Deep endometriosis infiltrating the recto-sigmoid: critical factors to consider before management
Open accessAbstract
BACKGROUND: Deep endometriosis invading the bowel constitutes a major challenge for the gynecologist. In addition to the greater impact on pain, the high incidence of surgical morbidity involved with bowel endometriosis poses a therapeutic dilemma for the surgeon. Intestinal involvement by deep endometriotic nodules has been estimated to occur in 8-12% of women with endometriosis. Individual and clinical factors, pre-operative morphologic characteristics from imaging, surgical considerations and impact on quality of life are critical variables that should be considered in determining the best therapeutic strategy for a patient with deep endometriosis involving the sigmoid and/or the rectum. Pre-operative planning is fundamental for defining the optimal therapeutic strategy; patient counseling of treatment options, and when surgery is indicated, involvement of a multidisciplinary surgical team is required. METHODS: The PubMed and Cochrane database were searched for all original and review articles published in English, French and Italian, until June 2014. Search terms included 'deep endometriosis', 'surgical and clinical approach', 'bowel disease', 'quality of life', 'management of deep endometriosis'. Special attention was paid to articles comparing features of discoid and segmental resection. RESULTS: The rationale for the best therapeutic options for patients with deep endometriosis has been shown and an evidence-based treatment algorithm for determining when and which surgical intervention may be required is proposed. In deciding the best treatment option for patients with deep endometriosis involving the sigmoid and rectum, it is important to understand how the different clinical factors and pre-operative morphologic imaging affect the algorithm. Surgery is not indicated in all patients with deep endometriosis, but, when surgery is chosen, a complete resection by the most appropriate surgical team is required in order to achieve the best patient outcome. CONCLUSION: In women with deep endometriosis, surgery is the therapy of choice for symptomatic patients when deep lesions do not improve with a medical treatment.
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Recurring release of mediators of inflammation, such as prostaglandins and cytokines, may cause functional-type, mostly cyclic pain, such as irritative-type intestinal symptoms, whereas occlusive-type intestinal symptoms are generally the mechanical consequence of fibrotic tissue retraction, but they may be influenced also by inflammatory changes of bowel wall nodules.
“Recurring release of mediators of inflammation, such as prostaglandins and cytokines, may cause a functional-type, mostly cyclic pain, such as irritative-type intestinal symptoms, whereas occlusive-type intestinal symptoms are generally the mechanical consequence of fibrotic tissue retraction, but they may be influenced also by inflammatory changes of bowel wall nodules (3,6,7).”
From Medical treatment in the management of deep endometriosis infiltrating the proximal rectum and sigmoid colon: a comprehensive literature review (2018) · cites this paper as [3]
Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.
Experimental — accuracy not yet measuredThe majority of gynecological and/or colorectal surgeons may prefer segmental resection for multifocal and large nodules exceeding at least 3-4 cm, whereas small nodules <3 cm and/or DE not deeply infiltrating the muscular layer would be treated with FTDR resection or partial thickness discoid resection, or shaving.
“In general, the majority of gynecological and/or colorectal surgeons may prefer segmental resection for multifocal and large nodules exceeding at least 3–4 cm, whereas small nodules <3 cm and/or DE not deeply infiltrating the muscular layer would be treated with FTDR resection or partial thickness discoid resection, or so‐called shaving.”
From Pain, gastrointestinal function and fertility outcomes of modified nerve‐vessel sparing segmental and full thickness discoid resection for deep colorectal endometriosis – A prospective cohort study (2023) · cites this paper as [10]
Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.
Experimental — accuracy not yet measuredMedical treatment for bowel endometriosis may constitute a therapeutic alternative when established intestinal fibrotic stenosis with severely sub-occlusive symptoms are absent.
“Medical treatment for bowel endometriosis may constitute a therapeutic alternative when established intestinal fibrotic stenosis with severely sub-occlusive symptoms are absent (2,3,6).”
From Medical treatment in the management of deep endometriosis infiltrating the proximal rectum and sigmoid colon: a comprehensive literature review (2018) · cites this paper as [3]
There is no real consensus on how to optimally treat colorectal endometriosis surgically.
“There is, so far, no real consensus on how to optimally treat colorectal endometriosis surgically, since the application of the main three techniques, namely, segmental colorectal resection, full thickness discoid resection (FTDR) and so‐called shaving, depends on various factors which may differ from unit to unit and surgeon to surgeon.”
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Self-citationAnterior Focal Adenomyosis and Bladder Deep Infiltrating Endometriosis, Is There a Link?
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Self-citationAdvances in the medical management of bowel endometriosis
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Progression of deep infiltrating rectosigmoid endometriotic nodules
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Mycoplasma genitalium can modulate the local immune response in patients with endometriosis
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Female Sexual Function in Women with Suspected Deep Infiltrating Endometriosis
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Postoperative hormonal therapy after surgical excision of deep endometriosis
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Imaging of gastrointestinal endometriosis: what the radiologist should know
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Role of surgical treatment in endometriosis
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Imaging for evaluation of endometriosis and adenomyosis
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Self-citationUltrasound of Pelvic Pain in the Nonpregnant Woman
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Rectal endometriosis: predictive MRI signs for segmental bowel resection
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- Authors
- Abrao, M. S., Petraglia, F., Falcone, T., Keckstein, J., Osuga, Y., & Chapron, C.
- Affiliations
- University of Siena (IT)
- Cleveland Clinic (US)
- The University of Tokyo (JP)
- Centre National de la Recherche Scientifique (FR)
- Venue
- Human Reproduction Update
- Publisher
- Oxford University Press (OUP)
- Published
- 2015-01-24
- Volume
- 21
- Issue
- 3
- Pages
- 329-339
- ISSN
- 1355-4786 (ISSN-L)
- 1460-2369
- OpenAlex
- W2017403994
- Cited by
- 398
- References
- 136
- Citations by year
- 2026: 24 · 2025: 28 · 2024: 30 · 2023: 26 · 2022: 37 · 2021: 48 · 2020: 67 · 2019: 33 · 2018: 42 · 2017: 26 · 2016: 19 · 2015: 18
- FWCI
- 5.27
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Human Reproduction Update (publishedVersion)
- PubMed (publishedVersion)
- Florence Research (University of Florence) (submittedVersion)
- HighWire Press Open Archive (submittedVersion)
- Use Siena air (University of Siena) (submittedVersion)
- INFM-OAR (INFN Catania) (submittedVersion, other-oa)
- Topics
- Health Sciences › Medicine › Reproductive Medicine › Endometriosis Research and Treatment
- Health Sciences › Medicine › Obstetrics and Gynecology › Gynecological conditions and treatments
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Ectopic Pregnancy Diagnosis and Management
- Keywords
- deep infiltrating endometriosis, bowel endometriosis, rectosigmoid endometriosis, endometrioma, surgical planning, segmentectomy, surgical management, quality of life, multidisciplinary surgical team, treatment algorithm
- MeSH terms
- Endometriosis, Female, Humans, Lymph Nodes, Quality of Life, Rectal Diseases, Rectum, Colon, Sigmoid, Ultrasonography, Minimally Invasive Surgical Procedures
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