Bowel endometriosis: colorectal surgeon's perspective in a multidisciplinary surgical team

Abstract

Endometriosis is a gynecological condition that presents as endometrial-like tissue outside the uterus and induces a chronic inflammatory reaction. Up to 15% of women in their reproductive period are affected by this condition. Deep endometriosis is defined as endometriosis located more than 5 mm beneath the peritoneal surface. This type of endometriosis is mostly found on the uterosacral ligaments, inside the rectovaginal septum or vagina, in the rectosigmoid area, ovarian fossa, pelvic peritoneum, ureters, and bladder, causing a distortion of the pelvic anatomy. The frequency of bowel endometriosis is unknown, but in cases of bowel infiltration, about 90% are localized on the sigmoid colon or the rectum. Colorectal involvement results in alterations of bowel habits such as constipation, diarrhea, tenesmus, dyschezia, and, rarely, rectal bleeding. Differential diagnosis must be made in case of irritable bowel syndrome, solitary rectal ulcer syndrome, and a rectal tumor. A precise diagnosis about the presence, location, and extent of endometriosis is necessary to plan surgical treatment. Multidisciplinary laparoscopic treatment has become the standard of care. Depending on the size of the lesion and site of involvement, full-thickness disc excision or bowel resection needs to be performed by an experienced colorectal surgeon. Long-term outcomes, following bowel resection for severe endometriosis, regarding pain and recurrence rate are good with a pregnancy rate of 50%.

Keywords: Colorectal endometriosis; Deeply infiltrative endometriosis; Diagnosis; Endometriosis; Laparoscopy; Treatment.

Figure 1

Transvaginal ultrasound image, sagittal view. A: Hypoechoic nodule in the rectovaginal septum measuring 1 cm × 0.9 cm (arrow). The nodule obliterates the pouch of Douglas, invades the anterior rectal wall, and causes anatomical distorsion (dotted arrow); B: A large hypoechoic retrocervical nodule affecting the rectosigmoid colon is seen (arrow). Note the typical “indian headdress sign”, indicating deep endometriosis into the bowel wall.

Figure 2

Barium enema, sagittal view. A: Extrinsic mass compressing the rectum secondary to severe pelvic endometriosis (arrow); B: Stricture of the sigmoid colon secondary to endometriosis (arrow). Note the fine crenulation of the mucosa (dotted arrow).

Figure 3

Laparoscopic view of bowel endometriosis invading the sigmoid colon (arrow). Same patient as in Figure 2B.

Figure 4

Small bowel adhesions secondary to invasion by endometriosis (arrow).

Figure 5

Segmental enterectomy (8 cm) for small bowel endometriosis. The bowel is cut open longitudinally. Note the two foci of non-transmural endometriosis (arrows) obliterating the bowel lumen.