Endometriosis and Colorectal Surgeon Involvement

Endometriosis is a poorly understood systemic disease with a current definition as the presence of endometrial tissue outside the uterus. Multiple other abnormalities are present and the clinical picture can include a wide array of signs and symptoms. Pain, dyspareunia (painful intercourse), infertility and menstrual bleeding irregularities are common features. Bowel symptoms such as bloating, change in bowel habit, tenesmus (sensation of incomplete evacuation), rectal bleeding or difficulty evacuating can occur but usually with advanced pelvic disease.

From a surgical perspective, endometriosis may be present anywhere within the abdominal cavity but most commonly within the pelvis. Extra-pelvic sites can include deposits in the abdominal wall, scar, umbilical and inguinal (groin) region. Other sites can also include the chest wall lining and lung. The disorder has been identified in multiple other sites and rarely in men.

Treatment can include medical and surgical therapy. Surgery with removal of the deposits is most often recommended for the treatment of deeply invasive disease, patients unresponsive to medical treatment or patients desiring fertility. The disease has an inflammatory and adhesive quality and can impact multiple organ systems including the gastrointestinal and urinary system. Severe, high stage disease may require multi-specialty surgical management. In most instances a gynaecologist would be expected to excise the disease usually with laparoscopic or robotic approaches.

Colorectal involvement will largely depend both on the extent of disease and the experience of the gynaecologist involved in the surgery. Options include shaving, disc or segmental resection of the rectum or colon. The decision as to which option can be difficult at times and should largely be individualised. Segmental resection is the ideal approach and preferred over larger resection for colorectal disease. A conservative approach to resection is recommended. It is notable that stoma rates vary widely within the literature and may relate to experience, extent of disease, and previous surgeries, especially previous bowel resections.

The advent of robotic surgery creates a new paradigm in relation to this type of surgery. Experienced gynaecological surgeons who have previously operated in parallel together with a colorectal surgeon at laparoscopy will understand and be aware of the significant difficulties operating on patients with endometriosis, especially those who have had multiple surgeries for endometriosis. Thus, would include and seek the expertise of a colorectal surgeon colleague to operate collectively for the best outcome for the patient.

Prior to surgery patients will require to prepare and empty the bowel by ingesting a solution the day before whilst on a clear fluid diet for 24 hours. There are many different bowel preparations and the surgeon will have their own preference.

As with any operation, there is a risk of complications and the surgeons, both gynaecologist and colorectal surgeon, will discuss these with the patient prior to surgery. The colorectal surgeon will discuss the risk of complications such as a bowel perforation and anastomotic leak following bowel resection, bleeding, pelvic collection and abscess/infection, ureteric injury (the ureter connects the kidney to the bladder), bladder injury and urinary retention (difficulty passing urine). A colovaginal fistula (an abnormal connection from the bowel to the vagina) is a reported complication but it is rare.

As with cancer surgery the best results are likely to be in the hands of high-volume surgeons with significant experience dealing with this enigmatic condition.

Authors:

Peter Lee, Colorectal Surgeon

Michael Cooper, Gynaecologist.

Updated: May 2022