Computed tomography-based virtual colonoscopy in the assessment of bowel endometriosis: The surgeon's point of view.

OBJECTIVE: To discuss the role of computed tomography-based virtual colonoscopy (CTC) in preoperative assessment of bowel endometriosis. METHODS: Retrospective study using data prospectively recorded, including 127 patients with colorectal endometriosis, having undergone CTC for bowel endometriosis. The study was conducted in a tertiary referral center during 38 consecutive months. Preoperative assessment included CTC, magnetic resonance imaging (MRI), endorectal ultrasound (ERUS) and clinical examination. Information concerning identification of deep infiltrating endometriosis (DIE) of the bowel, the length and height of colorectal involvement, stenosis of digestive lumen and associated digestive localizations were compared with intraoperative findings. RESULTS: Sensitivity and specificity of CTC for DIE of the rectum, the sigmoid colon, associated digestive localizations, and stenosis of the digestive lumen were respectively 97% and 84%, 93% and 88%, 84% and 97%, 96% and 96%. Intraoperative estimation of the length of digestive tract involved by DIE was closer to that provided by CTC than those provided by MRI and ERUS. When CTC revealed stenosis of digestive lumen, higher rates of colorectal resection (63% vs. 9.6%, < 0.001) and disc excision (25.9% vs. 11%, 0.03) were recorded. DISCUSSION: For those surgeons using various procedures for management of bowel endometriosis, accurate information on the length and height of bowel involvement, as well as the existence of bowel stenosis enables informed decision regarding the feasibility of conservative techniques versus bowel resection. Preoperative identification of associated localizations above the sigmoid colon is another major advantage related to CTC. CONCLUSIONS: CTC provides accurate data on the length and height of colorectal involvement by DIE, stenosis of digestive lumen and associated lesions of digestive tract, which impact on the choice of surgical procedure.

[Infected hematoma of Douglas pouch: a specific complication of the surgical excision of deep endometriosis involving the vagina]. / Hématome infecté du cul-de-sac de Douglas : une complication spécifique de la chirurgie de l'endométriose profonde postérieure du fond vaginal.

OBJECTIVE: Surgical management of deep pelvic endometriosis may be responsible for various complications, such as infected pelvic haematic collection of the Douglas pouch. The aim of this study is to describe this unfavourable outcome and to estimate its frequency in the series of women managed by our team. PATIENTS AND METHODS: Retrospective study enrolling 163 women undergoing surgical removal of deep posterior endometriosis involving the vagina, from January 2008 to September 2011. We indentified women presenting with postoperative fever associated with computed tomographic findings suggesting an abscess of the Douglas pouch. Women characteristics, complication's management and outcomes were analysed in each case. RESULTS: Ten patients presented an inflammatory syndrome associated to hypothetical Douglas pouch abscess, revealed 6 days postoperatively on average. All women reported increasing pelvic pain, fever higher than 38.5°C, increased level of leucocytes and C reactive protein, and liquid collection of the Douglas pouch. Surgical management was carried out in nine women, revealing a pelvic collection of cloudy haematic liquid. Various bacteria were identified in six cases out of nine, suggesting liquid contamination through vagina opening. Postoperative outcome were immediately favourable. DISCUSSION AND CONCLUSION: Inflammatory syndrome associated with infected haematic collection of the Douglas pouch is a postoperative complication of the surgical removal of deep endometriosis involving the posterior vagina. Surgical removal of the haematic collection allows rapid and definitive favourable outcomes.

[Assessment of ovarian volume reduction with three-dimensional ultrasonography after cystectomy for endometrioma]. / Évaluation par échographie tridimensionnelle de la réduction du volume des ovaires après kystectomie des endométriomes.

OBJECTIVE: The aim of our study was to assess ovarian tissue loss related to endometrioma cystectomy by 3D-ultrasonography. PATIENTS AND METHODS: We have retrospectively included 15 women with no previous ovarian surgery who benefited from cystectomy of an unilateral endometrioma the diameter of which was superior to 30mm. Cystectomy has been performed using an ovarian tissue-sparing procedure with no incision of the ovarian cortex. Patients underwent ultrasonography at least 9 months after the surgery. Several ovarian parameters, such as the area on longitudinal cross-section, the volume and the antral follicles count (AFC), were measured on both operated and contra lateral ovary, and then were compared using Mann and Whitney test. The relationship between the reduction of operated ovary volume and preoperative endometrioma diameter was evaluated by multiple regression. RESULTS: Operated ovary presented a significant reduction in area (mean reduction 229.8mm(2)±47.6; P<0.0001), volume (mean reduction 5.8cm(3)±1.16; P<0.0001) and AFC (mean reduction 5.1±3.8, P=0.002). No statistically significant correlation was found between operated ovary volume reduction and preoperative endometrioma diameter. DISCUSSION AND CONCLUSION: Endometrioma cystectomy leads to significant reduction in ovarian parenchyma volume and AFC, when compared to contra lateral ovary. This event must be taken into account in the choice of treatment strategy, especially in the case of enlarged, bilateral and recurrent endometriomas, recurrence, as well as in women presenting with other risk factor for ovarian failure.

[Umbilical endometriosis in women free of abdominal surgical antecedents]. / Endométriose ombilicale chez les femmes sans antécédents chirurgicaux.

Primary umbilical endometriosis represents a very rare localization of the disease and is represented by blue, papular, nodular or cystic lesions whose symptoms are related to ovarian cycle. We report the management of three women, free of surgical antecedents presenting with primary umbilical endometriosis. In each woman, abdominal laparoscopy revealed peritoneal pelvic endometriosis. The excision of umbilical lesions was performed with satisfactory esthetical outcomes. In our experience, umbilical endometriosis responsible for highly characteristic features appears playing the role of clinical marker for pelvic endometriosis.

[Computed tomography-based virtual colonoscopy: an examination useful for the choice of the surgical management of colorectal endometriosis]. / Coloscanner à l'air avec coloscopie virtuelle: arguments dans le choix du traitement chirurgical des endométrioses colorectales.

OBJECTIVE: To evaluate the use of computed tomography-based virtual colonoscopy in the preoperative assessment of colorectal endometriosis. PATIENTS AND METHODS: We included in the study consecutive women undergoing surgical management of deep infiltrating endometriosis from August 2009 to April 2010, whose colorectal involvement had been assessed by magnetic resonance imaging (MRI) and rectal endoscopic sonography (RES). Prior to surgical procedure, a computed tomography-based virtual coloscopy was performed. Computed tomography was performed by insufflating air into the distal rectum, along with an intravenous injection of contrast agent. Then, 3D reconstruction of pictures was carried out, to allow visualization of the lumen of the rectum and the colon. Data provided by virtual colonoscopy were compared to those given by other imaging techniques and surgical exploration. RESULTS: Twenty-seven patients were included in the study: 7 women underwent colorectal segmental resection, 2 full thickness excision, 15 shaving, while in 3 of them no digestive surgical step was performed. Virtual colonoscopy provided the measurement of the length and the diameter of colorectal stenosis due to infiltrating nodule through rectal and sigmoid wall, which was presenting as an endoluminal indentation. The number of patients presenting with endometriotic nodules arising on the rectum, sigmoid colon, or both of them, were respectively 13, 7 and 7. Ovarian endometriomas were responsible for extrinsic compression leading to digestive tract stenosis in nine cases. The number of lesions and their height reported to the anus were accurately assessed in 24 women out of 27 (sensitivity of 88%). The origin of the digestive tract stenosis, i.e. either infiltrating endometriotic nodules or extrinsic compression due to ovarian endometriomas, was accurately assessed in all cases, by combining information provided by virtual colonoscopy, IRM, RES and transvaginal ultrasonography. CONCLUSION: Computed tomography-based virtual colonoscopy provides useful information about the degree and the height of digestive tract stenosis due to colorectal endometriosis. In our opinion, this information is of major interest to argue the choice of shaving or full thickness excision of nodules in a majority of women presenting with colorectal endometriosis.