Deep endometriosis, including intestinal involvement – the interdisciplinary approach

Abstract

Deep endometriosis is a disease which may involve all organs of the pelvis. The lesion is most often located at the backside of the uterus, involving the uterosacral ligaments and/or the rectovaginal septum. The involvement of adjacent organs, e.g. bowel, ureter, and bladder, makes an interdisciplinary approach necessary. There is a correlation between the radicalness of endometriosis resection and the postoperative improvement of complaints. In a series of 202 patients with deep endometriosis including the bowel we performed a segmental resection with anterior anastomosis including radical excision of all endometriotic lesions. The follow-up of 142 patients shows a significant improvement of pelvic pain (96%), dyschezia (88%), and dyspareunia (87%). Of 95 patients with a desire for children, 50% became pregnant. The postoperative complication rate was low. A leakage of anastomosis was seen in six cases (3%).

Surgical treatment of rectovaginal endometriosis with rectal involvement

“…When they compared these results to those obtained after laparotomic colorectal resection, they found a similar rate of complications [51]. Keckstein and Weisinger [25] found a 7.4% complications rate and Daraï et al [26] reported a 10% complications rate, with 6% being rectovaginal fistulas. When the laparotomic approach is used, Dousset et al [5] reported a 16% complications rate, with 4% being rectovaginal fistulas.…”

“…There were also five nonsystematic revisions published [3,28,[32][33][34]. In some of the studies, a radical treatment was assessed [5,13,15,[25][26][27][40][41][42][43][44][45][46][47][48][49][50][51][52][53][54][55][56], while others assessed a conservative one [57][58][59][60][61][62][63]. There were six nonrandomized papers in which groups of patients with different therapeutic options were compared [30,[35][36][37][38][39].…”

“…Initially, the majority of papers defended a conservative surgical approach directed toward the extirpation or ablation of the endometriosic lesions with minimal excisional surgery of the rectum [6,12,[65][66][67][68]. However, in the last decade, multiple authors have proposed more aggressive techniques including intestinal resection, especially in those cases with an affected muscularis propia of the rectum but also in those having an intact mucosa [5,13,15,[25][26][27][40][41][42][43][44][45][46][47][48][49][50][51][52][53][54][55][56]. The argument used for the practice of this radical surgery is that of achieving the greatest resection possible of the endometriosic lesions, diminishing the postoperative symptomatology and avoiding any early relapse of the disease [41,42].…”

“…At present, some gynecological surgeons prefer colorectal resection for symptomatic patients, as they are convinced that resection of all intestinal endometriosic foci is the choice of treatment to improve pain and to avoid relapses [5,13,[25][26][27]. On the other hand, other groups prefer the excision of the endometriosic nodule to colorectal resection, since the rate of morbidity is lower and the recurrence of pain is similar [3,[28][29][30].…”

Identical Ovarian and Deep Pelvic Endometriosis with Colorectal Involvement in Monozygotic Twins: A Case Report and Review of the Literature

“…Lately, there has been a great deal of effort to advocate shaving as the treatment of choice, mainly because of higher early and late complications in segmental colorectal resection [36]. The efficacy of segmental colorectal resection is very debatable; data in this regard is controversial and, to a great deal, dependent upon the surgeon's experience [37,38]. Findings from histopathologic analysis of specimens from segmental bowel resection indicates that in 50% of cases there is a satellite lesion independent of the primary deep nodule.The deepest layer of the bowel wall containing endometrioticfoci at the primary lesion is in the submucosal layer in 70% of cases and the internal circular muscle layer in 30%.…”