June 2021: First patients treated at IFEM Endo with HIFU for rectal endometriosis
Deep endometriosis can affect the digestive system, infiltrating the various layers of the wall of the rectum, colon, small intestine and appendix.
The frequency of this type of endometriosis is difficult to estimate accurately. In a survey (1) carried out in 2015 in 56 French facilities, it was estimated that over 1,200 patients are operated on each year in France for endometriosis of the colon and rectum.
Involvement of the digestive tract is probably the most common "non-gynecological" location for endometriosis. In the vast majority of cases, it occurs in the rectum and sigmoid colon. In less than 10% of cases, endometriosis lesions are also found in the appendix, the terminal part of the small intestine (the last 30-40 cm), or the most proximal part of the colon (cecum). In contrast, endometriosis lesions are very rare or absent in the stomach, duodenum, proximal and intermediate small intestine, or on the surface of the liver and spleen.
Digestive lesions are single in around 2/3 of cases, and multifocal in around 1/3, where they may be separated by several centimetres of uninjured intestine.
Lesions in the digestive tract may be superficial, 2-3 mm thick, involving only the superficial layer of the intestine (serosa, A), or larger and deeper, involving the muscular (B), submucosal or mucosal layers.
Deep nodules are responsible for a marked thickening of the digestive tract wall, with a proliferation of muscle cells pushing the mucosa towards the digestive lumen. In around 2/3 of cases, the infiltration remains localized to the muscular layer, while penetration of the mucous layer is very rare (around 5%) and mainly characterizes very large, virtually sub-occlusive nodules. This characteristic explains why digestive nodules, even large ones, are not visible from inside the digestive tract, as in the case of colonoscopy, which can be interpreted as normal.
Digestive endometriosis nodules therefore infiltrate the digestive tract from the outside in, giving them a fan-shaped, orange-peel or mushroom-like appearance, with the base wider than the top. The base may be extended by infiltration of another organ (e.g. uterus, utero-sacral ligaments, vagina), resulting in the digestive tract becoming attached to the organs concerned (falsely interpreted as simple adhesion).
In other cases, digestive nodules may be solitary, with a base that is more or less difficult to identify on the surface of a mobile intestine.
It's important to understand that digestive endometriosis nodules are predominantly made up of muscular or fibrous tissue, while endometrial-like cells (hormone-dependent) account for 15-20% of nodule volume. This composition explains the minimal variations in digestive nodules (2) under the effect of amenorrhea, which in the majority of cases only manages to stabilize the lesions, without causing them to regress.
Symptoms associated with digestive nodules can be very diverse, and the intensity of pain varies greatly from patient to patient. These symptoms are not necessarily painful, and have an insidious, low-key onset and evolution, which can lead to a considerable delay in diagnosis and management. In other cases, patients may be asymptomatic for a long time.
The onset of symptoms is generally linked to several mechanisms (3):
Blood loss through the anus (rectorrhagia), on the other hand, is only exceptionally due to bleeding from digestive nodules. In the vast majority of cases, it is a hemorrhage from an internal hemorrhoid that has developed as a result of chronic defecatory efforts. A colonic polyp must also be ruled out.
Digestive symptoms may also be enhanced by other mechanisms, independent of the infiltration of the digestive tract itself, which may in theory persist despite complete surgery of the digestive lesions:
Despite a limited effect on the size of digestive nodules, amenorrhea leads to a significant improvement in digestive symptoms in the majority of cases. In a study carried out at Rouen University Hospital, we observed that digestive symptoms can disappear in around 50% of cases in women undergoing medical treatment (7).
On the other hand, we sometimes have to operate on postmenopausal women with large nodules in the digestive tract, because of the persistence of sub-occlusive symptoms even several years after the onset of menopause.
Because of the low risk of complications, medical treatment is generally the first choice, especially for women who tolerate it perfectly and those who do not wish to become pregnant.
Surgery for digestive endometriosis lesions follows 2 main principles:
It is important to offer patients with endometriosis the surgical treatment best suited to their situation, i.e. individualized or tailor-made. Our team respects this principle, as demonstrated by the overall balanced ratio between the three techniques used in current practice: shaving, discoid excision or colorectal resection (8).
Shaving is an excisional technique that removes the endometriosis nodule without opening the lumen of the digestive tract.
The principles, benefits and risks of each technique are presented academically in the video below.
The major advantage of this technique is that it avoids contamination of the abdominal cavity by bacteria contained in the colon, and drastically reduces the risk of certain dreaded complications of this surgery (such as digestive fistula, the risk of which is reduced 5-6 times, or haemorrhages occurring at the level of digestive sutures, which are completely avoided). The improvement in postoperative symptoms is significant, as we have shown in clinical studies including patients operated on at Rouen University Hospital (4,5,9,10). On the other hand, exeresis of endometriosis nodules may be incomplete, with a risk of recurrence that may be higher than with other techniques in the long term. In our experience, we have estimated a risk of recurrence of around 8% at 5-10 years after surgery (11). On the basis of these observations, to avoid rectal recurrence in a single patient, 12 patients would have to undergo segmental colorectal resection instead of shaving, with a logically higher risk of postoperative complications (12). These arguments for and against shaving should be discussed during the preoperative consultation. Most experts agree that shaving is the technique of first choice, when the characteristics of the nodule (small, shallow nodules) and the patient (women over 30, who already have children and accept postoperative medical treatment, patients who refuse transfusions, etc.) allow it.
Discoid excision is a technique of "cutting" the nodule, opening the lumen of the digestive tract, followed by repair of the tube with a transverse suture (perpendicular to the axis of the digestive tract).
It's a technique used by teams around the world, and one that represents a point of excellence for our team. Indeed, the two founding surgeons of IFEM Endo have together performed over 450 discoid exereses, making them among the most experienced practicing surgeons for this technique in the world. Our team has published a large number of scientific and didactic articles on discoid resection, which are regularly cited in the international literature (4,13,14,15,16). The advantages of discoid resection over conventional segmental resection are better preservation of the rectum, its length and volume, its vascularization, and the nerves that control its function, as well as the absence of the risk of colonic stricture after surgery. This could lead to better function of the operated rectum in women who have had a discoid excision compared with those who have had a segmental colorectal resection, particularly when the nodules concern the last 10 centimetres of the rectum (endometriosis of the lower or middle rectum). Compared with shaving, the advantage of discoid exeresis is that it is probably more complete at the limits of the nodule, particularly at depth, in contact with the lumen of the digestive tract. On the other hand, compared with shaving, discoid exeresis carries a notable risk: that of digestive fistula (1,17). As the cutting of the nodule creates an opening in the digestive tract, this opening requires a suture that may become loose in 1-3% of cases, leading to the emission of stool outside the colon and necessitating emergency re-operation with the creation of a stoma (artificial anus). The risk of fistula is comparable to that of segmental resection (which also involves suturing the colon), but is 5 to 6 times greater than that of shaving, which does not require suturing. Recurrences in the rectum after discoid excision are very rare, less than 2% in our experience.
Segmental resection is a "classic" technique for the treatment of colonic lesions of all kinds (endometriosis, infectious lesions, cancer), enabling the removal of an entire segment of colon with more or less wide healthy margins around the lesion.
This requires connection of the proximal and distal ends of the removed segment, with a circular suture. Segmental excision is a technique well mastered by digestive surgeons, even those with no particular experience of endometriosis, as they also use it for other pathologies of the digestive tract. The advantage of this technique lies in the more radical nature of the exeresis, with wide healthy margins, as in cancer, which means that the risk of recurrence in the rectum is very low, at around 1% (18). Also, segmental resection enables all nodules to be removed, whatever their size, particularly very large nodules where shaving and discoid excision are technically impossible. On the other hand, the risk of immediate complications after segmental resection is higher than with shaving and discoid excision (12). There is also probably a higher risk of dysfunction of the operated rectum when the nodule involves the lower or middle rectum (the last 10 cm of the rectum) (19), characterized by a syndrome known as LARS (low anterior resection syndrome), which associates difficulty in eliminating stool, very frequent bowel movements, difficulty in retaining stool or even anal incontinence (20,21). Post-operative functional disorders following segmental resection can sometimes be very inconvenient, which has led us to innovate in surgery for nodules of the lower rectum by proposing original techniques for discoid excision of very large nodules, such as the "Rouen technique" (22) and "double discoid" excision (14).
The use of the three techniques is chosen prior to surgery, based on the characteristics of the digestive endometriosis nodules and the patient. Our surgeons calculate the best benefit/risk balance in each case, but the final decision rests with the patient.
The relatively balanced use of the 3 techniques reflects the absence of preconceived ideas on the part of our surgeons, and the individualized, tailor-made choice of each type of surgery, with the aim of ensuring the best result for each case (8).
Before performing surgery for digestive endometriosis, surgeons need to know the number and location of the various lesions. This is made possible by a preoperative imaging work-up, including MRI, endopelvic ultrasound, endorectal ultrasound, coloscanner, etc., depending on the case. These examinations will be recommended according to the characteristics of your disease.
Surgery for colorectal endometriosis is generally complex, and the complication rate must be known before agreeing to the procedure. The following list of complications is not exhaustive, and concerns only those whose frequency is greater than 1%. Depending on your particular situation, the risk of certain complications may be higher or lower, and will be discussed in detail before surgery.
Thanks to our extensive experience in this type of surgery (8,23), our surgeons are able to avoid these complications wherever possible, by choosing the surgical strategy best suited to your case, identifying the first signs of a complication and intervening without delay to repair it.
Intraoperative risks (during surgery), whose cumulative risk remains below 1%:
Immediate post-operative risks (during the first 2 weeks after surgery):
Late post-operative risks (beyond one or two months post-operatively):
Surgery for endometriosis of the digestive tract requires consideration of the possibility of a temporary stoma (artificial anus).
The purpose of a stoma is to divert feces upstream of the surgical site, to allow better healing. The stoma may be performed immediately during endometriosis surgery, when the surgeons (gynecologist and digestive surgeon) consider that there is a significant risk of impaired healing of the digestive suture, which may lead to digestive fistula. Digestive fistula is one of the most serious complications of digestive surgery (17), and is due to the opening of the digestive suture, with the release of stool into the abdomen (with the onset of peritonitis) or into the vagina (when vaginal excision has been performed). When the stoma has not been made from the outset, the occurrence of a fistula necessitates emergency surgery with the insertion of a temporary stoma. The stoma is maintained for around 2 months, and is closed by a new surgical procedure once complete healing of the digestive tract suture is certain. In the case of a digestive fistula, on the other hand, the stoma may be maintained for several months, until the fistula has completely healed (17). One or more additional surgical procedures may also be required to close the fistula definitively (17).
The creation of a stoma does not completely avoid the risk of digestive fistula, but it does reduce the risk of complications secondary to the appearance of a fistula (peritonitis, complete disunion of the digestive suture, etc.). On the other hand, the creation of a stoma exposes the patient to specific complications that would not have arisen if the stoma had not been created. These complications require surgical repair in around 8% of cases (24).
Consequently, whether or not to perform an ostomy will be discussed in detail with the gynecological and digestive surgeons prior to surgery, trying to find the best balance between expected risks and expected benefits.
On the other hand, in the absence of surgical treatment of your disease, it is possible that the evolution of your disease, even minimal, and despite medical treatment, may lead to the appearance of the following events:
Surgery for digestive endometriosis cannot be considered without taking into account the long-term consequences on digestive function. Generally speaking, we do not propose surgery to patients who have no symptoms, for the simple reason that surgery may be followed by the appearance of certain disorders. Even if these disturbances are minimal, we feel that they are unacceptable in patients with normal digestive function prior to surgery. The preoperative consultation will enable a thorough discussion of these risks, which must be weighed against the risks of complications associated with the evolution of non-operated digestive endometriosis, so that patients can make an informed decision.
1 400
patients operated on each year in France for digestive endometriosis
60%
no digestive symptoms after surgery
3%
have a 10-year recurrence risk after colorectal resection or discoid resection
Bibliography
Our team has a wealth of experience in digestive endometriosis surgery. With over 300 patients operated on for this condition in 2019, our center is currently one of the most experienced in Europe and the world (8).
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