Treatment of bowel endometriosis: a report of six cases of colorectal endometriosis and a survey of the literature

doi:10.1016/S0301-2115(96)02617-6

European Journal of Obstetrics & Gynecology and Reproductive Biology

Volume 71, Issue 1, January 1997, Pages 81-84

https://doi.org/10.1016/S0301-2115(96)02617-6 Get rights and content

Abstract

From October 1989 to September 1994, we performed six intestinal resections for rectal and sigmoidal endometrosis. The average age of the patients was 32 years old, and most had symptoms. In all cases coloscopy showed a normal mucosa. Patients had sucessfully been treated with hormones previously, but had relapsed when the treatment was stopped. Bowel resection was segmental, with immediate end to end anastomosis in five patients, and partial in one patient. Genital endometriosis was diagnosed in three cases and was then treated during the same procedure. A low colorectal anastomosis was complicated by a fistula, but no recurrence was observed after surgical treatment. Intestinal endometriosis tract is in 70% of cases located on the rectosigmoid. An association with genital endometrosis tract is observed in 80% of the cases. Deep rectosigmoidal endometriosis with symptoms is resistant to hormonal therapy and necessitates a surgical treatment by intestinal resection. The pelvis has always to be explored, with full evaluation and surgical treatment of genital endometriosis when necessary. Appendicular endometriosis should be removed surgically. Postoperative treatment can be additionally prescribed in cases of genital endometriosis and for leftover digestive location.

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Cited by (41)

Surgical Outcomes after Colorectal Surgery for Endometriosis: A Systematic Review and Meta-analysis
2021, Journal of Minimally Invasive Gynecology
Citation Excerpt :
For the meta-analysis, 17 studies on rectovaginal fistula, 10 on anastomotic leakage, 5 on anastomotic stenosis, and 9 on voiding dysfunction <30 days were included. Twenty-four studies were prospective [9,18–40], 1 was a randomized controlled trial [41], and 35 were retrospective [10,42–75]. The 60 studies included in the review enrolled a total of 17 495 patients: 9673 (55.3%) underwent rectal shaving, 1510 (8.6%) disc excision, and 6312 (36.1%) segmental resection.
To assess the impact of type of surgery for colorectal endometriosis—rectal shaving or discoid resection or segmental colorectal resection—on complications and surgical outcomes.
We performed a systematic review of all English- and French-language full-text articles addressing the surgical management of colorectal endometriosis, and compared the postoperative complications according to surgical technique by meta-analysis. The PubMed, Clinical Trials.gov, Cochrane Library, and Web of Science databases were searched for relevant studies published before March 27, 2020. The search strategy used the following Medical Subject Headings terms: (“bowel endometriosis” or “colorectal endometriosis”) AND (“surgery for endometriosis” or “conservative management” or “radical management” or “colorectal resection” or “shaving” or “full thickness resection” or “disc excision”) AND (“treatment”, “outcomes”, “long term results” and “complications”).
Two authors conducted the literature search and independently screened abstracts for inclusion, with resolution of any difference by 3 other authors. Studies were included if data on surgical management (shaving, disc excision, and/or segmental resection) were provided and if postoperative outcomes were detailed with at least the number of complications. The risk of bias was assessed according to the Cochrane recommendations.
Of the 168 full-text articles assessed for eligibility, 60 were included in the qualitative synthesis. Seventeen of these were included in the meta-analysis on rectovaginal fistula, 10 on anastomotic leakage, 5 on anastomotic stenosis, and 9 on voiding dysfunction <30 days. The mean complication rate according to shaving, disc excision, and segmental resection were 2.2%, 9.7%, and 9.9%, respectively. Rectal shaving was less associated with rectovaginal fistula than disc excision (odds ratio [OR] = 0.19; 95% confidence interval [CI], 0.10–0.36; p <.001; I² = 33%) and segmental colorectal resection (OR = 0.26; 95% CI, 0.15–0.44; p <.001; I² = 0%). No difference was found in the occurrence of rectovaginal fistula between disc excision and segmental colorectal resection (OR = 1.07; 95% CI, 0.70–1.63; p = .76; I² = 0%). Rectal shaving was less associated with leakage than disc excision (OR = 0.22; 95% CI, 0.06–0.73; p = .01; I² = 86%). No difference was found in the occurrence of leakage between rectal shaving and segmental colorectal resection (OR = 0.32; 95% CI, 0.10–1.01; p = .05; I² = 71%) or between disc excision and segmental colorectal resection (OR = 0.32; 95% CI, 0.30–1.58; p = .38; I² = 0%). Disc excision was less associated with anastomotic stenosis than segmental resection (OR = 0.15; 95% CI, 0.05–0.48; p = .001; I² = 59%). Disc excision was associated with more voiding dysfunction <30 days than rectal shaving (OR = 12.9; 95% CI, 1.40–119.34; p = .02; I² = 0%). No difference was found in the occurrence of voiding dysfunction <30 days between segmental resection and rectal shaving (OR = 3.05; 95% CI, 0.55–16.87; p = .20; I² = 0%) or between segmental colorectal and discoid resections (OR = 0.99; 95% CI, 0.54–1.85; p = .99; I² = 71%).
Colorectal surgery for endometriosis exposes patients to a risk of severe complications such as rectovaginal fistula, anastomotic leakage, anastomotic stenosis, and voiding dysfunction. Rectal shaving seems to be less associated with postoperative complications than disc excision and segmental colorectal resection. However, this technique is not suitable for all patients with large bowel infiltration. Compared with segmental colorectal resection, disc excision has several advantages, including shorter operating time, shorter hospital stay, and lower risk of postoperative bowel stenosis.
Recurrence after Surgery for Colorectal Endometriosis: A Systematic Review and Meta-analysis
2020, Journal of Minimally Invasive Gynecology
Citation Excerpt :
Ten of the remaining 51 articles were ineligible for review: three reported a surgical technique that was unclear and 7 reported an overall recurrence rate without specifying the colorectal technique. Among the 41 articles included in the review (Table 1) [11,20–59], 37 were excluded from the meta-analysis according to the inclusion criteria: eleven were excluded because of a follow-up period <12 months and 26 on the basis of the definition of recurrence (either nonspecified or without follow-up surgery with histologic proof of recurrence). In total, 41 studies were retained for the systemic review [11,20–59], 4 of which were included (Table 2) [21,25,30,47] in the meta-analysis (Fig. 1).
The recurrence rate after colorectal surgery for endometriosis is up to 50% at 5 years. The aim of the current review and meta-analysis was to assess recurrence associated with shaving, disc excision, and segmental resection for endometriosis with colorectal involvement.
A systematic review was performed by searching the PubMed, ClinicalTrials.gov, EMBASE, Cochrane Library, and Web of Science databases for publications before February 28, 2019, using the terms “colorectal endometriosis” and “recurrence” in English. The outcome measure was histologically proven recurrence 1 year after the index surgery.
Studies rated as good or fair by a study quality assessment tool were included. Two reviewers independently assessed the quality of the studies; discrepancies were discussed, and if a consensus was not reached, a third reviewer was consulted.
Of 156 relevant published trials, 41 were systematically reviewed and 4 were included in the meta-analysis. The risk of recurrence was higher after rectal shaving than after both segmental resection (odds ratio [OR], 5.53; 95% confidence interval [CI], 2.33–13.12; I² = 0%; p = .001) and disc excision for histologically proven recurrence (OR, 3.83; 95% CI, 1.33–11.05; I² = 0%; p = .01). This difference was not significant when comparing disc excision with segmental resection (OR, 2.63; 95% CI, 0.8–8.65; I² = 0%; p = .11).
The current analysis shows that the risk of recurrence is lower when segmental resection or disc excision is performed than when rectal shaving is performed. This finding is important when deciding the most appropriate surgical management.
Rare case of perplexing ovarian endometriosis
2010, Fertility and Sterility
To document a rare case of coexisting endometriosis and mature cystic teratoma in the same ovary.
Case report.
Gynecology unit in a tertiary training and teaching hospital in Cape Town, South Africa.
A 30-year-old healthy nulligravida woman with a large ovarian tumor.
After a basic examination, a diagnostic and management laparotomy was performed. A unilateral oophorectomy and staging laparotomy were performed.
Final diagnosis of a complex ovarian tumor.
Histologic analysis confirmed endometriosis of the pelvis and concomitant compound pathology in the right ovary, which included endometriosis, mature teratoma, and mucinous cystadenoma.
Co-existence of varied pathology in a single organ presents a challenge to the pathologist and the clinician. Accurate clinical (i.e., surgical) assessment and decisive histologic verification forms a critical part in this process. This case of coexisting endometriosis and teratoma in a single ovary is, to our knowledge, only the third case reported in literature.
Letrozole and norethisterone acetate in colorectal endometriosis
2010, European Journal of Obstetrics and Gynecology and Reproductive Biology
Citation Excerpt :
Medical therapies have been shown to be safe, well tolerated and effective in long-term treatment of pain symptoms caused by deep pelvic endometriosis [11]. Although some authors reported a temporary improvement in pain and intestinal complaints during treatment with gonadotropin releasing hormone analogues [12,13], up to now few studies have investigated the effects of hormonal therapies on the symptoms caused by bowel endometriosis [1,14,15]. Over the last 10 years, several case reports and pilot studies proposed the use of aromatase inhibitors in the treatment of pain symptoms caused by pelvic endometriosis [16]; however, no study examined the effects of these agents in treating intestinal symptoms of women with colorectal endometriosis.
Up to now limited attention has been given to the medical treatment of bowel endometriosis. This study evaluates the efficacy of aromatase inhibitors and norethisterone acetate in treating pain and gastrointestinal symptoms caused by bowel endometriosis.
This prospective pilot study included six women with colorectal endometriosis; all women had intestinal nodules infiltrating at least the muscularis propria of the bowel and did not have a stenosis of the bowel lumen >60%; the patients suffered from pain and intestinal symptoms. The study subjects received letrozole (2.5 mg/day) and norethisterone acetate (2.5 mg/day) continuously for 6 months. The presence and intensity of symptoms were evaluated before starting the treatment, and after 3 and 6 months of treatment.
The double-drug regimen improved pain, non-menstrual pelvic pain, deep dyspareunia, dyschezia, symptoms mimicking diarrhoea-predominant irritable bowel syndrome, intestinal cramping, abdominal bloating and passage of mucus in the stools, and 67% of the patients declared that the treatment improved their gastrointestinal symptoms.
The administration of letrozole and norethisterone acetate reduces pain and gastrointestinal symptoms of women with colorectal endometriosis, particularly when patients suffer from symptoms mimicking diarrhoea-predominant irritable bowel syndrome.
Intestinal obstruction secondary to endometriosis: A rare case of synchronous bowel localization
2007, Surgical Oncology
Although endometriosis is a common disease in women of childbearing age, intestinal endometriosis is unusual and may cause clinically significant complications. We report a 35-year-old woman with endometriosis involving the ileocaecal junction and rectum who presented with intestinal obstruction. She was operated with a preoperative diagnosis of malignancy. The diagnosis of endometriosis was made only after histological examination of the resected specimen. Intestinal endometriosis has a diverse clinical spectrum, with nonspecific features in many patients. In female patients who have unexplained digestive complaints, endometriosis should also be considered in the differential diagnosis.
Small Intestine and Colonic Diseases
2004, Principles of Gender-Specific Medicine

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Treatment of bowel endometriosis: a report of six cases of colorectal endometriosis and a survey of the literature

Abstract

Obstet Gynecol Clin North Am

Fertil Steril

Digestive endometriosis: results of a multicentric investigation

Contr Gynecol Obstet

Different types of extragenital endometriosis: a review

Gynecol Endocrinol

Endometriosis of the bowel

Obstet Gynecol

Gastrointestinal endometriosis

Incidence and indications for resection

Arch Surg

Diagnosis and management of endometriosis of the colon and rectum

Dis Colon Rectum

Diagnostic et traitement de l'endométriose digestive

Ann Chir

La place de la suppression ovarienne dans le traitement de l'endométriose

Réf en Gynécol Obstét

L'endométriose rectosigmoidienne, Résultats d'une enquête multicentrique collectant 69 dossiers

Lyon Chir

Pelvic endometriosis simulating colonic malignant neoplasm

Arch Intern Med

Aggressive surgical management for advanced colorectal endometrioisis

Colon Rectum