ENDOMETRIOSISand the Colorectal Surgeon

I J AdamConsultant Colorectal Surgeon, Northern General Hospital, Sheffield

Dukes Club Annual Meeting, Chesford Grange Hotel, Kenilworth9 March 2013

ENDOMETRIOSIS

A superficial peritoneal disease

caroline-overton.co.ukgynaesafe.com/endometriosis

ENDOMETRIOSIS

A nodular peritoneal disease

gynaesafe.com/endometriosisHuman Reproduction 2004; 19: 760-68

A COLORECTAL SURGEON!

Location of infiltrating endometriosis

Cullen TS (1920). Arch Surg 1,215±283.

ENDOMETRIOSIS

gynaesafe.com/endometriosiscolorectalsurgeonssydney.com.au/wp-content

A GYNAECOLOGISTS DISEASE …..

…. THAT NEEDS A COLORECTAL SURGEON

OPTIMAL RECTOVAGINAL ENDOMETRIOSIS SURGERY?

Dr D RedwineBend, Oregon

Fertil Steril 2001; 76: 358-65

OPTIMAL RECTOVAGINAL ENDOMETRIOSIS SURGERY?

Dr D RedwineSt. Charles Medical Centre, Bend, Oregon11 years

1149 patients presenting with endometriosis100 patients with complete obliteration of rectovaginal septum 84 required excisional surgery

Fertil Steril 2001; 76: 358-65

RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL SURGERY

RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL SURGERY

J Am Assoc Gynecol Laparosc 2003; 10:182–89

RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL SURGERY

Incise normal peritoneum lateral and parallel to uterosacral ligamentsUndermine the uterosacralsTransverse incision across posterior cervix

Fertil Steril 2001; 76: 358-65J Am Assoc Gynecol Laparosc 2003; 10:182–89

RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL SURGERY

Dissect between endometriotic mass and vagina

Fertil Steril 2001; 76: 358-65J Am Assoc Gynecol Laparosc 2003; 10:182–89

RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL SURGERY

Dissect between endometriotic mass and vagina

Fertil Steril 2001; 76: 358-65J Am Assoc Gynecol Laparosc 2003; 10:182–89

RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL SURGERY

Dissect between endometriotic mass and vagina

Fertil Steril 2001; 76: 358-65J Am Assoc Gynecol Laparosc 2003; 10:182–89

RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL SURGERY

Dissect between endometriotic mass and vaginaProceed down RV septum to clear tissueLeaves endometriosis nodule on rectum

Fertil Steril 2001; 76: 358-65J Am Assoc Gynecol Laparosc 2003; 10:182–89

RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL SURGERY

Finally remove endometriosis nodule from anterior rectum

Fertil Steril 2001; 76: 358-65J Am Assoc Gynecol Laparosc 2003; 10:182–89

RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL SURGERY

Depth of invasion in rectovaginal endometriosis- 1/10 through mucosa- 1/3 through muscle

Human Reprod 2005; 20: 2317-20

RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL SURGERY

Finally remove endometriosis nodule from anterior rectum

Human Reprod. 2010;25:1949-1958

RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL SURGERY

Finally remove endometriosis nodule from anterior rectum

ANZ J Surg 2003; 73: 647-8

RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL SURGERY

Finally remove endometriosis nodule from anterior rectum

Human Reproduction 2003: 18; 1323-1327Fertil Steril 2001; 76: 358-65

RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL SURGERY

Finally remove endometriosis nodule from anterior rectum

Fertil Steril 2001; 76: 358-65

St. Charles Medical Centre, Oregonn = 84

Superficial shave 20%Partial thickness shave 13%Disc excision (nodulectomy) 31%Anterior resection 8%

RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL SURGERY

Fertil Steril 2001; 76: 358-65

St. Charles Medical Centre, Oregonn = 67

Percentage improved

Nonmenstrual pelvic pain 78%Menstrual pelvic pain 68%Dyspareunia 66%Tenderness on examination 59%

A NZ J Surg 2007; 77: 562-71

PREDICTING WHEN A COLORECTAL SURGEON IS NEEDED

PREDICTING WHEN A COLORECTAL SURGEON IS NEEDED

Digital assessment

epubbed.com

PREDICTING RECTAL INVOLVEMENT

Digital assessment

Rectal involvement low sensitivitymoderate specificity

J Am Assoc Gynecol Laparosc 2002; 9: 115-9

PREDICTING RECTAL INVOLVEMENT

Laparoscopy

radiographics.rsna.org/content

PREDICTING RECTAL INVOLVEMENT

Laparoscopy

danmartinmd.com/_images/RV_Endometriosis

PREDICTING RECTAL INVOLVEMENT

Laparoscopy

danmartinmd.com/_images/RV_Endometriosis

PREDICTING RECTAL INVOLVEMENT

Laparoscopy

Redwine series100 consecutive obliteration POD27% did not have rectal or vaginal endometriosis

Fertil Steril 2001; 76: 358-65

PREDICTING RECTAL INVOLVEMENT

ColonoscopyEndoanal ultrasoundTransvaginal ultrasoundMRI Barium enema

PREDICTING RECTAL INVOLVEMENT

Colonoscopy

Poor

Human Reproduction 2003: 18; 1323-1327A NZ J Surg 2007; 77: 562-71

PREDICTING RECTAL INVOLVEMENT

Transrectal ultrasound90% sensitivity for rectovaginal nodules

Endoscopy 2005; 7: 357-61Hum Reprod 2003; 18: 1686-92

PREDICTING RECTAL INVOLVEMENT

Transvaginal ultrasoundSimilar effectiveness to TRUSS

Human Reprod 2005; 18: 1686-92

PREDICTING RECTAL INVOLVEMENT

MRI

radiographics.rsna.org

PREDICTING RECTAL INVOLVEMENT

MRI72-90% positive predictive value for surgical findings

Radiology 2004; 232: 379-89Fertil Steril 2005; 83: 442-7

Digital exam vs. TV USS vs. TRUSS vs. MRI

Bazot et al, Hôpital Tenon, Paris N = 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 0.14

LR (+) = likelihood ratio of positive test being positiveLR (+) = likelihood ratio of positive test being positive

Fertil Steril. 2009 Dec;92(6):1825-33

PREDICTING RECTAL INVOLVEMENT

Barium enemaRoad map

J Am Assoc Gynecol Laparosc 2002; 9: 115-9

DCBE

Landi et al, Verona108 pts suspected LB endometriosis55 – DCBE 28/28 adhesions, no endometriosis53 + DCBE 38/39 endometriosis, 1 adhesions

DCBESensitivity 85% Kappa 0.97Specificity 50% X2 p<0.00001

PPV 96%NPV 20%

J Am Assoc Gynecol Laparosc 2004; 11: 223-28

MRI vs. DCBE

Faccioli et al, University of Verona83 pts suspected to have large bowel endometriosis65 had surgery50 confirmed endometriosis

MRI DCBESensitivity 71% 85%Specificity 83% 94%

PPV 93% 63%NPV 75% 87%

Abdominal Imaging 2009 EPub

HOW OFTEN DO YOU NEED A COLORECTAL SURGEON?

HOW OFTEN DO YOU NEED A COLORECTAL SURGEON?

Redwine series11 years

1149 patients presenting with endometriosis100 patients with complete obliteration of rectovaginal septum 84 had excisional surgery

Fertil Steril 2001; 76: 358-65

HOW OFTEN DO YOU NEED A COLORECTAL SURGEON?

Melbourne series 11 years

213 operations rectal endometriosis

A NZ J Surg 2007; 77: 562-71

HOW OFTEN DO YOU NEED A COLORECTAL SURGEON?

Melbourne series 11 years

213 operations Rectal endometriosis

91 operations Separation/protection of rectum from gynae organs

A NZ J Surg 2007; 77: 562-71

HOW OFTEN DO YOU NEED A COLORECTAL SURGEON?

Melbourne series (Rodney Woods)11 years

213 operations Rectal endometriosis

91 operations Separation/protection of rectum from gynae organs

252 operations “others”A NZ J Surg 2007; 77: 562-71

AN EXTENDED ROLE FOR THE COLORECTAL SURGEON?

Mr R WoodsMelbourne

A NZ J Surg 2007; 77: 562-71

AN EXTENDED ROLE FOR THE COLORECTAL SURGEON?

Mr R WoodsSt. Vincent’s Hospital, Melbourne11 years

213 operations rectal endometriosis

18 shave58 disc excision137 segmental resection

A NZ J Surg 2007; 77: 562-71

AN EXTENDED ROLE FOR THE COLORECTAL SURGEON?

Evolution over last 10 years

Rectal shave

Wedge excision

Segmental resection

A NZ J Surg 2007; 77: 562-71

AN EXTENDED ROLE FOR THE COLORECTAL SURGEON?

What are they doing in Melbourne?

En bloc excision

A NZ J Surg 2007; 77: 562-71Human Reproduction 2003: 18; 1323-1327

HISTOLOGICAL STUDIES

Remorgida et al, Genoa16 pts undergoing surgery for LB endometriosis

Nodulectomy then resectionHistological evaluation

Human Reprod 2005; 20: 2317-20

HISTOLOGICAL STUDIES

Remorgida et al, Genoa16 pts undergoing surgery for LB endometriosis

Endometriosis outside the nodule in 7 cases (44%)

Human Reprod 2005; 20: 2317-20

AN EXTENDED ROLE FOR THE COLORECTAL SURGEON?

Evolution over last 10 years

Rectal shave

Wedge excision

Segmental resection

A NZ J Surg 2007; 77: 562-71Human Reproduction 2003: 18; 1323-1327

AN EXTENDED ROLE FOR THE COLORECTAL SURGEON?

Evolution over last 10 years

Rectal shave

Wedge excision

Segmental resection

Is this overtreatment?A NZ J Surg 2007; 77: 562-71Human Reproduction 2003: 18; 1323-1327

ARE WE OVER TREATING?

Mr R WoodsSt. Vincent’s Hospital, Melbourne11 years

213 operations rectal endometriosis

18 shave58 disc excision137 segmental resection5% stoma rate

A NZ J Surg 2007; 77: 562-71Human Reproduction 2003: 18; 1323-1327

ARE WE OVER TREATING?

Melbourne series

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

Nodulectomy ResectionNumber 16 25

Human Reprod 2010; Jan: dep407ul

DIFFERENTIAL OUTCOMES?Roman et al, Rouen University Hospital41 pts had surgery for LB endometriosis12-53 month follow-up

Nodulectomy ResectionNumber 16 25% dysmenorrhea 35% 20%% non-cyclical pain 31% 19%

% dyspareunia 38% 57%BO>3x/day 19% 52%

Human Reprod 2010; Jan: dep407ul

CONCLUSION

CONCLUSION

Evidence base supports excisional surgeryfor rectovaginal

endometriosis with laparoscopic technique

Uncertain whether nodulectomy or anterior

resection preferable

CONCLUSION

“stage 4 endometriosis involving the bowel,

retroperitoneal fibrosis and the rectovaginal septum are

among some of the most challenging conditions facing

the pelvic surgeon”

Surgery of the Anus, Rectum & Colon. 2nd ed, W B Saunders. 1999

Questions?