Prise en charge chirurgicale des nodules endométriosiques de la cloison recto-vaginale. A propos d'une série continue de 40 cas

Conservative vs radical bowel surgery for endometriosis: A systematic analysis of complications

BACKGROUND

Endometriosis of the bowel can be associated with significant morbidity. Surgery to remove it carries risks. Options include conservative shaving or discoid resection and more radical segmental bowel resection.

AIMS

To determine if more conservative shaving or discoid bowel resection is associated with fewer risks than more radical segmental resection.

MATERIAL AND METHODS

This study is a systematic review. We considered eligible any cohort, observational or randomised controlled trial (RCT) study of at least ten women per arm comparing conservative vs radical bowel surgery for endometriosis. We divided complications into two groups, major and minor. One additional article was added due to its significance in answering our study question as well as the high quality of the study design as an RCT.

RESULTS

There were 3041 studies screened. Eleven studies were included (n = 1648). For major complications, the risk ratio for shaving and disc excision vs segmental resection is 0.31 (95% CI 0.21-0.46), while the risk difference is -0.25 (95% CI -0.41 to 0.10). For minor complications, the risk ratio is 0.63 (95% CI 0.36-1.09), while the risk difference is -0.03 (95% CI -0.12 to 0.05).

CONCLUSIONS

Conservative shaving or discoid excision surgery is associated with reduced complications. Previous studies demonstrated a trend toward this finding, but suffered from relatively low participant numbers, increasing the risk of type one statistical error. Our results allow surgeons to make informed choices about potential complications when deciding how to approach bowel endometriosis. The results also allow patients to have more information about the risks. However, outcomes in the studies analysed are heterogenous and are from low-quality evidence.

[Intestinal endometriosis]

Endometriosis affects 6 to 10 % of all women of childbearing age. Intestinal involvement is defined by muscularis infiltration and has been estimated to occur in 8 % to 12 % of women with endometriosis. The most common sites are rectum, sigmoid and ileocaecal junction. In most cases, intestinal endometriosis is associated with deep infiltrating endometriosis, multifocal and aggressive form of endometriosis, responsible for refractory pelvic pain and infertility. The symptoms are nonspecific but are characterized by cyclic exacerbation of pain. The preoperative work-up includes a rectal endoscopic ultrasonography, a transvaginal ultrasonography, a pelvic magnetic resonance imaging and a multidetector CT scan. There is currently no cure other than surgical removal of lesions. Medical treatments are based on a hormone used to block ovarian function.

Traitement chirurgical de l’endométriose rectale

Intestinal endometriosis accounts for 8-12% of all endometriosis and rectal involvement is most often encountered in the context of deep pelvic infiltration. Intestinal symptoms, often nonspecific, are most typically seen as painful defecation or constipation worsening in the premenstrual period associated with pelvic pain, dysmenorrheal, dyspareunia, and infertility. Physical examination should include a pelvic exam under anesthesia. Endorectal ultrasound best evaluates rectal muscle invasion, while pelvic MRI and CT will evaluate the full extent of pelvic involvement and other GI sites of implantation. Only radical extirpative surgery of all intestinal, urologic, deep pelvic, and adnexal sites of endometriosis will permit relief of pain, prevent recurrence, and hopefully preserve fertility. In view of the frequency of extra-intestinal sites of involvement and technical difficulties augmented by previous surgical interventions, open laparotomy remains the preferred approach. A laparascopic approach would be reserved only for well-selected patients presenting with isolated colorectal involvement.

Accuracy of rectal endoscopic ultrasonography and magnetic resonance imaging in the diagnosis of rectal involvement for patients presenting with deeply infiltrating endometriosis

OBJECTIVE

To compare the accuracy of rectal endoscopic ultrasonography (REU) and magnetic resonance imaging (MRI) for predicting rectal wall involvement in patients presenting histologically proven deeply infiltrating endometriosis (DIE).

METHODS

This was a retrospective study of a continuous series of 81 patients presenting histologically proven DIE who underwent preoperative investigations using both REU and MRI. The sonographer and the radiologist, who were unaware of the clinical findings and patient history, but knew that DIE was suspected, were asked whether there was involvement of the digestive wall.

RESULTS

Rectal DIE was confirmed histologically in 34 of the 81 (42%) patients. For the diagnosis of rectal involvement, sensitivity, specificity and positive and negative predictive value for REU were 97.1%, 89.4%, 86.8% and 97.7% and for MRI they were 76.5%, 97.9%, 96.3% and 85.2%.

CONCLUSION

The sensitivity and negative predictive value of REU were higher than those of MRI suggesting that REU performs better than MRI in the diagnosis of rectal involvement for patients presenting with DIE. Prospective studies with a large number of patients are needed in order to validate these preliminary results.

[Surgical management of rectovaginal septum endometriosis from a continuous series of 50 cases]

OBJECTIVES

To assess the value of MRI and ano-rectal endosonography (ARES) for the diagnosis and surgical prognosis of rectovaginal septum endometriosis and to analyse the surgical management in order to evaluate its functional results and complications.

PATIENTS AND METHODS

Retrospective study of 50 consecutive patients operated for a clinical presumption of endometriosis nodule of the recto vaginal septum. Thirty-nine patients had a MRI, 31 an ARES and 28 both exams. All the patients had a complete dissection of the rectovaginal septum and all lesions were excised.

RESULTS

For the diagnosis of rectovaginal septum endometriosis nodule, MRI results are: sensitivity 73%, specificity 50%, positive predictive value (PPV) 89%, negative predictive value (NPV) 25%; for uterosacral ligaments involvement: sensitivity 84%, specificity 95%, PPV 94%, NPV 86% and for rectal wall infiltration: sensitivity 53%, specificity 82%, PPV 69%, NPV 69%. The ARES results for diagnosis of rectovaginal septum endometriosis nodule are: sensitivity 93%, specificity 100%, PPV 100%, NPV 50% and for rectal wall infiltration: sensitivity 100%, specificity 71%, PPV 81%, NPV 100%. ARES appeared more sensitive than MRI for the detection of rectal wall infiltration (P = 0.002) and for rectovaginal septum endometriosis nodule diagnosis (P = 0.03). Eighty-nine percent of the patients had a coelioscopy in first intention and 15 laparoconversions were performed, 11 in order to perform a digestive resection: 45 nodules were found. In 43cases the nodule was excised, associated to 19 digestive resections, 30 colpectomys, and 22 uterosacral ligaments resections. Three patients required an additional surgical treatment by Hartman's procedure with Mickulicz's drainage for peritonitis. Forty-one nodules were endometriosis nodules: the two other cases were fibrosis nodules. Thirty-three patients were interviewed about the evolution of their pains over a mean history of 20 months: 90% of the patients were satisfied with the management results.

DISCUSSION AND CONCLUSIONS

Our data support the efficiency of MRI for rectovaginal septum endometriosis nodule and uterosacral ligaments involvement diagnosis; accord ARES to rectovaginal septum endometriosis nodule diagnosis and its reliability in establishing a diagnosis of rectal wall involvement. The surgical cure of rectovaginal septum nodules without digestive infiltration is performed by coelioscopic or coelio-vaginal procedure, but in case of associated digestive affliction, laparotomy is actually the standard procedure in order to achieve a complete cure of the lesions. Complications, in particular peritonitis, are not frequent. Our data support the efficiency of radical surgical treatment for the improvement of pain symptoms. Results on fertility seem to be satisfactory, but complication risks suggest being careful in this indication. Clinical examination during a catamenial period is essential in order to evoke the diagnosis. MRI yields a complete map of the sub-peritoneal and peritoneal lesions and ARES allows for the diagnosis of an infiltration of the rectal wall. Pre-operative association of those two exams is actually indispensable for the surgical management of those patients, which consists of complete excision of endometriosical lesions and is efficient at treating pain symptoms and fertility. Complications are rare but severe, therefore, justifying a cure in specialised centres.

[Deep pelvic endometriosis: management and proposal for a "surgical classification"]

Deep pelvic endometriosis presents essentially in the form of a painful syndrome dominated by deep dyspareunia and painful functional symptoms that recur according to the menstrual cycle, with the semiology directly correlated with the location of the lesions (bladder, rectum). It is essential to investigate these deep endometriosis lesions and draw up a precise map, which is the only way to be sure that exeresis will be complete. The treatment of first intention remains surgery, and medical treatment is only palliative in the majority of cases. Success of treatment depends on how radical surgical exeresis is. Based on analysis of the anatomical distribution of deep pelvic endometriosis lesions, a "surgical classification" is proposed with the aim of establishing standard modes for surgical treatment. Further studies are required to clarify the place and modes for pre- and postoperative medical treatment.

[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.