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

Diagnostic value of endoscopic ultrasonography in pelvic masses with bowel involvement

Benign and malignant pelvic masses with or without intestinal invasion are common in women of childbearing age. Patients may have nonspecific symptoms and signs or experience no symptoms. Laparoscopic resection of pelvic masses is currently the mainstream treatment; therefore, accurate preoperative evaluation is not only essential for patients suspected of having intestinal invasion, but also extremely important for the selection of follow-up treatment. Procedures, including endoscopic ultrasonography (EUS), pelvic magnetic resonance imaging, abdominal computed tomography, vaginal ultrasonography, barium enema, and colonoscopy, aid in determining the presence, depth, and histology of the disease. In particular, the wide application and continuous developments in EUS techniques have improved the diagnostic accuracy for intestinal subepithelial and peripheral organ lesions. This article reviewed the clinical value of EUS in the diagnosis of benign and malignant pelvic masses with bowel involvement.

MRI and rectal endoscopy sonography performance to diagnose the digestive depth infiltration of pelvic endometriosis

INTRODUCTION

The main objective of this study was to evaluate the performances of MRI and rectal endoscopy sonography (RES) in predicting the depth of bowel wall infiltration by deep infiltrating endometriosis (DIE).

MATERIAL AND METHOD

We conducted a single center retrospective study from April 2014 to March 2020 including all patients who had undergone digestive tract resection (discoid or segmental) for DIE removal and who had benefited from full preoperative imaging workup based on both pelvic MRI and RES.

RESULTS

Fifty two patients were enrolled in the study. Median age was 35.8 years (26.1-44.5 years). Indications for surgery mainly comprised chronic pelvic pain (94.2%) and infertility (36.5%). Overall, pathological examination showed digestive involvement in 92.3% of patients, while transmural infiltration was found in 38.4% of cases. In contrast, both MRI and RES suspected transmural involvement in 42 patients (80.8%). Corresponding sensitivity and specificity were 0.95 [95% CI (0.751-0.999)] and 0.28 [95% CI (0.137-0.467)], respectively. Our results revealed agreement between MRI and RES in 85% of cases with a kappa at 0.5 [95% CI (0.207-0.803), moderate agreement]. Subgroup analysis in patients with transmural MRI lesions showed a sensitivity of 0.95 [95% CI (0.740-0.999)] and a specificity of 0.13 [95% CI (0.028-0.336)].

CONCLUSION

Our study suggests that performing a second-line examination is not useful if there is no transmural impairment in MRI or RES. Nevertheless, the combination of these two preoperative examinations seems to be essential for the evaluation of the depth of digestive involvement of endometriosis to guide surgical management as effectively as possible. The constitution and training of multidisciplinary expert groups must be developed to be able to offer optimal patient management.

Anatomic significance of a positive barium enema in deep infiltrating endometriosis of the large bowel

PURPOSE

The anatomopathological significance of a positive double-contrast barium enema (DCBE) for suspicion of deep infiltrating endometriosis of the large bowel was studied. This is a retrospective study of a prospective database.

METHODS

A large-bowel resection was proposed for patients who were suspicious for large-bowel endometriosis and had a positive DCBE. In a series of 73 patients, 71 large-bowel resections were performed. Histology and immunohistochemistry with the monoclonal antibody CD-10 were performed on the resection specimen. Outcome measures were the length of the resected specimen, the largest diameter of the lesion, the positivity of the resection margins, and the degree of infiltration of the large bowel. We also compared the mean largest diameters of the lesions with the degree of infiltration of the large bowel.

RESULTS

Between December 1997 and October 2005, 80 patients were suspicious for large-bowel endometriosis: 73 (91%) had positive DCBEs, and 7 (9%) had negative DCBEs. Of the 73 with positive DCBEs, 4 (5%) refused digestive resection and 1 (1.4%) was excluded. Three patients underwent two large-bowel resections because of the presence of bifocal lesions (left and right colon). A total of 71 resections were performed. In case of positive DCBE, the perivisceral fat and the whole muscularis were infiltrated in 100% of cases. The infiltration reached the submucosa and the mucosa respectively in 82% and 18% of cases. A total of 9.9% of resection margins were positive at histology but only focally. The mean largest diameter of the lesions infiltrating the whole thickness of the large bowel was not statistically different from the mean largest diameter of more superficial lesions.

CONCLUSIONS

Findings of mass effect with indentations and ridging of the mucosa on DCBE in a setting suspicious for large-bowel endometriosis correspond well with pathologic findings of deep infiltration of the large-bowel wall. Clinicians dealing with deep infiltrating endometriosis should be aware of these findings, which could influence their choice of surgical treatment.

[Intestinal endometriosis. Current status]

Endometriosis affects a wide spectrum of premenopausal women. Intestinal involvement, affecting mainly the large bowel and sometimes the small bowel, is much less frequent. Diagnosis is relatively straightforward in women with long standing pelvic endometriosis but is difficult in acute intestinal obstruction, since a diagnosis of endometriosis is not often considered in this entity. We performed an exhaustive review of the medical literature, including the option of medical treatment, which is rarely effective in intestinal endometriosis. In most patients with intestinal symptoms, the disease is so severe that surgical treatment is required. Recent studies indicate that the most effective approach is laparoscopic. We analyze the most important classical and recent series of patients and discuss treatment results.

Role of EUS and EUS-guided FNA in the diagnosis of symptomatic rectosigmoid endometriosis

BACKGROUND

Rectosigmoid endometriosis is an underrecognized cause of GI symptoms in women. Pelvic magnetic resonance imaging and CT have a low sensitivity in making this diagnosis. The role of EUS and EUS-guided FNA (EUS-FNA) in the diagnosis of rectosigmoid endometriosis in symptomatic patients is not well studied.

METHODS

A review of medical records identified 5 women who were diagnosed with rectosigmoid endometriosis by EUS and EUS-FNA over a period of 1 year.

OBSERVATIONS

Five women with nonspecific GI complaints underwent EUS examination of a rectosigmoid subepithelial mass found on colonoscopy. EUS revealed a hypoechoic lesion infiltrating the muscularis propria and the serosa of the rectal wall, and extending outside the rectal wall, findings consistent with rectosigmoid endometriosis. This diagnosis was confirmed by EUS-FNA, surgical exploration, and/or the patient's clinical course.

CONCLUSIONS

EUS and EUS-FNA are noninvasive, sensitive techniques for the diagnosis of rectosigmoid endometriosis in symptomatic patients.

[Laparoscopic colorectal resection for endometriosis: preliminary results]

OBJECTIVE

Colorectal endometriosis is source of chronic pelvic pain greatly affecting quality-of-life. Colorectal resection is indicated after failure of medical treatment. Few data are available on complications and functional results after laparoscopic colorectal resection for endometriosis. Therefore, the aims of this prospective study were to evaluate the feasibility, peri-operative complications and functional results of laparoscopic colorectal resection for endometriosis.

MATERIALS AND METHODS

From March 2001 to March 2003, 32 consecutive women with clinically-suspected colorectal endometriosis confirmed by MR imaging and rectal endoscopic sonography were included in this prospective study.

RESULTS

Conversion to open surgery was required for four of the 32 women (12.5%). Mean operating time was 6 hours (range 4 to 13). Associated surgical procedures were: adhesiolysis (n=24), ureteral lysis (n=19), ovarian cystectomy (n=11), and hysterectomy (n=4). Mean blood loss was 2.4 g/dl (range: 0 to 8.6). Blood transfusion was required in 6 women including two who underwent laparoconversion. Two rectovaginal fistulae (6.3%) occurred requiring a colostomy. Urinary retention was noted in 6 women (15.6%).

CONCLUSION

Laparoscopic colorectal resection for endometriosis is feasible and is associated with a significant improvement of symptoms. However, the benefit of this procedure has to be weighed against the high morbidity.