Coloscanner à l’air avec coloscopie virtuelle : arguments dans le choix du traitement chirurgical des endométrioses colorectales

"The Sword in the Stone": radical excision of deep infiltrating endometriosis with bowel shaving-a single-centre experience on 703 consecutive patients

BACKGROUND

Laparoscopic segmental bowel resection, disc excision and rectal shaving are described as surgical options for the treatment of bowel endometriosis, but the gold standard has not yet established. The aim of the study is to investigate the efficacy of the laparoscopic bowel shaving technique in terms of pain symptomatology and to analyse early and late postoperative complications.

METHODS

Retrospective cohort study of a series of 703 consecutive patients treated between January 2014 and December 2019 in a tertiary care referral centre. All patients underwent laparoscopic bowel shaving with concomitant radical excision of DIE.

RESULTS

Bilateral posterolateral parametrectomy and ureterolysis were performed, respectively, in 314 (44.7%) and 318 cases (45.2%). A radical hysterectomy was performed in 107 cases (82.9%). Postoperative complications were infrequent: 17 patients required a reoperation (2.4%) and in this subgroup we registered 2 rectovaginal fistulas (0.3%), 4 patients received blood transfusion (0.6%), 12 patients (1.7%) experienced postoperative fever, 6 patients experienced impaired bladder voiding (0.9%) after 6 months. Median follow-up was 14 months. The study reported good clinical and surgical results, with a regression of symptoms (p < 0.0001) and an overall rate of recurrence of 6.5%. Clinical and instrumental criteria of bowel endometriosis relapse were exclusively detected in 5 patients (0.8%). Eleven patients (1.7%) with relapsed endometriosis were reoperated.

CONCLUSIONS

Bowel shaving is a feasible and valuable surgical procedure. It is only the last step of a complex surgery which is aimed to minimize the residual quote of infiltrating nodule and requires a multidisciplinary team to achieve optimal treatment preoperatively, intraoperatively and postoperatively.

[Contribution of the pre-operative Mri-coloscan couple in the surgical planning of deep digestive pelvic endometriosis]

INTRODUCTION

The digestive involvement of endometriosis accounts for up to 20-25% of deep localisations. Precise mapping of digestive lesions is essential in order to plan surgery and specialized teams. The aim of this study is to assess the contribution of the MRI-coloscan couple in the preoperative assessment of digestive endometriosis.

METHODS

We analyzed 45 files of patients referred for suspected digestive endometriosis. They had all undergone a preoperative MRI and coloscan associated with surgery throughout the year. We first compared the data collected in imaging, and then compared the synthesis of this data with the surgical procedure performed.

RESULTS

35 patients required digestive surgery. 24 of 45 files were concordant in MRI and coloscanner. Data from MRI alone matched with surgery in 69% of cases, against 84% for the coloscan. The synthesis allowed a concordance of 89%. 25 segmental resections, 2 discoid and 16 shaving were performed. The use of coloscan made up for nine extra cases: the detection of four additional cases of multifocality, a single undiagnosed case of a deep lesion, and allowed to specify the depth of the involvement in four cases. On the contrary, the MRI was correct compared to the CT in four cases. The presence of a digestive surgeon was necessary in 53% of cases.

CONCLUSION

In the era of imaging staging, it would seem interesting to turn towards a subclassification of the digestive involvement of endometriosis in order to decide which surgery to perform. In our experience, the coloscan is a useful complement of MR, especially to assess the depth of involvement and the multifocality.

Other imaging techniques: Double-contrast barium enema, endoscopic ultrasonography, multidetector CT enema, and computed tomography colonoscopy

Double-contrast barium enema (DCBE), transrectal endoscopic ultrasonography (REU), multidetector computerized tomography enema (MDCT-e), and computed tomography colonoscopy (CTC) have been successfully used for the diagnosis of bowel endometriosis. DCBE provides a complete overview of the entire colon and allows detecting cecal nodules. The accuracy of DCBE is operator dependent and, thus, it may have low specificity. It does not allow identifying the cause of the mass effect. DCBE requires the administration of barium and exposure to radiation. REU precisely estimates the distance between the rectosigmoid nodule and the anal verge. However, it allows investigating only the distal part of rectosigmoid, it misses anterior pelvic lesions, and it has poor sensitivity for the diagnosis of endometriomas. MDCT-e is accurate and reproducible in diagnosing intestinal endometriosis and in assessing its characteristics: the largest diameter of the nodule, the distance between the distal part of the nodule and the anal verge, and depth of infiltration of endometriosis in the intestinal wall. MDCT-e requires the administration of iodinated contrast medium (CM) and the exposure to radiations. CTC has good performance in the diagnosis of rectosigmoid endometriosis. It allows estimating the degree of intestinal stenosis CTC, and the distance between the intestinal endometriotic nodule and the anal verge. It requires exposure to radiations, and it may require the administration of an iodinated CM.

Diagnostic performance of computed tomography for bowel endometriosis: A systematic review and meta-analysis

PURPOSE

To perform a systematic review and meta-analysis regarding the performance of CT for diagnosis of bowel endometriosis.

MATERIALS AND METHODS

Pubmed and EMBASE were systematically searched up to March 28, 2019. Diagnostic accuracy studies using CT for diagnosis of bowel endometriosis using laparoscopy followed by histopathology as the reference standard were included. Methodological quality of the included studies was evaluated using Quality Assessment of Diagnostic Accuracy Studies-2. Sensitivity and specificity were pooled using hierarchical summary receiver operating modelling. Meta-regression analysis was done to explore heterogeneity.

RESULTS

Twelve studies (1091 patients) were included. Pooled sensitivity and specificity were 0.92 (95% confidence interval [CI], 0.83-0.97) and 0.95 (95% CI, 0.88-0.98), respectively. Substantial heterogeneity was present: I² = 92.38% for sensitivity and 89.09% for specificity. Deeks' asymmetry test suggested publication bias (p = 0.04). At meta-regression analysis, history of prior surgery for endometriosis was the only significant factor affecting heterogeneity (p < 0.01). Specifically, studies that included patients with such history demonstrated significantly greater specificity than studies that did not (0.95 [95% CI, 0.91-1.00] vs 0.75 [95% CI, 0.43-1.00]).

CONCLUSIONS

CT shows excellent performance in the diagnosis of bowel endometriosis. Due to small number of included studies and publication bias, further studies may be needed to validate these results.

Does Computed Tomography-Based Virtual Colonoscopy Improve the Accuracy of Preoperative Assessment Based on Magnetic Resonance Imaging in Women Managed for Colorectal Endometriosis?

STUDY OBJECTIVE

To evaluate whether combining computed tomography-based virtual colonoscopy (CTC) with magnetic resonance imaging (MRI) improves preoperative assessment of colorectal endometriosis.

DESIGN

Retrospective study using prospectively recorded data (Canadian Task Force classification II-2).

SETTING

University tertiary referral center.

PATIENTS

Seventy-one women treated for colorectal endometriosis managed between June 2015 and May 2016.

INTERVENTIONS

Patients included in our study underwent colorectal surgery for deep endometriosis infiltrating the rectum or the sigmoid colon and had preoperative assessment using MRI and CTC. To establish the correlation between preoperative and intraoperative findings, the concordance kappa index was used.

MEASUREMENTS AND MAIN RESULTS

Preoperative data provided by MRI, CTC, and a combination of both were compared with intraoperative findings. All 71 patients had a total of 105 endometriotic intestinal lesions intraoperatively confirmed. Some 71.2% of rectal nodules and 60.0% of sigmoid nodules infiltrated the muscularis propria of the intestinal wall, with most infiltrating between 25% and 50% of the rectal circumference; 73% of rectal nodules and 96% of sigmoid nodules led to varying degrees of stenosis. The concordance between intraoperative and preoperative findings concerning the presence of rectal nodules was high, at .88 when associating CTC with MRI, whereas each imaging technique taken individually provided lower concordance coefficients. In our study 80.3% of patients underwent the procedure that had been preoperatively planned.

CONCLUSION

Our study suggests that associating MRI with CTC leads to improved accuracy in preoperative assessment of colorectal endometriosis and in subsequent preoperative choice of surgical procedures on the digestive tract.

Choosing the right surgical technique for deep endometriosis: shaving, disc excision, or bowel resection?

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.

Computed tomographic colonography vs rectal water- contrast transvaginal sonography in diagnosis of rectosigmoid endometriosis: a pilot study

OBJECTIVES

To compare the performance of computed tomographic colonography (CTC) and rectal water-contrast transvaginal sonography (RWC-TVS) in the diagnosis of rectosigmoid endometriosis, and compare precision in estimating the length of the rectosigmoid nodules and the distance between the nodules and the anal verge.

METHODS

This prospective study included 70 patients of reproductive age with clinical suspicion of rectosigmoid endometriosis. Patients underwent RWC-TVS and CTC before laparoscopic excision of endometriotic nodules. The findings of RWC-TVS and CTC were compared with surgical and histological results.

RESULTS

Of the 70 patients included in the study, 40 (57.1%) had rectosigmoid endometriosis. CTC and RWC-TVS had similar accuracy in the diagnosis of rectosigmoid endometriosis (P = 0.508) and similar precision in estimating the length of the endometriotic nodules (P = 0.077). CTC was more precise than RWC-TVS in estimating the distance between the rectosigmoid nodule and the anal verge (P < 0.001). The intensity of pain experienced during CTC was higher than that perceived during RWC-TVS (P < 0.001); however, intestinal distension for CTC was well-tolerated in all patients without significant adverse effects.

CONCLUSIONS

RWC-TVS and CTC have similar accuracy in the diagnosis of rectosigmoid endometriosis and similar precision in estimating the size of the nodules; however, CTC is more precise than RWC-TVS in estimating the distance between the nodules and the anal verge, yet patients tolerate RWC-TVS better than CTC. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

[Comparison of the accuracy of rectal endoscopic sonography and magnetic resonance imaging in the diagnosis of colorectal endometriosis]

OBJECTIVE

To compare the accuracy of magnetic resonance imaging (MRI) and rectal endoscopic sonography (RES) for the diagnosis of colorectal endometriosis.

METHODS

In retrospective study, 407 patients operated on service of gynecology of Tenon hospital for deep endometriosis with suspected colorectal involvement. All patients underwent MRI and then RES.

RESULTS

In the study, 239 patients (59%) had colorectal endometriosis which were diagnosed with the histology. The sensitivity, specificity, positive and negative predictive value (PPV and NPV) of RES and MRI for the diagnosis of colorectal endometriosis were respectively 92%, 87%, 91%, 88% and 85%, 88%, 91%, 80%. The accuracy of RES was not significantly different than MRI (90% versus 86%, P=0.09).

CONCLUSION

RES is a good exam to diagnose colorectal endometriosis. It is able to improve diagnosis performances.

[Pictures balance for optimal surgical management of pelvic endometriosis. Imaging and surgery of endometriosis]

Endometriosis is a frequent benign pathology that is found in 10-15% of women and in 20% of infertile women. It has an impact on fertility, but also in everyday life. If medical treatment fails, surgical treatment can be offered to the patient. To provide adequate treatment and give clearer information to patients, it seems essential to achieve an optimal preoperative imaging assessment. Thus, the aim of this work is to define the information expected by the surgeon and the indications of each imaging test for each compartment of the pelvis, allowing an ideal surgical management of pelvic endometriosis. We will not discuss imaging techniques' principles and we will not develop the indications and surgical techniques.

Computed tomography-based virtual colonoscopy in the assessment of bowel endometriosis: The surgeon's point of view

OBJECTIVE

To discuss the role of computed tomography-based virtual colonoscopy (CTC) in preoperative assessment of bowel endometriosis.

METHODS

Retrospective study using data prospectively recorded, including 127 patients with colorectal endometriosis, having undergone CTC for bowel endometriosis. The study was conducted in a tertiary referral center during 38 consecutive months. Preoperative assessment included CTC, magnetic resonance imaging (MRI), endorectal ultrasound (ERUS) and clinical examination. Information concerning identification of deep infiltrating endometriosis (DIE) of the bowel, the length and height of colorectal involvement, stenosis of digestive lumen and associated digestive localizations were compared with intraoperative findings.

RESULTS

Sensitivity and specificity of CTC for DIE of the rectum, the sigmoid colon, associated digestive localizations, and stenosis of the digestive lumen were respectively 97% and 84%, 93% and 88%, 84% and 97%, 96% and 96%. Intraoperative estimation of the length of digestive tract involved by DIE was closer to that provided by CTC than those provided by MRI and ERUS. When CTC revealed stenosis of digestive lumen, higher rates of colorectal resection (63% vs. 9.6%, < 0.001) and disc excision (25.9% vs. 11%, 0.03) were recorded.

DISCUSSION

For those surgeons using various procedures for management of bowel endometriosis, accurate information on the length and height of bowel involvement, as well as the existence of bowel stenosis enables informed decision regarding the feasibility of conservative techniques versus bowel resection. Preoperative identification of associated localizations above the sigmoid colon is another major advantage related to CTC.

CONCLUSIONS

CTC provides accurate data on the length and height of colorectal involvement by DIE, stenosis of digestive lumen and associated lesions of digestive tract, which impact on the choice of surgical procedure.

Bowel dysfunction before and after surgery for endometriosis

The relationship between deep fibrotic endometriosis of the rectum and digestive symptoms as well as the impact of surgical treatment on digestive complaints appears increasingly complex. With the exception of cases in which the disease leads to rectal stenosis, it seems likely that certain digestive symptoms are a result of cyclic inflammatory phenomena leading to irritation of the digestive tract and not necessarily the result of actual involvement of the rectum by the disease itself because they frequently occur in women free of rectal nodules. Functional or inflammatory bowel diseases and rectal hypersensitivity may be associated with pelvic endometriosis and consequently joepardize the hypothetical causal relationship between the presence of a rectal nodule and digestive complaints. Women treated surgically for rectal endometriosis may continue to experience postoperative digestive complaints, such as constipation. Despite successful surgery free of intra- and postoperative complications and significant improvement in well-being and pelvic pain, several unpleasant digestive symptoms may be incompletely cured by the surgery. Furthermore, de novo postoperative digestive complaints may occur after rectal surgery. Retrospective data suggest that performing colorectal resection is related to less favorable digestive functional outcomes than the use of conservative procedures such as shaving or full-thickness disc excision. These hypotheses need to be confirmed by prospective randomized trials comparing rectal radical and conservative approaches. Bearing in mind the complex relationship between rectal nodules, digestive symptoms and rectal surgery, particular care must be taken in the preoperative assessment of digestive function and in choosing the most suitable surgical procedure.

Diagnosis, management, and long-term outcomes of rectovaginal endometriosis

Rectovaginal endometriosis is the most severe form of endometriosis. Clinically, it presents with a number of symptoms including chronic pelvic pain, dysmenorrhea, deep dyspareunia, dyschezia, and rectal bleeding. The gold standard for diagnosis is laparoscopy with histological confirmation; however, there are a number of options for presurgical diagnosis, including clinical examination, transvaginal/transrectal ultrasound, magnetic resonance imagining, colonoscopy, and computed tomography colonography. Treatment can be medical or surgical. Medical therapies include birth control pills, oral progestins, gonadotropin-releasing hormone agonists, danazol, and injectable progestins. Analgesics are often used as well. Surgery improves up to 70% of symptoms. Surgery is either ablative or excisional, and is conducted via transvaginal, laparoscopic, laparotomy, or combined approaches. Common surgical techniques involve shaving of the superficial rectal lesion, laparoscopic anterior discoid resection, and low anterior bowel resection and reanastomosis. Outcomes are generally favorable, but postoperative complications may include intra-abdominal bleeding, anastomotic leaks, rectovaginal fistulas, strictures, chronic constipation, and the need for reoperation. Recurrence of rectal endometriosis is a possibility as well. Other outcomes are improved pain-related symptoms and fertility. Long-term outcomes vary according to the management strategy used. This review will provide the most recent approaches and techniques for the diagnosis and treatment of rectovaginal endometriosis.

Postoperative digestive function after radical versus conservative surgical philosophy for deep endometriosis infiltrating the rectum

OBJECTIVE

To compare delayed digestive outcomes in women managed by two different surgical philosophies: a radical approach mainly related to colorectal resection, and a conservative approach involving rectal shaving and rectal nodule excision.

DESIGN

"Before and after" comparative retrospective study.

SETTING

University tertiary referral center.

PATIENT(S)

Seventy-five patients managed by surgery for deep endometriosis infiltrating the rectum.

INTERVENTION(S)

Twenty-four women were managed during a period when surgeons pursued a radical philosophy toward treatment, and 51 women were managed during a period when a conservative philosophy was adopted.

MAIN OUTCOMES MEASURE(S)

Standardized gastrointestinal questionnaires: the Gastrointestinal Quality of Life Index, the Knowles-Eccersley-Scott Symptom Questionnaire, the Bristol Stool Score, and the Fecal Incontinence Quality of Life Score.

RESULT(S)

Preoperative patient characteristics, rectal nodule features, and associated localizations of the disease were comparable between the two groups. During the radical period, colorectal resection was carried out in 67% of patients, whereas during the second period only 20% of women underwent colorectal resection. Women managed according to the conservative philosophy had significantly improved results on the Knowles-Eccersley-Scott Symptom Questionnaire, Gastrointestinal Quality of Life Index, and depression/self-perception Fecal Incontinence Quality of Life Score, and significantly improved values for various items related to postoperative constipation: unsuccessful evacuatory attempts, feeling incomplete evacuation, abdominal pain, time taken to evacuate, difficulty evacuating causing a painful effort, and stool consistency.

CONCLUSION(S)

It seems that reducing the rate of colorectal resection leads to better functional outcomes in women presenting with rectal endometriosis, lending support to the conservative surgical philosophy over mandatory colorectal resection.