laparoscopic treatment of stage iv … stage iv endometriosis ... • total abdominal hysterectomy...

LAPAROSCOPIC TREATMENT

OF STAGE IV ENDOMETRIOSIS

‘’Intestinal complications’’ Korhan Taviloglu, MD

Department of Surgery Florence Nightingale Hospital,

Istanbul, Turkey www.taviloglu.com

1

2 Lobo RA. Endometriosis. In Comprehensive gynecology,

Katz ed. 5th ed, p 473-499, 2007, Mosby, USA.



Endometriosis



Endometriosis epithelium



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

Endometriosis: A disease of clinical contrasts

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)

6

Kocakoc E, et al, Ultrasound Clin 2008. Tepleman C, Obstet Gynecol Clin N Am, 2009.

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.

7

Kocakoc E, et al. Endometriosis. Ultrasound Clin 2008. Tepleman C. Adolescent endometriosis. Obstet Gynecol Clin N Am, 2009.

Endometriosis localizations Intraperitoneal

•  Ovaries: 30% •  Uterosacral and large

ligaments: 18%-24% •  Fallopian tubes: 20% •  Pelvic peritoneum •  Pouch of Douglas •  Gastrointestinal (GI) tract

8

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

Endometriosis localizations Extraperitoneal

9

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

•  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

Endometriosis intestinal involvement

Endometriosis involves the intestine in 4-35 % of patients.

10 Indraccolo U. Cecal endometriosis. JSLS 2010



Locations of bowel endometriosis

68 % 31 %

Bowel endometriosis characteristics

12

•  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.

Bowel endometriosis characteristics

13 Bailey HR.. Perspect Colon Rectal Surg 1992.

•  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.

Endometriosis bowel symptoms

14

•  Intermittent abdominal crampy pain •  Rectal or pelvic pain •  Cyclical rectal bleeding •  Tenesmus •  Constipation (especially with menses) •  Decreased stool caliber •  Bloating •  Nausea •  Vomiting •  Diarrhea


Endometriosis gynecologic symptoms

15

•  Dysmenorrhea •  Cyclic lower abdominal &

pelvic pain •  Dyspareunia •  Menometrorrhagia •  Infertility


Intestinal perforation from endometriosis

16 Pisanu A, et al. World J Gastroenterol 2010.

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

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

Endometriosis diagnosis

18

Kocakoc E, et al. Endometriosis. Ultrasound Clin 2008.

Utrasound MRI

Barium enema

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

Barium enema

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

Laparoscopy



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.



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%).

23 Coronado C, et al. Fertil Steril 1990.

Colonic endometriosis treatment result of pelvic symptoms

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

24 Coronado C, et al. Fertil Steril 1990.

THANK YOU!! Korhan Taviloglu, MD

Department of Surgery Florence Nightingale Hospital,

Istanbul, Turkey www.taviloglu.com

25

laparoscopic treatment of stage iv … stage iv endometriosis ... • total abdominal hysterectomy...

Documents