Fast-Track Surgery in Intestinal Deep Infiltrating Endometriosis

Study ObjectiveTo evaluate the length of hospital stay (LOS) and the readmission rate in patients undergoing laparoscopic surgery to treat intestinal deep infiltrating endometriosis (DIE) with application of the concepts of fast-track surgery.DesignRetrospective study of women undergoing laparoscopic treatment of intestinal DIE (Canadian Task Force classification II-3).SettingTertiary referral private hospital.InterventionsWe evaluated 161 women who underwent laparoscopic surgery between January 2010 and April 2013 for complete treatment of intestinal DIE, via either conservative surgery (rectal shaving, mucosal skinning, or anterior disk resection) or radical surgery (segmental bowel resection). After surgery, all specimens were sent for pathologic examination to confirm the presence of endometriosis.Measurements and Main ResultsPatients were divided into 2 groups according to type of surgery (conservative [n = 102] or radical [n = 59]), and LOS and readmission rate were measured in both groups. Median LOS was shorter in the conservative group compared with the segmental bowel resection group (19 vs 28 hours; p < .001). Ninety-two patients (90.2%) in the conservative surgery group were discharged to home on the first postoperative day, compared with only 38 patients (64.4%) in the segmental bowel resection group. Overall, the readmission rate was low (3.1%): 6.8% in the segmental bowel resection group and 1% in the conservative group (p = .04; odds ratio, 7.34; 95% confidence interval, 0.8–67.3); however, the need for repeat operation was similar in both groups (3.4% vs 1%; p = .28; odds ratio, 3.54; 95% confidence interval, 0.31–39.95).ConclusionImplementation of fast-track concepts in the laparoscopic treatment of intestinal DIE resulted in a short LOS and low readmission rate in both the segmental bowel resection and conservative surgery groups.     

深部浸润型子宫内膜异位症相关肠道功能紊乱的研究进展

深部浸润型子宫内膜异位症（deeply infiltrating endometriosis,DIE）是子宫内膜异位症（endometriosis,EMs）最严重的类型,其伴随的周期性的排便痛、便血、肠绞痛、腹泻腹胀,甚至肠梗阻等肠道症状严重影响患者的生活和工作质量,但临床重视不足。目前,手术仍然是有症状的DIE患者首选的治疗方式,但关于手术对患者肠道症状的改善程度以及术后新发的肠道功能紊乱尚没有明确的临床研究。影响患者术后肠道功能恢复的因素有很多,因此术前需通过多种方法详细评估其肠道功能,联合多学科协同制定治疗方案,并在术后进一步探讨可能改善肠道功能的方法,从而改善患者肠道症状,促进其全面康复。     

Sexual Function in Patients with Deep Infiltrating Endometriosis

IntroductionEndometriosis is a benign condition that causes pain and infertility. Sexual dysfunction, particularly deep dyspareunia, is common in patients with endometriosis and interferes with quality of life and conjugal satisfaction.AimThe study aims to assess sexual function in women with deep infiltrating endometriosis.MethodFifty-seven women diagnosed with deep infiltrating endometriosis were recruited from Hospital Universitário Pedro Ernesto (HUPE) between July and December 2011. The control group comprised 38 healthy women recruited at the HUPE family planning clinic.Main Outcome MeasuresThe main outcomes are full-scale and individual domain scores on the Female Sexual Function Index (FSFI), a validated questionnaire for functional assessment of sexual function in women.ResultsPatients with endometriosis had more pain in intercourse than controls, which correlates with lower scores in the FSFI pain domain. However, there were no statistically significant between-group differences in overall (full-scale) FSFI scores.ConclusionWomen with endometriosis exhibit significant dysfunction in the pain domain of the FSFI questionnaire, but this finding was not sufficient to affect the overall sexual function. Evangelista A, Dantas T, Zendron C, Soares T, Vaz G, and Oliveira MAP. Sexual function in patients with deep infiltrating endometriosis. J Sex Med 2014;11:140–145.     

深部浸润型子宫内膜异位症的诊断研究新进展

深部浸润型子宫内膜异位症（deep infiltrating endometriosis,DIE）是子宫内膜异位症（endometriosis,EMs）的一种特殊类型,其特指浸润深度≥5 mm的EMs病灶。其可累及盆腔不同部位,主要位于后盆腔,如宫骶韧带、直肠阴道隔和结直肠等。目前诊断DIE的方法有多种,如病史问诊、妇科检查、超声、磁共振成像（MRI）、腹腔镜探查结合病理检查,但由于操作者经验不足或技术的局限性等原因,临床上有多数患者被误诊或漏诊。目前研究者们针对DIE的检出率低提出了改良方法,如3D或4D超声、融合成像、3D-MRI、多层螺旋CT结肠水膨胀（msCT-c）技术等,可能提高DIE的诊断率。     

深部浸润型子宫内膜异位症的治疗研究新进展

深部浸润型子宫内膜异位症（deep infiltrating endometriosis,DIE）是子宫内膜异位症（endometriosis,EMs）的一种特殊类型,其特指浸润深度≥5 mm的EMs病灶,可累及盆腔不同部位,主要位于后盆腔,如宫骶韧带、子宫直肠陷凹、阴道直肠隔和结直肠等。疼痛是其主要临床症状,且形式多样,包括痛经、慢性盆腔痛、深部性交痛及泌尿消化系统相关的疼痛等。目前DIE的治疗主要以手术为主,但手术困难、手术安全、术后并发症较难避免等均是非常棘手的问题。研究者据此提出的保留神经功能的病灶切除术,机器人辅助腹腔镜手术等方法正在被探究中。综述DIE的治疗研究新进展。     

深部浸润型子宫内膜异位症手术治疗进展

手术治疗是深部浸润型子宫内膜异位症(DIE)的主要治疗方式。腹腔镜下完整切除DIE病灶具有高疼痛缓解率和低复发率的特点,目前已成为首选治疗方法,但完整DIE病灶切除后导致膀胱和直肠等功能障碍日益受到关注。最近的研究发现,保留盆腔自主神经的DIE手术可避免术后膀胱、直肠以及性功能紊乱。综述近年有关保留盆腔自主神经的DIE手术的治疗进展。     

深部浸润型子宫内膜异位症诊治进展

深部浸润型子宫内膜异位症（DIE）是指子宫内膜异位病灶在腹膜下浸润深度超过5mm，主要分布于直肠子宫陷凹、子宫骶骨韧带、直肠阴道隔、膀胱及肠道。病史及临床症状仍然是DIE诊断的主要线索；妇科检查是DIE诊断的主要手段；阴道超声、核磁共振成像及直肠超声尤其是内镜直肠超声是DIE诊断和分型的重要辅助检查方法；手术治疗是DIE的主要治疗方法。     

深部浸润型子宫内膜异位症诊治进展

深部浸润型子宫内膜异位症(DIE)是指子宫内膜异位病灶在腹膜下浸润深度超过5mm,主要分布于直肠子宫陷凹、子宫骶骨韧带、直肠阴道隔、膀胱及肠道.病史及临床症状仍然是DIE诊断的主要线索;妇科检查是DIE诊断的主要手段;阴道超声、核磁共振成像及直肠超声尤其是内镜直肠超声是DIE诊断和分型的重要辅助检查方法;手术治疗是DIE的主要治疗方法.     

Nerve-sparing Surgery for Deep Infiltrating Endometriosis: Laparoscopic Eradication of Deep Infiltrating Endometriosis with Rectal and Parametrial Resection According to the Negrar Method

ObjectiveTo show technical highlights of a nerve-sparing laparoscopic eradication of deep infiltrating endometriosis with rectal and parametrial resection according to the Negrar method.DesignStepwise demonstration of the technique with narrated video footage.SettingTertiary care endometriosis unit. Bowel endometriosis accounts for about 12% of the total cases of endometriosis. Most frequently, rectal infiltration also means parametrial infiltration from the widespread infiltrating disease. Its removal with inadequate anatomical surgical knowledge may lead to severe damage to visceral pelvic innervation, causing bladder, rectal, and sexual function impairments and lasting lifelong. Nerve-sparing techniques, which are the heritage of onco-gynecologic surgery, have been described to have lower post-operative bladder, rectal, and sexual dysfunctions than classical approaches.InterventionsLaparoscopic excision of deep infiltrating endometriosis was performed by following the nerve-sparing Negrar technique in 6 steps: step 0—adhesiolysis, ovarian surgery, and removal of the involved peritoneal tissues; step 1—opening of pre-sacral space, development of avascular spaces, and identification and preservation of pelvic sympathetic fibers of the inferior mesenteric plexus, superior hypogastric plexus, upper hypogastric nerves, and lumbosacral sympathetic trunk and ganglia; step 2—dissection of parametrial planes, isolation of ureteral course, lateral parametrectomy, and preservation of sympathetic fibers of postero-lateral parametrium and lower mesorectum (the lower hypogastric nerves and proximal part of the inferior hypogastric plexus or pelvic plexus); step 3—posterior parametrectomy, deep uterine vein identification, and preservation of the parasympathetic pelvic splanchnic nerves and the cranial and middle part of the mixed inferior hypogastric plexus in caudad posterior parametrium and lower mesorectal planes; step 4—preserving the caudad part of the inferior hypogastric plexus in postero-lateral parametrial ligaments; step 5—preserving the caudad part of the inferior hypogastric plexus in paravaginal planes; and step 6—rectal resection and colorectal anastomosis.ConclusionAs shown in this case, the laparoscopic nerve-sparing complete excision of endometriosis is a feasible and reproducible technique in expert hands and, as reported in the literature, offers good results in terms of bladder morbidity reduction with higher satisfaction than the classical technique.     

Termino-terminal Ureteral Laparoscopic Anastomosis in a Case of Deep Infiltrating Endometriosis

Study ObjectiveLaparoscopic termino-terminal ureteral anastomosis has all the advantages of a minimally invasive approach in addition to the treatment of the pathologic condition [1]. Ureteral deep endometriosis can lead to severe consequences, such as hydroureteronephrosis and renal failure [2,3]. The main objective of this video is to present our surgical strategy and technique for cases of ureteral deep infiltrating endometriosis, which could help surgeons to understand and perform this surgery in a safe way in patients.DesignVideo demonstration of the technique.SettingFrench university tertiary-care hospital.InterventionsThis video presents a termino-terminal laparoscopic ureteral anastomosis and shows our team's strategy for surgical treatment in a 42-year-old woman with deep infiltrating ureteral left endometriosis, with consequent stenosis and left hydroureteronephrosis. A full resection of the endometriotic ureteral nodule was performed, followed by a termino-terminal anastomosis of the ureter. The use of intravenous indocyanine green to assess the postanastomotic ureteral perfusion and its risk of leakage or fistula are described in the video [2, 3, 4, 5].ConclusionUreteral endometriosis can lead to severe consequences, and the surgical treatment can be difficult and, most times, incomplete. This video gives a detailed example of the strategy our team used to perform a termino-terminal ureteral laparoscopic anastomosis in a structured way.     

Changes of Th1 and Th2 Cytokines in Superficial Endometriosis and Deep Infiltrating Endometriosis

目的:研究深部浸润型与表浅型子宫内膜异位症(EMs)临床特征以及腹腔液Th1、Th2细胞因子的表达差异.方法:收集术后病理证实诊断为EMs患者的临床资料及其腹腔液,根据术中诊断分为:表浅型(腹膜型,n=30)、深部浸润型(n=16);以同期因输卵管因素不孕症行腹腔镜探查的妇女(n=16)为对照组.用ELISA法测定3组腹腔液中IL-2、IL-4、IL-6、IL-10、TNF-α、IFN-γ的表达差异性.结果:表浅型EMs患者年龄较轻、不孕率高、腹水发生率高,而性交痛则是深部浸润型EMs患者的典型临床特征.与对照组相比,EMs组腹腔液中IL-4、IL-6、IL-10、TNF-α表达均升高,IFN-γ在EMs组表达均降低.IL-2仅在深部浸润型EMs组升高;深部浸润型EMs组与表浅型EMs组之间对比,IL-6在表浅型EMs的升高明显(P＜0.01),IL-10与TNF-α则在深部浸润型EMs组升高明显(P＜0.01),IFN-γ在深部浸润型EMs组下降更为明显(P＜0.01),IL-4在2个EMs组间表达无差异.结论:在表浅型与深部浸润型EMs的发病机制中,两者具有不同的免疫学改变.     

深部浸润型与表浅型子宫内膜异位症者腹腔液Th1、Th2细胞因子变化

目的:研究深部浸润型与表浅型子宫内膜异位症(EMs)临床特征以及腹腔液Th1、Th2细胞因子的表达差异。方法:收集术后病理证实诊断为EMs患者的临床资料及其腹腔液,根据术中诊断分为:表浅型(腹膜型,n=30)、深部浸润型(n=16);以同期因输卵管因素不孕症行腹腔镜探查的妇女(n=16)为对照组。用ELISA法测定3组腹腔液中IL-2、IL-4、IL-6、IL-10、TNF-α、IFN-γ的表达差异性。结果:表浅型EMs患者年龄较轻、不孕率高、腹水发生率高,而性交痛则是深部浸润型EMs患者的典型临床特征。与对照组相比,EMs组腹腔液中IL-4、IL-6、IL-10、TNF-α表达均升高,IFN-γ在EMs组表达均降低。IL-2仅在深部浸润型EMs组升高;深部浸润型EMs组与表浅型EMs组之间对比,IL-6在表浅型EMs的升高明显(P<0.01),IL-10与TNF-α则在深部浸润型EMs组升高明显(P<0.01),IFN-γ在深部浸润型EMs组下降更为明显(P<0.01),IL-4在2个EMs组间表达无差异。结论:在表浅型与深部浸润型EMs的发病机制中,两者具有不同的免疫学改变。     

Recurrence in Deep Infiltrating Endometriosis: A Systematic Review of the Literature

Deep infiltrative endometriosis (DIE) is an enigmatic disease that typically impacts the rectovaginal septum, uterosacral ligaments, pararectal space, and vesicouterine fold but can involve the rectum, sigma, ileum, ureters, diaphragm, and other less common sites. Surgery is the treatment of choice because medical management alone commonly fails in controlling the symptoms although recurrence is very high after surgical treatment. The goal of the current study was to review recurrence rates and identify risk factors related to recurrence after surgery for DIE. The review involved searching the Cochrane Library, PubMed, and Google Scholar for relevant articles in accordance with the study's inclusion criteria; 45 studies were considered suitable. The results showed a wide heterogeneity regarding DIE recurrence because of inconsistent recurrence definitions and follow-up length. Younger age and high body mass index were found to be risk factors for DIE recurrence. Lack of complete surgical excision was another independent risk factor for recurrence of disease. In conclusion, there is a need for prospective studies and a more homogeneous standard for surgical treatment of DIE.     

Predictive Factors for Voiding Dysfunction after Surgery for Deep Infiltrating Endometriosis

Study ObjectiveTo evaluate the prognostic value of pre- and perioperative factors for voiding dysfunction after surgery for deep infiltrating endometriosis (DIE).DesignSingle-center retrospective cohort study.SettingUniversity hospital.PatientsA total of 198 women with DIE in the posterior compartment who underwent surgery and a postoperative bladder scan.InterventionsSurgical resection of the DIE nodule from the dorsal compartment.Measurements and Main ResultsAfter surgery, 41% of the patients initially experienced voiding dysfunction (defined as >100 mL postvoid residual urine volume at second bladder scan). The number decreased to 11% by the time of hospital discharge. Among those with a need for self-catheterization after discharge (n = 17), voiding dysfunction lasted for a median of 41 days before a return to normal bladder function, with a residual urine volume of <100 mL. The preoperative presence of DIE nodules in the ENZIAN compartment B was associated with postoperative voiding dysfunction (p = .001). The hazard ratio for elevated residual urine volume was highest when the disease stage was B3 (hazard ratio 6.43; CI, 2.3–18.2; p <.001), describing a nodule diameter of >3 cm in lateral distension. Receiver operating characteristic curve analyses showed that a first residual urine volume >220 mL has a good predictive value for the risk of intermittent self-catheterization (area under the receiver operating characteristic curve 0.893; p <.001).ConclusionPostoperative voiding dysfunction is frequent; of note, in most cases the problem is temporary. When DIE with an ENZIAN classification B is noted intraoperatively and, most of all, when the diameter of the lesion is >3 cm, a higher risk of postoperative voiding dysfunction is to be expected.     

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.     

Tigers in the Sidewall: Surgical Approaches to Excision of Lateral Deep Infiltrating Endometriosis

ObjectiveTo describe the surgical approaches and excisional techniques used in an extreme case of deep infiltrating endometriosis (DIE) affecting the lateral pelvic side wall.DesignA technical video showing the excision of advanced lateral DIE.SettingAn academic tertiary care hospital.InterventionsA 32-year-old woman, gravida 2, para 1, presented for definitive surgical management of endometriosis-associated pelvic pain. Intraoperative findings revealed severe retroperitoneal fibrosis tethering the external iliac vein, internal iliac artery, obturator nerve, medial umbilical ligament, and ureter. The patient underwent laparoscopic management of the DIE involving the lateral pelvic side wall. We demonstrate the surgical methods and tools required to overcome a unique endometriotic nodule that would not allow for traditional lysis of adhesions from the pelvic side wall. Instead, we used a nontraditional surgical approach by tunneling under the external iliac vascular to tackle the dissection from a lateral to medial direction to free the obturator nerve and internal iliac artery from the ureter and endometriotic nodule.ConclusionExtreme cases of DIE involving the pelvic side wall require surgical finesse when normal planes of dissection are obliterated. Knowledge of retroperitoneal anatomy is critical to overcome unexpected lateral pelvic side wall endometriosis because the disease is rarely confined to the surface. Innovative surgical thinking complemented by an array of surgical tools will ultimately allow the surgeon to master these difficult endometriotic resections.     

Deep Infiltrating Endometriosis and Spontaneous Hemoperitoneum: A Life-Threatening Situation Treated by Laparoscopy

ObjectiveTo describe a case of spontaneous hemoperitoneum in a woman affected by deep infiltrating endometriosis (DIE).DesignTechnical video showing laparoscopic management of a spontaneous hemoperitoneum in a patient with DIE.SettingMinimally Invasive Gynecological Unit, Sant'Orsola Academic Hospital, Bologna, Italy.InterventionA 35-year-old nulliparous woman was admitted to our gynecologic emergency room because of pelvic pain and a fainting sensation. She had a history of DIE and had been followed for 6 months by our outpatient clinics. The patient underwent an immediate laparoscopy because of the rapid worsening of clinical conditions. After blood suction and difficult adhesiolysis, a vascular lesion with a huge blood flow, close to the left utero-ovarian ligament, was detected. Selective coagulation was performed with good results. During the follow-up visit after 1 month, the patient reported good health. Written informed consent was obtained from the patient for publication of this case report.ConclusionSpontaneous hemoperitoneum represents a rare and life-threatening complication associated with endometriosis. In patients with hemoperitoneum and a history of endometriosis, it is important to pay attention to the possible presence of uncommon bleeding localizations. Laparoscopy was useful and effective in this challenging situation, identifying the bleeding source and performing selective coagulation.