CC BY-NC-ND 4.0 · Rev Bras Ginecol Obstet 2018; 40(07): 390-396
DOI: 10.1055/s-0038-1660827
Original Article
Thieme Revinter Publicações Ltda Rio de Janeiro, Brazil

Surgical Treatment of Intestinal Endometriosis: Outcomes of Three Different Techniques

Tratamento cirúrgico de endometriose intestinal: resultados de três técnicas operatórias
Fernando Bray-Beraldo
1   Gastroenterology Surgery Service, Hospital do Servidor Público Estadual, São Paulo, SP, Brazil
,
Ana Maria Gomes Pereira
2   Ginecology Service, Hospital do Servidor Público Estadual, São Paulo, SP, Brazil
,
Cláudia Gazzo
2   Ginecology Service, Hospital do Servidor Público Estadual, São Paulo, SP, Brazil
,
Marcelo Protásio Santos
1   Gastroenterology Surgery Service, Hospital do Servidor Público Estadual, São Paulo, SP, Brazil
,
Reginaldo Guedes Coelho Lopes
2   Ginecology Service, Hospital do Servidor Público Estadual, São Paulo, SP, Brazil
› Institutsangaben
Weitere Informationen

Publikationsverlauf

17. Oktober 2017

16. April 2018

Publikationsdatum:
27. Juni 2018 (online)

Abstract

Objective To outline the demographic and clinical characteristics of patients with deep intestinal endometriosis submitted to surgical treatment at a tertiary referral center with a multidisciplinary team, and correlate those characteristics with the surgical procedures performed and operative complications.

Methods A prospective cohort from February 2012 to November 2016 of 32 women with deep intestinal endometriosis operations. The variables analyzed were: age; obesity; preoperative symptoms (dysmenorrhea, dyspareunia, acyclic pain, dyschezia, infertility, urinary symptoms, constipation and intestinal bleeding); previous surgery for endometriosis; Enzian classification; size of the intestinal lesion; and surgical complications.

Results The mean age was 37.75 (±5.72) years. A total of 7 patients (22%) had a prior history of endometriosis. The mean of the largest diameter of the intestinal lesions identified intraoperatively was of 28.12 mm (±14.29 mm). In the Enzian classification, there was a predominance of lesions of the rectum and sigmoid, comprising 30 cases (94%). There were no statistically significant associations between the predictor variables and the outcome complications, even after the multiple logistic regression analysis. Regarding the size of the lesion, there was also no significant correlation with the outcome complications (p = 0.18; 95% confidence interval [95%CI]:0.94–1.44); however, there was a positive association between grade 3 of the Enzia classification and the more extensive surgical techniques: segmental intestinal resection and rectosigmoidectomy, with a prevalence risk of 4.4 (p < 0.001; 95%CI:1.60–12.09).

Conclusion The studied sample consisted of highly symptomatic women. A high prevalence of deep infiltrative endometriosis lesions was found located in the rectum and sigmoid region, and their size correlated directly with the extent of the surgical resection performed.

Resumo

Objetivo Delinear as características das pacientes portadoras de endometriose profunda intestinal submetidas a tratamento cirúrgico em centro de referência com equipe multidisciplinar, e correlacionar tais achados com a extensão de doença e com os procedimentos cirúrgicos realizados.

Métodos Tratamento cirúrgico no período de fevereiro de 2012 a novembro de 2016 em 32 mulheres portadoras de endometriose profunda intestinal. Variáveis analisadas: idade; obesidade; queixas pré-operatórias: dismenorreia, dispareunia, dor acíclica, disquezia, sangramento uterino anormal, infertilidade, sintomas urinários, constipação, e sangramento intestinal; cirurgia prévia para tratamento de endometriose profunda; classificação de Enzian; técnica cirúrgica aplicada; tamanho da lesão intestinal; e complicações operatórias.

Resultados A média de idade foi de 37,75 (±5,72) anos. Um total de 7 (22%) pacientes tinha histórico de abordagem prévia da endometriose. A média do maior diâmetro das lesões intestinais foi de 28,12 mm (±14,29 mm). Na classificação de Enzian, houve predomínio das lesões da região de reto ou retossigmoide no compartimento posterior, num total de 30 casos (94%). Não foi observada associação estatística significativa entre as variáveis preditivas e o desfecho da complicação, mesmo após análise de regressão logística múltipla. Quanto ao tamanho da lesão, também não houve correlação significativa com o desfecho complicação (p = 0,18; intervalo de confiança de 95% [IC95%]: 0,94–1,44). No entanto, Houve associação positiva entre o grau 3 da classificação de Enzian e a técnica cirúrgica mais extensa: ressecção intestinal segmentar e retossigmoidectomia, com risco de prevalência de 4,4 (p = 0,00003; IC95%: 1,60–12,09).

Conclusão A amostra populacional estudada foi constituída de mulheres muito sintomáticas. Foi encontrada prevalência alta de lesões de endometriose infiltrativa profunda localizadas em região de retossigmoide, e seu tamanho correlacionou-se diretamente com a extensão da ressecção cirúrgica realizada.

Contributions

Bray-Beraldo F, Pereira AMG, Gazzo C, Santos MP and Lopes RGC contributed with the conception and design, data collection and analysis, interpretation of data, writing of the article, critical review of the intellectual content, and final approval of the version to be published.


 
  • References

  • 1 Klugsberger B, Shamiyeh A, Oppelt P, Jabkowski C, Schimetta W, Haas D. Clinical outcome after colonic resection in women with endometriosis. BioMed Res Int 2015; 2015 (15) 514383
  • 2 Alkatout I, Egberts JH, Mettler L. , et al. Interdisciplinary diagnosis and treatment of deep infiltrating endometriosis. Zentralbl Chir 2016; 141 (06) 630-638 . Doi: 10.1055/s-0034-1383272
  • 3 Arruda MS, Petta CA, Abrão MS, Benetti-Pinto CL. Time elapsed from onset of symptoms to diagnosis of endometriosis in a cohort study of Brazilian women. Hum Reprod 2003; 18 (04) 756-759
  • 4 Santos TMV, Pereira AMG, Lopes RGC, Depes DdeB. Lag time between onset of symptoms and diagnosis of endometriosis. Einstein (Sao Paulo) 2012; 10 (01) 39-43 . Doi: 10.1590/S1679-45082012000100009
  • 5 Prystowsky JB, Stryker SJ, Ujiki GT, Poticha SM. Gastrointestinal endometriosis. Incidence and indications for resection. Arch Surg 1988; 123 (07) 855-858
  • 6 Bachmann R, Bachmann C, Lange J. , et al. Surgical outcome of deep infiltrating colorectal endometriosis in a multidisciplinary setting. Arch Gynecol Obstet 2014; 290 (05) 919-924 . Doi: 10.1007/s00404-014-3257-x
  • 7 Cornillie FJ, Oosterlynck D, Lauweryns JM, Koninckx PR. Deeply infiltrating pelvic endometriosis: histology and clinical significance. Fertil Steril 1990; 53 (06) 978-983 . Doi: 10.1016/S0015-0282(16)53570-5
  • 8 Abrão MS, Petraglia F, Falcone T, Keckstein J, Osuga Y, Chapron C. Deep endometriosis infiltrating the recto-sigmoid: critical factors to consider before management. Hum Reprod Update 2015; 21 (03) 329-339 . Doi: 10.1093/humupd/dmv003
  • 9 Chapron C, Fauconnier A, Vieira M. , et al. Anatomical distribution of deeply infiltrating endometriosis: surgical implications and proposition for a classification. Hum Reprod 2003; 18 (01) 157-161
  • 10 Neme RM, Schraibman V, Okazaki S. , et al. Deep infiltrating colorectal endometriosis treated with robotic-assisted rectosigmoidectomy. JSLS 2013; 17 (02) 227-234 . Doi: 10.4293/108680813 × 13693422521836
  • 11 Wolthuis AM, Meuleman C, Tomassetti C, D'Hooghe T, de Buck van Overstraeten A, D'Hoore A. Bowel endometriosis: colorectal surgeon's perspective in a multidisciplinary surgical team. World J Gastroenterol 2014; 20 (42) 15616-15623 . Doi: 10.3748/wjg.v20.i42.15616
  • 12 Seracchioli R, Poggioli G, Pierangeli F. , et al. Surgical outcome and long-term follow up after laparoscopic rectosigmoid resection in women with deep infiltrating endometriosis. BJOG 2007; 114 (07) 889-895 . Doi: 10.1111/j.1471-0528.2007.01363.x
  • 13 Jerby BL, Kessler H, Falcone T, Milsom JW. Laparoscopic management of colorectal endometriosis. Surg Endosc 1999; 13 (11) 1125-1128
  • 14 Bailey HR, Ott MT, Hartendorp P. Aggressive surgical management for advanced colorectal endometriosis. Dis Colon Rectum 1994; 37 (08) 747-753 . Doi: 10.1007/BF02050136
  • 15 Ruffo G, Scopelliti F, Manzoni A. , et al. Long-term outcome after laparoscopic bowel resections for deep infiltrating endometriosis: a single-center experience after 900 cases. BioMed Res Int 2014; 2014 (14) 463058
  • 16 Donnez J, Jadoul P, Colette S, Luyckx M, Squifflet J, Donnez O. Deep rectovaginal endometriotic nodules: perioperative complications from a series of 3,298 patients operated on by the shaving technique. Gynecol Surg 2013; 10 (01) 31-40 . Doi: 10.1007/s10397-012-0759-z
  • 17 Ceccaroni M, Clarizia R, Bruni F. , et al. Nerve-sparing laparoscopic eradication of deep endometriosis with segmental rectal and parametrial resection: the Negrar method. A single-center, prospective, clinical trial. Surg Endosc 2012; 26 (07) 2029-2045 . Doi: 10.1007/s00464-012-2153-3
  • 18 Ribeiro PAA, Rodrigues FC, Kehdi IPA. , et al. Laparoscopic resection of intestinal endometriosis: a 5-year experience. J Minim Invasive Gynecol 2006; 13 (05) 442-446 . Doi: 10.1016/j.jmig.2006.05.010
  • 19 Abrao MS, Gonçalves MO, Dias Jr JA, Podgaec S, Chamie LP, Blasbalg R. Comparison between clinical examination, transvaginal sonography and magnetic resonance imaging for the diagnosis of deep endometriosis. Hum Reprod 2007; 22 (12) 3092-3097 . Doi: 10.1093/humrep/dem187
  • 20 Haas D, Chvatal R, Habelsberger A, Wurm P, Schimetta W, Oppelt P. Comparison of revised American Fertility Society and ENZIAN staging: a critical evaluation of classifications of endometriosis on the basis of our patient population. Fertil Steril 2011; 95 (05) 1574-1578 . Doi: 10.1016/j.fertnstert.2011.01.135
  • 21 Haas D, Wurm P, Shamiyeh A, Shebl O, Chvatal R, Oppelt P. Efficacy of the revised Enzian classification: a retrospective analysis. Does the revised Enzian classification solve the problem of duplicate classification in rASRM and Enzian?. Arch Gynecol Obstet 2013; 287 (05) 941-945 . Doi: 10.1007/s00404-012-2647-1
  • 22 Fahmy WM, Lopes RCG, Ramos JFD. , et al. Evaluation of the results of surgical treatment of patients with endometriosis of the rectovaginal septum. Rev Bras Ginecol Obstet 2005; 27 (10) 613-618 . Doi: 10.1590/S0100-72032005001000008
  • 23 Dubernard G, Piketty M, Rouzier R, Houry S, Bazot M, Darai E. Quality of life after laparoscopic colorectal resection for endometriosis. Hum Reprod 2006; 21 (05) 1243-1247 . Doi: 10.1093/humrep/dei491
  • 24 Bassi MA, Podgaec S, Dias Jr JA, D'Amico Filho N, Petta CA, Abrao MS. Quality of life after segmental resection of the rectosigmoid by laparoscopy in patients with deep infiltrating endometriosis with bowel involvement. J Minim Invasive Gynecol 2011; 18 (06) 730-733 . Doi: 10.1016/j.jmig.2011.07.014
  • 25 Remorgida V, Ferrero S, Fulcheri E, Ragni N, Martin DC. Bowel endometriosis: presentation, diagnosis, and treatment. Obstet Gynecol Surv 2007; 62 (07) 461-470 . Doi: 10.1097/01.ogx.0000268688.55653.5c
  • 26 Revised American Society for Reproductive Medicine classification of endometriosis: 1996. Fertil Steril 1997; 67 (05) 817-821 . Doi: 10.1016/S0015-0282(97)81391-X
  • 27 de Almeida A, Fernandes LF, Averbach M, Abrão MS. Disc resection is the first option in the management of rectal endometriosis for unifocal lesions with less than 3 centimeters of longitudinal diameter. Surg Technol Int 2014; 24: 243-248
  • 28 Meuleman C, Tomassetti C, D'Hoore A. , et al. Surgical treatment of deeply infiltrating endometriosis with colorectal involvement. Hum Reprod Update 2011; 17 (03) 311-326 . Doi: 10.1093/humupd/dmq057
  • 29 Roman H, Tuech JJ, Arambage K. Deep rectal shaving followed by transanal disc excision in large deep endometriosis of the lower rectum. J Minim Invasive Gynecol 2014; 21 (05) 730-731 . Doi: 10.1016/j.jmig.2014.03.003
  • 30 Fedele L, Bianchi S, Zanconato G, Bettoni G, Gotsch F. Long-term follow-up after conservative surgery for rectovaginal endometriosis. Am J Obstet Gynecol 2004; 190 (04) 1020-1024 . Doi: 10.1016/j.ajog.2003.10.698
  • 31 De Cicco C, Corona R, Schonman R, Mailova K, Ussia A, Koninckx P. Bowel resection for deep endometriosis: a systematic review. BJOG 2011; 118 (03) 285-291 . Doi: 10.1111/j.1471-0528.2010.02744.x
  • 32 Acién P, Núñez C, Quereda F, Velasco I, Valiente M, Vidal V. Is a bowel resection necessary for deep endometriosis with rectovaginal or colorectal involvement?. Int J Womens Health 2013; 5: 449-455 . Doi: 10.2147/IJWH.S46519
  • 33 Koh CE, Juszczyk K, Cooper MJW, Solomon MJ. Management of deeply infiltrating endometriosis involving the rectum. Dis Colon Rectum 2012; 55 (09) 925-931 . Doi: 10.1097/DCR.0b013e31825f3092
  • 34 Darai E, Ackerman G, Bazot M, Rouzier R, Dubernard G. Laparoscopic segmental colorectal resection for endometriosis: limits and complications. Surg Endosc 2007; 21 (09) 1572-1577 . Doi: 10.1007/s00464-006-9160-1