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She YM, Ge N. Diagnostic value of endoscopic ultrasonography in pelvic masses with bowel involvement. Therap Adv Gastroenterol 2023; 16:17562848231163414. [PMID: 37153498 PMCID: PMC10161300 DOI: 10.1177/17562848231163414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 02/26/2023] [Indexed: 05/09/2023] Open
Abstract
Benign and malignant pelvic masses with or without intestinal invasion are common in women of childbearing age. Patients may have nonspecific symptoms and signs or experience no symptoms. Laparoscopic resection of pelvic masses is currently the mainstream treatment; therefore, accurate preoperative evaluation is not only essential for patients suspected of having intestinal invasion, but also extremely important for the selection of follow-up treatment. Procedures, including endoscopic ultrasonography (EUS), pelvic magnetic resonance imaging, abdominal computed tomography, vaginal ultrasonography, barium enema, and colonoscopy, aid in determining the presence, depth, and histology of the disease. In particular, the wide application and continuous developments in EUS techniques have improved the diagnostic accuracy for intestinal subepithelial and peripheral organ lesions. This article reviewed the clinical value of EUS in the diagnosis of benign and malignant pelvic masses with bowel involvement.
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Affiliation(s)
- Yu Mo She
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
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Advances in Imaging for Assessing Pelvic Endometriosis. Diagnostics (Basel) 2022; 12:diagnostics12122960. [PMID: 36552967 PMCID: PMC9777476 DOI: 10.3390/diagnostics12122960] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/18/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022] Open
Abstract
In recent years, due to the development of standardized diagnostic protocols associated with an improvement in the associated technology, the diagnosis of pelvic endometriosis using imaging is becoming a reality. In particular, transvaginal ultrasound and magnetic resonance are today the two imaging techniques that can accurately identify the majority of the phenotypes of endometriosis. This review focuses not only on these most common imaging modalities but also on some additional radiological techniques that were proposed for rectosigmoid colon endometriosis, such as double-contrast barium enema, rectal endoscopic ultrasonography, multidetector computed tomography enema, computed tomography colonography and positron emission tomography-computed tomography with 16α-[18F]fluoro-17β-estradiol.
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Gerges B, Li W, Leonardi M, Mol BW, Condous G. Meta-analysis and systematic review to determine the optimal imaging modality for the detection of uterosacral ligaments/torus uterinus, rectovaginal septum and vaginal deep endometriosis. Hum Reprod Open 2021; 2021:hoab041. [PMID: 34869918 PMCID: PMC8634567 DOI: 10.1093/hropen/hoab041] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 10/20/2021] [Indexed: 01/01/2023] Open
Abstract
STUDY QUESTION Is there an ideal imaging modality for the detection of uterosacral ligaments/torus uterinus (USL), rectovaginal septum (RVS) and vaginal deep endometriosis (DE) in women with a clinical history of endometriosis? SUMMARY ANSWER The sensitivity for the detection of USL, RVS and vaginal DE using MRI seems to be better than transvaginal ultrasonography (TVS), whilst the specificity of both were excellent. WHAT IS KNOWN ALREADY The surgical management of women with DE can be complex and requires advanced laparoscopic skills with maximal cytoreduction being vital at the first procedure to provide the greatest symptomatic benefit. Owing to a correlation of TVS findings with surgical findings, preoperative imaging has been used to adequately consent women and plan the appropriate surgery. However, until publication of the consensus statement by the International Deep Endometriosis Analysis Group in 2016, there were significant variations within the terms and definitions used to describe DE in the pelvis. STUDY DESIGN SIZE DURATION A systematic review and meta-analysis was conducted using Embase, Google Scholar, Medline, PubMed and Scopus to identify studies published from inception to May 2020, of which only those from 2010 were included owing to the increased proficiency of the sonographers and advancements in technology. PARTICIPANTS/MATERIALS SETTING METHODS All prospective studies that preoperatively assessed any imaging modality for the detection of DE in the USL, RVS and vagina and correlated with the reference standard of surgical data were considered eligible. Study eligibility was restricted to those including a minimum of 10 unaffected and 10 affected participants. MAIN RESULTS AND THE ROLE OF CHANCE There were 1977 references identified from which 10 studies (n = 1188) were included in the final analysis. For the detection of USL DE, the overall pooled sensitivity and specificity for all TVS techniques were 60% (95% CI 32-82%) and 95% (95% CI 90-98%), respectively, and for all MRI techniques were 81% (95% CI 66-90%) and 83% (95% CI 62-94%), respectively. For the detection of RVS DE, the overall pooled sensitivity and specificity for all TVS techniques were 57% (95% CI 30-80%) and 100% (95% CI 92-100%), respectively. For the detection of vaginal DE, the overall pooled sensitivity and specificity for all TVS techniques were 52% (95% CI 29-74%) and 98% (95% CI 95-99%), respectively, and for all MRI techniques were 64% (95% CI 40-83%) and 98% (96% CI 93-99%). Pooled analyses were not possible for other imaging modalities. LIMITATIONS REASONS FOR CAUTION There was a low quality of evidence given the high risk of bias and heterogeneity in the included studies. There are also potential biases secondary to the risk of misdiagnosis at surgery owing to a lack of either histopathological findings or expertise, coupled with the surgeons not being blinded. Furthermore, the varying surgical experience and the lack of clarity regarding complete surgical clearance, thereby also contributing to the lack of histopathology, could also explain the wide range of pre-test probability of disease. WIDER IMPLICATIONS OF THE FINDINGS MRI outperformed TVS for the per-operative diagnosis of USL, RVS and vaginal DE with higher sensitivities, although the specificities for both were excellent. There were improved results with other imaging modalities, such as rectal endoscopy-sonography, as well as the addition of bowel preparation or ultrasound gel to either TVS or MRI, although these are based on individual studies. STUDY FUNDING/COMPETING INTERESTS No funding was received for this study. M.L. reports personal fees from GE Healthcare, grants from the Australian Women's and Children's Foundation, outside the submitted work. B.W.M. reports grants from NHMRC, outside the submitted work. G.C. reports personal fees from GE Healthcare, outside the submitted work; and is on the Endometriosis Advisory Board for Roche Diagnostics. REGISTRATION NUMBER Prospective registration with PROSPERO (CRD42017059872) was obtained.
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Affiliation(s)
- B Gerges
- Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Sydney Medical School Nepean, University of Sydney, Nepean Hospital, Kingswood, NSW, Australia.,Sydney West Advanced Pelvic Surgery (SWAPS), Blacktown Hospital, Blacktown, NSW, Australia
| | - W Li
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - M Leonardi
- Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Sydney Medical School Nepean, University of Sydney, Nepean Hospital, Kingswood, NSW, Australia.,Department of Obstetrics and Gynecology, McMaster University, Hamilton, Canada
| | - B W Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia.,Aberdeen Centre for Women's Health Research, University of Aberdeen, Aberdeen, UK
| | - G Condous
- Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Sydney Medical School Nepean, University of Sydney, Nepean Hospital, Kingswood, NSW, Australia
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Gerges B, Li W, Leonardi M, Mol BW, Condous G. Optimal imaging modality for detection of rectosigmoid deep endometriosis: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:190-200. [PMID: 33038269 DOI: 10.1002/uog.23148] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 09/22/2020] [Accepted: 09/28/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES To review the accuracy of different imaging modalities for the detection of rectosigmoid deep endometriosis (DE) in women with clinical suspicion of endometriosis, and to determine the optimal modality. METHODS A search was conducted using PubMed, MEDLINE, Scopus, EMBASE and Google Scholar to identify studies using imaging to evaluate women with suspected DE, published from inception to May 2020. Studies were considered eligible if they were prospective and used any imaging modality to assess preoperatively for the presence of DE in the rectum/rectosigmoid, which was then correlated with the surgical diagnosis as the reference standard. Eligibility was restricted to studies including at least 10 affected and 10 unaffected women. The QUADAS-2 tool was used to assess the quality of the included studies. Mixed-effects diagnostic meta-analysis was used to determine the overall pooled sensitivity and specificity of each imaging modality for rectal/rectosigmoid DE, which were used to calculate the likelihood ratio of a positive (LR+) and negative (LR-) test and diagnostic odds ratio (DOR). RESULTS Of the 1979 records identified, 30 studies (3374 women) were included in the analysis. The overall pooled sensitivity and specificity, LR+, LR- and DOR for the detection of rectal/rectosigmoid DE using transvaginal sonography (TVS) were, respectively, 89% (95% CI, 83-92%), 97% (95% CI, 95-98%), 30.8 (95% CI, 17.6-54.1), 0.12 (95% CI, 0.08-0.17) and 264 (95% CI, 113-614). For magnetic resonance imaging (MRI), the respective values were 86% (95% CI, 79-91%), 96% (95% CI, 94-97%), 21.0 (95% CI, 13.4-33.1), 0.15 (95% CI, 0.09-0.23) and 144 (95% CI, 70-297). For computed tomography, the respective values were 93% (95% CI, 84-97%), 95% (95% CI, 81-99%), 20.3 (95% CI, 4.3-94.9), 0.07 (95% CI, 0.03-0.19) and 280 (95% CI, 28-2826). For rectal endoscopic sonography (RES), the respective values were 92% (95% CI, 87-95%), 98% (95% CI, 96-99%), 37.1 (95% CI, 21.1-65.4), 0.08 (95% CI, 0.05-0.14) and 455 (95% CI, 196-1054). There was significant heterogeneity and the studies were considered methodologically poor according to the QUADAS-2 tool. CONCLUSIONS The sensitivity of TVS for the detection of rectal/rectosigmoid DE seems to be slightly better than that of MRI, although RES was superior to both. The specificity of both TVS and MRI was excellent. As TVS is simpler, faster and more readily available than the other methods, we believe that it should be the first-line diagnostic tool for women with suspected DE. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- B Gerges
- Sydney Medical School Nepean, University of Sydney Nepean Hospital, Kingswood, NSW, Australia
- Sydney West Advanced Pelvic Surgery (SWAPS), Blacktown Hospital, Blacktown, NSW, Australia
| | - W Li
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - M Leonardi
- Sydney Medical School Nepean, University of Sydney Nepean Hospital, Kingswood, NSW, Australia
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Canada
| | - B W Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
- Aberdeen Centre for Women's Health Research, University of Aberdeen, Aberdeen, UK
| | - G Condous
- Sydney Medical School Nepean, University of Sydney Nepean Hospital, Kingswood, NSW, Australia
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Marcello C, Roberto C, Adele ME, Katarzyna SA, Paola DM, Matteo C, Giacomo R, Francesco B, Lorenzo R, Daniela S. "The Sword in the Stone": radical excision of deep infiltrating endometriosis with bowel shaving-a single-centre experience on 703 consecutive patients. Surg Endosc 2021; 36:3418-3431. [PMID: 34312725 DOI: 10.1007/s00464-021-08663-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 07/18/2021] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Ceccaroni Marcello
- 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, 37024, Negrar, Verona, Italy.
| | - Clarizia Roberto
- 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, 37024, Negrar, Verona, Italy
| | - Mussi Erica Adele
- Department of Obstetrics and Gynecology, "Maggiore della Carità" Hospital, "Università del Piemonte Orientale", Corso Mazzini 18, 28100, Novara, Italy
| | - Stepniewska Anna Katarzyna
- 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, 37024, Negrar, Verona, Italy
| | - De Mitri Paola
- 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, 37024, Negrar, Verona, Italy
| | - Ceccarello Matteo
- 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, 37024, Negrar, Verona, Italy
| | - Ruffo Giacomo
- Department of General Surgery, IRCCS "Sacro Cuore-Don Calabria" Hospital, Via Don A. Sempreboni 5, 37024, Negrar, Verona, Italy
| | - Bruni Francesco
- 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, 37024, Negrar, Verona, Italy
| | - Rettore Lorenzo
- Department of General Surgery, IRCCS "Sacro Cuore-Don Calabria" Hospital, Via Don A. Sempreboni 5, 37024, Negrar, Verona, Italy
| | - Surico Daniela
- Department of Obstetrics and Gynecology, "Maggiore della Carità" Hospital, "Università del Piemonte Orientale", Corso Mazzini 18, 28100, Novara, Italy
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Gerges B, Li W, Leonardi M, Mol BW, Condous G. Meta-analysis and systematic review to determine the optimal imaging modality for the detection of bladder deep endometriosis. Eur J Obstet Gynecol Reprod Biol 2021; 261:124-133. [PMID: 33932683 DOI: 10.1016/j.ejogrb.2021.04.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 03/18/2021] [Accepted: 04/19/2021] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To review the diagnostic accuracy and determine the optimum imaging modality for the detection of bladder deep endometriosis (DE) in women with a clinical suspicion of endometriosis. METHODS A systematic review of studies published from inception to May 2020 using Embase, Google Scholar, Medline, PubMed and Scopus. Prospective studies, which pre-operatively assessed any imaging modality for the presence of bladder DE, and correlated with the gold standard surgical data as a reference were included. The QUADAS-2 tool was used to assess quality. This review was prospectively registered with PROSPERO (CRD42017059872). RESULTS Of the 1,977 references identified, 8 studies (n = 1,052) were included in the analysis. The overall pooled sensitivity and specificity, from which the likelihood ratio of a positive test (LR+), likelihood ratio of a negative test (LR-) and diagnostic odds ratio (DOR) were calculated, for all transvaginal ultrasonography (TVS) techniques were 55 % (95 % CI 28-79%), 99 % (95 % CI 98-100%), 54.5 (95 % CI 18.9-157.4), 0.46 (95 % CI 0.25 - 0.85) and 119 (95 % CI 24-577), and for only two-dimensional (2D) TVS 53 % (95 % CI 23-82%), 99 % (96 % CI 97-100%), 48.8 (95 % CI 13.1-181.4), 0.47 (95 % CI 0.23 - 0.98), and 104 (95 % CI 15-711), respectively. Meta-analyses of the other modalities, namely magnetic resonance imaging (MRI) and transrectal endoscopic sonography (RES), were not possible due to the limited number of studies. There was significant heterogeneity and the studies were considered poor methodologically according to the QUADAS-2 tool. CONCLUSIONS Whilst the sensitivity of TVS was limited, the specificity was excellent. Given that there is a paucity of literature for other imaging modalities, until more studies are performed, TVS should be considered as the first-line tool given it is the only modality with sufficient evidence.
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Affiliation(s)
- B Gerges
- Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Sydney Medical School Nepean, University of Sydney, Nepean Hospital, Kingswood, NSW, 2750, Australia; Sydney West Advanced Pelvic Surgery (SWAPS), Blacktown Hospital, Blacktown, NSW, 2148, Australia.
| | - W Li
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, 3168, Australia
| | - M Leonardi
- Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Sydney Medical School Nepean, University of Sydney, Nepean Hospital, Kingswood, NSW, 2750, Australia; Department of Obstetrics and Gynecology, McMaster University, Hamilton, L8S 4L8, Canada
| | - B W Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, 3168, Australia; Aberdeen Centre for Women's Health Research, University of Aberdeen, Aberdeen, UK
| | - G Condous
- Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Sydney Medical School Nepean, University of Sydney, Nepean Hospital, Kingswood, NSW, 2750, Australia
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Ferrero S, Barra F, Scala C, Condous G. Ultrasonography for bowel endometriosis. Best Pract Res Clin Obstet Gynaecol 2021; 71:38-50. [DOI: 10.1016/j.bpobgyn.2020.05.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/08/2020] [Indexed: 01/07/2023]
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Takeda T, Hayashi S, Kobayashi Y, Tsuji K, Nagai S, Tominaga E, Suzuki T, Okuda S, Banno K, Aoki D. Evaluation of preoperative prediction of intestinal invasion in patients with ovarian cancer. Int J Gynaecol Obstet 2020; 153:398-404. [PMID: 33222157 PMCID: PMC8246869 DOI: 10.1002/ijgo.13492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 09/22/2020] [Accepted: 11/19/2020] [Indexed: 12/09/2022]
Abstract
Objective To optimize prediction for intestinal invasion of epithelial ovarian cancer. It is important to achieve debulking surgery to improve prognosis in ovarian cancer; intestinal resection is adopted if the cancer is invaded and resectable, but the preoperative evaluation method of intestinal invasion is still controversial. Methods Patients (n = 174) who underwent primary debulking surgery for epithelial ovarian cancer were recruited for retrospective study; 28 and 146 patients were classified into the invasion and non‐invasion groups, whether they needed intestinal resection or not. We collected clinical data including evaluation of computed tomography (CT), magnetic resonance imaging (MRI), and barium contrast radiography, and analyzed their accuracy. Results The sensitivity and specificity for intestinal invasion were 33.3% and 98.6%, 42.9% and 98.6%, and 66.7% and 93.9% in CT, MRI, and barium contrast radiography, respectively. CT and MRI combined showed a sensitivity of 58.3% and specificity of 96.9%; all three methods combined was the most sensitive combination, showing a sensitivity of 79.2% and specificity of 90.8%. Conclusion Combination of CT, MRI, and barium contrast radiography predicts intestinal invasion with the highest sensitivity. These three modalities, however, could not predict all intestinal invasion. Patients should be informed of the possibility of unexpected extensive resection. Combination of CT, MRI, and barium contrast radiography give the best prediction of intestinal invasion in ovarian cancer.
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Affiliation(s)
- Takashi Takeda
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo, Japan
| | - Shigenori Hayashi
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo, Japan
| | - Yusuke Kobayashi
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo, Japan
| | - Kosuke Tsuji
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo, Japan
| | - Shimpei Nagai
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo, Japan
| | - Eiichiro Tominaga
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo, Japan
| | - Tatsuya Suzuki
- Department of Radiology, Keio University School of Medicine, Tokyo, Japan
| | - Shigeo Okuda
- Department of Radiology, Keio University School of Medicine, Tokyo, Japan
| | - Kouji Banno
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo, Japan
| | - Daisuke Aoki
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo, Japan
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Zhang X, He T, Shen W. Comparison of physical examination, ultrasound techniques and magnetic resonance imaging for the diagnosis of deep infiltrating endometriosis: A systematic review and meta-analysis of diagnostic accuracy studies. Exp Ther Med 2020; 20:3208-3220. [PMID: 32855690 PMCID: PMC7444323 DOI: 10.3892/etm.2020.9043] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 05/15/2020] [Indexed: 01/21/2023] Open
Abstract
Visual inspection via laparoscopy is considered the gold standard for the diagnosis of deep infiltrating endometriosis. Laparoscopy is an invasive procedure; therefore, it would be beneficial to patients if accurate non-invasive modalities were available for the diagnosis of deep infiltrating endometriosis. The purpose of the current review and meta-analysis was to assess the diagnostic accuracy of clinical examination, transvaginal ultrasound (TVUS), transrectal ultrasound (TRUS) and MRI as alternative methods for diagnosis of deep infiltrating endometriosis. A systematic search of the Medline, Scopus, Embase and Cochrane library databases, between their inception and September 2019, was performed. The quality of trials was assessed using the quality assessment of diagnostic accuracy studies-2 tool. Meta-analyses were conducted to obtain the pooled sensitivity, specificity, positive and negative likelihood ratios and diagnostic odds ratio for each of the three imaging modalities and clinical examination. A total of 30 studies with 4,565 participants were included in the review. Physical examination had a pooled sensitivity of 71% and a specificity of 69%, with an average diagnostic accuracy [area under the curve (AUC) =0.76]. TVUS had a pooled sensitivity of 76% and a specificity of 94%, with higher diagnostic accuracy than physical examination (AUC =0.92). TRUS had a pooled sensitivity of 91% and a specificity of 80% with an AUC of 0.93. MRI had a pooled sensitivity of 82% and a specificity of 87% with higher diagnostic accuracy than physical examination (AUC =0.91). All the imaging modalities had good clinical utility, as indicated by the Fagan plot. The present analysis demonstrates that the imaging modalities TVUS, TRUS and MRI may be highly useful alternatives to laparoscopy for diagnosis of deep infiltrating endometriosis and that these techniques have a high sensitivity and specificity.
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Affiliation(s)
- Xiao Zhang
- Department of Ultrasound, Hanchuan People's Hospital, Hanchuan, Hubei 431600, P.R. China
| | - Tao He
- Department of Ultrasound, Hanchuan People's Hospital, Hanchuan, Hubei 431600, P.R. China
| | - Wen Shen
- Department of Ultrasound, Hanchuan People's Hospital, Hanchuan, Hubei 431600, P.R. China
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Biscaldi E, Barra F, Leone Roberti Maggiore U, Ferrero S. Other imaging techniques: Double-contrast barium enema, endoscopic ultrasonography, multidetector CT enema, and computed tomography colonoscopy. Best Pract Res Clin Obstet Gynaecol 2020; 71:64-77. [PMID: 32698994 DOI: 10.1016/j.bpobgyn.2020.05.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/08/2020] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Ennio Biscaldi
- Department of Radiology, Galliera Hospital, via Mura delle Cappuccine 14, Genova, 16128, Italy
| | - Fabio Barra
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Largo R. Benzi 10, 16132, Genoa, Italy; Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Italy.
| | | | - Simone Ferrero
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Largo R. Benzi 10, 16132, Genoa, Italy; Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Italy
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Ferrero S, Morotti M, Menada MV, Venturini PL, Biscaldi E, Camerini G, Remorgida V. Diagnosis of Bowel Endometriosis: A Review. ACTA ACUST UNITED AC 2018. [DOI: 10.1177/228402651000200204] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Since the presence of intestinal endometriosis cannot be reliably established by physical examination or the evaluation of intestinal symptoms, imaging techniques are required for the diagnosis of bowel endometriosis. This review evaluates the techniques available for the diagnosis of intestinal endometriosis based on a search of the Medline database and Embase up to February 2010. Several studies have proved that radiological techniques (double contrast barium enema, magnetic resonance imaging, and multidetector computerized tomography enteroclysis) are able to accurately diagnose intestinal endometriosis. Magnetic resonance imaging has the advantage of determining the presence of deep endometriotic lesions in other pelvic locations. Rectal endoscopic ultrasonography can precisely determine the presence of bowel endometriosis but its use is limited by the availability of the equipment required to carry out the exam. Over the last five years, several studies have proved that transvaginal ultrasonography is accurate in the diagnosis of rectosigmoid endometriosis; in addition, this exam is well tolerated by patients and is inexpensive. Therefore, transvaginal ultrasonography should be the first-line investigation in patients with suspected intestinal endometriosis.
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Affiliation(s)
- Simone Ferrero
- Department of Obstetrics and Gynecology, San Martino Hospital and University of Genoa, Genoa - Italy
| | - Matteo Morotti
- Department of Obstetrics and Gynecology, San Martino Hospital and University of Genoa, Genoa - Italy
| | - Mario Valenzano Menada
- Department of Obstetrics and Gynecology, San Martino Hospital and University of Genoa, Genoa - Italy
| | - Pier Luigi Venturini
- Department of Obstetrics and Gynecology, San Martino Hospital and University of Genoa, Genoa - Italy
| | - Ennio Biscaldi
- Department of Radiology, Duchesse of Galliera Hospital, Genoa - Italy
| | - Giovanni Camerini
- Department of Surgery, San Martino Hospital and University of Genoa, Genoa - Italy
| | - Valentino Remorgida
- Department of Obstetrics and Gynecology, San Martino Hospital and University of Genoa, Genoa - Italy
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Allan Z. A case of endometriosis causing acute large bowel obstruction. Int J Surg Case Rep 2017; 42:247-249. [PMID: 29294460 PMCID: PMC5752211 DOI: 10.1016/j.ijscr.2017.12.031] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 12/16/2017] [Indexed: 12/31/2022] Open
Abstract
Endometriosis causing acute large bowel obstruction is extremely rare. Diagnostic challenges still remain in recognising intestinal endometriosis with or without intestinal obstruction. Definitive surgical management is needed for endometriosis causing acute intestinal obstruction.
Introduction Endometriosis is a gynaecological condition which produce symptoms such as pelvic pain, abnormal menstruation and infertility. Intestinal endometriosis can occur however endometriosis causing acute large bowel obstruction is extremely rare. Presentation of case We present a 37-year-old lady with acute large bowel obstruction caused by endometriosis. Despite initial endoscopic decompression being unsuccessful due to severe mucosal stenosis, she underwent emergency laparoscopic wedge resection and decompression successfully. Discussion Diagnosing intestinal endometriosis is difficult. While different modalities of investigation help, definitive diagnosis is achieved via laparoscopy. Treatment of obstruction is decompression followed by surgical resection. Conclusion Diagnosing intestinal endometriosis with or without obstruction is challenging. Correct diagnosis is needed for definitive management.
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Affiliation(s)
- Zexi Allan
- Department of General Surgery, Box Hill Hospital, 8 Arnold Street, Victoria, 3128, Australia.
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Bazot M, Daraï E. Diagnosis of deep endometriosis: clinical examination, ultrasonography, magnetic resonance imaging, and other techniques. Fertil Steril 2017; 108:886-894. [DOI: 10.1016/j.fertnstert.2017.10.026] [Citation(s) in RCA: 113] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 10/19/2017] [Accepted: 10/19/2017] [Indexed: 12/16/2022]
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Bowel Preparation Improves the Accuracy of Transvaginal Ultrasound in the Diagnosis of Rectosigmoid Deep Infiltrating Endometriosis: A Prospective Study. J Minim Invasive Gynecol 2017; 24:1145-1151. [DOI: 10.1016/j.jmig.2017.06.024] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 05/22/2017] [Accepted: 06/27/2017] [Indexed: 01/07/2023]
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Nisenblat V, Bossuyt PMM, Farquhar C, Johnson N, Hull ML. Imaging modalities for the non-invasive diagnosis of endometriosis. Cochrane Database Syst Rev 2016; 2:CD009591. [PMID: 26919512 PMCID: PMC7100540 DOI: 10.1002/14651858.cd009591.pub2] [Citation(s) in RCA: 111] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND About 10% of women of reproductive age suffer from endometriosis. Endometriosis is a costly chronic disease that causes pelvic pain and subfertility. Laparoscopy, the gold standard diagnostic test for endometriosis, is expensive and carries surgical risks. Currently, no non-invasive tests that can be used to accurately diagnose endometriosis are available in clinical practice. This is the first review of diagnostic test accuracy of imaging tests for endometriosis that uses Cochrane methods to provide an update on the rapidly expanding literature in this field. OBJECTIVES • To provide estimates of the diagnostic accuracy of imaging modalities for the diagnosis of pelvic endometriosis, ovarian endometriosis and deeply infiltrating endometriosis (DIE) versus surgical diagnosis as a reference standard.• To describe performance of imaging tests for mapping of deep endometriotic lesions in the pelvis at specific anatomical sites.Imaging tests were evaluated as replacement tests for diagnostic surgery and as triage tests that would assist decision making regarding diagnostic surgery for endometriosis. SEARCH METHODS We searched the following databases to 20 April 2015: MEDLINE, CENTRAL, EMBASE, CINAHL, PsycINFO, Web of Science, LILACS, OAIster, TRIP, ClinicalTrials.gov, MEDION, DARE, and PubMed. Searches were not restricted to a particular study design or language nor to specific publication dates. The search strategy incorporated words in the title, abstracts, text words across the record and medical subject headings (MeSH). SELECTION CRITERIA We considered published peer-reviewed cross-sectional studies and randomised controlled trials of any size that included prospectively recruited women of reproductive age suspected of having one or more of the following target conditions: endometrioma, pelvic endometriosis, DIE or endometriotic lesions at specific intrapelvic anatomical locations. We included studies that compared the diagnostic test accuracy of one or more imaging modalities versus findings of surgical visualisation of endometriotic lesions. DATA COLLECTION AND ANALYSIS Two review authors independently collected and performed a quality assessment of data from each study. For each imaging test, data were classified as positive or negative for surgical detection of endometriosis, and sensitivity and specificity estimates were calculated. If two or more tests were evaluated in the same cohort, each was considered as a separate data set. We used the bivariate model to obtain pooled estimates of sensitivity and specificity when sufficient data sets were available. Predetermined criteria for a clinically useful imaging test to replace diagnostic surgery included sensitivity ≥ 94% and specificity ≥ 79%. Criteria for triage tests were set at sensitivity ≥ 95% and specificity ≥ 50%, ruling out the diagnosis with a negative result (SnNout test - if sensitivity is high, a negative test rules out pathology) or at sensitivity ≥ 50% with specificity ≥ 95%, ruling in the diagnosis with a positive result (SpPin test - if specificity is high, a positive test rules in pathology). MAIN RESULTS We included 49 studies involving 4807 women: 13 studies evaluated pelvic endometriosis, 10 endometriomas and 15 DIE, and 33 studies addressed endometriosis at specific anatomical sites. Most studies were of poor methodological quality. The most studied modalities were transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI), with outcome measures commonly demonstrating diversity in diagnostic estimates; however, sources of heterogeneity could not be reliably determined. No imaging test met the criteria for a replacement or triage test for detecting pelvic endometriosis, albeit TVUS approached the criteria for a SpPin triage test. For endometrioma, TVUS (eight studies, 765 participants; sensitivity 0.93 (95% confidence interval (CI) 0.87, 0.99), specificity 0.96 (95% CI 0.92, 0.99)) qualified as a SpPin triage test and approached the criteria for a replacement and SnNout triage test, whereas MRI (three studies, 179 participants; sensitivity 0.95 (95% CI 0.90, 1.00), specificity 0.91 (95% CI 0.86, 0.97)) met the criteria for a replacement and SnNout triage test and approached the criteria for a SpPin test. For DIE, TVUS (nine studies, 12 data sets, 934 participants; sensitivity 0.79 (95% CI 0.69, 0.89) and specificity 0.94 (95% CI 0.88, 1.00)) approached the criteria for a SpPin triage test, and MRI (six studies, seven data sets, 266 participants; sensitivity 0.94 (95% CI 0.90, 0.97), specificity 0.77 (95% CI 0.44, 1.00)) approached the criteria for a replacement and SnNout triage test. Other imaging tests assessed in small individual studies could not be statistically evaluated.TVUS met the criteria for a SpPin triage test in mapping DIE to uterosacral ligaments, rectovaginal septum, vaginal wall, pouch of Douglas (POD) and rectosigmoid. MRI met the criteria for a SpPin triage test for POD and vaginal and rectosigmoid endometriosis. Transrectal ultrasonography (TRUS) might qualify as a SpPin triage test for rectosigmoid involvement but could not be adequately assessed for other anatomical sites because heterogeneous data were scant. Multi-detector computerised tomography enema (MDCT-e) displayed the highest diagnostic performance for rectosigmoid and other bowel endometriosis and met the criteria for both SpPin and SnNout triage tests, but studies were too few to provide meaningful results.Diagnostic accuracies were higher for TVUS with bowel preparation (TVUS-BP) and rectal water contrast (RWC-TVS) and for 3.0TMRI than for conventional methods, although the paucity of studies precluded statistical evaluation. AUTHORS' CONCLUSIONS None of the evaluated imaging modalities were able to detect overall pelvic endometriosis with enough accuracy that they would be suggested to replace surgery. Specifically for endometrioma, TVUS qualified as a SpPin triage test. MRI displayed sufficient accuracy to suggest utility as a replacement test, but the data were too scant to permit meaningful conclusions. TVUS could be used clinically to identify additional anatomical sites of DIE compared with MRI, thus facilitating preoperative planning. Rectosigmoid endometriosis was the only site that could be accurately mapped by using TVUS, TRUS, MRI or MDCT-e. Studies evaluating recent advances in imaging modalities such as TVUS-BP, RWC-TVS, 3.0TMRI and MDCT-e were observed to have high diagnostic accuracies but were too few to allow prudent evaluation of their diagnostic role. In view of the low quality of most of the included studies, the findings of this review should be interpreted with caution. Future well-designed diagnostic studies undertaken to compare imaging tests for diagnostic test accuracy and costs are recommended.
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Affiliation(s)
- Vicki Nisenblat
- The University of AdelaideDiscipline of Obstetrics and Gynaecology, School of Medicine, Robinson Research InstituteLevel 6, Medical School North,Frome RdAdelaideSAAustralia5005
| | - Patrick MM Bossuyt
- Academic Medical Center, University of AmsterdamDepartment of Clinical Epidemiology, Biostatistics and BioinformaticsRoom J1b‐217, PO Box 22700AmsterdamNetherlands1100 DE
| | - Cindy Farquhar
- University of AucklandDepartment of Obstetrics and GynaecologyFMHS Park RoadGraftonAucklandNew Zealand1003
| | - Neil Johnson
- The University of AdelaideDiscipline of Obstetrics and Gynaecology, School of Medicine, Robinson Research InstituteLevel 6, Medical School North,Frome RdAdelaideSAAustralia5005
| | - M Louise Hull
- The University of AdelaideDiscipline of Obstetrics and Gynaecology, School of Medicine, Robinson Research InstituteLevel 6, Medical School North,Frome RdAdelaideSAAustralia5005
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Noventa M, Saccardi C, Litta P, Vitagliano A, D'Antona D, Abdulrahim B, Duncan A, Alexander-Sefre F, Aldrich CJ, Quaranta M, Gizzo S. Ultrasound techniques in the diagnosis of deep pelvic endometriosis: algorithm based on a systematic review and meta-analysis. Fertil Steril 2015; 104:366-83.e2. [DOI: 10.1016/j.fertnstert.2015.05.002] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 05/03/2015] [Accepted: 05/05/2015] [Indexed: 01/07/2023]
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Colaiácovo R, Assef MS, Ganc RL, Carbonari APC, Silva FAOB, Bin FC, Rossini LGB. Rectal cancer staging: Correlation between the evaluation with radial echoendoscope and rigid linear probe. Endosc Ultrasound 2014; 3:161-6. [PMID: 25184122 PMCID: PMC4145476 DOI: 10.4103/2303-9027.138786] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 01/29/2014] [Indexed: 01/18/2023] Open
Abstract
Background and Objectives: The National Cancer Institute estimated 40,340 new cases of rectal cancer in the United States in 2013. The correct staging of rectal cancer is fundamental for appropriate treatment of this disease. Transrectal ultrasound is considered one of the best methods for locoregional staging of rectal tumors, both radial echoendoscope and rigid linear probes are used to perform these procedures. The objective of this study is to evaluate the correlation between radial echoendoscopy and rigid linear endosonography for staging rectal cancer. Patients and Methods: A prospective analysis of 48 patients who underwent both, radial echoendoscopy and rigid linear endosonography, between April 2009 and May 2011, was done. Patients were staged according to the degree of tumor invasion (T) and lymph node involvement (N), as classified by the American Joint Committee on Cancer. Anatomopathological staging of surgical specimen was the gold standard for discordant evaluations. The analysis of concordance was made using Kappa index. Results: The general Kappa index for T staging was 0.827, with general P < 0.001 (confidence interval [CI]: 95% 0.627-1). The general Kappa index for N staging was 0.423, with general P < 0.001 (CI: 95% 0.214-0.632). Conclusion: The agreement between methods for T staging was almost perfect, with a worse outcome for T2, but still with substantial agreement. The findings may indicate equivalence in the diagnostic value of both flexible and rigid devices. For lymph node staging, there was moderate agreement between the methods.
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Affiliation(s)
- Rogério Colaiácovo
- Department of Endoscopy and French-Brazilian Centre of Endoscopic Ultrasound (CFBEUS), Santa Casa de São Paulo Hospital, São Paulo, Brazil
| | - Maurício Saab Assef
- Department of Endoscopy and French-Brazilian Centre of Endoscopic Ultrasound (CFBEUS), Santa Casa de São Paulo Hospital, São Paulo, Brazil
| | - Ricardo Leite Ganc
- Department of Endoscopy and French-Brazilian Centre of Endoscopic Ultrasound (CFBEUS), Santa Casa de São Paulo Hospital, São Paulo, Brazil
| | - Augusto Pincke Cruz Carbonari
- Department of Endoscopy and French-Brazilian Centre of Endoscopic Ultrasound (CFBEUS), Santa Casa de São Paulo Hospital, São Paulo, Brazil
| | - Flávio Amaro Oliveira Bitar Silva
- Department of Endoscopy and French-Brazilian Centre of Endoscopic Ultrasound (CFBEUS), Santa Casa de São Paulo Hospital, São Paulo, Brazil
| | - Fang Chia Bin
- Department of Endoscopy and French-Brazilian Centre of Endoscopic Ultrasound (CFBEUS), Santa Casa de São Paulo Hospital, São Paulo, Brazil
| | - Lúcio Giovanni Baptista Rossini
- Department of Endoscopy and French-Brazilian Centre of Endoscopic Ultrasound (CFBEUS), Santa Casa de São Paulo Hospital, São Paulo, Brazil
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Multidisciplinary laparoscopic treatment for bowel endometriosis. Best Pract Res Clin Gastroenterol 2014; 28:53-67. [PMID: 24485255 DOI: 10.1016/j.bpg.2013.11.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Revised: 10/02/2013] [Accepted: 11/23/2013] [Indexed: 01/31/2023]
Abstract
Endometriosis is a handicapping disease affecting young females in the reproductive period. It mainly occurs in the pelvis and affects the bowel in 3-37%. Endometriosis can cause menstrual and non-menstrual pelvic pain and infertility. Colorectal involvement results in alterations of bowel habit such as constipation, diarrhoea, tenesmus, and rarely rectal bleeding. A precise diagnosis about the presence, location and extent is necessary. Based on clinical examination, the diagnosis of bowel endometriosis can be made by transvaginal ultrasound, barium enema examination and magnetic resonance imaging. Multidisciplinary laparoscopic treatment has become the standard of care and depending on size of the lesion and site of involvement full-thickness disc excision or bowel resection is performed by an experienced colorectal surgeon. Anastomotic complications occur around 1%. Long-term outcome after bowel resection for severe endometriosis is good with a pregnancy rate of 50%.
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Impact of laparoscopic colorectal segment resection on quality of life in women with deep endometriosis: one year follow-up. Qual Life Res 2013; 23:639-43. [DOI: 10.1007/s11136-013-0481-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2013] [Indexed: 11/27/2022]
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Scardapane A, Lorusso F, Bettocchi S, Moschetta M, Fiume M, Vimercati A, Pepe ML, Angelelli G, Stabile Ianora AA. Deep pelvic endometriosis: accuracy of pelvic MRI completed by MR colonography. Radiol Med 2012; 118:323-38. [PMID: 22744354 DOI: 10.1007/s11547-012-0850-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2011] [Accepted: 09/07/2011] [Indexed: 01/07/2023]
Abstract
PURPOSE This study assessed the diagnostic accuracy of pelvic magnetic resonance (MR) imaging completed by MR colonography for the preoperative evaluation of deep pelvic endometriosis in patients undergoing laparoscopic surgery. MATERIALS AND METHODS A total of 143 patients (mean age 34.3 ± 5.1 years) with a clinical suspicion of deep pelvic endometriosis were assessed by pelvic MR and MR colonography. All patients underwent laparoscopic surgery 3-10 weeks after the MR examination. The presence, location, number and extent of endometriotic lesions were evaluated. Data obtained with MR were compared with surgical findings. MR sensitivity, specificity, positive (PPV) and negative (NPV) predictive values and diagnostic accuracy values were calculated for each site by considering the laparoscopic and histological findings as the reference standard. RESULTS Laparoscopy confirmed the presence of endometriosis in 119/143 patients (83%); in 76/119 (64%) deep pelvic endometriosis was diagnosed, whereas in the remaining 43/119 (36%), superficial peritoneal implants and endometriomas were found. In 32/119 (27%) patients, intestinal lesions were detected. MR had sensitivity, specificity, PPV, NPV and diagnostic accuracy values of 67-100%, 85-100%, 83-100%, 84-100% and 84-100%, respectively, in recognising lesions located in different pelvic sites. CONCLUSIONS MR imaging combined with colonography is a highly accurate tool for characterising deep endometriotic lesions in patients scheduled for laparoscopic surgery. In particular, MR colonography has very high accuracy in detecting colorectal involvement.
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Affiliation(s)
- A Scardapane
- Sezione di Diagnostica per Immagini, Di.M.I.M.P. - Centro interdipartimentale per lo studio dell'HHT, Azienda Universitario Ospedaliera Consorziale Policlinico, Università degli Studi di Bari, Bari, Italy.
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Li YP, Wang N, Zhang L, Zhu HM, Wang LS, Shi RY. Value of linear endoscopic ultrasonography in the diagnosis of rectal endometriosis. Shijie Huaren Xiaohua Zazhi 2012; 20:1252-1255. [DOI: 10.11569/wcjd.v20.i14.1252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess the value of linear endoscopic ultrasonography (EUS) in the diagnosis of rectal endometriosis (RE).
METHODS: Twenty patients with endometriosis were referred for linear EUS prior to the surgical intervention to evaluate the rectal involvement. RE was diagnosed by the presence of a hypoechoic nodule or mass with irregular margins in the rectal wall. Linear EUS findings were compared with the results of surgical exploration and histopathologic examination.
RESULTS: Linear EUS allowed to detect endometriotic lesions in the rectal wall in 12 cases, and the rectal wall was considered normal in 8 cases. In RE cases diagnosed by linear EUS, surgical exploration showed that pelvic ectopic endometrial lesions adhered closely to the rectal wall, and the histopathologic results confirmed infiltration of the rectal wall by endometriotic lesions. For the 8 patients with no linear EUS evidence of rectal infiltration, there was mild adhesion or no adhesion between pelvic ectopic endometrial lesions and the rectal wall, and histopathologic examination showed that the rectum was not involved by endometriotic lesions. The findings of linear EUS were coincident with those of surgical exploration and histopathologic examination.
CONCLUSION: Linear EUS is a reliable method for diagnosis of rectal endometriosis and can be used for accurate pre-surgical assessment of the rectal involvement in patients with endometriosis.
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Rossini LG, Ribeiro PA, Rodrigues FC, Filippi SS, Zago RDR, Schneider NC, Okawa L, Klug WA. Transrectal ultrasound - Techniques and outcomes in the management of intestinal endometriosis. Endosc Ultrasound 2012; 1:23-35. [PMID: 24949332 PMCID: PMC4062201 DOI: 10.7178/eus.01.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Revised: 03/16/2012] [Accepted: 03/26/2012] [Indexed: 01/30/2023] Open
Abstract
The widespread use of endoscopic ultrasound has facilitated the evaluation of subepithelial and surrounding lesions of the gastrointestinal tract. Deep pelvic endometriosis, with or without infiltration of the intestinal wall, is a frequent disease that can be observed in women in their fertile age. Patients of this disease may present nonspecific signs and symptoms or be completely asymptomatic. Laparoscopic surgical resection of endometriotic lesions is the treatment of choice in symptomatic patients. An accurate preoperative evaluation is indispensable for therapeutic decisions mainly in the suspicion of intestinal wall and/or urinary tract infiltration, and also in cases where we need to establish histological diagnosis or to rule out malignant disease. Diagnostic tools, including transrectal ultrasound, magnetic resonance image, transvaginal ultrasound, barium enema, and colonoscopy, play significant roles in determining the presence, depth, histology, and other relevant data about the extension of the disease. Diagnostic algorithm depends on the clinical presentation, the expertise of the medical team, and the technology available at each institution. This article reviews and discusses relevant clinical points in endometriosis, including techniques and outcomes of the study of the disease through transrectal ultrasound and fine-needle aspiration.
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Affiliation(s)
- Lucio G.B. Rossini
- Medical School of Science of Santa Casa de São Paulo (FCMSCSP) / French-Brazilian Centre of Endoscopic Ultrasonography (CFBEUS), Brazil
| | | | | | - Sheila S. Filippi
- Medical School of Science of Santa Casa de São Paulo (FCMSCSP) / French-Brazilian Centre of Endoscopic Ultrasonography (CFBEUS), Brazil
| | - Rodrigo de R. Zago
- Medical School of Science of Santa Casa de São Paulo (FCMSCSP) / French-Brazilian Centre of Endoscopic Ultrasonography (CFBEUS), Brazil
| | - Nutianne C. Schneider
- Medical School of Science of Santa Casa de São Paulo (FCMSCSP) / French-Brazilian Centre of Endoscopic Ultrasonography (CFBEUS), Brazil
| | - Luciano Okawa
- Medical School of Science of Santa Casa de São Paulo (FCMSCSP) / French-Brazilian Centre of Endoscopic Ultrasonography (CFBEUS), Brazil
| | - Wilmar A. Klug
- Medical School of Science of Santa Casa de São Paulo (FCMSCSP), Brazil
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KRUSE CHRISTINA, SEYER-HANSEN MIKKEL, FORMAN AXEL. Diagnosis and treatment of rectovaginal endometriosis: an overview. Acta Obstet Gynecol Scand 2012; 91:648-57. [DOI: 10.1111/j.1600-0412.2012.01367.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Symptomatic intestinal endometriosis requiring surgical resection: clinical presentation and preoperative diagnosis. Am J Gastroenterol 2011; 106:1325-32. [PMID: 21502995 DOI: 10.1038/ajg.2011.66] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Intestinal endometriosis (IE) can present with varied symptoms, making the diagnosis difficult. Modalities have been described to evaluate IE, but few can provide a confirmatory diagnosis. A preoperative diagnosis of IE may help guide management. We sought to describe the presentation, diagnostic evaluation, histology and operative management of 89 patients with tissue-confirmed symptomatic IE. METHODS The records of 89 patients from a single institution with histologically confirmed, symptomatic IE from 1 January 1994 to 30 September 2009 were reviewed. RESULTS Abdominal pain was the most common symptom in patients with IE; however, rectal bleeding was significantly associated with IE of the distal colon (P=0.02), while dysfunctional uterine bleeding was seen more in patients with proximal IE (P=0.01). Preoperative confirmation of IE was uncommon; colonoscopy with biopsy confirmed the diagnosis in 29.6% of patients tested and only 15% of patients with IE had histologic lesions involving mucosa. In the five patients who underwent endoscopic ultrasound (EUS), the diagnosis of IE was established in all cases (n=4) where histology or cytology was obtained. Malignancy was considered nearly as frequently as IE preoperatively, and 90.4% of patients underwent laparotomy as the initial surgical approach. CONCLUSIONS IE can present with a variety of manifestations, which may provide clues to location of bowel affected. Patients with known pelvic endometriosis and rectal bleeding are more likely to have distal bowel affected; EUS with tissue sampling may play a role if routine endoscopy fails to reveal the diagnosis. Making a diagnosis of IE preoperatively may allow for less invasive surgical approaches and better patient outcomes.
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Abstract
Endometriosis is defined as the presence of endometrial glands and stroma outside the uterine cavity. Although the exact pathophysiology is unclear, endometriosis is a well-known cause of pelvic pain and infertility in reproductive-aged women. Endometriosis can have extrapelvic manifestations relevant for colorectal surgeons to appreciate, such as cyclic constipation, diarrhea, hematochezia, and dyschezia. The treatment of endometriosis involves a combination of medical and surgical interventions where close collaboration between the gynecologist and colorectal surgeon can help achieve prolonged periods of symptom remission.
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Affiliation(s)
- Katrina Slaughter
- Department of Obstetrics and Gynecology, Ochsner Clinic Foundation, New Orleans, Louisiana
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Vassilieff M, Suaud O, Collet-Savoye C, Da Costa C, Marouteau-Pasquier N, Belhiba H, Tuech JJ, Marpeau L, Roman H. Coloscanner à l’air avec coloscopie virtuelle : arguments dans le choix du traitement chirurgical des endométrioses colorectales. ACTA ACUST UNITED AC 2011; 39:339-45. [DOI: 10.1016/j.gyobfe.2011.04.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2010] [Indexed: 01/07/2023]
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Ferrero S, Camerini G, Leone Roberti Maggiore U, Venturini PL, Biscaldi E, Remorgida V. Bowel endometriosis: Recent insights and unsolved problems. World J Gastrointest Surg 2011; 3:31-38. [PMID: 30689680 PMCID: PMC3069336 DOI: 10.4240/wjgs.v3.i3.31] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2010] [Revised: 03/14/2011] [Accepted: 03/21/2011] [Indexed: 02/06/2023] Open
Abstract
Bowel endometriosis affects between 3.8% and 37% of women with endometriosis. The evaluation of symptoms and clinical examination are inadequate for an accurate diagnosis of intestinal endometriosis. Transvaginal ultrasonography is the first line investigation in patients with suspected bowel endometriosis and allows accurate determination of the presence of the disease. Radiological techniques (such as magnetic resonance imaging and multidetector computerized tomography enteroclysis) are useful for estimating the extent of bowel endometriosis. Hormonal therapies (progestins, gonadotropin releasing hormone analogues and aromatase inhibitors) significantly improve pain and intestinal symptoms in patients with bowel stenosis less than 60% and who do not wish to conceive. However, hormonal therapies may not prevent the progression of bowel endometriosis and, therefore, patients receiving long-term treatment should be periodically monitored. Surgical excision of bowel endometriosis should be offered to symptomatic patients with bowel stenosis greater than 60%. Intestinal endometriotic nodules may be excised by nodulectomy or segmental resection. Both surgical procedures improve pain, intestinal symptoms and fertility. Nodulectomy may be associated with a lower rate of complications.
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Affiliation(s)
- Simone Ferrero
- Simone Ferrero, Umberto Leone Roberti Maggiore, Pier L Venturini, Valentino Remorgida, Department of Obstetrics and Gynecology, San Martino Hospital and University of Genoa, Largo R. Benzi 1, 16132 Genoa, Italy
- Giovanni Camerini, Department of Surgery, San Martino Hospital and University of Genoa, Largo R. Benzi 1, 16132 Genoa, Italy
- Ennio Biscaldi, Department of Radiology, Galliera Hospital, Via Mura delle Cappuccine 14, 16128 Genoa, Italy
| | - Giovanni Camerini
- Simone Ferrero, Umberto Leone Roberti Maggiore, Pier L Venturini, Valentino Remorgida, Department of Obstetrics and Gynecology, San Martino Hospital and University of Genoa, Largo R. Benzi 1, 16132 Genoa, Italy
- Giovanni Camerini, Department of Surgery, San Martino Hospital and University of Genoa, Largo R. Benzi 1, 16132 Genoa, Italy
- Ennio Biscaldi, Department of Radiology, Galliera Hospital, Via Mura delle Cappuccine 14, 16128 Genoa, Italy
| | - Umberto Leone Roberti Maggiore
- Simone Ferrero, Umberto Leone Roberti Maggiore, Pier L Venturini, Valentino Remorgida, Department of Obstetrics and Gynecology, San Martino Hospital and University of Genoa, Largo R. Benzi 1, 16132 Genoa, Italy
- Giovanni Camerini, Department of Surgery, San Martino Hospital and University of Genoa, Largo R. Benzi 1, 16132 Genoa, Italy
- Ennio Biscaldi, Department of Radiology, Galliera Hospital, Via Mura delle Cappuccine 14, 16128 Genoa, Italy
| | - Pier L Venturini
- Simone Ferrero, Umberto Leone Roberti Maggiore, Pier L Venturini, Valentino Remorgida, Department of Obstetrics and Gynecology, San Martino Hospital and University of Genoa, Largo R. Benzi 1, 16132 Genoa, Italy
- Giovanni Camerini, Department of Surgery, San Martino Hospital and University of Genoa, Largo R. Benzi 1, 16132 Genoa, Italy
- Ennio Biscaldi, Department of Radiology, Galliera Hospital, Via Mura delle Cappuccine 14, 16128 Genoa, Italy
| | - Ennio Biscaldi
- Simone Ferrero, Umberto Leone Roberti Maggiore, Pier L Venturini, Valentino Remorgida, Department of Obstetrics and Gynecology, San Martino Hospital and University of Genoa, Largo R. Benzi 1, 16132 Genoa, Italy
- Giovanni Camerini, Department of Surgery, San Martino Hospital and University of Genoa, Largo R. Benzi 1, 16132 Genoa, Italy
- Ennio Biscaldi, Department of Radiology, Galliera Hospital, Via Mura delle Cappuccine 14, 16128 Genoa, Italy
| | - Valentino Remorgida
- Simone Ferrero, Umberto Leone Roberti Maggiore, Pier L Venturini, Valentino Remorgida, Department of Obstetrics and Gynecology, San Martino Hospital and University of Genoa, Largo R. Benzi 1, 16132 Genoa, Italy
- Giovanni Camerini, Department of Surgery, San Martino Hospital and University of Genoa, Largo R. Benzi 1, 16132 Genoa, Italy
- Ennio Biscaldi, Department of Radiology, Galliera Hospital, Via Mura delle Cappuccine 14, 16128 Genoa, Italy
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Diagnosis of colorectal endometriosis: contribution of contrast enhanced MR-colonography. Eur Radiol 2011; 21:1553-63. [DOI: 10.1007/s00330-011-2079-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Revised: 12/20/2010] [Accepted: 01/13/2011] [Indexed: 01/07/2023]
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Mezzi G, Ferrari S, Arcidiacono PG, Di Puppo F, Candiani M, Testoni PA. Endoscopic rectal ultrasound and elastosonography are useful in flow chart for the diagnosis of deep pelvic endometriosis with rectal involvement. J Obstet Gynaecol Res 2010; 37:586-90. [PMID: 21159047 DOI: 10.1111/j.1447-0756.2010.01413.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
AIM Endometriosis is defined by the presence of endometrial glands and stroma outside the uterus. The disease causes pelvic pain, dysmenorrhea, dyspareunia, dyschezia and urinary symptoms. The aim of this study was to assess the usefulness of endoscopic ultrasound (EUS) and elastosonography for detecting rectosigmoid endometriosis and to compare the findings, in selected and symptomatic patients, with surgical specimens in order to select the best surgical strategy. MATERIAL & METHODS Sixty-three consecutive patients (mean age 34.2; range 25-50 years) with diagnosis of endometriosis were referred for rectal endosonography to evaluate the rectal involvement. Patients complained of abdominal pain, rectal bleeding, constipation and dysmenorrhea. Sub-stenosis of the rectosigmoid lumen was found endoscopically in one patient (1.5%), bulging in 21 (33.3%), mucosal hyperemia or edema in one (1.5%), and no lesions in 39 patients (61.9%); no abdominal masses or obstruction were reported. Each woman completed a self-administered 100-point questionnaire to evaluate endometriosis-related pain (intensity of symptoms: 0 = absent, 100 = unbearable). After clinical imaging evaluation, 10 symptomatic patients (mean age 32.2; range 26-45 years) were evaluated for surgery. RESULTS EUS detected endometriotic lesions in all patients as a hypoechoic mass, poorly vascularized with irregular, undefined margins. In cases where the rectosigmoid wall was involved, there was invasion of the fourth layer. All patients who were operated had histologic findings of endometriotic lesions involving the rectal wall, as indicated by EUS. CONCLUSION EUS and elastosonography offers a non-invasive and sensitive technique to better define the endometriotic infiltration in the rectosigmoid wall.
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Affiliation(s)
- Gianni Mezzi
- Departments of Gastroenterology and Gastrointestinal Endoscopy, IRCCS Vita-Salute University, San Raffaele Scientific Institute, Milan, Italy.
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Ruffo G, Stepniewska A, Crippa S, Serboli G, Zardini C, Steinkasserer M, Ceccaroni M, Minelli L, Falconi M. Laparoscopic ileocecal resection for bowel endometriosis. Surg Endosc 2010; 25:1257-62. [PMID: 20848137 DOI: 10.1007/s00464-010-1354-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2010] [Accepted: 08/26/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND Ileocecal endometriosis is a very rare entity, and its diagnosis is usually made during surgery for other endometriosis sites or, rarely, because of direct complications of ileal involvement. This study was designed to analyze perioperative and long-term outcomes after bowel resection for ileocecal endometriosis. METHODS All patients who underwent surgery for ileocecal endometriosis between October 2004 and January 2008 were prospectively collected and analyzed. RESULTS Thirty-one women (median age, 34 (range, 25-40) years) were identified. Ileocecal endometriosis was diagnosed during surgery in all patients, and it was associated with colorectal endometriosis in 29 patients (94%). All patients underwent laparoscopic ileocecal resection with no laparotomic conversion. Rectosigmoid or rectal resections was associated in 28 patients (90%) and nodulectomy for sigmoid endometriosis in 1 patient. Median duration of surgery was 301 (range, 90-480) min. Other associated surgical procedures included total hysterectomy (n = 3, 14%), ureterolysis (n = 7, 23%), excision of vesical (n = 4, 13%), vaginal (n = 8, 26%), and parametrial (n = 3, 14%) nodules. There was no mortality. Four patients (13%) required blood transfusions and one a reoperation for bleeding. In a patient who performed ureterolysis, a ureteral fistula occurred. The median hospital stay was 7 (range, 5-18) days. Long-term (>12 months) follow-up data were available for 18 patients. After a median follow-up of 27 months, in 12 of 18 patients (67%) defecation after surgery was normal. Only one patient developed recurrence, which is under medical treatment. CONCLUSIONS Laparoscopic ileocecal resection is safe and feasible and should be considered as part of surgery for endometriosis with radical intent.
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Affiliation(s)
- Giacomo Ruffo
- Department of Surgery, Ospedale Sacro Cuore, Via Sempreboni, 5, 37024 Negrar, VR, Italy.
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Goncalves MODC, Podgaec S, Dias JA, Gonzalez M, Abrao MS. Transvaginal ultrasonography with bowel preparation is able to predict the number of lesions and rectosigmoid layers affected in cases of deep endometriosis, defining surgical strategy. Hum Reprod 2009; 25:665-71. [PMID: 20023291 DOI: 10.1093/humrep/dep433] [Citation(s) in RCA: 124] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Successful surgical treatment of deep bowel endometriosis depends on obtaining detailed information about the lesions, prior to the procedure. The objective of this study was to determine the capability of transvaginal ultrasonography with bowel preparation (TVUS-BP) to predict the presence of one or more rectosigmoid nodules and the deepest bowel layer affected by the disease. METHODS A prospective study of 194 patients with clinical and TVUS-BP suspected deep endometriosis submitted to videolaparoscopy. Image data were compared with surgical and histological results. RESULTS With respect to bowel nodule detection and presence of at least two rectosigmoid lesions, TVUS-BP had a sensitivity of 97 and 81%, specificity 100 and 99%, positive predictive value (PPV) 100 and 93% and negative predictive value (NPV) 98 and 96%, respectively. Regarding diagnosis of infiltration of the submucosal/mucosal layer, TVUS-BP had a sensitivity of 83%, specificity 94%, PPV 77%, NPV 96%. CONCLUSIONS These findings show that TVUS-BP is an adequate exam for evaluating the presence of one or more rectosigmoid nodules and the deepest layer affected in deep infiltrating bowel endometriosis, confirming the importance of this technique for defining the most appropriate surgical strategy to be implemented.
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Schizas AMP, Williams AB, Meenan J. Endosonographic staging of lower intestinal malignancy. Best Pract Res Clin Gastroenterol 2009; 23:663-70. [PMID: 19744631 DOI: 10.1016/j.bpg.2009.06.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2009] [Accepted: 06/22/2009] [Indexed: 02/08/2023]
Abstract
The use of EUS in the assessment of rectal pathology is well established. The accurate staging of lower intestinal tumours predicts prognosis and guides the planning of individual patient treatment. Increased experience and the development of high resolution three-dimensional EUS has lead to the greater accuracy of rectal staging with EUS of rectal tumours now considered the gold standard showing T stage accuracy that ranges from 75% to 95%, with N stage accuracy ranging from 65% to 80%. The use of EUS in the staging of colonic pathology, however, is not so well established though advances in miniprobe EUS has improved the assessment of colonic tumours. EUS is also of benefit in the assessment of anal pathology though here, accurate correlation with histology has not been firmly established.
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Affiliation(s)
- Alexis M P Schizas
- Department of Colo-rectal Surgery, Guy's and St. Thomas' Hospital, London, UK
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Current World Literature. Curr Opin Obstet Gynecol 2009; 21:353-63. [DOI: 10.1097/gco.0b013e32832f731f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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