Dr. LOI HOI SUN

1. Bowel Endometriosis in Surgery
TUTOR: DR. JOSE EDUARDO FERNANDES DA COSTA MAIA
O&G IC: LOI HOI SUN
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2. Content
 Introduction
 Pathogenesis
 Distribution of disease
 Clinical manifestations
 Diagnostic evaluation
 Management(Surgery and Medical)
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3. Endometriosis 15+%
Bowel
Endometriosis
3-37%
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Bowel endometriosis: Colorectal surgeon’s perspective in a multidisciplinary surgical team
World J Gastroenterol. 2014 Nov 14; 20(42): 15616–15623.
Published online 2014 Nov 14. doi: 10.3748/wjg.v20.i42.15616

4. Introduction
 Endometriosis is the presence of endometrial glands
and stroma at extrauterine sites throughout the
pelvis and beyond.
 Rectovaginal and bowel endometriosis are forms of
deep infiltrating endometriosis (DIE), which is
defined as an endometriotic lesion situated more
than 5 mm below the peritoneum.
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Bowel resection for deep endometriosis: a systematic review.
De Cicco C, Corona R, Schonman R, Mailova K, Ussia A, Koninckx P
BJOG. 2011;118(3):285. Epub 2010 Oct 13.

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6. Pathogenesis
 Spread of endometrial cells from
1) Retrograde menstruation
2) Lymphatic
3) Hematogenous dissemination
 Müllerian or coelomic metaplasia
 Spread of endometrium-derived stem or progenitor
cells
 Changes in the balance of cell proliferation and/or
apoptosis
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7. Distribution of disease
 Rectum (13 to 53 percent)
 Sigmoid colon (18 to 47 to percent)
 Ileum or other small bowel (2 to 5 percent)
 Appendix (3 to 18 percent)
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Endometriosis of the bowel.
Weed JC, Ray JE
Obstet Gynecol. 1987;69(5):727.
Aggressive surgical management for advanced colorectal endometriosis.
Bailey HR, Ott MT, Hartendorp P
Dis Colon Rectum. 1994;37(8):747.

8. Clinical manifestations
 Abdominal pain
 Rectal bleeding
 Dysmenorrhea
 Dyspareunia
 Infertility
 Painful defecation
 Dyschezia
 Constipation, and/or bloating
 Diarrhea
 Bloating
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9. Diagnostic evaluation
 History and physical examination
 Laboratory testing
 Imaging
1) Ultrasound(TVUS, TRUS, EUS)
2) MRI
3) CT
 Bowel endoscopy
 Endometriosis is definitively diagnosed by
histologic evaluation of a biopsied lesion
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10. Management
Confirmation and delineation of
colorectal endometriosis
Does the patient have
symptoms and findings of bowel
occlusion/obstruction?
Refer to other information on
management of endometriosis
without colorectal involvement
Colorectal endometriosis
confirmed
Colorectal endometriosis
not confirmed
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11. Does the patient have
symptoms and findings of bowel
occlusion/obstruction?
Pursue immediate evaluation
and surgical treatment of
mechanical colorectal obstruction
Assess for subocclusive GI
symptoms
Symptoms may be cyclic or noncyclic
and include:
-Nausea and vomiting
-Frequent episodes of colicky pain
with abdominal distension(>1 per
month)
-Habitual elimination of small-caliber
stool
Yes No
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12. Assess for subocclusive GI
symptoms
Symptoms may be cyclic or noncyclic
and include:
-Nausea and vomiting
-Frequent episodes of colicky pain with
abdominal distension(>1 per month)
-Habitual elimination of small-caliber
stool
Absent Present
Offer surgical resection
(nodule or segmental resection)
We favor initial medical therapy
because it is effective in half of women
and avoids the risks of surgery
Surgery is an alternative option
After review of the risks and benefits of
each, what is the patient’s treatment
preference?
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13. We favor initial medical therapy
because it is effective in half of women and avoids
the risks of surgery
Surgery is an alternative option
After review of the risks and benefits of each, what is
the patient’s treatment preference?
Offer surgical resection
(nodule or segmental resection)
Medical therapy Surgery
Trial of medical hormonal therapy
After three to four months of
medical therapy, has the patient
had adequate improvement in her
symptoms?
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14. After three to four months of medical
therapy, has the patient had adequate
improvement in her symptoms?
Yes No
Continue medical therapy and
follow up
During continued follow-up, does
the patient develop progressive
symptoms?
Continue medical therapy and
follow-up
Has the patient developed new
subocclusive symptoms?
No Yes
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15. Has the patient developed new
subocclusive symptoms?
No Yes
Offer surgical resection
(nodule or segmental resection)
We discuss the risks and benefits of
further medical therapy compared with
surgical treatment, and pursue the
treatment approach desired by the
patient
Continued medical therapy, which may
include:
-Alternate form of hormonal therapy
-Stool softeners to ease constipation
-Dietary modifications to address bloating
-Consultation with GI specialist
Medical management Surgical treatment
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16. Management
 Medical treatment
1) Estrogens and progestins
2) Progestin-only hormonal treatment
3) Gonadotropin-releasing hormone agonists
4) Danazol
5) Aromatase inhibitors
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Medical treatment for rectovaginal endometriosis: what is the evidence?
Vercellini P, Crosignani PG, Somigliana E, Berlanda N, Barbara G, Fedele L
Hum Reprod. 2009;24(10):2504. Epub 2009 Jul 2.

17.  Surgical treatment
Surgical treatment of rectovaginal or bowel
endometriosis is guided by the location, size, and
depth of infiltration of the endometriotic lesions.
When surgery for the removal of bowel disease is
chosen, we remove all sites of endometriosis
found throughout the pelvis. A multi-disciplinary
surgical approach is typically required as these
patients can have deep endometriosis lesions of
the rectosigmoid colon, bowel, bladder, and
ureters.
18
Bowel endometriosis: Colorectal surgeon’s perspective in a multidisciplinary surgical team
World J Gastroenterol. 2014 Nov 14; 20(42): 15616–15623.
Published online 2014 Nov 14. doi: 10.3748/wjg.v20.i42.15616

18. Management
 Surgical treatment
1) Shaving or superficial excision:
This may be performed only for lesions that do not
invade beyond the serosa (Diameter<1cm).
19
Complications, pregnancy and recurrence in a prospective series of 500 patients operated on by
the shaving technique for deep rectovaginal endometriotic nodules.
Donnez J, Squifflet J
Hum Reprod. 2010;25(8):1949. Epub 2010 Jun 13.

19. Management
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2) Discoid full thickness bowel excision and
repair:
The lesion and full thickness of the surrounding bowel
wall are excised (Lesions <3cm, ectopic lesions with
full-thickness infiltration of the intestinal wall but less
than 1/3 of the circumference of the intestinal tract).

20. Management
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3) Segmental bowel resection and anastomosis:
The lesion and bowel segment are resected, followed
by bowel anastomosis.
Indications for bowel resection include stenosis,
multifocal lesions, sigmoid involvement, and lesions >3
cm or involving more than 50 percent of the bowel wall
circumference.
Quality of life after segmental resection of the rectosigmoid by laparoscopy in patients with deep infiltrating
endometriosis with bowel involvement.
Bassi MA, Podgaec S, Dias JA Jr, D'Amico Filho N, Petta CA, Abrao MS
J Minim Invasive Gynecol. 2011 Nov-Dec;18(6):730-3.

21. Management
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 There are limited data to guide the choice of
resection technique and the comparative studies
are not randomly assigned trials. When choosing
a surgical approach, issues to consider include
efficacy of pain relief, risk of repeat surgery, and
risk of complication.
Surgical treatment of deeply infiltrating endometriosis with colorectal involvement.
Meuleman C, Tomassetti C, D'Hoore A, Van Cleynenbreugel B, Penninckx F, Vergote I, D'Hooghe T
Hum Reprod Update. 2011;17(3):311. Epub 2011 Jan 13.

22. Management
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 Outcome
1) Pain symptoms:
Surgical treatment results in improvement of pain
symptoms, based upon consistent results from
retrospective case series. Overall, for all sites of
rectovaginal or bowel endometriosis, substantial
postoperative short-term pain relief is reported by
approximately 70 to 90 percent of the patients.
However, at one-year follow-up, approximately 50
percent of the women needed analgesics or hormonal
treatments.
Reproductive performance in infertile women with rectovaginal endometriosis: is surgery worthwhile?
Vercellini P, Pietropaolo G, De Giorgi O, Daguati R, Pasin R, Crosignani PG
Am J Obstet Gynecol. 2006;195(5):1303.

23. Management
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2) Long-term bowel dysfunction:
Surgery is offered to treat symptoms of rectovaginal or
bowel endometriosis, including diarrhea, constipation,
rectal bleeding, proctitis, tenesmus, and pain. However,
surgery to remove bowel endometriosis may
incompletely treat or may worsen bowel symptoms.
Symptoms before and after surgical removal of colorectal endometriosis that are assessed by
magnetic resonance imaging and rectal endoscopic sonography.
Thomassin I, Bazot M, Detchev R, Barranger E, Cortez A, Darai E
Am J Obstet Gynecol. 2004;190(5):1264.

24. Management
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3) Infertility:
Surgical treatment of rectovaginal endometriosis does
not appear to improve fertility based on studies of
conception rates.
Bowel surgery as a fertility-enhancing procedure in patients with colorectal
endometriosis: methodological, pathogenic and ethical issues.
Vercellini P, ViganòP, Frattaruolo MP, Borghi A, Somigliana E
Hum Reprod. 2018;33(7):1205.

25. Management
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4) Need for repeat surgery:
After initial surgical resection of rectovaginal or bowel
endometriosis, approximately 20 percent of women
will require additional conservative or definitive surgery
because of pain relapse. Risk factors for repeat
surgery include younger age, elevated body mass
index, and positive margins for endometriosis at the
time of initial bowel resection.
Laparoscopic treatment of deep endometriosis with segmental colorectal resection: short-term morbidity.
Mereu L, Ruffo G, Landi S, Barbieri F, Zaccoletti R, Fiaccavento A, Stepniewska A, Pontrelli G, Minelli L
J Minim Invasive Gynecol. 2007;14(4):463.
Laparoscopic management of bowel endometriosis: resection margins as a predictor of recurrence.
Nirgianakis K, McKinnon B, Imboden S, Knabben L, Gloor B, Mueller MD
Acta Obstet Gynecol Scand. 2014 Dec;93(12):1262-7. Epub 2014 Sep 17.

26. Summary
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 Deep infiltrating endometriosis (DIE): Endometriotic
lesion situated more than 5 mm below the peritoneum.
 Imaging can identify findings highly suggestive of
endometriosis and map the location and extent of
disease, which is extremely important for surgical
planning.
 Surgical treatment of rectovaginal or bowel endometriosis
is guided by the location, size, and depth of infiltration of
the endometriotic lesions. A multi-disciplinary surgical
approach is typically required.

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