1 Service de Chirurgie Gynécologique, 2 Service de Chirurgie Digestive and 3 Service Central dAnatomie et Cytologie Pathologiques, Assistance PubliqueHôpitaux de Paris (AP-HP), Paris, France 4 To whom correspondence should be addressed at: Service de Chirurgie Gynécologique, Clinique Universitaire Baudelocque, 123, Boulevard Port-Royal, CHU CochinSaint Vincent de Paul, 75014 Paris, France. e-mail: charles.chapron{at}cch.ap-hop-paris.fr
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Abstract |
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Key words: deep endometriosis/deeply infiltrating endometriosis/operative laparoscopy/surgery
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Introduction |
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Several studies in the literature have addressed the topography of endometriotic lesions (Gruppo dellendometriosi, 1994; Jenkins et al., 1986; Redwine, 1987
). In these publications the majority of the lesions were superficial peritoneal lesions and ovarian endometriomas, with very few instances of deep endometriosis. To our knowledge no study has specifically addressed the topography of DIE lesions.
Since 1992, we have made continuous assessment by collection of data concerning the patients operated in our department for DIE. Results of routine clinical examination of the first 160 patients were previously published (Chapron et al., 2002a). The aim of this study, based on a homogeneous population of patients consulting in a context of pelvic pain, is to ascertain if knowledge of the DIE lesion locations might lead to recommendations for surgical management of these patients.
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Materials and methods |
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When a patient presented multiple DIE locations, we classified her in the category corresponding to the worst one. According to the definition, we classified lesions in the following order from least to worst: USL, vagina, bladder and intestine. For example, a patient presenting with posterior vaginal fornix infiltration associated with disease of the left USL was classified as being in the vaginal group. Similarly a patient presenting rectal disease associated with bladder endometriosis and bilateral infiltration of the USL was classified in the intestinal one. A DIE lesion was defined as being isolated when not associated with any of the three other DIE locations. In parallel, and again by definition, we classified DIE lesions into two groups: anterior compartment which corresponded to bladder DIE, and posterior compartment which corresponded to USL, vaginal and intestinal disease.
We studied the DIE location(s) for each patient according to the above criteria (USL, vagina, bladder, intestine) and also as to whether it was isolated or not. For each patient, general data were assessed [age, parity, gravidity, body mass index (BMI)]; together with the existence of pelvic pain (dysmenorrhoea, deep dyspareunia, chronic pelvic pain), past history of medical or surgical treatment for endometriosis, stage of the disease according to the revised American Fertility Society (1985) classification and the main surgical procedure performed to achieve complete exeresis of DIE lesions (uterosacral resection, posterior colpectomy, partial cystectomy, digestive surgery, etc.).
Statistical tests
Pearsons 2-test was used for comparison of categorical data and KruskalWallis one-way analysis of variance for testing heterogeneity between quantitative and categorical data. All analyses were performed with StatView 5.0 software (SAS Institute, Inc.).
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Results |
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Surgical procedures carried out for complete exeresis of DIE lesions are presented in Table IV. For the 218 patients treated by operative laparoscopy (90.5%), 239 operative procedures were performed. For the 23 patients operated by laparotomy (9.5%), 46 operative procedures were performed.
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Discussion |
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The question of operative technique is far more complex when the digestive tract is involved. Before clarifying the methods of surgical treatment in the case of intestinal DIE, a definition of the latter must first be agreed upon. In our opinion, lesions of the serosa without infiltration of the muscularis should not be considered as intestinal DIE. Logically speaking, these superficial lesions do not justify any specific intestinal procedure since from the histological point of view there is no deep infiltration into the intestine. Therefore, for the purposes of this study, these superficial intestinal lesions were not considered as intestinal DIE. This type of superficial intestinal lesion is secondary to associated pelvic adhesions that result in more or less complete obliteration of the pouch of Douglas in a context of USL and/or vaginal DIE. This fact explains why, in series that sometimes contain a high number of patients with DIE, treatment can be carried out exclusively by operative laparoscopy without any digestive tract procedure (Donnez et al., 1995). The situation is quite different for patients presenting true intestinal DIE with infiltration of the muscularis. In this situation, two crucial parameters have to be taken into account. Firstly, the multifocal character of bowel involvement, that we observed in almost 40% of cases; multiple sites of bowel disease are more easily treated by laparotomy than by operative laparoscopy (Redwine and Wright, 2001
). Secondly, in nearly 70% of cases intestinal DIE is associated with other DIE lesions that require specific procedures with respect to the vagina, bladder and/or the USL. The other parameters to be taken into consideration are as follows: the patients past surgical history; the existence and extent of associated pelvic adhesion process; the extent of intestinal DIE; the distance between the intestinal DIE lesion and the linea dentata (Possover et al., 2000
); the depth to which the DIE lesions penetrate into the bowel wall (Redwine and Wright, 2001
). All these reasons explain why, in a recent study reported by a highly experienced laparoscopic surgeon perfectly familiar with DIE, only 9.1% of patients presenting with intestinal DIE underwent segmental resection by operative laparoscopy (Redwine and Wright, 2001
). Although several cases of laparoscopic management or laparoscopically assisted vaginal resection of intestinal endometriosis are reported in the literature (Redwine, 1991b
; Nezhat et al., 1992
; Redwine et al., 1996
; Reich et al., 1998
; Possover et al., 2000
), this does not mean that laparotomy should be abandoned in this context (Crosignani and Vercellini, 1995
). For the majority of patients with true intestinal DIE, laparotomy remains the surgical technique of reference (Coronado et al., 1990
; Bailey et al., 1994
; Canis et al., 1996
).
The importance of the DIE anatomic distribution when deciding on surgical management prompted us to propose a classification system for DIE lesions (Table V). Our classification is based on where DIE lesions are located (Table V). Other classifications were previously proposed (Koninckx and Martin, 1992; Adamyan, 1993
; Martin and Batt, 2001
); that of Koninckx and Martin is essentially based on the pathogenesis of DIE [infiltration (Type 1); retraction (Type 2); adenomyosis externa (Type 3)]. We feel that our approach is advantageous in that whatever the pathogenesis, the operative technique is defined by the location of the DIE lesions. Two other methods of classification have been proposed (Adamyan, 1993
; Martin and Batt, 2001
) which also take the DIE lesions topography into account; in our opinion these are limited by two factors: (i) they do not take into account the possibility of associated anterior disease (bladder DIE) in cases of posterior DIE (present study; Donnez et al., 2000
); (ii) they place patients requiring different operative techniques into the same category. For example with the classification of Martin and Batt (2001
), surgical management (approach: operative laparoscopy or laparotomy; modality of exeresis) will be very different according to whether a bowel lesion is isolated or not and whether or not it is associated with infiltration of the posterior vaginal fornix. Similarly with Adamyans classification the operative technique would not appear to differ much according to whether the disease is stage I or stage III, since in stage III there is no rectal wall invasion. Furthermore Adamyans stage IV (Adamyan, 1993
) groups together patients for whom the surgical treatment may be very different. The originality of our classification is that there is a well-defined operating technique for each location.
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Acknowledgements |
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References |
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Submitted on February 18, 2002; resubmitted on July 1, 2002. accepted on September 28, 2002