Updates Surg (2014) 66:59–64 DOI 10.1007/s13304-013-0240-1
ORIGINAL ARTICLE
Management of rectosigmoid obstruction due to severe bowel endometriosis Giacomo Ruffo • Stefano Crippa • Alberto Sartori Stefano Partelli • Luca Minelli • Massimo Falconi
•
Received: 7 May 2013 / Accepted: 14 November 2013 / Published online: 28 November 2013 Ó Springer-Verlag Italia 2013
Abstract Bowel obstruction is a rare complication of intestinal endometriosis. The aim of this work was to evaluate outcomes after colorectal resection for bowel obstruction due to endometriosis. Of 720 patients who underwent colorectal resection for bowel endometriosis, 12 (1.7 %) presented with bowel obstruction. Preoperative work-up, management, perioperative and long-term outcomes were analyzed. All lesions were localized in the rectosigmoid tract. All patients underwent colorectal resection, which was carried out laparoscopically in 4 (33 %). Rate of low or ultra-low colorectal anastomoses was 83 %. Four patients (33 %) required blood transfusions. Two patients developed rectovaginal fistulas. After a median follow-up of 38 months, there were no cases of disease recurrence and dyschezia improved in 75 % of patients. Bowel endometriosis should be considered in the differential diagnosis of young women with bowel obstruction. Despite challenging operations, colorectal resections are associated with good outcomes.
G. Ruffo (&) S. Crippa A. Sartori S. Partelli M. Falconi Department of Surgery, Ospedale Sacro Cuore-Don Calabria, Via Sempreboni, 5, 37024 Negrar, VR, Italy e-mail: [email protected] S. Crippa e-mail: [email protected] S. Crippa S. Partelli M. Falconi Department of Surgery, Ospedali Riuniti, Universita` Politecnica delle Marche, Ancona, Italy L. Minelli Department of Gynaecology, Ospedale Sacro Cuore-Don Calabria, Negrar, Italy
Keywords Colonic obstruction Deep pelvic endometriosis Rectosigmoid endometriosis Colorectal resection Laparoscopy
Introduction Endometriosis, defined as ectopic endometrial gland tissue and stroma outside the uterine cavity, is a common disease in women of reproductive age and it is associated with a chronic inflammatory reaction, with smooth muscle metaplasia and fibrosis in endometriosis nodules [1]. Although endometriosis implants are usually found on genital organs, bowel endometriosis is not rare, with an estimated incidence between 5 and 12 %, and rectum and rectosigmoid junction being the most common site [2–4]. Endometriosis can deeply invade the bowel wall through the muscularis leading to a progressive narrowing of bowel lumen [5]. Patients may complain of dyschezia, rectal bleeding and progressive constipations [1–4]. Complete bowel occlusion may also occur [6–8]. Based on the extension and the depth of invasion, rectal or sigmoid resections may be required in treating symptomatic bowel endometriosis [1–4]. Several studies have shown that laparoscopic colorectal resections are safe and effective in treating the disease, and are associated with significant symptoms relief [4, 9–12]. In experienced hands, laparoscopic management of these conditions was safe and effective, allowing these patients to enjoy the benefits of minimally invasive surgery [9–12]. The aim of this work was to review our experience with bowel obstruction due to deep infiltrating endometriosis, analysing surgical treatments, perioperative and long-term outcomes.
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Materials and methods
Results
A prospective database of bowel resections maintained at the Department of Surgery of the Sacro Cuore-Don Calabria Hospital, Negrar, Italy was queried to identify patients who underwent rectosigmoid resection for bowel obstruction due to histologically confirmed endometriosis between 2002 and 2009. All patients had stage IV endometriosis according to the American Society of Reproductive Medicine [13]. Patients who underwent emergency explorative surgery resulting in a colostomy/ ileostomy before referral to our hospital were included as well. Demographic characteristics, medical history, clinical presentation, preoperative work-up, intraoperative and postoperative data, complications and pathology were collected. Bowel obstruction was defined as a progressive, severe, constipation up to absence of defecation associated with nausea and/or vomiting, abdominal pain and distension. Plain abdominal X-ray was performed in all cases confirming the presence of bowel occlusion (multiple air-fluid levels, distended loops of large bowel). Computed tomography (CT) scan of the abdomen was performed in selected cases. All patients underwent endoscopic examination of the rectum or of rectosigmoid endoscopy to exclude the presence of a primary colorectal disease. At our institution, double contrast barium enema (DCBE) is routinely performed in patients with bowel endometriosis. However, in the setting of bowel obstruction, water-soluble contrast enema (WSCE) was carried out. Intraoperative colonic irrigation was performed in obstructed patients without further bowel preparation. In patients who underwent diverting stoma before referral to our institution and who underwent subsequently ‘‘elective’’ colorectal resection, bowel preparation consisted of oral intake of 4 l of Selg-Esse 1000 (polyethylene glycol plus simethicone, Promefarm, Milano, Italy) 24 h before surgery. All operations were performed by the same surgical team. Laparoscopic approach was considered in selected cases by the operating surgeon, especially in those patients who had a diverting stoma at previous emergency surgery. Laparoscopic surgical procedures were performed as previously described [14]. The level of the colorectal anastomosis was defined according to the distance from the anal verge as high/medium (C8 cm), low ([5 and \8 cm) and ultra-low (B5 cm). All patients were given postoperative GnRH analogues for 6 months. Follow-up work-up was performed after 1, 6, 12 months from initial surgery and yearly thereafter and it included a careful clinical evaluation, bimanual palpation, assessment of cancer antigen 125 levels, vaginal and abdominal ultrasounds.
In the study period, 720 colorectal resections were performed for severe bowel endometriosis. Overall, 12 (1.7 %) patients (median age 32 years, range 24–46) presented with bowel obstruction and they represent the population under study. All patients had obstruction of the rectosigmoid with obstruction of the large bowel. Dysmenorrhoea and chronic pelvic pain were present in all cases. Eight patients (67 %) reported dyschezia while sporadic rectal bleeding was reported in 2 cases (17 %). All patients complained of progressive constipation up to absence of defecation. Eight patients (67 %) presented a paradoxical diarrhoea and vomiting. Three patients (25 %) had previous laparoscopic (n = 1) or laparotomic (n = 2) surgery for pelvic endometriosis with segmental bowel resection in one case. Endoscopy, performed in all cases, showed submucosal mass with eccentric wall thickening without polypoid lesions. Subsequent diagnostic work-up as well as initial management before referral to our hospital is reported in Table 1. Seven patients (58 %) underwent CT scan that confirmed the presence of large bowel obstruction. WSCE (Fig. 1) was performed in 9 patients (75 %) including all 6 patients who initially underwent diverting stoma. Mean rate of bowel stenosis was 90 % at WSCE. Unilateral hydronephrosis was present in one patient as showed by CT scan and renal ultrasound. Overall, in 9 patients (75 %), there was a certain diagnosis of multiorgan involvement by endometriosis at admission. In two of the remaining three patients, endometriosis was highly suspected considering their preoperative work-up and the suspect was confirmed by intraoperative biopsy. In the last patient, a 46-year-old woman, a rectosigmoid neoplasm was ruled out with endoscopic examination that showed extrinsic compression of the colonic wall and submucosal mass, and differential diagnosis included endometriosis as well as primary ovarian carcinoma. Table 2 shows surgical procedures performed at our institution with postoperative and long-term outcomes. Median operative time was 305 min (range 200–720) and median blood loss was 400 ml (range 100–2,000). Overall, four patients underwent laparoscopic resection (two rectosigmoid resections, one Hartmann procedure and one LAR). In another patient, laparoscopic resection was attempted but conversion to laparotomy was necessary because of intra-abdominal bleeding. Ten of 12 patients (83 %) received a temporary ileostomy/cecostomy. All stomas were finally reconstructed. Six of the ten patients underwent diverting stoma at other hospitals as emergency treatment for their colonic obstruction. In all patients who received a colostomy before referral to our hospital, colostomy was resected with
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Table 1 Past medical history, preoperative work-up and management of 12 patients with severe bowel endometriosis presenting with bowel obstruction before referral to our hospital Pts no.
Age
Year
Previous surgery
Preoperative workup
Site of bowel stenosis
Management at outside hospitals
1
28
2002
–
WSCE proctoscopy
Sigmoid
Laparotomy and ileostomy
2
46
2003
–
Abdominal CT scan
Rectosigmoid
–
3
27
2003
–
Rectosigmoid
Laparotomy and colostomy
Sigmoid
–
Rectosigmoid
Laparotomy and cecostomy
Sigmoid
Laparotomy and cecostomy
Rectum
–
Rectosigmoid
–
Sigmoidoscopy Abdominal CT scan WSCE 4
28
2004
–
Proctoscopy WSCE Proctoscopy
5
34
2004
–
Abdominal CT scan WSCE Proctoscopy
6
32
2004
–
Abdominal CT scan WSCE Proctoscopy
7
33
2005
1999, laparotomy: removal of pelvic endometriosis
8
30
2007
–
Abdominal CT scan Proctoscopy WSCE Proctoscopy
9
35
2007
2004, laparoscopy: removal of pelvic endometriosis
WSCE Proctoscopy
Rectosigmoid
–
10
36
2009
–
Abdominal CT scan
Sigmoid
Laparotomy and colostomy
Sigmoid
–
Rectum
Laparotomy and colostomy
WSCE Proctoscopy 11 12
40 24
2009 2009
2008, laparotomy: removal of pelvic endometriosis
WSCE
–
Abdominal CT scan
Proctoscopy
Proctoscopy Abdominal X-ray was performed in all cases as first imaging modality to diagnose bowel obstruction WSCE water-soluble contrast enema, CT computed tomography
the surgical specimen during colorectal resection, and ileostomy was carried out if necessary. In the remaining patients, an ileostomy was carried because of ultra-low colorectal anastomosis or since the hydropneumatic test performed for the integrity of the colorectal anastomosis was positive [14]. Low or ultra-low end-to-end colorectal stapled anastomoses were performed in 10 patients (83 %) because of the extension of the disease to the rectovaginal septum. Excision of all visible endometriosis implants/ nodules within the pelvis and the abdomen was carried out. No hysterectomy was performed. In one patient during
laparotomy, a reconstruction of the distal ureter was carried out on a transvesical stent because of ureter obstruction with associated hydronephrosis. In all cases, bowel infiltration by endometriosis lesions was confirmed by definitive pathology. Median length of bowel removed was 14 cm (range 12–27). No resection margin was infiltrated by endometriosis. Median postoperative hospital stay was 8 days (range 5–33). Median duration of postoperative ileus was 2 days (range 1–4). Drain(s) were removed after a median of 4.5 days (range 2–20). Two patients developed
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Fig. 1 Complete stenosis of the sigmoid due to obstructing endometriosis
rectovaginal fistulas after low colorectal anastomoses with ileostomy/cecostomy (Table 2) and removal of vaginal endometriosis nodules with vaginal suture. They underwent fistula repair with mucosal flap and ileostomy/
cecostomy closure. No bowel re-resection was required. Another patient required prolonged length of stay and antibiotic administration for sepsis with no evidence of intra-abdominal abscesses or anastomotic leakage at imaging. Four patients (33 %) required heterologous blood transfusions. Median follow-up time was 38 months (range 12–72). One patient developed anastomotic stricture that required several endoscopic dilatations. Another two patients developed chronic constipations. Of the eight patients who had severe dyschezia before surgery, six reported a complete regression of pain, while the last two reported persistence of mild dyschezia. No cases of rectal bleeding were recorded. During follow-up, there were no cases of colorectal recurrence of the disease. Childbearing was reported in 8 (67 %) women and 2 (17 %) complained of a miscarriage.
Discussion Bowel obstruction is a rare complication of intestinal endometriosis. In fact, although bowel involvement is
Table 2 Management at our institution of 12 patients with severe bowel endometriosis associated with bowel obstruction including postoperative and long-term outcomes Pts no.
First operation
Second operation
Level of bowel anastomosis
Postoperative course
Long-term outcomes
1
Rectosigmoid resection with ileostomya
Ileostomy closure
High/medium
Uncomplicated
–
2
LAR
–
Low
Uncomplicated
–
3 4
LAR Laparoscopic rectosigmoid resection with ileostomy
– Ileostomy closure
Low Low
Sepsis Rectovaginal fistula
– Anastomotic stricture requiring dilatation
Blood transfusions 5
Laparoscopy, conversion to laparotomy, LAR with cecostomya Laparoscopic rectosigmoid resection with cecostomya
Cecostomy closure
Ultra-low
Cecostomy closure
Low
7
LAR with ileostomy
Ileostomy closure
8
Rectosigmoid resection with ileostomy, neo implantation of the left ureter LAR with ileostomy
Ileostomy closure Ileostomy closure
10
Rectosigmoid resection, right colectomy, ileostomy
Ileostomy closure
11
Laparoscopic Hartmann resection
12
Laparoscopic LAR with ileostomy
6
9
Rectovaginal fistula Blood transfusions
Chronic constipation
Ultra-low
Blood transfusions
–
Low
Chronic constipation
Low
Blood transfusions Uncomplicated
Low
Uncomplicated
–
Laparoscopic Hartmann resection reversal
High/medium
Uncomplicated
–
Ileostomy closure
Low
Uncomplicated
–
LAR low anterior resection a
Colostomy/cecostomy performed at previous laparotomy
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estimated in up to 12 % of patients suffering from the disease, bowel obstruction occurs in about 1 % of these patients [1–4, 7]. Our results confirm these data, with only 12 patients (1.7 %) undergoing colorectal resection for bowel obstruction due to endometriosis over a 7-year period at our institution. In this series six patients, who underwent emergency surgery with diverting stoma at other hospitals, were included. In most of these latter cases, the aetiology of intestinal obstruction was unknown, and endometriosis was an ‘‘unexpected’’ finding at explorative laparotomy. This can be related to the low clinical suspicion that surgeons have for such a disease. In this setting, an accurate clinical history looking for symptoms of endometriosis (i.e. dysmenorrhoea, dyspareunia, dyschezia, cyclic rectal bleeding) is of paramount importance. It is remarkable that, despite that endometriosis should be considered in young patients with colorectal symptoms, physicians have to rule out firstly other diseases including inflammatory bowel diseases and colorectal carcinoma. Since direct mucosal involvement by endometriosis nodules is very rare, endoscopy is usually aspecific showing extrinsic compression of the mucosa, submucosal mass and/or eccentric wall thickening [7, 15, 16]. In the preoperative work-up of patients with bowel obstruction, abdomino-pelvic CT scan is of paramount importance. In patients with endometriosis-related bowel obstruction, CT scan frequently reveals non-specific abnormalities of the bowel wall [17]. However, CT-based virtual colonoscopy may provide more useful information about the degree and site of bowel stenosis due to colorectal endometriosis [18, 19]. In this setting, multislice CT enteroclysis proved to be also effective in the diagnosis and depth of bowel endometriosis lesions [20]. Magnetic resonance imaging (MRI) showed promising results in detecting intestinal endometriosis, but MRI is not always available in acute setting and endometriosis-associated fibrosis may alter the signal intensity pattern [21]. Finally, from our experience, DCBE or WSCE—that are rapidly available and easily performed at low cost—can be useful in demonstrating the site and extent of bowel obstruction due to endometriosis [22–24]. In the setting of bowel obstruction, WSCE should be performed instead of DCBE [22–24]. Transvaginal ultrasound can be of help even in the acute setting to characterize bowel endometriosis and can be combined with DCBE/WSCE [25, 26]. Although management of deep pelvic endometriosis is debated, surgery is associated with symptoms relief, improvements in quality of life and renewed fertility [3, 4, 10, 11]. It is unlikely that large ([2 cm) bowel endometriosis lesions may benefit from medical therapy since endometriosis-associated fibrosis is unresponsive to hor-
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monal manipulation [4]. In such cases, a surgical approach including intestinal surgery is indicated, aiming to ablate all visible endometriosis lesions. Indeed, no doubt exists that surgery must be considered in case of intestinal endometriosis with bowel obstruction. In this series, diverting stoma was initially performed in 6 patients (50 %) to obtain bowel decompression. In three of these six patients, a laparoscopic approach was subsequently attempted to perform colorectal resection, with one conversion to laparotomy because of bleeding. Other two patients (without stoma) underwent successfully laparoscopic resection. However, considering the small number of patients in this cohort, larger studies are needed to properly evaluate laparoscopic approach. The presence of a stoma may allow a ‘‘two-step’’ approach with delayed laparoscopic resection in patients presenting with bowel obstruction. All patients in this series had endometriosis of the rectum/rectosigmoid, in keeping with previous studies that report up to 90 % of endometriosis lesions involving this tract [1–13]. It is remarkable that even if the stenosis is in the sigmoid colon or in the upper third of the rectum, endometriosis would usually involve the rectovaginal septum, thus requiring a low rectal resection [3, 4, 27]. Consequently, low or ultra-low colorectal anastomoses were performed in 83 % of cases. Major complications may occur after colorectal resections [2–4, 7–13]. In this series, two patients with low colorectal anastomosis as well as vaginal suture, because of the removal of endometriosis nodules, developed rectovaginal fistulas, which can be related to an anastomotic leakage. Although there were no reoperations, median operative time was 305 min, median blood loss 400 ml and overall rate of blood transfusions was 33 %. These data taken together reflect the complexity of this surgery, which is time consuming and, as other have pointed out, is often challenging [3, 4, 27]. Long-term follow-up data were satisfactory with significant improvements in regard to dyschezia and no cases of rectal bleeding. In addition, there were no recurrences of colorectal endometriosis, and this may be related to the performance of formal colorectal resections with negative margins. In conclusion, bowel obstruction is an uncommon complication of deep infiltrating bowel endometriosis. Colorectal resections for severe endometriosis represent a demanding surgery, requiring specific experience and a multidisciplinary approach. Results of long-term follow-up are satisfactory with no colorectal recurrences and improvements in bowel symptoms. Intraoperative biopsy may be useful in selected cases to confirm the presence of endometriosis and to plan the most appropriate surgical strategy.
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Acknowledgments All authors report no funding nor relevant financial relationship. 15. Conflict of interest
None.
16.
References 1. Giudice LC, Kao LC (2004) Endometriosis. Lancet 364:1789–1799 2. Bailey HR, Ott MT, Hartendorp P (1994) Aggressive surgical management for advanced colorectal endometriosis. Dis Colon Rectum 37:747–753 3. Dousset B, Leconte M, Borghese B, Millischer AE, Roseau G, Arkwright S, Chapron C (2010) Complete surgery for low rectal endometriosis: long-term results of a 100—case prospective study. Ann Surg 251:887–895 4. Minelli L, Fanfani F, Fagotti A, Ruffo G, Ceccaroni M, Mereu L, Landi S, Pomini P, Scambia G (2009) Laparoscopic colorectal resection for bowel endometriosis: feasibility, complications, and clinical outcome. Arch Surg 144:234–239 5. Clement PB (2007) The pathology of endometriosis: a survey of the many faces of a common disease emphasizing diagnostic pitfalls and unusual and newly appreciated aspects. Adv Anat Pathol 14:241–260 6. Takai N, Ueda T, Nishida M, Nasu K, Narahara H (2008) Bowel obstruction due to endometriosis in the rectovaginal septum. Clin Exp Obstet Gynecol 35:295–296 7. de Jong MJ, Mijatovic V, van Waesberghe JH, Cuesta MA, Hompes PG (2009) Surgical outcome and long-term follow-up after segmental colorectal resection in women with a complete obstruction of the rectosigmoid due to endometriosis. Dig Surg 26:50–55 8. De Ceglie A, Bilardi C, Blanchi S, Picasso M, Di Muzio M, Trimarchi A, Conio M (2008) Acute small bowel obstruction caused by endometriosis: a case report and review of the literature. World J Gastroenterol 14:3430–3434 9. Ruffo G, Scopelliti F, Scioscia M, Ceccaroni M, Mainardi P, Minelli L (2010) Laparoscopic colorectal resection for deep infiltrating endometriosis: analysis of 436 cases. Surg Endosc 24:63–67 10. Stepniewska A, Pomini P, Guerriero M, Scioscia M, Ruffo G, Minelli L (2010) Colorectal endometriosis: benefits of long-term follow-up in patients who underwent laparoscopic surgery. Fertil Steril 93:2444–2446 11. Garry R, Clayton R, Hawe J (2000) The effect of endometriosis and its radical laparoscopic excision on quality of life indicators. BJOG 107:44–54 12. Daraı¨ E, Dubernard G, Coutant C, Frey C, Rouzier R, Ballester M (2010) Randomized trial of laparoscopically assisted versus open colorectal resection for endometriosis: morbidity, symptoms, quality of life, and fertility. Ann Surg 251:1018–1023 13. Revised American Society for Reproductive Medicine classification of endometriosis: 1996 (1997) Fertil Steril 67:817–821 14. Landi S, Ceccaroni M, Perutelli A, Allodi C, Barbieri F, Fiaccavento A, Ruffo G, McVeigh E, Zanolla L, Minelli L (2006)
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ORIGINAL ARTICLE
Management of rectosigmoid obstruction due to severe bowel endometriosis Giacomo Ruffo • Stefano Crippa • Alberto Sartori Stefano Partelli • Luca Minelli • Massimo Falconi
•
Received: 7 May 2013 / Accepted: 14 November 2013 / Published online: 28 November 2013 Ó Springer-Verlag Italia 2013
Abstract Bowel obstruction is a rare complication of intestinal endometriosis. The aim of this work was to evaluate outcomes after colorectal resection for bowel obstruction due to endometriosis. Of 720 patients who underwent colorectal resection for bowel endometriosis, 12 (1.7 %) presented with bowel obstruction. Preoperative work-up, management, perioperative and long-term outcomes were analyzed. All lesions were localized in the rectosigmoid tract. All patients underwent colorectal resection, which was carried out laparoscopically in 4 (33 %). Rate of low or ultra-low colorectal anastomoses was 83 %. Four patients (33 %) required blood transfusions. Two patients developed rectovaginal fistulas. After a median follow-up of 38 months, there were no cases of disease recurrence and dyschezia improved in 75 % of patients. Bowel endometriosis should be considered in the differential diagnosis of young women with bowel obstruction. Despite challenging operations, colorectal resections are associated with good outcomes.
G. Ruffo (&) S. Crippa A. Sartori S. Partelli M. Falconi Department of Surgery, Ospedale Sacro Cuore-Don Calabria, Via Sempreboni, 5, 37024 Negrar, VR, Italy e-mail: [email protected] S. Crippa e-mail: [email protected] S. Crippa S. Partelli M. Falconi Department of Surgery, Ospedali Riuniti, Universita` Politecnica delle Marche, Ancona, Italy L. Minelli Department of Gynaecology, Ospedale Sacro Cuore-Don Calabria, Negrar, Italy
Keywords Colonic obstruction Deep pelvic endometriosis Rectosigmoid endometriosis Colorectal resection Laparoscopy
Introduction Endometriosis, defined as ectopic endometrial gland tissue and stroma outside the uterine cavity, is a common disease in women of reproductive age and it is associated with a chronic inflammatory reaction, with smooth muscle metaplasia and fibrosis in endometriosis nodules [1]. Although endometriosis implants are usually found on genital organs, bowel endometriosis is not rare, with an estimated incidence between 5 and 12 %, and rectum and rectosigmoid junction being the most common site [2–4]. Endometriosis can deeply invade the bowel wall through the muscularis leading to a progressive narrowing of bowel lumen [5]. Patients may complain of dyschezia, rectal bleeding and progressive constipations [1–4]. Complete bowel occlusion may also occur [6–8]. Based on the extension and the depth of invasion, rectal or sigmoid resections may be required in treating symptomatic bowel endometriosis [1–4]. Several studies have shown that laparoscopic colorectal resections are safe and effective in treating the disease, and are associated with significant symptoms relief [4, 9–12]. In experienced hands, laparoscopic management of these conditions was safe and effective, allowing these patients to enjoy the benefits of minimally invasive surgery [9–12]. The aim of this work was to review our experience with bowel obstruction due to deep infiltrating endometriosis, analysing surgical treatments, perioperative and long-term outcomes.
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Materials and methods
Results
A prospective database of bowel resections maintained at the Department of Surgery of the Sacro Cuore-Don Calabria Hospital, Negrar, Italy was queried to identify patients who underwent rectosigmoid resection for bowel obstruction due to histologically confirmed endometriosis between 2002 and 2009. All patients had stage IV endometriosis according to the American Society of Reproductive Medicine [13]. Patients who underwent emergency explorative surgery resulting in a colostomy/ ileostomy before referral to our hospital were included as well. Demographic characteristics, medical history, clinical presentation, preoperative work-up, intraoperative and postoperative data, complications and pathology were collected. Bowel obstruction was defined as a progressive, severe, constipation up to absence of defecation associated with nausea and/or vomiting, abdominal pain and distension. Plain abdominal X-ray was performed in all cases confirming the presence of bowel occlusion (multiple air-fluid levels, distended loops of large bowel). Computed tomography (CT) scan of the abdomen was performed in selected cases. All patients underwent endoscopic examination of the rectum or of rectosigmoid endoscopy to exclude the presence of a primary colorectal disease. At our institution, double contrast barium enema (DCBE) is routinely performed in patients with bowel endometriosis. However, in the setting of bowel obstruction, water-soluble contrast enema (WSCE) was carried out. Intraoperative colonic irrigation was performed in obstructed patients without further bowel preparation. In patients who underwent diverting stoma before referral to our institution and who underwent subsequently ‘‘elective’’ colorectal resection, bowel preparation consisted of oral intake of 4 l of Selg-Esse 1000 (polyethylene glycol plus simethicone, Promefarm, Milano, Italy) 24 h before surgery. All operations were performed by the same surgical team. Laparoscopic approach was considered in selected cases by the operating surgeon, especially in those patients who had a diverting stoma at previous emergency surgery. Laparoscopic surgical procedures were performed as previously described [14]. The level of the colorectal anastomosis was defined according to the distance from the anal verge as high/medium (C8 cm), low ([5 and \8 cm) and ultra-low (B5 cm). All patients were given postoperative GnRH analogues for 6 months. Follow-up work-up was performed after 1, 6, 12 months from initial surgery and yearly thereafter and it included a careful clinical evaluation, bimanual palpation, assessment of cancer antigen 125 levels, vaginal and abdominal ultrasounds.
In the study period, 720 colorectal resections were performed for severe bowel endometriosis. Overall, 12 (1.7 %) patients (median age 32 years, range 24–46) presented with bowel obstruction and they represent the population under study. All patients had obstruction of the rectosigmoid with obstruction of the large bowel. Dysmenorrhoea and chronic pelvic pain were present in all cases. Eight patients (67 %) reported dyschezia while sporadic rectal bleeding was reported in 2 cases (17 %). All patients complained of progressive constipation up to absence of defecation. Eight patients (67 %) presented a paradoxical diarrhoea and vomiting. Three patients (25 %) had previous laparoscopic (n = 1) or laparotomic (n = 2) surgery for pelvic endometriosis with segmental bowel resection in one case. Endoscopy, performed in all cases, showed submucosal mass with eccentric wall thickening without polypoid lesions. Subsequent diagnostic work-up as well as initial management before referral to our hospital is reported in Table 1. Seven patients (58 %) underwent CT scan that confirmed the presence of large bowel obstruction. WSCE (Fig. 1) was performed in 9 patients (75 %) including all 6 patients who initially underwent diverting stoma. Mean rate of bowel stenosis was 90 % at WSCE. Unilateral hydronephrosis was present in one patient as showed by CT scan and renal ultrasound. Overall, in 9 patients (75 %), there was a certain diagnosis of multiorgan involvement by endometriosis at admission. In two of the remaining three patients, endometriosis was highly suspected considering their preoperative work-up and the suspect was confirmed by intraoperative biopsy. In the last patient, a 46-year-old woman, a rectosigmoid neoplasm was ruled out with endoscopic examination that showed extrinsic compression of the colonic wall and submucosal mass, and differential diagnosis included endometriosis as well as primary ovarian carcinoma. Table 2 shows surgical procedures performed at our institution with postoperative and long-term outcomes. Median operative time was 305 min (range 200–720) and median blood loss was 400 ml (range 100–2,000). Overall, four patients underwent laparoscopic resection (two rectosigmoid resections, one Hartmann procedure and one LAR). In another patient, laparoscopic resection was attempted but conversion to laparotomy was necessary because of intra-abdominal bleeding. Ten of 12 patients (83 %) received a temporary ileostomy/cecostomy. All stomas were finally reconstructed. Six of the ten patients underwent diverting stoma at other hospitals as emergency treatment for their colonic obstruction. In all patients who received a colostomy before referral to our hospital, colostomy was resected with
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Table 1 Past medical history, preoperative work-up and management of 12 patients with severe bowel endometriosis presenting with bowel obstruction before referral to our hospital Pts no.
Age
Year
Previous surgery
Preoperative workup
Site of bowel stenosis
Management at outside hospitals
1
28
2002
–
WSCE proctoscopy
Sigmoid
Laparotomy and ileostomy
2
46
2003
–
Abdominal CT scan
Rectosigmoid
–
3
27
2003
–
Rectosigmoid
Laparotomy and colostomy
Sigmoid
–
Rectosigmoid
Laparotomy and cecostomy
Sigmoid
Laparotomy and cecostomy
Rectum
–
Rectosigmoid
–
Sigmoidoscopy Abdominal CT scan WSCE 4
28
2004
–
Proctoscopy WSCE Proctoscopy
5
34
2004
–
Abdominal CT scan WSCE Proctoscopy
6
32
2004
–
Abdominal CT scan WSCE Proctoscopy
7
33
2005
1999, laparotomy: removal of pelvic endometriosis
8
30
2007
–
Abdominal CT scan Proctoscopy WSCE Proctoscopy
9
35
2007
2004, laparoscopy: removal of pelvic endometriosis
WSCE Proctoscopy
Rectosigmoid
–
10
36
2009
–
Abdominal CT scan
Sigmoid
Laparotomy and colostomy
Sigmoid
–
Rectum
Laparotomy and colostomy
WSCE Proctoscopy 11 12
40 24
2009 2009
2008, laparotomy: removal of pelvic endometriosis
WSCE
–
Abdominal CT scan
Proctoscopy
Proctoscopy Abdominal X-ray was performed in all cases as first imaging modality to diagnose bowel obstruction WSCE water-soluble contrast enema, CT computed tomography
the surgical specimen during colorectal resection, and ileostomy was carried out if necessary. In the remaining patients, an ileostomy was carried because of ultra-low colorectal anastomosis or since the hydropneumatic test performed for the integrity of the colorectal anastomosis was positive [14]. Low or ultra-low end-to-end colorectal stapled anastomoses were performed in 10 patients (83 %) because of the extension of the disease to the rectovaginal septum. Excision of all visible endometriosis implants/ nodules within the pelvis and the abdomen was carried out. No hysterectomy was performed. In one patient during
laparotomy, a reconstruction of the distal ureter was carried out on a transvesical stent because of ureter obstruction with associated hydronephrosis. In all cases, bowel infiltration by endometriosis lesions was confirmed by definitive pathology. Median length of bowel removed was 14 cm (range 12–27). No resection margin was infiltrated by endometriosis. Median postoperative hospital stay was 8 days (range 5–33). Median duration of postoperative ileus was 2 days (range 1–4). Drain(s) were removed after a median of 4.5 days (range 2–20). Two patients developed
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Fig. 1 Complete stenosis of the sigmoid due to obstructing endometriosis
rectovaginal fistulas after low colorectal anastomoses with ileostomy/cecostomy (Table 2) and removal of vaginal endometriosis nodules with vaginal suture. They underwent fistula repair with mucosal flap and ileostomy/
cecostomy closure. No bowel re-resection was required. Another patient required prolonged length of stay and antibiotic administration for sepsis with no evidence of intra-abdominal abscesses or anastomotic leakage at imaging. Four patients (33 %) required heterologous blood transfusions. Median follow-up time was 38 months (range 12–72). One patient developed anastomotic stricture that required several endoscopic dilatations. Another two patients developed chronic constipations. Of the eight patients who had severe dyschezia before surgery, six reported a complete regression of pain, while the last two reported persistence of mild dyschezia. No cases of rectal bleeding were recorded. During follow-up, there were no cases of colorectal recurrence of the disease. Childbearing was reported in 8 (67 %) women and 2 (17 %) complained of a miscarriage.
Discussion Bowel obstruction is a rare complication of intestinal endometriosis. In fact, although bowel involvement is
Table 2 Management at our institution of 12 patients with severe bowel endometriosis associated with bowel obstruction including postoperative and long-term outcomes Pts no.
First operation
Second operation
Level of bowel anastomosis
Postoperative course
Long-term outcomes
1
Rectosigmoid resection with ileostomya
Ileostomy closure
High/medium
Uncomplicated
–
2
LAR
–
Low
Uncomplicated
–
3 4
LAR Laparoscopic rectosigmoid resection with ileostomy
– Ileostomy closure
Low Low
Sepsis Rectovaginal fistula
– Anastomotic stricture requiring dilatation
Blood transfusions 5
Laparoscopy, conversion to laparotomy, LAR with cecostomya Laparoscopic rectosigmoid resection with cecostomya
Cecostomy closure
Ultra-low
Cecostomy closure
Low
7
LAR with ileostomy
Ileostomy closure
8
Rectosigmoid resection with ileostomy, neo implantation of the left ureter LAR with ileostomy
Ileostomy closure Ileostomy closure
10
Rectosigmoid resection, right colectomy, ileostomy
Ileostomy closure
11
Laparoscopic Hartmann resection
12
Laparoscopic LAR with ileostomy
6
9
Rectovaginal fistula Blood transfusions
Chronic constipation
Ultra-low
Blood transfusions
–
Low
Chronic constipation
Low
Blood transfusions Uncomplicated
Low
Uncomplicated
–
Laparoscopic Hartmann resection reversal
High/medium
Uncomplicated
–
Ileostomy closure
Low
Uncomplicated
–
LAR low anterior resection a
Colostomy/cecostomy performed at previous laparotomy
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estimated in up to 12 % of patients suffering from the disease, bowel obstruction occurs in about 1 % of these patients [1–4, 7]. Our results confirm these data, with only 12 patients (1.7 %) undergoing colorectal resection for bowel obstruction due to endometriosis over a 7-year period at our institution. In this series six patients, who underwent emergency surgery with diverting stoma at other hospitals, were included. In most of these latter cases, the aetiology of intestinal obstruction was unknown, and endometriosis was an ‘‘unexpected’’ finding at explorative laparotomy. This can be related to the low clinical suspicion that surgeons have for such a disease. In this setting, an accurate clinical history looking for symptoms of endometriosis (i.e. dysmenorrhoea, dyspareunia, dyschezia, cyclic rectal bleeding) is of paramount importance. It is remarkable that, despite that endometriosis should be considered in young patients with colorectal symptoms, physicians have to rule out firstly other diseases including inflammatory bowel diseases and colorectal carcinoma. Since direct mucosal involvement by endometriosis nodules is very rare, endoscopy is usually aspecific showing extrinsic compression of the mucosa, submucosal mass and/or eccentric wall thickening [7, 15, 16]. In the preoperative work-up of patients with bowel obstruction, abdomino-pelvic CT scan is of paramount importance. In patients with endometriosis-related bowel obstruction, CT scan frequently reveals non-specific abnormalities of the bowel wall [17]. However, CT-based virtual colonoscopy may provide more useful information about the degree and site of bowel stenosis due to colorectal endometriosis [18, 19]. In this setting, multislice CT enteroclysis proved to be also effective in the diagnosis and depth of bowel endometriosis lesions [20]. Magnetic resonance imaging (MRI) showed promising results in detecting intestinal endometriosis, but MRI is not always available in acute setting and endometriosis-associated fibrosis may alter the signal intensity pattern [21]. Finally, from our experience, DCBE or WSCE—that are rapidly available and easily performed at low cost—can be useful in demonstrating the site and extent of bowel obstruction due to endometriosis [22–24]. In the setting of bowel obstruction, WSCE should be performed instead of DCBE [22–24]. Transvaginal ultrasound can be of help even in the acute setting to characterize bowel endometriosis and can be combined with DCBE/WSCE [25, 26]. Although management of deep pelvic endometriosis is debated, surgery is associated with symptoms relief, improvements in quality of life and renewed fertility [3, 4, 10, 11]. It is unlikely that large ([2 cm) bowel endometriosis lesions may benefit from medical therapy since endometriosis-associated fibrosis is unresponsive to hor-
63
monal manipulation [4]. In such cases, a surgical approach including intestinal surgery is indicated, aiming to ablate all visible endometriosis lesions. Indeed, no doubt exists that surgery must be considered in case of intestinal endometriosis with bowel obstruction. In this series, diverting stoma was initially performed in 6 patients (50 %) to obtain bowel decompression. In three of these six patients, a laparoscopic approach was subsequently attempted to perform colorectal resection, with one conversion to laparotomy because of bleeding. Other two patients (without stoma) underwent successfully laparoscopic resection. However, considering the small number of patients in this cohort, larger studies are needed to properly evaluate laparoscopic approach. The presence of a stoma may allow a ‘‘two-step’’ approach with delayed laparoscopic resection in patients presenting with bowel obstruction. All patients in this series had endometriosis of the rectum/rectosigmoid, in keeping with previous studies that report up to 90 % of endometriosis lesions involving this tract [1–13]. It is remarkable that even if the stenosis is in the sigmoid colon or in the upper third of the rectum, endometriosis would usually involve the rectovaginal septum, thus requiring a low rectal resection [3, 4, 27]. Consequently, low or ultra-low colorectal anastomoses were performed in 83 % of cases. Major complications may occur after colorectal resections [2–4, 7–13]. In this series, two patients with low colorectal anastomosis as well as vaginal suture, because of the removal of endometriosis nodules, developed rectovaginal fistulas, which can be related to an anastomotic leakage. Although there were no reoperations, median operative time was 305 min, median blood loss 400 ml and overall rate of blood transfusions was 33 %. These data taken together reflect the complexity of this surgery, which is time consuming and, as other have pointed out, is often challenging [3, 4, 27]. Long-term follow-up data were satisfactory with significant improvements in regard to dyschezia and no cases of rectal bleeding. In addition, there were no recurrences of colorectal endometriosis, and this may be related to the performance of formal colorectal resections with negative margins. In conclusion, bowel obstruction is an uncommon complication of deep infiltrating bowel endometriosis. Colorectal resections for severe endometriosis represent a demanding surgery, requiring specific experience and a multidisciplinary approach. Results of long-term follow-up are satisfactory with no colorectal recurrences and improvements in bowel symptoms. Intraoperative biopsy may be useful in selected cases to confirm the presence of endometriosis and to plan the most appropriate surgical strategy.
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Acknowledgments All authors report no funding nor relevant financial relationship. 15. Conflict of interest
None.
16.
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