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Holdsworth-Carson SJ, Chung J, Machalek DA, Li R, Jun BK, Griffiths MJ, Churchill M, McCaughey T, Nisbet D, Dior U, Donoghue JF, Montgomery GW, Reddington C, Girling JE, Healey M, Rogers PAW. Predicting disease recurrence in patients with endometriosis: an observational study. BMC Med 2024; 22:320. [PMID: 39113136 PMCID: PMC11304583 DOI: 10.1186/s12916-024-03508-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 07/01/2024] [Indexed: 08/11/2024] Open
Abstract
BACKGROUND Despite surgical and pharmacological interventions, endometriosis can recur. Reliable information regarding risk of recurrence following a first diagnosis is scant. The aim of this study was to examine clinical and survey data in the setting of disease recurrence to identify predictors of risk of endometriosis recurrence. METHODS This observational study reviewed data from 794 patients having surgery for pelvic pain or endometriosis. Patients were stratified into two analytic groups based on self-reported or surgically confirmed recurrent endometriosis. Statistical analyses included univariate, followed by multivariate logistic regression to identify risk factors of recurrence, with least absolute shrinkage and selection operator (Lasso) regularisation. Risk-calibrated Supersparse Linear Integer Models (RiskSLIM) and survival analyses (with Lasso) were undertaken to identify predictive features of recurrence. RESULTS Several significant features were repeatedly identified in association with recurrence, including adhesions, high rASRM score, deep disease, bowel lesions, adenomyosis, emergency room attendance for pelvic pain, younger age at menarche, higher gravidity, high blood pressure and older age. In the surgically confirmed group, with a score of 5, the RiskSLIM method was able to predict the risk of recurrence (compared to a single diagnosis) at 95.3% and included adenomyosis and adhesions in the model. Survival analysis further highlighted bowel lesions, adhesions and adenomyosis. CONCLUSIONS Following an initial diagnosis of endometriosis, clinical decision-making regarding disease management should take into consideration the presence of bowel lesions, adhesions and adenomyosis, which increase the risk of endometriosis recurrence.
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Affiliation(s)
- Sarah J Holdsworth-Carson
- Department of Obstetrics, Gynaecology and Newborn Health, University of Melbourne and Gynaecology Research Centre, Royal Women's Hospital, Grattan St & Flemington Rd, Parkville, VIC, 3052, Australia.
- The Julia Argyrou Endometriosis Centre, Epworth HealthCare, Ground Floor, 185-187 Hoddle Street, Richmond, VIC, 3121, Australia.
| | - Jessica Chung
- Department of Obstetrics, Gynaecology and Newborn Health, University of Melbourne and Gynaecology Research Centre, Royal Women's Hospital, Grattan St & Flemington Rd, Parkville, VIC, 3052, Australia
- Melbourne Bioinformatics, University of Melbourne, 21 Bedford St, North Melbourne, VIC, 3051, Australia
| | - Dorothy A Machalek
- The Kirby Institute, University of New South Wales, High Street, Kensington, NSW, 2052, Australia
- Centre for Women's Infectious Diseases, The Royal Women's Hospital, Grattan St & Flemington Rd, Parkville, VIC, 3052, Australia
| | - Rebecca Li
- Department of Obstetrics, Gynaecology and Newborn Health, University of Melbourne and Gynaecology Research Centre, Royal Women's Hospital, Grattan St & Flemington Rd, Parkville, VIC, 3052, Australia
| | - Byung Kyu Jun
- Department of Obstetrics, Gynaecology and Newborn Health, University of Melbourne and Gynaecology Research Centre, Royal Women's Hospital, Grattan St & Flemington Rd, Parkville, VIC, 3052, Australia
| | - Meaghan J Griffiths
- Department of Obstetrics, Gynaecology and Newborn Health, University of Melbourne and Gynaecology Research Centre, Royal Women's Hospital, Grattan St & Flemington Rd, Parkville, VIC, 3052, Australia
| | - Molly Churchill
- Department of Obstetrics, Gynaecology and Newborn Health, University of Melbourne and Gynaecology Research Centre, Royal Women's Hospital, Grattan St & Flemington Rd, Parkville, VIC, 3052, Australia
| | - Tristan McCaughey
- Department of Obstetrics, Gynaecology and Newborn Health, University of Melbourne and Gynaecology Research Centre, Royal Women's Hospital, Grattan St & Flemington Rd, Parkville, VIC, 3052, Australia
| | - Debbie Nisbet
- Ultrasound Services, Royal Women's Hospital, Grattan St & Flemington Rd, Parkville, VIC, 3052, Australia
- Department of Radiology, University of Melbourne, Royal Melbourne Hospital, Royal Parade, Parkville, VIC, 3050, Australia
| | - Uri Dior
- Faculty of Medicine, Department of Obstetrics and Gynaecology, Hadassah Medical Center, P.O Box 12000, Jerusalem, 91120, Israel
| | - Jacqueline F Donoghue
- Department of Obstetrics, Gynaecology and Newborn Health, University of Melbourne and Gynaecology Research Centre, Royal Women's Hospital, Grattan St & Flemington Rd, Parkville, VIC, 3052, Australia
| | - Grant W Montgomery
- Institute for Molecular Bioscience, University of Queensland, 306 Carmody Road, St Lucia, Brisbane, QLD, 4072, Australia
| | - Charlotte Reddington
- Department of Obstetrics, Gynaecology and Newborn Health, University of Melbourne and Gynaecology Research Centre, Royal Women's Hospital, Grattan St & Flemington Rd, Parkville, VIC, 3052, Australia
| | - Jane E Girling
- Department of Obstetrics, Gynaecology and Newborn Health, University of Melbourne and Gynaecology Research Centre, Royal Women's Hospital, Grattan St & Flemington Rd, Parkville, VIC, 3052, Australia
- Department of Anatomy, School of Biomedical Sciences, University of Otago, 270 Great King Street, Dunedin, 9016, New Zealand
| | - Martin Healey
- Department of Obstetrics, Gynaecology and Newborn Health, University of Melbourne and Gynaecology Research Centre, Royal Women's Hospital, Grattan St & Flemington Rd, Parkville, VIC, 3052, Australia
- The Julia Argyrou Endometriosis Centre, Epworth HealthCare, Ground Floor, 185-187 Hoddle Street, Richmond, VIC, 3121, Australia
| | - Peter A W Rogers
- Department of Obstetrics, Gynaecology and Newborn Health, University of Melbourne and Gynaecology Research Centre, Royal Women's Hospital, Grattan St & Flemington Rd, Parkville, VIC, 3052, Australia
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Robertson J, Abbott J, Corbett-Burns S, Bukhari M, Perera S, Kalantan A, Sarofim M, Chou R, Cario G, Rosen D, Choi S, Wynn-Williams M, Condous G, Chou D. Treatment of rectosigmoid endometriosis by laparoscopic reverse submucosal dissection (LRSD): The Sydney partial thickness discoid excision technique. Aust N Z J Obstet Gynaecol 2024; 64:147-153. [PMID: 37905841 DOI: 10.1111/ajo.13762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 10/09/2023] [Indexed: 11/02/2023]
Abstract
BACKGROUND Laparoscopic reverse submucosal dissection (LRSD) is a standardised surgical technique for removal of rectosigmoid endometriosis which optimises the anatomical dissection plane for excision of endometriotic nodules. AIM This cohort study assesses the outcomes of the first cohort of women treated by LRSD, for deeply infiltrating rectosigmoid endometriosis. MATERIALS AND METHODS Primary outcomes assessed were complication rate as defined by the Clavien-Dindo system, and completion of the planned LRSD. Secondary outcomes include mucosal breach, specimen margin involvement, length of hospital admission, and a comparison of pre-operative and post-operative pain, bowel function and quality of life surveys. These included the Endometriosis Health Profile Questionnaire (EHP-30), the Knowles-Eccersley-Scott Symptom Questionnaire (KESS) and the Wexner scale. RESULTS Of 19 patients treated, one required a segmental resection. The median length of hospital admission was two days (range 1-5) and no post-operative complications occurred. Median pain visual analogue scales (scale 0-10) were higher prior to surgery (dysmenorrhoea 9.0, dyspareunia 7.5, dyschezia 9.0, pelvic pain 6.0) compared to post-surgical median scores (dysmenorrhoea 5.0, dyspareunia 4.0, dyschezia 2.0, pelvic pain 4.0) at a median of six months (range 4-32). Quality of life studies suggested improvement following surgery with pre-operative median EHP-30 and KESS scores (EHP-30: 85 (5-106), KESS score 9 (0-20)) higher than post-operative scores (EHP-30: 48.5 (0-80), KESS score: 3 (0-19)). CONCLUSION This series highlights the feasibility of LRSD with low associated morbidity as a progression of partial thickness discoid excision (rectal shaving) for the treatment of rectosigmoid deep infiltrating endometriosis.
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Affiliation(s)
- Jessica Robertson
- Sydney Women's Endosurgery Centre, Sydney, New South Wales, Australia
| | - Jason Abbott
- Gynaecological Research and Clinical Evaluation (GRACE) Unit, Royal Hospital for Women, Sydney, New South Wales, Australia
- School of Clinical Medicine, Faculty of Medicine and Health, UNSW, Sydney, New South Wales, Australia
| | | | - Mujahid Bukhari
- Sydney Women's Endosurgery Centre, Sydney, New South Wales, Australia
| | - Shevy Perera
- Sydney Colorectal Associates, Sydney, New South Wales, Australia
| | - Assem Kalantan
- Sydney Women's Endosurgery Centre, Sydney, New South Wales, Australia
| | - Mikhail Sarofim
- Sydney Women's Endosurgery Centre, Sydney, New South Wales, Australia
| | - Rebecca Chou
- Liverpool Hospital, Sydney, New South Wales, Australia
| | - Greg Cario
- Sydney Women's Endosurgery Centre, Sydney, New South Wales, Australia
| | - David Rosen
- Sydney Women's Endosurgery Centre, Sydney, New South Wales, Australia
- School of Clinical Medicine, Faculty of Medicine and Health, UNSW, Sydney, New South Wales, Australia
| | - Sarah Choi
- Sydney Women's Endosurgery Centre, Sydney, New South Wales, Australia
| | | | - George Condous
- OMNI Ultrasound and Gynaecological Care, Sydney, New South Wales, Australia
| | - Danny Chou
- Sydney Women's Endosurgery Centre, Sydney, New South Wales, Australia
- School of Clinical Medicine, Faculty of Medicine and Health, UNSW, Sydney, New South Wales, Australia
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Canturk MM, D'Ancona G, François MO, Roman H. Robotic Management of Recurrent Rectal Endometriosis After Previous Segmental Bowel Resection. J Minim Invasive Gynecol 2024; 31:176-177. [PMID: 38043860 DOI: 10.1016/j.jmig.2023.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 11/22/2023] [Accepted: 11/28/2023] [Indexed: 12/05/2023]
Abstract
OBJECTIVE To describe the management of recurrent bowel endometriosis after previous colorectal resection. DESIGN Surgical video article. The local institutional board review was omitted due to the narration of surgical management. Patient consent was obtained. SETTING A tertiary referral center. The patient first underwent segmental bowel resection for deep infiltrating endometriosis of the rectum in the ENDORE randomized controlled trial in 2012 and then received a total hysterectomy in 2018. Five years later, she presented with recurrent nodules in the rectovaginal, left parametrium, and abdominal wall after discontinuing medical suppressive treatment. INTERVENTION Laparoscopic management using robotic assistance was employed to complete excision of the rectovaginal nodule. Disc excision was performed to remove rectal infiltration. The procedure started with rectal shaving and excision of vaginal infiltration . A traction stitch was placed over the limits of the rectal shaving area. The general surgeon placed a 28 mm circular anal stapler transanally and performed complete excision of the shaved rectal area. Anastomotic perfusion was checked with indocyanine green. A methylene blue enema test was conducted to rule out anastomotic leakage. Outcomes were favorable, with systematic self-catheterization during 5 postoperative weeks. No specific symptoms were related to the other 2 nodules, which were not removed. CONCLUSION Rectal recurrences may occur long after colorectal resection and outside the limits of the previous surgery site. To accurately assess this risk, long-term follow-up of patients is mandatory.. Postoperative medical amenorrhea may play a role in recurrence prevention. Surgical management of recurrences may be challenging and focus on only those nodules responsible for symptoms so as to best preserve the organ's function and reduce postoperative morbidity.
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Affiliation(s)
- Muhterem Melis Canturk
- Institut Franco-Européen Multidisciplinaire d'Endométriose (IFEMEndo) (Drs. Canturk, D'Ancona, and Roman), Clinique Tivoli-Ducos, Bordeaux, France.
| | - Gianmarco D'Ancona
- Institut Franco-Européen Multidisciplinaire d'Endométriose (IFEMEndo) (Drs. Canturk, D'Ancona, and Roman), Clinique Tivoli-Ducos, Bordeaux, France
| | - Marc Olivier François
- Bordeaux Colorectal Institute (Dr. François), Clinique Tivoli-Ducos, Bordeaux, France
| | - Horace Roman
- Institut Franco-Européen Multidisciplinaire d'Endométriose (IFEMEndo) (Drs. Canturk, D'Ancona, and Roman), Clinique Tivoli-Ducos, Bordeaux, France; Franco-European Multidisciplinary Institut of Endometriosis-Middle East Clinic (Dr. Roman), Burjeel Medical City, Abu Dhabi, UAE; Department of Gynecology and Obstetrics (Dr. Roman), Medical University Aarhus, Aarhus, Denmark
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Roman H, Dennis T, Forestier D, François MO, Assenat V, Tuech JJ, Hennetier C, Merlot B. Disk Excision Using End-to-End Anastomosis Circular Stapler for Deep Endometriosis of the Rectum: A 492-Patient Continuous Prospective Series. J Minim Invasive Gynecol 2023; 30:122-130. [PMID: 36334913 DOI: 10.1016/j.jmig.2022.10.009] [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: 10/05/2022] [Revised: 10/25/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022]
Abstract
STUDY OBJECTIVE To report a large series including women managed by disk excision using end-to-end anastomosis (EEA) circular transanal stapler to assess the feasibility of the technique, the features of nodules suitable for removal by disk excision, and the rate of major early complications. DESIGN Retrospective study on data prospectively recorded in 2 databases. SETTING Two tertiary referral centers. PATIENTS A total of 492 patients undergoing surgery for rectal endometriosis from May 2011 to June 2022. INTERVENTIONS Rectal disk excision using the EEA stapler. MEASUREMENT AND MAIN RESULTS Disk excision using EEA was performed in 492 patients (24.2%) of 2,029 women receiving surgery for deep endometriosis infiltrating the rectum during the 11-year study period. Deep endometriosis involved low rectum in 11% and mid rectum in 55.3%. The diameter of rectal nodules exceeded 3 cm in 65.9%. Mean operative time was 2 hours, mean diameter of rectal patches removed was 41 ± 11 mm, and the mean rectal suture height was 9.2 ± 5.5 cm. The presence of microscopic foci on the edges of rectal patches was identified in 30.2% of cases. Rectal fistula was recorded in 20 patients (4%). The distance from the anal verge was significantly lower in patients with fistula than women with no fistula (5.9 ± 2 cm vs 9.2 ± 5.6 cm, p = .027). Follow-up ranged from 1 to 120 months, with a median value of 36 months. Magnetic resonance imaging in 3 patients during follow-up revealed a recurrent nodule infiltrating the previous stapled line (0.6%) after a postoperative delay of, respectively, 36, 48, and 84 months. CONCLUSION Disk excision using the EEA stapler is suitable in nodules >3 cm if surgeons ensure deep shaving of the rectum, to allow complete inclusion of the shaved area into the stapler jaws. Postoperative rectal recurrences seem incidental, whereas bowel leakage rate is comparable with that after colorectal resection. This technique is suitable in almost a quarter of patients managed for rectal endometriosis nodules and is therefore a valuable technique that warrants more widespread use.
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Affiliation(s)
- Horace Roman
- Franco-European Multidisciplinary Endometriosis Institute (IFEMEndo), Clinique Tivoli-Ducos, Bordeaux, France (Drs. Roman, Dennis, Forestier, François, Assenat, and Merlot); Department of Gynecology and Obstetrics, Aarhus University Hospital, Aarhus, Denmark (Dr. Roman, Dr. Tuech, Dr. Hennetier).
| | - Thomas Dennis
- Franco-European Multidisciplinary Endometriosis Institute (IFEMEndo), Clinique Tivoli-Ducos, Bordeaux, France (Drs. Roman, Dennis, Forestier, François, Assenat, and Merlot)
| | - Damien Forestier
- Franco-European Multidisciplinary Endometriosis Institute (IFEMEndo), Clinique Tivoli-Ducos, Bordeaux, France (Drs. Roman, Dennis, Forestier, François, Assenat, and Merlot)
| | - Marc Olivier François
- Franco-European Multidisciplinary Endometriosis Institute (IFEMEndo), Clinique Tivoli-Ducos, Bordeaux, France (Drs. Roman, Dennis, Forestier, François, Assenat, and Merlot)
| | - Vincent Assenat
- Franco-European Multidisciplinary Endometriosis Institute (IFEMEndo), Clinique Tivoli-Ducos, Bordeaux, France (Drs. Roman, Dennis, Forestier, François, Assenat, and Merlot)
| | - Jean Jacques Tuech
- Department of Surgery, Rouen University Hospital, Rouen, France (Dr. Tuech)
| | - Clotilde Hennetier
- Department of Gynecology and Obstetrics, Rouen University Hospital, Rouen, France (Dr. Hennetier)
| | - Benjamin Merlot
- Franco-European Multidisciplinary Endometriosis Institute (IFEMEndo), Clinique Tivoli-Ducos, Bordeaux, France (Drs. Roman, Dennis, Forestier, François, Assenat, and Merlot)
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Roman H, Merlot B, Forestier D, Noailles M, Magne E, Carteret T, Tuech JJ, Martin DC. Nonvisualized palpable bowel endometriotic satellites. Hum Reprod 2021; 36:656-665. [PMID: 33432338 PMCID: PMC7891810 DOI: 10.1093/humrep/deaa340] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 10/03/2020] [Indexed: 11/16/2022] Open
Abstract
STUDY QUESTION What is the prevalence of laparoscopically nonvisualized palpable satellite bowel nodules at or near the planned stapler site in women undergoing segmental bowel resection for endometriosis? SUMMARY ANSWER Overall, 13 (25.5%) of 51 patients who underwent resection had nonvisualized palpable satellite lesions as small as 2 mm, including seven (14%) who had nonvisualized palpable lesions at or beyond the planned stapler site. WHAT IS KNOWN ALREADY Both laparoscopy and laparotomy for bowel resection are standard of care in Europe and the USA. Reoperation rates after laparoscopic bowel procedures are 1–16%. Endometriotic lesions at the stapler margin of bowel resections are associated with increased repeat surgery. Nodules of 0.1 mm to 1 cm in size were not recognized during laparoscopic bowel surgery but were recognized on histological examination. Up to 20 nodules not visualized at laparoscopy have been recognized and excised at laparotomy. Tenderness is found at up to 27 mm from a recognized lesion. The size of a lesion does not always predict its symptoms or behavior. STUDY DESIGN, SIZE, DURATION This single-arm, observational study focused on the presence of nonvisualized palpable satellite lesions of the bowel. Fifty-one patients scheduled for laparoscopic-assisted bowel resection for deep infiltrating endometriosis with suprapubic incision for placement of the stapler’s anvil and removal of the specimen in the course of routine clinical care were included. There were no additional inclusion or exclusion criteria. PARTICIPANTS/MATERIALS, SETTING, METHODS Laparoscopic-assisted segmental bowel resection for endometriosis was performed in a private referral center on women aged 24–49 years. MAIN RESULTS AND THE ROLE OF CHANCE Forty-nine (96.1%) of the 51 patients underwent segmental resection of the sigmoid or rectum, and 14 (27.5%) underwent segmental resection of the ileum for large nodule(s) recognized on MRI. Twelve patients underwent both procedures. Eleven (22.4%) of the 49 patients with recognized sigmoid or rectal lesions and 5 (35.7%) of the 14 patients with recognized ileal lesions had nonvisualized, palpable, satellite lesions. All the large lesions and none of the satellite lesions had been recognized preoperatively on MRI. Five (10%) of 49 patients with lesions of the large bowel and 4 (28.6%) of the 14 patients with lesions of the ileum had nonvisualized palpable satellite lesions at or beyond the planned stapler site. Lesions as small as 2 mm were palpable. LIMITATIONS, REASONS FOR CAUTION This is an observational study. It is not known if the small lesions of this study contributed to the symptoms or were progressive, stable or regressive. This study analyzed lesions in the bowel segment proximal to the primary large bowel lesion, but not in the distal segment as that would have required a change in standard of care surgical technique. This study protocol did not include shaving or disk resection or patients in whom no lesions were visualized. The use of additional techniques for recognition, such as hand-assisted laparoscopy or rectal probes, was not investigated. WIDER IMPLICATIONS OF THE FINDINGS This study confirms that some nonvisualized satellite lesions as small as 2 mm are palpable and that an increased length of resection can be used to remove lesions recognized by palpation and to avoid lesions at and beyond the stapler site. This may decrease recurrent surgery in 1–16% of the women undergoing surgery for bowel endometriosis. Knowledge of the occurrence of these small lesions may also be particularly useful in plans for repeat surgery or for women with clinically significant bowel symptoms and no visible lesions at laparoscopy. Moreover, small lesions are considered to be important as there is no current technique to determine whether a large primary lesion, smaller lesions, an associated adjacent tissue reaction or a combination of those cause symptoms. STUDY FUNDING/COMPETING INTEREST(S) This CIRENDO cohort was supported by the G4 Group (the University Hospitals of Rouen, Lille, Amiens and Caen) and the ROUENDOMETRIOSE association. No specific funding was received for the study. H.R. reports receiving personal fees from Plasma Surgical Inc., Ethicon Endosurgery, Olympus and Nordic Pharma for presentations related to his experience with endometriosis surgery. D.C.M. reports being given access to Lumenis Surgical CO2 Lasers’ lab at a meeting. None of the other authors have conflicts of interest to disclose. TRIAL REGISTRATION NUMBER N/A
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Affiliation(s)
- H Roman
- Endometriosis Center, Clinique Bordeaux Tivoli-Ducos, Bordeaux, France
- Department of Gynecology and Obstetrics, Aarhus Medical University, Aarhus, Denmark
| | - B Merlot
- Endometriosis Center, Clinique Bordeaux Tivoli-Ducos, Bordeaux, France
| | - D Forestier
- Endometriosis Center, Clinique Bordeaux Tivoli-Ducos, Bordeaux, France
| | - M Noailles
- Endometriosis Center, Clinique Bordeaux Tivoli-Ducos, Bordeaux, France
| | - E Magne
- Endometriosis Center, Clinique Bordeaux Tivoli-Ducos, Bordeaux, France
| | - T Carteret
- Endometriosis Center, Clinique Bordeaux Tivoli-Ducos, Bordeaux, France
| | - J-J Tuech
- Department of Surgery, Rouen University Hospital, Rouen, France
| | - D C Martin
- School of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
- Office of Research Subjects Protection, Institutional Review Board, Virginia Commonwealth University, Richmond, VA, USA
- Correspondence address. Office of Research Subjects Protection, Institutional Review Board, Virginia Commonwealth University, 201 Wakefield Road, Richmond, VA 23221-3258, USA. Tel: +1 (901) 761-4787; E-mail:
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Abdalla-Ribeiro H, Maekawa MM, Lima RF, de Nicola ALA, Rodrigues FCM, Ribeiro PA. Intestinal endometriotic nodules with a length greater than 2.25 cm and affecting more than 27% of the circumference are more likely to undergo segmental resection, rather than linear nodulectomy. PLoS One 2021; 16:e0247654. [PMID: 33857130 PMCID: PMC8049285 DOI: 10.1371/journal.pone.0247654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 02/10/2021] [Indexed: 11/18/2022] Open
Abstract
Study objective To analyze the efficacy of intestinal ultrasonography with bowel preparation (TVUSBP) for endometriosis mapping in evaluating intestinal endometriosis to choose the surgical technique (segmental resection or linear nodulectomy) for treatment. Design Cross-sectional observational study. Setting University Hospital—Center for Advanced Endoscopic Gynecologic Surgery from April 2010 to November 2014. Patient(s) One hundred and eleven women with clinically suspected endometriosis and intestinal endometriotic nodule or intestinal adherence in TVUSBP for endometriosis mapping. Intervention(s) All patients with suspected endometriosis underwent TVUSBP for endometriosis mapping prior to videolaparoscopy for complete excision of endometriosis foci, including intestinal foci, using the linear nodulectomy or segmental resection techniques, depending on the characteristics of the intestinal lesion with confirmation of endometriosis on anatomopathological examination. Measurements and main results Preoperative ultrasonographic assessment of the length of the intestinal nodule, circumference of the intestinal loop affected by the endometriotic lesion, distance from the anal verge and intestinal wall layers infiltrated by endometriosis, as well as other endometriosis sites. Of the 111 patients who participated in the study, 63 (56.7%) presented intestinal endometriotic nodules in ultrasonography, performed by a single examiner (A.L.A.N.), and underwent intestinal surgical treatment of deep endometriosis—linear nodulectomy or segmental resection. The analysis of the receiver operating characteristic (ROC) curve showed that a longitudinal length of the intestinal nodule of 2.25 cm and a loop circumference of 27% are cutoff points separating linear nodulectomy from segmental resection techniques for excising intestinal endometriosis. The information obtained by TVUSBP helps the surgeon and patient, in the preoperative period, to select the surgical technique to be performed for resection of intestinal endometriosis and plan the surgical procedure while taking into account postoperative morbidity.
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Affiliation(s)
- Helizabet Abdalla-Ribeiro
- Department of Obstetrics and Gynecology of Santa Casa de de Misericórdia São Paulo, Sector of Gynecological Endoscopy and Endometriosis at Santa Casa de São Paulo, São Paulo, São Paulo, Brazil
- School of Medical Science of Santa Casa de Misericórdia de São Paulo, São Paulo, São Paulo, Brazil
| | - Marina Miyuki Maekawa
- Department of Obstetrics and Gynecology of Santa Casa de de Misericórdia São Paulo, Sector of Gynecological Endoscopy and Endometriosis at Santa Casa de São Paulo, São Paulo, São Paulo, Brazil
- * E-mail:
| | - Raquel Ferreira Lima
- Department of Obstetrics and Gynecology of Santa Casa de de Misericórdia São Paulo, Sector of Gynecological Endoscopy and Endometriosis at Santa Casa de São Paulo, São Paulo, São Paulo, Brazil
| | - Ana Luisa Alencar de Nicola
- Department of Obstetrics and Gynecology of Santa Casa de de Misericórdia São Paulo, Sector of Gynecological Endoscopy and Endometriosis at Santa Casa de São Paulo, São Paulo, São Paulo, Brazil
| | - Francisco Cesar Martins Rodrigues
- Department of Obstetrics and Gynecology of Santa Casa de de Misericórdia São Paulo, Sector of Gynecological Endoscopy and Endometriosis at Santa Casa de São Paulo, São Paulo, São Paulo, Brazil
| | - Paulo Ayroza Ribeiro
- Department of Obstetrics and Gynecology of Santa Casa de de Misericórdia São Paulo, Sector of Gynecological Endoscopy and Endometriosis at Santa Casa de São Paulo, São Paulo, São Paulo, Brazil
- School of Medical Science of Santa Casa de Misericórdia de São Paulo, São Paulo, São Paulo, Brazil
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Klapczynski C, Derbal S, Braund S, Coget J, Forestier D, Seyer-Hansen M, Tuech JJ, Roman H. Evaluation of functional outcomes after disc excision of deep endometriosis involving low and mid rectum using standardized questionnaires: a series of 80 patients. Colorectal Dis 2021; 23:944-954. [PMID: 33320419 DOI: 10.1111/codi.15485] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 10/14/2020] [Accepted: 11/14/2020] [Indexed: 12/26/2022]
Abstract
AIM The aim was to assess the functional outcome and quality of life in patients with low and mid rectal endometriosis who have undergone disc excision using a semicircular transanal staple device, a procedure we have named the Rouen technique. METHODS This was a retrospective study of patients undergoing the Rouen technique between October 2009 and November 2018. Preoperative and postoperative demographic and operative data were recorded prospectively (mean ± SEM). Postoperative complications were recorded using the Clavien-Dindo classification. Rectal function and quality of life were assessed by the low anterior resection syndrome (LARS) and Bowel Endometriosis Syndrome (BENS) scores respectively at ≥6 months. RESULTS The Rouen procedure was performed on 80 patients (29.7 ± 4.3). The mean diameter of resected specimens was 57 ± 10 mm, and the height of the rectal suture from the anal verge was 4.6 ± 1.2 cm. The Clavien-Dindo complications were Clavien-Dindo 1 (leg compression), Clavien-Dindo 2 (urinary tract infection, bladder self-catheterization) and Clavien-Dindo 3b (bowel obstruction, rectovaginal fistula, pyelic dilation, colorectal stenosis after resection). A rectovaginal fistula (Clavien-Dindo 3b) developed in nine (11.3%) patients and their stoma could be reversed after 99-162 days. The majority of patients (n = 50, 62.5%) had normal postoperative rectal function with LARS score ≤20. However, minor (LARS ≥ 21-29) and major rectal dysfunction (LARS ≥ 30) was seen in 18 (22.5%) and 12 (15%) patients respectively. Quality of life as measured using the BENS score was normal (BENS score 0-8) in 51 (63.8%) patients, slightly reduced (BENS score 9-16) in 24 (30%) patients and in only five (6.3%) was this a major issue (BENS score > 17). The development of a rectovaginal fistula was independently related to risk of major rectal dysfunction (adjusted OR 6.3, 95% CI 1.3-30.6). CONCLUSIONS In our series of 80 patients with transmural low and mid rectal endometriosis disc excision using a semicircular staple device can result in good functional outcomes and quality of life and avoid the complexity and potential complications of a low anterior resection.
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Affiliation(s)
- Clémence Klapczynski
- Expert Centre in the Diagnosis and Multidisciplinary Management of Endometriosis, Rouen University Hospital, Rouen, France
| | - Sophiane Derbal
- Department of Digestive Surgery, Rouen University Hospital, Rouen, France
| | - Sophia Braund
- Expert Centre in the Diagnosis and Multidisciplinary Management of Endometriosis, Rouen University Hospital, Rouen, France
| | - Julien Coget
- Department of Digestive Surgery, Rouen University Hospital, Rouen, France
| | | | - Mikkel Seyer-Hansen
- Department of Gynecology and Obstetrics, Aarhus University Hospital, Aarhus, Denmark
| | - Jean-Jacques Tuech
- Department of Digestive Surgery, Rouen University Hospital, Rouen, France.,Digestive Tract Research Group EA3234/IFRMP23, Rouen University Hospital, Rouen, France
| | - Horace Roman
- Endometriosis Centre, Clinique Tivoli-Ducos, Bordeaux, France.,Department of Gynecology and Obstetrics, Aarhus University Hospital, Aarhus, Denmark
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Koninckx PR, Fernandes R, Ussia A, Schindler L, Wattiez A, Al-Suwaidi S, Amro B, Al-Maamari B, Hakim Z, Tahlak M. Pathogenesis Based Diagnosis and Treatment of Endometriosis. Front Endocrinol (Lausanne) 2021; 12:745548. [PMID: 34899597 PMCID: PMC8656967 DOI: 10.3389/fendo.2021.745548] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 10/26/2021] [Indexed: 12/18/2022] Open
Abstract
Understanding the pathophysiology of endometriosis is changing our diagnosis and treatment. Endometriosis lesions are clones of specific cells, with variable characteristics as aromatase activity and progesterone resistance. Therefore the GE theory postulates GE incidents to start endometriosis, which thus is different from implanted endometrium. The subsequent growth in the specific environment of the peritoneal cavity is associated with angiogenesis, inflammation, immunologic changes and bleeding in the lesions causing fibrosis. Fibrosis will stop the growth and lesions look burnt out. The pain caused by endometriosis lesions is variable: some lesions are not painful while other lesions cause neuroinflammation at distance up to 28 mm. Diagnosis of endometriosis is made by laparoscopy, following an experience guided clinical decision, based on history, symptoms, clinical exam and imaging. Biochemical markers are not useful. For deep endometriosis, imaging is important before surgery, notwithstanding rather poor predictive values when confidence limits, the prevalence of the disease and the absence of stratification of lesions by size, localization and depth of infiltration, are considered. Surgery of endometriosis is based on recognition and excision. Since the surrounding fibrosis belongs to the body with limited infiltration by endometriosis, a rim of fibrosis can be left without safety margins. For deep endometriosis, this results in a conservative excision eventually with discoid excision or short bowel resections. For cystic ovarian endometriosis superficial destruction, if complete, should be sufficient. Understanding pathophysiology is important for the discussion of early intervention during adolescence. Considering neuroinflammation at distance, the indication to explore large somatic nerves should be reconsidered. Also, medical therapy of endometriosis has to be reconsidered since the variability of lesions results in a variable response, some lesions not requiring estrogens for growth and some being progesterone resistant. If the onset of endometriosis is driven by oxidative stress from retrograde menstruation and the peritoneal microbiome, medical therapy could prevent new lesions and becomes indicated after surgery.
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Affiliation(s)
- Philippe R. Koninckx
- Latifa Hospital, Dubai, United Arab Emirates
- Prof Emeritus Obstet Gynecol (OBGYN), Catholic University Leuven (KU), Leuven, Belgium
- University of Oxford-Hon Consultant, Oxford, United Kingdom
- University Cattolica, Roma, Italy
- Moscow State University, Moscow, Russia
- Gruppo Italo Belga, Villa Del Rosario, Rome, Italy
- *Correspondence: Philippe R. Koninckx,
| | - Rodrigo Fernandes
- Instituto do Cancer do Estado de São Paulo, University of São Paulo, São Paulo, Brazil
| | - Anastasia Ussia
- University Cattolica, Roma, Italy
- Gruppo Italo Belga, Villa Del Rosario, Rome, Italy
| | - Larissa Schindler
- Dubai Fertility Centre of the Dubai Health Authority, Dubai, United Arab Emirates
| | - Arnaud Wattiez
- Latifa Hospital, Dubai, United Arab Emirates
- Prof Department of Obstetrics and Gynaecology, University of Strasbourg, Strasbourg, France
| | | | | | | | | | - Muna Tahlak
- Latifa Hospital, Dubai, United Arab Emirates
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Goldberg JM, Falcone T, Diamond MP. Current controversies in tubal disease, endometriosis, and pelvic adhesion. Fertil Steril 2019; 112:417-425. [DOI: 10.1016/j.fertnstert.2019.06.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 06/07/2019] [Accepted: 06/17/2019] [Indexed: 12/20/2022]
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10
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Long Q, Zheng H, Liu X, Guo SW. Perioperative Intervention by β-Blockade and NF-κB Suppression Reduces the Recurrence Risk of Endometriosis in Mice Due to Incomplete Excision. Reprod Sci 2019; 26:697-708. [DOI: 10.1177/1933719119828066] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Qiqi Long
- Shanghai OB/GYN Hospital, Fudan University, Shanghai, Peoples Republic of China
| | - Hanxi Zheng
- Shanghai OB/GYN Hospital, Fudan University, Shanghai, Peoples Republic of China
| | - Xishi Liu
- Shanghai OB/GYN Hospital, Fudan University, Shanghai, Peoples Republic of China
- Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Fudan University, Shanghai, Peoples Republic of China
| | - Sun-Wei Guo
- Shanghai OB/GYN Hospital, Fudan University, Shanghai, Peoples Republic of China
- Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Fudan University, Shanghai, Peoples Republic of China
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