Endometriosis

Nigel A Scott & RJ Slade Hope Hospital, Salford

Powerpoint File

AETIOLOGY AND INCIDENCE

Theories as to the aetiology of endometriosis include :

• Retrograde menstruation as the cause of most peritoneal endometriosis

• Coelomic metaplasia or transformation of pluri-potential mesenchymal cells from one cell type to another might account for some endometriosis.

• Lymphatic dissemination of endometrial cells

• Vascular dissemination of endometrial cells

• Iatrogenic transplantation of endometrial cells to surgical wounds in the abdominal wall

Endometriosis is a common disease occurring in about 10% of all women. It is seen most frequently amongst women being investigated for infertility (21%) and less often amongst those presenting for sterilisation (6%) . Involvement of the gastrointestinal tract is not infrequent and endometriosis should therefore be considered in the differential diagnosis of colon lesions in women of childbearing and middle age. Colorectal endometriosis is mostly localized to the sigmoid or the anterior rectal wall with extramucosal radiologic appearance and is difficult to diagnose by sigmoidoscopy.

Deep rectovaginal endometriosis because of direct rectal involvement, has a specific significance for the colorectal surgeon. It may arise through embryonic remnants in the recto-vaginal septum undergoing metaplastic change to “endometrial-like” tissue, and by proliferation become surrounded by hyperplastic smooth muscle, representing a typical “adenomyotic nodule” deep in the recto-vaginal septum. POD depth measurements in those affected with deep rectovaginal endometriosis are on average 1/3 less than those without deep disease, and therefore others believe that deep rectovaginal disease is from primary peritoneal disease, extending into a pseudo-recto-vaginal septum by adhesion formation between the anterior rectal wall and anterior POD peritoneum. Alternatively deep rectovaginal endometriosis may arise from infiltrative utero-sacral disease, with involvement of the lateral rectal wall.

DIAGNOSIS AND INVESTIGATION

The symptoms associated with endometriosis such as dysmenorrhoea and pelvic pain are common. Establishing the diagnosis can be difficult because the presentation is so variable and there is considerable overlap with other conditions such as irritable bowel syndrome and pelvic inflammatory disease. As a result there is often delay between symptom onset and surgical diagnosis. The choice of treatment will depend upon factors such as the woman's age, fertility plans, previous treatment, the nature and severity of the symptoms, and the location and severity of disease. Women with endometriosis-associated infertility and pain may have to decide which is the major priority as there is no evidence that hormonal therapy alone improves fertility. Endometriosis may present with any combination of the following:

• secondary dysmenorrhoea,

• deep dyspareunia,

• pelvic pain,

• infertility

• pelvic mass.

However, the predictive value of any one symptom or set of symptoms remains uncertain. Furthermore, endometriosis is often found coincidentally in asymptomatic women. Laparoscopy is still regarded for the moment as the 'gold standard' diagnostic test looking for evidence of all types and stages of endometriosis. However, diagnostic laparoscopy is associated with 0.06% risk of major complications (e.g. bowel perforation) whilst this risk is increased to 1.3% in operative laparoscopy.

Cyclical Rectal bleeding - case reports of cyclical rectal bleeding in endometriosis affecting rectum and sigmoid colon emphasize the close relationship between such cyclical bleeding and intestinal endometriosis. The cause of bleeding, however, is still unclear. The predilection of endometriotic deposits for the outer layers of the bowel wall suggests that mucosal involvement is not a prerequisite for rectal bleeding. The frequent absence of identifiable intramural haemorrhage casts doubt on the premise that intestinal endometriotic deposits 'menstruate'. The cause may simply be a transient tear in normal mucosa due to swelling of an underlying endometriotic deposit at the time of menstruation. (levitt et al)

Endorectal Ultrasound and Rectal Involvement - In 31 of 32 patients with suspected rectal wall infiltration, preoperative endorectal ultrasound diagnosis was confirmed. In patients in whom endorectal ultrasound showed no rectal wall involvement, histopathology revealed infiltration in one patient, leading to sensitivity of 97 percent and specificity of 97 percent with regard to rectal wall involvement. In terms of the deepness of rectal wall infiltration, endorectal ultrasound had a sensitivity of 76 percent with regard to infiltration of the muscularis propria and 66 percent for infiltration of the submucosa. Operations led to a significant (P < 0.05) reduction of preoperative symptoms by approximately 60 percent.

Staging Endometriosis Laparoscopy - determines the number, size, and location of endometrial implants and adhesions and can be used to rank endometriosis by the extent of the disease:

• Minimal (Stage I)

• Mild (Stage II)

• Moderate (Stage III)

• Severe (Stage IV)

MANAGEMENT

The aim of medical treatment is to induce atrophy in the ectopic endometrial tissue with the use of hormones. The drugs available are equally effective in relieving endometriosis-associated symptoms (see the four systematic reviews of randomised controlled trials, summarised below). However, these drugs are associated with significant side-effects that limit their long-term use and often produce poor compliance. In addition, hormonal manipulation probably does not affect any of the primary biological mechanisms responsible for the disease process. Consequently, medical treatment does not always provide complete pain relief and some patients fail to respond. Symptom recurrence is common following medical treatment. Thus, in a follow-up study, the cumulative recurrence rates for the fifth year after the completion of GnRH agonist treatment were 37% for minimal disease and 74% for severe disease.11 The following reviews have been considered:

Endometriosis and pain - Medical management

Non-steroidal anti-inflammatory drugs may be effective in reducing the pain associated with endometriosis - Some women prefer to avoid hormonal therapy and can manage their symptoms effectively with analgesia and/or a complementary medicine approach. Non-steroidal anti-inflammatory drugs may be effective.

If a woman is not trying to conceive and there is no evidence of a pelvic mass on examination, there may be a role for a therapeutic trial of a combined oral contraceptive (monthly or tricycling) or a progestogen to treat pain symptoms suggestive of endometriosis without performing a diagnostic laparoscopy first.

The choice between the combined oral contraceptive, progestogens, danazol and GnRH agonists depends principally upon their side-effect profiles because they relieve pain associated with endometriosis equally well. The aim of medical treatment is to induce atrophy in the ectopic endometrial tissue with the use of hormones. The drugs available are equally effective in relieving endometriosis-associated symptoms. However, these drugs are associated with significant side-effects that limit their long-term use and often produce poor compliance. In addition, hormonal manipulation probably does not affect any of the primary biological mechanisms responsible for the disease process. Consequently, medical treatment does not always provide complete pain relief and some patients fail to respond. Symptom recurrence is common following medical treatment. Thus, in a follow-up study, the cumulative recurrence rates for the fifth year after the completion of GnRH agonist treatment were 37% for minimal disease and 74% for severe disease.

Endometriosis and pain - Surgical management

The role of surgery in the management of both endometriosis-associated pain and infertility has been assessed in a recent systematic review. One double-blind RCT has compared the effects of laser ablation of minimal-moderate endometriosis plus uterine nerve ablation versus diagnostic laparoscopy alone for pain relief. At six months' follow-up, 62.5% of the treated patients reported improvement or resolution of symptoms compared with 22.6% in the no-treatment group. Outcome was poorest in patients with minimal endometriosis. However, 73.7% of women with mild-moderate disease experienced pain relief. Symptom relief continued at one year follow-up in 90% of those who initially responded.

Although there are limited data available from RCTs assessing the effectiveness of surgery in relieving pain, it is clearly effective for many women. However, clinical experience shows that some women fail to respond to surgical treatment either because of incomplete excision or because of post-operative disease recurrence.

There is evidence to suggest that post-operative medical treatment with GnRH agonists significantly prolongs the pain-free interval after conservative surgery in symptomatic women, although in an earlier review it was suggested otherwise. More evidence is needed to verify the reduced symptom recurrence rate found in two trials in women allocated to post-operative medical therapy.

RADICAL SURGERY FOR STAGE IV DISEASE

Radical surgery means doing a hysterectomy with removal of both ovaries and is reserved for women with very severe symptoms, who have not responded to medical treatment or conservative operations. Rectal involvement with complete destruction of the rectovaginal plane means that separation of the rectum from the vagina is required to complete the hysterectomy and BSO.

Deep infiltrating, retroperitoneale endometriosis is considered as a special entity of endometriosis with respect to the histological characteristics. The nodules are containing glands, stroma,and muscle cells resembling adenomyotic foci For the clinician the question is of importance, whether this endometriotic nodules react to hormonal therapy or surgery is the only option of choice as known from adenomyosis of the uterus.

Primary surgical treatment of rectovaginal endometriosis in one series of 25 patients (19 primary and 6 with recurrence after medical therapy included:

Procedure Number Recurrence

Removal of the rectovaginal endometrial plaque alone 4 2 (50%)

Disc resection of the rectum 9 3 (33%)

Anterior resection and anastomosis 12 2 (16%)

The authors concluded that in case of rectovaginal endometriosis radical surgery is the preferred treatment

Practical considerations in radical surgery for rectovaginal endometriosis include:

PREOPERATIVE

• MDT discussion of the indications and likely extent of pelvic surgery

• Preoperative counselling of patient and family as to the indications and extent of surgery, including the risk of stoma formation, autonomic pelvic nerve injury and bladder dysfunction, ureteric injury and pelvic haemorrhage

• Bowel preparation and stoma siting

INTRAOPERATIVE

• Lloyd Davies position

• Use of illuminated ureteric stents

• MDT operating (Gynaecologist, Colorectal Surgeon)

• Mobilisation of the rectum posteriorly and laterally. Once the rectum has been mobilised laterally, the most difficult part of the surgery commences. It is necessary to mobilise the rectum from the posterior cervix until the areolar tissue of the normal recto-vaginal septum is reached. It may be possible to find a tissue plane between the nodule and the posterior cervix / vagina, and it may be possible to find a plane between the nodule and the rectum.

• Judgement as to extent of anterior rectal wall involvement and awareness that the rectovaginal plane may be compromised for a considerable distance.

• Determination as to whether excision of the endometrial plaque alone, excision of a disc of anterior rectum or formal anterior resection is required.

• Rectal reconstruction +/- stoma formation.

OUTCOMES AND RADICAL SURGERY FOR STAGE IV DISEASE

In one series twelve radical resections were performed by laparotomy, 48 by laparoscopy. Ten patients had a hysterectomy. Forty-eight patients underwent shaving of the pre-rectal fascia, two had a disc resection of the rectum, 10 had an anterior rectal resection. Two patients required a colostomy and two needed subsequent dilation of a stenosed anastomosis. Forty-four of the first 46 patients replied. The median follow up period was 12 months (range 2 to 22 months) and 86% (38/44) reported an improvement or whom 27 (61%) had a good response (pain completely gone or greatly improved). Patients having a hysterectomy or a disc or segmental resection of the rectum reported a good response and had a normal quality of life. Quality of life scores in the study group overall were lower than the background population.Radical resection is an effective treatment for rectovaginal endometriosis. Hysterectomy and rectal resection were associated with a better response and quality of life.

In a second series of 29 patients - 93 percent underwent low anterior resection of the rectum and distal sigmoid. Thirty-four percent of patients had simultaneous total abdominal hysterectomy and bilateral salpingooophorectomy. Complete follow-up was obtained on 26 patients (90 percent; mean follow-up 22.6 (range, 8-63) months). All patients (100 percent) reported subjective improvement. Forty-six percent of patients were "cured" according to the prospectively applied definition (resolution of symptoms without need for further medical or surgical therapy). The only variable analyzed that was associated with "cure" was concomitant total abdominal hysterectomy and bilateral salpingooophorectomy (odds ratio, 12; 95 percent confidence interval, 1.8-81.7). This association remained significant after correcting for age and the presence of gastrointestinal symptoms. Total abdominal hysterectomy and bilateral salpingooophorectomy at the time of bowel resection correlates with improved outcome.

REFERENCES

Clinical Green Top Guidelines The Investigation and Management of Endometriosis (24) - Jul 2000 http://www.rcog.org.uk/guideline

Zondervan KT, Yudkin PL, Vessey MP, Dawes MG, Barlow DH, Kennedy SH. The prevalence of chronic pelvic pain in women in the United Kingdom: a systematic review. Br J Obstet Gynaecol 1998; 105:93-9.

Zondervan K, Yudkin PL, Vessey MP, Dawes M, Barlow DH, Kennedy SH. Prevalence and incidence in primary care of chronic pelvic pain in women: evidence from a national general practice database. Br J Obstet Gynaecol 1999; 106:1149-55.

Hughes E, Fedorkow D, Collins J, Vandekeckhove P. Ovulation suppression vs. placebo in the treatment of endometriosis (Cochrane Review). In: The Cochrane Library 1999, Issue 3. Oxford:Update Software.

Harkki-Siren P, Sjoberg J, Kurki T. Major complications of laparoscopy: a follow-up Finnish study. Obstet Gynecol 1999; 94:94-8.

Forsgren H, Lindhagen J, Melander S, Wagermark J. Colorectal endometriosis.

Acta Chir Scand. 1983;149(4):431-5.

Doniec JM, Kahlke V, Peetz F, Schniewind B, Mundhenke C, Lohnert MS, Kremer B. Rectal endometriosis: high sensitivity and specificity of endorectal ultrasound with an impact for the operative management. Dis Colon Rectum. 2003 Dec;46(12):1667-73.

Levitt MD, Hodby KJ, van Merwyk AJ, Glancy RJ. Cyclical rectal bleeding in colorectal endometriosis. Aust N Z J Surg. 1989 Dec;59(12):941-3.

Farquhar C, Sutton C. The evidence for the management of endometriosis. Curr Opin Obstet Gynecol 1998; 10:321-32.

Sutton CJ, Ewen SP, Whitelaw N, Haines P. Prospective, randomized, double-blind, controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal, mild, and moderate endometriosis. Fertil Steril 1994; 62:696-700.

Sutton CJ, Pooley AS, Ewen SP, Haines P. Follow-up report on a randomized controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal to moderate endometriosis. Fertil Steril 1997; 68:1070-4.

Hornstein MD, Hemmings R, Yuzpe AA, Heinrichs W.LeRoy. Use of nafarelin versus placebo after reductive laparoscopic surgery for endometriosis. Fertil Steril 1997; 68:860-4.

Vercellini P, Crosignani PG, Fadini R, Radici E, Belloni C, Sismondi P. A gonadotrophin-releasing hormone agonist compared with expectant management after conservative surgery for symptomatic endometriosis. Br J Obstet Gynaecol 1999; 106:672-7.

Parazzini F, Fedele L, Busecca M, et al. Postsurgical medical treatment of advanced endometriosis: results of a randomized clinical trial. Am J Obstet Gynecol 1994; 171:1205-7.

Rodney J. Woods* , Alexander G. Heriot and Frank C. Chen* Anterior rectal wall excision for endometriosis using the circular stapler ANZ Journal of Surgery 2003;73:647

Jolyon Forda, James Englisha*, William A. Milesb, Theo Giannopoulosa Pain, quality of life and complications following the radical resection of rectovaginal endometriosis BJOG: An International Journal of Obstetrics & Gynaecology 2003;111:353

Urbach DR, Reedijk M, Richard CS, Lie KI, Ross TM. Bowel resection for intestinal endometriosis. Dis Colon Rectum. 1998 Sep;41(9):1158-64