Department of Obstetrics and Gynecology, Friedrich Schiller University, Bachstrasse 18, 07740 Jena, Germany
1 To whom correspondence should be addressed. e-mail: Achim.Schneider{at}med.uni-jena.de
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Abstract |
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Key words: histopathological evaluation/rectovaginal endometriosis
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Introduction |
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There is no study which evaluates the histopathological findings of bowel specimens resected for rectovaginal endometriosis in a standardized fashion. Such data are mandatory in order to discuss the appropriate surgical approach. We evaluated the histopathological pattern of endometriosis in surgical specimens removed by en-bloc resection of rectovaginal endometriosis which included the adjacent part of the rectosigmoid in order to define the extent of disease.
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Materials and methods |
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With a combined laparoscopic vaginal technique an en-bloc surgical specimen of part of the posterior vaginal wall, cul-de-sac, rectovaginal septum, and part of the rectosigmoid was obtained (Figure 1). The procedure is started by vaginal excision of the involved vagina which is left on the rectum followed by bilateral dissection of the para- and retrorectal space. Para- and retrosigmoido-rectal spaces are developed laparoscopically along the coccygeo-sacral bone and medially of the pelvic splanchnic nerves toward the para- and retrorectal opening which had been developed transvaginally. Rectal transection is done using a laparoscopic stapling device caudally to the endometriotic lesion. Using a suprapubic minilaparotomy the bowel is eviscerated and transected cranial to the lesion, reintroduced into the abdomen, and a transanal circular stapler anastomosis (47 patients) or handsawn anastomosis with continuous sero-muscular sutures in two layers (three patients) is performed (Possover et al., 2000). Histopathology was performed in order to evaluate resection margins, multifocality and multicentricity, and growth pattern of endometriosis in the resected part of the bowel (Figure 2). The largest lesion was defined as the main lesion and all other lesions as satellite lesions. We took tissue sections from the main lesion and all satellite lesions. In addition, every 2 cm a tissue section was taken from the macroscopically normal bowel wall. Clean margins were defined as absence of endometriosis if the tissue rings from the circular stapler were free of endometriosis (94 specimens). In the three patients with handsawn anastomosis the aboral and oral resection margin of the bowel specimen were used for evaluating the resection status (Figure 2). The tissue sections taken from the bowel specimen encompassing an area of 1x1 cm were paraffin-embedded and three histological sections of 4 µm thickness were cut from the blocks and stained with haematoxylineosin. A total of 804 histological sections were evaluated for number, size, localization and extension of microscopic endometriotic lesions.
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Multifocal involvement was defined as presence of endometriotic lesions within a 2 cm area to the main lesion which was differentiated from multicentric involvement where endometriotic lesions were found >2 cm from the main lesion. This differentiation was done since a stapling anastomosis includes resection of a 2 cm area from the main lesion. Thus, multifocal disease is resected with clear margins by the stapling technique which is, however, not the case for multicentric disease.
In May 2002, all patients underwent a telephone interview. The questionnaire asked about presence or absence of symptoms such as dyspareunia, dysmenorrhoea or bowel symptoms, history of fertility, and diagnosis of recurrence of disease. All demographic data such as age, menarche, duration of menstruation, fertility, use of nicotine, hormonal treatment, history of surgeries, symptoms of bowel and menstruation, histopathological data, and data of the telephone interview were registered in an electronic format (Excel; Microsoft).
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Results |
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Surgical data
End-to-end anastomosis was performed in 47 patients using a circular stapler device and in three patients by sutures. Two patients experienced leakage of the colorectal anastomosis and underwent laparoscopic assisted protective ileostomy which could be taken down after 3 months in both patients.
Histopathological data
Endometriosis involved serosa and muscularis propria in all patients, invaded up to the submucosa in 17 patients, and reached the mucosa in five patients (Figure 3). The mesocolon was involved by endometriosis in four patients. Laparoscopically the rectum was always involved by endometriosis. Additional endometriotic lesions were identified after evisceration of the transected rectosigmoid colon by palpation.
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In each patient only the biggest endometriotic lesion was measured histopathologically: the size of the individual endometriotic lesion was 0.6 cm2 in 91.8% and >0.6 cm2 in 8.2%.
Follow-up data
After a mean follow-up of 32 months the majority of patients (72%) were free of symptoms (Table I). Of 25 patients with dyspareunia, 20 patients (80%) were free of symptoms, four patients (16%) reported considerable improvement, and one patient (4%) found no change. Two patients (4%) reported recurrent disease in the bowel which was diagnosed by rectovaginal palpation and sigmoidoscopy. In both patients resection had been performed with histopathologically clean margins. One of the patients reported mild improvement of symptoms. Thirty-eight (76%) patients had a history of primary sterility of which 17 patients (44.7%) tried to become pregnant post-operatively and eight of these (47%) became pregnant: four patients delivered healthy newborns (in two patients IVF had been used), three patients had an abortion in the first trimester, and one patient was pregnant at the time of the interview.
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Discussion |
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Partial bowel resection has been used for treatment of rectovaginal endometriosis in three major case series (Gray et al., 1973; Coronado et al., 1990
; Turnwald et al., 1998
). The extent of disease was not evaluated histopathologically in any of these studies.
In our series, all patients showed involvement of the bowel wall at least to the level of the muscular layer. Involvement of the serosa exclusively was not found in our patients. Therefore, superficial excision or ablation does not result in complete removal of disease in patients with rectovaginal endometriosis. In 62% of surgical specimens we found multifocal disease and in 38% we found multicentric disease. This shows that in more than one-third of patients a distance of 2 cm from the main lesion is not sufficient to obtain clean margins. There was no patient with a unicentric, unilocular endometriotic lesion. Thus, the extent of lesions cannot be macroscopically assessed with certainty and 2 cm of surrounding tissue must be removed in order to obtain clear margins in two-thirds of patients. In four patients (8%) involvement of the resection margins was found. Only 4% (two patients) developed recurrent disease. It remains to be seen whether additional patients will develop recurrence, especially since the telephone interview we used may have underdiagnosed recurrent disease. The two patients who reported clinical signs of recurrent disease were in the group of patients with clean margins.
In 45 of the 50 (90%) patients interventions were secondary, i.e. following laser or electrosurgical procedures. It may be speculated whether an incomplete first excision induces a rebound phenomenon and a more aggressive growth. History of unsuccessful ablative surgery in 90% of patients, the depth of infiltration, the multifocal or multicentric nature of disease, and involvement of resection margins in 8% of our patients indicate that resection with reanastomsis was most probably the best treatment option in these series. However, since we did not perform a systematic histopathological evaluation of the whole circumference of the involved bowel, we cannot rule out that some of our patients may have been candidates for a discoid resection with removal of part of the muscularis or resection including the mucosa with suture of the defect.
The main argument against partial bowel resection and in favour of local excision or ablation is the rate of intra- and post-operative complications. Severe intra- or post-operative complications were reported in 15 and 17% respectively in studies with partial bowel resection (Coronado et al., 1990; Turnwald et al., 1998
) compared with 4% in our study. In studies where local excision or ablation was performed, the complication rate varied between 1.2 and 24% (Donnez et al., 1995
; Crosignani et al., 1995
; Marcoux et al., 1997
; Garry et al., 2000
). Thus, there is no obvious difference in complications between resection and ablation. However, recurrence rate is significantly higher when local excision or ablation is performed: after partial bowel resection the rate of recurrence varies between 0% (Coronado et al., 1990
) and 4% in our series as compared with 3.7, 5, 19, 32 or 74.7% in studies with local excision or ablation (Wheeler and Malinak, 1989
; Redwine, 1991
; Crosignani et al., 1996
; Donnez et al., 1997
; Koninckx and Martin, 1997
). It may be concluded that, with similar complication rate and lower recurrence rate, local resection of the cul-de-sac with partial resection of the posterior vaginal wall and rectum is a valid therapeutic option. This conclusion, however, has to be made with caution: the patients included in the various studies might be different and any comparison could be rather a comparison of the surgeon than of the technique.
Our data show that, in patients with macroscopically visible endometriosis of the rectosigmoid colon and a history of bowel symptoms and positive rectovaginal examination, bowel resection with a distance of >2 cm from the main lesion is justified. This en-bloc resection can be done with complete preservation of the reproductive organs.
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Acknowledgement |
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References |
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Submitted on October 2, 2002; resubmitted on December 11, 2002; accepted on February 27, 2003.