonoscopy findings (eccentric wall thickening with or without surface nodularities and polypoid lesions with or without surface nodularities of endometriosis) were compared with laparoscopic and histological findings. We calculated the sensitivity, specificity, positive predictive value and negative predictive value for the presence of colonoscopic findings of intestinal endometriosis.

RESULTS: A total of 174 consecutive women aged between 21-42 years with a diagnosis of deep pelvic endometriosis who underwent colonoscopy and surgical intervention were included in our analysis. In 76 of the women (43.6%), intestinal endometrial implants were found at surgery and histopathological examination. Specifically, 38 of the 76 lesions (50%) were characterized by the presence of serosal bowel nodules; 28 of the 76 lesions (36.8%) reached the muscularis layer; 8 of the 76 lesions (10.5%) reached the submucosa; and 2 of the 76 lesions (2.6%) reached the mucosa. Colonoscopic findings suggestive of intestinal endometriosis were detected in 7 of the 174 (4%) examinations. Colonoscopy failed to diagnose intestinal endometriosis in 70 of the 76 women (92.1%). A colonoscopic diagnosis of endometriosis was obtained in all cases of mucosal involvement, in 3 of 8 cases (37.5%) of submucosal involvement, in no cases of muscularis layer involvement and in 1 of 38 cases (2.6%) of serosa involvement. The sensitivity, specificity, positive predictive and negative predictive values of colonoscopy for the diagnosis of intestinal endometriosis were 7%, 98%, 85% and 58%, respectively.

CONCLUSION: Being an invasive procedure, colonoscopy should not be routinely performed in the diagnostic work-up of bowel endometriosis.

Rectal obstruction due to endometriosis: A case report and review of the Japanese literature

INTRODUCTION

Colorectal obstructive endometriosis is relatively rare in Japan and its differentiation from malignancy is often difficult. We report a case of rectal obstructive endometriosis.

PRESENTATION OF CASE

A 37-year-old woman was referred to our hospital with a suspected ileus. Her chief symptoms were left lower abdominal pain and vomiting. Colonoscopy showed an intraluminal mass of redness in the upper rectum. A proctectomy was performed because of the bowel obstruction. The rectum was filled with an intraluminal mass measuring 5cm×4cm, and endometriosis was diagnosed pathologically.

DISCUSSION

A preoperative diagnosis of colorectal obstructive endometriosis is often difficult because of the lack of definite diagnostic, clinical, sonographic, or radiological findings that are characteristic of this disease. Medical treatment is not always effective for colorectal obstructive endometriosis, and surgery is often performed.

CONCLUSION

Colorectal obstructive endometriosis should be considered as a differential diagnosis in cases of various gastrointestinal symptoms in women who are of reproductive age.

Clinical outcome after radical excision of moderate-severe endometriosis with or without bowel resection and reanastomosis: a prospective cohort study

OBJECTIVE

To assess the clinical outcome of women requiring laparoscopic excision of moderate-severe endometriosis in women with and without bowel resection and reanastomosis.

METHODS

Two hundred three patients with laparoscopically excised moderate (n = 67) or severe (n = 136) endometriosis (rAFS: revised endometriosis classification of the American Fertility Society) were prospectively followed during a median of 20 months (1-45 months) using a CONSORT-inspired checklist. Patients completed the EHP30 Quality-of-Life Questionnaire and visual analogue scales (VAS) for dysmenorrhea, chronic pelvic pain, and deep dyspareunia and answered questions about postoperative complications, reinterventions/recurrences, and fertility outcome 1 month before and 6, 12, 18, and 24 months after surgery. Clinical outcome was compared between women with deeply infiltrative endometriosis undergoing CO2 laser ablative surgery with bowel resection (study group, 76/203; 37%) and without bowel resection (control group, 127/203; 63%).

RESULTS

Both groups were similar with respect to population characteristics and clinical outcome, except for mean rAFS score [higher in study group (73 ± 31) than in control group (48 ± 26)] and minor complication rate [higher in study group (11%) than in control group (1%)]. In both groups, mean VAS and EHP30 scores improved significantly and remained stable for 24 months after surgery, with a pregnancy rate of 51%. Within 1, 2, and 3 years follow-up, the cumulative reintervention rate was 1%, 7%, and 10%, respectively, and the cumulative endometriosis recurrence rate was 1%, 6%, and 8%, respectively.

CONCLUSIONS

Clinical outcome after CO2 laser laparoscopic excision of moderate-severe endometriosis was comparable in women with or without bowel resection and reanastomosis, except for a higher minor complication rate occurring in women with bowel resection and reanastomosis (NCT00463398).

Effect of laparoscopic surgery for moderate and severe endometriosis on depression, relationship satisfaction and sexual functioning: comparison of patients with and without bowel resection

STUDY QUESTION

Is there a difference between women with endometriosis who underwent laparoscopic surgery with bowel resection or without bowel resection regarding depressive symptoms, relational adjustment and sexual functioning?

SUMMARY ANSWER

Radical surgery for endometriosis in both groups improved the levels of depression and sexual functioning, but only the bowel resection patients showed improvements in relationship satisfaction. WHAT IS KNOWN ALREADY?: The frequent pain symptoms in endometriosis patients can have an impact on psychological issues, relationships and sexual functioning. There are no data available on depression and relationship adjustment after endometriosis surgery. Sexual dysfunction problems have been described after bowel resection for rectal cancer, but no data are available for endometriosis surgery.

STUDY DESIGN, SIZE, DURATION

This prospective cohort study included 203 consecutive women operated at the Leuven University Fertility Center (LUFC) between 1 September 2006 and 30 September 2008 for moderate (n = 67) or severe (n = 136) endometriosis. The preoperative response rate was respectively 84% in the bowel resection group and 79% in the no bowel resection group.

PARTICIPANTS, SETTING, METHODS

The beck depression inventory (BDI) measured depression, the dyadic adjustment scale (DAS) measured relationship satisfaction and the short sexual functioning scale (SSFS) measured sexual functioning before and 6, 12 and 18 months after women had laparoscopic surgery at the LUFC, a tertiary referral centre for fertility exploration, treatment and surgery.

MAIN RESULTS AND THE ROLE OF CHANCE

Both groups had better post-operative outcomes when compared with the preoperative assessments. Mean BDI and DAS levels were comparable with the normal population. Overall assessment points, the bowel resection patients had better outcomes for DAS (P < 0.05) and SSFS 'arousal' (P < 0.05) than the no bowel resection patients. At 6 months after the operation, when compared with the no bowel resection group, the bowel resection group reported lower mean levels of BDI (P < 0.05), a lower incidence of SSFS 'pain during intercourse' and 'orgasm problems' (P < 0.05), and a lower proportion of patients with severe orgasm problems (P < 0.05). The data show that radical but fertility sparing surgery, with or without bowel resection, for the treatment of endometriosis results in comparable and good psychological outcomes concerning depression levels, relationship satisfaction and sexual functioning.

LIMITATIONS, REASONS FOR CAUTION

Although the initial response rate was good, response dropped over time and was significantly higher for bowel resection patients compared with the no bowel resection patients (P = 0.05). A responder/non-responder analysis for the whole study population showed no significant differences concerning pain problems. This reduces the possible risk of (positive) bias in the results.

WIDER IMPLICATIONS OF THE FINDINGS

Endometriosis is a complex condition and the focus should not be on a one-dimensional end-organ gynaecological outcome, but should take into account the role of psychological factors in pain-related outcome. To this end, more prospective data are needed on sexual functioning and psychological outcomes.

Clinical outcome after laparoscopic radical excision of endometriosis and laparoscopic segmental bowel resection

PURPOSE OF REVIEW

To present the clinical outcome after laparoscopic radical excision of deeply infiltrative endometriosis (DIE) with colorectal extension and laparoscopic segmental bowel resection.

RECENT FINDINGS

In three different studies including mostly patients with recurrent DIE with colorectal extension, we showed that radical reconstructive CO2 laser laparoscopic resection of DIE with colorectal extension in a multidisciplinary setting resulted in a low complication rate, a low cumulative reintervention and recurrence rate and a high cumulative pregnancy rate, also when bowel resection reanastomosis was performed. In a systematic review to assess the clinical outcome of surgical treatment of DIE with colorectal involvement, data were reported in such a way that comparison of different surgical techniques was not possible. A checklist is proposed to achieve standardized reporting of presenting symptoms, preoperative tests, inclusion criteria, preoperative and postoperative care, complications, follow-up, patient-centered assessment of pain and quality of life, fertility and recurrence corrected for postoperative use of hormonal suppression or infertility treatment.

SUMMARY

CO2 laser laparoscopic radical excision of DIE with colorectal extension and laparoscopic segmental bowel resection in centers of expertise is associated with good clinical outcome. To make real progress, international agreement is needed on terms and definitions used in surgical endometriosis research.

Transrectal ultrasound - Techniques and outcomes in the management of intestinal endometriosis

The widespread use of endoscopic ultrasound has facilitated the evaluation of subepithelial and surrounding lesions of the gastrointestinal tract. Deep pelvic endometriosis, with or without infiltration of the intestinal wall, is a frequent disease that can be observed in women in their fertile age. Patients of this disease may present nonspecific signs and symptoms or be completely asymptomatic. Laparoscopic surgical resection of endometriotic lesions is the treatment of choice in symptomatic patients. An accurate preoperative evaluation is indispensable for therapeutic decisions mainly in the suspicion of intestinal wall and/or urinary tract infiltration, and also in cases where we need to establish histological diagnosis or to rule out malignant disease. Diagnostic tools, including transrectal ultrasound, magnetic resonance image, transvaginal ultrasound, barium enema, and colonoscopy, play significant roles in determining the presence, depth, histology, and other relevant data about the extension of the disease. Diagnostic algorithm depends on the clinical presentation, the expertise of the medical team, and the technology available at each institution. This article reviews and discusses relevant clinical points in endometriosis, including techniques and outcomes of the study of the disease through transrectal ultrasound and fine-needle aspiration.

Clinical outcome after CO₂ laser laparoscopic radical excision of endometriosis with colorectal wall invasion combined with laparoscopic segmental bowel resection and reanastomosis

BACKGROUND

Laparoscopic segmental bowel resection and reanastomosis for endometriosis with colorectal wall invasion can be associated with high complication rates. This study was performed to test the hypothesis that this high complication rate can be prevented and combined with a good clinical outcome, following a multidisciplinary surgical approach.

METHODS

A retrospective cohort study of all patients with deep endometriosis and colorectal invasion treated by CO₂ laser laparoscopic radical excision between September 2004 and September 2006 (n = 45) to document the clinical outcome: complications, recurrence and fertility (life table analysis), pain, quality of life (QOL) and sexual function.

RESULTS

No immediate major post-operative complications requiring surgical reintervention were recorded. Gynaecological pain (P < 0.0001), sexual function (P < 0.03) and QOL (P< 0.0001), improved significantly after a median follow-up period of 27 (range: 16-40) months. Although five patients (11%) had a surgical reintervention, histologically proven recurrent endometriosis was observed in only two (4%), with a cumulative endometriosis recurrence rate of 2.2 and 4.4% after 1 and 3 years, respectively. Thirteen of 28 patients who wanted to become pregnant conceived after surgery. One patient delivered twice. These 14 pregnancies were achieved spontaneously (n = 9) or after IVF (n = 5). The cumulative pregnancy rate was 47% after 3 years.

CONCLUSION

Pain, sexual function and QOL improved significantly and were associated with a good fertility rate and a low complication and recurrence rate after a CO₂ laser laparoscopic radical excision of endometriosis with colorectal wall invasion combined with laparoscopic segmental bowel resection and reanastomosis.

Sigmoid endometriosis and a diagnostic dilemma - A case report and literature review

INTRODUCTION

Intestinal endometriosis is often an infrequently considered diagnosis in female of childbearing age by general surgeon. There is a delay in diagnosis because of constellation of symptoms and lack of specific diagnostic modalities. Patients suffer from intestinal endometriosis for many years before they are diagnosed. Often, such patients are labelled with irritable bowel syndrome. Intestinal endometriosis has a diagnostic time delay of 8-11 years due to its non-specific clinical features and multi-system involvement.

PRESENTATION OF CASE

Our patient was a 32 years old Caucasian female who was referred to us with features of intestinal obstruction. Despite repeated clinical assessments and use of different diagnostic modalities the diagnosis was still inconclusive even after 21 days of her first presentation to primary care physician. She had an exploratory laparotomy, sigmoid colectomy, and Hartmann's procedure with a temporary colostomy with us. Histopathology confirmed endometriosis and also showed melanosis coli. She was referred to the gynaecological team for review and follow up.

DISCUSSION

Intestinal endometriosis should be considered as a differential diagnosis in female patients of childbearing age group presenting with non-specific gastrointestinal signs and symptoms. Our patient manifested intestinal endometriosis and melanosis coli on histopathology suggesting symptoms of long duration.

CONCLUSION

Bowel endometriosis is a less considered and often ignored differential diagnosis in acute and chronic abdomen. This condition has considerable effect on patient's health both physically and psychologically.

Laparoscopic excision of rectovaginal endometriosis: report of a prospective study and review of the literature

AIM

The surgical management of rectovaginal endometriosis is challenging. We present our experience of the laparoscopic management of these difficult cases, together with a review of the current literature.

METHOD

A prospective database was established for all patients undergoing surgery for Deep Infiltrating Endometriosis (DIE) with rectovaginal and/or ureteric and bladder nodules. Outcomes analysed include operation performed, conversion and complication rates, and length of stay. These outcomes were compared with other laparoscopic rectal resections for alternative diagnoses recorded in the database and with outcomes seen in a literature review of studies on the surgical management of endometriosis.

RESULTS

Between April 2004 and November 2007, 54 patients underwent laparoscopic excision of rectovaginal endometriosis by a combined colorectal and gynaecological surgical team. Out of the 54 patients, 37% of patients underwent a rectal wall shave, 13% had a disc excision of the rectal wall, and 50% underwent segmental resection. There was a conversion rate of 4%, median duration of stay was 3 days, with 2% requiring transfusion. Major complications occurred in 7% of patients, with 4% requiring reoperation. Patients undergoing segmental resection for endometriosis had a higher complication rate than those having surgery for other diagnoses. There was an increased incidence of anastomotic stenosis, with histopathological results suggesting that the disease process might have contributed to this occurrence.

CONCLUSIONS

Laparoscopic resection of rectovaginal endometriosis may be associated with a higher incidence of complications than resections performed for other diagnoses.

Complete surgery for low rectal endometriosis: long-term results of a 100-case prospective study

OBJECTIVE

We conducted a prospective study to assess the long-term results of complete surgery for low rectal endometriosis (LRE), paying particular attention to surgical complications, functional results, and disease recurrence after a follow-up of at least 5 years.

SUMMARY BACKGROUND DATA

Deep infiltrating endometriosis (DIE) may infiltrate the midlow rectum and lead to severe pelvic pain. Complete resection of LRE is reluctantly considered by young women of childbearing age.

METHODS

From 1995 to 2003, 100 women with severe pelvic pain and previous incomplete surgery (n=82) underwent complete open surgery for LRE after thorough preoperative imaging work-up. This included total or subtotal rectal excision with combined resection of all extrarectal endometriotic lesions. Univariate analysis of predictive factors for transient neurogenic bladder and surgical complications was performed. Mean follow-up was 78+/-15 months.

RESULTS

All patients underwent rectal resection with straight coloanal (n=16) or low colorectal anastomosis (n=84). A concomitant extrarectal procedure was required in all instances, including gynecologic procedures (n=100), additional intestinal (n=45), and urologic (n=23) resections. A fertility-preserving procedure was possible in 92% of the patients. Mean numbers of DIE and endometriotic lesions were 3.9+/-1.4 and 5.5+/-1.6 per patient, respectively. There were no deaths and the surgical morbidity rate was 16%. Sixteen patients developed a transient peripheral neurogenic bladder, which was more frequently observed after colonanal anastomosis (P<0.001) or concomitant hysterectomy (P<0.01) and in patients with more than 4 DIE lesions (P<0.05). At last follow-up, 94 patients had complete (n=83) or very satisfactory (n=11) relief of symptoms. Urine voiding and fecal continence was satisfactory in all cases. There was no recurrence of colorectal and/or urologic endometriosis and the overall DIE recurrence rate was 2%.

CONCLUSIONS

Complete surgery for LRE provides excellent long-term functional results in 94% of the patients, provided all extraintestinal endometriotic lesions are resected during the same surgical procedure. In that setting, the overall 5-year recurrence rate is very low.

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.

Spontaneous viable pregnancies in cervical and rectal endometriosis: a report of two cases

OBJECTIVE

To report two cases of advanced pelvic endometriosis, both with deep rectal involvement and one with extensive cervical involvement appearing like a carcinoma, where both patients achieved spontaneous pregnancy and delivered viable babies.

DESIGN

Case report.

SETTING

Institute of Reproductive Medicine.

PATIENT(S)

Two nulliparous patients, one with extensive cervical and rectal and other with deep rectal endometriosis and primary infertility.

INTERVENTION(S)

Medical management.

MAIN OUTCOME MEASURE(S)

Description and treatment of two patients with advanced pelvic endometriosis and pregnancy.

RESULT(S)

Delivery of viable babies in both cases.

CONCLUSION

Prolonged medical treatment may have helped to arrest the progression of the disease by restoring anatomic proximity leading to spontaneous pregnancy in both cases.

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.

Intestinal Obstruction Due to Rectal Endometriosis: A Surgical Enigma

Obstructed rectal endometriosis is an uncommon presentation. The clinical and intraoperative presentation may present as malignant obstruction. The difficulty in making the diagnosis may delay the definitive management of the patient. We report a unique case of rectal endometriosis mimicking malignant rectal mass causing intestinal obstruction and discuss the management of the case.

Laparoscopic management of rectal endometriosis

PURPOSE

Surgical treatment of females with rectal endometriosis is challenging. The aim of this study was to review the results of laparoscopic intervention in the management of females with this complex disorder.

METHOD

All cases of complex tertiary referral pelvic endometriosis requiring laparoscopic surgical intervention of the rectum were identified and reviewed from a prospective database.

RESULTS

Between April 1996 and August 2004, 95 patients with pelvic endometriosis involving the rectum had laparoscopic surgical procedures performed by one gynecologist and one colorectal surgeon. Eighty percent of rectal procedures were completed laparoscopically. Forty-three (45 percent) were treated with diathermy excision, 18 (19 percent) had shave partial-thickness disc excision, 20 (21 percent) had full-thickness disc excision (including 14 endoanally using a circular stapler), while 14 (15 percent) were managed with laparoscopic-assisted segmental low anterior resection. A history of rectal pain during defecation present only during menstruation (adjusted odds ratio=8.6, 95 percent confidence interval (CI)=1.8-41.2) and previous laparoscopy (adjusted odds ratio=3.2, 95 percent CI=1.2-8.3) independently predicted a need for more extensive surgery than diathermy excision. There were no rectal anastomotic leaks, with 8 percent overall morbidity. The only significant predictor of ongoing postoperative symptoms was a history of dyspareunia (P=0.03).

CONCLUSIONS

Patients with complex endometriosis of the rectum can be safely managed laparoscopically using a multidisciplinary approach. This case series suggests that a history of rectal pain during defecation that occurs only during menstruation is predictive of females with more extensive rectal disease.

Treatment of rectosigmoid endometriosis by laparoscopically assisted vaginal rectosigmoidectomy

OBJECTIVE

To describe the use of mechanical anastomoses in cases of laparoscopically assisted vaginal rectosigmoidectomy for the treatment of rectosigmoid endometriosis.

METHODS

Pilot study evaluating eight patients with rectosigmoid endometriosis referred for surgical treatment. All patients were submitted to laparoscopically assisted vaginal segmental resection of the rectosigmoid with anastomoses performed using linear and circular staplers.

RESULTS

The average length of the surgical procedure was 177.5 min and average duration of hospitalization was 4.13 days. There were no intra-operative complications and integrity of the anastomoses was confirmed in all patients. One patient reported partial improvement of symptoms and 7 patients presented complete clinical remission 12 months following surgery.

CONCLUSION

Laparoscopically assisted vaginal segmental resection of the sigmoid infiltrated by endometriosis is a feasible surgical procedure. The technique combines transvaginal access with mechanical intestinal anastomoses performed using linear and circular staplers, and achieves good results with low morbidity.

Laparoscopic colorectal resection for endometriosis

BACKGROUND

The rectosigmoid colon is affected by deep pelvic endometriosis in 3-37% of cases. In the past, treatment of the affected gastrointestinal tract generally required conversion to conventional surgery. We describe our experience with complete laparoscopic management of deep pelvic endometriosis with bowel involvement.

METHODS

From March 1995 to March 2003, 29 consecutive patients with endometriosis requiring laparoscopic intervention were evaluated. In seven patients (24%) colorectal involvement was identified prior to the operation. A low anterior resection was performed in four patients (57%) and a sigmoid resection in three (43%). In all cases, colonoscopy showed a normal mucosa. In all cases, treatment consisted of resection of the bowel involved together with the excision of all other implants. Data analysis included age, previous abdominal operations, previous history of endometriosis, operative time, conversion rate, complications, length of stay, and pain relief.

RESULTS

There were seven patients with colorectal involvement whose median age was 32.8 years (range, 28-40), with a history of previous abdominal operation in two (28%). Preoperative symptoms were as follow: dysmenorrea in four patients (57%), dyspareunia in four (57%), pelvic pain in seven (100%), rectal bleeding in one (14%), and tenesmus in five (71%). Mean operative time was 190 min (range, 165-230). Length of stay was 8.3 days (range, 7-11). There were no anastomotic leak and no major postoperative complication. One patient had temporary urinary retention. At a median follow-up of 38.7 months (range, 1-84), complete relief of pelvic symptoms was achieved in five patients (71%), and there was improvement in one patient. In one patient complaining of persistent pain, a new colonic implant was diagnosed two years after the surgery requiring reoperation.

CONCLUSIONS

The results show that provided that the surgeon is highly skilled in laparoscopy, laparoscopic resection of deep pelvic endometriosis with rectosigmoid involvement is feasible and effective in nearly all patients.

Rectal endometriosis: high sensitivity and specificity of endorectal ultrasound with an impact for the operative management

PURPOSE

In patients with histopathologically proven or suspected endometriosis with possible involvement of the rectum, endorectal ultrasound was performed to determine the sensitivity and specificity of this method with regard to rectal wall involvement and the impact on the following operation.

METHODS

In an historical cohort analysis, 85 females with histopathologically proven or suspected endometriosis with possible involvement of the rectum were treated between 1992 and 2001. Endorectal ultrasound was performed with a 7.5 MHz real-time unit, and results of endorectal ultrasound were compared with intraoperative findings and histopathologic diagnosis of 65 patients undergoing operation. A questionnaire was used to evaluate postoperative signs and symptoms.

RESULTS

Of 65 patients undergoing surgery, 37 underwent laparotomy with 25 resections of the bowel and 28 laparoscopy. In 31 of 32 patients with suspected rectal wall infiltration, preoperative endorectal ultrasound diagnosis was confirmed. In patients in whom endorectal ultrasound showed no rectal wall involvement, histopathology revealed infiltration in one patient, leading to sensitivity of 97 percent and specificity of 97 percent with regard to rectal wall involvement. In terms of the deepness of rectal wall infiltration, endorectal ultrasound had a sensitivity of 76 percent with regard to infiltration of the muscularis propria and 66 percent for infiltration of the submucosa. Operations led to a significant (P < 0.05) reduction of preoperative symptoms by approximately 60 percent.

CONCLUSIONS

Endorectal ultrasound is a useful, noninvasive technique for preoperative evaluation of possible rectal wall involvement in endometriosis. Based on the high sensitivity and specificity, recommendation for laparotomy and bowel resection in cases with suspected rectal involvement can be facilitated.

[Utility of rectal endoscopic ultrasonography for digestive involvement of pelvic endometriosis. Technique and results]

Intestinal endometriosis present in up to 37% of cases is difficult to diagnose and treatment remains complex. Until recently barium enema and colonoscopy are the only two diagnostic tools. However there were many drawbacks and technical limitations due to the particular development of the endometrial lesions with frequent respect of the mucosa. Digestive involvement was often preoperative discovery and treatment was frequently incomplete. Development of endoscopic ultrasonography has improved the potential for preoperative diagnosis of digestive endometriosis. Many publications have now demonstrated its utility. Compared to other imaging techniques endoscopic ultrasonography has better sensibility close to 100%. Endoscopic ultrasonography is superior to Magnetic Resonance Imaging for the diagnosis of rectosigmoid endometriosis. Magnetic Resonance Imaging however gives a largest view of the pelvis. Using preoperatively endoscopic ultrasonography in patients who are at risk of digestive involvement will help to choose between different therapeutic modalities and surgical techniques.

Laparoscopic resection of deep pelvic endometriosis with rectosigmoid involvement

BACKGROUND

Adequate treatment of severe deep pelvic endometriosis requires complete excision of all implants, but formal bowel resection is not generally recommended. The purpose of this study was to describe our experience with planned complete laparoscopic management of deep pelvic endometriosis with bowel involvement.

STUDY DESIGN

All patients presenting to the Department of Obstetrics and Gynecology and the Department of Colorectal Surgery at our institution with stage IV endometriosis and bowel involvement from February 1998 to December 2001 were identified from a prospective database and were retrospectively analyzed. Data analysis included age, previous history of endometriosis, previous pregnancies, operative procedure, body mass index, operating room time, intra- and postoperative complications, length of stay, 30-day readmission, and pain relief. Laparoscopic excision of all visible disease was planned.

RESULTS

The series consisted of 51 patients with median age of 34 years (range, 32 to 39 years), with history of earlier abdominal operation in 66.7%. Preoperative symptoms were present as dysmenorrhea (85.3%), dyspareunia (55.9%), rectal pain (41.2%), constipation (44.1%), rectal bleeding (14.7%), bloating (29.4%), and tenesmus (8.8%). Management of the bowel disease included superficial excision of serosal endometriosis implants (n = 26), bowel resection (n = 18), and disc excision (n = 5). Five patients required management of disease other than rectosigmoid involvement. Median operating room time was 187 minutes (range, 145 to 277 minutes), and the median length of stay was 2 days (range, 1 to 4 days). Thirty-three percent of excisions were outpatient procedures. Postoperative complications occurred in 10.3%: four cases (7.8%) were converted to formal laparotomy, and three patients (7.7%) were readmitted within 30 days. Only 7 of 47 patients with a uterus (14.9%) required abdominal hysterectomy or bilateral salpingo-oophorectomy. Postoperatively, 87% of patients reported a clinically significant improvement of their symptoms.

CONCLUSIONS

Though technically demanding, complete radical laparoscopic excision of endometriotic implants can be accomplished with preservation of the reproductive organs and appropriate use of bowel resection in the majority of patients. The surgeon or gynecologist who plans to perform laparoscopic excision of deep pelvic endometriosis should have the ability or access to expertise for laparoscopic partial or segmental bowel resection or plan to convert to laparotomy when faced with this disease location.

[Colorectal endometriosis. Diagnosis and management]

Endometriosis occurs in 5 to 10% of the female population. Bowel involvement present in 6 to 30% of cases is predominantly localized in the pelvic parts of the colon and rectum, close to the uterus. The goal of this work was to describe the present diagnostic and therapeutic management of deep colorectal endometriosis defined as infiltrating the digestive wall and usually requiring surgery. Colorectal endometriosis is a disabling disease. Anatomic lesions mimic those of a cancer. Modern investigations include endorectal endosonography, recognized as the best mean to assess the depth of invasion into the intestinal wall, and magnetic resonance imaging. Associated to exploratory laparoscopy, these investigations allow to select the optimal operative strategy for multifocal and complex lesions. Surgical objective is a total resection of endometriomas, to guarantee symptom relief and avoid recurrence. Difficulties in these procedures are usually due to fibrotic and vascularised lesions and associated gynaecological disorders. In elective cases, preoperative GH-RH analog hormonal treatment makes easier the surgical procedure. Colonic and/or rectal restorative resections, performed through laparoscopic approach or more frequently through laparotomy, have to be done according to the usual standards of colorectal surgery. Conservative surgery of the ovaries is mandatory in premenopausal patients.

Successful laparoscopic treatment of ileo-cecal endometriosis producing bowel obstruction

Bowel endometriosis manifesting with ileus is difficult to diagnose, often requiring laparotomy for diagnosis and treatment. We report here a case of ileo-cecal endometriosis causing bowel obstruction. A diagnosis of intestinal endometriosis with menstruation-associated bowel symptoms was made, and the patient was successfully treated by laparoscopic ileo-cecal resection.

Rectal endometrial stromal sarcoma arising in endometriosis: report of a case

PURPOSE

Endometriosis of the rectovaginal septum can harbor different types of secondary tumors that may involve the rectal wall and protrude into its lumen, thus making diagnosis difficult. Extrauterine low-grade endometrial stromal sarcoma may rarely arise in endometriosis. The purpose of this article was to present the third case of this association.

METHOD

This was a clinicopathologic study.

RESULTS

A 42-year-old female presented with abdominal pain and fever. Laparotomy revealed a large pelvic mass involving the rectovaginal septum and the colonic wall and which protruded into the lumen forming endoluminal polypoid masses. Concomitant peritoneal nodules and a metastatic paracolic lymph node were also found. Histopathologically, primary endometriotic foci were found in close relationship with an endometrial stromal sarcoma which invaded the rectal wall. The female genital tract had no endometriotic lesions. The patient was treated by surgery and subsequent chemotherapy and was alive and well 20 months later.

CONCLUSIONS

Endometriosis and its possible malignant changes should be taken into account in the differential endoscopic diagnosis of rectal masses in females.

Bowel resection for intestinal endometriosis

PURPOSE

The study contained herein was undertaken to evaluate which factors predict a good outcome following intestinal resection for endometriosis.

METHODS

A retrospective analysis of all patients undergoing bowel resection for severe (American Fertility Society Stage IV) endometriosis at one institution between the years 1992 and 1996 was conducted using systematic chart review and follow-up by telephone interview.

RESULTS

Twenty-nine patients were identified within the study period. The most frequent symptoms were pelvic pain, abdominal pain, rectal pain, and dysmenorrhea. Nearly all patients (93 percent) underwent low anterior resection of the rectum and distal sigmoid. Other intestinal procedures were appendectomy, terminal ileal resection, cecectomy, and sigmoid resection. Thirty-four percent of patients had simultaneous total abdominal hysterectomy and bilateral salpingooophorectomy. Complete follow-up was obtained on 26 patients (90 percent; mean follow-up 22.6 (range, 8-63) months). All patients (100 percent) reported subjective improvement. Forty-six percent of patients were "cured" according to the prospectively applied definition (resolution of symptoms without need for further medical or surgical therapy). The only variable analyzed that was associated with "cure" was concomitant total abdominal hysterectomy and bilateral salpingooophorectomy (odds ratio, 12; 95 percent confidence interval, 1.8-81.7). This association remained significant after correcting for age and the presence of gastrointestinal symptoms.

CONCLUSION

Intestinal resection can be performed safely in most women with severe endometriosis and bowel involvement, although many of these patients experience persistent or recurrent symptoms. Total abdominal hysterectomy and bilateral salpingooophorectomy at the time of bowel resection correlates with improved outcome.

Management and causes of acute large-bowel obstruction

Acute LBO has many possible causes. In the United States, the most common cause is colorectal carcinoma. Mechanical obstruction should be differentiated from pseudo-obstruction by contrast enema or colonoscopy because the treatments differ. The high postoperative mortality and morbidity of LBO compared with elective resection are explained by the multiple associated pathophysiologic changes of obstruction. Management of this condition requires careful assessment, awareness, and expertise in the current modalities of treatment. Gangrene and perforation should be avoided because they limit treatment options and are associated with an increase in mortality. We prefer, in most instances, to perform a single-stage procedure, which has the advantages of reduced hospital stay (and cost) and avoidance of a stoma. However, the appropriate treatment needs to be tailored to the individual situation. Recent developments in nonoperative decompressing procedures may demonstrate advantages in the future.

Endoluminal ultrasound diagnosis and operative management of rectal endometriosis

PURPOSE

Endorectal ultrasound was performed in patients with endometriosis to evaluate the role of this technique for rectal wall involvement and to evaluate the position of preoperative diagnosis in the operative management of rectal endometriosis.

METHODS

Sixteen patients with suspected fixation of endometriomas to the rectal wall during bimanual examination were included in the study. Endorectal ultrasound was performed using a real time unit with a 7.5 MHz endorectal transducer. The probe was introduced via a rectoscope into the rectum up to the rectosigmoid.

RESULTS

Endometriosis was confirmed histopathologically in all patients. In six patients rectal wall involvement was diagnosed, in two patients endometriomas were adjacent to the rectal wall, and in eight patients rectal wall involvement could be excluded. Preoperative diagnosis was confirmed in all patients during operation. Laparotomy was performed in those patients with preoperatively diagnosed rectal wall involvement, whereas the remaining patients were treated laparoscopically. Endometriomas with rectal wall involvement were treated in five of six patients with resection of the affected bowel predominantly by low anterior resection.

CONCLUSIONS

Preoperative endorectal ultrasound is a reliable technique to visualize perirectal endometriomas and to assess rectal wall involvement. Based on preoperative endosonographic diagnosis, an operative management was established with laparotomy and resection of the affected bowel in cases of rectal wall involvement.

Treatment of bowel endometriosis: a report of six cases of colorectal endometriosis and a survey of the literature

From October 1989 to September 1994, we performed six intestinal resections for rectal and sigmoidal endometriosis. The average age of the patients was 32 years old, and most had symptoms. In all cases coloscopy showed a normal mucosa. Patients had successfully been treated with hormones previously, but had relapsed when the treatment was stopped. Bowel resection was segmental, with immediate end to end anastomosis in five patients, and partial in one patient. Genital endometriosis was diagnosed in three cases and was then treated during the same procedure. A low colorectal anastomosis was complicated by a fistula, but no recurrence was observed after surgical treatment. Intestinal endometriosis tract is in 70% of cases located on the rectosigmoid. An association with genital endometriosis tract is observed in 80% of the cases. Deep rectosigmoidal endometriosis with symptoms is resistant to hormonal therapy and necessitates a surgical treatment by intestinal resection. The pelvis has always to be explored, with full evaluation and surgical treatment of genital endometriosis when necessary. Appendicular endometriosis should be removed surgically. Postoperative treatment can be additionally prescribed in cases of genital endometriosis and for leftover digestive location.

Intestinal endometriosis: presentation, investigation, and surgical management

The study was undertaken to identify the presenting features of intestinal endometriosis and to evaluate its investigation and surgical management. Twenty-six cases of intestinal endometriosis were identified during a fourteen year period. The commonest site of occurrence was the rectosigmoid region (11 cases) followed by the appendix (9 cases), and ileocaecal region (6 cases). Abdominal pain was the main presenting feature in 20 cases, with associated nausea and vomiting in 12 cases and altered bowel habit in ten. Other presenting features included rectal bleeding, abdominal bloating and tenesmus. Endometriosis was not suspected preoperatively in any of the patients without a past history of this condition. Accurate preoperative diagnosis proved very difficult, with only laparoscopy providing definite evidence of intestinal endometriosis prior to formal surgery. Colonic resections were performed in 12 cases, small bowel resection in six cases and appendicectomy in nine cases, together with resection of adjacent adherent structures. This series illustrates the difficulty of establishing an accurate preoperative diagnosis, and the propensity of intestinal endometriosis to mimic other gastrointestinal diseases, particularly carcinoma and inflammatory bowel disease.

Mucosal changes in the large bowel with endometriosis: a possible cause of misdiagnosis of colitis?

Endometriotic deposits are not uncommon in the large bowel of women. Because the symptoms produced by endometriosis may lead to investigation by colorectal endoscopic biopsy, the aims of this study were to assess the range of mucosal abnormalities that may occur and to determine whether this could represent a significant potential diagnostic problem. We found mucosal changes in eight of 10 cases of colorectal endometriosis; however, the abnormalities (ulceration, gland architectural disturbance, crypt abscess formation, increased inflammatory cell presence, and smooth muscle fibers between glands in the mucosa) were focal and directly related to endometrial deposits. In one case an abnormal colonic biopsy specimen from a patient with endometriosis supported the erroneous clinical diagnosis of Crohn's disease. Comparing a group of women with endometriosis to a group with adenomyosis of the uterus showed that although more women with endometriosis have endoscopic large bowel biopsies, there was no significant excess of biopsy specimens showing inflammatory changes. Our conclusion is that the endometriosis of the large bowel can masquerade as inflammatory bowel disease or ischemic changes and the possibility should be borne in mind, particularly in cases with atypical clinical features or very focal histological changes.

Aggressive surgical management for advanced colorectal endometriosis

PURPOSE

The aim of this study was to evaluate the results of aggressive surgical management in patients with advanced colorectal endometriosis.

METHODS

The medical records of 130 women who had undergone aggressive surgical management of advanced colorectal endometriosis were reviewed. They were then interviewed a mean of 60 months following surgery and asked to rank relief of their symptoms.

RESULTS

The most common symptoms before surgery were pelvic pain, dyspareunia, rectal pain, change in bowel habit, and cyclic rectal bleeding. Colorectal operations included low anterior resection, sigmoid resection, disc excision of the rectal wall, right colectomy, appendectomy, and small bowel resection. At follow-up symptom relief was high, ranging from 100 percent in cyclic bleeding to 91 percent for rectal pain. Mortality and clinical leakage rates were 0 percent, small bowel obstruction 3 percent, and abscess 1 percent. The crude pregnancy rate following surgery was 49 percent.

CONCLUSIONS

These findings strongly support the use of aggressive surgical extirpation of all visible colorectal endometriosis for patients with advanced disease.

Endometriosis: radical surgery

Radical ablative surgery for endometriosis is indicated chiefly for symptoms of pain that fail to respond to conservative treatment. The sites of involvement must be carefully assessed and surgery planned taking account of the wishes of the patient concerning her fertility. Procedures include oophorectomy, salpingo-oophorectomy, hysterectomy, appendicectomy, and the excision of deeply infiltrating endometriosis possibly involving bowel resection. The most important arbiter of therapeutic success is the removal of the ovaries, hysterectomy and bilateral salpingo-oophorectomy offering the ultimate cure for this chronic condition. Whereas laparotomy has been the traditional approach for most of these procedures, vaginal and laparoscopic surgery are modern alternatives for many of these cases offering important advantages in terms of reduced postoperative discomfort, shorter hospitalization, faster recovery and a superior cosmetic result. Preoperative and postoperative medical therapy has a limited role in surgery, whereas postoperative hormone replacement therapy after bilateral oophorectomy is generally recommended.

Different types of extragenital endometriosis: a review

Endometriotic growth may appear in any structure in the body. As well as affecting the internal genitalia, lesions are not uncommon in the bowel, urinary tract and thorax and reports of a number of cases at rarer sites have been published. This review is based on more than 1000 publications on the subject, that allows an overview of the appearance of the disease in different organs.

Endoscopic diagnosis of colonic endometriosis

Involvement of the colon or rectum with endometriosis is uncommon but may be a cause of gastrointestinal symptoms such as diarrhea, pain, and bleeding. To determine whether endoscopy has a role in evaluating endometriosis of the colon, we reviewed all cases of endometriosis undergoing colonic resection from 1984 to 1989. There were nine patients, six of whom had intermittent hematochezia. All had lesions detected at endoscopy described as a polyp, mass, or stricture. Five of the six patients with symptoms of hematochezia had mucosal involvement in the resected specimen. Four of these five had a visible lesion at endoscopy with endometriosis on biopsy. The three patients without hematochezia had no mucosal endometriosis in the resected colonic specimen or endometrial tissue on biopsy. In patients with colonic endometriosis and hematochezia, endoscopy and biopsy can confirm the diagnosis of colonic endometriosis.

True and false large bowel obstruction

Acute large bowel obstruction can be the result of mechanical causes (such as colorectal cancer) or motility disturbances, the latter being termed colonic pseudo-obstruction. Whatever the aetiology, the pathophysiology of large bowel obstruction has clinical significance. Changes in motility augmented by increased colonic blood flow may play a role in dissemination of tumour cells and/or bacteria. Intravascular fluid depletion, especially shortly after intestinal decompression, has important haemodynamic implications. The diagnosis is often confirmed on plain abdominal X-ray, but water-soluble contrast studies are important in distinguishing a mechanical obstruction (which almost always requires an operation) from a pseudo-obstruction (which can usually be managed without surgery). Mortality and morbidity may be reduced by optimization of the patient's condition both before and after the operation using intensive care facilities and by careful timing of surgery. The surgical management of malignant large bowel obstruction is best directed by a senior surgeon. For tumours up to and including the splenic flexure, an extended right hemicolectomy is advisable since it offers adequate removal of the tumour and allows an immediate safe ileocolic anastomosis. More distal tumours should be resected if possible, and there is much to recommend on-table irrigation and immediate anastomosis, although a colostomy with a mucous fistula or Hartmann's procedure still have a place. Endoscopic diagnosis and decompression enables definitive surgery to be undertaken electively and several techniques are being evaluated. Non-operative reduction of sigmoid volvulus by rigid or flexible endoscopy is achieved with high success rates, but is not recommended for caecal volvulus. Resection is usually necessary in both to prevent recurrence. Mortality of colonic volvulus is closely related to bowel viability. Uncomplicated colonic pseudo-obstruction may be managed medically or by endoscopic decompression. It often occurs in association with systemic medical conditions, which need to be treated vigorously. Surgery is indicated if there are signs of impending or frank perforation, or if non-operative measures fail.