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Endometriosis and the Colorectal Surgeon

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Title: Endometriosis and the Colorectal Surgeon Author: Nigel Scott Last modified by: Mike Created Date: 3/26/2004 6:25:45 AM Document presentation format – PowerPoint PPT presentation

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Title: Endometriosis and the Colorectal Surgeon


1
Endometriosis and the Colorectal Surgeon
  • NA Scott

2
Endometriosis and the Colorectal Surgeon
  • Aetiology and Incidence
  • Diagnosis and Investigation
  • Management endometriosis and pain
  • Radical surgery for stage IV disease
    (Rectovaginal disease)

3
Endometriosis and the Colorectal Surgeon
Aetiology and Incidence
  • 10 of all women 6 presenting for
    sterilisation, 21 of those presenting for
    infertility treatment
  • Retrograde menstruation peritoneal
    endometriosis
  • Coelomic metaplasia (?rectovaginal septum)
  • Vascular dissemination surgical implantation

4
Endometriosis and the Colorectal Surgeon
Diagnosis and Investigation
  • Secondary dysmenorrhoea
  • Deep dyspareunia
  • Pelvic (rectal) pain
  • Infertility
  • Pelvic mass

5
Endometriosis and the Colorectal Surgeon
Diagnosis and Laparoscopy
  • laparoscopy is gold standard
  • 0.06 bowel perforation in diagnostic procedure
  • 1.3 bowel perforation in operative laparoscopy

Harkki-Siren P, Sjoberg J, Kurki T. Major
complications of laparoscopy a follow-up Finnish
study. Obstet Gynecol 1999 9494-8. .
6
Endometriosis and the Colorectal Surgeon
Diagnosis and Laparoscopy
  • Minimal (Stage I)
  • Mild (Stage II)
  • Moderate (Stage III)
  • Severe (Stage IV)

7
Endometriosis and the Colorectal Surgeon
Diagnosis and Cyclical Rectal Bleeding
  • based on case reports rectal and sigmoid
    endometriosis associated with cyclical bleeding
  • endometriosis is in seromuscular layer not
    mucosa
  • ? Disruption of mucosa not menstruation into
    bowel

Forsgren H, Lindhagen J, Melander S, Wagermark J.
Colorectal endometriosis. Acta Chir Scand.
1983149(4)431-5
8
Endometriosis and the Colorectal Surgeon
Management
  • age
  • fertility plans
  • previous treatment
  • nature and severity of symptoms
  • location and severity of disease

Women with endometriosis-associated infertility
and pain may have to decide which is the major
priority as there is no evidence that hormonal
therapy alone improves fertility
9
Endometriosis and the Colorectal Surgeon
Endometriosis and pain medical management
  • complementary medicines, analgesics, NSAIDs
  • hormonal therapy (combined OC, progestogens,
    danazol, GnRH agonists)

10
Endometriosis and the Colorectal Surgeon
Endometriosis and pain hormonal therapy
  • induce atrophy in ectopic endometrial tissue
  • equally effective in producing symptom relief
  • significant side effects - poor long term
    compliance
  • do not affect biological mechanisms responsible
    for disease
  • recurrence 37 minimal disease 74 severe
    disease

Clinical Green Top Guidelines The Investigation
and Management of Endometriosis (24) - Jul 2000
http//www.rcog.org.uk/guideline
11
Endometriosis and the Colorectal Surgeon
Endometriosis and pain surgical therapy
Diagnostic laparoscopy alone Ablation mild-moderate endometriosis plus uterine nerve ablation
22.6 symptom relief at 6 months 73.7 symptom relief at 6 months effect still present in 90 at 1 year
Sutton CJ, Ewen SP, Whitelaw N, Haines P.
Prospective, randomized, double-blind, controlled
trial of laser laparoscopy in the treatment of
pelvic pain associated with minimal, mild, and
moderate endometriosis. Fertil Steril 1994
62696-700.
12
Endometriosis and the Colorectal Surgeon
Endometriosis and pain Stage IV disease
Radical surgery means doing a hysterectomy with
removal of both ovaries and is reserved for women
with very severe symptoms, who have not responded
to medical treatment or conservative operations
13
Why involve a Colorectal Surgeon in radical
surgery for pelvic endometriosis ?
14
Endometriosis and the Colorectal Surgeon
Stage IV disease rectovaginal endometriosis
embryonic remnants in the recto-vaginal septum
undergoing metaplastic change to
endometrial-like tissue, and by proliferation
become surrounded by hyperplastic smooth muscle,
representing a typical adenomyotic nodule deep
in the recto-vaginal septum
15
Endometriosis and the Colorectal Surgeon
Stage IV disease rectovaginal endometriosis
16
Endometriosis and the Colorectal Surgeon
Stage IV disease rectovaginal endometriosis
17
Endometriosis and the Colorectal Surgeon
Rectovaginal endometriosis - preoperative
  • MDT discussion of the indications and likely
    extent of pelvic surgery
  • Preoperative counselling of patient and family
    as to the indications and extent of surgery,
    including the risk of stoma formation, autonomic
    pelvic nerve injury and bladder dysfunction,
    ureteric injury and pelvic haemorrhage
  • Bowel preparation and stoma siting

18
Endometriosis and the Colorectal Surgeon
Rectovaginal endometriosis - intraoperative
  • Lloyd Davies position
  • Midline incision
  • Ureteric stents

19
Endometriosis and the Colorectal Surgeon
Rectovaginal endometriosis - intraoperative
  • round ligaments and ovarian pedicles divided
  • uterine artery divided to release the ureters
  • separate rectum to complete the hysterectomy by
    reaching the normal rectovaginal plane below the
    endometriosis

20
Endometriosis and the Colorectal Surgeon
Stage IV disease rectovaginal endometriosis
21
Endometriosis and the Colorectal Surgeon
22
Endometriosis and the Colorectal Surgeon
Rectovaginal endometriosis en bloc anterior
resection
  • uterus mobilised, bladder separated from
    anterior vaginal wall
  • rectum mobilised laterally and posteriorly
  • approach and enter the rectovaginal plane from
    the sides below the endometriosis

23
Endometriosis and the Colorectal Surgeon
Rectovaginal endometriosis en bloc anterior
resection
  • approach and enter the rectovaginal plane from
    the sides below the endometriosis

24
Endometriosis and the Colorectal Surgeon
Rectovaginal endometriosis en bloc anterior
resection
  • is lateral pelvic side wall involved
  • how far down does the process extend ?

25
Endometriosis and the Colorectal Surgeon
Rectovaginal endometriosis en bloc anterior
resection
  • successive division of anterior and posterior
    vaginal walls
  • staple across the rectum
  • remove specimen en bloc

26
Endometriosis and the Colorectal Surgeon
Rectovaginal endometriosis en bloc anterior
resection
  • stapled anastomosis
  • loop stoma
  • OUTCOMES

27
Jolyon Forda, James Englisha, William A. Milesb,
Theo Giannopoulosa Pain, quality of life and
complications following the radical resection of
rectovaginal endometriosis BJOG An
International Journal of Obstetrics Gynaecology
2003111353
  • 48 shaving of the pre-rectal fascia,
  • 2 had a disc resection of the rectum,
  • 10 had an anterior rectal resection
  • median follow up period was 12 months (range 2
    to 22 months)
  • 86 (38/44) reported an improvement
  • 27 (61) had a good response (pain completely
    gone or greatly improved).

Radical resection is an effective treatment for
rectovaginal endometriosis. Hysterectomy and
rectal resection were associated with a better
response and quality of life.
28
Urbach DR, Reedijk M, Richard CS, Lie KI, Ross
TM. Bowel resection for intestinal
endometriosis. Dis Colon Rectum. 1998
Sep41(9)1158-64.
  • 1992- 1996 29 patients undergoing bowel
    resection for Stage IV endometriosis
  • 93 low anterior resection
  • (Other appendicectomy, terminal ileum
    resection, sigmoid resection)
  • mean follow up 22 months in 26 patients
  • 100 subjective improvement
  • 46 cured (resolution of symptoms without
    further medical or surgical therapy)
  • concomitant TAH, BSO and anterior resection (OR
    12 95 CI 1.8-81.70

Total abdominal hysterectomy and bilateral
salpingo-oophorectomy at the time of bowel
resection correlates with improved outcome
29
Endometriosis and the Colorectal Surgeon
Summary
  • very common condition that is managed in large
    majority by gynaecological medical and
    laparoscopic ablative therapy (NB bowel
    perforation rate)
  • cyclical rectal bleeding is of interest only to
    exclude a sinister cause it is rarely an
    indication for surgery (rectal pain in Stage IV
    disease is a much more relevant problem)
  • Stage IV pelvic surgery with rectovaginal
    involvement can be exceptionally difficult.
    Preoperative planning and counselling as to the
    risks and morbidity is essential
  • Rectovaginal endometriosis can be managed by
    sharp separation but a difficult low anterior
    resection must be planned for

30
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