Bowel endometriosis: presentation, diagnosis, and treatment

Follow-up of bowel endometriosis resections performed using the double circular stapler technique: A decade's experience

STUDY OBJECTIVE

To report individual early and long-term functional outcomes of 43 women who underwent double circular stapler technique (DCST) for colorectal deep endometriosis (DE).

METHODS

This multidisciplinary observational study was a retrospective case series report exploiting a long-established database of clinical information from a single private institution. The cohort consists of consecutive patients from January/2010 through July/2021 who underwent minimally invasive surgical treatment of DE. Inclusion criteria: all women whose bowel DE was managed by DCST. The assessment of bowel function was based on Obstructed Defecation Syndrome score, Gastrointestinal Symptom Rating Scale and Bowel Function in the Community Tool. Outcomes also included intra and postoperative complications, lower urinary tract symptoms, endometriosis-related menstrual and nonmenstrual pain (numeric rating scale), and conception. The analysis of the results was guided by a semi-qualitative reasoning based on individual changes.

RESULTS

The follow-up ranged from 1.4 to 123.8 months (median 38.2). All women presented with DE (mostly rASRM stage 4) and underwent large resections. No procedure was converted to open surgery nor required blood transfusion or ostomies. There was no anastomotic leakage. The risk of rectovaginal bowel fistula was 2.3% (CI 95%: <0.1-7.0) - one case. No patient had long-term urinary retention after surgery. At the most recent follow-up on dysuria, dyschezia, dysmenorrhea, dyspareunia and cyclic low back pain, 88 to 100% of women had favorable responses (improvements ≥ 3 points in symptomatic women or asymptomatic women who remained pain-free). One patient reported important worsening of her intestinal function, requiring continuous use of laxatives. Considering the 20 women with pregnancy intent, 14 (70%) conceived after surgery.

DISCUSSION / CONCLUSION

Preliminary results were encouraging in the past. The current assessment including long-term follow-up supports DCST for colorectal DE as a feasible, useful, and safe strategy for avoiding segmental colorectal resection when appropriately indicated and properly performed.

Gastrointestinal function outcomes following radical and conservative colorectal surgery for deep endometriosis: A systematic review and meta-analysis

INTRODUCTION

Patients who have undergone colorectal surgery for symptomatic deep endometriosis may still encounter persistent or worsening digestive complaints. The aim of the present work was to analyze gastrointestinal function outcomes after radical and conservative colorectal surgery to further elucidate the effect of surgery on postoperative bowel function.

MATERIAL AND METHODS

PubMed, EMBASE, Web of Science, Clinical Trials.gov and the Cochrane Database databases were searched from January 1, 2010 until April 1, 2024. The quality of included studies was assessed by the Downs and Black quality checklist. Studies including patients with colorectal endometriosis who either underwent segmental resection (SR) or conservative approaches and reported data on bowel function were included.

RESULTS

From the initial pool of 55 studies, 14 reported patient reported outcome measures eligible to be pooled in the meta-analysis. Conservative surgery was less associated with constipation and increased number of daily stool (>3/day) when compared to SR (p = 0.02 and p = 0,0004, respectively). No difference was found in the occurrence of gas and stool incontinence (p = 0.72), postsurgical defecation pain (p = 0.44) and time to defer defecation (≤ 15 min; p = 0.64). Patients in the conservative surgery group reported higher postoperative Gastrointestinal Quality of Life Index (GIQLI) when compared to SR (p = 0.01). However, when comparing changes between pre- and postsurgical patient reported outcome measures within the respective groups, rather than evaluating postsurgical outcomes alone, none of the intervention groups showed significant changes between pre- and postsurgical GIQLI, Knowles Eccersley Scott Symptom Score(KESS) and Wexner scores (p = 0.28, p = 0.94 and p = 0.78, respectively).

CONCLUSIONS

Segmental resection seems to be associated with higher rates of post-operative constipation and lower GIQLI scores when compared to conservative surgery. However, when comparing the change of gastrointestinal function symptoms reflected by changes of gastrointestinal function parameters from pre- to postoperative rather than focusing on purely postoperative parameters alone, no significant difference of these parameters was observed between surgical techniques.

Safety and efficacy of pharmacotherapies for pelvic inflammatory disease and endometriosis

INTRODUCTION

Endometriosis and pelvic inflammatory disease (PID) are gynecological conditions affecting women of reproductive age and causing pain symptoms. The symptoms caused by these conditions are similar; thus, the differential diagnosis may be challenging. The treatment of these conditions is very different because PID is treated with antibiotic therapy, while endometriosis is treated with hormonal therapies suppressing estrogen levels.

AREAS COVERED

A narrative review was conducted through a comprehensive literature search on endometriosis and PID. The search strategy incorporated relevant keywords and MeSH terms related to these topics.

EXPERT OPINION

The antibiotics used to manage PID have high efficacy and safety profiles. Commonly prescribed regimens include a combination of ceftriaxone, doxycycline, and metronidazole. These antibiotics are generally well-tolerated, with most adverse effects being mild and manageable (gastrointestinal disturbances or hypersensitivity reactions). Hormonal therapies are a cornerstone in the management of endometriosis; they include combined oral contraceptives (COCs), progestins, gonadotropin-releasing hormone (GnRH) agonists, and antagonists. COCs and progestins are generally well-tolerated with a favorable safety profile, though they may cause side effects (breakthrough bleeding and mood changes). Oral GnRH antagonists have emerged as a noteworthy option, offering partial estrogen suppression and thereby overcoming the limitations associated with previously used GnRH agonists.

A quality-of-life meta-analysis comparing pre- and postoperative symptoms in women undergoing colorectal resection for deep infiltrating endometriosis

AIM

Deep infiltrating endometriosis (DIE) may involve the rectum or colon and is associated with pain, gastrointestinal dysfunction and reduced quality of life (QoL). While hormonal treatment may be effective, surgical intervention including colorectal resection can be required. Colorectal resection can result in functional changes and complications, which can also impair QoL. The aim of this study is to examine all available comparative pre- and postoperative data on QoL and symptom outcomes following colorectal resection for DIE.

METHOD

An electronic database search was conducted for studies reporting pre- and postoperative QoL and symptom outcomes following colorectal resection for DIE. The study was registered with PROSPERO and followed PRISMA (Preferred Reporting Items in Systematic Reviews and Meta-analyses) guidelines. Data were combined using random-effects models.

RESULTS

Fourteen studies including 1142 patients were included. Colorectal resection was associated with improved outcomes for all items in the SF-36 QoL questionnaire as well as symptom outcomes including dysmenorrhoea, chronic pelvic pain and deep dyspareunia. Importantly, the gastrointestinal QoL index was significantly improved (mean difference 24.50, 95% CI 15.93-33.08, p < 0.0001) as was dyschezia (mean difference -4.1, 95% CI -4.77 to -3.42, p < 0.0001). There was no change in low anterior resection syndrome scores (mean difference -5.28, 95% CI -11.65 to 1.10, p = 0.1046).

CONCLUSION

This study demonstrates a significant postoperative improvement in patient-reported QoL, pain symptoms and gastrointestinal function following colorectal resection for endometriosis.

Intestinal endometriosis amongst other extra-pelvic endometriosis foci presenting as acute/subacute bowel obstruction in women of reproductive age: a retrospective case series study

BACKGROUND

This study aimed to investigate the prevalence and clinicopathological correlates of intestinal endometriosis, amongst other extra-pelvic endometriosis foci, presenting as bowel obstruction in general surgery practice.

METHODS

A total of 23 female patients (mean ± SD age: 34.9 ± 6.5 years) who underwent abdominal surgery for acute bowel obstruction and received histopathological diagnosis of endometriosis were included in this retrospective case-series study. Data on patient characteristics, obstetric history, preoperative laboratory and imaging findings, preoperative provisional diagnosis, type of surgical intervention and the pathological diagnosis, and postoperative outcomes were recorded.

RESULTS

Definitive diagnoses on histopathological work-up involved intestinal endometriosis (52.2%), scar endometriosis (26.0%), ovarian endometriosis (13.0%) and inguinal endometriosis (8.7%). Postoperative complication, reoperation and recurrence rates were 8.7%, 8.7%, and 13.0%, respectively. Intestinal endometriosis, when compared to other extra-pelvic endometriosis foci (scar and inguinal), was associated with significantly higher preoperative platelet counts (332.0(284.0-528.0)vs. 239.0(223.0-370.0) 103/µL, p = 0.010), lower albumin levels (4.0(2.7-4.7) vs. 4.5(4.2-4.9) g/dL, p = 0.029), higher rates of preoperative CT utilization (91.7% vs. 0.0%, p < 0.001) and emergent surgery (83.3% vs. 0.0%, p = 0.001) and longer LOS (median 4.5 (1.0-26.0) vs. 1.0(1.0-1.0) days, p = 0.001) along with a non-significant tendency for higher postoperative complication (16.7% vs. 0.0%) and ICU stay (25.0% vs. 0.0%) rates.

CONCLUSION

Our findings revealed intestinal endometriosis, predominantly in the terminal ileum/appendix, was the most common extra-pelvic cause of acute bowel obstruction. The scar endometriosis, inguinal endometriosis and ovarian endometriosis appeared to be other potential but less prevalent aetiologies in this setting.

Ultrasound Diagnosis of Bowel Endometriosis

BACKGROUND

Bowel endometriosis is one of the more severe manifestations of deep endometriosis; it may cause pain and intestinal symptoms. The noninvasive diagnosis of bowel endometriosis is of crucial importance in planning the management of patients affected by this condition.

OBJECTIVES

This review aims to describe how transvaginal ultrasonography (TVS) is performed in patients with suspicion of rectosigmoid endometriosis, the diagnostic performance, and the strengths and limitations of this technique.

METHODS

To identify relevant literature, a literature search was performed across the PubMed and Google Scholar databases up to July 2024.

OUTCOME

Numerous meta-analyses have demonstrated that TVS has high diagnostic accuracy in diagnosing rectosigmoid endometriosis. Rectosigmoid nodules can present with different morphological characteristics, but they are typically described as irregular, hypoechoic nodules located in the anterior wall of the rectosigmoid colon. The presence of "soft markers," such as a negative sliding sign and kissing ovaries, can further reinforce the diagnosis of this condition. Posterolateral parametrial involvement often coexists with large rectal nodules. Introducing water contrast into the rectosigmoid does not improve the performance of TVS in diagnosing rectosigmoid endometriosis.

CONCLUSIONS AND OUTLOOK

TVS should be the first-line investigation in women suspected of having rectosigmoid endometriosis. The widespread use of TVS for the diagnosis of intestinal endometriosis can reduce diagnostic delays and facilitate the treatment of patients affected by this condition.

Conservative Management of Bowel Endometriosis: Cross-Sectional Analysis for Assessing Clinical Outcomes and Quality-of-Life

Background/Objectives: Bowel endometriosis (BE) is characterized by the presence of endometrial-like tissue within the muscular layer of the bowel wall. When BE does not result in the severe obstruction to fecal transit and in the absence of (sub)occlusive symptoms, the decision to perform surgery can be challenging, as intestinal procedures are associated with higher complication rates and long-term bowel dysfunction. This cross-sectional study aims to evaluate the quality of life (QoL) in patients with BE who avoided surgery, as well as to investigate the impact of the characteristics of BE nodules on the QoL and intestinal function. Methods: A retrospective cross-sectional analysis was conducted involving 580 patients with BE who did not undergo surgery but were treated conservatively with medical therapy or expectant management between January 2017 and August 2022. The diagnosis of BE was established through transvaginal ultrasound and confirmed via double contrast barium enema. After at least one year of follow-up, the QoL and intestinal function were assessed using the Endometriosis Health Profile-5 (EHP-5) questionnaire and the Bowel Endometriosis Symptom (BENS) score, while pain symptoms were quantified with the Visual Analog Scale (VAS 0-10). Statistical analyses were performed to explore potential associations between the QoL and the characteristics of BE nodules (size, location, and evidence of stenosis), as well as the type and duration of medical therapy. Results: Patients with BE reported a satisfactory overall QoL, with a mean EHP-5 score of 105.42 ± 99.98 points and a VAS score below three across all pain domains. They did not demonstrate significant impairment in bowel function, as indicated by a mean BENS score of 4.89 ± 5.28 points. Notably, patients receiving medical therapy exhibited a better QoL compared to those not receiving treatment (p < 0.05), with the exception of postmenopausal patients, who reported the highest QoL overall (p < 0.05). Among the characteristics of BE, nodule location significantly impacted the QoL and symptom intensity, with low (rectal or rectosigmoid) nodules less tolerated compared to sigmoid nodules, particularly regarding non-menstrual pelvic pain (NMPP), dyschezia, and psychological impact on daily life (p < 0.05). Conclusions: Women can effectively manage BE conservatively in the absence of (sub)occlusive symptoms, even when large nodules are present, causing significant radiological stenosis. The characteristics of BE nodules do not significantly affect the QoL or symptom intensity; however, the location of BE nodules is a crucial factor negatively influencing these outcomes. Medical therapy may confer a beneficial impact on patients of reproductive age with BE, but its use should be carefully considered for those approaching menopause, weighing the risks and benefits.

Endometrioma surgery: Hit with your best shot (But know when to stop)

Ovarian endometriomas (OEs) are commonly detected by ultrasound in individuals affected by endometriosis. Although surgery was widely regarded in the past as the gold standard for treating OEs, especially in the case of large cysts, the surgical management of OEs remains debated. Firstly, OEs often represent the "tip of the iceberg" of underlying deep endometriosis, and this should be considered when treating OEs to ameliorate patients' pain for focusing on the surgical objectives and providing better patient counseling. In the context of fertility care, OEs may have a detrimental effect on ovarian reserve through structural alterations, inflammatory responses, and oocyte reserve depletion. Conversely, the surgical approach may exacerbate the decline within the same ovarian reserve. While evidence suggests no improvement in in-vitro fertilization (IVF) outcomes following OE surgery, further studies are needed to understand the impact of OE surgery on spontaneous fertility. Therefore, optimal management of OEs is based on individual patient and fertility characteristics such as the woman's age, length of infertility, results of ovarian reserve tests, and surgical background. Among the available surgical approaches, cystectomy appears advantageous in terms of reduced recurrence rates, and traditionally, bipolar coagulation has been used to achieve hemostasis following this approach. Driven by concerns about the negative impact on ovarian reserve, alternative methods to obtain hemostasis include suturing the cyst bed, and novel methodologies such as CO2 laser and plasma energy have emerged as viable surgical options for OEs. In instances where sonographic OE features are non-reassuring, surgery should be contemplated to obtain tissue for histological diagnosis and rule out eventual ovarian malignancy.

Endometriosis of the Colon and Pericolic Lymph Nodes Presenting as Cecal Volvulus

Endometriosis, characterized by the ectopic implantation of endometrial tissue, typically involves pelvic structures but infrequently extends to extrapelvic sites such as the gastrointestinal tract. In this report, we present a case of a 44-year-old woman with diffuse abdominal discomfort and constipation. Computed tomography imaging revealed a mass in the cecum, leading to diagnostic colonoscopy and subsequent magnetic resonance imaging. Ultimately, laparoscopy revealed a puckered cecal mass suspected to be invasive malignancy but pathologically confirmed as extensive endometriosis involving the colonic wall and pericolic lymph nodes. Cecal volvulus secondary to endometriosis is exceedingly rare, with surgical intervention being the primary treatment modality. Endometriosis-associated gastrointestinal involvement often masquerades as irritable bowel syndrome, highlighting the importance of considering atypical presentations in young women. This case underscores the need to maintain a high index of suspicion for unusual etiologies in patients with gastrointestinal symptoms and atypical imaging findings to facilitate timely diagnosis and management.

Is this an adenocarcinoma? A case report of extragenital endometriosis with hydroureteronephrosis

Introduction and importance

Endometriosis is a prevalent condition within the female reproductive age group, but its presentation and diagnosis still pose a challenge as it mimics other diseases and affects multiple organ systems.

Case presentation

A 24-year-old nulliparous female presented with complaints of menorrhagia, lower abdominal pain, post-coital bleeding, and significant weight loss for 7 months.

Clinical discussion

The case highlights the challenge of diagnosing endometriosis due to its ability to mimic other conditions, such as carcinoma cervix and rectum. The presence of elevated Cancer Antigen-125 (CA-125), typically associated with malignancy, underscores the need for a comprehensive evaluation to differentiate between endometriosis and other pathologies. Furthermore, the involvement of multiple organ systems emphasizes the systemic nature of endometriosis and the importance of considering it in the differential diagnosis of pelvic masses and symptoms in young women.

Conclusion

Endometriosis, although a common disease among females of reproductive age its variation in presentation causes significant misdiagnosis and undertreatment. Multi-modal diagnosis and early treatment are necessary for proper outcomes.

Is high-intensity focused ultrasound a magical solution to endometriosis? A systematic review

Background

Endometriosis presents a significant challenge in gynecological endocrinology, affecting approximately 1 in 10 women of reproductive age. Abdominal wall endometriosis (AWE) and rectosigmoid deep infiltrating endometriosis (DIE) pose unique clinical complexities. High-intensity focused ultrasound (HIFU) has emerged as a novel alternative for treating these conditions, offering a noninvasive option with potential therapeutic benefits.

Methods

A systematic review was conducted following PRISMA guidelines to investigate the safety and efficacy of HIFU therapy for AWE and rectosigmoid DIE. The literature search encompassed databases from inception to January 20, 2024. Eligible studies included observational studies, case reports, and clinical trials evaluating HIFU treatment for endometriosis. Data extraction and risk of bias assessment were performed following established protocols.

Results

Fourteen studies were included, comprising 330 patients with AWE and 28 patients with rectosigmoid DIE. HIFU treatment demonstrated significant efficacy, with many patients experiencing complete remission, and clinical effectiveness. Reductions in lesion volume posttreatment were consistent across studies. However, safety concerns were noted, including pain at the treatment site, hematuria, and skin burns. Adverse effects underscored the importance of careful patient selection and monitoring during HIFU therapy.

Conclusion

HIFU therapy shows promise as a noninvasive approach for managing AWE and rectosigmoid DIE. While efficacy outcomes are encouraging, safety considerations warrant attention. Further research, particularly randomized controlled trials with larger sample sizes, is needed to validate findings and optimize treatment protocols.

Functional outcomes of bowel resection versus shaving or disc excision of colorectal endometriosis: a systematic review protocol

INTRODUCTION

Endometriosis is a prevalent gynaecological condition for women of reproductive age worldwide. While endometriosis primarily involves the reproductive system, it can also infiltrate additional viscera such as the gastrointestinal tract. Patients with colorectal endometriosis can have severe symptoms that require surgical intervention. There are limited data available to guide the choice of resection technique based on the functional outcomes of bowel resection versus shaving or disc excision in treating colorectal endometriosis. This protocol aims to outline the methods that will be used in a systematic review of the literature comparing the functional outcomes of bowel resection to shaving and disc excision when surgically treating colorectal endometriosis.

METHODS AND ANALYSIS

Papers will be identified through database searches, scanning reference lists of relevant studies and citation searching of key papers. Two independent reviewers will screen studies against eligibility criteria and extract data using standardised forms. Databases including MEDLINE, EMBASE and Cochrane will be searched from the beginning of each database until February 2024. The primary outcome is comparing the functional bowel outcomes between the different methods of surgical treatment. Secondary outcome will be quality of life, based on the Low Anterior Resection Syndrome score and the incidence of postoperative pain. A meta-analysis will be performed if the data are homogenous.

ETHICS AND DISSEMINATION

This study does not require ethics approval. The results of the systematic review described within this protocol will be disseminated through presentations at relevant conferences and publication in a peer-reviewed journal. The methods will be used to inform future reviews.

PROSPERO REGISTRATION NUMBER

CRD42023461711.

[Surgical treatments for endometriosis]

Complete resection of scattered superficial lesions can be paradoxically more complex. If the endometriosis is ovarian, priority should be given to preserving the oocyte capital, and ovarian function should be assessed in patients of childbearing age who wish to become pregnant, prior to treatment by alcoholization of the cyst, abrasion of its contents by laser or plasma energy, or even cystectomy. Laparoscopic resection is recommended in cases of deep endometriosis. After a thorough clinical examination and precise imaging, deep lesions are treated by resection and shaving in the case of digestive or ureteral localizations, or even by discoid resection or digestive anastomosis resection with or without stoma, depending on fistula risk criteria. The aim is to reduce pain and functional consequences, while preserving ovarian function to improve pregnancy rates.

A Case of Rectal Endometriosis Misdiagnosed as Rectal Malignancy on Three Colonoscopies and Biopsies Sharing a Combined Literature Review

BACKGROUND

Endometriosis involves the intestine, and its clinical manifestations are nonspecific and lack of etiological manifestations. The diagnosis is difficult, which often leads to misdiagnosis. We report a case of endometriosis which was misdiagnosed as intestinal malignant tumor after colonoscopy and three biopsies.

CASE PRESENTATION

We reported a 42-year-old woman who went to see a doctor because of anal distension. She was examined by three gastrointestinal endoscopists at different levels in different hospitals and underwent biopsy at the same time. Combined with clinical manifestations, imaging examination, endoscopic examination and pathological examination, she was misdiagnosed as intestinal malignant tumor, and partial intestinal resection was performed according to the surgical principle of malignant tumor.

CONCLUSION

Although there are advanced gastrointestinal endoscopy and imaging techniques, intestinal endometriosis is still easy to be misdiagnosed. As our case report shows, after three colonoscopy and biopsy, it is still misdiagnosed as intestinal malignant tumor. Further research is needed to improve the ability of preoperative diagnosis, which deserves the attention of gastroenterologists and obstetricians and gynecologists.

A review of phase II and III drugs for the treatment and management of endometriosis

INTRODUCTION

Endometriosis is an estrogen-dependent disease that gives rise to pelvic pain and infertility. Although estroprogestins and progestins currently stand as the first-line treatments for this condition, demonstrating efficacy in two-thirds of patients, a significant portion of individuals experience only partial relief or symptom recurrence following the cessation of these therapies. The coexistence of superficial, deep endometriosis, and ovarian endometriomas, as three distinct phenotypes with unique pathogenetic and molecular characteristics, may elucidate the current heterogeneous biological response to available therapy.

AREAS COVERED

The objective of this review is to furnish the reader with a comprehensive summary pertaining to phase II-III hormonal treatments for endometriosis.

EXPERT OPINION

Ongoing research endeavors are directed toward the development of novel hormonal options for this benign yet debilitating disease. Among them, oral GnRH antagonists emerge as a noteworthy option, furnishing rapid therapeutic onset without an initial flare-up; these drugs facilitate partial or complete estrogen suppression, and promote prompt ovarian function recovery upon discontinuation, effectively surmounting the limitations associated with previously employed GnRH agonists. Limited evidence supports the use of selective estrogen and progesterone receptor modulators. Consequently, further extensive clinical research is imperative to garner a more profound understanding of innovative targets for novel hormonal options.

En-block butterfly excision of posterior compartment deep endometriosis: The first experience with the new surgical robot Hugo™ RAS

Background

Minimally invasive surgery is the gold standard treatment for deep endometriosis when medical management fails. In selected cases, such as when bowel or urinary tract are involved, robotic assisted surgery can be useful due to its characteristics of high dexterity and manoeuvrability. This is the first case of robotic en-bloc excision of posterior compartment deep endometriosis performed with the new HugoTM RAS system.

Objective

The purpose of this video article is to show for the first time the feasibility of bowel surgery for deep endometriosis with this new robotic device.

Materials and Methods

A 24-years-old woman affected by severe dysmenorrhea, chronic pelvic pain, dyschezia and dyspareunia underwent to deep endometriosis excision using the new robotic platform HugoTM RAS system at the Unit of Gynaecological Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.

Main outcome measures

Intraoperative data, docking set up, post-operative outcomes up to three months follow up were evaluated.

Results

The surgical procedure was carried out without intra-operative or post-operative complications, operative time (OT) was 200 minutes, while docking time was 8 minutes. No system errors or faults in the robotic arms were registered. Post-operative complete disease-related symptoms relief was reported.

Conclusion

According to our results, the introduction of this new robotic platform in the surgical management of deep endometriosis seems to be feasible, especially in advanced cases. However, further studies are needed to demonstrate the benefits of this surgical system and the advantages of robotic surgery compared to laparoscopy in this subset of patients.

Endometriosis as an Uncommon Cause of Intestinal Obstruction-A Comprehensive Literature Review

The prevalence of intestinal endometriosis has been estimated to be between 3% and 37% of all endometriosis cases. Cases of intestinal occlusion due to endometriosis foci on the small bowel and on the large bowel are even rarer, with a reported prevalence of 0.1-0.7%. The aim of this literature review was to summarize the available published evidence on the diagnosis, characteristics, and management of intestinal occlusion due to endometriosis. The search on PubMed retrieved 295 records, of which 158 were rejected following a review of the title and abstract. After reviewing the full text, 97 studies met the Population, Intervention, Comparator, Outcomes, and Study (PICOS) criteria and were included in the analysis. The total number of patients with bowel occlusion due to endometriosis included in the studies was 107. The occlusive endometrial foci were localized on the ileum in 38.3% of the cases, on the rectosigmoid in 34.5% of the cases, at the ileocecal junction and the appendix in 14.9% of the cases, and at the rectum in 10.2% of the cases. Only one case reported large bowel obstruction by endometriosis of the hepatic flexure of the colon extending to the transverse colon (0.9%), and in one case the obstruction was caused by an omental giant endometrioid cyst compressing the intestines. We identified six cases of postmenopausal females with acute bowel obstruction due to endometriosis. Malignant degeneration of endometriosis was also identified as a cause of intestinal occlusion. The mechanisms of obstruction include the presence of a mass in the lumen of the intestine or in the wall of the intestine, extrinsic compression, adhesions, or intussusception.

Deep Endometriosis of the Terminal Ileum Presenting With Cyclic Recurrent Small Bowel Obstruction

Here, we discuss a case of a 42-year-old premenopausal female who presented with chronic pelvic pain and recurrent small bowel obstruction during menstruation. The patient reported a nine-year history of pelvic pain and a four-year history of episodic small bowel obstruction requiring multiple prior inpatient admissions. During these admissions, the obstruction was managed conservatively with bowel rest and nasogastric tube placement; however, symptoms would recur with subsequent menstrual cycles. Computed tomography showed diffusely dilated loops of small bowel with a transition point in the central anterior pelvis, and magnetic resonance enterography revealed a mass-like area involving small bowel loops in the mid pelvis. The patient underwent laparoscopic surgical intervention including bowel resection with re-anastomosis, hysterectomy, bilateral salpingectomy, and left oophorectomy. Intraoperative findings included severe distention of the proximal bowel with a discrete deep endometriosis lesion of the terminal ileum which was confirmed on final pathologic examination. This case emphasizes the importance of considering endometriosis as the etiology of recurrent catamenial small bowel obstruction, particularly in premenopausal women.

Large bowel perforation secondary to endometriosis

Endometriosis is described as the implantation of ectopic, viable endometrium. Among the complications associated with this phenomenon, ectopic foci that localizes to the bowel can result in many presentations. An uncommon presentation of such an occurrence is a mass effect on the colon causing an obstruction. This case report describes the progression of endometriosiscausing mass effect in the colon and resulting in perforated hollow viscous. Hence, this demonstrates the importance of maintaining endometriosis as a differential diagnosis in women of childbearing age presenting with bowel obstruction. Although the presence of endometriosis as a cause of bowel obstruction has been reported in the literature, the presentation of large bowel perforation is rare. In this case, an extremely rare presentation of sigmoid obstruction with transverse colonic perforation is observed.

Differences in intensity and quality of bowel symptoms in patients with colorectal endometriosis : An observational cross-sectional study

BACKGROUND

Patients suffering from colorectal deep endometriosis (DE) experience gastrointestinal symptoms with almost the same frequency as gynecological pain symptoms. Preoperatively existing gastrointestinal symptoms may translate into pathological gastrointestinal quality of life index (GIQLI) and low anterior resection syndrome scores (LARS). This prospective questionnaire-based case control study aims to assess the prevalence of gastrointestinal complaints reflected by changes in LARS and GIQLI scores in patients with colorectal deep endometriosis prior to surgical treatment and compare those to a healthy control group.

METHODS

The study was conducted at the Hospital St. John of God in Vienna and included a total of 97 patients with histologically confirmed colorectal DE with radical surgical treatment and 96 women in whom DE was excluded via transvaginal sonography (TVS) or visually. Gastrointestinal symptoms reflected by LARS and GIQLI scores were evaluated presurgically and in controls.

RESULTS

A total of 193 premenopausal patients were included in this study. A mean GIQLI of 90.7 ± 22.0 and 129.4 ± 11.1 was observed among patients and controls, respectively, showing a significantly higher morbidity concerning gastrointestinal symptoms and decreased quality of life (QoL) compared to healthy controls (p < 0.001). The LARS score results demonstrated that 18.6% of the patients with bowel DE presented with a major LARS and 27.8% with a minor LARS presurgically compared to 2.1% and 9.4% of control patients, respectively (p < 0.001).

CONCLUSION

Patients with colorectal DE experience a quality of gastrointestinal symptoms translating into a decreased QoL and pathological GIQLI and LARS scores already presurgically. As a consequence, these instruments should be interpreted with caution.

Surgery vs. hormone-based treatment for pain control in deep infiltrating endometriosis: a retrospective cohort study

OBJECTIVE

To evaluate the outcome of surgical or hormone-based pharmacological treatment for deep infiltrating endometriosis (DIE) in patients with pain symptoms.

STUDY DESIGN

A retrospective cohort study of 122 women with DIE of the bowel was conducted: 61 women underwent surgical treatment due to poor pain control and 61 received hormone-based treatment alone for at least six months. Chronic pelvic pain, dysmenorrhea, deep dyspareunia, dyschezia and dysuria were evaluated by a visual analog scale (VAS) to measure pain on a scale from 0 to 10. Dyspareunia was further evaluated using the Deep Dyspareunia Scale (scores of 0-3).

RESULTS

Surgery (n = 61 women) was performed at a mean of 3.3 ± 1.6 years previously, while hormone-based treatment alone (n = 61 women) was used for a mean of 3.0 ± 1.41 years. After surgery, women without a desire to procreate received hormone-based treatment. Before treatment, the most intense endometriosis-related pain in the surgical treatment group and hormone-based treatment group alone were chronic pelvic pain (VAS = 9.48 ± 1.49; 8.57 ± 2.22), dysmenorrhea (VAS = 9.61 ± 1.45; 9.02 ± 1.35) and deep dyspareunia (VAS = 8.04 ± 2.82; 7.47 ± 3.21, respectively), all with mean pain scores of around 8 (0-10) in both groups. Both treatments were effective at reducing all symptoms (p < .001). The surgical treatment proved to be more effective and more enduring at improving chronic pelvic pain (p < .001), dyschezia (p = .003) and deep dyspareunia (p < .001). Regarding deep dyspareunia, using the deep dyspareunia scale, ∼70% of surgically treated women scored 0 or 1 (absent or mild deep dyspareunia) after treatment, compared to scores 2 or 3 (intense dyspareunia) in about 70% of the group using hormone-based treatment (p < .001).

CONCLUSION

Both types of treatment, surgical and pharmacological, effectively improved pain symptoms associated with DIE. However, improvement in chronic pelvic pain, dyschezia and deep dyspareunia was greater and longer-lasting after surgery.

Beyond borders: A case report of small bowel obstruction secondary to undiagnosed florid endometriosis

Introduction and importance

Endometriosis is a gynecological condition referring to the presence of endometrial tissue outside the endometrium with the potential of progressing to malignancy. It mostly affects pelvic organs; however, it has been described beyond the pelvis. In 10% of cases it occurs in the bowel, mostly rectum and sigmoid. Involvement of the small bowel is rare. Here we report endometriosis of the terminal ileum and appendix in a patient with no previous diagnosis of endometriosis.

Case presentation

We describe a case of a 39-year-old-female who presented with abdominal pain, nausea and vomiting to the emergency department. This was on background history of intermittent abdominal pain every 2 weeks for the previous 5 months. Further investigation with computed tomography (CT) of the abdomen and pelvis showed small bowel dilatation with a polypoidal lesion obstructing the terminal ileum. On colonoscopy, no intraluminal lesions were identified in the terminal ileum. The patient underwent right hemicoloectomy. Histopathological results revealed endometriosis. The patient had uneventful recovery post-operatively and at her follow-up review at 4 weeks and 2 months from surgery.

Discussion

The presentation of endometriosis of the bowel is highly variable and difficult to diagnose pre-operatively. Due to lack of specific diagnostic measures, surgical resection and histology can be the only reliable way for first-time endometriosis diagnosis presenting as small bowel obstruction.

Conclusion

Extra-pelvic endometriosis should be considered as the cause of small bowel obstruction in the absence of other causes of bowel obstruction in young female patients.

•

Bowel endometriosis can be asymptomatic or can present with wide range of symptoms

•

Small bowel obstruction is a rare presentation of first-time endometriosis diagnosis

•

There is no specific diagnostic measure for endometriosis presenting as small bowel obstruction

•

Intra-operative and histological examinations can be the only reliable measure to diagnose small bowel endometriosis.

Endometriosis and adverse pregnancy outcome

INTRODUCTION

Endometriosis is a gynecologic disease affecting approximately 10% of reproductive age women, around 21-47% of women presenting subfertility and 71-87% of women with chronic pelvic pain. Main symptoms are chronic pelvic pain, dysmenorrhea, dyspareunia and infertility that seem to be well controlled by oral contraceptive pill, progestogens, GnRh antagonists. The aim of this review was to illustrate the modern diagnosis of endometriosis during pregnancy, to evaluate the evolution of endometriotic lesions during pregnancy and the incidence of adverse outcomes.

EVIDENCE ACQUISITION

Published literature was retrieved through searches of the database PubMed (National Center for Biotechnology Information, US National Library of Medicine, Bethesda, MD, USA). We searched for all original articles published in English through April 2020 and decided to extract every notable information for potential inclusion in this review. The search included the following MeSH search terms, alone or in combination: "endometriosis" combined with "endometrioma," "biomarkers," "complications," "bowel," "urinary tract," "uterine rupture," "spontaneous hemoperitoneum in pregnancy" and more "adverse pregnancy outcome," "preterm birth," "miscarriage," "abruption placentae," "placenta previa," "hypertensive disorder," "preeclampsia," "fetal grow restriction," "small for gestation age," "cesarean delivery."

EVIDENCE SYNTHESIS

Pregnancy in women with endometriosis does not always lead to disappearance of symptoms and decrease in the size of endometriotic lesions, but it may be possible to observe a malignant transformation of ovarian endometriotic lesions. Onset of complications may be caused by many factors: chronic inflammation, adhesions, progesterone resistance and a dysregulation of genes involved in the embryo implantation. As results, the pregnancy can be more difficult because of endometriosis related complications (spontaneous hemoperitoneum [SH], bowel complications, etc.) or adverse outcomes like preterm birth, FGR, hypertensive disorders, obstetrics hemorrhages (placenta previa, abruptio placenta), miscarriage or cesarean section. Due to insufficient knowledge about its pathogenesis, currently literature data are contradictory and do not show a strong correlation between endometriosis and these complications except for miscarriage and cesarean delivery.

CONCLUSIONS

Future research should focus on the potential biological pathways underlying these relationships in order to inform patients planning a birth about possible complications during pregnancy.

Pelvic floor dysfunction at transperineal ultrasound and chronic constipation in women with endometriosis

OBJECTIVE

To assess the association between sonographic findings at transperineal ultrasound (TPU) and chronic constipation (CC) in women with endometriosis.

METHODS

An observational prospective cohort study was performed by enrolling all endometriosis women scheduled for surgery between September 2019 and October 2020. Women underwent TPU at rest and during Valsalva maneuver evaluating levator-hiatal-area (LHA), antero-posterior diameter (APD), levator-ani muscle (LAM)-coactivation. Ultrasound findings were compared between women with and without CC in the whole study population, and subsequently in two subgroups [only ovarian and deep infiltrating endometriosis (DIE)].

RESULTS

87 women were enrolled: 29 (33%) with CC and 58 (67%) without CC. Women with endometriosis and CC showed a smaller LHA during Valsalva, less LHA and APD enlargement from rest to maximum Valsalva, a higher prevalence of LAM-coactivation compared to women without CC. In ovarian-subgroup, women with CC had smaller LHA at Valsalva, less enlargement of LHA and APD from rest to maximum Valsalva and higher prevalence of LAM-coactivation compared to non-CC patients. In DIE-subgroup, TPU did not significantly differ between CC and non-CC patients.

CONCLUSION

TPU signs of pelvic floor muscle hypertone are more frequent in endometriosis patients with CC compared to those without constipation, particularly in women affected by isolated ovarian endometriosis.

3D Patient-Specific Virtual Models for Presurgical Planning in Patients with Recto-Sigmoid Endometriosis Nodules: A Pilot Study

Background and Objective: In recent years, 3D printing has been used to support surgical planning or to guide intraoperative procedures in various surgical specialties. An improvement in surgical planning for recto-sigmoid endometriosis (RSE) excision might reduce the high complication rate related to this challenging surgery. The aim of this study was to build novel presurgical 3D models of RSE nodules from magnetic resonance imaging (MRI) and compare them with intraoperative findings. Materials and Methods: A single-center, observational, prospective, cohort, pilot study was performed by enrolling consecutive symptomatic women scheduled for minimally invasive surgery for RSE between November 2019 and June 2020 at our institution. Preoperative MRI were used for building 3D models of RSE nodules and surrounding pelvic organs. 3D models were examined during multi-disciplinary preoperative planning, focusing especially on three domains: degree of bowel stenosis, nodule's circumferential extension, and bowel angulation induced by the RSE nodule. After surgery, the surgeon was asked to subjectively evaluate the correlation of the 3D model with the intra-operative findings and to express his evaluation as "no correlation", "low correlation", or "high correlation" referring to the three described domains. Results: seven women were enrolled and 3D anatomical virtual models of RSE nodules and surrounding pelvic organs were generated. In all cases, surgeons reported a subjective "high correlation" with the surgical findings. Conclusion: Presurgical 3D models could be a feasible and useful tool to support surgical planning in women with recto-sigmoidal endometriotic involvement, appearing closely related to intraoperative findings.

Perspectives on modes of labour and delivery after different modalities of surgery for bowel endometriosis

Bowel or intestinal endometriosis is estimated to affect 5-37% of women with deep infiltrative endometriosis (DIE), especially in the rectum and recto-sigmoid junction. However, there are no current guidelines or consensus regarding safest mode of delivery in pregnant women after different surgical interventions for bowel/intestinal endometriosis. From October 2019 to February 2020, we conducted an online survey of members of the British Society for Gynaecological Endoscopy (BSGE). These included questions on what gynaecologist members would recommend as modes of delivery in women who had different surgical modalities for bowel endometriosis, and the particular factors that influence such recommendations. Analysis of data was performed using SPSS for Windows (V9) software package. One hundred and two members of BSGE completed the survey (61.76% of BSGE gynaecologist members). Only 30.39% of respondents counsel women, pre-operatively, about possible effects of surgical treatment of bowel endometriosis on their subsequent mode of delivery. Our survey highlights wide variation in practice that currently exists. Around 70% of clinicians are not counselling patients regarding delivery options pre-surgery despite almost one-third recommending planned caesarean section if the vagina is opened. Further studies are required to stratify the risk factors for such patients when attempting vaginal delivery or caesarean section.IMPACT STATEMENTWhat is already known on this subject? Treatment of colorectal endometriosis consists of rectal shaving, discoid resection or segmental colorectal resection. However, the relationship between different surgical modalities for bowel endometriosis and the subsequent safe mode of labour and delivery remains unclear.What do the results of this study add? No study has been published that specifically looked at the particular course and outcome of labour and delivery after each of these bowel surgeries; rectal shaving, disc excision, or segmental colorectal resection. Our study highlights the wide variations in practice that currently exists. Despite around 70% of clinicians not counselling women regarding delivery options pre-surgery, almost one-third would recommend a planned caesarean section if the vagina is opened.What are the implications of these findings for clinical practice and/or further research? This study suggests that risk factors should be stratified for such patients when attempting a vaginal delivery or undergoing a caesarean section. Guidance from the ESGE and/or BSGE would be useful to aid in the counselling and informed consent of such patients.

Ileocecal intussusception as the initial presentation of endometriosis: case report

Cecal endometriosis is a rare entity that can present as nonspecific acute abdominal pain and can be complicated by ileocolic intussusception, which is extremely infrequent. We present the case of a 33-year-old woman with no relevant pathological antecedents who consulted for abdominal pain for 5 days, associated with rebound tenderness and abdominal guarding on the right lower quadrant and a palpable mass during the physical examination. Computed tomography was realized and emergency surgery performed due to suspected ileocolic intussusception. The laparoscopic examination identified an ileocolic intussusception associated with a tumor. Conversion to open surgery was needed, and an oncological right hemicolectomy with ileotransverse anastomosis was carried out. Histopathological study reported ileocolic intussusception and a focus of cecal endometriosis. Currently, the patient does not have recurrences. Ileocolic intussusception secondary to deep endometriosis requires great diagnostic presumption in women of childbearing age with acute abdomen diagnosis.

Evaluation of Bowel Function After Surgical Treatment for Intestinal Endometriosis: A Prospective Study

BACKGROUND

Defecation symptoms related to intestinal deep infiltrative endometriosis are caused by anatomical and functional disorders and are probably linked to the course of the disease and surgical treatment.

OBJECTIVE

The primary aim of this study was to assess bowel function before and after intestinal deep infiltrative endometriosis surgery. Secondarily, we sought to correlate defecatory symptoms with preoperative risk factors.

DESIGN/SETTINGS

This is a single-center prospective cohort study, using the low anterior resection syndrome score to evaluate bowel function 4 weeks before, as well as at 6 months and 1 year after surgery. The Wilcoxon signed-rank test and logistic multiple regression analyses were performed to compare preoperative and postoperative scores. The level of significance was set at <0.05 for all comparisons.

PATIENTS

Thirty-seven adult female patients who underwent intestinal resection for deep infiltrative endometriosis between 2015 and 2017 were included.

MAIN OUTCOME MEASURES

The primary outcome was bowel function appraisement in deep infiltrative endometriosis intestinal surgery.

RESULTS

During the preoperative evaluation, 48.6% of patients reported low anterior resection syndrome score ≥21. This group presented a mean score of 17.9 ± 13.7, with a median of 20 and a range of 5 to 30. After 1 year, the mean score was decreased to 9.6 ± 11.1, with a median of 4 and a range of 0 to 22. A significant difference was detected when comparing the post- and preoperative scores (p = 0.0006). Improvements in defecatory symptoms such as reduced fecal incontinence for flatus (p = 0.004) and liquid stools (p = 0.014) were also reported. The clustering of stools (p = 0.005) and fecal urgency (p = 0.001) also improved 1 year after surgery. The preoperative multiple logistic regression showed that dyschezia was the only independent variable associated with bowel symptoms.

LIMITATIONS

This is a well-documented prospective study, but the data presented have a relatively small population.

CONCLUSIONS

This study provides evidence that intestinal deep infiltrative endometriosis surgery improves bowel function and has a positive impact on evacuation symptoms. See Video Abstract at http://links.lww.com/DCR/B534.

EVALUACIN DE LA FUNCIN INTESTINAL DESPUS DEL TRATAMIENTO QUIRRGICO PARA LA ENDOMETRIOSIS INTESTINAL UN ESTUDIO PROSPECTIVO

ANTECEDENTES:Se considera que los síntomas defecatorios relacionados con la endometriosis intestinal infiltrativa profunda, son causados por trastornos anatómicos y funcionales, y probablemente estén relacionados con el curso de la enfermedad y tratamiento quirúrgico.OBJETIVO:El objetivo principal fue evaluar la función intestinal antes y después de la cirugía por endometriosis intestinal infiltrativa profunda. En segundo lugar, correlacionar los síntomas defecatorios con los factores de riesgo preoperatorios.DISEÑO / AJUSTES:Es un estudio de cohorte prospectivo de un solo centro, utilizando la puntuación del síndrome de resección anterior baja (LARS Score) para evaluar la función intestinal 4 semanas antes, 6 meses y un año después de la cirugía. Se realizaron pruebas de rango firmado de Wilcoxon y análisis de regresión logística múltiple para comparar puntuaciones preoperatorias y postoperatorias. Para todas las comparaciones, el nivel de significancia se estableció en <0.05.ENTORNO CLINICO:Se incluyeron 37 mujeres adultas sometidas a resección intestinal por endometriosis infiltrativa profunda entre 2015 y 2017.PRINCIPALES MEDIDAS DE VALORACION:El resultado principal, fue la evaluación de la función intestinal en cirugía de endometriosis infiltrativa profunda intestinal.RESULTADOS:Durante la evaluación preoperatoria, el 48,6% de los pacientes reportaron Síndrome de Resección Anterior Baja ≥ 21. Este grupo presentó una puntuación media de 17,9 ± 13,7, con una mediana de 20 y un rango de 5 a 30. Después de un año, la puntuación media se redujo a 9,6 ± 11,1, con una mediana de 4 y un rango de 0 a 22 Se detectó una diferencia significativa al comparar las puntuaciones postoperatorias y preoperatorias (p = 0,0006). Se informó de mejoras en los síntomas defecatorios como la reducción de la incontinencia fecal por flatos (p = 0,004) y heces líquidas (p = 0,014). La agrupación de heces (p = 0,005) y la urgencia fecal (p = 0,001) presentaron mejoría a un año después de la cirugía. La regresión logística múltiple preoperatoria mostró que la disquecia fue la única variable independiente asociada con los síntomas intestinales.LIMITACIONES:A pesar de que es un estudio prospectivo bien documentado, los datos presentados son de una población relativamente pequeña.CONCLUSIONES:El estudio proporciona evidencia de que la cirugía intestinal por endometriosis infiltrativa profunda, mejora la función intestinal y tiene un impacto positivo en los síntomas de evacuación. Consulte Video Resumen en http://links.lww.com/DCR/B534.

Linzagolix: a new GnRH-antagonist under investigation for the treatment of endometriosis and uterine myomas

INTRODUCTION

Uterine myomas and endometriosis are benign hormone-dependent diseases affecting women of reproductive age. Substantial efforts have been made to develop innovative medical options for treating these gynecologic diseases. Elagolix and relugolix have been approved in some countries for treating endometriosis and myomas, respectively; however, linzagolix (OBE 2109, KLH 2109) is a new oral gonadotropin-releasing hormone (GnRH) antagonist in phase II-III trials. Treatment options for women with contraindications for hormonal therapies or who refuse particular options, are the driving force behind the development of new drugs in this area.

AREA COVERED

This drug evaluation highlights definitive and preliminary results from previous and ongoing studies of linzagolix for the treatment of endometriosis and myomas.

EXPERT OPINION

Linzagolix showed a dose-dependent and rapidly reversible action on the pituitary-gonadal axis. In a recent phase II trial (EDELWEISS), linzagolix significantly reduced pain related to endometriosis and improved quality of life at single daily doses of 75-200 mg. The preliminary results of international, double-blind phase III trials (PRIMROSE 1 and 2) reported its efficacy in treating heavy menstrual bleeding related to myomas with a good safety profile. Further studies will determine the necessity of add-back therapy during long-term use of linzagolix.

"The Sword in the Stone": radical excision of deep infiltrating endometriosis with bowel shaving-a single-centre experience on 703 consecutive patients

BACKGROUND

Laparoscopic segmental bowel resection, disc excision and rectal shaving are described as surgical options for the treatment of bowel endometriosis, but the gold standard has not yet established. The aim of the study is to investigate the efficacy of the laparoscopic bowel shaving technique in terms of pain symptomatology and to analyse early and late postoperative complications.

METHODS

Retrospective cohort study of a series of 703 consecutive patients treated between January 2014 and December 2019 in a tertiary care referral centre. All patients underwent laparoscopic bowel shaving with concomitant radical excision of DIE.

RESULTS

Bilateral posterolateral parametrectomy and ureterolysis were performed, respectively, in 314 (44.7%) and 318 cases (45.2%). A radical hysterectomy was performed in 107 cases (82.9%). Postoperative complications were infrequent: 17 patients required a reoperation (2.4%) and in this subgroup we registered 2 rectovaginal fistulas (0.3%), 4 patients received blood transfusion (0.6%), 12 patients (1.7%) experienced postoperative fever, 6 patients experienced impaired bladder voiding (0.9%) after 6 months. Median follow-up was 14 months. The study reported good clinical and surgical results, with a regression of symptoms (p < 0.0001) and an overall rate of recurrence of 6.5%. Clinical and instrumental criteria of bowel endometriosis relapse were exclusively detected in 5 patients (0.8%). Eleven patients (1.7%) with relapsed endometriosis were reoperated.

CONCLUSIONS

Bowel shaving is a feasible and valuable surgical procedure. It is only the last step of a complex surgery which is aimed to minimize the residual quote of infiltrating nodule and requires a multidisciplinary team to achieve optimal treatment preoperatively, intraoperatively and postoperatively.

Rare cause of painless lower gastrointestinal bleeding: A case report

Introduction and importance

Endometriosis is a complex disease in which an abnormal uterine lining-like estrogen-dependent cells settle outside the uterine cavity. Gastrointestinal tract is the commonly affected region in extragenital endometriosis.

Case presentation

A 44-year-old female patient suffering from intermittent hematochezia for the past three months was presented with no medical history or any other symptoms correlating with current complaints. Clinical examination showed the patient in good condition with soft abdomen without evidence of tenderness or palpable mass or any sign of haemorrhoids or fissures. Initial abdominal sonography revealed a 20 × 25 mm hypoechoic change in caecal region. Colonoscopic biopsies and histopathological examination revealed only colon mucosa with mucosal oedema and an unspecific inflammatory reactive regenerative polypoid with no evidence of tumor tissue adenoma. Intermittent hematochezia of the patient got worse in the following months without any other concurrent symptom. Laparoscopically assisted ileocecal resection with a sutured side-to-side ileoascendostomy was then performed. The patient was kept on enhanced recovery program and was discharged on the fourth post-operative day with analgesics.

Clinical discussion

Patients who present with diagnostic challenges or fails to respond to initial treatments for alternative gastrointestinal diagnoses (e.g., IBS), should be analyzed for endometriosis especially in patients with a history or risk factors including nulliparity, early menarche, haematocolpos, retrograde menstruation or even positive family history.

Conclusion

Endometriosis must be considered as a gastrointestinal pathology as much as gynecological one, and the gastrointestinal surgeons and physicians should be aware of its symptoms or presentation.

•

A case with painless recurrent lower gastrointestinal bleeding with no diagnosis even after repeated colonoscopy.

•

Endometriosis must be considered in patients with diagnostic challenge and did not respond to other abdominal diagnoses.

•

Patient with history of nulliparity, early menarche, haematocolpos, retrograde menstruation must be examined particularly.

Transvaginal Ultrasound Findings After Laparoscopic Rectosigmoid Segmental Resection for Deep Infiltrating Endometriosis

OBJECTIVES

To evaluate transvaginal ultrasound (TVUS) findings in patients who underwent segmental rectosigmoid resection for deep infiltrating endometriosis (DIE) and to correlate postsurgical ultrasound findings with symptoms.

METHODS

A retrospective study including 50 premenopausal women with bowel endometriosis who underwent segmental rectosigmoid resection was conducted. Within 12 months after surgery, a TVUS examination was conducted in all patients to evaluate the presence of postsurgical endometriosis locations and symptoms, including dysmenorrhea, dyspareunia, dysuria, dyschezia, and chronic pelvic pain. Pelvic pain was assessed in all women by a visual analog scale.

RESULTS

At the follow-up 32 of 50 patients were receiving medical treatment, whereas 18 women declined postsurgical medical therapy and tried to conceive. A high percentage of adhesions (90%) was found. A negative sliding sign (a simple diagnostic sign that can be performed during a TVUS examination, consisting of gentle pressure applied by both the vaginal transducer and the examiner's hand on the abdomen; if the uterus does not glide freely along with the rectum and posterior fornix, the sign is considered negative, and adhesions can be suspected) was found in 29 (58%) women and was associated with bowel symptoms. Recurrence of posterior DIE was found in 9 cases (18%) and endometriomas in 8 cases (16%). Adenomyosis was observed in 80% of women and was present in all symptomatic patients.

CONCLUSIONS

After rectosigmoid segmental resection patients with DIE may continue to be symptomatic, and postoperative TVUS may reveal foci of disease or pelvic adhesions. Moreover, adenomyosis could be linked to symptoms experienced during follow up. Women should be aware that painful symptoms and alterations of pelvic organs could still be present after surgery and be detectable by TVUS.

Nonvisualized palpable bowel endometriotic satellites

STUDY QUESTION

What is the prevalence of laparoscopically nonvisualized palpable satellite bowel nodules at or near the planned stapler site in women undergoing segmental bowel resection for endometriosis?

SUMMARY ANSWER

Overall, 13 (25.5%) of 51 patients who underwent resection had nonvisualized palpable satellite lesions as small as 2 mm, including seven (14%) who had nonvisualized palpable lesions at or beyond the planned stapler site.

WHAT IS KNOWN ALREADY

Both laparoscopy and laparotomy for bowel resection are standard of care in Europe and the USA. Reoperation rates after laparoscopic bowel procedures are 1–16%. Endometriotic lesions at the stapler margin of bowel resections are associated with increased repeat surgery. Nodules of 0.1 mm to 1 cm in size were not recognized during laparoscopic bowel surgery but were recognized on histological examination. Up to 20 nodules not visualized at laparoscopy have been recognized and excised at laparotomy. Tenderness is found at up to 27 mm from a recognized lesion. The size of a lesion does not always predict its symptoms or behavior.

STUDY DESIGN, SIZE, DURATION

This single-arm, observational study focused on the presence of nonvisualized palpable satellite lesions of the bowel. Fifty-one patients scheduled for laparoscopic-assisted bowel resection for deep infiltrating endometriosis with suprapubic incision for placement of the stapler’s anvil and removal of the specimen in the course of routine clinical care were included. There were no additional inclusion or exclusion criteria.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Laparoscopic-assisted segmental bowel resection for endometriosis was performed in a private referral center on women aged 24–49 years.

MAIN RESULTS AND THE ROLE OF CHANCE

Forty-nine (96.1%) of the 51 patients underwent segmental resection of the sigmoid or rectum, and 14 (27.5%) underwent segmental resection of the ileum for large nodule(s) recognized on MRI. Twelve patients underwent both procedures. Eleven (22.4%) of the 49 patients with recognized sigmoid or rectal lesions and 5 (35.7%) of the 14 patients with recognized ileal lesions had nonvisualized, palpable, satellite lesions. All the large lesions and none of the satellite lesions had been recognized preoperatively on MRI. Five (10%) of 49 patients with lesions of the large bowel and 4 (28.6%) of the 14 patients with lesions of the ileum had nonvisualized palpable satellite lesions at or beyond the planned stapler site. Lesions as small as 2 mm were palpable.

LIMITATIONS, REASONS FOR CAUTION

This is an observational study. It is not known if the small lesions of this study contributed to the symptoms or were progressive, stable or regressive. This study analyzed lesions in the bowel segment proximal to the primary large bowel lesion, but not in the distal segment as that would have required a change in standard of care surgical technique. This study protocol did not include shaving or disk resection or patients in whom no lesions were visualized. The use of additional techniques for recognition, such as hand-assisted laparoscopy or rectal probes, was not investigated.

WIDER IMPLICATIONS OF THE FINDINGS

This study confirms that some nonvisualized satellite lesions as small as 2 mm are palpable and that an increased length of resection can be used to remove lesions recognized by palpation and to avoid lesions at and beyond the stapler site. This may decrease recurrent surgery in 1–16% of the women undergoing surgery for bowel endometriosis. Knowledge of the occurrence of these small lesions may also be particularly useful in plans for repeat surgery or for women with clinically significant bowel symptoms and no visible lesions at laparoscopy. Moreover, small lesions are considered to be important as there is no current technique to determine whether a large primary lesion, smaller lesions, an associated adjacent tissue reaction or a combination of those cause symptoms.

STUDY FUNDING/COMPETING INTEREST(S)

This CIRENDO cohort was supported by the G4 Group (the University Hospitals of Rouen, Lille, Amiens and Caen) and the ROUENDOMETRIOSE association. No specific funding was received for the study. H.R. reports receiving personal fees from Plasma Surgical Inc., Ethicon Endosurgery, Olympus and Nordic Pharma for presentations related to his experience with endometriosis surgery. D.C.M. reports being given access to Lumenis Surgical CO₂ Lasers’ lab at a meeting. None of the other authors have conflicts of interest to disclose.

TRIAL REGISTRATION NUMBER

N/A

A Targeted Biopsy during Menstruation for the Definitive Diagnosis of Rectovaginal Endometriosis: A Report of Two Cases

We herein report the definitive diagnosis of rectovaginal endometriosis in two cases. Case 1 involved a 46-year-old woman with abdominal pain and hematochezia. The diagnosis after the first and second examinations using lower gastrointestinal (GI) endoscopy was unclear. Differential diagnoses included mucosa-associated lymphoid tissue and colorectal cancer. The third lower GI endoscopy with a targeted biopsy, performed during menstruation, confirmed rectovaginal endometriosis. Case 2 involved a 38-year-old woman with hematochezia. Lower GI endoscopy during menstruation revealed rectovaginal endometriosis. When rectovaginal or bowel endometriosis is suspected, lower GI endoscopy and a targeted biopsy during menstruation can prevent unnecessary surgery.

[Contribution of the pre-operative Mri-coloscan couple in the surgical planning of deep digestive pelvic endometriosis]

INTRODUCTION

The digestive involvement of endometriosis accounts for up to 20-25% of deep localisations. Precise mapping of digestive lesions is essential in order to plan surgery and specialized teams. The aim of this study is to assess the contribution of the MRI-coloscan couple in the preoperative assessment of digestive endometriosis.

METHODS

We analyzed 45 files of patients referred for suspected digestive endometriosis. They had all undergone a preoperative MRI and coloscan associated with surgery throughout the year. We first compared the data collected in imaging, and then compared the synthesis of this data with the surgical procedure performed.

RESULTS

35 patients required digestive surgery. 24 of 45 files were concordant in MRI and coloscanner. Data from MRI alone matched with surgery in 69% of cases, against 84% for the coloscan. The synthesis allowed a concordance of 89%. 25 segmental resections, 2 discoid and 16 shaving were performed. The use of coloscan made up for nine extra cases: the detection of four additional cases of multifocality, a single undiagnosed case of a deep lesion, and allowed to specify the depth of the involvement in four cases. On the contrary, the MRI was correct compared to the CT in four cases. The presence of a digestive surgeon was necessary in 53% of cases.

CONCLUSION

In the era of imaging staging, it would seem interesting to turn towards a subclassification of the digestive involvement of endometriosis in order to decide which surgery to perform. In our experience, the coloscan is a useful complement of MR, especially to assess the depth of involvement and the multifocality.

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.

Endometriosis of the rectosigmoid colon mimicking gastrointestinal stromal tumor

Endometriosis is defined as the growth of functional endometriotic gland and stroma outside the uterine cavity. Although it is common in women of reproductive age, extragenital endometriosis is considerably rare. Due to its frequent localization at the rectosigmoid junction in the gastrointestinal system, endometriosis may manifest with abdominal pain, constipation, and rectal bleeding. Gastrointestinal stromal tumor is the most common mesenchymal tumor of the gastrointestinal system and develops from the muscularis propria. Its extraluminal component is prominent. This study aimed to report a rare case of a 37-year-old patient who was operated with laparoscopic colon resection for a malignant-appearing submucosal mass with indistinct borders at the rectosigmoid junction that received the final diagnosis in histopathological examination. Endometriosis should be considered in the differential diagnosis of non-specific gastrointestinal symptoms in female subjects of reproductive age as the one reported here.

Fertility in patients with untreated rectosigmoid endometriosis

RESEARCH QUESTION

Several studies have investigated reproductive outcomes following surgical treatment of colorectal endometriosis, mainly segmental colorectal resection. This study examines pregnancy and live birth rates of women with rectosigmoid endometriosis not treated by surgery.

DESIGN

A retrospective analysis of data collected between May 2009 and January 2020 related to 215 women affected by rectosigmoid endometriosis wishing to conceive. Patients had a diagnosis of rectosigmoid endometriosis by transvaginal ultrasonography and magnetic resonance imaging enema. Patients with estimated bowel stenosis >70% at computed tomographic colonography and/or subocclusive/occlusive symptoms were excluded.

RESULTS

During the median length of follow-up of 31 months (range 13-63 months), the total pregnancy and live birth rates of the study population were 47.9% and 45.1%, respectively. Sixty-two women had a live birth after natural conception (28.8%; 95% confidence interval [CI] 22.8-35.6%) with a median time required to conceive of 10 months (range 2-34 months). Eighty-three women underwent infertility treatments (38.6%, 95% CI 32.1-45.5%); among these, 68 patients underwent IVF either directly (n = 51) or after intrauterine insemination (IUI) failure (n = 17). Time to conception was significantly higher in women having conceived by IVF than in those having conceived naturally (P < 0.001) or by IUI (P = 0.006). In patients undergoing IVF cycles, a worsening of some pain and intestinal symptoms was observed.

CONCLUSIONS

At median follow-up of 31 months, women with rectosigmoid endometriosis have a 48% pregnancy rate. However, these patients must be referred to centres specialized in managing endometriosis to properly assess symptoms and degree of bowel stenosis.

Novel drug delivery methods for improving efficacy of endometriosis treatments

INTRODUCTION

Pharmacotherapy has a key role in the management of endometriosis. However, a significant proportion of patients gains only intermittent or limited benefits. In this regard, alternative and novel drug delivery methods are of paramount importance to improve efficacy and compliance of available treatments and develop alternative medical approaches.

AREAS COVERED

This review aims to provide the reader with a complete overview of available evidence about alternative and novel drug delivery methods for endometriosis pharmacotherapy and highlight new research lines.

EXPERT OPINION

Progestins and estroprogestins, which represent the first-line therapy, are already available in different formulations, being employed for contraception. Nevertheless, evidence on their adoption is still limited for some drug delivery methods, such as vaginal rings, patches, and subcutaneous implants. Further research is needed to define better their clinical utility in patients with endometriosis. Nanotechnologies have been investigated as novel drug delivery methods able to target the drug at the disease level. However, data are very limited and preliminary, and further research is needed to consider a possible clinical application in endometriosis.

Endometriosis within the sigmoid colon: A rare cause of bowel obstruction

Endometriosis is a common gynecological disease, ectopic endometrium can invade any part of the body, usually in the ovary and uterine sacral ligament, while endometriosis invades the intestinal wall to cause intestinal obstruction is very rare, which easily leads to misdiagnosis. In this case report, we present a case of sigmoid endometriosis with bowel obstruction. Pathological examination is the main basis for the diagnosis of intestinal endometriosis, and the comprehensive treatment of surgery and hormonal therapy is an effective method for the treatment of intestinal endometriosis.