Double-contrast barium enema and transrectal endoscopic ultrasonography in the diagnosis of intestinal deeply infiltrating endometriosis

STUDY OBJECTIVE: To evaluate the sensitivity, specificity, negative predictive value, positive predictive value, association, and agreement of double-contrast barium enema (DCBE) and transrectal endoscopic ultrasonography (Tr EUS) in the diagnosis of rectosigmoid colon endometriosis. DESIGN: Prospective nonrandomized (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS: We evaluated 37 patients with clinically suspected deeply infiltrating endometriosis (DIE) from January 2004 through January 2005. INTERVENTIONS: Clinical examination, DCBE, Tr EUS, and laparoscopy for histologic confirmation. MEASUREMENTS AND MAIN RESULTS: Deeply infiltrating endometriosis was confirmed by laparoscopic visualization and by histopathologic examination in all patients. Intestinal endometriosis was observed in 27 patients (72.9%). DCBE showed abnormalities suggestive of bowel endometriosis in 24 patients (64.9%) and Tr EUS in 28 patients (75.7%). Considering the DCBE findings we observed among the 24 abnormal examination results, 16 (42.3%) had spiculation, 16 (42.3%) had circumferential narrowing of the bowel, and 4 (10.8%) had the mass effect sign. For DCBE the sensitivity was 88%, the specificity was 54%, the negative predictive value (NPV) was 70%, and the positive predictive value (PPV) was 78%. For Tr EUS the sensitivity, specificity, NPV, and PPV were 96%, 100%, 90%, and 100%. A significant association of the DCBE and the Tr EUS in the diagnosis of intestinal DIE (p = .017) and a moderate agreement of the methods (kappa = 0.44) was also observed. CONCLUSION: Our data, although limited by sample size, confirmed that DCBE has a good sensitivity and a low specificity in the diagnosis of intestinal DIE. The Tr EUS proved to have a higher sensitivity and specificity with elevated NPV and PPV. A significant association of the DCBE and the Tr EUS in the diagnosis of intestinal DIE and a moderate agreement of the methods was also observed.     

Preoperative double-contrast barium enema in patients with suspected intestinal endometriosis

STUDY OBJECTIVES: To assess the usefulness of double-contrast barium enema (DCBE) in the diagnosis of endometriotic lesions of the bowel and to define its potential value in preoperative decision making for intestinal surgery. DESIGN: Retrospective study (Canadian Task Force classification II-2). SETTING: General hospital with a specialized endometriosis unit. PATIENTS: One hundred and eight women with symptoms suggestive of intestinal endometriosis who underwent DCBE before laparoscopic surgery. INTERVENTION: Laparoscopic complete excision of endometriosis. MEASUREMENTS AND MAIN RESULTS: Fifty-five patients were found to have an entirely normal colon on DCBE studies. Twenty-eight of these were found to have adhesions of the bowel at laparoscopy. Radiographic abnormalities suggestive of endometriosis were detected in 53 patients; 20 of these underwent laparoscopic bowel segmental resection, 10 laparoscopic full-thickness disc excision, 4 laparoscopic mucosal skinning, and 4 total laparoscopic hysterectomy with bilateral salpingo-oophorectomies. Fourteen patients refused intestinal surgery. One patient had no endometriosis but severe adhesions. In all cases but one, the radiographic findings on DCBE were confirmed by surgery and with histopathologic examination of the resected specimens (accuracy 99%). In these same cases, the preoperative choice of intestinal surgery remained unchanged during the procedure. CONCLUSION: Our data show that, in expert hands, DCBE correlated with a patient's clinical history and clinical findings is capable of diagnosing bowel wall involvement due to endometriosis, which could require intestinal surgery. This allows for proper preoperative planning of surgical procedures and a thorough informed consent.     

Ultrasonography for bowel endometriosis

Transvaginal ultrasonography (TVS) should be the first-line investigation in patients with suspicion of deep endometriosis and, in particular, of rectosigmoid endometriosis. TVS cannot assess the presence of intestinal nodules located proximally to the sigmoid (such as ileal or cecal endometriotic nodules), because these lesions are beyond the field of the transvaginal probe. The ultrasonographic findings of rectosigmoid endometriosis are the presence of an irregular hypoechoic nodule in the anterior wall of the rectosigmoid colon. The learning curve for diagnosing rectosigmoid endometriosis by TVS is quite short; approximately, 40 scans are required to a sonographer who trained in general gynecologic ultrasonography to become proficient at diagnosing bowel endometriosis. Several meta-analyses confirmed the high diagnostic performance of TVS in diagnosing rectosigmoid endometriosis. The presence of “soft markers” (negative sliding sign and kissing ovaries) facilitates the diagnosis of rectosigmoid endometriosis. Enhanced TVS (rectal water-contrast transvaginal ultrasonography, sonovaginography, and tenderness-guided transvaginal ultrasonography) does not improve the performance of TVS in diagnosing rectosigmoid endometriosis. These investigations, however, may be useful to ascertain the depth of infiltration of endometriosis in the intestinal wall or the presence of rectal stenosis. Magnetic resonance imaging has the same performance of TVS in diagnosing rectosigmoid endometriosis; however, it should be recommended as a second-line technique in the preoperative workup of patients with previous equivocal TVS findings.     

Postoperative Bowel Symptoms Improve over Time after Rectosigmoidectomy for Endometriosis

Study ObjectiveTo evaluate bowel function (changes in stool caliber, sensation of incomplete evacuation, stooling frequency, and rectal bleeding) and urinary function (dysuria and retention) after segmental resection in patients with bowel endometriosis.DesignRetrospective study.SettingTertiary hospital.PatientsA total of 413 (mean age = 33.6 ± 5.1 years) of reproductive aged women, with bowel endometriosis that underwent segmental bowel resection of the rectosigmoid from 2005 to 2018, without history of prior bowel surgery, without existing or history of malignancy.InterventionsLaparoscopic segmental bowel resection performed by the same team and with the same technique.Measurements and Main ResultsData collected from the patients’ records included length of resected segment, distance of the lesion from the anal verge, and complications. Information on intestinal and urinary function was obtained from a questionnaire applied before the surgery and at 2, 6, and 12 months after the surgery. There was a significant increase in the incidence of stool thinning and rectal bleeding 2 months after surgical procedure; these symptoms decreased significantly over time. The incidence of urinary symptoms decreased significantly over time after surgery. The length of the bowel segment resected was not associated with the postoperative symptoms, but the rectosigmoid lesion was significantly closer to the anal verge in patients with rectal bleeding and urinary symptoms. There was no association between the length of intestinal segment resected and the frequency of stooling. At 6 months, patients who had a decreased frequency of stooling underwent a resection closer to the anal verge (9.7 cm) in comparison with the ones with unchanged or increase frequency of stooling (10.1 cm and 10.7 cm, respectively; p <.05).ConclusionPatient complaints on bowel and urinary alterations after segmental resection were transient with significant improvement over time up to 12 months. Bowel and urinary symptoms were not associated with the size of the bowel segment resected, whereas rectal bleeding at 2 months after surgery was significantly associated with the distance from anal verge. Segmental resection was also associated with a great improvement in constipation at 12 months postoperative.     

Laparoscopic Technique for Discoid Resection of Rectal Endometriotic Nodules

ObjectiveTo show the surgical steps used to perform a rectal disc excision in the context of deep infiltrating endometriosis characterized by contiguity between an intestinal lesion and the retrocervical region.DesignStep-by-step video demonstration of the technique.SettingAlthough surgical options for the management of rectosigmoid endometriosis have been investigated increasingly, there is no consensus regarding patient eligibility for shaving, discoid resection, or segmental resection. In our practice, women with nodules ≤3 cm in size and >7 mm deep were considered as candidates for rectosigmoid disc excision [1]. Therefore patients’ selection, together with the adoption of a standardized surgical technique, has allowed us to maximize the chance of a successful discoid resection, minimizing the complications potentially derivable from this surgical procedure.InterventionsThe patient was a 30-year-old woman with a history of constipation, dyschezia, dysmenorrhea, dyspareunia, and chronic pelvic pain unresponsive to hormonal therapies. A preoperative ultrasonography showed complete obliteration of the pouch of Douglas owing to a rectal endometriotic nodule (21 × 7 × 12 mm) in contiguity with a deeply infiltrating retrocervical lesion (28 × 10 × 27 mm). As a result, the rectal nodule infiltrated the tunica muscularis with a distance from the anal verge of 9 cm and an estimated stenosis of 35%. A 3-dimensional laparoscopy was performed. After rectal mobilization and rectovaginal space opening, the intestinal nodule was isolated in its entire circumference (Fig. 1). A 33-mm transanal circular stapler was inserted into the rectum through the anus and used to perform disc excision and suture the rectal wall. The overall operative time was 55 minutes. No intraoperative complication occurred. A complete excision of endometriosis was achieved. The estimated blood loss was 10 mL. An intra-abdominal drain was not placed, and the urinary catheter was removed at the end of the surgery. The patient was discharged 3 days after surgery and did not experience postoperative complications. The diameters of the bowel endometriotic nodule, on measuring fresh specimen, were 20 × 7 × 13 mm.ConclusionsAdvanced laparoscopic surgical skills are needed to perform an effective and safe rectal discoid resection. Subspecialization and an adequate preoperative evaluation are of utmost importance to appropriately plan the treatment strategy against bowel endometriosis.     

Diagnosis and management of intestinal endometriosis. A report of five cases

Five cases of intestinal endometriosis presented with infertility and pelvic pain. Rectal bleeding occurred in two patients and diarrhea in one. A diagnosis was achieved with a barium enema study and colonoscopy. All the patients had pelvic endometriosis as documented by laparoscopy. Endometriosis was present in the sigmoid colon in three patients and in the cecum in one; it was pericecal in the fifth. Bowel resection and pathologic study are necessary to relieve the symptoms and avoid neglecting a malignant tumor or other lesions.     

Surgical Principles of Segmental Rectosigmoid Resection and Reanastomosis for Deep Infiltrating Endometriosis

Study ObjectiveTo demonstrate the surgical steps involved in segmental rectosigmoid resection and reanastomosis in a deep infiltrating endometriosis (DIE) setting.DesignStep-by-step video demonstration of the technique.SettingDespite efforts made to identify criteria able to reliably predict which patients would be more likely to benefit from segmental bowel resection, such predictability remains an area of controversy and ambiguity. Furthermore, a standardized surgical technique has not yet been defined. Based on our experience, patients with DIE and colorectal involvement should be considered for segmental resection followed by anastomosis if they present with lesions not suitable for shaving/nodulectomy (i.e., large, deeply infiltrating nodules with extensive circumferential involvement). In our practice, careful patient selection together with the adoption of a standardized surgical technique allowed us to minimize the potential complications associated with segmental bowel resection.InterventionThe patient was a 27-year-old woman diagnosed by ultrasonography with a bowel endometriotic nodule of 33 × 8 × 14 mm infiltrating the inner layer of the muscularis propria at the rectosigmoid junction, with a distance from the anal verge of approximately 12 cm and an estimated stenosis of 50%. A 3-dimensional laparoscopic segmental rectosigmoid resection was performed, and indocyanine green-enhanced fluorescent angiography was used to assess perfusion of the bowel before completion of the anastomosis. The total operative time was 135 minutes, and no intraoperative complications occurred. Complete excision of endometriosis was achieved. The estimated blood loss was 30 mL. An intra-abdominal drain was not placed, and the urinary catheter was removed at the end of surgery. The patient was discharged at 6 days after surgery and did not experience any postoperative complications. The bowel endometriotic nodule measured 34 × 8 × 13 mm in a fresh specimen.ConclusionAdvanced laparoscopic surgical skills are needed to properly perform segmental rectosigmoid resection. Subspecialization and adequate pretreatment evaluation are crucial to ensure the correct decision making process within a complex algorithm for surgical management of bowel endometriosis.     

Pathologies observed in barium enema examination in patients with gynecological disorders

The aim of our study was to analyse retrospectively 171 patients with gynaecological diseases, who have undergone barium enema examination in Third Teaching Hospital in Poznań between 1992 and 1998. 79 patients were diagnosed with ovarian tumours, in 24 cases their colon was dislocated. Stenosis was detected in 20 women and in five situations inflammatory changes of the colon were present. Malignant infiltration of large intestine was suspected in ten patients. The second group included 24 women diagnosed with tubo-ovarian abscesses and adnexitis. Three of them had dislocated colons. Stenosis of large bowel was detected in 11 patients and inflammatory changes in 8. In the next group of 35 patients' myoma uteri, myometrial endometriosis and carcinoma of colli uteri were detected. Barium enema examination revealed that 10 women had dislocated colons. In the third group stenosis was detected in eight cases, two patients had radiological signs of cancer infiltration and twice inflammatory changes of the large bowel were present. Frequency of radiological changes in barium enema examination was evaluated in the aforementioned groups. Results were compared with group of 33 patients treated for endocrinological disorders, sterility and minor pelvis pain syndrome. Frequency of dislocation of colon was compared with size of changes of ovaries measured during ultrasound examination. Our results showed that barium enema is still an important supplementary examination, which can give a great deal of beneficial information concerning the clinical condition of the patient. This procedure is useful before surgical intervention especially in cases of suspected ovarian cancer. We must underline that the same or similar information can be obtained using other methods without such radiation exposure.     

MRI of intestinal endometriosis

Endometriosis is a common gynecological condition of unknown etiology, which mainly affects women of reproductive age. The commonest site of gastrointestinal endometriosis is the rectosigmoid colon. Involvement of the sigmoid, cecum, appendix, and small bowel are less common, but one third of rectosigmoid endometriosis is associated with right-sided extra-pelvic bowel endometriosis. Intestinal endometriosis represents one of the most severe forms of deep endometriosis (DE).Magnetic resonance imaging (MRI) is recommended as a second-line technique in the preoperative workup of DE, especially for gastrointestinal endometriosis. An optimal MRI protocol is required for a complete mapping of endometriotic lesions. MRI could be used as a triage test in the diagnosis of rectosigmoid colon endometriosis. Magnetic resonance enterography should be additionally performed requiring a specific additional MRI protocol for the evaluation of multicentric intestinal endometriotic lesions.Except other imaging techniques, the aim of this chapter is to expose indications for MRI, technical requirements, patient preparation, MRI protocols, and criteria for the diagnosis of intestinal endometriosis.     

Utility of rectal endoscopic ultrasonography for digestive involvement of pelvic endometriosis. Technique and results

Intestinal endometriosis present in up to 37% of cases is difficult to diagnose and treatment remains complex. Until recently barium enema and colonoscopy are the only two diagnostic tools. However there were many drawbacks and technical limitations due to the particular development of the endometrial lesions with frequent respect of the mucosa. Digestive involvement was often preoperative discovery and treatment was frequently incomplete. Development of endoscopic ultrasonography has improved the potential for preoperative diagnosis of digestive endometriosis. Many publications have now demonstrated its utility. Compared to other imaging techniques endoscopic ultrasonography has better sensibility close to 100%. Endoscopic ultrasonography is superior to Magnetic Resonance Imaging for the diagnosis of rectosigmoid endometriosis. Magnetic Resonance Imaging however gives a largest view of the pelvis. Using preoperatively endoscopic ultrasonography in patients who are at risk of digestive involvement will help to choose between different therapeutic modalities and surgical techniques.     

Fertility in patients with untreated rectosigmoid endometriosis

Research questionSeveral studies have investigated reproductive outcomes following surgical treatment of colorectal endometriosis, mainly segmental colorectal resection. This study examines pregnancy and live birth rates of women with rectosigmoid endometriosis not treated by surgery.DesignA retrospective analysis of data collected between May 2009 and January 2020 related to 215 women affected by rectosigmoid endometriosis wishing to conceive. Patients had a diagnosis of rectosigmoid endometriosis by transvaginal ultrasonography and magnetic resonance imaging enema. Patients with estimated bowel stenosis >70% at computed tomographic colonography and/or subocclusive/occlusive symptoms were excluded.ResultsDuring the median length of follow-up of 31 months (range 13–63 months), the total pregnancy and live birth rates of the study population were 47.9% and 45.1%, respectively. Sixty-two women had a live birth after natural conception (28.8%; 95% confidence interval [CI] 22.8–35.6%) with a median time required to conceive of 10 months (range 2–34 months). Eighty-three women underwent infertility treatments (38.6%, 95% CI 32.1–45.5%); among these, 68 patients underwent IVF either directly (n = 51) or after intrauterine insemination (IUI) failure (n = 17). Time to conception was significantly higher in women having conceived by IVF than in those having conceived naturally (P < 0.001) or by IUI (P = 0.006). In patients undergoing IVF cycles, a worsening of some pain and intestinal symptoms was observed.ConclusionsAt median follow-up of 31 months, women with rectosigmoid endometriosis have a 48% pregnancy rate. However, these patients must be referred to centres specialized in managing endometriosis to properly assess symptoms and degree of bowel stenosis.     

Assessment of Nerve Fiber Density and Expression of Hormonal Receptors Within Rectosigmoid Endometriosis Nodules

Study ObjectiveTo assess nerve fiber density and expression of hormone receptors in bowel endometriosis.DesignCross-sectional study.SettingPrivate hospital.PatientsWomen with endometriosis undergoing laparoscopic segmental bowel resection (n = 54).InterventionsTissue samples were obtained from patients with surgically treated rectosigmoid endometriosis.Measurements and Main ResultsThe rectosigmoid specimen containing the endometriosis nodule was manually sectioned and divided into 3 areas: core of the nodule, margin of the nodule, and healthy bowel tissue. The intensity of expression of estrogen and progesterone receptors was evaluated by immunohistochemistry and measured according to the Allred score. Nerve fibers were stained by immunohistochemistry using Protein Gene Product 9.5, and the density of nerve fillets was counted and expressed in number/mm². All glandular and stromal cells stained for estrogen; however, glandular cells stained more strongly than stromal cells (61.1% vs 35.2%; p = .01). Most of glandular and stromal cells stained strongly for progesterone receptors (90.7% vs 98.1%; p = .2). The density of nerve fibers was very high in the margin of the nodule (172.22±45.66/mm²), moderate in healthy bowel tissue (111.48±48.57/mm²), and very low in the core of the nodule (7.31±4.9/mm²); p = .01.ConclusionBoth glandular and stromal cells within the rectosigmoid endometriosis nodule express estrogen and progesterone receptors. Higher intensity of expression of estrogen receptors occurs in glandular cells. The density of nerve fibers is extremely high at the nodule margin and very low in the center of the nodule.     

Bowel endometriosis: presentation, diagnosis, and treatment

Bowel endometriosis opens a new frontier for the gynecologist, as it forces the understanding of a new anatomy, a new physiology, and a new pathology. Although some women with bowel endometriosis may be asymptomatic, the majority of them develop a variety of gastrointestinal complains. No clear guideline exists for the evaluation of patients with suspected bowel endometriosis. Given the fact that, besides rectal nodules, bowel endometriosis can not be diagnosed by physical examination, imaging techniques should be used. Several techniques have been proposed for the diagnosis of bowel endometriosis including double-contrast barium enema, transvaginal ultrasonography, rectal endoscopic ultrasonography, magnetic resonance imaging, and multislice computed tomography enteroclysis. Medical management of bowel endometriosis is currently speculative; expectant management should be carefully balanced with the severity of symptoms and the feasibility of prolonged follow-up. Several studies demonstrated an improvement in quality of life after extensive surgical excision of the disease. Bowel endometriotic nodules can be removed by various techniques: mucosal skinning, nodulectomy, full thickness disc resection, and segmental resection. Although the indications for colorectal resection are controversial, recent data suggest that aggressive surgery improves symptoms and quality of life. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader should be able to describe the varied appearance of bowel endometriosis, recall that it is difficult to diagnose preoperatively, and explain that surgical treatment offers the best treatment in symptomatic patients through a variety of surgical techniques which is best accomplished with a team approach.     

Endometriosis causing extensive intestinal obstruction simulating carcinoma of the sigmoid colon: a case report and review of the literature

Endometriosis with intestinal serosal involvement is not uncommon in women of childbearing age, however, presentation as colon obstruction is rare. Lack of pathognomonic symptoms makes diagnosis difficult, the main problem being differential diagnosis with neoplasm, even intraoperatively. Reported here is a case of extensive bowel obstruction due to sigmoid colon endometriosis in a 43-year-old woman who presented with signs and symptoms of bowel obstruction. Barium enema showed sigmoid obstruction; subsequent exploratory laparotomy showed the sigmoid colon surrounded by fibrous tissue, leading to its angulation and extensive lumen obstruction. Left oophorectomy and radical resection of descending and sigmoid colon as for bowel carcinoma were successfully employed. Pathological examination revealed endometriosis in the bowel wall with preservation of the mucosa. Aetiology, clinical presentation, differential diagnosis and therapeutic options for intestinal obstruction due to endometriosis are discussed.     

Deep endometriosis: definition, diagnosis, and treatment

Deep endometriosis, defined as adenomyosis externa, mostly presents as a single nodule, larger than 1 cm in diameter, in the vesicouterine fold or close to the lower 20 cm of the bowel. When diagnosed, most nodules are no longer progressive. In >95% of cases, deep endometriosis is associated with very severe pain (in >95%) and is probably a cofactor in infertility. Its prevalence is estimated to be 1%?-2%. Deep endometriosis is suspected clinically and can be confirmed by ultrasonography or magnetic resonance imaging. Contrast enema is useful to evaluate the degree of sigmoid occlusion. Surgery requires expertise to identify smaller nodules in the bowel wall, and difficulty increases with the size of the nodules. Excision is feasible in over 90% of cases often requiring suture of the bowel muscularis or full-thickness defects. Segmental bowel resections are rarely needed except for sigmoid nodules. Deep endometriosis often involves the ureter causing hydronephrosis in some 5% of cases. The latter is associated with 18% ureteral lesions. Deep endometriosis surgery is associated with late complications such as late bowel and ureteral perforations, and recto-vaginal and uretero-vaginal fistulas. Although rare, these complications require expertise in follow-up and laparoscopic management. Pain relief after surgery is excellent and some 50% of women will conceive spontaneously, despite often severe adhesions after surgery. Recurrence of deep endometriosis is rare. In conclusion, defined as adenomyosis externa, deep endometriosis is a rarely a progressive and recurrent disease. The treatment of choice is surgical excision, while bowel resection should be avoided, except for the sigmoid.     

The Utility of Pretreatment Barium Enema in Women with Endometrial Carcinoma

Objective.The objective of this study was to assess the clinical utility of a pretreatment barium enema in women with endometrial cancer.Methods.The medical records of 249 patients with endometrial cancer who underwent a pretreatment barium enema were retrospectively reviewed. The patients’ charts were abstracted for demographic information, stage, grade, histology, current disease status, and barium enema results.Results.The pretreatment barium enema was normal in 122 (49%) patients. Diverticulosis was the most common abnormality, reported in 112 (45%) patients. Apparent intraluminal abnormalities were found in 15 (6.0%) patients. Each of these patients underwent colonoscopy prior to treatment for endometrial carcinoma. During colonoscopy, benign colonic polyps were removed from 11 (4.4%) patients. Primary colonic adenocarcinoma was discovered in polypoid lesions removed from 2 (0.8%) patients. Significant luminal narrowing from extrinsic lesions was noted in 2 (0.8%) patients, one at the rectosigmoid and the other at the cecum. No patient was found to have colonic mucosal involvement by endometrial cancer.Conclusion.The results of this study do not justify routine pretreatment barium enema to assess the colonic mucosa for metastatic involvement by endometrial cancer or as a screening tool for colorectal cancer in women with endometrial cancer.     

ENZIAN-score, a classification of deep infiltrating endometriosis

The ENZIAN-Score is presented as a new instrument to classify the deep infiltrating endometriosis. Especially the retroperitoneal part of the severe endometriosis is focussed on. In analogy to an oncological staging four different stages are pronounced. The localisation and the expansion of the endometriosis nodule was indicated to different subgroups. The still used rAFS-score is of no clinical evidence, as we pointed out in a retrospective study of our patients with severe intestinal endometriosis.     

Patients with endometriosis of the rectosigmoid have a higher percentage of natural killer cells in peripheral blood

Study ObjectiveTo estimate the concentration of natural killer (NK) cells in the peripheral blood in patients with and without endometriosis.DesignCase-control study (Canadian Task Force classification II-2).SettingTertiary referral hospital.PatientsOne hundred fifty-five patients who had undergone videolaparoscopy were divided into 2 groups: those with endometriosis (n = 100) and those without endometriosis (n = 55).InterventionsThe percentage of NK cells relative to peripheral lymphocytes was quantified at flow cytometry in 155 patients who had undergone laparoscopy. In addition to verifying the presence of endometriosis, stage of disease and the sites affected were also evaluated.Measurements and Main ResultsThe mean (SD) percentage of NK cells was higher (15.3% [9.8%]) in patients with endometriosis than in the group without the disease (10.6% [5.8%]) (p < .001). The percentage of NK cells was highest (19.8 [10.3%]) in patients with advanced stages of endometriosis and in those in whom the rectosigmoid colon was affected. In a statistical model of probability, the association of this marker (NK cells ≥11%) with the presence of symptoms such as pain and intestinal bleeding during menstruation and the absence of previous pregnancy yielded a 78% likelihood of the rectosigmoid colon being affected.ConclusionCompared with patients without endometriosis, those with endometriosis demonstrate a higher concentration of peripheral NK cells. The percentage of NK cells is greater, primarily in patients with advanced stages of endometriosis involving the rectosigmoid colon. Therefore, it may serve as a diagnostic marker for this type of severe endometriosis, in particular if considered in conjunction with the symptoms.     

94 months follow-up after laparoscopic assisted vaginal resection of septum rectovaginale and rectosigmoid in women with deep infiltrating endometriosis

Background  

Endometriosis with bowel involvement is the most invasive form and can cause infertility, chronic pelvic pain and bowel symptoms. Effective surgical treatment of endometriosis requires complete excision of endometriosis and in same case may require segmental rectosigmoid resection.