Acta Obstet Gynecol Scand 57: 277-279. 1978
OPERATIVE TREATMENT OF RECTAL ENDOMETRIOSIS S. Ruponen and E. Taina From the Department of Obstetrics and Gynaecology, Turku Universitv Central Hospitul. Turku, Finland
Abstract. 27 patients with rectal endometriosis were operated upon in Turku University Central Hospital in 1%7-1976. The main symptom was defecation pain especially during menstruation. Eighteen patients had had previous surgery for endometriosis of the pelvic area. A palpable tumor was found on gynaecological examination in every patient. The tumors did not grow through the rectal wall. Three kinds of operative procedures were applied (a simple excision method, a so called “window” operation, and resection of rectum) and the results were good.
The literature concerning this subject has so far been scarce. Sampson (3) wrote his first case report 50 years ago, but surgical treatment at that time was very risky. The biggest series of rectal endometriosis in recent years was published by Gray in 1966 (2). In his article he also discussed surgical treatment. Many textbooks deal with the incidence of this disease and suggest that endometnosis is found in the rectum or the sigmoid colon in about 10-13 % (Kaiser, Ikle) of all cases of endometriosis.
MATERIAL AND METHODS In 1969-1976 27 patients with rectal endometriosis were treated surgically in the Women’s Clinic of Turku University Central Hospital. Table I shows the age of the patients of whom 18 had had previous surgery for endometriosis. The time between the first operation and the operation for rectal endometriosis was on average 32 months. During the first operation rectal endometriosis was found in 6 cases but in none of these was the rectal endometriosis treated surgically. The patients had the same kinds of symptoms as endometriosis patients generally. The symptoms are shown in Table 11. The main complaint of the patient with rectal endometriosis is a change in the bowel function during menstruation. She has either constipation or diarrhea but blood or mucus is not seen in the stool. In the 16 parous patients the average time from the last pregnancy was 10 years. On gynaecological examination a palpable tumor was found in the rectovaginal space in every patient. A barium enema was performed in 4 cases preoperatively and sigmoidoscopy in 7 patients but the findings were normal. 18 -782863
OPERATIVE TREATMENT The operative procedures performed are found in Table 111. During the operation pelvic endometriosis was found in 24 patients and ovarian endometriosis in 22 patients. The size of the tumors varied from 1 x 3 cm to 12x3 cm. The tumors were at the sacrouterine level in 15 cases, below the sacrouterine level in 3 cases, above the level in 3 cases and extending from below to above the sacrouterine level in 3 cases. Most often the tumor was located in the anterior wall of the rectum but in 6 cases the tumor extended around the wall to the dorsal side of the rectum. OPERATIVE TECHNIQUE The patients were prepared preoperatively as follows. The bowel was emptied and preoperative Neomycin@was given. The surgical treatment was determined by the findings during the operation and a frozen section was obtained in every case to exclude malignancy. In the excision operation the window that was made in the front wall of rectum was closed end to end in two layers using atraumatic plain catgut 00 in the first layer and plain catgut 0 in the second layer. When endometnosis had extended to the dorsal side of the rectum the simple excision operation could not be performed. In those cases we performed resection of rectum and the length of the resected area varied from 5 to 20 cm. A so called ‘pull-through’ operation can also be done Table 1. A g e distribution Age range
No. of patients
2 1-25 26-30 3 1-35 3640 4 t-45 46-50
2 4 10 8 2 I
278
S . Ruponen and E . Taina
Table 2
Dysmenorrhea pareunia
Earlier operations for endometriosis
25
18
DYS-
General symptoms
14
Obstipation Diarrhea 3 (during 2 menstruation) 2 (during 1 intermenstrual period)
Defecation pain
symptoms. The troubles with the bowel function during menstruation had disappeared. There were no strictures of the rectum at the operation site. Two cases had barium enemas and the findings were normal. DISCUSSION
Rectal endometriosis is often associated with other pelvic endometriosis. In our material rectal endoRectal 15 metriosis was found alone in only one case. Ususymptoms ally these patients have already been operated upon 12 for pelvic endometriosis and, when symptoms recur, rectal endometriosis is sometimes found. The change in the bowel function during menstruation is Number of patients: 27. the main complaint. The patient may have either constipation or diarrhea but the stool does not conwhen rectal endometriosis is growing close to the tain blood or mucus because endometriosis does anus. We have often used this kind of operation in not grow through the rectal wall into the lumen. correction rectovaginal fistulas, but so far we have This is why barium enemas and sigmoidoscopy do not used this operation to treat rectal endo- not reveal this disease. This is important for the metriosis. Endometriosis found in other parts of differential diagnosis of carcinoma of the recthe pelvic was treated as usual. Bilateral oophorec- tum. Nevertheless the finding of a palpable tumor tomy had to be done in 2 cases because of se- must always suggest the possibility of malignancy. vere ovarian endometriosis. Hysterectomy was Therefore operation for rectal endometriosis should performed in 8 cases. The size of the area excised only be performed in a hospital where there is the from the rectum was decided by inspection and facility for a frozen section. This examination palpation. At the end of the operation a careful should always be done. A frozen section is also lavage of the pelvis was performed with physiologi- very useful to confirm the diagnosis of rectal encal saline solution and one dose of Hyalostop@ dometriosis. Surgical treatment of rectal endometriosis should (Leo) was instillated into the pelvic cavity. not be attempted if rectal endometriosis is discovered unexpectedly in an unprepared patient. BiPOSTOPERATIVE TREATMENT lateral oophorectomy will of course also lead to the All the patients received antibiotics after the opera- regression of rectal endometriosis. On the other tion, either ampicillin intravenously or, in the case hand with careful preoperative management, with of allergy, cephalothin intravenously. The antibio- good surgical technique and postoperative care, tic treatment was continued until the first defeca- rectal endometriosis can be cured with surgery tion had occurred and at the same time parenteral without doing bilateral ovariectomy at the same nutrition was stopped. We used no stimulation for time. The operation provides great satisfaction for the bowel function. The average time to the first defecation was 4-5 days, the shortest being 3 days Table 3 and the longest 6 days after the operation. Postoperative fever occurred in 5 cases (over Rectal Hyster38°C). The patients stayed in the hospital 8-14 days, procedures ectomy the average being 9-10 days. In every case the Excision of tumor (without histological diagnosis was rectal endometriosis. 7 2 penetrating rectal wall) Excision of tumor 12 2 (window-method) FINAL EXAMINATION Resection of rectum 6 4 Pull through All the patients were examined in the hospital 2 Bilateral ovariectomy 2 months after the operation. None had any rectal A(,ttr Ohsrrr
Cvnrcol Sctrrid 57 (1978)
Operative treatment of rectal endometriosis
the patient because it effectively relieves defecation symptoms during menstruation. The operator must have experience in intestinal surgery and therefore this operation is not a routine gynaecological technique.
REFERENCES 1 . Gray, L. H.: Endometriosis of the bowel: treatment by excision or castration. South Med 558: 815, 1%5.
279
2. Gray, L. H.: The management of endometriosis involving the bowel. Clin Obst Gyn 9: 309, 1966. 3. Sampson, J. A.: Intestinal adenomas of endometrial type. Arch Surg.5: 217, 1922. Submitted for publication May 9, 1977
Seppo Ruponen Department of Obstetrics and Gynecology University Central Hospital 205 20 Turku 52 Finland
OPERATIVE TREATMENT OF RECTAL ENDOMETRIOSIS S. Ruponen and E. Taina From the Department of Obstetrics and Gynaecology, Turku Universitv Central Hospitul. Turku, Finland
Abstract. 27 patients with rectal endometriosis were operated upon in Turku University Central Hospital in 1%7-1976. The main symptom was defecation pain especially during menstruation. Eighteen patients had had previous surgery for endometriosis of the pelvic area. A palpable tumor was found on gynaecological examination in every patient. The tumors did not grow through the rectal wall. Three kinds of operative procedures were applied (a simple excision method, a so called “window” operation, and resection of rectum) and the results were good.
The literature concerning this subject has so far been scarce. Sampson (3) wrote his first case report 50 years ago, but surgical treatment at that time was very risky. The biggest series of rectal endometriosis in recent years was published by Gray in 1966 (2). In his article he also discussed surgical treatment. Many textbooks deal with the incidence of this disease and suggest that endometnosis is found in the rectum or the sigmoid colon in about 10-13 % (Kaiser, Ikle) of all cases of endometriosis.
MATERIAL AND METHODS In 1969-1976 27 patients with rectal endometriosis were treated surgically in the Women’s Clinic of Turku University Central Hospital. Table I shows the age of the patients of whom 18 had had previous surgery for endometriosis. The time between the first operation and the operation for rectal endometriosis was on average 32 months. During the first operation rectal endometriosis was found in 6 cases but in none of these was the rectal endometriosis treated surgically. The patients had the same kinds of symptoms as endometriosis patients generally. The symptoms are shown in Table 11. The main complaint of the patient with rectal endometriosis is a change in the bowel function during menstruation. She has either constipation or diarrhea but blood or mucus is not seen in the stool. In the 16 parous patients the average time from the last pregnancy was 10 years. On gynaecological examination a palpable tumor was found in the rectovaginal space in every patient. A barium enema was performed in 4 cases preoperatively and sigmoidoscopy in 7 patients but the findings were normal. 18 -782863
OPERATIVE TREATMENT The operative procedures performed are found in Table 111. During the operation pelvic endometriosis was found in 24 patients and ovarian endometriosis in 22 patients. The size of the tumors varied from 1 x 3 cm to 12x3 cm. The tumors were at the sacrouterine level in 15 cases, below the sacrouterine level in 3 cases, above the level in 3 cases and extending from below to above the sacrouterine level in 3 cases. Most often the tumor was located in the anterior wall of the rectum but in 6 cases the tumor extended around the wall to the dorsal side of the rectum. OPERATIVE TECHNIQUE The patients were prepared preoperatively as follows. The bowel was emptied and preoperative Neomycin@was given. The surgical treatment was determined by the findings during the operation and a frozen section was obtained in every case to exclude malignancy. In the excision operation the window that was made in the front wall of rectum was closed end to end in two layers using atraumatic plain catgut 00 in the first layer and plain catgut 0 in the second layer. When endometnosis had extended to the dorsal side of the rectum the simple excision operation could not be performed. In those cases we performed resection of rectum and the length of the resected area varied from 5 to 20 cm. A so called ‘pull-through’ operation can also be done Table 1. A g e distribution Age range
No. of patients
2 1-25 26-30 3 1-35 3640 4 t-45 46-50
2 4 10 8 2 I
278
S . Ruponen and E . Taina
Table 2
Dysmenorrhea pareunia
Earlier operations for endometriosis
25
18
DYS-
General symptoms
14
Obstipation Diarrhea 3 (during 2 menstruation) 2 (during 1 intermenstrual period)
Defecation pain
symptoms. The troubles with the bowel function during menstruation had disappeared. There were no strictures of the rectum at the operation site. Two cases had barium enemas and the findings were normal. DISCUSSION
Rectal endometriosis is often associated with other pelvic endometriosis. In our material rectal endoRectal 15 metriosis was found alone in only one case. Ususymptoms ally these patients have already been operated upon 12 for pelvic endometriosis and, when symptoms recur, rectal endometriosis is sometimes found. The change in the bowel function during menstruation is Number of patients: 27. the main complaint. The patient may have either constipation or diarrhea but the stool does not conwhen rectal endometriosis is growing close to the tain blood or mucus because endometriosis does anus. We have often used this kind of operation in not grow through the rectal wall into the lumen. correction rectovaginal fistulas, but so far we have This is why barium enemas and sigmoidoscopy do not used this operation to treat rectal endo- not reveal this disease. This is important for the metriosis. Endometriosis found in other parts of differential diagnosis of carcinoma of the recthe pelvic was treated as usual. Bilateral oophorec- tum. Nevertheless the finding of a palpable tumor tomy had to be done in 2 cases because of se- must always suggest the possibility of malignancy. vere ovarian endometriosis. Hysterectomy was Therefore operation for rectal endometriosis should performed in 8 cases. The size of the area excised only be performed in a hospital where there is the from the rectum was decided by inspection and facility for a frozen section. This examination palpation. At the end of the operation a careful should always be done. A frozen section is also lavage of the pelvis was performed with physiologi- very useful to confirm the diagnosis of rectal encal saline solution and one dose of Hyalostop@ dometriosis. Surgical treatment of rectal endometriosis should (Leo) was instillated into the pelvic cavity. not be attempted if rectal endometriosis is discovered unexpectedly in an unprepared patient. BiPOSTOPERATIVE TREATMENT lateral oophorectomy will of course also lead to the All the patients received antibiotics after the opera- regression of rectal endometriosis. On the other tion, either ampicillin intravenously or, in the case hand with careful preoperative management, with of allergy, cephalothin intravenously. The antibio- good surgical technique and postoperative care, tic treatment was continued until the first defeca- rectal endometriosis can be cured with surgery tion had occurred and at the same time parenteral without doing bilateral ovariectomy at the same nutrition was stopped. We used no stimulation for time. The operation provides great satisfaction for the bowel function. The average time to the first defecation was 4-5 days, the shortest being 3 days Table 3 and the longest 6 days after the operation. Postoperative fever occurred in 5 cases (over Rectal Hyster38°C). The patients stayed in the hospital 8-14 days, procedures ectomy the average being 9-10 days. In every case the Excision of tumor (without histological diagnosis was rectal endometriosis. 7 2 penetrating rectal wall) Excision of tumor 12 2 (window-method) FINAL EXAMINATION Resection of rectum 6 4 Pull through All the patients were examined in the hospital 2 Bilateral ovariectomy 2 months after the operation. None had any rectal A(,ttr Ohsrrr
Cvnrcol Sctrrid 57 (1978)
Operative treatment of rectal endometriosis
the patient because it effectively relieves defecation symptoms during menstruation. The operator must have experience in intestinal surgery and therefore this operation is not a routine gynaecological technique.
REFERENCES 1 . Gray, L. H.: Endometriosis of the bowel: treatment by excision or castration. South Med 558: 815, 1%5.
279
2. Gray, L. H.: The management of endometriosis involving the bowel. Clin Obst Gyn 9: 309, 1966. 3. Sampson, J. A.: Intestinal adenomas of endometrial type. Arch Surg.5: 217, 1922. Submitted for publication May 9, 1977
Seppo Ruponen Department of Obstetrics and Gynecology University Central Hospital 205 20 Turku 52 Finland
