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Choi JDW, Hu H, Cao A, Pathma-Nathan N, Toh JWT. Unresolved debate on surgery for deep infiltrating endometriosis of the rectum: bowel resection or a more conservative approach? ANZ J Surg 2024. [PMID: 38873963 DOI: 10.1111/ans.19134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 05/09/2024] [Accepted: 06/05/2024] [Indexed: 06/15/2024]
Affiliation(s)
- Joseph Do Woong Choi
- Department of Colorectal Surgery, Westmead Hospital, Sydney, New South Wales, Australia
- Discipline of Surgery, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Hillary Hu
- Department of Obstetrics and Gynaecology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Amy Cao
- Department of Colorectal Surgery, Westmead Hospital, Sydney, New South Wales, Australia
| | - Nimalan Pathma-Nathan
- Department of Colorectal Surgery, Westmead Hospital, Sydney, New South Wales, Australia
- Discipline of Surgery, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - James Wei Tatt Toh
- Department of Colorectal Surgery, Westmead Hospital, Sydney, New South Wales, Australia
- Discipline of Surgery, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
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Peng J, Liu Q, Pu T, Zhang M, Zhang M, Du M, Li G, Zhang X, Xu C. Targeted Imaging of Endometriosis and Image-Guided Resection of Lesions Using Gonadotropin-Releasing Hormone Analogue-Modified Indocyanine Green. Mol Imaging 2023; 2023:6674054. [PMID: 38089464 PMCID: PMC10713253 DOI: 10.1155/2023/6674054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 10/17/2023] [Accepted: 11/15/2023] [Indexed: 12/18/2023] Open
Abstract
Objective In this study, we utilized gonadotropin-releasing hormone analogue-modified indocyanine green (GnRHa-ICG) to improve the accuracy of intraoperative recognition and resection of endometriotic lesions. Methods Gonadotropin-releasing hormone receptor (GnRHR) expression was detected in endometriosis tissues and cell lines via immunohistochemistry and western blotting. The in vitro binding capacities of GnRHa, GnRHa-ICG, and ICG were determined using fluorescence microscopy and flow cytometry. In vivo imaging was performed in mouse models of endometriosis using a near-infrared fluorescence (NIRF) imaging system and fluorescence navigation system. The ex vivo binding capacity was determined using confocal fluorescence microscopy. Results GnRHa-ICG exhibited a significantly stronger binding capacity to endometriotic cells and tissues than ICG. In mice with endometriosis, GnRHa-ICG specifically imaged endometriotic tissues (EMTs) after intraperitoneal administration, whereas ICG exhibited signals in the intestine. GnRHa-ICG showed the highest fluorescence signals in the EMTs at 2 h and a good signal-to-noise ratio at 48 h postadministration. Compared with traditional surgery under white light, targeted NIRF imaging-guided surgery completely resected endometriotic lesions with a sensitivity of 97.3% and specificity of 77.8%. No obvious toxicity was observed in routine blood tests, serum biochemicals, or histopathology in mice. Conclusions GnRHa-ICG specifically recognized and localized endometriotic lesions and guided complete resection of lesions with high accuracy.
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Affiliation(s)
- Jing Peng
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai 200011, China
| | - Qiyu Liu
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai 200011, China
| | - Tao Pu
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai 200011, China
| | - Mingxing Zhang
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai 200011, China
| | - Meng Zhang
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai 200011, China
| | - Ming Du
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai 200011, China
| | - Guiling Li
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai 200011, China
| | - Xiaoyan Zhang
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai 200011, China
- Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai 200011, China
| | - Congjian Xu
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai 200011, China
- Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai 200011, China
- Department of Obstetrics and Gynecology of Shanghai Medical School, Fudan University, Shanghai 200032, China
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Asencio FDA, Fins RJP, Mitie CK, Ussia A, Wattiez A, Ribeiro HS, Ribeiro PA, Koninckx PR. Segmental Rectum Resection for Deep Endometriosis and Excision Similarly Improve Sexual Function and Pain. Clin Pract 2023; 13:780-790. [PMID: 37489420 PMCID: PMC10366930 DOI: 10.3390/clinpract13040071] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 06/08/2023] [Accepted: 06/30/2023] [Indexed: 07/26/2023] Open
Abstract
Segmental rectum resections for indications other than endometriosis were reported to result in up to 40% sexual dysfunctions. We, therefore, evaluated sexual function after low bowel resection (n = 33) for deep endometriosis in comparison with conservative excision (n = 23). Sexual function was evaluated with the FSFI-19 (Female Sexuality Functioning Index) and EHP 30 (Endometriosis Health Profile). The pain was evaluated with visual analogue scales. Linear excision and bowel resections improved FSFI, EHP 30, and postoperative pain comparably. By univariate analysis, a decreased sexual function was strongly associated with pain both before (p < 0.0001) and after surgery (p = 0.0012), age (p = 0.05), and duration of surgery (p = 0.023). By multivariate analysis (proc logistic), the FSFI after surgery was predicted only by FSFI before or EHP after surgery. No differences were found between low bowel segmental resection and a more conservative excision. In conclusion, improving pain after surgery can explain the improvement in sexual function. A deleterious effect of a bowel resection on sexual function was not observed for endometriosis. Sexual function in women with endometriosis can be evaluated using a simplified questionnaire such as FSFI-6.
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Affiliation(s)
| | | | - Carolina Kami Mitie
- Medicine College, University of Santa Casa de São Paulo, São Paulo 01224-001, Brazil
| | - Anastasia Ussia
- Gemelli Hospital, Universtità Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Arnauld Wattiez
- Department of Obstetrics and Gynaecology, University of Strasbourg, 67081 Strasbourg, France
- Latifa Hospital, Dubai P.O. Box 9115, United Arab Emirates
| | | | - Paulo Ayrosa Ribeiro
- Department of Gynaecology Endoscopy, Santa Casa de São Paulo Hospital, São Paulo 01221-010, Brazil
| | - Philippe Robert Koninckx
- Latifa Hospital, Dubai P.O. Box 9115, United Arab Emirates
- Department of Obstetrics and Gynecology, University Hospital Gasthuisberg, Catholic University Leuven, 3000 Leuven, Belgium
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Zhu S, Gu Z, Li X, Dai Y, Shi J, Leng J. Clinical presentation of perineal endometriosis and prognostic nomogram after surgical resection. BMC Womens Health 2022; 22:476. [DOI: 10.1186/s12905-022-02068-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 11/11/2022] [Indexed: 11/28/2022] Open
Abstract
Abstract
Background
This retrospective study evaluated the clinical features of perineal endometriosis (PEM) and established a prognostic nomogram for recurrence probability in patients treated with surgical resection.
Methods
This study enrolled 130 PEM patients who had received surgical treatment in Peking Union Medical College Hospital (PUMCH) between January 1992 and September 2020. We collected their clinical features and conducted outpatient or telephone follow-up. The predictive nomogram was constructed based on 104 patients who had completed follow-up by July 2021. The Cox proportional hazards regression model was used to evaluate the prognostic effects of multiple clinical parameters on recurrence. The Index of concordance (C-index) and calibration curves were used to access the discrimination ability and predictive accuracy of the nomogram respectively, and the results were further validated via bootstrap resampling. Calculating the area under the curve (AUC) via risk scores of patients aimed to further access the predictive power of the model. In addition, the survival curve was depicted using Kaplan–Meier plot and compared by log-rank method.
Results
Most PEM patients had been symptomatic for 24–48 months before the lesion resection. With a median 99.00 (interquartile range: 47.25–137.50) months of postoperative observation, there were 16 (15.1%) out of 104 cases who finished follow-up reported symptomatic recurrence. On multivariate analysis of derivation cohort, multiple lesions, microscopically positive margin (mPM) and anal sphincter involvement (ASI) were selected into the nomogram. The C-index of the nomogram for predicting recurrence was 0.84 (95% CI 0.77–0.91). The calibration curve for probability of recurrence for 36, 60 and 120 months showed great agreement between prediction by nomogram and actual observation. Furthermore, the AUCs of risk score for 36, 60 and 120 months were 0.89, 0.87 and 0.82 respectively.
Conclusions
PEM is a rare kind of endometriosis and surgery is the primary treatment. Multiple lesions and ASI are independent risk factors for postoperative recurrence, and wide resection with more peripheral tissue could be preferred. The proposed nomogram resulted in effective prognostic prediction for PEM patients receiving surgical excision. In addition, this predictive nomogram needs external data sets to further validate its prognostic accuracy in the future.
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Quintairos RDA, Brito LGO, Farah D, Ribeiro HSAA, Ribeiro PAAG. Conservative versus Radical Surgery for Women with Deep Infiltrating Endometriosis: Systematic Review and Meta-analysis of Bowel Function. J Minim Invasive Gynecol 2022; 29:1231-1240. [PMID: 36184064 DOI: 10.1016/j.jmig.2022.09.551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 09/21/2022] [Accepted: 09/23/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To assess bowel function in women with deep infiltrating endometriosis according to surgical approach (radical vs conservative). DATA SOURCES Five databases were searched from 1970 to September 2021 to retrieve studies comparing radical (colorectal segmental resection) and conservative (shaving or discoid excision) surgery for bowel function in women with deep infiltrating endometriosis. METHODS OF STUDY SELECTION No language restriction was applied. Two reviewers extracted and combined data from the included studies, applying a meta-analytic model with random effects in all calculations. Results are expressed in risk ratio (RR) with 95% confidence interval (CI). Assessment of risk of bias and quality of evidence was performed by the Newcastle-Ottawa and Grading of Recommendations, Assessment, Development and Evaluation, respectively. TABULATION, INTEGRATION, AND RESULTS We included 13 studies in our meta-analysis, and most of them were of nonrandomized design. Conservative surgery had fewer events of constipation and frequent bowel movements when compared with radical surgery (RR, 2.31; 95% CI, 1.21-4.43; I2 = 0%; 3 studies; RR, 2.80; 95% CI 1.17-6.75; I2 = 0%; 2 studies, respectively). Defecation pain, anal incontinence loss, minor and major lower anterior resection syndrome, and Clavien-Dindo complications grade I to IV showed no statistically significant difference between surgeries. Grading of Recommendations, Assessment, Development and Evaluation assessment was low to very low for all outcomes. CONCLUSION Conservative surgery (shaving or discoid excision) presented fewer events of constipation and frequent bowel movements than colorectal segmental resection. There was a very low quality of evidence to provide recommendations regarding bowel function.
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Affiliation(s)
- Ricardo de Almeida Quintairos
- From the Center of Endometriosis, Belem, Para (Dr. Quintairos); Division of Gynecology Endoscopy and Endometriosis (Drs. Quintairos and Ribeiro), Department of Obstetrics and Gynecology, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil.
| | | | - Daniela Farah
- Women's Health Technology Assessment Center (Dr. Farah), Gynecology Department, Federal University of Sao Paulo
| | - Helizabet Salomao Abdalla Ayroza Ribeiro
- Division of Gynecology Endoscopy and Endometriosis (Drs. Quintairos and Ribeiro), Department of Obstetrics and Gynecology, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
| | - Paulo Augusto Ayroza Galvao Ribeiro
- Division of Gynecology Endoscopy and Endometriosis (Drs. Quintairos and Ribeiro), Department of Obstetrics and Gynecology, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
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Long term outcomes following surgical management of rectal endometriosis: 7-year follow-up of patients enrolled in a randomized trial. J Minim Invasive Gynecol 2022; 29:767-775. [PMID: 35181523 DOI: 10.1016/j.jmig.2022.02.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/11/2022] [Accepted: 02/14/2022] [Indexed: 11/20/2022]
Abstract
STUDY OBJECTIVE To compare functional outcomes, recurrence rate and pregnancy likelihood in patients undergoing conservative or radical surgery in patients with deep rectal endometriosis 7 years post-operatively. DESIGN Prospective study in a cohort of patients enrolled in a 2-arm randomized trial from March 2011 to August 2013. SETTING A tertiary referral center. PATIENTS 55 patients with deep endometriosis infiltrating the rectum. INTERVENTIONS Patients underwent either segmental resection or nodule excision by shaving or disc excision, depending on a randomization which was performed preoperatively using sequentially numbered, opaque sealed envelopes. MEASUREMENT AND MAIN RESULTS The primary endpoint was the number of patients experiencing one of the following symptoms: constipation, frequent bowel movements, anal incontinence or bladder dysfunction 24 months postoperatively. Secondary endpoints were values of gastrointestinal and overall quality of life scores. The 7 year-recurrence rates (new deep endometriosis nodule infiltrating the rectum) in the excision vs. the segmental resection arms were 7.4 % vs. 0% (P=.24). One of more symptoms included in the definition of the primary outcomes were recorded in 55.6% vs. 60.7% of patients (P=0.79). However, 51.9% vs. 53.6% of patients considered their bowel movements as normal (P=.99). An intention-to-treat comparison of overall quality of life scores did not find differences between the two groups 7 years postoperatively. At the end of the 7-year study period, 31 of the 37 patients who tried to conceive were successful (83.8%) including: 27 (57.4%) natural conceptions and 20 (42.6%) pregnancies resulting from ART procedures. Pregnancy rate was 82.4% vs. 85% in the two arms (P=.99). A 75.7% live birth rate was recorded. At the end of the follow up there were 15 women with one child (40.5%) and 13 women with 2 children (35.1%). During the 7-year follow- up, the reoperation rate was respectively 37% and 35.7% in each arm, P=0.84). Among the 27 reoperation procedures during the follow up period, 11 were postoperative complications (40.7%), 7 were necessary prior to ART management (25.9%), 8 were for recurrent abdominal or pelvic pain (29.6%) and one for midline ventral hernia following pregnancy (3.7%). CONCLUSIONS Our study did not reveal a significant difference in terms of digestive functional outcomes, recurrence rate, reoperation risk and pregnancy likelihood when conservative and radical rectal surgery for deep endometriosis were compared 7 years postoperatively. Postoperative pregnancy rate observed in our series is high.
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Donnez O. Conservative Management of Rectovaginal Deep Endometriosis: Shaving Should Be Considered as the Primary Surgical Approach in a High Majority of Cases. J Clin Med 2021; 10:5183. [PMID: 34768704 PMCID: PMC8584847 DOI: 10.3390/jcm10215183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 10/29/2021] [Accepted: 11/03/2021] [Indexed: 12/12/2022] Open
Abstract
Deep endometriosis infiltrating the rectum remains a challenging situation to manage, and it is even more important when ureters and pelvic nerves are also infiltrated. Removal of deep rectovaginal endometriosis is mandatory in case of symptoms strongly impairing quality of life, alteration of digestive, urinary, sexual and reproductive functions, or in case of growing. Extensive preoperative imaging is required to choose the right technique between laparoscopic shaving, disc excision, or rectal resection. When performed by skilled surgeons and well-trained teams, a very high majority of cases of deep endometriosis nodule (>95%) is feasible by the shaving technique, and this is associated with lower complication rates regarding rectal resection. In most cases, removing a part of the rectum is questionable according to the risk of complications, and the rectum should be preserved as far as possible. Shaving and rectal resection are comparable in terms of recurrence rates. As shaving is manageable whatever the size of the lesions, surgeons should consider rectal shaving as first-line surgery to remove rectal deep endometriosis. Rectal stenosis of more than 80% of the lumen, multiple bowel deep endometriosis nodules, and stenotic sigmoid colon lesions should be considered as indication for rectal resection, but this represents a minority of cases.
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Affiliation(s)
- Olivier Donnez
- Institut du Sein et de Chirurgie Gynécologique d'Avignon, Polyclinique Urbain V (Elsan Group), 95 Chemin du Pont des 2 Eaux, 84000 Avignon, France
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Roman H, Merlot B, Forestier D, Noailles M, Magne E, Carteret T, Tuech JJ, Martin DC. Nonvisualized palpable bowel endometriotic satellites. Hum Reprod 2021; 36:656-665. [PMID: 33432338 PMCID: PMC7891810 DOI: 10.1093/humrep/deaa340] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 10/03/2020] [Indexed: 11/16/2022] Open
Abstract
STUDY QUESTION What is the prevalence of laparoscopically nonvisualized palpable satellite bowel nodules at or near the planned stapler site in women undergoing segmental bowel resection for endometriosis? SUMMARY ANSWER Overall, 13 (25.5%) of 51 patients who underwent resection had nonvisualized palpable satellite lesions as small as 2 mm, including seven (14%) who had nonvisualized palpable lesions at or beyond the planned stapler site. WHAT IS KNOWN ALREADY Both laparoscopy and laparotomy for bowel resection are standard of care in Europe and the USA. Reoperation rates after laparoscopic bowel procedures are 1–16%. Endometriotic lesions at the stapler margin of bowel resections are associated with increased repeat surgery. Nodules of 0.1 mm to 1 cm in size were not recognized during laparoscopic bowel surgery but were recognized on histological examination. Up to 20 nodules not visualized at laparoscopy have been recognized and excised at laparotomy. Tenderness is found at up to 27 mm from a recognized lesion. The size of a lesion does not always predict its symptoms or behavior. STUDY DESIGN, SIZE, DURATION This single-arm, observational study focused on the presence of nonvisualized palpable satellite lesions of the bowel. Fifty-one patients scheduled for laparoscopic-assisted bowel resection for deep infiltrating endometriosis with suprapubic incision for placement of the stapler’s anvil and removal of the specimen in the course of routine clinical care were included. There were no additional inclusion or exclusion criteria. PARTICIPANTS/MATERIALS, SETTING, METHODS Laparoscopic-assisted segmental bowel resection for endometriosis was performed in a private referral center on women aged 24–49 years. MAIN RESULTS AND THE ROLE OF CHANCE Forty-nine (96.1%) of the 51 patients underwent segmental resection of the sigmoid or rectum, and 14 (27.5%) underwent segmental resection of the ileum for large nodule(s) recognized on MRI. Twelve patients underwent both procedures. Eleven (22.4%) of the 49 patients with recognized sigmoid or rectal lesions and 5 (35.7%) of the 14 patients with recognized ileal lesions had nonvisualized, palpable, satellite lesions. All the large lesions and none of the satellite lesions had been recognized preoperatively on MRI. Five (10%) of 49 patients with lesions of the large bowel and 4 (28.6%) of the 14 patients with lesions of the ileum had nonvisualized palpable satellite lesions at or beyond the planned stapler site. Lesions as small as 2 mm were palpable. LIMITATIONS, REASONS FOR CAUTION This is an observational study. It is not known if the small lesions of this study contributed to the symptoms or were progressive, stable or regressive. This study analyzed lesions in the bowel segment proximal to the primary large bowel lesion, but not in the distal segment as that would have required a change in standard of care surgical technique. This study protocol did not include shaving or disk resection or patients in whom no lesions were visualized. The use of additional techniques for recognition, such as hand-assisted laparoscopy or rectal probes, was not investigated. WIDER IMPLICATIONS OF THE FINDINGS This study confirms that some nonvisualized satellite lesions as small as 2 mm are palpable and that an increased length of resection can be used to remove lesions recognized by palpation and to avoid lesions at and beyond the stapler site. This may decrease recurrent surgery in 1–16% of the women undergoing surgery for bowel endometriosis. Knowledge of the occurrence of these small lesions may also be particularly useful in plans for repeat surgery or for women with clinically significant bowel symptoms and no visible lesions at laparoscopy. Moreover, small lesions are considered to be important as there is no current technique to determine whether a large primary lesion, smaller lesions, an associated adjacent tissue reaction or a combination of those cause symptoms. STUDY FUNDING/COMPETING INTEREST(S) This CIRENDO cohort was supported by the G4 Group (the University Hospitals of Rouen, Lille, Amiens and Caen) and the ROUENDOMETRIOSE association. No specific funding was received for the study. H.R. reports receiving personal fees from Plasma Surgical Inc., Ethicon Endosurgery, Olympus and Nordic Pharma for presentations related to his experience with endometriosis surgery. D.C.M. reports being given access to Lumenis Surgical CO2 Lasers’ lab at a meeting. None of the other authors have conflicts of interest to disclose. TRIAL REGISTRATION NUMBER N/A
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Affiliation(s)
- H Roman
- Endometriosis Center, Clinique Bordeaux Tivoli-Ducos, Bordeaux, France
- Department of Gynecology and Obstetrics, Aarhus Medical University, Aarhus, Denmark
| | - B Merlot
- Endometriosis Center, Clinique Bordeaux Tivoli-Ducos, Bordeaux, France
| | - D Forestier
- Endometriosis Center, Clinique Bordeaux Tivoli-Ducos, Bordeaux, France
| | - M Noailles
- Endometriosis Center, Clinique Bordeaux Tivoli-Ducos, Bordeaux, France
| | - E Magne
- Endometriosis Center, Clinique Bordeaux Tivoli-Ducos, Bordeaux, France
| | - T Carteret
- Endometriosis Center, Clinique Bordeaux Tivoli-Ducos, Bordeaux, France
| | - J-J Tuech
- Department of Surgery, Rouen University Hospital, Rouen, France
| | - D C Martin
- School of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
- Office of Research Subjects Protection, Institutional Review Board, Virginia Commonwealth University, Richmond, VA, USA
- Correspondence address. Office of Research Subjects Protection, Institutional Review Board, Virginia Commonwealth University, 201 Wakefield Road, Richmond, VA 23221-3258, USA. Tel: +1 (901) 761-4787; E-mail:
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Klapczynski C, Derbal S, Braund S, Coget J, Forestier D, Seyer-Hansen M, Tuech JJ, Roman H. Evaluation of functional outcomes after disc excision of deep endometriosis involving low and mid rectum using standardized questionnaires: a series of 80 patients. Colorectal Dis 2021; 23:944-954. [PMID: 33320419 DOI: 10.1111/codi.15485] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 10/14/2020] [Accepted: 11/14/2020] [Indexed: 12/26/2022]
Abstract
AIM The aim was to assess the functional outcome and quality of life in patients with low and mid rectal endometriosis who have undergone disc excision using a semicircular transanal staple device, a procedure we have named the Rouen technique. METHODS This was a retrospective study of patients undergoing the Rouen technique between October 2009 and November 2018. Preoperative and postoperative demographic and operative data were recorded prospectively (mean ± SEM). Postoperative complications were recorded using the Clavien-Dindo classification. Rectal function and quality of life were assessed by the low anterior resection syndrome (LARS) and Bowel Endometriosis Syndrome (BENS) scores respectively at ≥6 months. RESULTS The Rouen procedure was performed on 80 patients (29.7 ± 4.3). The mean diameter of resected specimens was 57 ± 10 mm, and the height of the rectal suture from the anal verge was 4.6 ± 1.2 cm. The Clavien-Dindo complications were Clavien-Dindo 1 (leg compression), Clavien-Dindo 2 (urinary tract infection, bladder self-catheterization) and Clavien-Dindo 3b (bowel obstruction, rectovaginal fistula, pyelic dilation, colorectal stenosis after resection). A rectovaginal fistula (Clavien-Dindo 3b) developed in nine (11.3%) patients and their stoma could be reversed after 99-162 days. The majority of patients (n = 50, 62.5%) had normal postoperative rectal function with LARS score ≤20. However, minor (LARS ≥ 21-29) and major rectal dysfunction (LARS ≥ 30) was seen in 18 (22.5%) and 12 (15%) patients respectively. Quality of life as measured using the BENS score was normal (BENS score 0-8) in 51 (63.8%) patients, slightly reduced (BENS score 9-16) in 24 (30%) patients and in only five (6.3%) was this a major issue (BENS score > 17). The development of a rectovaginal fistula was independently related to risk of major rectal dysfunction (adjusted OR 6.3, 95% CI 1.3-30.6). CONCLUSIONS In our series of 80 patients with transmural low and mid rectal endometriosis disc excision using a semicircular staple device can result in good functional outcomes and quality of life and avoid the complexity and potential complications of a low anterior resection.
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Affiliation(s)
- Clémence Klapczynski
- Expert Centre in the Diagnosis and Multidisciplinary Management of Endometriosis, Rouen University Hospital, Rouen, France
| | - Sophiane Derbal
- Department of Digestive Surgery, Rouen University Hospital, Rouen, France
| | - Sophia Braund
- Expert Centre in the Diagnosis and Multidisciplinary Management of Endometriosis, Rouen University Hospital, Rouen, France
| | - Julien Coget
- Department of Digestive Surgery, Rouen University Hospital, Rouen, France
| | | | - Mikkel Seyer-Hansen
- Department of Gynecology and Obstetrics, Aarhus University Hospital, Aarhus, Denmark
| | - Jean-Jacques Tuech
- Department of Digestive Surgery, Rouen University Hospital, Rouen, France.,Digestive Tract Research Group EA3234/IFRMP23, Rouen University Hospital, Rouen, France
| | - Horace Roman
- Endometriosis Centre, Clinique Tivoli-Ducos, Bordeaux, France.,Department of Gynecology and Obstetrics, Aarhus University Hospital, Aarhus, Denmark
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10
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Tschann P, Vitlarov N, Hufschmidt M, Lechner D, Girotti PNC, Offner F, Abendstein B, Königsrainer I. Colorectal resection in endometriosis patients: correlation between histopathological findings and postoperative outcome. Eur J Med Res 2021; 26:12. [PMID: 33485396 PMCID: PMC7824935 DOI: 10.1186/s40001-021-00484-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 01/08/2021] [Indexed: 01/02/2023] Open
Abstract
Introduction Endometriosis is associated with a high number of chronic pelvic pain and reduced quality of life. Colorectal resections in case of bowel involvement of endometriosis are associated with an unneglectable morbidity in young and healthy patients. There is no linear correlation established between the degree of symptoms and stage of endometriosis. The aim of this study was to correlate the histological findings to preoperative pain scores in colorectal resected patients with endometriosis. Methods Twenty-five patients who underwent laparoscopic colorectal resection for endometriosis between 2014 and 2019 were included in this retrospective study. Pain level was assessed preoperatively and postoperatively via phone call in May 2020. Histopathology was correlated to preoperative symptoms and postoperative outcome. Results Average follow-up time was 38.68 months (± 19.92). Preoperative VAS-score was 8.32 (± 1.70). We observed a significant reduction of pain level in all patients after surgery (p ≤ 0.005). Pain levels were equal regarding the presence of satellite spots and various degrees of infiltration depth. The resection margins were clear in all patients. Postoperative complications occurred in 6 cases (24%) and anastomotic leakage was observed in 3 patients (12%). Average VAS-score at time of follow-up was 1.70 (± 2.54). Conclusion Our data demonstrate that adequate colorectal resection leads to reduction of pain and an increase of quality of life irrespective of histopathological findings. An experienced team is necessary to improve intraoperative outcome and to reduce postoperative morbidity in case of complication.
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Affiliation(s)
- Peter Tschann
- Department of General and Thoracic Surgery, Academic Teaching Hospital Feldkirch, Carinagasse 47, 6800, Feldkirch, Austria.
| | - Nikola Vitlarov
- Institute for Pathology, Academic Teaching Hospital Feldkirch, Feldkirch, Austria
| | - Martin Hufschmidt
- Department of General and Thoracic Surgery, Academic Teaching Hospital Feldkirch, Carinagasse 47, 6800, Feldkirch, Austria
| | - Daniel Lechner
- Department of General and Thoracic Surgery, Academic Teaching Hospital Feldkirch, Carinagasse 47, 6800, Feldkirch, Austria
| | - Paolo N C Girotti
- Department of General and Thoracic Surgery, Academic Teaching Hospital Feldkirch, Carinagasse 47, 6800, Feldkirch, Austria
| | - Felix Offner
- Institute for Pathology, Academic Teaching Hospital Feldkirch, Feldkirch, Austria
| | - Burghard Abendstein
- Department of Gynaecology, Academic Teaching Hospital Feldkirch, Feldkirch, Austria
| | - Ingmar Königsrainer
- Department of General and Thoracic Surgery, Academic Teaching Hospital Feldkirch, Carinagasse 47, 6800, Feldkirch, Austria
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Koninckx PR, Fernandes R, Ussia A, Schindler L, Wattiez A, Al-Suwaidi S, Amro B, Al-Maamari B, Hakim Z, Tahlak M. Pathogenesis Based Diagnosis and Treatment of Endometriosis. Front Endocrinol (Lausanne) 2021; 12:745548. [PMID: 34899597 PMCID: PMC8656967 DOI: 10.3389/fendo.2021.745548] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 10/26/2021] [Indexed: 12/18/2022] Open
Abstract
Understanding the pathophysiology of endometriosis is changing our diagnosis and treatment. Endometriosis lesions are clones of specific cells, with variable characteristics as aromatase activity and progesterone resistance. Therefore the GE theory postulates GE incidents to start endometriosis, which thus is different from implanted endometrium. The subsequent growth in the specific environment of the peritoneal cavity is associated with angiogenesis, inflammation, immunologic changes and bleeding in the lesions causing fibrosis. Fibrosis will stop the growth and lesions look burnt out. The pain caused by endometriosis lesions is variable: some lesions are not painful while other lesions cause neuroinflammation at distance up to 28 mm. Diagnosis of endometriosis is made by laparoscopy, following an experience guided clinical decision, based on history, symptoms, clinical exam and imaging. Biochemical markers are not useful. For deep endometriosis, imaging is important before surgery, notwithstanding rather poor predictive values when confidence limits, the prevalence of the disease and the absence of stratification of lesions by size, localization and depth of infiltration, are considered. Surgery of endometriosis is based on recognition and excision. Since the surrounding fibrosis belongs to the body with limited infiltration by endometriosis, a rim of fibrosis can be left without safety margins. For deep endometriosis, this results in a conservative excision eventually with discoid excision or short bowel resections. For cystic ovarian endometriosis superficial destruction, if complete, should be sufficient. Understanding pathophysiology is important for the discussion of early intervention during adolescence. Considering neuroinflammation at distance, the indication to explore large somatic nerves should be reconsidered. Also, medical therapy of endometriosis has to be reconsidered since the variability of lesions results in a variable response, some lesions not requiring estrogens for growth and some being progesterone resistant. If the onset of endometriosis is driven by oxidative stress from retrograde menstruation and the peritoneal microbiome, medical therapy could prevent new lesions and becomes indicated after surgery.
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Affiliation(s)
- Philippe R. Koninckx
- Latifa Hospital, Dubai, United Arab Emirates
- Prof Emeritus Obstet Gynecol (OBGYN), Catholic University Leuven (KU), Leuven, Belgium
- University of Oxford-Hon Consultant, Oxford, United Kingdom
- University Cattolica, Roma, Italy
- Moscow State University, Moscow, Russia
- Gruppo Italo Belga, Villa Del Rosario, Rome, Italy
- *Correspondence: Philippe R. Koninckx,
| | - Rodrigo Fernandes
- Instituto do Cancer do Estado de São Paulo, University of São Paulo, São Paulo, Brazil
| | - Anastasia Ussia
- University Cattolica, Roma, Italy
- Gruppo Italo Belga, Villa Del Rosario, Rome, Italy
| | - Larissa Schindler
- Dubai Fertility Centre of the Dubai Health Authority, Dubai, United Arab Emirates
| | - Arnaud Wattiez
- Latifa Hospital, Dubai, United Arab Emirates
- Prof Department of Obstetrics and Gynaecology, University of Strasbourg, Strasbourg, France
| | | | | | | | | | - Muna Tahlak
- Latifa Hospital, Dubai, United Arab Emirates
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12
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Yang YP, Yu LY, Shi J, Li JN, Wang M, Liu TJ. Laparoscopic anterior resection of rectum for rectal deeply infiltrating endometriosis: A short-term prospective randomized trial. Medicine (Baltimore) 2020; 99:e23309. [PMID: 33217865 PMCID: PMC7676554 DOI: 10.1097/md.0000000000023309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 09/24/2020] [Accepted: 10/21/2020] [Indexed: 11/26/2022] Open
Abstract
Laparoscopic anterior resection of rectum (AR) is one of surgical approaches for deeply infiltrating endometriosis (DIE). Up to date, no clinical trials have clearly analyzed the short-term and long-term complications post-surgically, indications or feasibilities for surgical procedure, or post-operative recovery. The aims of this trial were to evaluate the indications for laparoscopic AR, the short-term and long-term complications post-surgically, post-operative recovery.We conducted a prospective study of 29 patients. They were divided into 2 groups. The period of follow-up was 12 months post-surgery. In our study, we recruited patents with laparoscopic AR experiencing failure of medical treatment (3 months) or associated infertility (>2cycles). The operative data and short term and long term complications were recorded. The outcomes of laparoscopic AR group were assessed by questionnaires, such as NRS (numeric rating scale), KESS (Knowles-Eccersley-Scott Symptom Questionnaire), VAS (visual analogue scale), WCS (Wexner constipation score) and ABS (Abdominal Bloating Score), which were compared with the outcomes of medicine group at set time points of baseline, 3 months, 6 months, 9 months and 12 months. The overall outcomes of the two groups were assessed with 5-point Likert Scale.Patients in surgery group were recovery rapidly without serious short term or long term complications. All of NRS, KESS, VAS, WCS, and ABS in surgery group were getting better greatly than that in medicine group (3.04 ± 1.91 vs 5.41 ± 3.01, 5.64 ± 1.54 vs 7.01 ± 1.03, 0.50 ± 0.38 vs 3.58 ± 2.01, 4.43 ± 1.02 vs 8.92 ± 2.45, and 0.61 ± 0.34 vs 1.42 ± 0.71) at 3 months post-operation. However, the advantage of surgery group was almost vanished at 12 months (4.02 ± 2.53 vs 5.99 ± 2.31, 7.42 ± 3.17 vs 10.98 ± 2.53, 1.59 ± 1.3 vs 2.23 ± 1.59, 6.01 ± 2.53 vs 7.90 ± 3.25, and 1.31 ± 1.05 vs 1.39 ± 1.02). Furthermore, we compared the overall outcomes between the 2 groups with 5-point Likert Scale, with confirmation of the advantage at 3 months post-surgically. Additionally, we compared these questionnaires, with the finding that VAS and 5-point Likert Scale of surgery group had the same changes. Finally, a table of indications for laparoscopic AR were tabulated according our clinical experience.Patients can receive benefit from both medicine and laparoscopic AR. However, laparoscopic AR has obvious advantage of rapid symptom relief. Further studies and clinical data collections are required for indications and feasibility of combined therapy.
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Affiliation(s)
- Yong-Ping Yang
- Department of General Surgery, the Second Hospital of Jilin University
| | - Ling-Yun Yu
- Department of Ear Nose and Throat Surgery, the First Hospital of Jilin University, Changchun, China
| | - Jian Shi
- Department of General Surgery, the Second Hospital of Jilin University
| | - Jian-nan Li
- Department of General Surgery, the Second Hospital of Jilin University
| | - Min Wang
- Department of General Surgery, the Second Hospital of Jilin University
| | - Tong-Jun Liu
- Department of General Surgery, the Second Hospital of Jilin University
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13
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Guo SW, Martin DC. The perioperative period: a critical yet neglected time window for reducing the recurrence risk of endometriosis? Hum Reprod 2020; 34:1858-1865. [PMID: 31585460 DOI: 10.1093/humrep/dez187] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 07/11/2019] [Indexed: 12/11/2022] Open
Abstract
While surgery is commonly the management of symptomatic endometriosis when patients do not respond to medical or supportive therapy, recurrence after surgery poses a serious challenge, and repeat surgery increases the risk of premature ovarian failure, adhesion and organ injury. Conceivably, the recurrent endometriotic lesions could arise from minimal residual lesions (MRLs) or from de novo lesions. However, several lines of evidence suggest that the former is more likely. So far, most, if not all, efforts to combat recurrence have been focused on postoperative medication of hormonal drugs to reduce recurrence risk through lesional dormancy and possibly atrophy. However, the perioperative period may exert a disproportionally high impact on the risk of recurrence; it is likely to be amendable for possible intervention but has been generally neglected. Indeed, many perioperative factors are known to or conceivably could facilitate the recurrence of endometriosis through the suppression of cell-mediated immunity due to the activation of adrenergic signaling and the release of prostaglandins. Perioperative use of β-blockers and/or nuclear factor κB/jCycloxygenase 2 (NF-κB/COX-2) inhibitors may boost the cell-mediated immunity suppressed by surgery, resulting in the partial or even complete removal of MRLs and reduced recurrence risk. This is both biologically plausible and supported by a recent experimental study. We call for more research on possible perioperative interventions to reduce the recurrence risk of endometriosis. The potential payoff might be a substantial reduction in the risk of recurrence and cost when compared with the traditional approach of postoperative intervention.
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Affiliation(s)
- Sun-Wei Guo
- Shanghai OB/GYN Hospital, Fudan University, Shanghai, China.,Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Fudan University, Shanghai, China
| | - Dan C Martin
- School of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.,Institutional Review Board, Virginia Commonwealth University, Richmond, VA, USA
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Ferrero S, Stabilini C, Barra F, Clarizia R, Roviglione G, Ceccaroni M. Bowel resection for intestinal endometriosis. Best Pract Res Clin Obstet Gynaecol 2020; 71:114-128. [PMID: 32665125 DOI: 10.1016/j.bpobgyn.2020.05.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 05/13/2020] [Indexed: 01/12/2023]
Abstract
Over the last twenty years, segmental resection (SR) has been the technique most frequently used to treat bowel endometriosis. Nowadays, it is most commonly performed by laparoscopy; however, there is evidence that it can be safely performed by robotic-assisted laparoscopic surgery. Rectovaginal fistula and anastomotic leakage are the two major complications of SR; other complications include pelvic abscess, postoperative bleeding, ureteral damage, and anastomotic stricture. Several studies showed that SR causes improvement in pain and intestinal symptoms; nerve-sparing SR may improve the functional outcomes. The rates of postoperative recurrence of bowel endometriosis vary across the studies, possibly because of the different definitions of recurrence.
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Affiliation(s)
- Simone Ferrero
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Largo R. Benzi 10, Genoa, 16132, Italy; Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Italy
| | - Cesare Stabilini
- Department of Surgical Science, IRCCS Ospedale Policlinico San Martino, Largo R. Benzi 10, Genoa, 16132, Italy; Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Italy
| | - Fabio Barra
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Largo R. Benzi 10, Genoa, 16132, Italy; Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Italy.
| | - Roberto Clarizia
- Department of Obstetrics and Gynecology, Gynecologic Oncology and Minimally-Invasive Pelvic Surgery, International School of Surgical Anatomy, IRCCS "Sacro Cuore - Don Calabria" Hospital, Via Don A. Sempreboni 5, Negrar, 37024, Verona, Italy
| | - Giovanni Roviglione
- Department of Obstetrics and Gynecology, Gynecologic Oncology and Minimally-Invasive Pelvic Surgery, International School of Surgical Anatomy, IRCCS "Sacro Cuore - Don Calabria" Hospital, Via Don A. Sempreboni 5, Negrar, 37024, Verona, Italy
| | - Marcello Ceccaroni
- Department of Obstetrics and Gynecology, Gynecologic Oncology and Minimally-Invasive Pelvic Surgery, International School of Surgical Anatomy, IRCCS "Sacro Cuore - Don Calabria" Hospital, Via Don A. Sempreboni 5, Negrar, 37024, Verona, Italy
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15
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Jago CA, Nguyen DB, Flaxman TE, Singh SS. Bowel surgery for endometriosis: A practical look at short- and long-term complications. Best Pract Res Clin Obstet Gynaecol 2020; 71:144-160. [PMID: 32680784 DOI: 10.1016/j.bpobgyn.2020.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 06/04/2020] [Indexed: 02/06/2023]
Abstract
Endometriosis involving the bowel requires a thorough evaluation prior to deciding upon surgical treatment. Patient symptoms, treatment goals, extent and location of disease, surgeon experience, and anticipated risks all play a part in the preoperative decision-making process. Short- and long-term complications after bowel surgery for endometriosis are the focus of this article. Unfortunately, the literature to date has inherent limitations that prevent generalizability. Most studies are retrospective or prospective single-center case series. Publication bias is unavoidable with mainly large volume experts sharing their experience. As a result, there is a need for high-quality prospective studies that standardize inclusion criteria and outcome measures among various centers with an aim to present long-term outcomes. In the meantime, care for those with endometriosis involving the bowel requires a thorough preoperative plan to minimize risks and a need for early diagnosis and management of complications unique to bowel surgery.
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Affiliation(s)
- Caitlin Anne Jago
- Minimally Invasive Gynecology Research Group, Department of Ob/Gyn and Newborn Care, University of Ottawa & the Ottawa Hospital, 501 Smyth Rd, K1H 8L6, Ottawa ON Canada
| | - Dong Bach Nguyen
- Minimally Invasive Gynecology Research Group, Department of Ob/Gyn and Newborn Care, University of Ottawa & the Ottawa Hospital, 501 Smyth Rd, K1H 8L6, Ottawa ON Canada
| | - Teresa E Flaxman
- Minimally Invasive Gynecology Research Group, Department of Ob/Gyn and Newborn Care, University of Ottawa & the Ottawa Hospital, 501 Smyth Rd, K1H 8L6, Ottawa ON Canada; Ottawa Hospital Research Institute, Department of Clinical Epidemiology, 1053 Carling Ave, K1Y 4E9, Ottawa ON Canada
| | - Sukhbir S Singh
- Minimally Invasive Gynecology Research Group, Department of Ob/Gyn and Newborn Care, University of Ottawa & the Ottawa Hospital, 501 Smyth Rd, K1H 8L6, Ottawa ON Canada; Ottawa Hospital Research Institute, Department of Clinical Epidemiology, 1053 Carling Ave, K1Y 4E9, Ottawa ON Canada.
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16
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Donnez O, Donnez J. Deep endometriosis: The place of laparoscopic shaving. Best Pract Res Clin Obstet Gynaecol 2020; 71:100-113. [PMID: 32653335 DOI: 10.1016/j.bpobgyn.2020.05.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 05/28/2020] [Indexed: 02/06/2023]
Abstract
Deep endometriosis (DE) is considered to be one of the most challenging conditions to manage, especially when it invades surrounding organs like the rectum. Surgical excision of deep rectovaginal endometriosis is required when lesions are symptomatic, impairing bowel, urinary, sexual, and reproductive functions, or if they evolve. Preoperative radiological examination should be extensive to determine the appropriate surgery: laparoscopic shaving, disc excision, or rectal resection. We demonstrated that in the hands of experienced surgeons, rectal shaving is possible for DE in more than 95% of cases, with low complication rates compared to rectal resection. Shaving and bowel resection are associated with comparable recurrence rates. As shaving is indicated whatever the size of deep lesions, surgeons should first consider rectal shaving to remove DE. Bowel resection should only be performed in case of major rectal stenosis (>80%), multiple and/or posterior rectal lesions and stenotic sigmoid colon lesions.
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Affiliation(s)
- Olivier Donnez
- Institut du Sein et de Chirurgie Gynécologique d'Avignon, Polyclinique Urbain V (Elsan Group), Avignon, France; Pôle de Recherche en Gynécologie, IREC Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Jacques Donnez
- Université Catholique de Louvain and Société de Recherche pour l'Infertilité (SRI), Brussels, Belgium.
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17
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Abstract
Endometriosis is a disease of reproductive age women that is commonly characterized by symptoms that often negatively impact quality of life. The clinical management of endometriosis remains highly variable and mostly influenced by geographic location, practice patterns, and breadth of clinician experience. This variability in treatment has inspired a trend towards multidisciplinary and specialized care of patients suffering from this disease. Surgical sampling, followed by histologic confirmation of endometrial-like tissue, remains the standard for the definitive diagnosis of endometriosis. However, the high sensitivity and specificity of MRI and ultrasound has shed light on the path towards non-surgical diagnosis of deep infiltrating endometriosis. Molecular variability and intricacy of this disease has limited the development of biologic markers to target for non-invasive diagnosis and pharmacologic therapies. Surgical management of advanced-stage endometriosis can be difficult, mostly secondary to the invasive nature of the disease, and anatomical distortion requiring advanced surgical skills to manage. The high prevalence of chronic pelvic pain and other complex pain syndromes in patients with endometriosis also requires knowledge in the management of these types of issues in order to provide comprehensive care. Menopausal endometriosis, extrapelvic presentation, and potential malignant transformation of lesions are infrequent, requiring a high index of suspicion for timely diagnosis and treatment.
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Affiliation(s)
- Miguel A Luna Russo
- Section of Benign Gynecology, Obstetrics and Gynecology, Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA -
| | - Julia N Chalif
- Obstetrics and Gynecology, Women's Health Institute, Cleveland Clinic, Cleveland, Ohio, USA
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18
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Bendifallah S, Vesale E, Daraï E, Thomassin-Naggara I, Bazot M, Tuech JJ, Abo C, Roman H. Recurrence after Surgery for Colorectal Endometriosis: A Systematic Review and Meta-analysis. J Minim Invasive Gynecol 2020; 27:441-451.e2. [DOI: 10.1016/j.jmig.2019.09.791] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 09/17/2019] [Accepted: 09/23/2019] [Indexed: 01/27/2023]
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19
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Habib N, Centini G, Lazzeri L, Amoruso N, El Khoury L, Zupi E, Afors K. Bowel Endometriosis: Current Perspectives on Diagnosis and Treatment. Int J Womens Health 2020; 12:35-47. [PMID: 32099483 PMCID: PMC6996110 DOI: 10.2147/ijwh.s190326] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 11/29/2019] [Indexed: 12/13/2022] Open
Abstract
Endometriosis is a chronic condition primarily affecting young women of reproductive age. Although some women with bowel endometriosis may be asymptomatic patients typically report a myriad of symptoms such as alteration in bowel habits (constipation/diarrhoea) dyschezia, dysmenorrhoea and dyspareunia in addition to infertility. To date, there are no clear guidelines on the evaluation of patients with suspected bowel endometriosis. Several techniques have been proposed including transvaginal and/or transrectal ultrasonography, magnetic resonance imaging, and double-contrast barium enema. These different imaging modalities provide greater information regarding presence, location and extent of endometriosis ensuring patients are adequately informed whilst also optimizing preoperative planning. In cases where surgical management is indicated, surgery should be performed by experienced surgeons, in centres with access to multidisciplinary care. Treatment should be tailored according to patient symptoms and wishes with a view to excising as much disease as possible, whilst at the same time preserving organ function. In this review article current perspectives on diagnosis and management of bowel endometriosis are discussed.
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Affiliation(s)
- Nassir Habib
- Department of Obstetrics and Gynaecology, Beaujon Hospital-University of Paris, Clichy Cedex 92110, France
| | - Gabriele Centini
- Department of Molecular and Developmental Medicine, University of Siena, Ospedale Santa Maria alle Scotte, Siena 53100, Italy
| | - Lucia Lazzeri
- Department of Molecular and Developmental Medicine, University of Siena, Ospedale Santa Maria alle Scotte, Siena 53100, Italy
| | - Nicola Amoruso
- Department of Molecular and Developmental Medicine, University of Siena, Ospedale Santa Maria alle Scotte, Siena 53100, Italy
| | - Lionel El Khoury
- Department of Colorectal Surgery-Delafontaine Hospital, Saint Denis 93200, France
| | - Errico Zupi
- Department of Molecular and Developmental Medicine, University of Siena, Ospedale Santa Maria alle Scotte, Siena 53100, Italy
| | - Karolina Afors
- Department of Obstetrics and Gynaecology, Whittington Hospital, London, UK
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20
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Laganà AS, Garzon S, Götte M, Viganò P, Franchi M, Ghezzi F, Martin DC. The Pathogenesis of Endometriosis: Molecular and Cell Biology Insights. Int J Mol Sci 2019; 20:E5615. [PMID: 31717614 PMCID: PMC6888544 DOI: 10.3390/ijms20225615] [Citation(s) in RCA: 237] [Impact Index Per Article: 47.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 11/01/2019] [Accepted: 11/07/2019] [Indexed: 12/15/2022] Open
Abstract
The etiopathogenesis of endometriosis is a multifactorial process resulting in a heterogeneous disease. Considering that endometriosis etiology and pathogenesis are still far from being fully elucidated, the current review aims to offer a comprehensive summary of the available evidence. We performed a narrative review synthesizing the findings of the English literature retrieved from computerized databases from inception to June 2019, using the Medical Subject Headings (MeSH) unique ID term "Endometriosis" (ID:D004715) with "Etiology" (ID:Q000209), "Immunology" (ID:Q000276), "Genetics" (ID:D005823) and "Epigenesis, Genetic" (ID:D044127). Endometriosis may origin from Müllerian or non-Müllerian stem cells including those from the endometrial basal layer, Müllerian remnants, bone marrow, or the peritoneum. The innate ability of endometrial stem cells to regenerate cyclically seems to play a key role, as well as the dysregulated hormonal pathways. The presence of such cells in the peritoneal cavity and what leads to the development of endometriosis is a complex process with a large number of interconnected factors, potentially both inherited and acquired. Genetic predisposition is complex and related to the combined action of several genes with limited influence. The epigenetic mechanisms control many of the processes involved in the immunologic, immunohistochemical, histological, and biological aberrations that characterize the eutopic and ectopic endometrium in affected patients. However, what triggers such alterations is not clear and may be both genetically and epigenetically inherited, or it may be acquired by the particular combination of several elements such as the persistent peritoneal menstrual reflux as well as exogenous factors. The heterogeneity of endometriosis and the different contexts in which it develops suggest that a single etiopathogenetic model is not sufficient to explain its complex pathobiology.
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Affiliation(s)
- Antonio Simone Laganà
- Department of Obstetrics and Gynecology, “Filippo Del Ponte” Hospital, University of Insubria, Piazza Biroldi 1, 21100 Varese, Italy; (S.G.); (F.G.)
| | - Simone Garzon
- Department of Obstetrics and Gynecology, “Filippo Del Ponte” Hospital, University of Insubria, Piazza Biroldi 1, 21100 Varese, Italy; (S.G.); (F.G.)
| | - Martin Götte
- Department of Gynecology and Obstetrics, Münster University Hospital, D-48149 Münster, Germany;
| | - Paola Viganò
- Reproductive Sciences Laboratory, Division of Genetics and Cell Biology, San Raffaele Scientific Institute, Via Olgettina 60, 20136 Milan, Italy;
| | - Massimo Franchi
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Piazzale Aristide Stefani 1, 37126 Verona, Italy;
| | - Fabio Ghezzi
- Department of Obstetrics and Gynecology, “Filippo Del Ponte” Hospital, University of Insubria, Piazza Biroldi 1, 21100 Varese, Italy; (S.G.); (F.G.)
| | - Dan C. Martin
- School of Medicine, University of Tennessee Health Science Center, 910 Madison Ave, Memphis, TN 38163, USA;
- Virginia Commonwealth University, 907 Floyd Ave, Richmond, VA 23284, USA
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21
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Ceccaroni M, Bounous VE, Clarizia R, Mautone D, Mabrouk M. Recurrent endometriosis: a battle against an unknown enemy. EUR J CONTRACEP REPR 2019; 24:464-474. [PMID: 31550940 DOI: 10.1080/13625187.2019.1662391] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Recurrence of endometriosis after conservative surgery is not an uncommon finding. There is no uniformity, however, on what the term 'recurrence' means. Recurrence is variously defined in the literature as the relapse of pain, clinical or instrumental detection of an endometriotic lesion, repeat rise in CA 125 levels, or evidence of recurrence found during repeat surgery. Consequently, the reported recurrence rate varies widely (0-89%) in the different series, depending on its definition and the type of study performed. As endometriosis recurrence seems to be an indeterminate enemy, we set out to examine exactly what we were fighting in our everyday battle. In this narrative review, we aimed to seek an answer to questions related to endometriosis recurrence, some of which are often asked by our patients.
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Affiliation(s)
- Marcello Ceccaroni
- Department of Obstetrics and Gynaecology, Gynaecological Oncology and Minimally Invasive Pelvic Surgery, International School of Surgical Anatomy, Sacred Heart Hospital, Negrar, Verona, Italy
| | - Valentina Elisabetta Bounous
- Department of Surgical Sciences, Unit of Gynaecology and Obstetrics, Mauriziano Umberto I Hospital, University of Turin, Turin, Italy
| | - Roberto Clarizia
- Department of Obstetrics and Gynaecology, Gynaecological Oncology and Minimally Invasive Pelvic Surgery, International School of Surgical Anatomy, Sacred Heart Hospital, Negrar, Verona, Italy
| | - Daniele Mautone
- Department of Obstetrics and Gynaecology, Gynaecological Oncology and Minimally Invasive Pelvic Surgery, International School of Surgical Anatomy, Sacred Heart Hospital, Negrar, Verona, Italy
| | - Mohamed Mabrouk
- Minimally Invasive Pelvic Surgery Unit, Sant'Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
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22
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Balla A, Quaresima S, Subiela JD, Shalaby M, Petrella G, Sileri P. Outcomes after rectosigmoid resection for endometriosis: a systematic literature review. Int J Colorectal Dis 2018; 33:835-847. [PMID: 29744578 DOI: 10.1007/s00384-018-3082-y] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/02/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE "Endometriosis" is defined such as the presence of endometrial glands and stroma outside the uterine cavity. This ectopic condition may develop as deeply infiltrating endometriosis (DIE) when a solid mass is located deeper than 5 mm underneath the peritoneum including the intestinal wall. The ideal surgical treatment is still under search, and treatment may range from simple shaving to rectal resection. The aim of the present systematic review is to report and analyze the postoperative outcomes after rectosigmoid resection for endometriosis. METHODS We performed a systematic review according to Meta-analysis of Observational Studies in Epidemiology guidelines. The search was carried out in the PubMed database, using the keywords: "rectal resection" AND "endometriosis" and "rectosigmoid resection" AND "endometriosis." The search revealed 380 papers of which 78 were fully analyzed. RESULTS Thirty-eight articles published between 1998 and 2017 were included. Three thousand seventy-nine patients (mean age 34.28 ± 2.46) were included. Laparoscopic approach was the most employed (90.3%) followed by the open one (7.9%) and the robotic one (1.7%). Overall operative time was 238.47 ± 66.82. Conversion rate was 2.7%. In more than 80% of cases, associated procedures were performed. Intraoperative complications were observed in 1% of cases. The overall postoperative complications rate was 18.5% (571 patients), and the most frequent complication was recto-vaginal fistula (74 patients, 2.4%). Postoperative mortality rate was 0.03% and mean hospital stay was 8.88 ± 3.71 days. CONCLUSIONS Despite the large and extremely various number of associated procedures, rectosigmoid resection is a feasible and safe technique to treat endometriosis.
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Affiliation(s)
- Andrea Balla
- Department of General Surgery and Surgical Specialties "Paride Stefanini", Sapienza, University of Rome, Viale del Policlinico 155, 00161, Rome, Italy.
| | - Silvia Quaresima
- Department of General Surgery and Surgical Specialties "Paride Stefanini", Sapienza, University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - José D Subiela
- Department of Urology, Fundació Puigvert, Carrer de Cartegena 340, Universidad Autónoma de Barcelona, 08025, Barcelona, Spain
| | - Mostafa Shalaby
- Department of General Surgery, University of Rome "Tor Vergata", Viale Oxford 81, 00133, Rome, Italy
| | - Giuseppe Petrella
- Department of General Surgery, University of Rome "Tor Vergata", Viale Oxford 81, 00133, Rome, Italy
| | - Pierpaolo Sileri
- Department of General Surgery, University of Rome "Tor Vergata", Viale Oxford 81, 00133, Rome, Italy
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Ianieri MM, Mautone D, Ceccaroni M. Recurrence in Deep Infiltrating Endometriosis: A Systematic Review of the Literature. J Minim Invasive Gynecol 2018; 25:786-793. [DOI: 10.1016/j.jmig.2017.12.025] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 11/27/2017] [Accepted: 12/13/2017] [Indexed: 11/28/2022]
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Nezhat C, Li A, Falik R, Copeland D, Razavi G, Shakib A, Mihailide C, Bamford H, DiFrancesco L, Tazuke S, Ghanouni P, Rivas H, Nezhat A, Nezhat C, Nezhat F. Bowel endometriosis: diagnosis and management. Am J Obstet Gynecol 2018; 218:549-562. [PMID: 29032051 DOI: 10.1016/j.ajog.2017.09.023] [Citation(s) in RCA: 104] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 07/19/2017] [Accepted: 09/27/2017] [Indexed: 12/29/2022]
Abstract
The most common location of extragenital endometriosis is the bowel. Medical treatment may not provide long-term improvement in patients who are symptomatic, and consequently most of these patients may require surgical intervention. Over the past century, surgeons have continued to debate the optimal surgical approach to treating bowel endometriosis, weighing the risks against the benefits. In this expert review we will describe how the recommended surgical approach depends largely on the location of disease, in addition to size and depth of the lesion. For lesions approximately 5-8 cm from the anal verge, we encourage conservative surgical management over resection to decrease the risk of short- and long-term complications.
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Ota Y, Andou M, Ota I. Laparoscopic surgery with urinary tract reconstruction and bowel endometriosis resection for deep infiltrating endometriosis. Asian J Endosc Surg 2018; 11:7-14. [PMID: 29444547 DOI: 10.1111/ases.12464] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Accepted: 01/10/2018] [Indexed: 01/11/2023]
Abstract
Deep infiltrating endometriosis (DIE) is the most severe form of endometriosis. It causes chronic pelvic pain, severe dysmenorrhea, deep dyspareunia, dyschezia, and dysuria, markedly impairing the quality of life of women of reproductive age. A number of randomized controlled trials on surgical and medical treatments to reduce the pain associated with endometriosis have been reported, but few have focused on this in DIE. DIE causes not only pain but also functional invasion to the urinary organs and bowel, such as hydronephrosis and bowel stenosis. In addition to DIE resection, surgical treatment involves adhesion separation as well as resection and reconstruction of the urinary organs and bowel; high-level skills are required. The severity of DIE should be evaluated preoperatively as accurately as possible. Using ENZIAN in conjunction with the AFS (The revised American Fertility Society classification of endometriosis) classification makes a more detailed assessment of DIE possible. The operative procedures used for laparoscopic resection of urinary DIE and reconstruction of the urinary organs are chosen based on the type of lesion (intrinsic/extrinsic) and length of stenosis. In addition to ureteroneocystostomy, the psoas bladder hitch and Boari bladder flap procedures are applied when necessary to extend the urinary tract. Bowel resection for bowel endometriosis is classified into classic segmental resection and conservative approaches (shaving/discoid). When these procedures are employed, it is advisable to work in consultation with urologists and gastroenterologists and to inform the patients of the associated risks and outcomes. Furthermore, postoperative medication is essential because it is difficult to conduct repeated surgeries.
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Affiliation(s)
| | | | - Ikuko Ota
- Kurashiki Heisei Hospital, Kurashiki, Japan
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Bourdel N, Comptour A, Bouchet P, Gremeau AS, Pouly JL, Slim K, Pereira B, Canis M. Long-term evaluation of painful symptoms and fertility after surgery for large rectovaginal endometriosis nodule: a retrospective study. Acta Obstet Gynecol Scand 2017; 97:158-167. [PMID: 29143306 DOI: 10.1111/aogs.13260] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 10/23/2017] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Optimal surgical treatment of rectovaginal endometriosis remains a controversial topic. The objective of this study was to evaluate long-term postoperative outcomes after rectal shaving or colorectal resection for rectovaginal endometriosis. MATERIAL AND METHODS 195 patients underwent surgery (172 managed by shaving, 23 by colorectal resection) between January 2000 and June 2013 for rectovaginal endometriosis (>2 cm) involving at least the serosa of the rectum. Primary outcome measures were pain and fertility. Secondary outcome measures were complications, recurrence rates and quality of life. RESULTS Mean follow-up was 60 ± 42 months in the shaving group and 67 ± 47 months in the resection group. The mean VAS score for pelvic pain between the pre and postoperative period decreased from 5.5 ± 3.5 (shaving group) and 7.3 ± 2.9 (resection group) to 2.3 ± 2.4 (p < 0.001) and 2.0 ± 1.8 (p < 0.001), respectively. For dysmenorrhea, the mean baseline VAS score fell postoperatively from 7.7 ± 2.8 (shaving group) and 8.2 ± 2.6 (resection group) to 3.3 ± 2.9 (p < 0.001) and 2.7 ± 2.7 (p < 0.001), respectively. Pregnancy rates were 73% for shaving and 69% for resection. Major complications occurred in 4% of patients in the shaving group and in 26% in the resection group (p = 0.001). Thirteen patients (7.6%) from the shaving group and none from the resection group were reoperated for suspicion of endometriosis recurrence (p = 0.37). Postoperative quality of life scores revealed no differences between the two groups. CONCLUSION Our study demonstrates that rectal shaving, when feasible for rectovaginal nodule (>2 cm) infiltrating the digestive serosa, has equal impact on pain and pregnancy rates compared with colorectal resection at long-term follow-up, with low complication and favorable pregnancy rates.
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Affiliation(s)
- Nicolas Bourdel
- Gynecological Surgery Service, CHU University Hospital Clermont-Ferrand, Clermont-Ferrand, France
| | - Aurélie Comptour
- Gynecological Surgery Service, CHU University Hospital Clermont-Ferrand, Clermont-Ferrand, France
| | - Paméla Bouchet
- Gynecological Surgery Service, CHU University Hospital Clermont-Ferrand, Clermont-Ferrand, France
| | - Anne-Sophie Gremeau
- Gynecological Surgery Service, CHU University Hospital Clermont-Ferrand, Clermont-Ferrand, France
| | - Jean-Luc Pouly
- Gynecological Surgery Service, CHU University Hospital Clermont-Ferrand, Clermont-Ferrand, France
| | - Karem Slim
- Service of Hepato Gastro Enterology, CHU University Hospital Clermont-Ferrand, Clermont-Ferrand, France
| | - Bruno Pereira
- Biostatistics Units (DRCI), CHU University Hospital Clermont-Ferrand, Clermont-Ferrand, France
| | - Michel Canis
- Gynecological Surgery Service, CHU University Hospital Clermont-Ferrand, Clermont-Ferrand, France
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Young S, Burns MK, DiFrancesco L, Nezhat A, Nezhat C. Diagnostic and treatment guidelines for gastrointestinal and genitourinary endometriosis. J Turk Ger Gynecol Assoc 2017; 18:200-209. [PMID: 29278234 PMCID: PMC5776160 DOI: 10.4274/jtgga.2017.0143] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Accepted: 12/03/2017] [Indexed: 01/28/2023] Open
Abstract
Endometriosis is commonly misdiagnosed, even among many experienced gynecologists. Gastrointestinal and genitourinary endometriosis is particularly difficult to diagnose, and is commonly mistaken for other pathologies, such as irritable bowel syndrome, interstitial cystitis, and even psychological disturbances. This leads to delays in diagnosis, mismanagement, and unnecessary testing. In this review, we will discuss the diagnosis and management of genitourinary and gastrointestinal endometriosis. Medical management may be tried first, but often fails in cases of urinary tract endometriosis. This is particularly important in cases of ureteral endometriosis because silent obstruction can lead to eventual kidney failure. Thus, we recommend complete surgical treatment in these cases. Bladder endometriosis may be managed more conservatively, and only if symptomatic, because these rarely lead to significant morbidity. In cases of bowel endometriosis, we recommend medical management first in all cases, and the least invasive surgical management only if medical treatment fails. This is due to the extensive nervous and vasculature supply to the lower rectum. Injury to these nerves and vessels can cause significant complications and postoperative morbidity.
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Affiliation(s)
- Stacy Young
- Camran Nezhat Institute and Center for Special Minimally Invasive and Robotic Surgery, California, USA
- Stanford University Medical Center, California, USA
| | - Megan Kennedy Burns
- Camran Nezhat Institute and Center for Special Minimally Invasive and Robotic Surgery, California, USA
- Stanford University Medical Center, California, USA
| | - Lucia DiFrancesco
- Camran Nezhat Institute and Center for Special Minimally Invasive and Robotic Surgery, California, USA
- Stanford University Medical Center, California, USA
| | - Azadeh Nezhat
- Camran Nezhat Institute and Center for Special Minimally Invasive and Robotic Surgery, California, USA
- Stanford University Medical Center, California, USA
- University of California, San Francisco, School of Medicine, San Francisco, USA
| | - Camran Nezhat
- Camran Nezhat Institute and Center for Special Minimally Invasive and Robotic Surgery, California, USA
- Stanford University Medical Center, California, USA
- University of California, San Francisco, School of Medicine, San Francisco, USA
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Donnez O, Roman H. Choosing the right surgical technique for deep endometriosis: shaving, disc excision, or bowel resection? Fertil Steril 2017; 108:931-942. [PMID: 29202966 DOI: 10.1016/j.fertnstert.2017.09.006] [Citation(s) in RCA: 156] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 09/03/2017] [Accepted: 09/05/2017] [Indexed: 12/17/2022]
Abstract
Deep endometriosis (DE) remains the most difficult endometriotic entity to treat. Medical treatment for DE can reduce symptoms but does not cure the disease, and surgical removal of the lesion is required when lesions are symptomatic, impairing bowel, urinary, sexual, and reproductive functions. Although several surgical techniques such as laparoscopic bowel resection, disc excision, and rectal shaving have been described, there is no consensus regarding the choice of technique or the timing of surgery. Our review of publications reporting results and complications of surgery for rectovaginal DE reveals a relatively higher complication rate after bowel resection compared with shaving and disc excision, especially for rectovaginal fistulas, anastomotic leakage, delayed hemorrhage, and long-term bladder catheterization. Data show that shaving is feasible even in advanced disease. The risk of immediate complications after shaving and disc excision is probably lower than after colorectal resection, allowing for better functional outcomes. The presumed higher risk of recurrence related to shaving has not been demonstrated. For these reasons, surgeons should consider rectal shaving as a first-line surgical treatment of rectovaginal DE, regardless of nodule size or association with other digestive localizations. When the result of rectal shaving is unsatisfactory (rare cases), disc excision may be performed either exclusively by laparoscopy or by using transanal staplers. Segmental resection may ultimately be reserved for advanced lesions responsible for major stenosis or for several cases of multiple nodules infiltrating the rectosigmoid junction or sigmoid colon.
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Affiliation(s)
- Olivier Donnez
- Institut du sein et de Chirurgie gynécologique d'Avignon, Polyclinique Urbain V (Elsan Group), Avignon, France, and Pôle de recherche en gynécologie, IREC institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium.
| | - Horace Roman
- Expert Center in Diagnosis and Management of Endometriosis, Department of Gynecology and Obstetrics and Research Group EA 4308 Spermatogenesis and Male Gamete Quality, Rouen University Hospital, Rouen, France
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Marty N, Touleimat S, Moatassim-Drissa S, Millochau JC, Vallee A, Stochino Loi E, Desnyder E, Roman H. Rectal Shaving Using Plasma Energy in Deep Infiltrating Endometriosis of the Rectum: Four Years of Experience. J Minim Invasive Gynecol 2017; 24:1121-1127. [DOI: 10.1016/j.jmig.2017.06.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 06/12/2017] [Accepted: 06/23/2017] [Indexed: 10/19/2022]
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Badescu A, Roman H, Barsan I, Soldea V, Nastasia S, Aziz M, Puscasiu L, Stolnicu S. Patterns of Bowel Invisible Microscopic Endometriosis Reveal the Goal of Surgery: Removal of Visual Lesions Only. J Minim Invasive Gynecol 2017; 25:522-527.e9. [PMID: 29097234 DOI: 10.1016/j.jmig.2017.10.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 10/20/2017] [Accepted: 10/23/2017] [Indexed: 01/19/2023]
Abstract
STUDY OBJECTIVE To document the presence of bowel invisible microscopic endometriosis implants and their relationship with deep endometriosis macronodule infiltrating the bowel. DESIGN A series of consecutive patients with deep endometriosis infiltrating the rectum and/or sigmoid colon (Canadian Task Force classification II-2). SETTINGS A university referral center. PATIENTS Ten patients managed by colorectal resection. INTERVENTIONS A microscopic study of endometriotic foci of the bowel involving 3272 microsection slides was established using a unique method of step serial sections using combined transverse and longitudinal macrosection. Two-dimensional reconstruction based on slide scanning highlighted the presence and localization of the deep endometriosis macronodule in contrast with bowel invisible microscopic endometriosis microimplants. MEASUREMENTS AND MAIN RESULTS The distance separating the microimplants and the nodule and their histologic characteristics. The mean length of the colorectal specimens was 91 ± 19 mm. The maximum distance between the farthest microimplants was 7.2 cm. The maximum distance from the macroscopic nodule limit to the farthest microimplant was 31 mm. Bowel invisible microscopic endometriosis microimplants presented with similar features independently of the type of spread. They had an active appearance including stroma and glands, were sometimes decidualized, and were free of fibrosis. They were found on the distal/rectal limit of the specimen in 3 patients and on both limits (distal/rectal and proximal/sigmoid colon) in 1 patient. CONCLUSION Invisible microscopic endometriosis implants surround the bowel macroscopic endometriosis nodule at variable distances, suggesting that complete surgical microscopic removal may be a challenging goal. These results may help to reconsider the principles and feasibility of the surgical management of bowel endometriosis.
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Affiliation(s)
- Alexandra Badescu
- Department of Gynecology and Obstetrics, Rouen University Hospital, Rouen France; Department of Obstetrics and Gynecology, University of Medicine and Pharmacy, Targu Mures, Romania
| | - Horace Roman
- Department of Gynecology and Obstetrics, Rouen University Hospital, Rouen France; Research Group 4308 "Spermatogenesis and Gamete Quality," IHU Rouen Normandy, IFRMP23, Reproductive Biology Laboratory, Rouen University Hospital, Rouen France.
| | - Iulia Barsan
- Department of Pathology, University of Medicine and Pharmacy, Targu Mures, Romania
| | - Valentin Soldea
- Department of Pathology, University of Medicine and Pharmacy, Targu Mures, Romania; Department of Thoracic Surgery, Rouen University Hospital, Rouen France
| | - Serban Nastasia
- Department of Obstetrics and Gynecology, Cantacuzino Hospital, University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
| | - Moutaz Aziz
- Department of Pathology, Rouen University Hospital, Rouen France
| | - Lucian Puscasiu
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy, Targu Mures, Romania
| | - Simona Stolnicu
- Department of Pathology, University of Medicine and Pharmacy, Targu Mures, Romania
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Long-term functional outcomes following colorectal resection versus shaving for rectal endometriosis. Am J Obstet Gynecol 2016; 215:762.e1-762.e9. [PMID: 27393269 DOI: 10.1016/j.ajog.2016.06.055] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 06/20/2016] [Accepted: 06/28/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND Two surgical approaches usually are used in the surgical management of deep infiltrating endometriosis of the rectum: the radical approach that mainly is based on colorectal resection and the conservative or symptom-guided approach that prioritizes conservation of the rectum. There are no data available that compare long-term functional digestive outcomes of 1 approach to the other. OBJECTIVE The purpose of this study was to compare long-term digestive outcomes in women who were treated by either rectal shaving or colorectal resection for deep endometriosis infiltrating the rectum. STUDY DESIGN A retrospective comparative study was performed. All women who were treated with surgery for deep endometriosis infiltrating the rectum by either shaving or colorectal resection at the University Hospital of Rouen from January 2005 to January 2010 were enrolled. Follow-up evaluation was carried out for a minimum of 5 years. Postoperative evaluation of digestive symptoms was performed by 4 standardized gastrointestinal questionnaires: the Gastrointestinal Quality of Life Index, the Knowles-Eccersley-Scott-Symptom score for constipation, the Wexner score for anal continence, and the Bristol Stool Score. Symptoms that were related to endometriosis, fertility, and disease recurrence were obtained from a specific questionnaire. RESULTS A total of 77 women were included. Three women were lost to follow up (3.9%), and 3 were treated by disc excision (3.9%). The mean follow-up time was 80±19 months. Forty-six women underwent conservative rectal shaving, and 25 women underwent colorectal resection. Patient characteristics and the severity of the disease were comparable in both groups. Patients who were treated by rectal shaving had significantly better Gastrointestinal Quality of Life Index values, lower Knowles-Eccersley-Scott-Symptom scores for postoperative constipation, and better anal continence. No statistically significant differences were revealed for postoperative pelvic pain. Rectal recurrence occurred in 8.7% of patients who were treated by conservative surgery: 4.3% underwent secondary colorectal resection and 4.3% were treated secondarily by rectal shaving. Consequently, avoiding a recurrence for merely 1 patient would have required 11 patients to undergo colorectal resection instead of shaving. CONCLUSION Our data suggest that, in patients who are treated for rectal endometriosis, colorectal resection does not improve long-term postoperative functional outcomes when compared with rectal shaving.
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Roman H, Moatassim-Drissa S, Marty N, Milles M, Vallée A, Desnyder E, Stochino Loi E, Abo C. Rectal shaving for deep endometriosis infiltrating the rectum: a 5-year continuous retrospective series. Fertil Steril 2016; 106:1438-1445.e2. [DOI: 10.1016/j.fertnstert.2016.07.1097] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 07/13/2016] [Accepted: 07/18/2016] [Indexed: 10/21/2022]
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Epidemiology of subtle, typical, cystic, and deep endometriosis: a systematic review. ACTA ACUST UNITED AC 2016. [DOI: 10.1007/s10397-016-0970-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Darwish B, Roman H. Surgical treatment of deep infiltrating rectal endometriosis: in favor of less aggressive surgery. Am J Obstet Gynecol 2016; 215:195-200. [PMID: 26851598 DOI: 10.1016/j.ajog.2016.01.189] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 01/17/2016] [Accepted: 01/28/2016] [Indexed: 02/08/2023]
Abstract
Deep infiltrating endometriosis of the rectum is a severe disease concerning young women of reproductive age. Because it is a benign condition, aggressive surgical treatment and subsequent complications are not always accepted by young patients. Two surgical approaches exist: the radical approach, employing colorectal resection; and the conservative approach, based on rectal shaving or full-thickness disc excision. At present, the majority of patients with rectal endometriosis worldwide are managed by the radical approach. Conversely, as high as 66% of patients with colorectal endometriosis can be managed by either rectal shaving or full-thickness disc excision. Most arguments that used to support the large use of the radical approach may now be disputed. The presumed higher risk of recurrence related to conservative surgery can be balanced by a supposed higher risk of postoperative bowel dysfunction related to the radical approach. Bowel occult microscopic endometriosis renders debatable the hypothesis that more aggressive surgery can definitively cure endometriosis. Although most surgeons consider that radical surgery is unavoidable in patients with rectal nodules responsible for digestive stenosis, conservative surgery can be successfully performed in a majority of cases. In multifocal bowel endometriosis, multiple conservative procedures may be proposed, provided that the nodules are separated by segments of healthy bowel of longer than 5 cm. Attempting conservation of a maximum length of rectum may reduce the risk of postoperative anterior rectal resection syndrome and subsequent debilitating bowel dysfunction and impaired quality of life. Promotion of less aggressive surgery with an aim to better spare organ function has become a general tendency in both oncologic and benign pathologies; thus the management of deep colorectal endometriosis should logically be concerned, too.
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Microscopic endometriosis: impact on our understanding of the disease and its surgery. Fertil Steril 2016; 105:305-6. [DOI: 10.1016/j.fertnstert.2015.10.038] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Accepted: 10/28/2015] [Indexed: 11/21/2022]
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