Aggiornamento Rectal Endometriosis

del 9-8-2010

Zhonghua Fu Chan Ke Za Zhi. 2010 Apr;45(4):269-72.

Meta-analysis of ultrasonography in diagnosis of deeply infiltrating endometriosis.

[Article in Chinese]

Huang XF, Han CN, Lin KQ, Zhang J, Xu H, Zhang XM.

Department of Gynecology, Women’s Hospital, School of Medicine, Zhejiang University, Hangzhou 310006, China.

OBJECTIVE: To evaluate the quality of literatures and the accuracy of ultrasonography in diagnosis of deeply infiltrating endometriosis (DIE). METHODS: The database of Medline (1966 to 2009), the excerpta medica database (EMBASE, 1980 to 2009), Chinese biological medicine on disc (CBMdisc, 1978 to 2009), China national knowledge infrastructure (CNKI, 1979 to 2009) and VIP for Chinese technology periodical database (VIP, 1989 to 2009) Cochrane library of studies about the diagnosis of ultrasound for DIE were searched and analyzed. Quality assessment of diagnostic accuracy studies (QUADAS) items were used to evaluate the quality of literatures. The sensitivity, specificity, positive likelihood ratio (+LR), negative likelihood ratio (-LR), diagnostic test odds ratio (DOR) for the pooled analysis and heterogeneity test were analyzed for transvaginal ultrasonography (TVUS), transrectal ultrasonography (TRUS) and rectal endoscopic sonography (EUS) by Meta-disc software, and drew the summary receiver operating characteristic (SROC) curves for those without heterogeneity. RESULTS: Totally 15 literatures in English were enrolled into this study. The positive rate of 10 items of QUADAS were above 60%, whereas that of the 11th item “Were the reference standard results interpreted without knowledge of the results of the index test” was 46.7%; none of studies had mentioned the 13th item “Were uninterpretable/intermediate test results reported”. All researches had no heterogeneity by explored threshold effect. The results of pooled sensitivity, specificity, +LR, -LR, DOR were 0.925, 0.986, 30.036, 0.107, 299.25 for TRUS, 0.799, 0.944, 11.972, 0.187, 69.126 for transvaginal ultrasonography (TVUS), and 0.635, 0.928, 8.022, 0.320, 39.606 for EUS, respectively. Area under the curve of EUS was 0.9479, and that of TVUS was 0.9246. CONCLUSIONS: TRUS, TVUS and EUS all showed optimal value in diagnosis of DIE. The bias identified from the 15 studies might be mainly resulted from reference standard review bias.

Minerva Ginecol. 2010 Jun;62(3):179-85.

Transvaginal ultrasonography with water-contrast in the rectum in the diagnosis of bowel endometriosis.

Morotti M, Ferrero S, Bogliolo S, Venturini PL, Remorgida V, Valenzano Menada M.

Department of Obstetrics and Gynecology, San Martino Hospital and University of Genoa, Genoa, Italy – dr@simoneferrero.com.

AIM: The rectosigmoid is the most frequent location of intestinal endometriosis. Although several techniques have been proposed for the diagnosis of intestinal endometriosis, no gold standard is currently available. In this review, we describe in details a new technique for the diagnosis of rectosigmoid endometriosis: rectal water-contrast transvaginal ultrasonography. METHODS: During transvaginal ultrasonography, an assistant inserts a 6-mm flexible catheter through the anal os into the rectal lumen; the insertion of this catheter is evaluated under ultrasonographic control. Water contrast is instilled slowly in the rectum to permit intestinal distension. The colonic wall evaluation is obtained by positioning the transvaginal probe against a length of the sigmoid colon to obtain either axial or longitudinal images. The injection of the saline solution facilitates the identification of recto-sigmoid endometriotic nodules which appear as rounded or triangular hypoechoic masses, located anterior or lateral to the bowel. RESULTS: This technique has high sensitivity and specificity in the diagnosis of rectal infiltration in women with rectovaginal endo-metriosis. The distance between the nodules and the mucosal layer permits to estimate the depth of infiltration of these endometriotic lesions within the intestinal wall. Rectal distensibility can be estimated. The procedure is well tolerated by the patients. CONCLUSION: Water distension of the rectum facilitates the identification of intestinal endometriosis during transvaginal ultrasonography.

Surg Today. 2010 Jul;40(7):672-5. Epub 2010 Jun 26.

Rectal endometriosis masquerading as dissemination in a patient with rectal cancer: report of a case.

Uchiyama S, Haruyama Y, Asada T, Nagaike K, Hotokezaka M, Yorita K, Chijiiwa K.

Department of Surgical Oncology and Regulation of Organ Function, Miyazaki University School of Medicine, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan.

A 57-year-old woman was diagnosed as having rectal cancer. A barium enema study showed the apple-core sign at the rectosigmoid colon, and colonoscopy revealed an encircled ulcerated tumor. A laparoscope-assisted resection of the rectum was planned; however, the rectal cancer directly invaded the uterus body. The operation was converted to open surgery. An elastic hard tumor suspected of being peritoneal dissemination at the peritoneal reflection was detected and excised together with the rectum below the peritoneal reflection. A histological examination of this tumor revealed that cystic glands lined by nonmucinous columnar epithelial cells were seen on the serosal side and were embedded in the proper muscle of the rectum. This tumorous lesion was diagnosed as endometriosis.

Hum Reprod. 2010 Aug;25(8):1949-58. Epub 2010 Jun 13.

Complications, pregnancy and recurrence in a prospective series of 500 patients operated on by the shaving technique for deep rectovaginal endometriotic nodules.

Donnez J, Squifflet J.

Department of Gynecology, Université Catholique de Louvain, Cliniques Universitaires St Luc, 1200 Brussels, Belgium. jacques.donnez@uclouvain.be

BACKGROUND: The debate continues between advocates of the shaving technique and supporters of bowel resection in case of deep endometriosis with rectal muscularis involvement, despite little evidence for better improvement with bowel resection. METHODS: We analyzed complication, pregnancy and recurrence rates after deep endometriotic nodule excision by shaving surgery. This is a prospective analysis of 500 cases (<40 years old) of deep endometriotic nodules. RESULTS: Laparoscopic nodule resection was performed successfully in all cases. Major complications included: (i) rectal perforation in seven cases (1.4%); (ii) ureteral injury in four cases (0.8%); (iii) blood loss >300 ml in one case (0.2%); and (iv) urinary retention in four cases (0.8%). The median follow-up duration was 3.1 years (range 2-6 years). In our prospective series of 500 women, 388 wished to conceive. Of this number, 221 (57%) became pregnant naturally and 107 by means of IVF. In total, 328 women (84%) conceived. The recurrence rate was 8% among these 500 women, and it was significantly lower (P < 0.05) in women who became pregnant (3.6%) than in those who did not (15%). In women who failed to conceive, or were not interested in conceiving, severe pelvic pain recurred in 16-20% of patients. CONCLUSION: In young women, conservative surgery using the shaving technique preserves organs, nerves and the vascular blood supply, yielding a high pregnancy rate and low complication and recurrence rates. There is a need, however, for further strong and energetic debate to weigh up the benefits of shaving (debulking surgery) versus rectal resection (radical surgery).

JSLS. 2010 Jan-Mar;14(1):140-2.

Cecal endometriosis as a cause of ileocolic intussusception.

Indraccolo U, Trevisan P, Gasparin P, Barbieri F.

Operative Unit of Obstetrics and Gynecology, ULSS 17, Veneto, Italy. ugo.indraccolo@libero.it

Endometriosis is a disease that can affect various organs, has an unclear symptomatology, and in extreme cases, can result in intestinal obstruction. This particular case illustrates the synchronous localization of endometriosis, both genital and intestinal, resulting in ileo-colic and colonic intussusception. The relative diagnostic and therapeutic approach for such a rare occurrence is discussed.

Eur J Gynaecol Oncol. 2010;31(2):211-3.

Primary adenocarcinoma of the rectovaginal septum arising in pregnancy in the absence of endometriosis.

Giordano G, Bersiga A, Marchetti G, Melpignano M.

Department of Pathology and Medicine of Laboratory, Section of Pathology, Parma University, Italy. giovanna.giordano@unipr.it

A case of primary adenocarcinoma of the rectovaginal septum (PARVS) is reported with clinical and pathological findings. A 37-year-old Caucasian woman with a history of sterility and small posterior leiomyoma, a few months after a cesarean section, was admitted because of vaginal spotting, abdominal pain and constipation. Her previous history did not reveal exposure to diethylstil bestrol (DES). Pelvic computed tomography showed a heterogeneous pelvic mass in the Douglas pouch, measuring 9 cm in diameter, located in the rectovaginal septum, involving the rectal and vaginal wall. Histological examination of neoplastic tissue revealed solid sheet structures, occasional tubular lumen, extensive necrotic areas and clear cells. The neoplastic elements showed immunoreactivity for Mullerian markers (cytokeratin 7, CA-125 and vimentin). Because, the present case of PARVS cannot be due to DES exposure, the clear appearance of the neoplastic elements could represent only one differentiation of Mullerian rests. Moreover, because no foci of endometriosis were identified in several sections of the neoplasm, uterine and cervical wall, and tissues nearby the neoplasm could represent a rare subtype of PARVS arising in the absence of endometriosis.

Arq Gastroenterol. 2010 Mar;47(1):116-8.

Robotic rectosigmoidectomy – pioneer case report in Brazil. Current scene in colorectal robotic surgery.

Averbach M, Popoutchi P, Marques OW Jr, Abdalla RZ, Podgaec S, Abrão MS.

Hospital Sírio Libanês, Centro de Treinamento em Cirurgia Robótica, São Paulo, SP, Brasil. maverbach@uol.com.br

Laparoscopic colorectal surgery is believed to be technically and oncologically feasible. Robotic surgery is an attractive mode in performing minimally-invasive surgery once it has several advantages if compared to standard laparoscopic surgery. The aim of this paper is to report the first known case of colorectal resection surgery using the robotic assisted surgical device in Brazil. A 35-year-old woman with deep infiltrating endometriosis with rectal involvement was referred for colorectal resection using da Vinci surgical system. The authors also reviewed the most current series and discussed not only the safety and feasibility but also the real benefits of robotic colorectal surgery.

Acta Chir Belg. 2010 Mar-Apr;110(2):210-2.

Deeply infiltrating rectal endometriosis with lymph node involvement.

Rafailidis S, Symeonidis N, Ballas K, Psarras K, Pavlidis T, Patsiaoura K, Sakadamis A.

2nd Propedeutical Department of Surgery, Hippokration General Hospital, Medical School, Aristotles University of Thessaloniki, Greece. svrafail@otenet.gr

BACKGROUND: Sigmoidorectal endometriosis accounts for 70% of the cases of intestinal endometriosis. Symptoms are non-specific, frequently resembling adenocarcinomas. CASE: A 45-year-old woman complaining of recurrent rectal bleeding underwent colonoscopy in which a rectal polypoid mass was found. She underwent anterior rectosigmoidectomy and the histological examination of the resected bowel revealed rectal endometriosis with lymph node involvement. CONCLUSION: Lymphatic infiltration of epicolic lymph nodes raises questions about the benign nature of this presumed innocent disease.

Ann Surg. 2010 Jun;251(6):1018-23.

Randomized trial of laparoscopically assisted versus open colorectal resection for endometriosis: morbidity, symptoms, quality of life, and fertility.

Daraï E, Dubernard G, Coutant C, Frey C, Rouzier R, Ballester M.

Department of Gynecology and Obstetrics, Hôpital Tenon, Assistance Publique des Hôpitaux de Paris, CancerEst, Université Pierre et Marie Curie Paris 6, France. emile.darai@tnn.aphp.fr

OBJECTIVE: We report the first randomized trial of laparoscopically assisted versus open colorectal resection for endometriosis focusing on perioperative complications, improvement in symptoms, quality of life, and fertility. SUMMARY OF BACKGROUND DATA: Bowel endometriosis is one of the most severe forms of endometriosis. Although laparoscopically assisted surgery is a validated technique for colorectal cancer, there are serious concerns about its appropriateness for endometriosis in young women wishing to conceive because it is almost invariably a traumatic procedure. METHODS: We conducted a noninferiority trial and randomly assigned 52 patients with colorectal endometriosis to undergo laparoscopically assisted or open colorectal resection. The median follow-up was 19 months. The primary end point was improvement in dyschesia. RESULTS: Overall, a significant improvement in digestive symptoms (dyschesia P < 0.0001, diarrhea P < 0.01, and bowel pain and cramping P < 0.0001), gynecologic symptoms (dysmenorrhea P < 0.0001 and dyspareunia P < 0.0001), and general symptoms (back pain P = 0.001 and asthenia P = 0.0001) was observed. No difference in the symptom delta values and quality of life was noted between the groups. Median blood loss was lower in the laparoscopic group (P < 0.05). Total number of complications was higher in the open surgery group (P = 0.04), especially grade 3 (P = 0.03). Pregnancy rate was higher in the laparoscopic group (P = 0.006), and the cumulative pregnancy rate was 60%. CONCLUSION: Our findings support that laparoscopy is a safe option for women requiring colorectal resection for endometriosis. Moreover, laparoscopy offers a higher pregnancy rate than open surgery with similar improvements in symptoms and in quality of life.

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