Laparoscopic ileocecal resection for bowel endometriosis

Diagnosis and treatment of uncommon ileal endometriosis: a case report and literature review

Endometriosis is defined as the presence of endometrial tissue outside the uterine cavity. It is a common finding in premenopausal women and commonly affects the gastrointestinal tract, especially the rectosigmoid tract. Small bowel involvement is rare and usually asymptomatic making diagnosis difficult. Here we report an uncommon case of exophytic ileal endometriosis surgically treated. Detailed pre-operative counselling on the risk of ileal surgery should always be considered in all cases with endometriosis requiring surgery. We also present a review of the literature regarding the clinical presentation, diagnosis, and treatment of this challenging condition.

Value of sonography in assessing parametrial endometriotic involvement: Preliminary results

Objectives:

The aims of the study were to evaluate ultrasound (US) in the diagnosis of parametrial endometriosis compared with surgical-pathological findings, and to define an optimal cut-off of lesion size for correlation between torus/uterosacral ligaments (USL) or rectosigmoid and parametrial involvement by deep endometriosis.

Methods:

Longitudinal study of 60 patients referred for surgical management of pelvic endometriosis, who underwent sonography performed by an experienced sonographer. The presence of parametrial endometriosis shown by US was compared with surgical and histologic findings. The presence of endometrial cysts, deep endometriotic locations, and their potential association with parametrial endometriosis was assessed by US. The sensitivity, specificity, predictive values (PV), accuracy, and positive and negative likelihood ratios (LR) of US for predicting parametrial endometriosis and other pelvic endometriotic locations were assessed. Descriptive analysis, optimal cut-off analysis, categorical (Fisher’s exact test) and non-categorical variables (Mann—Whitney) were calculated.

Results:

Parametrial, ovarian, and deep endometriosis were found by surgery in respectively 30 (50%), 21 (35%), and 59 (98.63%) of the 60 patients. The sensitivity, specificity, PPV, NPV, accuracy, PLR, and NLR of US for the sonographic diagnosis of parametrial endometriosis were 40%, 96.7%, 92.3%, 61.7%, 68.3%, 12, and 0.62 respectively. In patients with parametrial involvement, a relation with rectosigmoid ( p = 0.005) and USL ( p = 0.0074) endometriosis was noted. For isolated torus/USL and rectosigmoid endometriosis, optimal cut-offs suggesting parametrial involvement by DE were 11 mm and 30 mm, respectively.

Conclusions:

US has low sensitivity but high specificity to diagnose parametrial endometriosis and could be used to rule in diagnosis before surgery.

Robotic treatment of bowel endometriosis

Endometriosis describes a condition with the presence of ectopic endometrial glands and stroma outside the endometrial cavity that affects up to 15% of reproductive-aged women. Of women affected with endometriosis, 3.8-37% will have endometriosis involving the bowel, primarily the rectosigmoid colon. While medical management is often recommended as a first-line therapy, it is not curative, and surgery is often required as an adjunct for the management of symptoms. Minimally invasive surgery has become the standard of care for managing these patients. The use of robotic-assisted laparoscopy offers benefits that may allow surgeons to perform these challenging surgical cases using a minimally invasive technique. For lesions that affect the colon, there are three primary techniques used for removal which include: 1) rectal shaving, 2) discoid excision and 3) segmental resection. The decision to pursue one approach over another is largely dependent on the number of lesions present, a lesion's size and depth of invasion as well as the involved circumference of the bowel. The available evidence of using robotic-assisted laparoscopy in cases of bowel endometriosis is limited in the literature. In this review, we will summarize the role of robotic-assisted laparoscopy in the management of bowel endometriosis.

The feasibility and safety of complete laparoscopic extended right hemicolectomy with preservation of the ileocecal junction in right-transverse colon cancer

BACKGROUND

To evaluate the feasibility and safety of a new surgical method, complete laparoscopic extended right hemicolectomy with preservation of the ileocecal junction in right-transverse colon cancer.

METHODS

We retrospectively analyzed and compared the data of consecutive patients with right-transverse colon cancer who underwent complete laparoscopic extended right hemicolectomy with preservation of the ileocecal junction (n = 23) and conventional complete laparoscopic extended right hemicolectomy (n = 34) in our hospital between October 2017 to May 2019, respectively.

RESULTS

The overall operation time of the ileocecal junction-preserved group was significantly shorter than that of the control group (p = 0.048). There was no difference in the number of harvested lymph nodes, metastatic lymph nodes, and rate of metastatic lymph nodes (p > 0.05). The ileocecal junction-preserved group showed shorter time of first flatus, lower frequency of postoperative diarrhea, and shorter duration of postoperative hospitalization. Furthermore, it also showed that the defecation frequency was lower in the ileocecal junction-preserved group than the control group on the 1st, 3rd, and 6th month (p < 0.05), and the number of patients who defecated at night or defecated four times or more a day was less in the ileocecal junction-preserved group than control group on the 1st month (p < 0.05).

CONCLUSION

The complete laparoscopic extended right hemicolectomy with preservation of the ileocecal junction promises as a safe and feasible surgical procedure for right-transverse colon cancer, associated with earlier recovery of bowel function, shorter operation time, and similar pathological outcomes when compared to the conventional laparoscopic procedure.

Colorectal Anastomotic Stenosis: Lessons Learned after 1643 Colorectal Resections for Deep Infiltrating Endometriosis

STUDY OBJECTIVE

To evaluate the incidence, risk factors, and treatment of colorectal anastomotic stenosis in patients who undergo rectosigmoid resection for deep infiltrating endometriosis (DIE).

DESIGN

Retrospective analysis of a prospective database (Canadian Task Force classification III).

SETTING

Public medical center.

PATIENTS

All women who underwent laparoscopic rectosigmoid resections for DIE at our hospital between January 2002 and December 2016.

INTERVENTION

All patients were evaluated clinically and endoscopically at 1 month and 3 months after bowel resection. Stenosis was defined as a lack of passage through the anastomosis of a 12-mm proctoscope. Symptomatic stenosis was defined as the presence of endoscopically confirmed stricture accompanied by at least 2 of the following symptoms: constipation, need to push, tenesmus, and ribbon stools. Only patients with symptomatic stenosis were studied. Demographic data, surgical techniques, and postoperative complications were recorded prospectively. Treatments and outcomes of anastomotic symptomatic strictures were analyzed.

MEASUREMENTS AND MAIN RESULTS

A total of 1643 patients underwent laparoscopic rectosigmoid resection at our hospital between January 2002 and December 2016. Among these, 104 patients (6.3%) presented with symptomatic anastomotic stenosis. The median patient age was 27 years (range, 23-44 years), and the median interval between diagnosis and the onset of symptomatic stenosis was 57 days (range, 21-64 days). The only statistically significant predictors of anastomotic stenosis were the presence of ileostomy (p = .01) and previous pelvic surgery (p = .002). Treatment of choice was always conservative. Of the 104 patients in the study cohort, 90 (86.5%) underwent 3 endoscopic dilatations. No patient required reoperation.

CONCLUSION

The anastomotic stricture is a recognized complication in patients following intestinal resection for DIE, and protective ileostomy is the sole modifiable factor related to anastomotic stenosis. Endoscopic dilatation is a valid option to treat this complication.

MR imaging of endometriosis: Spectrum of disease

Endometriosis is a common gynecological disorder defined by the presence of endometrial tissue outside the uterus. It is the most common cause of chronic pelvic pain and typically affects the ovaries, uterine ligaments, peritoneum, tubes, rectovaginal septum and bladder. It may, however, be found at various extrapelvic sites, including the perineum, liver, pancreas, lung or even the central nervous system, and in such cases, diagnosis may be quite challenging. Even though definitive diagnosis requires laparoscopy, preoperative identification of endometriosis is important not only to differentiate it from other diseases with similar clinical presentations but also, for accurate presurgical mapping, since complete removal of all endometriotic foci is critical for the effective treatment of the patient's symptoms. Ultrasound is performed initially, but magnetic resonance imaging (MRI) is increasingly being used, particularly when sonographic findings are unclear, when deep pelvic endometriosis is suspected or when surgery is planned, as it provides better contrast resolution and a larger field of view compared to ultrasound. In this article, we will discuss distinctive MRI appearances of endometriotic foci and we will review common and uncommon locations of endometriosis within the body, in an attempt to familiarize radiologists with its wide spectrum of manifestations.

Is pelvic MRI in women presenting with pelvic endometriosis suggestive of associated ileal, appendicular, or cecal involvement?

PURPOSE

To evaluate whether deep pelvic endometriosis or endometriomas diagnosed at pelvic MRI are associated with extrapelvic bowel endometriosis (EPBE) (ileal, appendicular, or cecal involvement) in order to suggest criteria for performing an additional imaging examination dedicated to the assessment of EPBE.

METHODS

Ninety-six patients operated on for deep pelvic endometriosis were retrospectively included. They were classified in two groups according to the presence of surgically and histologically proven EPBE. According to pelvic endometriotic lesions described on the preoperative pelvic MRI, a logistic regression analysis was performed to evaluate a possible association between EPBE and pelvic endometriosis.

RESULTS

Eleven patients had EPBE (5 appendicular, 2 cecal, and 4 ileocecal lesions) at surgery. In adjusted models, involvement of the right ureter, rectosigmoid, and sigmoid localizations were statistically associated with EPBE with adjusted OR of 9.13 (95% CI 1.98-42.19), 5.8 (95% CI 1.12-30.07), and 6.74 (95% CI 1.23-36.77), respectively.

CONCLUSIONS

Further imaging evaluation to assess ileal, appendicular, or cecal endometriosis should be proposed in case of sigmoid or rectosigmoid endometriosis diagnosed at pelvic MRI. A right ureteral lesion diagnosed preoperatively should be considered carefully as its association with EPBE is not described so far.

A case of rectal endometriosis

A young female patient presented with difficult defecation for 1 year and abdominal distension. Colonoscopy revealed an irregular regular mass with surface ulcers, and luminal stenosis. A second colonoscopy, which coincided with her period, revealed an oozing tumor, and pathology showed mucosal active inflammation with ulceration. The patient underwent rectal tumor excision, and pathological findings suggested rectal endometriosis. After surgery, the patient had no difficult defecation or abdominal distension, and she received progesterone treatment for half a year.

Bowel endometriosis: Colorectal surgeon’s perspective in a multidisciplinary surgical team

Endometriosis is a gynecological condition that presents as endometrial-like tissue outside the uterus and induces a chronic inflammatory reaction. Up to 15% of women in their reproductive period are affected by this condition. Deep endometriosis is defined as endometriosis located more than 5 mm beneath the peritoneal surface. This type of endometriosis is mostly found on the uterosacral ligaments, inside the rectovaginal septum or vagina, in the rectosigmoid area, ovarian fossa, pelvic peritoneum, ureters, and bladder, causing a distortion of the pelvic anatomy. The frequency of bowel endometriosis is unknown, but in cases of bowel infiltration, about 90% are localized on the sigmoid colon or the rectum. Colorectal involvement results in alterations of bowel habits such as constipation, diarrhea, tenesmus, dyschezia, and, rarely, rectal bleeding. Differential diagnosis must be made in case of irritable bowel syndrome, solitary rectal ulcer syndrome, and a rectal tumor. A precise diagnosis about the presence, location, and extent of endometriosis is necessary to plan surgical treatment. Multidisciplinary laparoscopic treatment has become the standard of care. Depending on the size of the lesion and site of involvement, full-thickness disc excision or bowel resection needs to be performed by an experienced colorectal surgeon. Long-term outcomes, following bowel resection for severe endometriosis, regarding pain and recurrence rate are good with a pregnancy rate of 50%.

Multidisciplinary laparoscopic treatment for bowel endometriosis

Endometriosis is a handicapping disease affecting young females in the reproductive period. It mainly occurs in the pelvis and affects the bowel in 3-37%. Endometriosis can cause menstrual and non-menstrual pelvic pain and infertility. Colorectal involvement results in alterations of bowel habit such as constipation, diarrhoea, tenesmus, and rarely rectal bleeding. A precise diagnosis about the presence, location and extent is necessary. Based on clinical examination, the diagnosis of bowel endometriosis can be made by transvaginal ultrasound, barium enema examination and magnetic resonance imaging. Multidisciplinary laparoscopic treatment has become the standard of care and depending on size of the lesion and site of involvement full-thickness disc excision or bowel resection is performed by an experienced colorectal surgeon. Anastomotic complications occur around 1%. Long-term outcome after bowel resection for severe endometriosis is good with a pregnancy rate of 50%.

Rectosigmoid endometriosis: Practical approaches to improve the possibility of obtaining a definite preoperative biopsy diagnosis

AIM: To discuss the methods for improving the accuracy of preoperative diagnosis of rectosigmoid endometriosis.

METHODS: From December 2002 up to now, six patients with intestinal endometriosis were treated at our hospital. The clinical manifestations, enteroscopic findings, and histopathological manifestations of preoperative biopsy specimens and postoperative specimens removed by laparotomy or laparoscope resection were analyzed. A review of the literature was also performed.

RESULTS: Four (66.7%) cases of the rectosigmoid endometriosis were misdiagnosed clinically, including 1 case misdiagnosed as glandular dysplasia and 3 cases as chronic inflammation (including 1 case as ulcers). Immunohistochemical staining for ER, PR, CK7, K20 and CD10 were performed. Normal colorectal epithelia were negative for CK7, ER, and PR, whereas rectosigmoid endometriosis was positive for CK7, ER, and PR and showed endometrial stromal expression of CD10.

CONCLUSION: Combination of clinical manifestations, colonoscopic findings, and immunohistochemistry can improve the accuracy of preoperative diagnosis of endometriosis.