ENDOMETRIOSIS       and the Colorectal Surgeon                           I J AdamConsultant Colorectal Surgeon, Northern G...
ENDOMETRIOSISA superficial peritoneal disease                                   caroline-overton.co.uk                    ...
ENDOMETRIOSISA nodular peritoneal disease                                 gynaesafe.com/endometriosis                     ...
A COLORECTAL SURGEON!Location of infiltrating endometriosis                                    Cullen TS (1920). Arch Surg...
ENDOMETRIOSIS         gynaesafe.com/endometriosis         colorectalsurgeonssydney.com.au/wp-content
A GYNAECOLOGISTS DISEASE …..
…. THAT NEEDS A COLORECTAL SURGEON
OPTIMAL RECTOVAGINAL ENDOMETRIOSIS                SURGERY?Dr D RedwineBend, Oregon                              Fertil Ste...
OPTIMAL RECTOVAGINAL ENDOMETRIOSIS             SURGERY?Dr D RedwineSt. Charles Medical Centre, Bend, Oregon11 years1149 pa...
RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL              SURGERY
RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL              SURGERY                   J Am Assoc Gynecol Laparosc 2003; 10:182–89
RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL                SURGERYIncise normal peritoneum lateral and parallel to  uterosacral ...
RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL               SURGERYDissect between endometriotic mass and vagina                  ...
RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL               SURGERYDissect between endometriotic mass and vagina                  ...
RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL               SURGERYDissect between endometriotic mass and vagina                  ...
RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL               SURGERYDissect between endometriotic mass and vaginaProceed down RV se...
RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL               SURGERYFinally remove endometriosis nodule from anterior rectum       ...
RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL                SURGERYDepth of invasion in rectovaginal endometriosis   - 1/10 throu...
RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL               SURGERYFinally remove endometriosis nodule from anterior rectum       ...
RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL               SURGERYFinally remove endometriosis nodule from anterior rectum       ...
RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL               SURGERYFinally remove endometriosis nodule from anterior rectum       ...
RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL               SURGERYFinally remove endometriosis nodule from anterior rectum    St....
RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL              SURGERY St. Charles Medical Centre, Oregon n = 67                      ...
A NZ J Surg 2007; 77: 562-71
PREDICTING WHEN A COLORECTAL SURGEON              IS NEEDED
PREDICTING WHEN A COLORECTAL SURGEON                IS NEEDEDDigital assessment                                    epubbed...
PREDICTING RECTAL INVOLVEMENTDigital assessmentRectal involvement low sensitivity                   moderate specificity  ...
PREDICTING RECTAL INVOLVEMENTLaparoscopy                               radiographics.rsna.org/content
PREDICTING RECTAL INVOLVEMENTLaparoscopy                          danmartinmd.com/_images/RV_Endometriosis
PREDICTING RECTAL INVOLVEMENTLaparoscopy                          danmartinmd.com/_images/RV_Endometriosis
PREDICTING RECTAL INVOLVEMENTLaparoscopyRedwine series100 consecutive obliteration POD27% did not have rectal or vaginal e...
PREDICTING RECTAL INVOLVEMENTColonoscopyEndoanal ultrasoundTransvaginal ultrasoundMRIBarium enema
PREDICTING RECTAL INVOLVEMENTColonoscopyPoor                        Human Reproduction 2003: 18; 1323-1327                ...
PREDICTING RECTAL INVOLVEMENTTransrectal ultrasound90% sensitivity for rectovaginal nodules                               ...
PREDICTING RECTAL INVOLVEMENTTransvaginal ultrasoundSimilar effectiveness to TRUSS                                 Human R...
PREDICTING RECTAL INVOLVEMENTMRI                                  radiographics.rsna.org
PREDICTING RECTAL INVOLVEMENTMRI72-90% positive predictive value for surgical findings                                    ...
Digital exam vs. TV USS vs. TRUSS vs. MRIBazot et al, Hôpital Tenon, ParisN = 92 suspected pelvic endometriosis           ...
PREDICTING RECTAL INVOLVEMENTBarium enemaRoad map                           J Am Assoc Gynecol Laparosc 2002; 9: 115-9
DCBELandi et al, Verona108 pts suspected LB endometriosis55 – DCBE      28/28 adhesions, no endometriosis53 + DCBE      38...
MRI vs. DCBEFaccioli et al, University of Verona83 pts suspected to have large bowel endometriosis65 had surgery50 confirm...
HOW OFTEN DO YOU NEED A COLORECTAL             SURGEON?
HOW OFTEN DO YOU NEED A COLORECTAL                SURGEON?Redwine series11 years1149 patients presenting with endometriosi...
HOW OFTEN DO YOU NEED A COLORECTAL                SURGEON?Melbourne series11 years213 operations rectal endometriosis     ...
HOW OFTEN DO YOU NEED A COLORECTAL                SURGEON?Melbourne series11 years213 operations     Rectal endometriosis9...
HOW OFTEN DO YOU NEED A COLORECTAL                SURGEON?Melbourne series (Rodney Woods)11 years213 operations   Rectal e...
AN EXTENDED ROLE FOR THE        COLORECTAL SURGEON?Mr R WoodsMelbourne                            A NZ J Surg 2007; 77: 56...
AN EXTENDED ROLE FOR THE          COLORECTAL SURGEON?Mr R WoodsSt. Vincent’s Hospital, Melbourne11 years213 operations rec...
AN EXTENDED ROLE FOR THE COLORECTAL                SURGEON?Evolution over last 10 yearsRectal shaveWedge excisionSegmental...
AN EXTENDED ROLE FOR THE COLORECTAL                SURGEON?What are they doing in Melbourne?         En bloc excision     ...
HISTOLOGICAL STUDIESRemorgida et al, Genoa16 pts undergoing surgery for LB endometriosisNodulectomy then resectionHistolog...
HISTOLOGICAL STUDIESRemorgida et al, Genoa16 pts undergoing surgery for LB endometriosisEndometriosis outside the nodule i...
AN EXTENDED ROLE FOR THE COLORECTAL                SURGEON?Evolution over last 10 yearsRectal shaveWedge excisionSegmental...
AN EXTENDED ROLE FOR THE COLORECTAL                SURGEON?Evolution over last 10 yearsRectal shaveWedge excisionSegmental...
ARE WE OVER TREATING?Mr R WoodsSt. Vincent’s Hospital, Melbourne11 years213 operations rectal endometriosis18 shave58 disc...
ARE WE OVER TREATING?Melbourneseries                               A NZ J Surg 2007; 77: 562-71
DIFFERENTIAL OUTCOMES?Roman et al, Rouen University Hospital41 pts had surgery for LB endometriosis12-53 month follow-up  ...
DIFFERENTIAL OUTCOMES?Roman et al, Rouen University Hospital41 pts had surgery for LB endometriosis12-53 month follow-up  ...
CONCLUSION
CONCLUSIONEvidence base supports   excisional surgery    for rectovaginal  endometriosis withlaparoscopic technique   Unce...
CONCLUSION    “stage 4 endometriosis     involving the bowel, retroperitoneal fibrosis and the rectovaginal septum are   a...
Questions?
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2013 dukes endometriosis

  1. 1. ENDOMETRIOSIS and the Colorectal Surgeon I J AdamConsultant Colorectal Surgeon, Northern General Hospital, Sheffield Dukes Club Annual Meeting, Chesford Grange Hotel, Kenilworth 9 March 2013
  2. 2. ENDOMETRIOSISA superficial peritoneal disease caroline-overton.co.uk gynaesafe.com/endometriosis
  3. 3. ENDOMETRIOSISA nodular peritoneal disease gynaesafe.com/endometriosis Human Reproduction 2004; 19: 760-68
  4. 4. A COLORECTAL SURGEON!Location of infiltrating endometriosis Cullen TS (1920). Arch Surg 1,215±283.
  5. 5. ENDOMETRIOSIS gynaesafe.com/endometriosis colorectalsurgeonssydney.com.au/wp-content
  6. 6. A GYNAECOLOGISTS DISEASE …..
  7. 7. …. THAT NEEDS A COLORECTAL SURGEON
  8. 8. OPTIMAL RECTOVAGINAL ENDOMETRIOSIS SURGERY?Dr D RedwineBend, Oregon Fertil Steril 2001; 76: 358-65
  9. 9. OPTIMAL RECTOVAGINAL ENDOMETRIOSIS SURGERY?Dr D RedwineSt. Charles Medical Centre, Bend, Oregon11 years1149 patients presenting with endometriosis100 patients with complete obliteration of rectovaginal septum84 required excisional surgery Fertil Steril 2001; 76: 358-65
  10. 10. RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL SURGERY
  11. 11. RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL SURGERY J Am Assoc Gynecol Laparosc 2003; 10:182–89
  12. 12. RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL SURGERYIncise normal peritoneum lateral and parallel to uterosacral ligamentsUndermine the uterosacralsTransverse incision across posterior cervix Fertil Steril 2001; 76: 358-65 J Am Assoc Gynecol Laparosc 2003; 10:182–89
  13. 13. RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL SURGERYDissect between endometriotic mass and vagina Fertil Steril 2001; 76: 358-65 J Am Assoc Gynecol Laparosc 2003; 10:182–89
  14. 14. RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL SURGERYDissect between endometriotic mass and vagina Fertil Steril 2001; 76: 358-65 J Am Assoc Gynecol Laparosc 2003; 10:182–89
  15. 15. RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL SURGERYDissect between endometriotic mass and vagina Fertil Steril 2001; 76: 358-65 J Am Assoc Gynecol Laparosc 2003; 10:182–89
  16. 16. RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL SURGERYDissect between endometriotic mass and vaginaProceed down RV septum to clear tissueLeaves endometriosis nodule on rectum Fertil Steril 2001; 76: 358-65 J Am Assoc Gynecol Laparosc 2003; 10:182–89
  17. 17. RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL SURGERYFinally remove endometriosis nodule from anterior rectum Fertil Steril 2001; 76: 358-65 J Am Assoc Gynecol Laparosc 2003; 10:182–89
  18. 18. RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL SURGERYDepth of invasion in rectovaginal endometriosis - 1/10 through mucosa - 1/3 through muscle Human Reprod 2005; 20: 2317-20
  19. 19. RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL SURGERYFinally remove endometriosis nodule from anterior rectum Human Reprod. 2010;25:1949-1958
  20. 20. RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL SURGERYFinally remove endometriosis nodule from anterior rectum ANZ J Surg 2003; 73: 647-8
  21. 21. RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL SURGERYFinally remove endometriosis nodule from anterior rectum Human Reproduction 2003: 18; 1323-1327 Fertil Steril 2001; 76: 358-65
  22. 22. RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL SURGERYFinally remove endometriosis nodule from anterior rectum St. Charles Medical Centre, Oregon n = 84 Superficial shave 20% Partial thickness shave 13% Disc excision (nodulectomy) 31% Anterior resection 8% Fertil Steril 2001; 76: 358-65
  23. 23. RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL SURGERY St. Charles Medical Centre, Oregon n = 67 Percentage improved Nonmenstrual pelvic pain 78% Menstrual pelvic pain 68% Dyspareunia 66% Tenderness on examination 59% Fertil Steril 2001; 76: 358-65
  24. 24. A NZ J Surg 2007; 77: 562-71
  25. 25. PREDICTING WHEN A COLORECTAL SURGEON IS NEEDED
  26. 26. PREDICTING WHEN A COLORECTAL SURGEON IS NEEDEDDigital assessment epubbed.com
  27. 27. PREDICTING RECTAL INVOLVEMENTDigital assessmentRectal involvement low sensitivity moderate specificity J Am Assoc Gynecol Laparosc 2002; 9: 115-9
  28. 28. PREDICTING RECTAL INVOLVEMENTLaparoscopy radiographics.rsna.org/content
  29. 29. PREDICTING RECTAL INVOLVEMENTLaparoscopy danmartinmd.com/_images/RV_Endometriosis
  30. 30. PREDICTING RECTAL INVOLVEMENTLaparoscopy danmartinmd.com/_images/RV_Endometriosis
  31. 31. PREDICTING RECTAL INVOLVEMENTLaparoscopyRedwine series100 consecutive obliteration POD27% did not have rectal or vaginal endometriosis Fertil Steril 2001; 76: 358-65
  32. 32. PREDICTING RECTAL INVOLVEMENTColonoscopyEndoanal ultrasoundTransvaginal ultrasoundMRIBarium enema
  33. 33. PREDICTING RECTAL INVOLVEMENTColonoscopyPoor Human Reproduction 2003: 18; 1323-1327 A NZ J Surg 2007; 77: 562-71
  34. 34. PREDICTING RECTAL INVOLVEMENTTransrectal ultrasound90% sensitivity for rectovaginal nodules Endoscopy 2005; 7: 357-61 Hum Reprod 2003; 18: 1686-92
  35. 35. PREDICTING RECTAL INVOLVEMENTTransvaginal ultrasoundSimilar effectiveness to TRUSS Human Reprod 2005; 18: 1686-92
  36. 36. PREDICTING RECTAL INVOLVEMENTMRI radiographics.rsna.org
  37. 37. PREDICTING RECTAL INVOLVEMENTMRI72-90% positive predictive value for surgical findings Radiology 2004; 232: 379-89 Fertil Steril 2005; 83: 442-7
  38. 38. Digital exam vs. TV USS vs. TRUSS vs. MRIBazot et al, Hôpital Tenon, ParisN = 92 suspected pelvic endometriosis Digital exam TV USS TRUSS MRISensitivity 46% 94% 89% 87%LR (+) 1.69 - 12.89 12.66LR (-) 0.75 0.06 0.12 0.14LR (+) = likelihood ratio of positive test being positiveLR (+) = likelihood ratio of positive test being positive Fertil Steril. 2009 Dec;92(6):1825-33
  39. 39. PREDICTING RECTAL INVOLVEMENTBarium enemaRoad map J Am Assoc Gynecol Laparosc 2002; 9: 115-9
  40. 40. DCBELandi et al, Verona108 pts suspected LB endometriosis55 – DCBE 28/28 adhesions, no endometriosis53 + DCBE 38/39 endometriosis, 1 adhesions DCBE Sensitivity 85% Kappa 0.97 Specificity 50% X2 p<0.00001 PPV 96% NPV 20% J Am Assoc Gynecol Laparosc 2004; 11: 223-28
  41. 41. MRI vs. DCBEFaccioli et al, University of Verona83 pts suspected to have large bowel endometriosis65 had surgery50 confirmed endometriosis MRI DCBE Sensitivity 71% 85% Specificity 83% 94% PPV 93% 63% NPV 75% 87% Abdominal Imaging 2009 EPub
  42. 42. HOW OFTEN DO YOU NEED A COLORECTAL SURGEON?
  43. 43. HOW OFTEN DO YOU NEED A COLORECTAL SURGEON?Redwine series11 years1149 patients presenting with endometriosis100 patients with complete obliteration of rectovaginal septum84 had excisional surgery Fertil Steril 2001; 76: 358-65
  44. 44. HOW OFTEN DO YOU NEED A COLORECTAL SURGEON?Melbourne series11 years213 operations rectal endometriosis A NZ J Surg 2007; 77: 562-71
  45. 45. HOW OFTEN DO YOU NEED A COLORECTAL SURGEON?Melbourne series11 years213 operations Rectal endometriosis91 operations Separation/protection of rectum from gynae organs A NZ J Surg 2007; 77: 562-71
  46. 46. HOW OFTEN DO YOU NEED A COLORECTAL SURGEON?Melbourne series (Rodney Woods)11 years213 operations Rectal endometriosis91 operations Separation/protection of rectum from gynae organs252 operations “others” A NZ J Surg 2007; 77: 562-71
  47. 47. AN EXTENDED ROLE FOR THE COLORECTAL SURGEON?Mr R WoodsMelbourne A NZ J Surg 2007; 77: 562-71
  48. 48. AN EXTENDED ROLE FOR THE COLORECTAL SURGEON?Mr R WoodsSt. Vincent’s Hospital, Melbourne11 years213 operations rectal endometriosis18 shave58 disc excision137 segmental resection A NZ J Surg 2007; 77: 562-71
  49. 49. AN EXTENDED ROLE FOR THE COLORECTAL SURGEON?Evolution over last 10 yearsRectal shaveWedge excisionSegmental resection A NZ J Surg 2007; 77: 562-71
  50. 50. AN EXTENDED ROLE FOR THE COLORECTAL SURGEON?What are they doing in Melbourne? En bloc excision A NZ J Surg 2007; 77: 562-71 Human Reproduction 2003: 18; 1323-1327
  51. 51. HISTOLOGICAL STUDIESRemorgida et al, Genoa16 pts undergoing surgery for LB endometriosisNodulectomy then resectionHistological evaluation Human Reprod 2005; 20: 2317-20
  52. 52. HISTOLOGICAL STUDIESRemorgida et al, Genoa16 pts undergoing surgery for LB endometriosisEndometriosis outside the nodule in 7 cases (44%) Human Reprod 2005; 20: 2317-20
  53. 53. AN EXTENDED ROLE FOR THE COLORECTAL SURGEON?Evolution over last 10 yearsRectal shaveWedge excisionSegmental resection A NZ J Surg 2007; 77: 562-71 Human Reproduction 2003: 18; 1323-1327
  54. 54. AN EXTENDED ROLE FOR THE COLORECTAL SURGEON?Evolution over last 10 yearsRectal shaveWedge excisionSegmental resectionIs this overtreatment? A NZ J Surg 2007; 77: 562-71 Human Reproduction 2003: 18; 1323-1327
  55. 55. ARE WE OVER TREATING?Mr R WoodsSt. Vincent’s Hospital, Melbourne11 years213 operations rectal endometriosis18 shave58 disc excision137 segmental resection5% stoma rate A NZ J Surg 2007; 77: 562-71 Human Reproduction 2003: 18; 1323-1327
  56. 56. ARE WE OVER TREATING?Melbourneseries A NZ J Surg 2007; 77: 562-71
  57. 57. DIFFERENTIAL OUTCOMES?Roman et al, Rouen University Hospital41 pts had surgery for LB endometriosis12-53 month follow-up Nodulectomy Resection Number 16 25 Human Reprod 2010; Jan: dep407ul
  58. 58. DIFFERENTIAL OUTCOMES?Roman et al, Rouen University Hospital41 pts had surgery for LB endometriosis12-53 month follow-up Nodulectomy Resection Number 16 25 % dysmenorrhea 35% 20% % non-cyclical pain 31% 19% % dyspareunia 38% 57% BO>3x/day 19% 52% Human Reprod 2010; Jan: dep407ul
  59. 59. CONCLUSION
  60. 60. CONCLUSIONEvidence base supports excisional surgery for rectovaginal endometriosis withlaparoscopic technique Uncertain whethernodulectomy or anterior resection preferable
  61. 61. CONCLUSION “stage 4 endometriosis involving the bowel, retroperitoneal fibrosis and the rectovaginal septum are among some of the mostchallenging conditions facing the pelvic surgeon” Surgery of the Anus, Rectum & Colon. 2nd ed, W B Saunders. 1999
  62. 62. Questions?

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