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					LAPAROSCOPIC TREATMENT
OF STAGE IV ENDOMETRIOSIS

‘’Intestinal complications’’
          Korhan Taviloglu, MD
          Department of Surgery
      Florence Nightingale Hospital,
             Istanbul, Turkey
           www.taviloglu.com



                                       1
Lobo RA. Endometriosis. In Comprehensive gynecology,
                                                       2
    Katz ed. 5th ed, p 473-499, 2007, Mosby, USA.
        Endometriosis




Lobo RA. Endometriosis. In Comprehensive gynecology,
                                                       3
    Katz ed. 5th ed, p 473-499, 2007, Mosby, USA.
Endometriosis epithelium




Lobo RA. Endometriosis. In Comprehensive gynecology,
                                                       4
    Katz ed. 5th ed, p 473-499, 2007, Mosby, USA.
       Endometriosis: A disease
         of clinical contrasts
Characteristics                   Contrasts
Benign disease                    Locally invasive
                                  Widespread disseminated foci
                                  Proliferates in plevic lymp nodes
Minimal disease                   Severe pain
Many large endometriomas          Asymptomatic patient
Cyclic hormones cause growth      Continous hormones reverse the
                                  growth pattern




        Lobo RA. Endometriosis. In Comprehensive gynecology,
                                                                      5
            Katz ed. 5th ed, p 473-499, 2007, Mosby, USA.
       Endometriosis etiology
•  Retrograde Menstruation
   and Implantation Theory
   (Sampson’s Theory)
•  Coelomic Metaplasia
   (Meyer’s Theory) and the
   Induction Theory
•  Vascular and Lymphatic
   Metastasis (Halban’s
   Theory)

                Kocakoc E, et al, Ultrasound Clin 2008.
             Tepleman C, Obstet Gynecol Clin N Am, 2009.
                                                           6
                   Lobo RA. Endometriosis, 2007,
  Endometriosis incidence
•  Affects about 4-17% of women of reproductive
   age, highest rate in Japan.
•  The mean age at diagnosis is 25 to 29 years.
•  It is an important cause of infertility (30-50 %)
   and pelvic pain.
•  20% of women undergoing laparoscopic
   evaluation for infertility and 25% of women who
   have pelvic pain have endometriosis.
•  50-80% of patients are symptomatic; such as
   dysmenorrhea, dyspareunia, and infertility.

Kocakoc E, et al. Endometriosis. Ultrasound Clin 2008.
Tepleman C. Adolescent endometriosis. Obstet Gynecol Clin N Am, 2009.
                                                                        7
 Endometriosis localizations
      Intraperitoneal
•  Ovaries: 30%
•  Uterosacral and large
   ligaments: 18%-24%
•  Fallopian tubes: 20%
•  Pelvic peritoneum
•  Pouch of Douglas
•  Gastrointestinal (GI) tract

     Kocakoc E, et al. Endometriosis. Ultrasound Clin 2008.
     Tepleman C. Adolescent endometriosis. Obstet Gynecol Clin N Am, 2009.
     De Ceglie A. World J Gastroenterol 2008                                 8
     Endometriosis localizations
          Extraperitoneal
•  Cervical portio: 0.5%
•  Vagina
•  Rectovaginal septum
•  Round ligament
•  Inguinal hernia sac: 0.3%-0.6%
•  Umbilicus (1%)
•  Abdominal scars after
   gynaecological surgery: 1.5%
•  Lungs
•  Nasal
•  Arms      Kocakoc E, et al. Endometriosis. Ultrasound Clin 2008.
                   Tepleman C. Adolescent endometriosis. Obstet Gynecol Clin N Am, 2009.
                   De Ceglie A. World J Gastroenterol 2008                                 9
Endometriosis intestinal
     involvement
Endometriosis involves the intestine in
4-35 % of patients.




   Indraccolo U. Cecal endometriosis. JSLS 2010
                                                  10
Locations of bowel endometriosis




   31 %
                                           68 %



    Lobo RA. Endometriosis. In Comprehensive gynecology,   11
        Katz ed. 5th ed, p 473-499, 2007, Mosby, USA.
     Bowel endometriosis
       characteristics
•  Multiple and vary in size.
•  Generally serosal, sometimes intramural, and only
   rarely mucosal.
•  Often on the antimesenteric surface of the bowel,
   or as a nodular constricting lesion extending into
   the wall or encircling it .
•  Further inspection may reveal rusty brown or
   purplish specks.
•  Thickening of the colonic wall.
•  May enlarge to present as a mass; endometrioma.

 Gordon PH. Endometriosis. In: Principles and Practice of Surgery for the
 Colon, Rectum, and Anus. Eds: Gordon PH, Nivatvongs S, Informa, 2007.      12
      Bowel endometriosis
        characteristics
•  In 1,616 operations for endometriosis, only 1 %
   involved bowel resections.
•  Endometriosis may mimic malignancy.
•  Gastrointestinal involvement commonly affects those
   segments of bowel close to genital organs.
•  In most instances there is only serosal involvement.
•  If intestinal symptoms are present, endometriosis is
   extensive, and resection is almost always required.
•  The diagnosis of small intestinal endometriosis is
   rarely made prior to operation. A history of colicky
   abdominal pain might be suggestive.
           Bailey HR.. Perspect Colon Rectal Surg 1992.   13
      Endometriosis bowel
          symptoms
     •    Intermittent abdominal crampy pain
     •    Rectal or pelvic pain
     •    Cyclical rectal bleeding
     •    Tenesmus
     •    Constipation (especially with menses)
     •    Decreased stool caliber
     •    Bloating
     •    Nausea
     •    Vomiting
     •    Diarrhea
Gordon PH. Endometriosis. In: Principles and Practice of Surgery for the
Colon, Rectum, and Anus. Eds: Gordon PH, Nivatvongs S, Informa, 2007.      14
Endometriosis gynecologic
      symptoms
      •  Dysmenorrhea
      •  Cyclic lower abdominal &
         pelvic pain
      •  Dyspareunia
      •  Menometrorrhagia
      •  Infertility

Gordon PH. Endometriosis. In: Principles and Practice of Surgery for the
Colon, Rectum, and Anus. Eds: Gordon PH, Nivatvongs S, Informa, 2007.      15
Intestinal perforation
 from endometriosis




      Pisanu A, et al. World J Gastroenterol 2010.   16
   Endometriosis diagnosis
No radiologic tests are diagnostic of endometriosis.
•  Barium enema: narrowed luminal caliber, intramural,
   intraluminal polypoid filling defect.
•  Endoscopy: stenotic lumen with normal mucosa, a
   mass or polypoid lesion may be visualized.
•  IVP: 15 % ureteral involvement
•  Ultrasound (US)
•  ERUS
•  Computed tomography (CT)
•  Magnetic resonance imaging (MRI)
•  Laparoscopy: direct visualization & biopsy

   Gordon PH. Endometriosis. In: Principles and Practice of Surgery for the
   Colon, Rectum, and Anus. Eds: Gordon PH, Nivatvongs S, Informa, 2007.      17
Endometriosis diagnosis

Utrasound                                     MRI




  Kocakoc E, et al. Endometriosis. Ultrasound Clin 2008.
                                                           18
                Barium enema




Anaf V, et al. Anatomic Significance of a Positive Barium Enema in
Deep Infiltrating Endometriosis of the Large Bowel. World J Surg, 2009   19
              Barium enema




Anaf V, et al. Anatomic Significance of a Positive Barium Enema in
Deep Infiltrating Endometriosis of the Large BowelWorld J Surg, 2009   20
         Laparoscopy




Lobo RA. Endometriosis. In Comprehensive gynecology,
                                                       21
    Katz ed. 5th ed, p 473-499, 2007, Mosby, USA.
  Endometriosis treatment
1.  Danazol: antiestrogen & androgenic agent
2.  Gonadotropin-releasing hormone
    antagonists: Leuprolide (Lupron) and Nafarelin
    (Synarel)
3.  Resection: for patients with obstructive
    symptoms
•  Rules out malignancy
•  Prevents later development of endometrial
   carcinoma.
•  Total abdominal hysterectomy and bilateral
   salpingo-oophorectomy is the only option to
   prevent recurrence.
       Lobo RA. Endometriosis. In Comprehensive gynecology,
                                                              22
           Katz ed. 5th ed, p 473-499, 2007, Mosby, USA.
Colonic endometriosis treatment
 •  Local excision of a colonic endometrioma
    may be an effective treatment.
 •  Coronado et al. presented 77 consecutive
    patients with deep colorectal endometriosis
    treated with a full thickness resection.
 •  A low anterior resection was performed in
    68 patients (88.3%); a disc excision of the
    anterior rectal wall in five (6.5%); sigmoid
    resection in three (3.9%), and partial cecal
    resection in one (1.3%).

           Coronado C, et al. Fertil Steril 1990.   23
Colonic endometriosis treatment
   result of pelvic symptoms

     •  Complete relief: 49%
     •  Improvement: 39%
     •  No improvement: 11%
     •  Worsening: 1%.



        Coronado C, et al. Fertil Steril 1990.   24
THANK YOU!!
      Korhan Taviloglu, MD
      Department of Surgery
  Florence Nightingale Hospital,
         Istanbul, Turkey
       www.taviloglu.com




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posted:11/26/2011
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