Management of deep endometriosis

Caecal endometriosis presenting with an acute abdomen in pregnancy

Endometriosis is defined as the presence of endometrial tissue outside the uterus, which induces a chronic inflammatory response. Its prevalence remains unknown, but it has been estimated to affect up to 10% of women of reproductive age. Although it is a benign oestrogen-dependent gynaecological condition, women may describe painful symptoms such as cyclical pelvic pain, dysmenorrhoea and dyschezia. Intestinal endometriosis may affect the ileum, appendix, sigmoid colon and rectum. It may present with a myriad of symptoms such as abdominal pain, vomiting, diarrhoea, constipation and haematochezia. Caecal endometriosis can present as an acute appendicitis, making the diagnosis challenging to establish in pregnancy. Transmural involvement and acute occlusion are very rare events. The gold standard for diagnosis remains laparoscopy with tissue sampling for histological confirmation. Although endometriosis improves during pregnancy under the effect of progesterone, the ectopic endometrium becomes decidualised with a progressive reduction in size. The authors present the case of a multiparous woman in her mid-30s with acute onset of right-sided abdominal pain at 35 weeks gestation. Physical examination was suggestive of an acute appendicitis and MRI showed an inflamed caecum. She became acutely unwell requiring an emergency caesarean section. A mass in the caecum was observed with impending perforation at the caecal pole. A right hemicolectomy was performed. Histopathological examination confirmed the diagnosis of endometriosis with decidualisation. Although endometriosis improves during pregnancy, this case shows the unexpected complications of the disease and demonstrates the importance of considering endometriosis in the differential diagnosis of an acute abdomen in women of childbearing age to prevent maternal morbidity and fetal loss.

Bowel Endometriosis: Current Perspectives on Diagnosis and Treatment

Endometriosis is a chronic condition primarily affecting young women of reproductive age. Although some women with bowel endometriosis may be asymptomatic patients typically report a myriad of symptoms such as alteration in bowel habits (constipation/diarrhoea) dyschezia, dysmenorrhoea and dyspareunia in addition to infertility. To date, there are no clear guidelines on the evaluation of patients with suspected bowel endometriosis. Several techniques have been proposed including transvaginal and/or transrectal ultrasonography, magnetic resonance imaging, and double-contrast barium enema. These different imaging modalities provide greater information regarding presence, location and extent of endometriosis ensuring patients are adequately informed whilst also optimizing preoperative planning. In cases where surgical management is indicated, surgery should be performed by experienced surgeons, in centres with access to multidisciplinary care. Treatment should be tailored according to patient symptoms and wishes with a view to excising as much disease as possible, whilst at the same time preserving organ function. In this review article current perspectives on diagnosis and management of bowel endometriosis are discussed.

Safety of the laparoscopic management of patients with deep infiltrative endometriosis in a reference center in Pereira, Colombia. Retrospective cohorte, 2007-2016

Objective

Describe the intraoperative findings, procedures and the safety of laparoscopic surgical management of Deep Infiltration Endometriosis (DIE).

Materials and methods

A descriptive historical cohort study of patients with suspected pre-surgical diagnosis of DIE due to clinical findings, pelvic ultrasound or magnetic resonance imaging and histological confirmation of the disease. The patients were taken to minimally invasive surgery between 2007 and 2016 in a reference health institution located in Pereira, Colombia. Sociodemographic, clinical, intraoperative findings, types of procedure performed, intra and postoperative complications and post-surgical pain levels at 6 weeks were evaluated. A descriptive analysis was performed.

Results

One hundred and sixty seven patients were included. The most frequent location of the disease was the recto-vaginal septum (85.7 %). A total of 83 patients (49.7 %) had bowel endometriosis. Of these, 86 % had a shaving and 13.2 % segmental bowel resection. Four patients (2.4 %) had intraoperative complications. One was converted to laparotomy and other five (2.9 %) had post-surgical infection.

Conclusions

Laparoscopic management of DIE is an option to be considered with a 5% of complication frequency. Randomized studies with a control group are required for a better evaluation of safety and efficacy.

Ureteroureteral anastomosis for endometriosis involving the ureter: Case series and literature review

Introduction:

The purpose of this study was to review operative management of endometriosis involving the ureter.

Materials and methods:

Retrospective case series of three patients undergoing resection of ureteral endometriosis with ureteroureterostomy for endometriosis involving the ureter by minimally invasive gynecologic surgeons between 2007 and 2018 at a large academic medical center in the Northeastern United States. A literature review was conducted to find cases with a similar approach.

Results:

Three cases of ureteral endometriosis surgically managed at our institution with ureteroureteral anastomosis were identified. Ureteral endometriosis was identified preoperatively by hydroureteronephrosis on imaging. Intrinsic ureteral endometriosis was confirmed by pathology in two cases; extrinsic endometriosis was grossly visualized in one case. Operative times ranged from 300 to 387 min. Estimated blood loss ranged from 150 to 250 mL. There were no intraoperative complications. A total of 151 cases with a similar approach were described in the literature. Recurrence of obstructive uropathy occurred in 11 cases.

Conclusion:

Ureteral endometriosis is a rare complication with several management options. Ureterectomy with ureteroureterostomy has been described in the literature and in three cases at our institution with low complication rates and rare stricture formation. This technique can be successful in the management of ureteral endometriosis and warrants further investigation.

Postmenopausal Deep Infiltrating Endometriosis of the Colon: Rare Location and Novel Medical Therapy

We report an uncommon case of deep infiltrating endometriosis of the colon presenting as iron deficiency anemia nine years after hysterectomy with bilateral salpingo-oophorectomy. The endometrial implant was found at the hepatic flexure, an exceedingly rare location for endometriosis invasion with no cases distinctly reported in the literature. Additionally, the presentation of gastrointestinal endometriosis as iron deficiency anemia is not well documented in the literature. Instead of surgery, we prescribed a novel medical therapeutic approach using conjugated estrogen-bazedoxifene to antagonize the proliferative effects of estrogen on endometrial tissue. After five months of therapy and repeat colonoscopy, no evidence of endometrial tissue remained in the hepatic flexure.

Correlation of polypeptide N-acetylgalactosamine transferases-3 and -6 to different stages of endometriosis

PURPOSE

To investigate the expression patterns of N-acetyl galactosamine transferases (GalNAc-Ts)-3 and GalNAc-T6 in clinicopathologically characterized endometriosis (EMS), and to explore their clinical significance.

METHODS

Ectopic and eutopic endometrial tissue samples were obtained and confirmed with CD-10 immunohistochemistry in patients with EMS (n = 12), whereas normal control endometrium was obtained from patients with uterine septum (n = 12). The mRNA and protein levels of GalNAc-T3 and GalNAc-T6 were detected in these samples using quantitative real-time PCR, immunohistochemistry, and western blotting.

RESULTS

GalNAc-T3 and GalNAc-T6 were expressed in the endometrium of all groups, with no significant changes observed during the menstrual cycle. The expression of GalNAc-T3 and GalNAc-T6 in ectopic endometrium was significantly lower than that in eutopic (P < 0.05) or control endometrium (P < 0.05), whereas there were no significant differences (P > 0.05) between eutopic and control endometria. Furthermore, the expression of GalNAc-T3 and GalNAc-T6 was significantly lower in patients with stage III/IV EMS compared to patients with stage I/II (P < 0.05).

CONCLUSIONS

Both GalNAc-T3 and GalNAc-T6 expression levels were downregulated in ectopic endometrium, which may increase the adhesion and invasion of endometrial cells and contribute to the development of EMS. Moreover, we found a strong correlation between the expression of GalNAc-T3 and GalNAc-T6 and different stages of EMS.

Endometriosis with an acute colon obstruction: a case report

Introduction

The presentation of an acute bowel obstruction caused by endometriosis in an emergency department setting is rare, as it usually presents through years of complaints in the absence of a distinct acute onset. In this report, we present a case of a patient who was familiar with abdominal complaints and eventually required emergency surgery to treat an acute bowel obstruction caused by endometriosis. Endometrioses present infrequently in the acute phase, and only a few cases in which emergency surgery was required have been described in the literature.

Case presentation

A 31-year-old Caucasian woman presented to the emergency room of our hospital with a distended abdomen, pain and nausea accompanied by a history of 14 years of chronic abdominal pain and constipation. An abdominal X-ray and subsequent computed tomographic scan showed a severely distended cecum of 9cm with stenosis in the sigmoid. Cecal blow-out was considered highly likely, and, during an emergency laparotomy, an obstructing process was found in the sigmoid. An oncologic resection of the sigmoid was performed with a primary anastomosis and loop ileostomy. A pathological examination revealed a tumor of 4cm in the sigmoid, which contained a tubelike structure with cytogenic stroma and the remains of focal bleeding. These are typical aspects of endometriosis.

Conclusions

Infiltrating endometriosis is an invalidating disease that can be misdiagnosed for a wide range of other diseases. Emergency room physicians and surgeons should be aware that it can present as an acute obstruction and should be considered in diagnosing women of childbearing age. After initial colonoscopy, emergency surgery is the best therapeutic approach if there is a complete obstruction.