Laparoscopic Management of Bowel Endometriosis: Predictors of Severe Disease and Recurrence.

2011·0.08 MB·English

by  Nezhat, Camran

S P
CIENTIFIC APER
Laparoscopic Management of Bowel Endometriosis:
Predictors of Severe Disease and Recurrence
Camran Nezhat, MD, Babak Hajhosseini, MD, Louise P. King, MD, JD
ABSTRACT KeyWords:Laparoscopicsurgery,Endometriosis,Bowel
endometriosis, Intestinal endometriosis.
BackgroundandObjectives:Theidentificationofhigh-
stage and recurrent cases of bowel endometriosis is criti-
cal,becausethesecasesrequirecarefulsurgicalplanning.
We aim to describe the clinical characteristics of women
INTRODUCTION
with bowel endometriosis, our principles in laparoscopic
management of this pathology, and to identify predictors
Endometriosis is an estrogen-dependent inflammatory
of severe disease and recurrence.
disease1 that was first described in 1860.2 It is a progres-
sive disease that affects 10% to 15% of reproductive age
Methods: This was a retrospective study of 193 patients
womenandnearlyhalfofallinfertilewomen.Itisdefined
with pathologically confirmed bowel endometriosis.
as the presence of endometrial-like tissue outside of the
Results:Predictorsofhigher-stageendometriosisinclude uterine cavity.3,4 The condition is commonly associated
a history of previous laparoscopic surgery (P(cid:1).04) and a with chronic pelvic pain and infertility.5,6 Superficial or
presenting complaint of abnormal uterine bleeding deep endometriosis can involve virtually any pelvic or
(P(cid:1).01).Thehigherthestageofendometriosis,themore extrapelvicorgan.7Themostcommonsiteofextragenital
likely there would be coexistent urinary tract endometri- endometriosis is the intestinal tract, which accounts for
osis (P(cid:1).02), a need for enterolysis (P(cid:1).002), ovarian approximately 80% of all extragenital endometriosis.3,4
cystectomy (P(cid:2).001), and bowel resection (P(cid:1).01) per-
Although bowel endometriosis may cause severe gastro-
formed during laparoscopy. Patients with higher body
intestinal (GI) symptoms, these disturbances are fre-
massindex(BMI)hadsignificantlyhigherrecurrencerates
quently not adequately investigated at the time of gyne-
of endometriosis compared to those with lower BMI
(P(cid:1).002).Withinourcohort,87%ofourpatientsachieved cologic evaluation. As a result, bowel endometriosis may
beanunexpectedfindingatsurgery,andthelesionsmay
amelioration of symptoms by the end of the first postop-
not be treated due to the lack of preoperative informed
erative month.
consentorsurgicalinexperience.8Moreover,theextentof
Conclusions:Ourstudyconfirmsthatlaparoscopicman- intestinal wall resection necessary to adequately treat the
agementofbowelendometriosisissafeandeffective.We disease is highly debated. Identifying high-stage and re-
found 2 statistically significant predictors of higher-stage current cases is critical, because they require careful sur-
disease that should prompt careful surgical planning. gical planning.
Obesity is associated with a higher rate of recurrence of
This article will describe the clinical characteristics of
endometriosis.
women with bowel endometriosis and will present the
results of our own experience in laparoscopic manage-
ment of the disease. We will identify possible predicting
CenterforSpecialMinimallyInvasiveandRoboticSurgery,DepartmentofObstet-
ricsandGynecology,StanfordUniversityMedicalCenter,PaloAlto,California,USA factorsfortheextentofthediseaseanditsrecurrence.Itis
(allauthors) useful for gynecologists and general surgeons to under-
DepartmentofSurgery,KeckSchoolofMedicine,UniversityofSouthernCalifornia, stand the spectrum of intestinal tract endometriosis so as
LosAngeles,California,USA(Dr.Hajhosseini).
tobeabletoanticipateitspresenceandplanaccordingly.
WewouldliketothankNarimanNezami,MD,forhiscontributiontothestatistical
analysisandLindaM.Nicoll,MD,forhereditorialassistance.
MATERIALS AND METHODS
Addresscorrespondenceto:CamranNezhat,MD,900WelchRoad,Suite403,Palo
Alto, California USA, 94304, Telephone: [phone], Fax: [phone],
We reviewed the charts of all patients at our tertiary
E-mail:[email protected]
referral center who underwent laparoscopic surgery be-
DOI:10.4293/108680811X13176785203752
tween February 2002 and September 2009 and identified
©2011byJSLS,JournaloftheSocietyofLaparoendoscopicSurgeons.Publishedby
theSocietyofLaparoendoscopicSurgeons,Inc. allthosewithpathologicallyconfirmedbowelendometri-
JSLS(2011)15:431–438 431
LaparoscopicManagementofBowelEndometriosis:PredictorsofSevereDiseaseandRecurrence,NezhatCetal.
osis. The final cohort consisted of 193 patients. We also identified. The mean age of the study group was 36(cid:3)7
reviewedtheoperativereportstoconfirmthatadiagnosis years (range, 17 to 52) with a mean BMI of
ofbowelendometriosiswasmadeduringthesurgeryand 23.2(cid:3)3.1kg/m2(range,18.2to34.3).Themostcommon
thatendometrioticlesionswerefoundtoinfiltratebeyond preoperative presenting symptom was chronic pelvic
the serosal layer of the intestinal wall. pain.Atthetimeofpresentation,59%ofpatientshadGI
symptoms, but only 36% (n(cid:1)70) included it as one of
Wethenabstracteddatafromthechartsofall193patients
their chief complaints. Of those with GI symptoms,
with respect to age, body mass index (BMI), previous
constipation and dyschezia were the most common.
surgery,presentingsymptomsandtheirtiming,intraoper-
Urinary frequency was the most common urinary com-
ativefindingsandprocedures,sitesandstageofendome-
plaint at the time of presentation. A complete list of
triosis, short- and long-term follow-up and pain relief,
presenting symptoms can be found in Table 1 along
perioperativemorbidity,andrecurrenceofendometriosis.
with baseline characteristics. A total of 45% of patients
The disease was staged according to the 1996 American
described their symptoms as cyclic in nature, occurring
SocietyforReproductiveMedicineclassification,basedon
at or around the time of menstruation. A total of 44%
the operative findings.9 (n(cid:1)85) had a history of laparoscopic surgery at other
Before surgery, each patient underwent a routine gyne- medical centers; these were mainly for treatment of
cologic and rectovaginal examination and a transvaginal endometriosis.Ofpatients,11%(n(cid:1)22)hadahistoryof
ultrasound. Each patient also underwent mechanical depression, and 6% (n(cid:1)11) had some type of uterine
bowel preparation and received perioperative intrave- anomaly (bicornuate or septate uterus).
nous antibiotics. The lesion distribution, depth of inva-
sion, and level of stricture dictated the laparoscopic
method of treatment of intestinal endometriosis. Superfi-
Table1.
cial lesions that did not invade the muscularis were BaselineCharacteristics
shavedwithCO laser.Discexcisionwasperformedwhen
2 Age 36(cid:3)7years(range,17–52)
endometriotic lesions partially invaded the muscular
BMI 23.2(cid:3)3.1kg/m2
layer, but not the mucosa of the bowel.10–12 When infil-
(range,18.2–34.3)
trativelesionsinvolvedmorethanone-thirdofthecircum-
PresentingSymptoms No.(%)aofPatients
ferenceofthebowelorcausedpartialbowelobstruction,
a segmental resection with end-to-end anastomosis was Chronicpelvicpain,not 159(82)
otherwisespecified
performed. We removed all visible endometriotic foci in
otherpartsofthepelvis,abdomen,andthoraciccavityas Abnormaluterinebleeding 128(66)
needed.13 Preoperative and intraoperative consultation Dysmenorrhea 101(52)
with a colorectal surgeon, urologist, or thoracic surgeon Dyspareunia 34(18)
was obtained as appropriate.
Gastrointestinalsymptoms 70(36)
(total)
Descriptive statistics were calculated and tabulated. Nor-
mally distributed data are presented as mean (cid:3) standard Constipation 65(34)
deviation(SD).Associationsbetweenstudyoutcomesand Dyschezia 54(28)
potentialpredictorswereexploredusingtheindependent Diarrhea 43(22)
sample t test for continuous variables and the chi-square Nausea/vomiting 41(21)
test for categorical variables. A P value (cid:2).05 was consid-
Melena 3(1.6)
ered to be statistically significant. All analyses were con-
Urinarysymptoms 55(28)
ducted using SPSS statistical software version 15 (SPSS
Stageofendometriosis
Inc., Chicago, IL). The Institutional Review Boards of the
StanfordUniversityMedicalCenterandElCaminoHospi- Stage1 13(6)
tal approved this study. Stage2 36(19)
Stage3 27(14)
RESULTS Stage4 117(61)
Duringthe7and1⁄2yearstudyperiod,193patientswith aTotal(cid:4)100%becausemostpatientspresentedwithmorethan
1symptom.
pathologically confirmed bowel endometriosis were
432 JSLS(2011)15:431–438
Stage IV endometriosis was present in 61% (n(cid:1)117) of mies, pathology reports indicated an abnormal appendix
patients (Table 1). More than half of the patients (58%) (endometriosis/fibroticobliteration)in65%ofcases.Vary-
had multiple sites of intestinal endometriosis, with the ing degrees of enterolysis were required in 65% (n(cid:1)126)
recto-sigmoid colon, recto-vaginal septum, and appendix ofpatients.Onepatientunderwentacombinationoflap-
being the most common sites in descending order of aroscopy for treatment of abdominopelvic endometriosis
frequency. A total of 97% (n(cid:1)187) of patients also had andthoracoscopyfortreatmentofthoracicendometriosis.
endometriotic lesions at sites other than the intestinal The operative procedures performed on patients in the
tract, with ovaries being the most common nongastroin- study are listed in Table 3. All procedures were carried
testinal site of endometriosis lesions. Coexistence of uri- out successfully by laparoscopy without conversion to
narytract(bladderand/orureter)endometriosiswasseenin laparotomy. We used a combination of conventional and
62% (n(cid:1)119) of patients and was treated at the time of robot-assisted laparoscopy in 7 cases (4%).
surgery. The complete list of sites of endometriosis is pro-
No major complications occurred. These were defined as
vided in Table 2. During surgery, 11% (n(cid:1)22) of patients
rectovaginal fistula, anastomotic leakage/stenosis, inad-
wereconcomitantlydiagnosedwithadenomyosis.
vertent ureteral damage, accidental bowel perforation,
Discexcision,segmentalbowelresection,andappendec- andpelvicabscesses.Minorcomplicationsoccurredin7%
tomy were performed on 73% (n(cid:1)141), 1.6% (n(cid:1)3), and (n(cid:1)13) of patients and included 4 cases of transient uri-
37% (n(cid:1)72) of patients, respectively. Of 72 appendecto- naryretentionand9casesofincision-siteinfection.Allof
these minor complications were treated in an outpatient
setting. Short-term follow-up visits in the outpatient set-
Table2. tingwereroutinelyconducted1,3,and6monthspostop-
SitesofEndometriosis(n(cid:1)193) eratively. Overall, 87% (n(cid:1)167) of the entire study group
Site No.(%)aofPatients achievedameliorationofsymptomsbytheendofthefirst
postoperative month. Long-term follow-ups were con-
IntestinalSites
RectosigmoidColon 144(75)
RectovaginalSeptum 110(57) Table3.
Appendix 47(24) LaparoscopicProceduresPerformed(n(cid:1)193)
LargeIntestine,nototherwise 20(10) Procedure No.(%)aof
specified patients
SmallIntestine 10(5)
Treatmentofsuperficialendometriosis 193(100)
NonintestinalSites
Discexcision 141(73)
Posteriorcul-de-sac 90(47)
Segmentalbowelresection 3(1.6)
Anteriorcul-de-sac 38(19)
Appendectomy 72(37)
Pelvicsidewall 87(45)
Enterolysis 126(65)
Uterosacralligaments 51(26)
Ovariancystectomy 86(45)
Ovaries 134(69)
Salpingo-oophorectomy 22(11)
Fallopiantubes 31(16)
Hysterectomy 13(7)
Uterus 52(27)
Myomectomy 56(29)
Ureters 84(43)
Cystoscopy 139(72)
Bladder 76(39)
Ureterolysis 148(76)
Diaphragm 15(8)
Partialvaginectomy 1(0.5)
Vagina 3(1.6)
Presacralneurectomy 6(3)
Cervix 3(1.6)
Thoracoscopyfortreatmentofdiaphragmatic 1(0.5)
Liver 3(1.6) endometriosis
Inguinalcanal 2(1) Robot-assistedlaparoscopy 7(4)
aTotal (cid:4)100% because most patients had more than 1 site of aTotal (cid:4)100% because all patients had more than 1 procedure
endometriosis. performed.
JSLS(2011)15:431–438 433
LaparoscopicManagementofBowelEndometriosis:PredictorsofSevereDiseaseandRecurrence,NezhatCetal.
ducted by either office visits or phone calls on a yearly pared with those with less advanced stages of disease.
basis. During 1 to 8 years of long-term follow-up (mean, Coexistenturinarytractendometriosiswassignificantlymore
4.5 years), 10% (n(cid:1)19) had recurrence of endometriosis likely in patients with more advanced stages of endometri-
thatnecessitatedasecondlaparoscopicintervention.Sim- osis (P(cid:1).02). A complete list of variables and their associa-
ilarly to their initial laparoscopic evaluation, the majority tions with stage of endometriosis is shown in Table 4. No
ofpatientswithrecurrentcaseswerediagnosedwithmul- significant associations were noted between the stage of
tiple sites of endometriosis at the time of the second endometriosis and the patients’ BMI, type of surgery (con-
surgery. The 3 most common sites of recurrent endome- ventional vs. robot-assisted laparoscopy), or frequency of
triosis in decreasing order of frequency were genital tract postoperativecomplications.
(8%), urinary tract (6%), and GI tract (4%).
Weconductedasubanalysisof19patientswithrecurrent
Wedividedourcohortinto2groupsforfurtheranalysis:1 endometriosis to identify possible predictors of recurrent
groupwithlower-stageendometriosis(stagesI,II,&III)and disease. Patients with higher BMI had significantly higher
1 group with high-stage endometriosis (stage IV). There recurrence rate of endometriosis compared to those with
were 2 preoperative factors significantly related to higher lower BMI (P(cid:1).002). No significant correlations existed
stage disease: a presenting complaint of abnormal uterine between recurrence rate and age, presenting symptoms,
bleeding (P(cid:1).01) or a history of laparoscopic surgery or history of previous laparoscopic surgery. Although a
(P(cid:1).04). There was also a significant association between higher recurrence rate was seen in patients with stage IV
the stage of endometriosis and some of the operative pro- endometriosis compared to patients with less advanced
cedures performed. Patients with stage IV endometriosis stages, the relationship did not reach statistical signifi-
weremorelikelytoneedenterolysis(P(cid:1).002),ovariancys- cance.Therewasnosignificantdifferencebetweenrecur-
tectomy (P(cid:2).001), and segmental bowel resection/disc ex- rence rate and the type of surgery performed (conven-
cision (P(cid:1).01) performed during their surgeries, as com- tional vs. robot-assisted laparoscopy).
Table4.
VariablesAssociatedwithStageofEndometriosis
LowStage(I,II,&III) HighStage(IV) PValue
Age 35(cid:3)7.6 35.8(cid:3)6.2 .4
BMI 23(cid:3)3.3 23.3(cid:3)3.1 .6
Presentingwithirregularbleeding 59% 70% .04
PresentingwithGIsymptoms 34% 41% .4
Presentingwithurinarysymptoms 32% 30% .7
Depression 10% 12% .8
Uterineanomalies 4% 7% .7
Pastlaparoscopy 29% 53% .003
Ovariancystectomyperformedduringsurgery 24% 57% (cid:2).001
Enterolysisperformedduringsurgery 51% 79% (cid:2).001
Myomectomyperformedduringsurgery 35% 27% .2
Hysterectomyperformedduringsurgery 6% 8% .7
Appendectomyperformedduringsurgery 35% 41% .5
Segmentalbowelresection/Discexcisionperformedduringsurgery 40% 85% .01
Presacralneurectomyperformedduringsurgery 0% 5% .1
Endometriosisofappendix 22% 28% .4
Endometriosisofurinarytract 51% 70% .02
Concomitantadenomyosis 6% 13% .1
Recurrenceofendometriosis 7% 11% .4
434 JSLS(2011)15:431–438
DISCUSSION satisfactory long-term results.5,8,36,37 This may be because
offibroticchangesandscartissue,resultinginpelvicpain
Bowelendometriosiswasfirstdescribedin1922bySamp-
that is refractory to medical therapy.3 Currently, surgical
son.14 It affects between 3% and 37% of patients with a
removal of endometriotic lesions appears to be the most
diagnosis of endometriosis. It can present at any level
effective treatment, because it is associated with a signif-
from the anal canal to the small intestine; however, the
icant improvement in pain, quality of life, and fertility
most frequent locations of involvement are the rectum
status.8,38,39
and sigmoid colon.3,4,15,16 Intestinal implantation begins
ontheserosaandsometimesinvadesthemuscularispro- Successfullaparoscopicbowelresectionforthetreatment
pria but rarely affects the mucosa.4,8,17 of bowel endometriosis was first described in 1988.10,40,41
Patientswithendometriosispresentwithdifferentclinical Over the last 2 decades, a variety of laparoscopic tech-
complaints at various stages of disease.5 The majority of niqueshaveproveneffectiveinthetreatmentofintestinal
those with bowel involvement develop a variety of GI endometriosis. These include laser vaporization, shaving,
complaints including constipation, diarrhea, abdominal disc excision, segmental bowel resection, and appendec-
bloating, tenesmus, lower abdominal pain, and occasion- tomy, all of which can be performed successfully via
allyrectalbleeding.3,5,8Symptomsusuallyoccurcyclically laparoscopy.11,12
atoraboutthetimeofmenstruation.5Appendicealendo-
Advances in laparoscopic management of severe bowel
metriosiscanmimicacuteappendicitis,oritmaycontrib-
endometriosiswouldnothavebeenpossiblewithoutmul-
utetochronicpelvicpain.18–23Bowelobstructionisarare
tiple advances in instrumentation and the introduction of
complication that can be confused with carcinoma3,17,24
videolaparoscopy.42–45 Before the introduction of video-
The differential diagnosis of bowel endometriosis in-
laparoscopy, the utility of operative laparoscopy was di-
cludesirritablebowelsyndrome,inflammatoryboweldis-
minishedbytwomajordrawbacks:poorvisualizationinto
ease, diverticulitis, and bowel carcinoma.8,17,25
the intra-abdominal cavity with one eye and the inability
of the operative team to view the operative field. Both of
Several techniques have been proposed to aid in the
these limitations were rectified with the incorporation of
diagnosis of bowel endometriosis. These include barium
the videolaparoscope.43,44 These advances made it possi-
enema, transvaginal ultrasound, transrectal ultrasound,
ble to treat even the most extensive pathology laparo-
colonoscopy, computed tomography, and magnetic reso-
scopically.
nance imaging.8 Although studies have shown varying
levels of success using these methodologies,23,26–28 it is Severalauthorsagreethatlaparoscopicbowelresectionis
generally believed that they are of little diagnostic feasible and can be performed safely when needed.46–49
value.3,7,29,30 In short, no clear guidelines exist for the However,adebateexistsregardingtheextentofintestinal
evaluation of patients with suspected bowel endome- wallresectionnecessarytoadequatelytreatthedisease.36
triosis.Whenclinicalevidencesuggeststhepresenceof Segmental bowel resection represents the most radical
deeply infiltrating endometriosis, we use imaging stud- approach but is characterized by a specific pattern of
ies to map the extent of disease. Nevertheless, laparo- major postoperative complications and lower pregnancy
scopic assessment in combination with histological ex- ratescomparedwithlessaggressivemethods,suchasdisc
amination of excised lesions remains the gold standard excision.11,12,50 Those in favor of segmental resection ar-
for diagnosis of any type of endometriosis including guethatthewidemarginofexcisionachievedresultsina
that of the bowel.4–5,30 lower recurrence rate of the endometriosis.37,51–53 How-
ever, the dissection necessary to achieve mobilization for
Historically, 2 major approaches exist for management of
a segmental bowel resection poses a greater risk of inad-
bowelendometriosis:medicalandsurgical.Medicaltreat-
vertent trauma to the superior and especially inferior hy-
mentsarefocusedonhormonalmanipulationofthemen-
pogastric plexus. Injury to these plexus could cause per-
strualcycleinanattempttoproduceapseudo-pregnancy,
sistent bowel and urinary symptoms postoperatively.
pseudo-menopause, or chronic anovulation.6 Alterna-
tively, targeting aromatase, cyclooxygenase-2, estrogen The majority of our patients were managed without seg-
receptor (cid:1), or progesterone receptors may reduce pelvic mentalbowelresection.Theyachievedhighlevelsofpain
pain and decrease visible endometriotic tissue.31–33 Al- relief and excellent long-term outcome with low recur-
though hormonal modulation may be useful in some set- renceratesandnomajorcomplications.Becausecolorec-
tings like preoperative preparation,23,34–35 it rarely yields talendometriosisisconsideredabenigndisease,22wefeel
JSLS(2011)15:431–438 435
LaparoscopicManagementofBowelEndometriosis:PredictorsofSevereDiseaseandRecurrence,NezhatCetal.
that segmental bowel resection should remain the last how valuable GI symptoms may be in predicting the
resort, appropriate only for those with lesions involving presence of bowel endometriosis. To determine the pre-
morethanone-thirdofthecircumferenceofthebowelor dictive nature of gastrointestinal symptoms and ade-
thosewithpartialbowelobstruction.Inaddition,intraop- quately compare disc excision to segmental bowel resec-
erative proctosigmoidoscopy should be performed when tion for treatment of bowel endometriosis, further
necessary.Thisprocedurehasbeenshowntobeeffective prospective controlled trials are warranted. We also be-
in assessment of bowel wall invasion, detecting bowel lieve that, based on our findings in terms of relation
injuriesduringlaparoscopyandevaluatinganastomosis.54 betweenhigherBMIandhigherrateofrecurrence,future
studiesarerequiredtoinvestigatetheassociationbetween
Similarly to other studies,55 we found that concomitant preoperative estrogen levels and recurrence of endome-
genitalandurinarytractendometriosisarefrequentlyseen
triosis.
inpatientswithbowelendometriosis.Therefore,acareful
and systematic inspection of the pelvic and abdominal
CONCLUSION
cavity is necessary to detect and treat all possible lesions.
Moreover, in findings that echo those of Redwine and Intestinalendometriosisshouldbesuspectedinwomen
Chapron et al,56,57 we found that a large portion of our of childbearing age who present with gastrointestinal
patientshadmultifocalendometriosislesionsoftheintes- symptoms and a history of endometriosis. High-stage
tines; however, in contrast to their opinions, we believe and recurrent cases necessitate careful surgical plan-
thatevenmultifocalcasesofbowelendometriosiscanbe ning. Our study confirms that laparoscopic manage-
managed successfully by laparoscopy with no need for ment of bowel endometriosis is feasible, safe, and effi-
conversion to laparotomy. cient. All patients who undergo laparoscopy for
treatment of endometriosis or chronic pelvic pain
We found that obese or overweight women had a signif-
should be counseled regarding the possibility of bowel
icantly higher rate of recurrence compared with patients
involvement and the risk, benefits, and alternatives of
with normal BMI. It is unlikely that the higher recurrence
treatment. Although it may be technically demanding,
rate in this subgroup is due to incomplete treatment of
removal of endometriotic lesions is critical for symp-
endometriosis, as it has been demonstrated that laparo-
tomatic relief and if carried out in specialist centers by
scopic approach in treatment of endometriosis is not sig-
surgeons with proper training and experience, leads to
nificantlyinfluencedbyBMIintermsofsurgicaloutcome
positive results with minimal morbidity.
orcomplicationsrate.58Instead,thiscouldbepartlydueto
the fact that obese women have more adipose tissue and
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