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Aggiornamento Rectal Endometriosis

del 26-02-2013

Ultrasound Obstet Gynecol. 2013 Feb 8. doi: 10.1002/uog.12431. [Epub ahead of print]

Uterine sliding sign – a simple sonographic predictor for presence of deep infiltrating endometriosis of the rectum.

Hudelist G, Fritzer N, Staettner S, Tammaa A, Tinelli A, Sparic R, Keckstein J.

Source

Department of Obstetrics and Gynaecology/ Stage III Center for Endometriosis & Pelvic Pain, Wilhelminen Hospital, Vienna, Austria; Stiftung Endometrioseforschung SEF.

Abstract

OBJECTIVE:

The aim of the study was to evaluate whether the presence of utero-rectal adhesions demonstrated by transvaginal sonography (TVS) could aid as a simple sonographic predictor for deep infiltrating endometriosis of the rectum in patients with symptoms suggestive of endometriosis.

METHODS:

A prospective study was conducted in pelvic pain clinics including one-hundred and forty-two symptomatic women scheduled for laparoscopy due to symptoms suggestive of endometriosis. Patients were prospectively assessed via TVS prior to laparoscopy and radical resection of disease and histological confirmation was performed. Sensitivity, specificity, positive predictive values (PPV), negative predictive values (NPV), accuracy and positive and negative likelihood ratios (LR+ and LR-) were calculated.

RESULTS:

In total, 34 (29%) of patients exhibited deep infiltrating endometriosis (DIE) of the bowel. Sensitivity, specificity, PPV, NPV, accuracy, LR+ and LR- for a negative sliding sign as shown by TVS regarding the presence of DIE of the rectum was 85%, 96%, 91%, 94%, 93.1%, 23.6 and 0.15.

CONCLUSIONS:

Sonographic demonstration of utero-rectal adhesions reflected by a positive uterine sliding sign is an easy at hand method for prediction of the presence of DIE involving the rectum. This could be a valuable “red flag sign” for triaging patients for tertiary referral centres and specialized clinics for detailed investigation.

Dig Endosc. 2012 Dec 17. doi: 10.1111/den.12008. [Epub ahead of print]

Primary clear cell adenocarcinoma arising from rectalendometriosis.

Min KW, Koh YW, Ryu YJ, Hong SM, Kim KR, Sung CO.

Source

Department of Pathology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.

Int J Surg Case Rep. 2012 Dec 25;4(3):253-255. doi: 10.1016/j.ijscr.2012.12.003. [Epub ahead of print]

Transmural sigmoid colon endometrioma in a young reproductive age woman.

Calasanz ER, Nazim M, Kauffman RP.

Source

Department of Surgery, Texas Tech University Health Sciences Center School of Medicine at Amarillo, 1400 South Coulter, Amarillo, TX 79106, USA. Electronic address: emily.r.calasanz@ttuhsc.edu.

Abstract

INTRODUCTION:

Endometriosis is a common disease affecting women of reproductive age. Endometrial tissue can implant to various tissues including gastrointestinal tissues and cause significant GI symptoms. Rarely, these implants cause constricting lesions that require surgical intervention.

PRESENTATION OF CASE:

We report a case of a 27-year-old woman with extensive endometriosis and new onset gastrointestinal symptoms. A near-complete constricting endometrioma involving the sigmoid colon was identified and required surgical resection with side-to-side anastomosis.

DISCUSSION:

When endometrial tissue implants to gastrointestinal tissues it can cause GI symptoms including rectal bleeding and dyschezia. If left untreated, progressive endometriosis may result in partial or complete bowel obstruction requiring surgical resection.

CONCLUSION:

Obstruction of the GI tract by endometrial implantation can be prevented with early identification and treatment (medical and surgical).

JSLS. 2012 Jul-Sep;16(3):461-5. doi: 10.4293/108680812X13462882736295.

Transvaginal hydrolaparoscopy.

Ezedinma NA, Phelps JY.

Source

School of Medicine, University of Texas Medical Branch, Galveston, TX 77555-0587, USA.

Abstract

Transvaginal hydrolaparoscopy (THL) is being performed regularly in Europe and China, but rarely in the United States. The reasons may be physicians’ unfamiliarity with the procedure and their uneasiness over potential rectal puncturing due to the proximity of the rectum to the vaginal trocar insertion site. THL has the advantage over hysterosalpingography (HSG) in that it allows for direct visualization of the tubal mucosa in addition to determining tubal patency. THL has advantages over traditional laparoscopy in that it does not require an abdominal incision and has the capability of being conducted in an outpatient office setting with local anesthesia. Studies have shown that THL has comparable accuracy to laparoscopy with 96.1% concordance between THL and laparoscopic findings. THL may be combined with chromopertubation and salpingoscopy. In addition to diagnostic purposes, THL may be used for operative intervention including adhesiolysis, endometriosis ablation, and ovarian drilling. Studies from France and China report the occurrence of rectal injury from 0% to1%. Despite the advantages of THL and low reports of rectal injury, THL has not gained popularity in the United States. The purpose of this article is to familiarize gynecologists in the United States with THL.

Rev Gastroenterol Peru. 2012 Oct;32(4):411-7.

[Colorectal cancer endometriosis resembling stenosing extrapelvic. Report of two cases].

[Article in Spanish]

Gallardo Arteaga J, Marin Calderón L, Barboza Beraun A, Rivas Wong L, Frisancho Velarde O.

Abstract

We present two women of 40 and 42 years with colorectal endometriosis, both with a history of pelvic endometriosis and simultaneous episodes of rectal bleeding with menstruation. In endoscopic evaluations detected a sigmoid tumor and rectosigmoid tumor respectively, which apparently corresponds to stenosing colorectal cancer of epithelial origin. KEY WORDS: intestinal endometriosis, colorectal endometriosis, extrapelvic endometriosis.

Diagn Interv Imaging. 2013 Jan 7. pii: S2211-5684(12)00392-0. doi: 10.1016/j.diii.2012.11.003. [Epub ahead of print]

Imaging of intestinal involvement in endometriosis.

Massein A, Petit E, Darchen MA, Loriau J, Oberlin O, Marty O, Sauvanet E, Afriat R, Girard F, Molinié V, Duchatelle V, Zins M.

Source

Medical Imaging Department, Endometriosis Centre, Groupe hospitalier Paris Saint-Joseph, 185, rue Raymond-Losserand, 75014 Paris, France. Electronic address: audreypellot@yahoo.fr.

Abstract

Deep gastrointestinal involvement in endometriosis is characterised by fibrous, retractile thickening of the intestinal wall. The most common location is the upper rectum, in contiguity with a lesion of the torus uterinus. As part of a preoperative assessment, it is essential to establish an accurate and exhaustive map of intestinal lesions so that the surgeon can plan his actions. Transvaginal sonography and MRI correctly analyse pelvic and rectal involvement. Given the frequency of multiple intestinal sites, particularly sigmoid and associated ileo-caecal lesions, water enema CT should be performed. The role of rectal endoscopic sonography is debated.

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.

Source

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

Abstract

INTRODUCTION:

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.

PRESENTATION OF CASE:

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.

DISCUSSION:

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.

CONCLUSION:

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.

J Gynecol Obstet Biol Reprod (Paris). 2012 Dec 19. pii: S0368-2315(12)00366-3. doi: 10.1016/j.jgyn.2012.11.009. [Epub ahead of print]

Recurrence of pain after surgery for deeply infiltrating endometriosis: How does it happen? How to manage?

[Article in French]

Borghese B, Santulli P, Streuli I, Lafay-Pillet MC, de Ziegler D, Chapron C.

Source

Service de gynécologie obstétrique 2 et médecine de la reproduction, groupe hospitalier Cochin Broca, Hôtel-Dieu, université Paris Descartes, Sorbonne Paris Cité, AP-HP, bâtiment Port-Royal, 53, avenue de l’Observatoire, 75679 Paris, France; Inserm U1016, CNRS UMR8104, département génétique développement cancer, institut Cochin, université Paris Descartes, 75014 Paris, France. Electronic address: bruno.borghese@cch.aphp.fr.

Abstract

Recurrence of deep endometriosis remains a major issue in the management of endometriosis. The main cause for recurrence appears to be an incomplete excisional surgery. Therefore, the goal of the primary surgery should be the complete resection of all endometriotic lesions. If surgical skills cannot meet this objective it seems preferable to refer the patient to a center with a recognized expertise in this field rather than performing an incomplete surgery. It seems also possible to tailor the indications according to the symptoms, especially when endometriosis affects the bladder in association with an asymptomatic vaginal and/or rectal involvement. This strategy does not increase the rate of recurrence. Postoperative medical treatment based on ovarian function suppression is attractive as it diminishes the recurrence rate. Facing the recurrence, appropriate assessment of the benefit risk balance must be performed. Medical treatment is an option. When surgery is chosen, it seems interesting to discuss carefully the indication of hysterectomy with bilateral oophorectomy, especially for women over 40years old with no desire for pregnancy and/or symptomatic adenomyosis. Risks of induced ovarian castration must be taken into account.

Surg Clin North Am. 2013 Feb;93(1):45-59. doi: 10.1016/j.suc.2012.09.008. Epub 2012 Oct 22.

Unexpected intra-operative findings.

Hall JF, Stein SL.

Source

Department of Colon and Rectal Surgery, Lahey Clinic, Burlington, MA 02139, USA. jason.f.hall@lahey.org

Abstract

Abdominal surgeons are often asked to manage challenging pathologic conditions with limited preoperative information. As such, unexpected intraoperative findings are commonly encountered. Often, there is little peer-reviewed evidence on which to base management decisions. This article reviews common unexpected surgical challenges and provides recommendations based on the latest available literature.

Gynecol Obstet Fertil. 2012 Nov;40(11):634-41. doi: 10.1016/j.gyobfe.2012.09.014. Epub 2012 Nov 2.

Preoperative imaging of deeply infiltrating endometriosis in: Transvaginal sonography, rectal endoscopic sonography and magnetic resonance imaging.

[Article in French]

Gauche Cazalis C, Koskas M, Martin B, Palazzo L, Madelenat P, Yazbeck C.

Source

Service de gynécologie obstétrique, hôpital Bichat-Claude-Bernard, 46, rue Henri-Huchard, 75018 Paris, France. c.gauchecazalis@orange.fr

Abstract

OBJECTIVES:

Compare the accuracy of transvaginal ultrasonography (TVUS), rectal endoscopic sonography (RES), and magnetic resonance imaging (MRI) before deeply infiltrating endometriosis surgery.

PATIENTS AND METHODS:

A retrospective study with 25 deeply endometriosis patients underwent the three imaging examinations before surgery. Calculation of sensitivity, specificity, positive predictive value, negative predictive value and accuracy for the different locations: ovaries, uterosacral ligaments and torus, rectovaginal septum, rectosigmoid junction, bladder.

RESULTS:

Ovarian and deep pelvic endometriosis was found in surgery and confirmed by histology in all patients. Sensitivity and specificity are respectively: for ovaries: 88.2% and 71% of TVUS; 80% and 81.2% of RES; 87.5% and 71% of MRI. For uterosacral ligaments: 63% and 82,6% of TVUS; 37% and 100% of RES; 69% and 82.6% of MRI. For torus: 57.1% and 100% of TVUS; 76.2% and 100% of RES; 76.2% and 100% of MRI. For rectovaginal septum: 63.2% and 100% for TVUS; 89.5% and 66.7% of EER; 47.4% and 100% of MRI. For rectosigmoid junction: 73.7% and 66.7% of TVUS; 94.7% and 66.7% of RES; 89.5% and 50% of MRI. For bladder: 16.7% and 100% of TVUS; 16.7% and 100% of RES; 33.3% and 89.5% of MRI.

DISCUSSION AND CONCLUSION:

We found that TVUS is the more performant for endometriomas, it is MRI for torus, uterosacral ligaments and little bladder lesions, RES for rectovaginal septum and rectosigmoid junction. So in the clinical practice, the three imaging examinations are complementary for the preoperative assessment of deeply endometriosis.

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]

Hum Reprod. 2012 Dec;27(12):3440-9. doi: 10.1093/humrep/des322. Epub 2012 Sep 7.

Are digestive symptoms in women presenting with pelvic endometriosis specific to lesion localizations? A preliminary prospective study.

Roman H, Ness J, Suciu N, Bridoux V, Gourcerol G, Leroi AM, Tuech JJ, Ducrotté P, Savoye-Collet C, Savoye G.

Source

Department of Gynecology and Obstetrics, Rouen University Hospital, Rouen, France. horace.roman@gmail.com

Abstract

STUDY QUESTION:

What are the types and frequency of digestive symptoms in patients with different localizations of pelvic endometriosis and which specific symptoms are related to rectal stenosis? SUMMARY ANSWER: There is a high prevalence of digestive complaints in women presenting with superficial pelvic endometriosis and deep endometriosis sparing the rectum. WHAT IS KNOWN ALREADY: Women presenting with pelvic endometriosis frequently report gastrointestinal complaints of increased intensity during menstruation, which are not necessarily linked to the infiltration of the disease into the rectal wall. Even though intrarectal protrusion of the nodule can have an impact on bowel movement, only a minority of women with rectal nodules seemed to be concerned by significant narrowing of the rectum. STUDY DESIGN AND SIZE: This three-arm cohort prospective study included 116 women and was carried out over 22 consecutive months. PARTICIPANTS, SETTING AND METHODS: Prospective recording of data was performed for women treated for Stage 1 endometriosis involving the Douglas pouch (n = 21), deep endometriosis without digestive infiltration (n = 42) and deep endometriosis infiltrating the rectum (n = 53). Patient characteristics, pelvic pain and data from preoperative standardized questionnaires The Gastrointestinal Quality of Life Index (GIQLI), the Knowles-Eccersley-Scott-Symptom Questionnaire (KESS) and the MOS 36-Item Short-Form Health Survey (SF-36) were compared according to endometriosis localization.

MAIN RESULTS:

The values of total KESS and total GIQLI score were comparable for the three groups, as were a majority of the digestive complaints. Women presenting with rectal endometriosis were more likely to report an increase in intensity and length of dysmenorrhoea, while deep dyspareunia appeared to be more severe in women with superficial endometriosis. Women presenting with rectal endometriosis were more likely to present cyclic defecation pain (67.9%), cyclic constipation (54.7%) and a significantly longer stool evacuation time, although these complaints were also frequent in the other two groups (38.1 and 33.3% in women with Stage 1 endometriosis and 42.9 and 26.2% in women with deep endometriosis without digestive involvement, respectively). No independent clinical factor was found to be related to infiltration of the rectum by deep endometriosis. Among women with rectal endometriosis, only 26.4% presented with rectal stenosis. These women were significantly more likely to report constipation, defecation pain, appetite disorders, longer evacuation time and increased stool consistency without laxatives.

LIMITATIONS:

Patients treated for pelvic endometriosis in a tertiary referral centre may not be representative of the general endometriosis population presenting with those lesions. Statistically significant differences were revealed between the three groups; however, the results were based on a small number of subjects, which carries an inherent risk of type II error particularly when comparing variables with closed values. WIDER IMPLICATIONS OF THE FINDINGS: In women presenting with pelvic endometriosis, it seems likely that various digestive symptoms are the consequence of cyclic inflammatory phenomena leading to irritation of the digestive tract, rather than to actual infiltration of the disease itself into the rectum, with the exception of a limited number of cases where the disease leads to rectal stenosis. STUDY FUNDING/COMPETING INTEREST: The North-West Inter Regional Female Cohort for Patients with Endometriosis (CIRENDO) is financed by the G4 Group (The University Hospitals of Rouen, Lille, Amiens and Caen). No financial support was specifically received for this study. The authors declare no conflict of interest.

BJOG. 2012 Nov;119(12):1538-43. doi: 10.1111/j.1471-0528.2012.03466.x. Epub 2012 Aug 20.

Pregnancy outcome in women with peritoneal, ovarian and rectovaginal endometriosis: a retrospective cohort study.

Vercellini P, Parazzini F, Pietropaolo G, Cipriani S, Frattaruolo MP, Fedele L.

Source

Clinica Ostetrica e Ginecologica, Istituto Luigi Mangiagalli, Università Statale di Milano, and Fondazione IRCCS Ca Granda – Ospedale Maggiore Policlinico, Milan, Italy. paolo.vercellini@unimi.it

Abstract

We retrospectively assessed pregnancy outcome in 419 women who achieved a first spontaneous singleton pregnancy after surgery for endometriosis. A miscarriage was observed in 87 of 419 women (20.8%) and an ectopic pregnancy in eight (1.9%). Among the remaining 324 women, 14 (4.3%) experienced gestational hypertension/pre-eclampsia, 38 (11.7%) had a preterm delivery, five (1.5%) had placental abruption and 12 (3.7%) had placenta praevia. The incidence of placenta praevia was 7.6% in 150 women with rectovaginal lesions, 2.1% in 69 with ovarian endometriomas plus peritoneal implants, and 2.4% in 100 women with peritoneal implants only, whereas no case was observed in 100 women with ovarian endometriomas only.

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.

Source

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

Abstract

BACKGROUND:

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.

OBJECTIVE:

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

DATA SOURCES:

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

STUDY SELECTION:

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

INTERVENTIONS:

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

MAIN OUTCOME MEASURES:

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

RESULTS:

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.

LIMITATIONS:

: This study is limited by its retrospective nature.

CONCLUSIONS:

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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Taiwan J Obstet Gynecol. 2012 Jun;51(2):324-5. doi: 10.1016/j.tjog.2012.04.035.

A challenge in the management of a patient with ovarian cancer associated with extensive endometriosis.

Shih CY, Lai CR, Huang CY, Twu NF, Chao KC, Wang PH.

Curr Opin Obstet Gynecol. 2012 Aug;24(4):245-52. doi: 10.1097/GCO.0b013e3283556285.

Clinical outcome after laparoscopic radical excision of endometriosis and laparoscopic segmental bowel resection.

Meuleman C, Tomassetti C, D’Hooghe TM.

Source

Leuven University Fertility Center, Department of Obstetrics and Gynecology, University Hospital Leuven, Leuven, Belgium.

Abstract

PURPOSE OF REVIEW:

To present the clinical outcome after laparoscopic radical excision of deeply infiltrative endometriosis (DIE) with colorectal extension and laparoscopic segmental bowel resection.

RECENT FINDINGS:

In three different studies including mostly patients with recurrent DIE with colorectal extension, we showed that radical reconstructive CO2 laser laparoscopic resection of DIE with colorectal extension in a multidisciplinary setting resulted in a low complication rate, a low cumulative reintervention and recurrence rate and a high cumulative pregnancy rate, also when bowel resection reanastomosis was performed. In a systematic review to assess the clinical outcome of surgical treatment of DIE with colorectal involvement, data were reported in such a way that comparison of different surgical techniques was not possible. A checklist is proposed to achieve standardized reporting of presenting symptoms, preoperative tests, inclusion criteria, preoperative and postoperative care, complications, follow-up, patient-centered assessment of pain and quality of life, fertility and recurrence corrected for postoperative use of hormonal suppression or infertility treatment.

SUMMARY:

CO2 laser laparoscopic radical excision of DIE with colorectal extension and laparoscopic segmental bowel resection in centers of expertise is associated with good clinical outcome. To make real progress, international agreement is needed on terms and definitions used in surgical endometriosis research.

Clin Imaging. 2012 Jul-Aug;36(4):295-300. doi: 10.1016/j.clinimag.2011.09.010. Epub 2012 Jun 8.

Pictorial review: rectosigmoid endometriosis on MRI with gel opacification after rectosigmoid colon cleansing.

Loubeyre P, Copercini M, Frossard JL, Wenger JM, Petignat P.

Source

Department of Imaging, Geneva University Hospitals, Geneva, Switzerland. pierre.loubeyre@hcuge.ch

Abstract

Posterior deeply infiltrating endometriosis (PDIE) is an invalidating disorder that may involve the rectosigmoid colon. MRI with gel opacification after rectosigmoid colon cleansing improves visualization of rectosigmoid endometriosis. Nonetheless, the depth of bowel wall infiltration is still difficult to assess. In this regard, the use of high-frequency echoendoscope may be needed. Recognition of rectosigmoid endometriosis is important to establish a correct diagnosis and provide counseling and appropriate therapy.

Colorectal Dis. 2013 Jan;15(1):102-8. doi: 10.1111/j.1463-1318.2012.03111.x.

Quality of life and sexual function 1 year after laparoscopic rectosigmoid resection for endometriosis.

Kössi J, Setälä M, Mäkinen J, Härkki P, Luostarinen M.

Source

Department of Surgery, Päijät-Häme Central Hospital, Lahti, Finland. jyrki.kossi@phsotey.fi

Abstract

AIM:

Endometriosis is relatively common condition in fertile women and may affect the alimentary tract. Laparoscopic rectosigmoid resection for endometriosis has been found to be both feasible and safe. The aim of the present study was to prospectively evaluate the quality of life and sexual function of patients who have undergone rectosigmoid resection for endometriosis.

METHOD:

All patients undergoing rectal or sigmoid resection for endometriosis in two specialist hospitals were prospectively recruited in the study. Details regarding demography, endometriosis-related symptoms, procedure and postoperative recovery were collected. One year after the operation patients were sent a postal questionnaire asking about endometriosis-related symptoms, quality of life and sexual functioning. The 15D Questionnaire and McCoy Female Sexuality Questionnaire were used for this purpose.

RESULTS:

A total of 26 patients responded to the 15D questionnaire. Endometriosis-related bowel symptoms decreased significantly after the operation. The responses showed improvements in the overall score and scores for five different dimensions (usual activities, P = 0.04; discomfort and symptoms, P < 0.001; distress, P < 0.001; vitality, P < 0.001; sexual activity, P < 0.001). Sexual satisfaction was greater 1 year after the operation (P = 0.01). Sexual problems and partner satisfaction scores had not changed significantly.

CONCLUSION:

Laparoscopic rectal and sigmoid resection for endometriosis significantly reduce endometriosis-related symptoms and improve quality of life and sexual well-being.

Cochrane Database Syst Rev. 2012 May 16;5:CD006568. doi: 10.1002/14651858.CD006568.pub3.

Chinese herbal medicine for endometriosis.

Flower A, Liu JP, Lewith G, Little P, Li Q.

Source

ComplementaryMedicine ResearchUnit, Dept PrimaryMedical Care, Southampton University, Ringmer, UK. flower.power@which.net.

Abstract

BACKGROUND:

Endometriosis is characterized by the presence of tissue that is morphologically and biologically similar to normal endometrium in locations outside the uterus. Surgical and hormonal treatment of endometriosis have unpleasant side effects and high rates of relapse. In China, treatment of endometriosis using Chinese herbal medicine (CHM) is routine and considerable research into the role of CHM in alleviating pain, promoting fertility, and preventing relapse has taken place.This review is an update of a previous review published in the Cochrane Database of Systematic Reviews 2009, issue No 3.

OBJECTIVES:

To review the effectiveness and safety of CHM in alleviating endometriosis-related pain and infertility.

SEARCH METHODS:

We searched the Menstrual Disorders and Subfertility Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library) and the following English language electronic databases (from their inception to 31/10/2011): MEDLINE, EMBASE, AMED, CINAHL, and NLH.We also searched Chinese language electronic databases: Chinese Biomedical Literature Database (CBM), China National Knowledge Infrastructure (CNKI), Chinese Sci & Tech Journals (VIP), Traditional Chinese Medical Literature Analysis and Retrieval System (TCMLARS), and Chinese Medical Current Contents (CMCC).

SELECTION CRITERIA:

Randomised controlled trials (RCTs) involving CHM versus placebo, biomedical treatment, another CHM intervention; or CHM plus biomedical treatment versus biomedical treatment were selected. Only trials with confirmed randomisation procedures and laparoscopic diagnosis of endometriosis were included.

DATA COLLECTION AND ANALYSIS:

Risk of bias assessment, and data extraction and analysis were performed independently by three review authors. Data were combined for meta-analysis using relative risk (RR) for dichotomous data. A fixed-effect statistical model was used, where appropriate. Data not suitable for meta-analysis were presented as descriptive data.

MAIN RESULTS:

Two Chinese RCTs involving 158 women were included in this review. Both these trials described adequate methodology. Neither trial compared CHM with placebo treatment.There was no evidence of a significant difference in rates of symptomatic relief between CHM and gestrinone administered subsequent to laparoscopic surgery (95.65% versus 93.87%; risk ratio (RR) 1.02, 95% confidence interval (CI) 0.93 to 1.12, one RCT). The intention-to-treat analysis also showed no significant difference between the groups (RR 1.04, 95% CI 0.91 to 1.18). There was no significant difference between the CHM and gestrinone groups with regard to the total pregnancy rate (69.6% versus 59.1%; RR 1.18, 95% CI 0.87 to 1.59, one RCT).CHM administered orally and then in conjunction with a herbal enema resulted in a greater proportion of women obtaining symptomatic relief than with danazol (RR 5.06, 95% CI 1.28 to 20.05; RR 5.63, 95% CI 1.47 to 21.54, respectively). Overall, 100% of women in all the groups showed some improvement in their symptoms.Oral plus enema administration of CHM showed a greater reduction in average dysmenorrhoea pain scores than did danazol (mean difference (MD) -2.90, 95% CI -4.55 to -1.25; P < 0.01). Combined oral and enema administration of CHM also showed a greater improvement measured as the disappearance or shrinkage of adnexal masses than with danazol (RR 1.70, 95% CI 1.04 to 2.78). For lumbosacral pain, rectal discomfort, or vaginal nodules tenderness, there was no significant difference between CHM and danazol.

AUTHORS’ CONCLUSIONS:

Post-surgical administration of CHM may have comparable benefits to gestrinone but with fewer side effects. Oral CHM may have a better overall treatment effect than danazol; it may be more effective in relieving dysmenorrhoea and shrinking adnexal masses when used in conjunction with a CHM enema. However, more rigorous research is required to accurately assess the potential role of CHM in treating endometriosis.

Update of

J Minim Invasive Gynecol. 2012 May-Jun;19(3):396-400. doi: 10.1016/j.jmig.2012.02.001.

Sacral nerve infiltrative endometriosis presenting as perimenstrual right-sided sciatica and bladder atonia: case report and description of surgical technique.

Lemos N, Kamergorodsky G, Ploger C, Castro R, Schor E, Girão M.

Source

Department of Gynecology, Pelvic Neurodysfunction Clinic, Federal University of São Paulo, São Paulo, Brazil. nucelio@gmail.com

Abstract

Endometriosis infiltrating the sacral nerve roots is a rarely reported manifestation of the disease. The objectives of this article are to report such a case and to describe the surgical technique for laparoscopic decompression of sacral nerve roots and treatment of endometriosis at this site. The patient as a 38-year-old woman who had undergone 2 previous laparoscopic procedures for electrocoagulation of peritoneal endometriosis and self-reported perimenstrual right-sided sciatica and urinary retention. Clinical examination revealed allodynia (pain from a stimulus that does not normally cause pain) on the S2 to S4 dermatomes and hypoesthesia on part of the S3 dermatome. Magnetic resonance imaging showed an endometriotic nodule infiltrating the anterior rectal wall. Laparoscopic exploration of the sacral nerve roots demonstrated vascular compression of the lumbosacral trunk and endometriosis entrapping the S2 to S4 sacral nerve roots, with an endometrioma inside S3. The endometriosis was removed from the sacral nerve roots and detached from the sacral bone, and a nodulectomy of the anterior rectal wall was performed. Normal urinary function was restored on postoperative day 2, and pain resolved after a period of post-decompression. Intrapelvic causes of entrapment of sacral nerve roots are rarely described in the current literature, either because of misdiagnosis or actual rareness of the condition. Recognition of the clinical markers for these lesions may lead to an increase in diagnosis and specific treatment.

Gynecol Obstet Invest. 2012;73(4):265-71. doi: 10.1159/000336522. Epub 2012 Apr 24.

Extragenital endometrial stromal sarcoma arising in endometriosis.

Alcázar JL, Guerriero S, Ajossa S, Parodo G, Piras B, Peiretti M, Jurado M, Idoate MÁ.

Source

Department of Obstetrics and Gynecology, Clínica Universitaria de Navarra, University of Navarra, Pamplona, Spain. jlalcazar@unav.es

Abstract

The diagnosis rate of deep pelvic endometriosis is increasing. Endometrial stromal sarcoma (ESS) is a rare neoplasm. Extragenital ESS is an extremely uncommon event. Very few cases of extragenital ESS have been reported to date. The diagnosis of this entity is very difficult in some instances. Knowledge about its management is also limited. In this paper, we review the current literature on the clinical management, histology, immunohistochemistry, treatment and outcome of ESS arising in pelvic endometriosis.

Eur J Obstet Gynecol Reprod Biol. 2012 Jun;162(2):121-4. doi: 10.1016/j.ejogrb.2012.02.030. Epub 2012 Apr 24.

Rectosigmoid deep infiltrating endometriosis and ureteral involvement with loss of renal function.

Muñoz JL, Jiménez JS, Tejerizo A, Lopez G, Duarte J, Sánchez Bustos F.

Source

Endometriosis Unit, Gynecology Service, Hospital 12 de Octubre, Madrid, Spain.

Abstract

Endometriosis is a complex disease with unclear pathogenesis, defined as the presence of endometrial tissue (glands and stroma) outside its usual location in the uterine cavity. Ureteral involvement is rare, with an estimated frequency of 10-14% in cases of deep endometriosis with nodules of 3 cm or larger. An important complication of ureteral involvement is asymptomatic loss of renal function. In a patient with asymptomatic renal failure the relevance of extrinsic ureteral involvement by deep endometriosis has been taken to account. CASE REPORT: A 32-year-old nulliparous woman presented with chronic pelvic pain associated with severe dysmenorrhea, dyspareunia and digestive problems including diarrhea, occasional constipation and rectal bleeding. She reported no urological symptoms. Magnetic resonance imaging (MRI) identified a 4 cm nodule in the recto-vaginal septum, compressing and infiltrating the rectal wall, and chronic left hydronephrosis. Isotope renogram revealed 91% function in the right kidney and 9% in the left kidney. A multidisciplinary surgical team including consultants from the departments of digestive surgery and urology assessed the patient. The treatment recommended was a joint approach of laparoscopic surgery to perform adhesiolysis, ureterolysis, freeing of the uterus and appendages, resection of the rectovaginal septum nodule, and left nephrectomy. COMMENT: Diagnosis and treatment of deep endometriosis should be performed in specialized centers and in the context of multidisciplinary collaboration. We must be aware of the potential risk of ureteral involvement and the asymptomatic loss of renal function in any patient with endometriosis nodules of 3 cm or larger.

Hum Reprod. 2012 Jun;27(6):1878; author reply 1878-9. doi: 10.1093/humrep/des122. Epub 2012 Apr 4.

New surgical approaches for the treatment of deep infiltrating endometriosis of the rectum.

Wolthuis AM, D’Hoore A.

Comment on

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Destroy user interface controlCombined transanal and laparoscopic approach for the treatment of deep endometriosis infiltrating the rectum.[Hum Reprod. 2012]

J Gastrointestin Liver Dis. 2012 Mar;21(1):7.

Predecidualized endometriosis presenting as rectosigmoid polyps with stenosis.

Park HS, Jang KY, Moon WS.

Source

Department of Pathology, Research Institute of Clinical Medicine, Research Institute for Endocrine Sciences, Chonbuk National University Medical School, Jeonju, Korea.

Hum Reprod. 2012 May;27(5):1314-9. doi: 10.1093/humrep/des048. Epub 2012 Mar 12.

Segmental bowel resection for colorectal endometriosis: is there a correlation between histological pattern and clinical outcomes?

Mabrouk M, Spagnolo E, Raimondo D, D’Errico A, Caprara G, Malvi D, Catena F, Ferrini G, Paradisi R, Seracchioli R.

Source

The Minimally Invasive Gynaecological Surgery Unit, Gynaecology Department, S.Orsola-Malpighi Hospital, University of Bologna, Via Massarenti 13, Bologna 40138, Italy.

Abstract

BACKGROUND:

Laparoscopic segmental resection as a treatment for intestinal endometriosis can be supported by favorable clinical outcomes, but carries a high risk of major complications. The purpose of this study is to evaluate histopathological patterns of colorectal endometriosis and investigate potential relationships between histological findings and clinical data.

METHODS:

We consecutively included 47 patients treated with laparoscopic segmental resection because of symptomatic colorectal endometriosis. All patients underwent follow-up for a median of 18 months (range: 6-35). We examined the histological patterns of colorectal endometriosis and evaluated the relationships between histological findings (satellite lesions, positive margins and vertical infiltration) and clinical outcomes (incidence of recurrence, quality of life and symptom improvement). Moreover, we observed if satellite lesions could influence preoperative scores of the short form-36 health survey (SF-36) questionnaire and visual analogue score (VAS) for pain symptoms.

RESULTS:

There were no statistically significant differences in terms of anatomical and pain recurrences, pain symptoms and quality of life improvement among patients with or without positive margins, satellite lesions and different degrees of vertical infiltration (P > 0.05). Furthermore, women with or without satellite lesions were no different in terms of preoperative VAS of pain symptoms and SF-36 scores (P > 0.05).

CONCLUSIONS:

The presence of satellite lesions or positive resection margins does not seem to influence clinical outcomes of segmental colorectal resection. Similarly, satellite lesions do not appear to have a major role in determining preoperative clinical presentation. These results may be useful to reconsider the surgical strategy for bowel endometriosis.

Comment in

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Destroy user interface controlPoor results after surgery for rectovaginal endometriosis can be related to uterine adenomyosis. [Hum Reprod. 2012]

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]

Reprod Biomed Online. 2012 Apr;24(4):389-95. doi: 10.1016/j.rbmo.2012.01.003. Epub 2012 Jan 24.

Effect of patient selection on estimate of reproductive success after surgery for rectovaginal endometriosis: literature review.

Vercellini P, Barbara G, Buggio L, Frattaruolo MP, Somigliana E, Fedele L.

Source

Department of Obstetrics and Gynecology, Istituto Luigi Mangiagalli, University of Milan, Milan, Italy. paolo.vercellini@unimi.it

Abstract

The effect of rectovaginal endometriosis on fertility is unclear. Several authors foster radical surgery, including colorectal resection, as a fertility-enhancing procedure. However, interpretation of data is difficult, as the baseline fertility status is often undefined and it is not always possible to discriminate between spontaneous conceptions and those resulting from IVF. A systematic literature review was performed with the aim of defining the pregnancy rate specifically in patients who were infertile before surgery and who sought spontaneous pregnancy. A PubMed search was conducted to identify English language studies published between 2005 and 2011 evaluating reproductive performance after surgery for rectovaginal and rectosigmoid endometriosis. According to the results of the 11 selected studies, the mean post-operative conception rate in all women seeking pregnancy independently of preoperative fertility status and IVF performance was 39% (95% CI 35-43%; 223/571), but dropped to 24% (95% CI 20-28%; 123/510) in infertile patients who sought spontaneous conception (odds ratio 0.50, 95% CI 0.38-0.65%). Patients’ selection significantly influences the estimate of the effect of rectovaginal endometriosis excision on infertility. This should be carefully taken into consideration at preoperative counselling. Rectovaginal endometriosis usually is associated with pain symptoms, but the effect of this disease form on fertility is uncertain, as burial of foci beneath rectouterine adhesions with exclusion of the deepest part of the pelvis may limit interference with fertilization processes. Several authors foster radical surgery, including colorectal resection, as a fertility-enhancing procedure. However, interpretation of data is difficult, as the baseline fertility status is often undefined and it is not always possible to discriminate between spontaneous conceptions and those resulting from IVF. A systematic literature review was performed with the aim of defining the pregnancy rate specifically in patients who were infertile before surgery and who sought pregnancy spontaneously. A PubMed search was conducted to identify English language studies published between 2005 and 2011 evaluating reproductive performance after surgery for rectovaginal and rectosigmoid endometriosis. According to the results of the 11 selected studies, the mean post-operative conception rate in all women seeking pregnancy independently of preoperative fertility status and IVF performance was 39% (223/571), but dropped to 24% (123/510) in infertile patients who sought conception spontaneously. The 15% difference is statistically significant. Infertile patients with rectovaginal endometriosis considering surgery, should be carefully informed of the real probability of post-operative conception avoiding generic overestimations.

J Reprod Med. 2012 Jan-Feb;57(1-2):81-4.

Can ovariopexy at the end of surgery for endometriosis be recommended? A case report.

Daraï E, Touboul C, Ballester M, Poncelet C.

Source

Department of Gynecology-Obstetrics, Hôpital Tenon, Université Pierre et Marie Curie, Paris. emile.darai@tnn.aphp.fr

Abstract

BACKGROUND:

Endometriosis affects 10-15% of the female population in the reproductive period and is detected in up to 40% of infertile women. Surgery is indicated to improve fertility and symptoms in these women, but some patients experience severe complications and develop postoperative adhesion. We discuss the potential impact on adhesion of systematic ovariopexy at the end of surgery for endometriosis.

CASE:

We report a case of a 31-year-old woman who underwent initial laparoscopic removal of endometriomas and rectovaginal endometriosis with bilateral transient ovariopexy five years ago. She was referred for recurrence of symptoms and infertility. Preoperative transvaginal sonography and MRI confirmed the recurrence of endometriosis with bilateral uterosacral ligament and rectal involvement. At laparoscopy severe and dense adhesions of the ovaries to the anterior abdominal wall using nonabsorbable suture were observed associated with distortion of tubal anatomy. In addition to the removal of these adhesions, a sigmoid adhesiolysis was performed with uterosacral ligament, rectosigmoid and vaginal resections, followed by a systematic protective colostomy.

CONCLUSION:

This case illustrates the deleterious impact on adhesions to the abdominal wall of transient ovariopexy at the end of surgery for endometriosis.

Gynecol Obstet Fertil. 2012 Feb;40(2):116-20. doi: 10.1016/j.gyobfe.2011.12.002. Epub 2012 Jan 26.

Segmental resection for colorectal endometriosis: are there alternatives?

[Article in French]

Daraï E, Touboul C, Chéreau E, Bazot M, Ballester M.

Source

Service de gynécologie-obstétrique, université Pierre et Marie Curie, hôpital Tenon, AP-HP, Paris 6, 4, rue de la Chine, 75020 Paris, France. emile.darai@tnn.aphp.fr

Abstract

Colorectal surgery for endometriosis is increasingly performed, but its assessment is still incomplete, especially regarding its impact on quality of life, the recurrence rate and subsequent fertility. Segmental resection is the technique most often performed and best evaluated with a proven efficacy but associated with significant morbidity. Alternatives to segmental resection consisting of shaving rectal resection, discoid resection or superficial resection have recently been proposed to provide equivalent efficacy while decreasing morbidity. To date, data are insufficient to clarify the respective indications of segmental resection and alternatives. Only randomized trials will resolve the existing controversy.

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