Bowel endometriosis: Colorectal surgeon’s perspective in a multidisciplinary surgical team

Endometriosis is a gynecological condition that presents as endometrial-like tissue outside the uterus and induces a chronic inflammatory reaction. Up to 15% of women in their reproductive period are affected by this condition. Deep endometriosis is defined as endometriosis located more than 5 mm beneath the peritoneal surface. This type of endometriosis is mostly found on the uterosacral ligaments, inside the rectovaginal septum or vagina, in the rectosigmoid area, ovarian fossa, pelvic peritoneum, ureters, and bladder, causing a distortion of the pelvic anatomy. The frequency of bowel endometriosis is unknown, but in cases of bowel infiltration, about 90% are localized on the sigmoid colon or the rectum. Colorectal involvement results in alterations of bowel habits such as constipation, diarrhea, tenesmus, dyschezia, and, rarely, rectal bleeding. Differential diagnosis must be made in case of irritable bowel syndrome, solitary rectal ulcer syndrome, and a rectal tumor. A precise diagnosis about the presence, location, and extent of endometriosis is necessary to plan surgical treatment. Multidisciplinary laparoscopic treatment has become the standard of care. Depending on the size of the lesion and site of involvement, full-thickness disc excision or bowel resection needs to be performed by an experienced colorectal surgeon. Long-term outcomes, following bowel resection for severe endometriosis, regarding pain and recurrence rate are good with a pregnancy rate of 50%.     

结直肠子宫内膜异位症恶变的研究进展

子宫内膜异位症在育龄期妇女中是一种相对常见的病变,但肠道的子宫内膜异位组织恶变比较罕见。其病因未明,目前用以解释其起源的理论较多。尽管目前针对这种少见疾病无标准治疗方法,但是根治性手术结合术后辅助治疗的模式可作为一种治疗选择。     

Role of colonoscopy in the diagnostic work-up of bowel endometriosis

AIM:To evaluate the accuracy of colonoscopy for the prediction of intestinal involvement in deep pelvic endometriosis.METHODS:This prospective observational study was performed between September 2011 and July 2014.Only women with both a clinical and imaging diagnosis of deep pelvic endometriosis were included.The study was approved by the local ethics committee and written informed consent was obtained in all cases.Both colonoscopy and laparoscopy were performed by expert surgeons with a high level of expertise with these techniques.Laparoscopy was performed within4 wk of colonoscopic examination.All hypothetical colonoscopy findings(eccentric wall thickening with or without surface nodularities and polypoid lesions with or without surface nodularities of endometriosis)were compared with laparoscopic and histological findings.We calculated the sensitivity,specificity,positive predictive value and negative predictive value for the presence of colonoscopic findings of intestinal endometriosis.RESULTS:A total of 174 consecutive women aged between 21-42 years with a diagnosis of deep pelvic endometriosis who underwent colonoscopy andsurgical intervention were included in our analysis.In 76 of the women(43.6%),intestinal endometrial implants were found at surgery and histopathological examination.Specifically,38 of the 76 lesions(50%)were characterized by the presence of serosal bowel nodules;28 of the 76 lesions(36.8%)reached the muscularis layer;8 of the 76 lesions(10.5%)reached the submucosa;and 2 of the 76 lesions(2.6%)reached the mucosa.Colonoscopic findings suggestive of intestinal endometriosis were detected in 7 of the174(4%)examinations.Colonoscopy failed to diagnose intestinal endometriosis in 70 of the 76 women(92.1%).A colonoscopic diagnosis of endometriosis was obtained in all cases of mucosal involvement,in 3of 8 cases(37.5%)of submucosal involvement,in no cases of muscularis layer involvement and in 1 of 38cases(2.6%)of serosa involvement.The sensitivity,specificity,positive predictive and negative predictive values of colonoscopy for the diagnosis of intestinal endometriosis were 7%,98%,85%and 58%,respectively.CONCLUSION:Being an invasive procedure,colonoscopy should not be routinely performed in the diagnostic work-up of bowel endometriosis.     

腹腔镜技术在诊治女性不孕症中的应用

目的 探讨腹腔镜诊治女性不孕症的临床价值.方法 对59例不孕症妇女进行腹腔镜检查,查找不孕的病因及不孕的影响因素,并对腹腔镜下的治疗情况进行分析.结果 慢性盆腔炎及子宫内膜异位症、多囊卵巢综合征是引起不孕的主要盆腔疾病.结论 腹腔镜在诊治不孕症中有一定的临床价值,可在腹腔镜直视下通液动态观察输卵管形态及通畅情况,降低了常规通液术的假阳性、假阴性率,提高不孕症的治疗效果.     

Diagnosis,surgical treatment and postoperative outcomes of hepatic endometriosis: A systematic review

Endometriosis is characterized by the presence of endometrial-like tissue and stroma in extra-uterine locations. Hepatic endometriosis (HE) is one of the rarest forms of extrapelvic endometriosis. We aimed to summarize the existing evidence on HE with special consideration to natural history, diagnosis and surgical treatment.Three electronic databases were systematically searched for articles published up to March 2019. All appropriate observational studies and case reports addressing cases of women with HE were considered eligible for inclusion.A total of 27 studies which comprised 32 patients with HE were included. Mean age of patients was 39.7 years. Ten (62.5%) were nulliparous and 24 (75%) were women of reproductive age. Eleven patients (36.7%) had a history of pelvic endometriosis of various sites. Abdominal pain was the primary symptom in 28 patients (87.5%). Preoperative diagnosis of endometriosis was available for 5 patients and 6 underwent a preoperative diagnostic procedure. Cyst resection, minor and major liver resections were performed in 14/31, 9/31 and 8/31 patients, respectively.Preoperative diagnosis of HE is challenging due to variable radiologic features and clinical symptomatology. Nonetheless, it should be considered in the differential diagnosis of a liver mass especially in premenopausal women with a history of endometriosis. The type of resection of the endometriotic lesion is based on the extent and the location of the disease and presented with favourable outcomes concerning morbidity, symptom relief and recurrence.     

Small bowel endometriosis masquerading as regional enteritis

Summary A 35-year-old female presented with recurrent right lower quadrant pain, nausea, and vomiting. She was afebrile with diffuse abdominal tenderness. Plain x-ray of abdomen revealed small bowel obstruction. A barium x-ray of the small bowel showed stricture of the terminal ileum. A CT scan of the abdomen showed a 6-cm mass in right lower quadrant. She was empirically managed as having Crohn's disease. She underwent laparotomy after failure of medical management with high-dose steroids. There was ulceration and narrowing of terminal ileum. Frozen sections revealed endometriosis. Ileocecectomy was performed. Histopathology of resected specimen confirmed the diagnosis of endometriosis, and there was no evidence of chronic inflammatory bowel disease or neoplasia. Ileal endometriosis should be considered in the differential diagnosis of Crohn's disease in menstruating females presenting with perimenstrual symptoms.     

Short-term outcomes of laparoscopic total mesorectal excision compared to open surgery

AIM:To investigate the short-term outcome of laparoscopic total mesorectal excision(TME) in patients with mid and low rectal cancers.METHODS:A consecutive series of 138 patients with middle and low rectal cancer were randomly assigned to either the laparoscopic TME(LTME) group or the open TME(OTME) group between September 2008 and July 2011 at the Department of Colorectal Cancer of Shanghai Cancer Center,Fudan University and pathological data,as well as surgical technique were reviewed retrospectively.Short-term clinical and oncological outcome were compared in these two groups.Patients were followed in the outpatient clinic 2 wk after the surgery and then every 3 mo in the first year if no adjuvant chemoradiation was indicated.Statistical analysis was performed using SPSS 13.0 software.RESULTS:Sixty-seven patients were treated with LTME and 71 patients were treated with OTME(sex ratio 1.3:1vs 1.29:1,age 58.4 ± 13.6 years vs 59.6 ± 9.4 years,respectively).The resection was considered curative in all cases.The sphincter-preserving rate was 65.7%(44/67) vs 60.6%(43/71),P = 0.046;mean blood loss was 86.9 ± 37.6 mL vs 119.1 ± 32.7 mL,P = 0.018;postoperative analgesia was 2.1 ± 0.6 d vs 3.9 ± 1.8 d,P = 0.008;duration of urinary drainage was 4.7 ± 1.8 d vs 6.9 ± 3.4 d,P = 0.016,respectively.The conversion rate was 2.99%.The complication rate,circumferential margin involvement,distal margins and lymph node yield were similar for both procedures.No port site recurrence,anastomotic recurrence or mortality was observed during a median follow-up period of 21 mo(range:9-56 mo).CONCLUSION:Laparoscopic TME is safe and feasible,with an oncological adequacy comparable to the open approach.Further studies with more patients and longer follow-up are needed to confirm the present results.     

炎症性肠病的诊治

近20年来，炎症性肠病（IBD），无论是溃疡性结肠炎（UC）还是克罗恩病（CD），在我国报告逐渐增多，以医院为基础的调查推测患病率，UC为11．6／10^5，CD为1．4／10^5，香港发病率UC为1．2／10^5，CD为1．0／10^5。由此带来纷繁复杂的临床问题，引起专业医生的高度重视。借鉴国外对疾病发病机制的研究直接用于临床的经验和不断更新的IBD处理指南，我国也在IBD的诊治方面进行了不懈的探索，并取得了一定的进展。     

线阵超声内镜对直肠子宫内膜异位症的诊断价值

目的:探讨线阵超声内镜对直肠子宫内膜异位症(rectal endometriosis,RE)的诊断价值.方法:对20例子宫内膜异位症患者于外科手术前行线阵超声内镜检查直肠,超声扫描频率为7.5MHz,根据直肠壁内有无边界不规则的低回声结节或团块判断直肠是否受累,并将超声内镜检查结果与手术中所见及术后病理进行比较.结果:20例患者中有12例经线阵超声内镜检查发现直肠壁内有异位子宫内膜病灶,其余8例患者的直肠壁正常.超声内镜诊断为RE的12例患者术中均见盆腔异位子宫内膜病灶与肠壁粘连紧密,手术切除的直肠病灶送检均见子宫内膜组织.超声内镜下未见直肠受累的8例患者盆腔子宫内膜异位病灶与肠壁无粘连或轻度粘连,易分离,分离缘组织送检未见子宫内膜组织.线阵超声内镜检查结果与手术中所见及术后病理完全一致.结论:线阵超声内镜检查是诊断RE的可靠方法,可对子宫内膜异位症患者是否伴有直肠受累做出准确的术前评估.     

Technique for laparoscopic autonomic nerve preserving total mesorectal excision

With the introduction of total mesorectal excision (TME) for treatment of rectal cancer, the prognosis of patients with rectal cancer is improved. With this better prognosis, there is a growing awareness about the quality of life of patients after rectal carcinoma. Laparoscopic total mesorectal excision (LTME) for rectal cancer offers several advantages in comparison with open total mesorectal excision (OTME), including greater patient comfort and an earlier return to daily activities while preserving the oncologic radicality of the procedure. Moreover, laparoscopy allows good exposure of the pelvic cavity because of magnification and good illumination. The laparoscope seems to facilitate pelvic dissection including identification and preservation of critical structures such as the autonomic nervous system. The technique for laparoscopic autonomic nerve preserving total mesorectal excision is reported. A three- or four-port technique is used. Vascular ligation, sharp mesorectal dissection and identification and preservation of the autonomic pelvic nerves are described.     

A totally mini-invasive approach for colorectal laparoscopic surgery

AIM: To study the short-term outcome of patients treated with laparoscopic right colectomy and how intracorporeal anastomosis has improved the outcome.METHODS: We retrospectively examined all patients affected by colorectal cancer who underwent a laparoscopic right colectomy between January 2006 and December 2010 in our department. Our evaluation criteria were: diagnosis of colorectal carcinoma at presurgical biopsy, elective surgery, and the same surgeon. We excluded: emergency surgery, conversions from laparotomic colectomy, and other surgeons. The endpoints we examined were: surgical time, number of lymph nodes removed, length of stay (removal of nasogastric tube, bowel movements, gas evacuation, solid and liquid feeding, hospitalization), and major complications. Seventy-two patients were divided into two groups: intracorporeal anastomosis (39 patients) and extracorporeal anastomosis (33 patients).RESULTS: Significant differences were observed between intracorporeal vs extracorporeal anastomosis, respectively, for surgical times (186.8 min vs 184.1 min, P < 0.001), time to resumption of gas evacuation (3 d vs 3.5 d, P < 0.001), days until resumption of bowel movements (3.8 d vs 4.9 d, P < 0.001), days until resumption of liquid diet (3.5 d vs 4.5 d, P < 0.001), days until resuming a solid diet (4.6 d vs 5.7 d, P < 0.001), and total hospitalization duration (7.4 d vs 8.5 d, P < 0.001). In the intracorporeal group, on average, 19 positive lymph nodes were removed; in the extracorporeal group, on average, 14 were removed P < 0.001). Thus, intracorporeal anastomosis for right laparoscopic colectomy improved patient outcome by providing faster recovery of nutrition, faster recovery of intestinal function, and shorter hospitalization than extracorporeal anastomosis.CONCLUSION: Short-term outcomes favor intracorporeal anastomosis, confirming that a less traumatic surgical approach improves patient outcome.     

Preoperative rectosigmoid endoscopic ultrasonography predicts the need for bowel resection in endometriosis

BACKGROUND Rectosigmoid endometriosis is an underdiagnosed disease responsible for abdominal pain, transit disorders and rectal bleeding. Two surgical approaches,rectosigmoid bowel resection(segmental or patch) or intramuscular layer dissection(shaving), are available.AIM To assess whether the lesion features observed via preoperative rectosigmoid endoscopic ultrasonography(RS-EUS) might predict the need for bowel resection.METHODS This multicentric retrospective study was conducted on patients with rectosigmoid endometriosis who underwent a curative surgical procedure,evaluated by RS-EUS performed by two trained operators, between January 2012 and March 2018. A univariate statistical analysis was performed on nodules' RSEUS features(thickness, width, infiltration of the submucosae, presence of a bump into the digestive lumen and presence of multiple rectosigmoid localizations). A multivariate logistic regression was then performed on the significant results.RESULTS Of the 367 patients, 73 patients with rectosigmoid endometriosis were evaluated by RS-EUS and underwent rectosigmoid surgery. After the univariate analysis was completed, thickness, width and infiltration of the submucosae were identified as potential predictive factors for bowel resection. In a multivariate logistic regression model, only thickness appeared to be a significant [odds ratio(OR) = 1.49, 95% confidence interval(CI): 1.04-2.12, P = 0.028] predictive factor for bowel resection. Receiver operating characteristic analysis performed showed that a thickness over 5.20 mm might be used as cut-off with a sensitivity of 76%, a specificity of 81%, and an area under carve = 0.82. The cut-off values for 100%sensitivity and 100% specificity were 0.90 mm and 10.00 mm, respectively. A trend concerning width to predict the need for resection was also observed(OR1.12, 95%CI: 1.00-1.26, P = 0.054)CONCLUSION The presence of a rectosigmoid nodule of endometriosis greater than 5.20 mm thick on RS-EUS might predict the need for bowel resection.     

中国结直肠癌及癌前病变内镜诊治共识（2023，广州）

结直肠癌是我国常见的恶性肿瘤之一,其发病率和死亡率均保持上升趋势,2020年中国结直肠癌新发病例55.5万例,死亡病例28.6万例,严重威胁人民生命健康。大量的研究和实践已经表明结直肠癌筛查和早诊早治可以有效降低结直肠癌的死亡率。因此,中华医学会消化内镜学分会结直肠学组牵头,联合国内消化、消化内镜以及消化病理专家共同制订了本共识,本共识主要从定义及术语、结肠镜筛查实施、结直肠癌及癌前病变早期诊断、治疗及术后注意事项和随访5个方面分别进行了阐述,以期为我国结直肠癌及癌前病变内镜诊治的规范开展提供参考,提高我国结直肠癌防治效果。     

A case-control-study comparing laparoscopic versusopen surgery for rectosigmoidal and rectal cancer

This study compared laparoscopic with open surgery for the cure of cancer of the rectosigmoid and rectum. Results of surgery, postoperative recovery, and oncological follow-up were compared between 32 laparoscopic curative procedures (19 laparoscopic-assisted anterior resections for cancer of the rectosigmoid or upper rectum and 13 laparoscopic abdominoperineal resections for low rectal cancer) and 32 controls matched for age, UICC stage, tumor site, and type of resection who underwent open surgery during the same observation period. Morbidity was identical after laparoscopic and open resection (31.3%). Surgery was equally radical in the two groups regarding yield of lymph nodes and lateral and distal margins. Survival, recurrence, and cancer-related mortality showed no statistical differences. There was no port-site recurrence. The benefits of laparoscopic surgery were shown with a reduction in perioperative blood transfusion and earlier return of bowel function. However, the operative time was significantly increased in the laparoscopic group. This study shows that laparoscopic surgery for the cure of colorectal cancer is technically feasible, and that oncological short-term outcome does not differ from the results achieved by open techniques. However, prospective randomized trials are mandatory to evaluate the definite role of laparoscopic surgery for malignancy. Accepted: 26 April 1999     

Concurrent laparoscopic right hemicolectomy and ultra-low anterior resection with colonic J-pouch anal anastomosis for synchronous carcinoma

An extensive large bowel resection with a single anastomosis is the accustomed management option for widely spaced synchronous colorectal neoplasms. We report a successful case of concurrent laparoscopic right hemicolectomy and ultra-low anterior resection with colonic J-pouch anal anastomosis in an 85-year-old man with synchronous cancers of the hepatic flexure and lowrectum. This surgical technique is advantageous for elderly patients as it provides the benefits of multiple segmental resection and laparoscopic surgery while potentially reducing mortality, time of procedure, postoperative pain, ileus, length of hospitalization and direct cost of care, and improving independence at discharge. The technique for efficient multiple extractions of specimens and effective reconstitution of pneumoperitoneum for a multistaged procedure is discussed.     

Choledocholithiasis： Evolving standards for diagnosis and management

Cholelithiasis, one of the most common medical conditions leading to surgical intervention, affects approximately 10 % of the adult population in the United States. Choledocholithiasis develops in about 10%-20% of patients with gallbladder stones and the literature suggests that at least 3%-10% of patients undergoing cholecys-tectomy will have common bile duct (CBD) stones. CBD stones may be discovered preoperatively, intraop-eratively or postoperatively Multiple modalities are available for assessing patients for Choledocholithiasis including laboratory tests, ultrasound, computed tomography scans (CT), and magnetic resonance cholangiopancrea-tography (MRCP). Intraoperative cholangiography during cholecystectomy can be used routinely or selectively to diagnose CBD stones. The most common intervention for CBD stones is ERCP. Other commonly used interventions include intra-operative bile duct exploration, either laparoscopic or open. Percutaneous, transhepatic stone removal other novel techniques of biliary clearance have been devised. The availability of equipment and skilled practitioners who are facile with these techniques varies among institutions. The timing of the intervention is often dictated by the clinical situation.     

Colorectal resection in deep pelvic endometriosis: Surgical technique and post-operative complications

AIM: To investigate the impact of different surgical techniques on post-operative complications after colorectal resection for endometriosis.METHODS: A multicenter case-controlled study using the prospectively collected data of 90 women(22 with and 68 without post-operative complications) who underwent laparoscopic colorectal resection for endometriosis was designed to evaluate any risk factors of post-operative complications. The prospectively collected data included: gender, age, body mass index, American Society of Anesthesiologists risk class, endometriosis localization(from anal verge), operative time, conversion, intraoperative complications, and post-operative surgical complications such as anastomotic dehiscence, bleeding, infection, and bowel dysfunction.RESULTS: A similar number of complicated cases have been registered for the different surgical techniques evaluated(laparoscopy, single access, flexure mobilization, mesenteric artery ligation, and transvaginal specimen extraction). A multivariate regression analysis showed that, after adjusting for major clinical, demographic, and surgical characteristics, complicated cases were only associated withendometriosis localization from the anal verge(OR = 0.8, 95%CI: 0.74-0.98, P = 0.03). After analyzing the association of post-operative complications and each different surgical technique, we found that only bowel dysfunction after surgery was associated with mesenteric artery ligation(11 out of 44 dysfunctions in the mesenteric artery ligation group vs 2 out of 36 cases in the no mesenteric artery ligation group; P = 0.03).CONCLUSION: Although further randomized clinical trials are needed to give a definitive conclusion, laparoscopic colorectal resection for deep infiltrating endometriosis appears to be both feasible and safe. Surgical technique cannot be considered a risk factor of post-operative complications.     

消化内镜在炎症性肠病诊治中的应用

炎症性肠病(IBD)的诊断与治疗仍有不少悬而未决的问题,加强消化内镜在IBD的诊断、鉴别诊断、指导治疗和随访中的应用,具有重要的临床应用价值。     

内镜超声诊断肠道子宫内膜异位症二例

子宫内膜异位症是指具有生长活力的子宫内膜组织在子宫腔以外部位的异常生长。肠壁异位内膜组织受卵巢激素周期性刺激而发生增生、出血、脱落,临床可有不同程度的肠道刺激症状。本文报道了2例因腹部非特异性症状就诊,肠镜下不典型,后经内镜超声、病灶活检确诊的肠道子宫内膜异位症的患者诊治情况。