Les formes anatomocliniques de l'endométriose

Decidualization of an ovarian endometrioma complicated by a sigmoid fistula during pregnancy: a case report

BACKGROUND

During pregnancy, the discovery of adnexal masses remains frequent. Such masses are mostly benign. Ovarian endometrioma is a rare etiology. The diagnosis may be difficult in some situations, such as decidualization. It may be asymptomatic or result in complications for which magnetic resonance imaging is needed.

CASE PRESENTATION

We describe an unusual case of decidualization of an ovarian endometrioma complicated by a sigmoid fistula during a 7-week, 1-day pregnancy in a Arabic patient aged 38 years who developed acute pelvic pain with fever. She had a medical history of unexplored secondary dysmenorrhea. The diagnosis was suspected on the basis of magnetic resonance imaging findings. The management was based on surgery, during which exploration revealed a mass at the expense of the left ovary being very adherent and fistulized to the sigmoid. We performed adnexectomy followed by digestive ostomy. The result of pathological study with immunohistochemistry led to a diagnosis of decidualization of an ovarian endometrioma altered by infection.

CONCLUSION

Decidualization of an ovarian endometrioma can lead sometimes to unexpected complications. The decision to provide surgery must be made with caution without delaying treatment in the event of a deep suspicion of malignancy and/or complication. The particular and exceptional complication discovered in our patient is the fistulization to the sigmoid.

[Anatomic reports of vegetative nerves within para rectal fossa, to the rectal endometriosis surgery application]

OBJECTIVES

The objective of the study was to describe the inferior hypogastric plexus and nerves constituting the para-rectal fossa in order to study the importance of anatomical knowledge in rectal endometriosis surgery.

METHODS

In order to discover the complete anatomy of the study area, we carried out a review of the literature and relied on dissection of a female cadaver and operative dissections in patients treated for rectal endometriosis.

RESULTS

The inferior hypogastric plexus, the hypogastric nerve and the pelvic splanchnic nerves are the nervous elements component the para-rectal fossa. These nerves were important urinary, digestive and sexual functions. The dissection of the Okabayashi and the Latzko spaces within the para-rectal fossa and sparing nerve within this zone is more important for the prevention of traumatic nervous sequelae during rectal endometriosis surgery. The pelvic anatomy can be by attraction and sheathing nerve structures by endometriosis lesions which can complicate preservation techniques.

CONCLUSION

Lesions of pelvic vegetative nerves running through the para-rectal fossa can be responsible for urinary, digestive and sexual disorders that can affect patients quality of life. There is currently only one standardized "nerve sparing" technique in pelvic endometriosis surgery. Knowledge of the anatomy of the nerves making up the para-rectal fossa helps to orient the operative dissection and prevent postoperative nerve complications after surgery for rectal endometriosis.

Chronic pelvic pain and the role of exploratory laparoscopy as diagnostic and therapeutic tool: a retrospective observational study

Background

Forty percent of exploratory laparoscopies are performed for chronic pelvic pain (CPP). However, a final diagnosis is still unreported in 35% of the patients. We decided to evaluate the identification of pathological lesions and the improvement of painful symptoms in patients with CPP and normal physical examination and imaging and who are scheduled for exploratory laparoscopy. The prospective study was designed in a tertiary referral center for endometriosis. Forty-eight patients complaining of CPP and scheduled for exploratory laparoscopy were included. Pelvic pain intensity was assessed using the visual analogue pain scale (VAS), and at inclusion, negative clinical and imaging assessments were required. During exploratory laparoscopy, the recognized lesions were reported and different surgical treatment options were performed depending on the location of the lesion.

Results

In 98% of the cases, exploratory laparoscopy demonstrated the presence of pelvic anomalies that had not been diagnosed at the time of clinical and imaging examination. After surgery, a significant improvement of CPP has been demonstrated in 24 (59%) patients with VAS < 5 postoperatively.

Conclusions

Exploratory laparoscopy is reasonable in patients complaining of CPP, allowing a final diagnosis in a high percentage of patients and a significant improvement in pain symptom in 59% of the cases. This study was retrospectively registered by our local Ethics Committee on February 7, 2018 (B412201835729).

A case of endometrial stromal sarcoma with synchronous bilateral adenocarcinoma of ovary

Endometrial stromal tumor is a rare mesenchymal uterine tumor. We report the case of a patient with endometrial stromal sarcoma and concomitant bilateral endometrioid adenocarcinoma of the ovary in the context of pelvic endometriosis. The patient underwent a complete cytoreduction including total hysterectomy and bilateral adnexectomy, pelvic lymphadenectomy, appendicectomy, infracolic omentectomy, and pelvic peritonectomy. This is the first report to our knowledge that describes a synchronous endometrial stromal sarcoma and bilateral endometrioid adenocarcinoma of the ovary.

Diagram to map the locations of endometriosis

OBJECTIVE

To develop and test a visual map that corresponds practically and objectively to the anatomical areas affected by endometriosis.

METHOD

The study comprised 150 questionnaires concerning 10 clinical cases of endometriosis presented as a visual diagram that were distributed at 3 different scientific events, among 3 groups of 50 gynecologists. Data were analyzed to evaluate the diagram's ability to graphically represent the endometriosis sites.

RESULTS

After presentation at the first event, the rate of correct answers on the site of endometriosis was 84.7%; at the second event, after modifications implemented after feedback from the first event, the rate of correct answers was 97.4%; and at the third event, when all suggestions and modifications had been made, the rate was 99.7%.

CONCLUSION

The diagram proposed to map the location of endometriosis lesions appears to be an adequate and effective instrument to represent the site of the disease, with correlation at almost 100%.

[Endometriosis and pelvic pain: epidemiological evidence of the relationship and implications]

The relationship between chronic pelvic pain symptoms and endometriosis is unclear because painful symptoms are frequent in women without this pathology, and because asymptomatic forms of endometriosis exist. Our comprehensive review attempts to clarify the links between the characteristics of lesions and the semiology of chronic pelvic pain symptoms. Based on randomized trials against placebo, endometriosis appears to be responsible for chronic pelvic pain symptoms in more than half of confirmed cases. A causal association between severe dysmenorrhoea and endometriosis is very probable. This association is independent of the macroscopic type of the lesions or their anatomical locations and may be related to recurrent cyclic microbleeding in the implants. Endometriosis-related adhesions may also cause severe dysmenorrhoea. There are histological and physiopathological arguments for the responsibility of deeply infiltrating endometriosis (DIE) in severe chronic pelvic pain symptoms. DIE-related pain may be in relation with compression or infiltration of nerves in the subperitoneal pelvic space by the implants. The painful symptoms caused by DIE present particular characteristics, being specific to involvement of precise anatomical locations (severe deep dyspareunia, painful defecation) or organs (functional urinary tract signs, bowel signs). They can thus be described as "location indicating pain". A precise semiological analysis of the chronic pelvic pain symptoms characteristics is useful for the diagnosis and therapeutic.