Deep endometriosis with severe rectal involvement

Joaquín Tognelli1, Alberto Manuel Ustarroz2

1Colorectal Surgeon at Hospital Juan A. Fernandez, Sanatorio Finochietto , and Sanatorio Sagrado Corazón. Buenos Aires, Argentina. Clinical Instructor, Faculty of Medicine, University of Buenos Aires

2Head of the Benign Pathology Section, Gynecology Division, Hospitalde Clinicas Jose de San Martin, Buenos Aires, Argentina. Chief Clinical Instructor, University of Buenos Aires

LINK https://youtu.be/FjqIsMATGXI

REV ARGENT COLOPROCT | 2024 | VOL 36, No 3 VIDEO

Keywords: Rectal Resection; Colonic Endometriosis; Extragenital Pelvic Endometriosis; Deep Endometriosis

INTRODUCTION

Deep infiltrating endometriosis is a severe form of endome- triosis that affects 1–2% of women of reproductive age. It is characterized by the presence of endometrial tissue that penetrates 5 mm or more below the peritoneum. This condi- tion is often associated with severe pelvic pain and infertili- ty. It frequently presents as a solitary nodule measuring over 1 centimeter, and in 5–12% of cases, it involves the intes- tine, predominantly the rectum and sigmoid colon (90%).1 Up to 80% of infertile women exhibit some degree of en- dometriosis.2,3 In certain cases, surgical intervention can lead to substantial improvements in fertility outcomes. Approximately one-third of patients achieve pregnancy within the first year, with two-thirds achieving pregnancy within three years following surgery.4,5

CASE DESCRIPTION

A 25-year-old patient with a medical history of laparoscopic ovarian cystectomy for hemorrhagic cysts was seeking pregnancy. The patient presented with dyspareunia and chronic pelvic pain in the left iliac fossa. These symptoms were unresponsive to oral contraceptives and exacerbated during defecation. A physical examination revealed a tender nodule in the pouch of Douglas, as detected during the bimanual examination. Due to the incomplete nature of the colonoscopy, specifically the presence of angulation at the rectosigmoid junction, a virtual colonoscopy was performed. This subsequent examination revealed the aforementioned narrowing, accompanied by indications of local inflamma- tion, with no additional proximal lesions detected. A pelvic magnetic resonance imaging scan revealed the presence of bilateral endometriomas, hematosalpinx, and retrocervical fibrous tissue with a cystic-hemorrhagic component. This component was found to be infiltrating both uterosacral ligaments, the posterior vaginal fornix, and the rectum, affecting 40% of the rectal circumference in at least two segments. Additionally, fibrous thickening of the vesicouter- ine peritoneum was observed. A laparoscopic approach with a uterine mobilizer was performed to achieve adequate exposure of the posterior compartment, which was improved by initially addressing the endometriomas. During the

dissection of the rectovaginal endometriotic nodules, both ureters were identified and lateralized to avoid injury. The uterosacral ligaments were resected, the rectovaginal space was entered, the rectum was released, and the anatomy was restored. This allowed for evaluation of colorectal involve- ment and definition of the surgical approach. In light of the two lesions with transmural involvement, a non-organ- sparing segmental resection was deemed the optimal surgi- cal intervention. A comprehensive mechanical anastomosis was executed, ensuring the preservation of the mesorectum. The patient demonstrated a positive progression and was discharged on the fourth day.

CONCLUSION

Determining the degree of colorectal involvement is essen- tial for defining treatment which may entail non-resective surgery (e.g., shaving and/or discoid resection of the rectum) or organ resection. The latter is recommended for multifocal lesions or involvement of more than 50% of the circumfer- ence, as in this case. This is a safe laparoscopic procedure, and given the benign nature of the disease, the mesorectum can be preserved.. The vast majority of patients demonstrate substantial improvement in pain and quality of life, accom- panied by low rates of recurrence.

REFERENCES

1. Habib N, Centini G, Lazzeri L, Amoruso N, El Khoury L, Zupi E, et al. Bowel Endometriosis: Current Perspectives on Diagnosis and Treatment. Int J Womens Health. 2020;12:35-47.

2. Koninckx PR, Ussia A, Adamyan L, Wattiez A, Donnez J. Deep endometriosis: Definition, diagnosis, and treatment. Fertil Steril. 2012;98(3):564-71.

3. Poon C, Rome R. Malignant extra-ovarian endometriosis: A case series of ten patients and review of the literature. Aust N Z J Obstet Gynaecol. 2020;60(4):585-91.

4. Bassi MA, Podgaec S, Dias 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(6):730-3.

5. Tognelli J. Endometriosis colorrectal. En: Lumi CM, Bianchi R, Canelas A, Collia Ávila K, Farina PA, Laporte M, Mattacheo AE, Pastore RLO, ed. Enfermedades del colon, recto y ano. Buenos Ai- res: Sociedad Argentina de Coloproctología; 2023. p. 420-29.

DEEP ENDOMETRIOSIS WITH SEVERE RECTAL INVOLVEMENT Tognelli J, Ustarroz AM