Bowel endometriosis: Recent insights and unsolved problems

Bowel endometriosis affects between 3.8% and 37% of women with endometriosis.The evaluation of symptoms and clinical examination are inadequate for an accurate diagnosis of intestinal endometriosis.Transvaginal ultrasonography is the first line investigation in patients with suspected bowel endometriosis and allows accurate determination of the presence of the disease.Radiological techniques (such as magnetic resonance imaging and multidetector computerized tomography enteroclysis) are useful for estimating the extent of bowel endometriosis.Hormonal therapies (progestins,gonadotropin releasing hormone analogues and aromatase inhibitors) significantly improve pain and intestinal symptoms in patients with bowel stenosis less than 60% and who do not wish to conceive.However,hormonal therapies may not prevent the progression of bowel endometriosis and,therefore,patients receiving long-term treatment should be periodically monitored.Surgical excision of bowel endometriosis should be offered to symptomatic patients with bowel stenosis greater than 60%.Intestinal endometriotic nodules may be excised by nodulectomy or segmental resection.Both surgical procedures improve pain,intestinal symptoms and fertility.Nodulectomy may be associated with a lower rate of complications.     

Fertility considerations in laparoscopic treatment of infiltrative bowel endometriosis.

OBJECTIVE: The purpose of this study was to examine our experience with laparoscopic and laparoscopically assisted management of bowel endometriosis and to recommend treatment approaches, considering patient goals for both pain mitigation or fertility, or both. METHODS: The medical records of 187 women treated laparoscopically for intestinal endometriosis were reviewed retrospectively for presenting symptoms, methods of surgical treatment, complications, and efficacy of treating pain and infertility. The extent of resection was determined by the severity of the endometriotic lesion, tempered by the patient's fertility goals. RESULTS: The most common patient complaint preceding surgery was pelvic pain. In addition, 58 (31%) patients experienced impaired fertility. Of the patients available for long-term follow-up, 152 (85%) reported complete or significant long-term pain relief. Complete pain relief in the immediate postoperative period was significantly more likely with partial bowel resection compared with shaving only, 92% vs 80%, respectively, P<0.04. The least invasive procedure, shaving, was associated with a significantly lower complication rate, 6%, compared with 23% for disc excision (P<0.007) and 38% for segmental resection (P<0.001), and higher pregnancy rates. The incidence of pregnancy in patients with a history of infertility was 34% during the follow-up period.     

Ileal endometriosis and Crohn's disease. A difficult differential diagnosis

Endometriosis is an endometrial tissue proliferation that occurs in any extrauterine site and is usually confined to the pelvis. When the terminal ileum is affected, this entity can simulate Crohn's disease both clinically and radiologically. We describe 2 patients previously diagnosed with Crohn's disease with inadequate response to treatment, who showed intestinal obstruction located in the ileum. One patient had an enterocutaneous fistula, which is extremely unusual. In both patients intestinal endometriosis was diagnosed after histopathologic assessment. Although complex, the differential diagnosis between endometriosis and Crohn's disease should be kept in mind since the prognosis and treatment of these 2 entities differ.     

Acute Small Bowel Obstruction Secondary to Ileal Endometriosis: Report of a Case

We report a case of acute small bowel obstruction occurring secondary to endometriosis of the terminal ileum. Ileal endometriosis is a rare condition that can cause acute small bowel obstruction. As this case and others in the literature highlight, establishing a preoperative diagnosis is very difficult due to the vagueness of symptoms and similarity in presentation to other causes of obstruction, and is based on a high index of suspicion. However, this disorder should be considered in the differential diagnosis of women of child-bearing age who present with symptoms of obstruction. The definitive treatment includes resection of the involved segment with primary anastomosis, and adjuvant hormonal therapy may prevent recurrence.     

Deep Infiltrating Colorectal Endometriosis Treated With Robotic-Assisted Rectosigmoidectomy

Background and Objective:

Deep infiltrating pelvic endometriosis with bowel involvement is one of the most aggressive forms of endometriosis. Nowadays, robotic technology and telemanipulation systems represent the latest developments in minimally invasive surgery. The aim of this study is to present our preliminary results and evaluate the feasibility of robotic-assisted laparoscopic colorectal resection for severe endometriosis.

Methods:

Between September 2009 and December 2011, 10 women with colorectal endometriosis underwent surgery with the da Vinci robotic surgical system (Intuitive Surgical, Sunnyvale, CA, USA). We evaluated the following parameters: short-term complications, clinical outcomes and long-term follow-up, pain relief recurrence rate, and fertility outcomes.

Results:

Extensive ureterolysis was required in 8 women (80%). Ovarian cystectomy with removal of the cystic wall was performed in 7 women (70%). Torus resection was performed in all women, with unilateral and bilateral uterosacral ligament resection in 1 woman (10%) and 8 women (80%), respectively. In addition to segmental colorectal resection in all cases, partial vaginal resection was necessary in 2 women (20%). An appendectomy was performed in 2 patients (20%). The mean operative time with the robot was 157 minutes (range, 90–190 minutes). The mean hospital stay was 3 days. Six patients had infertility before surgery, with a mean infertility time of 2 years. After a 12-month follow-up period, 4 women (67%) conceived naturally and 2 (33%) underwent in vitro fertilization.

Conclusion:

We show that robotic-assisted laparoscopic surgery for the treatment of deep infiltrating bowel endometriosis is feasible, effective, and safe.     

Laparoscopic management of bowel endometriosis: predictors of severe disease and recurrence

Background and Objectives:

The identification of high-stage and recurrent cases of bowel endometriosis is critical, because these cases require careful surgical planning. We aim to describe the clinical characteristics of women with bowel endometriosis, our principles in laparoscopic management of this pathology, and to identify predictors of severe disease and recurrence.

Methods:

This was a retrospective study of 193 patients with pathologically confirmed bowel endometriosis.

Results:

Predictors of higher-stage endometriosis include a history of previous laparoscopic surgery (P=.04) and a presenting complaint of abnormal uterine bleeding (P=.01). The higher the stage of endometriosis, the more likely there would be coexistent urinary tract endometriosis (P=.02), a need for enterolysis (P=.002), ovarian cystectomy (P<.001), and bowel resection (P=.01) performed during laparoscopy. Patients with higher body mass index (BMI) had significantly higher recurrence rates of endometriosis compared to those with lower BMI (P=.002). Within our cohort, 87% of our patients achieved amelioration of symptoms by the end of the first postoperative month.

Conclusions:

Our study confirms that laparoscopic management of bowel endometriosis is safe and effective. We found 2 statistically significant predictors of higher-stage disease that should prompt careful surgical planning. Obesity is associated with a higher rate of recurrence of endometriosis.     

Isolated endometriosis causing sigmoid colon obstruction: A case report

INTRODUCTIONIsolated endometriosis of the intestine causing large bowel obstruction is rare.PRESENTATION OF CASEWe present a case of endometriosis presenting as large bowel obstruction in a woman of childbearing age. She had no previous symptoms to suggest endometriosis and on presentation urgent surgery was required. The diagnosis of endometriosis was made only after pathological evaluation of the specimen.DISCUSSIONNo cases of endometriosis confined to this sigmoid colon without pelvic involvement were noted in the literature.CONCLUSIONThe diagnosis of endometriosis should be entertained when women of childbearing age presents with large bowel obstruction, whether or not the patient has other evidence of the disease.     

Rare manifestation of endometriosis causing complete recto-sigmoid obstruction: A case report

IntoductionEndometriosis is a disease in which endometrial epithelium implanted outside the uterus. Although the endometrial tissue can implant anywhere, the most common places are the ovary and pelvic peritoneum. We present a rare case of recto-sigmoid endometriosis that causes a complete large bowel obstruction in a non-reproductive age woman who came with no specific symptoms of endometriosis and the diagnosis was made after surgical resection.Case presentationA 50 years old female who never been married and admitted to have no sexual experience in her life, presented with symptoms of acute bowel obstruction. She underwent sigmoid colectomy as the primary diagnosis was colonic tumor, but the histopathological reports showed the diagnosis with recto-sigmoidal Endometriosis. At the second laparotomy for closure of colostomy, the uterus was abnormal and she had a hysterectomy with salpingio-oopherectomy to prevent recurrence. The histopathological report revealed cervical, ovarian, and fallopian tube endometriosis.DiscussionUnlike our patient, most patients complain of the common symptoms of endometriosis such as dysmenorrhea, dyspareunia, and dyschezia and many of them came with infertility as a main complaint which make them undergo further investigations like laparoscopy, and lead to pre-surgical diagnosis of endometriosis. But in case of complete bowel obstruction, urgent laparotomy is the treatment of choice.ConclusionAlthough Intestinal endometriosis is rare to cause bowel obstruction physicians and surgeons should always consider it as a differential diagnosis of bowel obstruction even without specific symptoms, to prevent surgery in incomplete obstruction.     

A case of intestinal occlusion caused by endometriosis of the cecum

The purpose of this study is to heighten awareness of intestinal endometriosis, a disease that may mimic other abdominal pathologies (bowel carcinoma, intestinal inflammatory disease, diverticulitis), sometimes found in the emergency setting. The Authors report a case of acute bowel obstruction due to coecal endometriosis with appendix mucocele, peritoneal pseudomyxoma and ovarian endometrioma. The patient was operated on in the emergency setting, a right colectomy was performed and she then received pharmacological suppressive treatment with Gn-RH analogues and danatrol. We remark that preoperative diagnosis is very difficult in those cases that do not have a past history of pelvic endometriosis. An accurate anamnesis regarding the chronology of pain onset (typically only during the menstruation at first), but especially intraoperative histopathologic examination are useful for diagnosis. An increased awareness of intestinal endometriosis in reproductive age women with acute bowel obstruction, associated with an accurate anamnesis of menstrual history may allow pre- or intraoperative diagnosis, which is the clue to a less aggressive operation. Postoperative follow up and hormonal therapy are mandatory.     

Accuracy of laparoscopic diagnosis of endometriosis.

BACKGROUND AND OBJECTIVE: Laparoscopy is the standard method to visually identify endometriotic lesions under magnification within and outside the minor pelvis. The aim of this study was to analyze the accuracy of laparoscopic visualization in diagnosing the various endometriotic sites as confirmed histologically. METHOD: Presumed endometriotic sites were observed in 164 patients operated on under the clinical suspicion of endometriosis. Targeted biopsies were performed for histologic corroboration, comparing the laparoscopic findings and diagnosis to the histological results. RESULT: The histological reports of the biopsies confirmed the presence of endometriosis in 138 patients (84.1%), but in 26 patients (15.9%), no evidence of endometriosis was observed. 100% of "red" lesions, 92% of "black" lesions, and 31% of "white" lesions turned out to be endometriosis. Of the 264 various suspected endometriotic sites observed, 142 (53.8%) were confirmed histologically. The most accurate diagnosis was in lesions on the parietal peritoneum of the pelvis, confirmed in 9/9 cases (100%); the ovarian fossa, confirmed in 8/12 cases (66.7%); and the uterosacral ligaments and posterior surface of the broad ligament, confirmed in 83/138 cases (60.1%). As for the other sites, the histologic confirmation rates in the ovarian surface, bowel serosa, and vesicouterine fold of the peritoneum were 48%, 40%, and 13%, respectively. CONCLUSION: Endometriosis has a multiple appearance, and the lesions may be confused with nonendometriotic lesions. It is clear that a nonhistology-based diagnosis may lead to unnecessary prolonged medical treatment and operations and may delay the proper treatment measures from being applied. Therefore, a meticulous histological confirmation should still be the first step in the laparoscopic diagnosis and treatment of suspected endometriosis.     

Long-term follow-up of a controlled trial of laser laparoscopy for pelvic pain.

BACKGROUND AND OBJECTIVES: The purpose of this study was to assess the long-term efficacy of laparoscopic laser surgery in the treatment of painful pelvic endometriosis. METHODS: We conducted a long-term follow-up of 56 patients who had participated in a randomized, double-blind controlled study at a tertiary referral center for the laparoscopic treatment of endometriosis. The patients had pelvic pain, minimal-to-moderate endometriosis, and underwent laser laparoscopy. We asked patients whether they had now achieved satisfactory symptom relief or whether they had received any further medical intervention for their endometriosis. The main outcome measure was continued symptom relief after treatment and subsequent medical history. RESULTS: Of the original 56 patients, we were able to contact 38 (67.9%). The mean (range) time since operation was 73 months. Painful symptoms had recurred in 28/38 (73.7%) patients at some point since their operation. The median (range) time for recurrence was 19.7 (5-60) months. At the time of follow-up, satisfactory symptom relief was reported in 21/38 (55.3%) patients. The remaining 17/38 (44.7%) patients continued to experience painful symptoms, and eight eventually had a hysterectomy. CONCLUSIONS: This study suggests that operative laparoscopy can have long-term benefits for the majority of women with pelvic pain due to endometriosis, but because of the small numbers, this study lacks the power to demonstrate this conclusively.     

Intussusception secondary to endometriosis of the cecum

INTRODUCTION

Intussusception in adults is a rare cause of bowel obstruction. Endometriosis of the bowel is also a rare entity that can be the cause of bowel obstruction. Here, we report a rare case of intussusception secondary to endometriosis of the cecum.

PRESENTATION OF CASE

A 40-year-old woman presented to the hospital with a one-week history of intermittent epigastric pain. On physical examination, there was a soft, round non-tender palpable mass in the right flank and abdominal computed tomography scan revealed an intussusception. We made the diagnosis of ileo-colic intussusception and performed ileocecal resection. The surgical specimen revealed a round submucosal cystic mass in the cecum and the histology showed endometriosis of the cecum.

DISCUSSION

Intussusception in adults is a rare entity present in just 1% of all patients with bowel obstruction, and 5% of all intussusceptions. In general, intussusception in adults has a pathologic lesion as the lead point and the lesion is a malignancy in 20–50% of the cases. Thus, the treatment of an intussusception in adults should be operative. Endometriosis of the bowel is a rare cause of intussusception. Small endometriosis lesions of the bowel are unlikely to cause symptoms; however, in patients presenting with bowel obstruction, urgent treatment is indicated.

CONCLUSION

Intussusception in an adult is a rare cause of bowel obstruction and intussusception caused by endometriosis is also rare. Although rare, the diagnosis of endometriosis as a cause of intussusception must be considered as part of the differential diagnosis.     

Laparoscopic disk resection for bowel endometriosis using a circular stapler and a new endoscopic method to control postoperative bleeding from the stapler line

BACKGROUND: Complete laparoscopic excision of endometriosis offers good longterm symptomatic relief, especially for those with severe or debilitating symptoms. Intestinal endometriosis affect between 3% and 36% of women with endometriosis and 50% of women with disease severe enough that intestinal surgery, with or without intestinal segmental resection, may be required. STUDY DESIGN: Between January 2003 and September 2006, we performed 35 laparoscopic complete excisions of endometriosis with full thickness disk resections of bowel endometriosis using the CEEA stapler (US Surgical) inserted transanally. RESULTS: The endometriotic nodule of the bowel was completely removed in all patients. No major or minor surgical complications occurred during the primary surgical procedure. One patient underwent a diverting temporary ileostomy because of air loss after insufflation of the rectosigmoid colon, which was closed successfully 1 month after surgery. In three of seven cases of rectal bleeding from the stapler line, for the first time, we successfully used conservative endoscopic management. CONCLUSIONS: In properly selected patients, full thickness disk excision using a circular stapler is a feasible procedure that avoids the potential morbidities of a low anastomosis. We suggest conservative management by endoscopic hemostasis before referring patients for a new operation in cases of rectal bleeding from the anastomotic site.     

An Ileal Endometrioma: Of Carcinoids and Cadherin

A 38-year-old woman with history of prior adrenalectomy for Cushing’s syndrome presented with intermittent right lower quadrant (RLQ) abdominal pain, nausea, bloating, and non-bloody diarrhea for 2 months. Symptoms were not related to her menstrual periods. Examination revealed only an ill-defined mass in the RLQ. Investigations for infectious causes, inflammatory bowel disease, and carcinoid tumor were negative. Computed tomography (CT) demonstrated a terminal ileal mass with mesenteric stranding and dilatation of the proximal bowel. At laparotomy, a fibrotic, terminal ileal mass with matted adhesions involving the mesentery and retroperitoneum was resected. Histopathological examination identified multiple foci of endometriosis extending from the serosal surface into the mucosa of the terminal ileum. Immunostaining revealed E- and P-cadherin, but not N-cadherin immunopositivity. Mucosal involvement without cyclical menstrual symptoms and intestinal obstruction is an unusual presentation of intestinal endometriosis. Although the mechanism of endometriosis is not clear, the role of cell adhesion molecules such as cadherins has received attention. Increased expression of E- and P-cadherin and decreased N-cadherin expression in our patient demonstrates differential expression of these cadherins in endometriotic tissue. Future studies may investigate patterns of differential expression of these cadherins in a series of cases to elucidate the mechanisms of migration of endometriotic tissue.     

小肠内置管排列术治疗放射性肠炎合并肠梗阻

目的：探讨小肠内置管排列术治疗放射性肠炎合并肠梗阻的临床效果。方法：对12例放射性肠炎合并肠梗阻的患者进行小肠内置管排列术，其中2例行病变肠段切除，一期肠吻合术，其余10例行捷径手术，病变肠段旷置术。结果：全部临床治愈，主要并发症为肠瘘（25％）、腹腔感染（16．7％）。结论：放射性肠炎合并肠梗阻需手术治疗，捷径手术＋小肠内置管排列术是有效的手术方式，围手术期积极的营养支持是手术成功的保证。     

Simultaneous laparoscopic treatment for rectosigmoid and ileal endometriosis

Endometriosis is common in women of childbearing age, while severe intestinal endometriosis requiring bowel resection is relatively rare. Intestinal endometriosis has recently been managed laparoscopically. We report the case of a 38-year-old patient with rectosigmoid and ileal endometriosis who was successfully treated by laparoscopic bowel resections. The patient had first presented at age 34 years with a chief complaint of rectal bleeding and lower abdominal pain related to the menstrual cycle. She underwent laparoscopic surgery and was diagnosed with severe endometriosis involving the rectosigmoid colon. Although an additional laparoscopic surgery had been planned, she did not return to the hospital. When she was 38 years old, she presented again with the same symptoms. Magnetic resonance imaging revealed a low intensity mass between the uterus and the rectosigmoid colon. A barium enema showed a stenotic site in the rectosigmoid colon. After hormone therapy, she underwent laparoscopic surgery. The anterior wall of the rectosigmoid colon adhered firmly to the corpus of the uterus, and another stenotic site was identified at the terminal ileum. The rectosigmoid colon and ileum were partially resected under laparoscopy. The postoperative course was uneventful and she was freed of symptoms. Laparoscopic treatment for patients with severe endometriosis of the bowel has becomes feasible and safe.     

Endometriosis of the caecum and ileo-caecal valve. A case report and review of the literature

Endometriosis is a non-cancerous disorder characterised by development of endometrial epithelium outside the uterus, in which involvement of the gastrointestinal tract is most common. The most frequent site is the rectosigmoid colon (72%), whereas the caecum is involved in 4% of cases. Endometriosis may present with abdominal pain, constipation, and sometimes intestinal bleeding. The treatment of the disease is surgical when medical therapy fails and in cases of surgical urgency. We report the case of a patient with bowel obstruction due endometriosis of the caecum and ileo-caecal valve in association with metrorrhagia. A segmentectomy of the right colon was performed. Since endometriosis is more frequent on the left side of the pelvis probably due to regurgitated endometrial cells, the case observed is not very frequent and is worth reporting.     

The success of laser laparoscopy in the treatment of endometriosis: a two-step analysis.

BACKGROUND AND OBJECTIVES: The most advantageous treatment for nonextensive endometriosis has long been the subject of debate. In recent years, the ability to detect atypical presentations has allowed the gynecological surgeon to treat this disease more readily. The treatment in the past has only been concerned with the singular treatment being applied at the time, not on the effects that previous treatments have had. The purpose of the current study was to see whether previous unsuccessful treatment modalities affected subsequent laser laparoscopy treatment of endometriosis. METHODS: Patients who were previously treated for their endometriosis (minimal and mild) underwent treatment of their disease by laser laparoscopy and the results were analyzed by chi2 (chi-square) analysis. RESULTS: Those patients previously treated with laser laparoscopy and laparotomy demonstrated poorer results than those previously treated with expectant, medical, or cautery. The sum of the original treatments plus the second treatment of laser laparoscopy was equal in all groups. CONCLUSIONS: If endometriosis is diagnosed at the time of laparoscopy and is easily amenable to treatment, it behooves the physician to treat it at the time of surgery.     

A Pilot Feasibility Multicenter Study of Patients After Excision of Endometriosis

Objective:

To serve as a pilot feasibility study for a randomized study of excision versus ablation in the treatment of endometriosis by (1) estimating the magnitude of change in symptoms after excision only at multiple referral centers and (2) determining the proportion of women willing to participate in a randomized trial.

Methods:

We performed a multicenter prospective study of women undergoing excision for endometriosis (Canadian Task Force class II-3) at Duke University Center for Endometriosis Research & Treatment (currently the Saint Louis University Center for Endometriosis), Center for Endometriosis Care, Northshore University Health System, Memorial University (Canada), and Florida Hospital. The study comprised 100 female patients, aged 18 to 55 years, with endometriosis-suspected pelvic pain. The intervention was laparoscopic excision only of the abnormal peritoneum suspicious for endometriosis. The main outcome measures were quality of life, pelvic pain, dysmenorrhea, dyspareunia, and bowel and bladder symptoms.

Results:

The mean follow-up period was 8.5 months. Excision of endometriosis showed a significant reduction in all pain scores except bowel symptoms, as well as significant improvement in quality of life. Of the patients, 84% were willing to participate in a randomized study.

Conclusions:

Quality of life is a needed primary outcome for any randomized study comparing excision versus ablation. A multicenter comparative trial is feasible, although quality assurance would have to be addressed. Patients were willing to be randomized even at surgical referral centers.     

Microlaparoscopy and a GnRH agonist: a combined minimally invasive approach for the diagnosis and treatment of occlusive salpingitis isthmica nodosa associated with endometriosis.

OBJECTIVE: To evaluate whether occlusive salpingitis isthmica nodosa associated with endometriosis can be diagnosed by microlaparoscopy and managed with medical therapy using leuprolide acetate. METHODS: This was a prospective, nonrandomized study conducted at a university hospital and a private community hospital. It included women with occlusive salpingitis isthmica nodosa associated with endometriosis. Diagnosis of salpingitis isthmica nodosa was made via microlaparoscopy with chromotubation. Patients with occlusive salpingitis isthmica nodosa were treated with leuprolide acetate 3.75 mg administered monthly for 6 months. RESULTS: Tubal patency in occlusive salpingitis isthmica nodosa following medical therapy with leuprolide acetate was evaluated. Thirteen of 16 (81.3%) women with bilateral salpingitis isthmica nodosa achieved patency of both fallopian tubes following treatment with leuprolide acetate; 3 of 16 (18.8%) developed patency in one of the fallopian tubes. All 5 women with unilateral SIN demonstrated bilateral patency following medical therapy. CONCLUSION: Diagnosis of occlusive salpingitis isthmica nodosa can be made by microlaparoscopy. These preliminary results suggest that medical therapy with leuprolide acetate may be the first-line treatment modality for women with occlusive salpingitis isthmica nodosa associated with endometriosis, possibly avoiding a more invasive surgical procedure.