Rates of severe complications in patients undergoing colorectal surgery for deep endometriosis-a retrospective multicenter observational study.

INTRODUCTION: Surgical experience and hospital procedure volumes have been associated with the risk of severe complications in expert centers for endometriosis in France. However, little is known about other certified units in Central European countries. MATERIAL AND METHODS: This retrospective observational study included 937 women who underwent surgery for colorectal endometriosis between January 2018 and January 2020 in 19 participating expert centers for endometriosis. All women underwent complete excision of colorectal endometriosis by rectal shaving, discoid or segmental resection. Postoperative severe complications were defined as grades III-IV of the Clavien-Dindo classification system including anastomotic leakage, fistula, pelvic abscess and hematoma. Surgical outcomes of centers performing less than 40 (group 1), 40-59 (group 2) and ≥60 procedures (group 3) over a period of 2 years were compared. RESULTS: The overall complication rate of grade III and IV complications was 5.1% (48/937), with rates of anastomotic leakage, fistula formation, abscess and hemorrhage in segmental resection, discoid resection and rectal shaving, respectively, as follows: anastomotic leakage 3.6% (14/387), 1.4% (3/222), 0.6% (2/328); fistula formation 1.6% (6/387), 0.5% (1/222), 0.9%; (3/328); abscess 0.5% (2/387), 0% (0/222) and 0.6% (2/328); hemorrhage 2.1% (8/387), 0.9% (2/222) and 1.5% (5/328). Higher overall complication rates were observed for segmental resection (30/387, 7.8%) than for discoid (6/222, 2.7%, P = 0.015) or shaving procedures (12/328, 3.7%, P = 0.089). No significant correlation was observed between the number of procedures performed and overall complication rates (rSpearman  = -0.115; P = 0.639) with a high variability of complications in low-volume centers (group 1). However, an intergroup comparison revealed a significantly lower overall severe complication rate in group 3 than in group 2 (2.9% vs 6.9%; P = 0.017) without significant differences between other groups. CONCLUSIONS: A high variability in complication rates does exist in centers with a low volume of activity. Major complications may decrease with an increase in the volume of activity but this effect cannot be generally applied to all institutions and settings.

Diagnosis and Treatment of Endometriosis. Guideline of the DGGG, SGGG and OEGGG (S2k Level, AWMF Registry Number 015/045, August 2020).

Aims The aim of this official guideline published and coordinated by the German Society of Gynaecology and Obstetrics (DGGG) in cooperation with the Austrian Society for Gynaecology and Obstetrics (OEGGG) and the Swiss Society for Gynaecology and Obstetrics (SGGG) was to provide consensus-based recommendations for the diagnosis and treatment of endometriosis based on an evaluation of the relevant literature. Methods This S2k guideline represents the structured consensus of a representative panel of experts with different professional backgrounds commissioned by the Guideline Committee of the DGGG, OEGGG and SGGG. Recommendations Recommendations on the epidemiology, aetiology, classification, symptomatology, diagnosis and treatment of endometriosis are given and special situations are discussed.

Comparative immunohistochemical study of deep infiltrating endometriosis, lymph node endometriosis and atypical ovarian endometriosis including description of a perineural invasion.

AIM: Endometriosis is an inflammatory condition that shares a number of similarities with malignant diseases, such as an abnormal morphology, migration along the nerve bundles and metastatic spread to lymph nodes and distant organs. Endometriotic lesions are associated with oestrogen and progesterone imbalance which seems to play a key role in the pathogenesis of endometriosis. The aim of this study was to compare the status of both oestrogen and progesterone receptors in tissue of deep infiltrating endometriosis, lymph node endometriosis and atypical ovarian endometriosis using immunohistochemical methods, as well as to investigate the relationship between endometriosis and protein p53. METHODS: A total of 40 cases with deep infiltrating endometriosis were included in our study. Based on histopathological analysis of resected specimens, the cases were divided into 2 groups: group 1 - lymph node endometriosis (cases with lymph node involvement; n=12) and group 2 - deep infiltrating endometriosis (cases without lymph node involvement; n=28). As a control group, eutopic endometrium of adenomyosis- and endometriosis-free women were used (n=16). Five cases of atypical ovarian endometriosis as well as descriptions of the nerve involvement in endometriosis were also included. Immunohistochemical staining with a total of 4 markers was performed - oestrogen and progesterone receptors (ER, PR), p53 and Ki-67 (proliferation index). RESULTS: The immunophenotype of the cases in groups 1 and 2 and in the control group was virtually identical in the proliferative phase - strong nuclear ER and PR expression in more than 90% of endometrial glandular and stromal cells. In the early and mid secretory phase, ER expression only slightly decreased (80%) in endometrial glandular cells in group 2 and the control group, whereas in the late secretory phase, significant decrease of ER expression only in the control group was observed (15-50%; P<0.001). In group 2 and the control group, significant decrease of PR expression only in endometrial glandular cells was observed in the mid and late secretory phase (less than 15%; P<0.001). Differences in receptor content were found only in isolated cases in group 2. In group 1, no secretory changes were found. In all three groups, sporadic and weak nuclear p53 expression in less than 3% in both endometrial glandular and stromal cells was detected (regardless of the phase of the menstrual cycle). In atypical ovarian endometriosis, higher and strong p53 expression (on average 26%) and decrease in ER (on average 56%) and PR (less than 1%) expression was observed; compared to the control group and groups 1 and 2, the differences for all 3 markers were highly significant (P<0.001). In all groups, the proliferation index (Ki-67) reached the highest values in the proliferation phase and decreased during the cycle. However, in endometriotic tissue, it was widely variable in the individual phases of the cycle. Perineural spread of endometriosis with significant neural hypertrophy, hyperplasia and involvement of the ganglia of the autonomic nervous system was detected in 5 cases (12.5%). Conlusion. From a histological and immunohistochemical point of view, deep infiltrating endometriosis and lymph node endometriosis appear to represent the same entity. For the first time, a simple immunohistochemical panel with antibodies against ER, PR and p53 useful in diagnosing atypical endometriosis has been described. The marked endometriosis-associated neural changes (endometriotic neuropathy) could be one of the causes of impaired function of the affected organs after debulking surgery with macroscopic negative resection margins as well as pain symptomatology in macroscopic inapparent endometriotic lesions.

Rectal perforation caused by deep infiltrating endometriosis in non-pregnant woman: Case report and short review of the literature.

AIM: The aim of this paper is to describe an unique case of deep infiltrating endometriosis of the rectum in non-pregnant woman with unusual clinical and pathological presentation resulting in spontaneous perforation. MATERIALS AND METHODS: A female (20 years of age) with a two year history of chronic recurrent abdominal pain of unknown etiology treated by a psychiatrist underwent diagnostic laparoscopy which revealed many peritoneal implants of endometriosis involving the right ovarian fossa, the vesico-uterine pouch and sacrouterine ligament; the bowel wall showed no structural abnormalities. Peritonectomy of the broad and uterosacral ligaments was used and eight days after the operation, the patient developed crampy abdominal pain and enterorrhagia necessitating laparoscopic revision; pelvic haematoma and rectosigmoiditis were found. Over the next three days, perforation of the rectum resulted in the presence of fecal material in the surgical drain. RESULTS: Lower rectal resection with ileostomy was performed. Microscopic examination revealed discrete small endometriotic lesions in submucosa, muscular layer and serosa of the rectum associated with perforation. DISCUSSION: Laparoscopy and laparotomy may be insufficient in the case of an inactive endometriosis. Definitive diagnosis is thus reached only by the histological examination. The pathophysiology of the bowel perforation secondary to endometriosis is not entirely clear. CONCLUSION: The presented case confirms the importance of interdisciplinary cooperation between surgeons, gynaecologists, and pathologists. We also want to emphasize the need for extensive pathological examination of the resected specimens which is essential for a proper diagnosis. KEY WORDS: Endometriosis, Rectum, Spontaneous perforation.

Endometriosis with an aberrant immunophenotype: Challenging differential diagnosis of glandular lesions in the pelvic lymph nodes.

CASE REPORT: We describe an unusual case of pelvic lymph node endometriosis with an aberrant immunophenotype mimicking metastasis of adenocarcinoma. A 37-year-old patient with a history of invasive cervical adenocarcinoma stage pT1a2 is presented. Due to insufficient loop electrosurgical excision procedure (LEEP) conization, total laparoscopic hysterectomy with pelvic lymphadenectomy was indicated. Intraoperatively, the diagnosis of deep infiltrating endometriosis of parametrial ligament and vesicouterine pouch, endometrioma of the left ovary and Allen Master's syndrome was suspected; the patient had no history or clinical symptoms of endometriosis. A PubMed search of similar cases was followed by a comparison to this case and discussion of the differential diagnosis of glandular lesions in the pelvic lymph nodes is reported. RESULTS: Histological investigation showed no residual neoplasia; the diagnosis of endometriosis was confirmed. An interesting microscopic finding was represented by a solitary glandular lesion in one pelvic lymph node. Using immunohistochemistry, it was demonstrated that there was a complete loss of oestrogen and progesterone receptor expression (unlike parametrial ligament endometriosis). The diagnosis of endometriosis was based on the presence of endometrial stroma; malignancy was excluded by bland cytomorphologic features and results of immunohistochemical examination. CONCLUSIONS: This type of aberrant of the endometriotic gland immunophenotype has never been presented in the scientific literature before. This finding plays a significant role from the pathology standpoint and, perhaps more importantly, from the clinical standpoint. An asymptomatic patient with a correct diagnosis of lymph node endometriosis did not undergo excessive treatment for false positive diagnosis of metastatic cervical adenocarcinoma.

Allen-Masters syndrome: do the classic risk factors also apply in patients with endometriosis?

AIM: To evaluate whether the classic risk factors for Allen-Masters syndrome, such as body mass index (BMI) and spontaneous births, are in fact responsible for the condition in patients with endometriosis. METHODS: A total of 26 women who underwent a laparoscopic procedure due to chronic pelvic pain, Allen-Masters syndrome and endometriosis from 2009-2011 were enrolled in this study from an endometriosis competence center specializing in minimally invasive surgery. This was a retrospective cohort study (Canadian Task Force classification II-2). RESULTS: Only eight of the 26 patients (30.77%; 95% confidence interval [CI], 14.33-51.79%) had the classic risk factors (BMI >25 kg/m(2) and/or at least one spontaneous birth). The mean age in the study group was 32.08 years (SD ± 5.45). The patients had a mean BMI (kg/m(2) ) of 19.61 (SD ± 3.07). The means for the patients' clinical data were 0.88 (SD ± 1.53) pregnancies, 0.81 (SD ± 1.23) for parity, 0.27 (SD ± 0.60) for cesareans and 0.54 (SD ± 0.99) for spontaneous births. The revised American Society for Reproductive Medicine (rASRM) stage showed a median of grade III. The left side of the posterior compartment was more often affected (73.1% of cases) than the right side in all patients. CONCLUSION: In all, 69.23% of the cases (95% CI, 48.21-85.67%) were not explained by the classic risk factors. In view of the absence of other diseases and otherwise unremarkable parameters, we consider mechanical damage of the lesser pelvis not to be solely responsible for AMS. Further observations in patients with AMS, with and without endometriosis, may be able to contribute to research into the actual etiology of the condition.

Preoperative planning of surgery for deeply infiltrating endometriosis using the ENZIAN classification.

OBJECTIVE: To use the ENZIAN classification for preoperative estimation of laparoscopic operating time in patients with deeply infiltrating endometriosis (DIE). STUDY DESIGN: Retrospective study of women with DIE (n=151) who underwent laparoscopic surgery. RESULTS: 151 of 470 patients had DIE (n=205 lesions) exclusively in compartments A (rectovaginal septum, vagina), B (sacrouterine ligament to the pelvic wall) and C (rectum, sigmoid colon). These laparoscopically treated lesions were used to calculate a model for estimating operating time for DIE, assuming complication-free procedures (overall significance for model's predictive power: P<0.001). The error of estimation for the operating time prediction is 0 ± 35.35 min (mean ± SD; range -83 to +117 min). The actual operating time for all operations was 109.32 ± 74.38 min (mean ± standard deviation). CONCLUSIONS: Using a model for predicting operating time based on the ENZIAN classification enables resources to be planned more precisely in surgery management. Patients with DIE can also be given more precise information regarding the expected operating time.

Efficacy of the revised Enzian classification: a retrospective analysis. Does the revised Enzian classification solve the problem of duplicate classification in rASRM and Enzian?

PURPOSE: The most widely accepted classification for endometriosis is the Revised American Society for Reproductive Medicine (rASRM) system, but this does not take deeply infiltrating endometriosis (DIE) into account. The Enzian classification enables clinicians to classify DIE. Due to complexity and partial overlap with rASRM, it was revised for a second time in February 2011. Using both the systems to classify lesions would be inappropriate, as they refer to different locations. The aim of this study was to analyze whether the revised Enzian classification is easier to use and avoids duplicate classifications. METHODS: Retrospective study of 460 women admitted for endometriosis. RESULTS: One hundred and eighty-seven of 460 patients (41 %) had histologically confirmed DIE based on the revised Enzian classification. Further classification of these 187 patients using Enzian revealed 270 retroperitoneal lesions, as some patients had several DIE-type lesions simultaneously: 66 in compartment A (rectovaginal septum, vagina), 112 in compartment B (sacrouterine ligaments, pelvic wall), 58 in compartment C (bowel), 15 with adenomyosis uteri, 7 with bladder involvement, 8 with intrinsic involvement of the ureter, and 4 with bowel involvement. All 270 lesions were classified using Enzian alone and not with the rASRM score. There were no duplicate classifications (rASRM and Enzian). CONCLUSIONS: The revised Enzian classification is an excellent complement to the rASRM score for morphological description of DIE.

Endometriosis: a premenopausal disease? Age pattern in 42,079 patients with endometriosis.

PURPOSE: The objectives of this study were to examine the age distribution among women suffering from endometriosis and to establish that endometriosis is not a disease that occurs only in premenopausal women. The null hypothesis was that there are also postmenopausal women with endometriosis. METHODS: In a retrospective epidemiological study, a descriptive analysis of data from the Federal Statistical Office in Germany for 2005 and 2006 was carried out. A total of 42,079 women in Germany were admitted for surgical treatment due to histologically confirmed endometriosis during this period. The patients' age distribution was examined and they were assigned to 5-year age groups and then to premenopausal, perimenopausal, and postmenopausal subgroups. RESULTS: A total of 20,835 women in 2005 and 21,244 in 2006 were admitted to hospital for the treatment of endometriosis. In the premenopausal group (age 0-45 years), there were 33,814 patients (80.36 %); 23 patients (0.05 %) in this premenopausal group were younger than 15. There were 7,191 patients (17.09 %) in the perimenopausal group (45-55 years), and the postmenopausal group (55-95 years) included 1,074 patients (2.55 %). CONCLUSIONS: The assumption that endometriosis is a disease of the premenopausal period and in women of reproductive age needs to be called into question, as well as the influence of estrogen in fully developed endometriosis. Due to the relatively high prevalence of the condition in patients aged over 40, physicians should consider endometriosis in cases of unclear pelvic pain in this age group.

Comparison of revised American Fertility Society and ENZIAN staging: a critical evaluation of classifications of endometriosis on the basis of our patient population.

OBJECTIVE: To develop a classification that takes deep infiltrating endometriosis into account, the ENZIAN score was introduced. The ENZIAN classification supplements the revised American Fertility Society (AFS) score with regard to the description of deep infiltrating endometriosis, retroperitoneal structures, and other organs. The null hypothesis was that classifying a lesion by the revised AFS as well as the ENZIAN system is not meaningful, because the two systems express different locations. DESIGN: Retrospective. SETTING: Hospital admissions. PATIENT(S): Two hundred nineteen women admitted for endometriosis. INTERVENTION(S): Surgical interventions. MAIN OUTCOME MEASURE(S): Classification of the severity of endometriosis according to the revised AFS and the ENZIAN classification, focusing on the distribution pattern in deep infiltrating endometriosis, and the identification of duplicate classifications of the same lesions in the revised AFS as well as the ENZIAN systems. RESULT(S): Deep infiltrating endometriosis was diagnosed in 160 of 219 patients (73%). These patients had 236 lesions of deep infiltrating endometriosis, which were classified by ENZIAN as follows: compartment a (vertical): 26%; compartment b (horizontal): 41%; compartment c (dorsal): 24%; uterine adenomyosis: 4%; bladder disease: 2%; ureter disease: 1%; and bowel disease: 2%. The severity of deep infiltrating endometriosis according to ENZIAN (grades 1 = mild to 4 = severe) was as follows: grade 1: 45%; grade 2: 26%; grade 3: 19%; grade 4: 10%. Fifty-eight patients were classified according to ENZIAN although they did not fulfill the criteria of deep infiltrating endometriosis and had previously been classified according to the revised AFS classification. Adaptation of the ENZIAN score would reduce the diagnoses of deep infiltrating endometriosis by 36% (95% confidence interval [CI] 29%-44%). CONCLUSION(S): The ENZIAN score is a helpful aid to describe deep infiltrating endometriosis, but needs to be adapted.

Simple trachelectomy of early invasive cervix carcinoma in the second trimester.

Although cervical carcinoma is among the most frequently encountered malignancies during pregnancy only a small number of cases during pregnancy have been reported. Usually, the patients have been treated by radical trachelectomy with or without chemotherapy during the pregnancy. Laparoscopic pelvic lymph node dissection with frozen section, simple trachelectomy and cerclage were performed in the 22(nd) week of pregnancy. The histologic examination confirmed a squamous cell carcinoma of the cervix of 35mm diameter, lymphangioinvasion (L1), low grade, clear surgical margin, negative pelvic lymph nodes according to stage Figo IB. Adjuvant chemotherapy with three cycles of cisplatin was performed after surgery. Delivery was performed by cesarean section followed by radical hysterectomy in the the 32(nd) week of pregnancy. Recurrent adjuvant chemotherapy with three cycles of cisplatin and local vaginal iridium radiation were performed after surgery. Patient had no surgery related complications. No relapse of cancer has been diagnosed during the following 16 months. Simple trachelectomy may be alternative treatment option to radical trachelectomy for pregnant women with early stage cervical cancer without lymph node metastasis.