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Aggiornamento Large bowel Endometriosis

del 26-02-2013

Int J Surg Case Rep. 2013;4(2):160-3. doi: 10.1016/j.ijscr.2012.11.007. Epub 2012 Nov 26.

Acute endometrial bowel obstruction-A rare indication for colonic stenting.

Whelton C, Bhowmick A.


University of Manchester, United Kingdom. Electronic address: crwhelton@doctors.org.uk.



Pelvic endometriosis is an extremely rare cause of large bowel obstruction and the management can be challenging. Urgent surgery for acute colonic obstruction is known to carry high morbidity and mortality, and operation may be made more difficult in extensive pelvic endometriosis. Less invasive alternatives in the acute situation may need to be considered.


Presented is the case of a 35-year-old lady with obstructive bowel symptoms caused by an endometriotic upper rectal stricture. She was initially treated using radiologically guided stent insertion, as an acute intervention, prior to an elective bowel resection and hysterectomy with bilateral salpingo-oophorectomy.


Colonic stenting is currently widely used in malignant obstruction. The use of self expanding metallic stents (SEMS) to treat benign conditions is controversial, however, due to associated long term complications. This case demonstrates that stenting can provide a bridge to major surgery in the rare event of acute endometriotic colonic obstruction. The initial acute treatment with stenting provides the advantage of time to involve the multi-disciplinary team, to medically optimise the patient and to better plan the definitive surgery.


The use of radiologically guided stents has a place in the treatment of benign recto-sigmoid obstruction due to endometriosis and therefore should be considered as a bridge to further surgical treatment.

Rofo. 2012 Nov;184(11):984. doi: 10.1055/s-0032-1318962. Epub 2012 Oct 26.

Endometriosis or colorectal carcinoma – better differentiation with diffusion weighted MRT?

[Article in German]

Manych M.

Dis Colon Rectum. 2012 Nov;55(11):e363-4. doi: 10.1097/DCR.0b013e31826cb858.

Re: Management of deeply infiltrating endometriosis involving the rectum.

Bailey HR, Snyder MJ.

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Destroy user interface controlManagement of deeply infiltrating endometriosis involving the rectum.[Dis Colon Rectum. 2012]

Lancet. 2012 Sep 29;380(9848):1202. doi: 10.1016/S0140-6736(12)60819-8.

Appendiceal intussusception caused by endometriosis.

Mehmood S, Phair A, Sahely S, Ong A, Law A, Onwudike M, Ferguson G.


Department of General Surgery, Royal Bolton Hospital, Bolton NHS Foundation Trust, Bolton, UK. drsajidm@hotmail.com

Dis Colon Rectum. 2012 Sep;55(9):925-31. doi: 10.1097/DCR.0b013e31825f3092.

Management of deeply infiltrating endometriosis involving the rectum.

Koh CE, Juszczyk K, Cooper MJ, Solomon MJ.


Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.



Rectal endometriosis can cause debilitating symptoms. Rectal resection in this setting has been shown to improve symptoms; however, there remain some reservations about this intervention because of the risk of complications such as anastomotic leak and rectovaginal fistula.


The aim of this study is to review our experience with rectal resection in patients with rectal endometriosis.


Hospital records and prospectively maintained electronic databases of an endogynecologist and colorectal surgeon were reviewed.


This is a retrospective study of consecutive patients who underwent rectal resection for endometriosis from 2001 to 2010.


All patients underwent either disc or segmental resection of the rectum.


Outcomes of interest were operative complications and recurrence requiring surgical reintervention.


Ninety-one patients underwent 92 resections for endometriosis. Sixty-five (71%) were disc resections, 25 (27%) were segmental resections, and 1 patient underwent both disc and segmental resections. Eighty-one (88%) procedures were completed laparoscopically. Patients requiring segmental resection had more extensive disease, and this was associated with open conversion (p ≤ 0.0001). Average duration of procedure was 209 minutes. Three patients (3%) required defunctioning ileostomies. Intramural endometriosis was confirmed in 96.7% of specimens. Complications occurred in 13 patients (15%); 4 were minor. Three patients had small pelvic collections treated with antibiotics, 5 patients required transfusion for bleeding (3 intraoperative, 2 anastomotic bleeds that settled conservatively), and 1 patient sustained ureteric injury that was reimplanted with no sequelae. None had anastomotic leak or rectovaginal fistula. Ten patients (11%) required reintervention for recurrent symptoms. Of these, 8 (8.8%) patients were found to have recurrent endometriosis. No correlation could be found between involved margins on pathology and need for redo surgery.


: This study is limited by its retrospective nature.


Laparoscopic rectal resection for deeply infiltrative endometriosis is feasible and safe, and it provides durable symptom control with acceptable recurrence rates.

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Destroy user interface controlRe: Management of deeply infiltrating endometriosis involving the rectum.[Dis Colon Rectum. 2012]

Eur J Radiol. 2012 Jun 27. [Epub ahead of print]

Current status on performance of CT colonography and clinical indications.

Laghi A, Rengo M, Graser A, Iafrate F.


Department of Radiological Sciences, Oncology and Pathology Sapienza – Università di Roma, Polo Pontino, I.C.O.T. Hospital, Via Franco Faggiana 43, 04100 Latina, Italy.


CT colonography (CTC) is a robust and reliable imaging test of the colon. Accuracy for the detection of colorectal cancer (CRC) is as high as conventional colonoscopy (CC). Identification of polyp is size dependent, with large lesions (≥10mm) accurately detected and small lesions (6-9mm) identified with moderate to good sensitivity. Recent studies show good sensitivity for the identification of nonpolypoid (flat) lesions as well. Current CTC indications include the evaluation of patients who had undergone a previous incomplete CC or those who are unfit for CC (elderly and frail individuals, patients with underlying severe clinical conditions, or with contraindication to sedation). CTC can also be efficiently used in the assessment of diverticular disease (excluding patients with acute diverticulitis, where the exam should be postponed), before laparoscopic surgery for CRC (to have an accurate localization of the lesion), in the evaluation of colonic involvement in the case of deep pelvic endometriosis (replacing barium enema). CTC is also a safe procedure in patients with colostomy. For CRC screening, CTC should be considered an opportunistic screening test (not available for population, or mass screening) to be offered to asymptomatic average-risk individuals, of both genders, starting at age 50. The use in individuals with positive family history should be discussed with the patient first. Absolute contraindication is to propose CTC for surveillance of genetic syndromes and chronic inflammatory bowel diseases (in particular, ulcerative colitis). The use of CTC in the follow-up after surgery for CRC is achieving interesting evidences despite the fact that literature data are still relatively weak in terms of numerosity of the studied populations. In patients who underwent previous polypectomy CTC cannot be recommended as first test because debate is still open. It is desirable that in the future CTC would be the first-line and only diagnostic test for colonic diseases, leaving to CC only a therapeutic role.

Gastrointest Endosc. 2012 Sep;76(3):672-4. doi: 10.1016/j.gie.2012.04.468. Epub 2012 Jun 23.

Unintended endoscopic appendectomy of an endometriosis-induced intussuscepted appendix presenting as a sessile cecal polyp.

Lopez-Roman O, Cruz-Corea M, Toro DH, Gonzalez-Keelan C.


Department of Gastroenterology, Veterans Affairs Caribbean Health Care System, San Juan, Puerto Rico.

Reprod Sci. 2012 Aug;19(8):851-62. doi: 10.1177/1933719112438443. Epub 2012 Apr 23.

Stress exacerbates endometriosis manifestations and inflammatory parameters in an animal model.

Cuevas M, Flores I, Thompson KJ, Ramos-Ortolaza DL, Torres-Reveron A, Appleyard CB.


Department of Physiology and Pharmacology, Ponce School of Medicine and Health Sciences, Ponce, PR 00716, USA.


Women with endometriosis have significant emotional distress; however, the contribution of stress to the pathophysiology of this disease is unclear. We used a rat model of endometriosis to examine the effects of stress on the development of this condition and its influence on inflammatory parameters. Female Sprague-Dawley rats were subjected to swim stress for 10 consecutive days prior to the surgical induction of endometriosis by suturing uterine horn implants next to the intestinal mesentery (endo-stress). Sham-stress animals had sutures only, and an endo-no stress group was not subjected to the stress protocol. At the time of sacrifice on day 60, endometriotic vesicles were measured and colons assessed for macroscopic and microscopic damage. Colonic tissue and peritoneal fluid were collected for inflammatory cell analysis. Endometriosis, regardless of stress, produced a decrease in central corticotropin-releasing factor immunoreactivity, specifically in the CA3 subregion of the hippocampus. Prior exposure to stress increased both the number and severity of vesicles found in animals with endometriosis. Stress also increased colonic inflammation, motility, myeloperoxidase levels, and numbers of mast cells. In summary, prior stress may contribute to the development and severity of endometriosis in this animal model through mechanisms involving cell recruitment (eg, mast cells), release of inflammatory mediators, and deregulation of hypothalamic-pituitary axis responses in the hippocampus.

Hum Reprod. 2012 Jun;27(6):1624-7. doi: 10.1093/humrep/des067. Epub 2012 Mar 15.

The clinical features and management of perineal endometriosis with anal sphincter involvement: a clinical analysis of 31 cases.

Chen N, Zhu L, Lang J, Liu Z, Sun D, Leng J, Fan Q, Zhang H, Cui Q.


Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Beijing, People’s Republic of China.



The aim of this study was to investigate the appropriate measures for diagnosing and treating perineal endometriosis (PEM) with anal sphincter involvement.


Between January 1992 and April 2011, the clinical features, diagnosis and management of 31 patients who were diagnosed with PEM with anal sphincter involvement at the Peking Union Medical College Hospital were retrospectively analyzed using their clinical records. A range of 6-78 months of outpatient follow-up after surgery were conducted for these 31 patients but was extended by telephone interviews with 29 patients conducted in December 2011.


All 31 patients had a history of vaginal delivery. The level of serum CA(125) was elevated in only 2 (6.5%) cases. All cases received surgical treatment, which included narrow excision (NE, close to the edge of the endometrioma) with primary sphincteroplasty (PSp) for 30 cases and incomplete excision (IE) for 1 case. Of the 30 cases in the NE group, 20 (66.7%) received hormone therapy preoperatively. Up until December 2011, there was one recurrence (3.6%) of PEM in the NE group. PEM relapse occurred in the IE patient 6 years after the initial IE surgery. Perineal abscesses were found in one patient post-operatively. No complaint of dyspareunia and no fecal incontinence episodes were observed during follow-up.


Based on our own experience, NE and PSp may be indicated for the treatment of PEM with anal sphincter involvement.

J Minim Invasive Gynecol. 2012 Mar-Apr;19(2):267; author reply 267-8. doi: 10.1016/j.jmig.2011.12.001.

Letter to the editor.

Daraï E, Ballester M, Zacharopoulou C, Bazot M.

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Destroy user interface controlQuality of life after segmental resection of the rectosigmoid by laparoscopy in patients with deep infiltrating endometriosis with bowel involvement. [J Minim Invasive Gynecol. 2011]

Surg Endosc. 2012 Jul;26(7):2029-45. doi: 10.1007/s00464-012-2153-3. Epub 2012 Jan 26.

Nerve-sparing laparoscopic eradication of deep endometriosis with segmental rectal and parametrial resection: the Negrar method. A single-center, prospective, clinical trial.

Ceccaroni M, Clarizia R, Bruni F, D’Urso E, Gagliardi ML, Roviglione G, Minelli L, Ruffo G.


Division of Gynecologic Oncology, International School of Surgical Anatomy, Sacred Heart Hospital, Ospedale Sacro Cuore-Don Calabria, Via Don A.Sempreboni no. 5, 37024 Negrar, VR, Italy. issaschool@gmail.com



The weight of surgical radicality, together with a lack of anatomical theoretical basis for surgery and inappropriate practical skills, can lead to serious impairments to bladder, rectal, and sexual functions after laparoscopic excision of deep infiltrating endometriosis. Although the “classical” laparoscopic technique for endometriosis excision involving segmental bowel resection has proven to relieve symptoms successfully, it is hampered by several postoperative long-term and/or definitive pelvic dysfunctions.


In this prospective cohort study, we compare the laparoscopic nerve-sparing approach to the classical laparoscopic procedure in a series of 126 cases. Satisfactory data for bowel, bladder, and sexual function were considered as primary endpoints.


A total of 126 patients were considered for analysis: 61 treated with nerve-sparing radical excision of pelvic endometriosis with segmental bowel resection (group B), and 65 treated with the classical technique (group A). Intraoperative, perioperative, and postoperative complications were similar between the two groups. Mean days of self-catheterization were significantly lower in the nerve-sparing group (39.8 days) compared with the non-nerve-sparing group (121.1 days; p < 0.001). The relapse rate within 12 months after surgery was comparable between the two groups. Patients of group A suffered from urinary retention more frequently between 1 and 6 months (p = 0.035) compared with group B and did not experience any improvement between 6 months and 1 year (p = 0.018). Overall detection of severe bladder/rectal/sexual dysfunctions was significantly different between the two groups, and 56 patients of group A (86.2%) reported a significantly higher rate of severe neurologic pelvic dysfunctions vs. 1 patient (1.6%) of group B (p < 0.001).


Our technique appears to be feasible and offers good results in terms of reduced bladder morbidity and apparently higher satisfaction than the classical technique. Considering that this kind of surgery requires uncommon surgical skills and anatomical knowledge, we believe that it should be performed only in selected reference centers.

Acta Obstet Gynecol Scand. 2012 Jun;91(6):648-57. doi: 10.1111/j.1600-0412.2012.01367.x. Epub 2012 Feb 28.

Diagnosis and treatment of rectovaginal endometriosis: an overview.

Kruse C, Seyer-Hansen M, Forman A.


Department of Obstetrics and Gynecology, Aarhus University Hospital Skejby, Brendstrupgaardsvej, Aarhus, Denmark. ckruse@dadlnet.dk


Rectovaginal endometriosis can be a cause of severe pain, dyspareunia and intestinal problems. A thorough examination is needed and should include diagnostic imaging, such as transvaginal or transrectal ultrasound or magnetic resonance imaging. Medical therapies, such as oral contraceptives, progestins and levonorgestrel-releasing intrauterine devices, all seem to reduce pain and should always be considered. Surgical treatment is challenging and implies a risk of severe complications. It is preferable to treat endometriotic lesions with superficial infiltration into the rectal wall by local laparoscopic excision, while segmental rectal resection is needed in the case of severe intestinal infiltration. This review describes available diagnostic tools, the possibilities for medical treatment and the alternative surgical approaches.

Fertil Steril. 2012 Mar;97(3):652-6. doi: 10.1016/j.fertnstert.2011.12.019. Epub 2012 Jan 18.

Does colorectal endometriosis alter intestinal functions? A prospective manometric and questionnaire-based study.

Mabrouk M, Ferrini G, Montanari G, Di Donato N, Raimondo D, Stanghellini V, Corinaldesi R, Seracchioli R.


Minimally Invasive Gynaecological Surgery Unit, S. Orsola Hospital, University of Bologna, Bologna, Italy.



To objectively evaluate using anorectal manometry whether endometriotic nodules influence intestinal function and to reveal subjective intestinal dysfunctions in patients with rectosigmoid deep infiltrating endometriosis.


Prospective study.


Tertiary care university hospital.


Patients (n = 25) with a preoperative diagnosis of rectosigmoid endometriosis.


Patients underwent anorectal manometry; after that, they filled a questionnaire about defecatory functions and ranked their pain symptoms.


The parameters studied were resting pressure, maximum squeezing pressure, pushing, rectoanal inhibitory reflex, and rectal sensibility. We analyzed the responses to the defecatory function questionnaire and the scored the endometriosis pain symptoms using a Visual Analogue Scale.


No alterations of the rectoanal inhibitory reflex were found. Hypertone of the internal anal sphincter was found in 20 of 25 patients. Almost half of the patients had an increase of the threshold of desire to defecate, and 7 patients had a reduction of the anal sphincter squeeze pressure. According to the responses to the defecatory function questionnaire, incomplete evacuation was the most common symptom.


We did not find marked motility or sensitive dysfunctions at the anorectal manometry, whereas subjectively patients reported some defecatory disorders. We revealed the presence of hypertone of the internal anal sphincter in most of the patients.



Copyright © 2012 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.

Diagn Cytopathol. 2012 Feb;40(2):159-62. doi: 10.1002/dc.21608. Epub 2011 Feb 9.

Endometriosis of sigmoid colon mimicking malignant tumor diagnosed by intraoperative imprint cytology.

Ohsaki H, Nakamura M, Arie K, Hirakawa E, Haba R, Norimatsu Y.


Department of Medical Technology, Ehime Prefectural University of Health Sciences, Ehime, Japan. ohsaki@epu.ac.jp


A case of endometriosis of the sigmoid colon on imprint cytology from an intraoperative biopsy is discussed. Cytologic specimens showed sheets or tubular epithelial clusters and stromal fragments. The epithelial cell nuclei were small and round to ovoid with finely granular chromatin and inconspicuous nucleoli. The background showed a few scattered spindle-type stromal cells without pigment-laden histiocytes. A definitive diagnosis of endometriosis can be based on cytology, provided that the cytologic findings are interpreted in the appropriate clinical context.

J Gynecol Obstet Biol Reprod (Paris). 2012 Apr;41(2):128-35. doi: 10.1016/j.jgyn.2011.06.018. Epub 2011 Nov 8.

Laparoscopic colorectal resection for deep pelvic endometriosis: Evaluation of post-operative outcome.

[Article in French]

Boileau L, Laporte S, Bourgaux JF, Rouanet JP, Filleron T, Mares P, de Tayrac R.


Service de gynécologie et d’obstétrique, CHU de Nîmes, place du Pr R.-Debré, 30029 Nîmes, France. boileau.laurent34@gmail.com



Evaluation of mid-term functional results and the quality of life after laparoscopic colorectal resection.


Twenty-three consecutive patients were included in a retrospective monocentric study. Postoperative functional outcomes and quality of life were analyzed.


The median follow-up after colorectal resection was of 24±15.7 months (6-72). Major complications occurred in three cases (12,9%) including one anastomotic stenosis, one digestive and one bladder fistula. A significant improvement in pelvic pain symptoms was observed. De novo constipation and pain on defecation occurred in respectively 23% and 42% of the cases. Transient de novo dysuria occurred in 18% of the cases. The quality of life has been significantly improved.


Laparoscopic colorectal resection is associated with unfavourable postoperative digestive and urological outcomes, such as bladder and rectal dysfunction. Radical treatment should be limited to selected patients.

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