Traitement chirurgical de l’endométriose rectale

[Rectal endometriosis: An exceptional etiology of acute intestinal occlusion]

The intestinal occlusion acute is an emergency and therapeutic diagnostic. A rectal tumor is rarely the cause in a young adult. We are carrying the case of a patient of 43years old, received at emergency on a board of intestinal occlusion acute due to a rectal tumor of a fortuitous discovery during the operation. The final diagnosis after a histopathologic examination was for the less unexpected. It was rectal endometriosis in its tumor-like. A complementary medical care obtains satisfactory results.

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

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

Rectal Endometriosis: An Exceptional Cause of Large-Bowel Obstruction

Acute large-bowel obstruction (LBO) is an emergency condition that requires early identification and intervention. A rectal tumor is rarely the cause in a young adult. We report the case of a 43-year-old patient who received emergency surgery for an LBO. A rectal tumor was fortuitously discovered during the operation. However, histopathologic examination revealed that the tumor-like mass was in fact rectal endometriosis. Appropriate medical care was established and obtained satisfactory results.

MAP kinases and the inflammatory signaling cascade as targets for the treatment of endometriosis?

INTRODUCTION

The pathogenesis of endometriosis, a common benign disease, remains ill-defined, although it is clear that chronic inflammation plays a crucial role through mitogen-activated protein kinase (MAPK) signaling pathways. All current medical therapies for endometriosis are antigonadotropic, and therefore have a contraceptive effect. A concerted research effort is hence warranted with the aim of delivering novel therapeutics that reduces disease symptoms without blocking ovulation.

AREAS COVERED

The authors review the complex pathogenic mechanisms of chronic inflammation in endometriosis and their relationships with MAPK pathways. The authors conducted a literature search of descriptive and functional targeted validation of MAPK in the pathogenesis of endometriosis. The effects of MAPK inhibitors, which constitute potential agents for future treatments, are also described.

EXPERT OPINION

Preliminary studies have highlighted a crucial role for MAPK in driving endometriosis-related inflammation. MAPK inhibitors exhibit potent activity in terms of controlling growth of endometriosis lesions both in vitro and in animal models. As MAPK inhibitors are known to have a multitude of undesirable side effects, their use in humans has to be approached with great care. Indeed, use of these drugs would probably be limited to short exposures prior to surgery in cases involving the most severe disease phenotypes.

Inhibition of MAPK and VEGFR by Sorafenib Controls the Progression of Endometriosis

INTRODUCTION

Sorafenib is a strong multikinase inhibitor targeting 2 different pathways of endometriosis pathogenesis: RAF kinase and vascular endothelial growth factor receptor (VEGFR). We investigate whether Sorafenib could control the growth of endometriotic lesions both in vitro and in vivo.

METHODS

Stromal primary cells were extracted from endometrial and endometriotic biopsies from patients with (n = 10) and without (n = 10) endometriosis. Proliferation, apoptosis, mitogen-activated protein kinases, and VEGFR-2 autophosphorylation were explored with and without Sorafenib treatment. Human endometriotic lesions were implanted in 30 nude mice randomized according to Sorafenib or placebo treatment.

RESULTS

Treating endometriotic cells with Sorafenib abrogated the phosphorylation of extracellular signal-regulated kinase in stromal cells of women with endometriosis compared to controls. In addition, this study highlights the antiangiogenic role of Sorafenib which translates as a decreased phosphorylated VEGFR-2-VEGFR-2 ratio in endometriosis. Using a xenogenic mouse model of endometriosis, we confirmed that Sorafenib regulates the endometriosis activity in vivo by targeting endometriosis-related proliferation and inflammation.

CONCLUSION

Our data suggest that Sorafenib controls the growth of endometriotic lesions in vitro and in vivo.

Robotic hybrid technique in rectal surgery for deep pelvic endometriosis

BACKGROUND

Deep pelvic endometriosis is a complex disorder that affects 6% to 12% of all women in childbearing age. The incidence of bowel endometriosis ranges between 5.3% and 12%, with rectum and sigma being the most frequently involved tracts, accounting for about 80% of cases. It has been reported that segmental colorectal resection is the best surgical option in terms of recurrence rate and improvement of symptoms. The aim of this study is to analyze indications, feasibility, limits, and short-term results of robotic (Da Vinci Surgical System)-assisted laparoscopic rectal sigmoidectomy for the treatment of deep pelvic endometriosis.

PATIENTS AND METHODS

Between January 2006 and December 2010, 19 women with bowel endometriosis underwent colorectal resection through the robotic-assisted laparoscopic approach. Intraoperative and postoperative data were collected. All procedures were performed in a single center and short-term complications were evaluated.

RESULTS

Nineteen robotic-assisted laparoscopic colorectal resections for infiltrating endometriosis were achieved. Additional procedures were performed in 7 patients (37%). No laparotomic conversion was performed. No intraoperative complications were observed. The mean operative time was 370 minutes (range = 250-720 minutes), and the estimated blood loss was 250 mL (range = 50-350 mL). The overall complication rate was 10% (2 rectovaginal fistulae).

CONCLUSIONS

Deep pelvic endometriosis is a benign condition but may have substantial impact on quality of life due to severe pelvic symptoms. We believe that robotic-assisted laparoscopic colorectal resection is a feasible and relatively safe procedure in the context of close collaboration between gynecologists and surgeons for treatment of deep pelvic endometriosis with intestinal involvement, with low rates of complications and significant improvement of intestinal symptoms.

[Surgical and functional results of rectosigmoidal resection for severe endometriosis]

OBJECTIVES

Indications of colorectal resection for endometriosis are controversial because of the risk of major complications. This study aims to evaluate the value of different diagnostic tests in decision-making, and to evaluate the surgical results and complications, as well as long-term functional results after surgery.

PATIENTS AND METHODS

In the set of a retrospective case series, 50 patients who have been admitted for a colorectal resection because of deep endometriosis were included. Most of them have had an MRI and an endorectal ultrasonography. Specific questionnaires have been proposed in order to evaluate symptoms, sexuality (BISF-W) and quality of life (EHP-30).

RESULTS

For the diagnosis of rectal involvement, the sensitivity of MRI and endorectal ultrasonography were 55 and 100%, respectively. Forty-one colorectal amputations and nine partial colorectal resections have been done by 24 laparotomies, two laparoscopies and 24 laparoconversions. Major complications included six (12.5%) digestive fistulas, three (6%) anastomotic strictures, one ureterovaginal fistula and one ureteral stricture. Risk factors associated with digestive fistulas were the association of a vaginal opening (p=0.002) and an additional ileocaecal resection (p=0.007). The mean follow-up period was of 42 months. A significant improvement of dysmenorrhea (p<10(-4)), dyschesia (p<10(-4)), chronic pelvic pain (p<10(-4)), and of some digestive symptoms such as catamenial epreintes (p=0.002) and catamenial diarrheas (p=0.006), was noted. We noted postoperative 14 dysurias, six constipations and 12 rectal polykynesias. Four patients have had deep recurrent lesions. Twenty patients had a desire of pregnancy after the operation, 17 pregnancies were obtained (eight spontaneous and nine by ART) giving birth to 14 living children. Sexuality evaluation was below normal range. The quality of life was improved for most of the items. The global satisfaction was good (91%).

DISCUSSION AND CONCLUSION

Colorectal resection for deep endometriosis improve significantly most of the pain symptoms, but the women should have detailed counselling about the risks of major complications and recurrence.