Bowel endometriosis: diagnosis and management

doi:10.1016/j.ajog.2017.09.023

American Journal of Obstetrics and Gynecology

Volume 218, Issue 6, June 2018, Pages 549-562

https://doi.org/10.1016/j.ajog.2017.09.023 Get rights and content

The most common location of extragenital endometriosis is the bowel. Medical treatment may not provide long-term improvement in patients who are symptomatic, and consequently most of these patients may require surgical intervention. Over the past century, surgeons have continued to debate the optimal surgical approach to treating bowel endometriosis, weighing the risks against the benefits. In this expert review we will describe how the recommended surgical approach depends largely on the location of disease, in addition to size and depth of the lesion. For lesions approximately 5-8 cm from the anal verge, we encourage conservative surgical management over resection to decrease the risk of short- and long-term complications.

Section snippets

Background

Endometriosis is a chronic, estrogen-dependent inflammatory condition affecting approximately 10% of all reproductive-aged women and approximately 35-50% of women with pelvic pain and infertility.¹ Endometriosis can be classified as genital vs extragenital.² Endometriosis along the bowel is the most common site for extragenital endometriosis.3, 4 Endometriosis of the bowel can manifest as deeply infiltrative lesions of the muscularis or mucosa, or as superficial disease that lines the bowel

Clinical presentation

Clinical suspicion for deeply infiltrative endometriosis and bowel endometriosis starts with a thorough clinical history. It should be suspected in women who report dysmenorrhea, deep dyspareunia, chronic pain, and/or dyschezia. Some women have catamenial diarrhea, blood in the stool, constipation, bloating, pain with sitting, and radiation of pain to the perineum. The pathogenesis of pain related to endometriosis is complex and multifactorial, with evidence suggesting that there may be an

Medical Management

Medical management may be utilized for symptomatic patients with bowel endometriosis, with the understanding that patients may still require subsequent future surgery. Ovulatory suppression can improve some patients’ symptoms, and may be advisable for those who are not surgical candidates or who prefer to avoid surgery. Hormonal suppression has been shown to significantly improve pain and GI symptoms in patients whose degree of bowel stenosis is <60%.²⁹ It is especially useful to prevent

Surgical Management

The exact mode of surgery will depend on surgeon expertise and experience, as well as availability of proper instrumentation. Cases of bowel endometriosis must often be managed in a multidisciplinary fashion, often with a minimally invasively trained gynecologic surgeon and involvement of a GI surgeon familiar with endometriosis.37, 38, 39, 40, 41, 42, 43, 44 As determined by the surgeon’s experience and access to instrumentation, we recommend video-assisted laparoscopic surgery, with or

Conclusions

Deep infiltrative endometriosis of the bowel may have various presentations. Unfortunately, it often goes undiagnosed, while in other instances it continues to be overaggressively treated. Bowel endometriosis can be encountered incidentally at the time of surgery performed for another indication, or it may be suspected when a premenopausal woman has significant pelvic pain, bloating, cyclic dyschezia, blood in the stool, changes in stool caliber, or irritable bowel syndrome–like symptoms. If a

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Robotic Management of Recurrent Rectal Endometriosis After Previous Segmental Bowel Resection
2024, Journal of Minimally Invasive Gynecology
To describe the management of recurrent bowel endometriosis after previous colorectal resection.
Surgical video article. The local institutional board review was omitted due to the narration of surgical management. Patient consent was obtained.
A tertiary referral center. The patient first underwent segmental bowel resection for deep infiltrating endometriosis of the rectum in the ENDORE randomized controlled trial in 2012 and then received a total hysterectomy in 2018. Five years later, she presented with recurrent nodules in the rectovaginal, left parametrium, and abdominal wall after discontinuing medical suppressive treatment.
Laparoscopic management using robotic assistance was employed to complete excision of the rectovaginal nodule. Disc excision was performed to remove rectal infiltration. The procedure started with rectal shaving and excision of vaginal infiltration . A traction stitch was placed over the limits of the rectal shaving area. The general surgeon placed a 28 mm circular anal stapler transanally and performed complete excision of the shaved rectal area. Anastomotic perfusion was checked with indocyanine green. A methylene blue enema test was conducted to rule out anastomotic leakage. Outcomes were favorable, with systematic self-catheterization during 5 postoperative weeks. No specific symptoms were related to the other 2 nodules, which were not removed.
Rectal recurrences may occur long after colorectal resection and outside the limits of the previous surgery site. To accurately assess this risk, long-term follow-up of patients is mandatory.. Postoperative medical amenorrhea may play a role in recurrence prevention. Surgical management of recurrences may be challenging and focus on only those nodules responsible for symptoms so as to best preserve the organ's function and reduce postoperative morbidity.
Authors' Reply
2023, Journal of Minimally Invasive Gynecology
Oocyte donation outcomes in endometriosis patients with multiple IVF failures
2023, Reproductive BioMedicine Online
What are the reproductive outcomes and the prognostic factors of live birth rates in patients with endometriosis referred to oocyte donation after multiple IVF failures?
Observational cohort study including all women with endometriosis-related infertility and two or more failed IVF/intracytoplasmic sperm injection (ICSI) cycles referred to oocyte donation between January 2013 and June 2022. Endometriosis was diagnosed based on published imaging criteria, and was confirmed histologically in women who had a history of surgery for endometriosis. The main outcome measured was the cumulative live birth rate (CLBR). The characteristics of women who had a live birth were compared with those who did not using univariate and multivariate analysis to identify determinant factors of fertility outcome.
Fifty-seven patients underwent 90 oocyte donation cycles after 244 failed autologous IVF cycles. The mean ± SD age of the population was 36.8 ± 3.3 years, with a mean duration of infertility of 3.6 ± 2.2 years, and a mean number of autologous IVF/ICSI cycles of 4.4 ± 2.3 cycles per patient. Three patients (5.3%) had superficial peritoneal endometriosis, two patients (3.5%) had ovarian endometriomas, and 52 patients (91.2%) had deep infiltrating endometriosis, among which 30 patients (57.7%) had bowel lesions. Thirty patients (52.6%) had associated adenomyosis. Overall, CLBR per patient was 36/57 (63.2%). After multivariate analysis, only being nulligravida (P=0.002) remained an independent negative predictive factor of the live birth rate. Previous surgery did not impact reproductive outcomes.
This study suggests that oocyte donation appears to be a viable option to optimize the live birth rate in women with endometriosis-related infertility and recurrent IVF failures.
“A Space Odyssey” on Laparoscopic Segmental Rectosigmoid Resection for Deep Endometriosis: A Seventeen-year Retrospective Analysis of Outcomes and Postoperative Complications among 3050 Patients Treated in a Referral Center
2023, Journal of Minimally Invasive Gynecology
To evaluate the feasibility of laparoscopic rectosigmoid resection for bowel endometriosis (RSE), reporting surgical and short-term postoperative outcomes in a consecutive large series of patients.
A retrospective cohort study.
Third-level national referral center for deep endometriosis (DE).
3050 patients with symptomatic RSE requiring surgical treatment.
Nerve-sparing laparoscopic resection for RSE perfomed by a multidisciplinary team. After collecting intraoperative surgical characteristics, postoperative complications were collected by evaluating the risk factors associated with their onset.
Clavien-Dindo IIIb postoperative complications were noted in 13.1% of patients, with anastomotic leakage and rectovaginal fistula accounting for 3.0% and 1.9%, respectively. Postoperative bladder impairment was observed in 13.9% of patients during hospital discharge but spontaneously decreased to 4.5% at the first evaluation after 30 days, alongside a statistically significant change towards global symptom improvement. Multivariate analyses were done to identify the risk factors for segmental bowel resection in terms of occurrence of postoperative major complications. Ultralow (≤5 cm from the anal verge), low rectal anastomosis (<8 cm, >5 cm), parametrectomy, vaginal resection, and previous surgeries seemed more related to anastomotic leakage, rectovaginal fistula, and bladder retention.
Laparoscopic rectosigmoid resection for RSE seems an effective and feasible procedure. The surgical complication rate is not negligible but could be reduced by implementing a multidisciplinary approach, an endless improvement in nerve-sparing techniques and surgical anatomy, as well as technological enhancements. Real future challenges will be to reduce the time for the first diagnosis of DE and the likelihood of surgical indications.
Anatomical and Surgical Considerations for Ileocolic Endometriosis
2023, Journal of Minimally Invasive Gynecology
We aim to review the incidence, location, and management of bowel endometriosis and demonstrate relevant surgical principles while emphasizing anatomic considerations for minimally invasive resection of ileocolic lesions.
This video briefly reviews the background of bowel endometriosis and indications for surgical excision. We present a case of a patient diagnosed with symptomatic terminal ileum endometriosis and review the preoperative imaging. We demonstrate the steps of a medial-to-lateral surgical approach for ileocolic resection and highlight the relevant surgical anatomy. Institutional review board approval was not required.
This procedure was performed at a large academic institution with a multidisciplinary team of minimally invasive gynecologic and colorectal surgeons.
The case presented is a 44-year-old female with a known history of stage IV endometriosis. She presented with acute abdominal pain and was found to have a small bowel obstruction from a 3-centimeter lesion thought to be an endometrioma. She failed conservative management and was thoroughly counseled about the need for surgical intervention. Pelvic magnetic resonance imaging was performed for preoperative planning.
Laparoscopic ileocolic resection is performed using a medial-to-lateral approach for excision of a symptomatic 3-centimeter ileocecal endometrioma. The following techniques are highlighted:
(1) Evaluation of the entire small bowel starting at the ligament of Treitz
(2) Entry into the retroperitoneum below the ileum with cranial and caudal dissection
(3) Mobilization of the ascending colon to the level of the falciform ligament
(4) Extension of the umbilical incision to perform an extracorporeal ileocecal resection and anastomosis
The bowel is the most common extragenital site for endometriosis to occur, with the highest rate of lesions located in the rectosigmoid colon [1]. Lesions can be either superficial or deeply infiltrative and can lead to a range of symptoms. A serious sequela of bowel endometriosis includes bowel obstruction requiring surgical intervention.
Robotic assisted rectal disk excision: the 3-cm diameter cut off may be abandoned
2023, Fertility and Sterility
To describe the robotic full-thickness rectal excision using a transanal circular stapler in rectovaginal endometriosis nodule infiltrating the rectum >3 cm.
Surgical video article. The local institutional review board was consulted, and the requirement for institutional review board approval was waived because the video describes a technique and the patient cannot be identified whatsoever. Written informed consent was obtained from the patient for the use of personal data.
A tertiary referral center.
Patients undergoing excision of rectal endometriosis.
Standardized technique of full-thickness disk excision of large rectovaginal endometriosis nodules employing a combined robotic and trans anal approach.
Feasibility of the technique.
The technique is designed for deep rectovaginal nodules infiltrating middle and low-rectum up to 3 to 5 cm in length. The procedure was performed with robotic assistance. The 7-degree freedom mobility of the robotic scissors allows for a deep rectal shaving, with the goal of progressive reduction of the thickness of rectal wall. The scissors follow the rectal wall tangentially and leave behind a thin rectal wall which can be bent and pushed into the trans anal stapler’s jaws. We employed end-to-end, 33 mm-diameter, circular trans anal staplers to increase the area of rectal wall to be caught into the stapler. A stitch was placed on the superior and the inferior limits of the shaved area, then the shaved area was bent and pushed into the stapler by tying a suture. The general surgeon closed and fired the stapler, then the stapler was removed together with a rectal patch of 4- to 6-cm diameter. The procedure ended in the bubble test which checked the integrity of the stapled line. Supplementary stitches may be placed to reinforce the suture, if required.
The preliminary rectal shaving represents the real keystone of this procedure, and our experience suggests that the robotic assistance improves its feasibility in large nodule responsible for intrarectal protrusion.
Escisión de disco rectal robóticamente asistida: se puede abandonar el límite de 3 centímetros.
Describir una escisión rectal robótica de espesor total empleando una grapadora circular transanal en un nódulo de endometriosis rectovaginal infiltrante del recto de >3cm.
Artículo de vídeo quirúrgico. Se consultó al consejo de revisión institucional (IRB) y no se requirió aprobación de éste porque el vídeo describe una técnica y resulta imposible identificar a la paciente. Se obtuvo consentimiento informado por escrito de la paciente para emplear sus datos personales.
Centro de referencia terciario.
Pacientes sometidas a escisión de endometriosis rectal.
Técnica estandarizada de escisión de disco de espesor total de grandes nódulos rectovaginales de endometriosis utilizando un enfoque combinado robótico y transanal.
Viabilidad de la técnica.
La técnica está diseñada para nódulos rectovaginales profundos infiltrantes del recto medio y bajo de hasta 3 a 5 cm de longitud. El procedimiento se realizó con asistencia robótica. La libre movilidad de 7 grados de las tijeras robóticas permite un rasurado rectal profundo, con el objetivo lograr una reducción progresiva del espesor de la pared rectal. Las tijeras siguen la pared rectal tangencialmente y dejan una pared rectal fina, que puede ser doblada y empujada dentro de las hojas de la grapadora transanal. Empleamos una grapadora transanal circular de 33mm de diámetro entre sus extremos para aumentar el área de pared rectal que se atraparía con la grapadora. Se colocó un punto en los límites superior e inferior del área rasurada, tras lo cual el área fue doblada y empujada dentro de la grapadora anudando una sutura. El cirujano general cerró y disparó la grapadora, después de lo cual la grapadora fue retirada junto con una sección rectal de 4 a 6cm de diámetro. El procedimiento concluyó con una prueba de burbujas para comprobar la integridad de la sutura de grapas. Se pueden aplicar puntos suplementarios para reforzar la sutura si fuera necesario.
La piedra angular de este procedimiento es el rasurado rectal preliminar y nuestra experiencia sugiere que la asistencia robótica mejora su viabilidad en grandes nódulos que causen protrusión intrarectal.

View all citing articles on Scopus

: The authors report no conflict of interest.

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Expert ReviewBowel endometriosis: diagnosis and management

Section snippets

Background

Clinical presentation

Medical Management

Surgical Management

Conclusions

Fertil Steril

J Minim Invasive Gynecol

Eur J Surg Oncol

Gynecol Oncol

Am J Obstet Gynecol

Fertil Steril

J Minim Invasive Gynecol

Fertil Steril

Fertil Steril

J Minim Invasive Gynecol

Fertil Steril

Fertil Steril

Fertil Steril

Am J Obstet Gynecol

Fertil Steril

Fertil Steril

Am J Obstet Gynecol

J Minim Invasive Gynecol

J Minim Invasive Gynecol

Fertil Steril

Fertil Steril

Fertil Steril

Fertil Steril

J Am Coll Surg

J Minim Invasive Gynecol

J Minim Invasive Gynecol

Am J Obstet Gynecol

J Minim Invasive Gynecol

J Am Coll Surg

Am J Obstet Gynecol

Fertil Steril

J Minim Invasive Gynecol

Gastroenterol Clin Biol

J Minim Invasive Gynecol

J Minim Invasive Gynecol

Gynecol Oncol

Clinical practice

Endometriosis. N Engl J Med

Pathophysiology and management of urinary tract endometriosis

Nat Rev Urol

Theories on the pathogenesis of endometriosis

Int J Reprod Med

Extragenital endometriosis

Clin Obstet Gynecol

Endometriosis of the bowel

Obstet Gynecol

Intestinal endometriosis: the great masquerader

Curr Gastroenterol Rep

Video-assisted laparoscopic treatment of endometriosis

Intestinal endometriosis. Surgical management of endometriosis

Endometriosis of the stomach

Vestn Khir Im I I Grek

Endometriosis of the transverse colon–a rare localization

Dtsch Med Wochenschr

The link between endometriosis and ovarian cancer: clinical implications

Int J Gynecol Cancer

Expert Review
Bowel endometriosis: diagnosis and management