Complications and long-term follow-up on colorectal resections in the treatment of deep infiltrating endometriosis extending to bowel wall.

OBJECTIVE: To evaluate the rate of complications, factors associated with complications and long-term results in colorectal resections for the treatment of deep infiltrating endometriosis of the bowel wall. DESIGN: Retrospective study. SETTING: Tertiary center in Finland. METHODS: Medical charts were reviewed for 164 women undergoing colorectal resections for deep infiltrating endometriosis between June 2004 and December 2012 at the Department of Obstetrics and Gynecology, Helsinki University Central Hospital; in 112 women (68%) bowel resection was performed laparoscopically and in 52 women (32%) laparotomy was needed. MAIN OUTCOME MEASURES: Complications, re-operations, fertility. RESULTS: The rate of major complications was 12% for both laparoscopies and laparotomies. However, the rate of complications during laparoscopies decreased from 27% in 2004-06 to 8% between 2010 and 2012. Similarly, the complication rate in laparoscopies fell with increased personal experience of the operating surgeon. A greater size (≥4 cm) of the nodules in the resected bowel was significantly associated with the development of a major complication. During the median follow up of 61 months (range 16-116 months) 7% needed a re-operation due to recurrence. Forty-seven percent of those women who preoperatively desired a pregnancy, subsequently had a child. CONCLUSIONS: Laparoscopy has become a feasible alternative to laparotomy for performing colorectal resection in cases of deep infiltrating endometriosis of the bowel wall. Moreover, colorectal resections seem to result in good long-term pain relief and fertility. With increasing experience the number of complications was reduced and therefore, the practice of centralizing these operations seems to be well justified.

Use of hormonal therapy is associated with reduced nerve fiber density in deep infiltrating, rectovaginal endometriosis.

OBJECTIVE: To study the density of nerve fibers in cases of deep infiltrating endometriosis (DIE) of the rectovaginal septum in relation to various clinical factors. DESIGN: A research laboratory-based study. SETTING: A tertiary center together with a research laboratory. METHODS: Archived DIE tissue samples from 45 women operated upon for rectovaginal septum DIE were re-examined histologically, and by immunohistochemistry. MAIN OUTCOME MEASURES: The effect of progestogens or combined oral contraceptives on the density of nerve fibers, and the expression of nerve growth factor (NGF) and its high-affinity receptor (tyrosine kinase receptor A, Trk-A). RESULTS: The use of hormonal therapy was associated with reduced densities of sympathetic, parasympathetic and sensory nerve fibers in DIE lesions. Density of total nerve fibers (with pan-neuronal marker PGP9.5) was significantly lower (p < 0.05) in lesions collected from hormone-treated women (8.6/mm², 4.2-20.8/mm²; median density, from 25th to 75th quartiles) compared with that in lesions from untreated women (24.9/mm², 11.2-34.9/mm²). DIE lesions stained strongly for NGF and its receptor Trk-A. Expression of NGF, but not of Trk-A, was significantly reduced during use of hormonal therapy. CONCLUSIONS: Use of hormonal therapy was associated with significantly reduced nerve fiber density in DIE lesions. This may be an important mechanism of action of hormonal therapy for controlling DIE pain symptoms. The expression of estrogen-regulated NGF and its receptor was only partially suppressed during the use of hormonal therapy, suggesting that local estrogen action is often maintained during conventional hormonal therapy in cases of DIE.

Radical excision of rectovaginal endometriosis results in high rate of pain relief - results of a long-term follow-up study.

OBJECTIVE: To evaluate the long-term results of radical excision for rectovaginal endometriosis (RVE) with special emphasis on current symptoms and risk factors as regards recurrence. METHODS: A total of 116 patients operated upon because of RVE were offered a clinical follow-up evaluation visit; 60 (52%) consented. The time (mean +/- SD) from the index surgery to the follow-up visit was 4.0 +/- 0.5 years. MAIN OUTCOME MEASURES: Daily symptoms using a visual analogue scale for 30 consecutive days prior to clinical assessment; the amount of uterine bleeding was also assessed. Endometriosis recurrence was evaluated via clinical and ultrasonographic examination. RESULTS: The symptom sum scores (maximum 300) were low with median scores (range) of 3 (0-32) for dysmenorrhea and 9 (0-72) for pelvic pain. Evidence of RVE recurrence was found or suspected in 29 (48%) of the 60 women assessed. Clinical recurrence was not associated with pain symptoms. In univariable analysis, amenorrhea at the time of clinical assessment was associated with a lower risk of recurrence (odds ratio; OR 0.13; 95% CI (confidence interval) 0.02-0.65, p = 0.01); the effect of bowel resection was not significant (OR 0.37: 95% CI 0.13-1.07, p = 0.07). In multivariable analysis, the protective effect of bowel resection on recurrence was significant (OR 0.23; 95% CI 0.06-0.89, p = 0.03). CONCLUSIONS: Radical surgery may result in long-term pain relief in cases of RVE. Bowel resection is associated with a lower risk of RVE recurrence. Therapy that induces amenorrhea may be effective in preventing recurrence following surgical treatment of RVE.

Rectovaginal endometriosis-characteristics of operative treatment and factors predicting bowel resection.

STUDY OBJECTIVE: The purpose of this study was to characterize operative treatment of patients with rectovaginal endometriosis (RVE), with special emphasis on factors predicting bowel resection. DESIGN: A total of 153 symptomatic cases undergoing radical resection of RVE at our institution between January 2000 and May 2004 were reviewed. Univariable and multivariable association models were used in connection with various factors associated with bowel resection. SETTING: Tertiary referral center. MEASUREMENTS AND MAIN RESULTS: In all, 57 (37%) patients were treated laparoscopically, and 96 (63%) patients via laparotomy. Gastrointestinal and/or urologic surgeon was present in 30% of cases. A total of 54 (35%) patients underwent bowel resection. The median (range) operating times were 145 (75-315) minutes and 100 (20-300) minutes for patients with and without bowel resection, respectively (p <.0001). Four (2.6%) major complications occurred. In the univariable association model, the risk of bowel resection was increased among patients with previous surgery for endometriosis (OR 2.74, 95% CI 1.35-5.54), intestinal symptoms (OR 2.55, 95% CI 1.29-5.02), and revised American Fertility Society score IV (OR 4.71, 95% CI 2.06-10.78). Preoperative use of combined oral contraceptives was associated with a lower risk of bowel resection (OR 0.32, 95% CI 0.15-0.66). CONCLUSION: Operative treatment of RVE is demanding; a multidisciplinary approach is often needed. Patients with intestinal symptoms and those with a history of endometriosis surgery are at increased risk of bowel resection.