MANAGEMENT OF COLORECTAL ENDOMETRIOSIS
Anthony J. Senagore, MD, MS
Professor and Chairman
Department of Colorectal Surgery
Medical University of Ohio
Toledo, OH
Endometriosis is classically defined as the presence of hormonally responsive
endometrial glands and stroma outside of the uterus affecting between 4% and
17% of women of reproductive age (1,2). Reports of occurrence of intestinal
endometriosis range from 3% to 36% of women with endometriosis (3-8); 50% of
those with severe endometriosis are reported to have bowel involvement (1). The
most common areas of intestinal involvement are reportedly the rectum and
rectosigmoid (2,3,6).
Symptoms characteristic of bowel involvement include
severe pelvic pain, dyspareunia, bowel irregularity associated with menses, cyclic
rectal bleeding, obstructive symptoms, rectal pain, constipation, and diarrhea
(2,3,6,9,10).
The definitive surgery for endometriosis has traditionally been
hysterectomy with bilateral salpingo-oophorectomy (11).
However, invasive
disease with intestinal tract involvement is more likely to remain symptomatic
following castration if these endometriotic lesions are not excised (12).
It has
been demonstrated that the more complete the excision, the greater the success in
the alleviation of pelvic pain (13). This has led to an increased implementation of
surgical extirpation of colorectal endometriosis (2).
The management of colorectal endometriosis remains controversial as
there is concern about the morbidity associated with bowel resection (2). It has
been demonstrated that patients with deeply infiltrating bowel disease have a
greater likelihood of remaining symptomatic following surgical castration when
disease is left behind (12) and that a more aggressive approach to remove all
visible disease has a higher success in ridding patients of their symptoms (5,13).
2
Reports of bowel endometriosis detected in postmenopausal women substantiate
the persistence of endometriosis in the absence of ongoing hormonal stimulation
(14-16). More recently, Redwine and Wright (17) demonstrated that laparoscopic
treatment of complete obliteration of the posterior cul-de-sac improved bowel
symptomatology.
Our data indicates that those who were found at the time of
surgery to have evidence of colorectal involvement presented with more
gynecologic symptoms as well as bowel symptoms. These patients were also
more likely to have undergone prior medical and surgical interventions. Despite
their greater preoperative pain and discomfort, patients with bowel involvement
reported similar postoperative satisfaction, resolution of symptoms as
demonstrated by comparable gynecologic and colorectal improvement scores, as
well as overall pain improvement. Our data supports the implementation of
aggressive laparoscopic management of colorectal endometriosis, demonstrating
comparable resolution of symptoms to those achieved in patients with lesser
endometriosis. Excision and segmental resection of bowel should be performed
in patients with bowel involvement to provide the most efficacious intervention.
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References
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endometriosis.
Laparoscopic management of intestinal
Journal of the American Association of Gynecologic
Laparoscopists 2000;7:405-409.
2. Bailey, HR, Ott, MT, Hartendorp, P. Aggressive surgical management for
advanced colorectal endometriosis.
Diseases of the Colon & Rectum
1994;37:747-753.
3. Markham, SM, Carpenter, SE, Rock, JA.
Extrapelvic endometriosis.
Obstetrics and Gynecology Clinics of North America 1989;16:193-219.
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Gastrointestinal
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clinical
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16. Colling, GR, Russel, JC. Endometriosis of the colon. American Surgeon
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the cul-de-sac associated with endometriosis: long-term follow-up of en bloc
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