2013 dukes endometriosis
TRANSCRIPT
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?