Rectosigmoid Endometriosis Research Articles

The impact of bowel preparation on MRI scans for confirming rectosigmoid endometriosis detected by transvaginal ultrasonography.

The study aims to assess the impact of bowel preparation on MRI scans in diagnosing rectosigmoid endometriosis (RSE) and to examine the level of agreement among investigators, including radiologists and clinicians with varying levels of MRI experience. Fifty-eight patients underwent MRI scans, with 34 showing RSE and 24 without involvement, according to TVUS as the reference standard. The scans were conducted both with and without a bowel preparatory protocol (BPP). The highest concordance was observed in the group 4, which included patients with RSE and BPP, with a Kappa value of 0.47-0.52. In contrast, for groups with MRI scans without the BPP, there was no consistency among the investigators (Kappa <0.20). The sensitivity, specificity, positive predictive value, and negative predictive value were 0.72, 0.47, 0.72, and 0.47 without BPP, and increased to 0.82, 0.74, 0.85, and 0.74, respectively, after BPP. The results reveal that the concordance between investigators in detecting RSE via MRI scan improves with the use of BPP. Additionally, the success rate of MRI and TVUS for detecting RSE can be comparable, but only if bowel preparatory techniques are utilized during MRI scans.

S2904 History Matters: A Rare Case of Rectosigmoid Endometriosis Disguised as Colorectal Malignancy

S2904 History Matters: A Rare Case of Rectosigmoid Endometriosis Disguised as Colorectal Malignancy

Feasibility of Intraoperative Proctosigmoidoscopy After Discoid Bowel Resection for Deep Infiltrating Endometriosis: A Pilot Multicenter Study

Although surgery is the gold standard treatment for pain refractory to medical management or partial occlusion owing to rectosigmoid endometriosis, surgical resection can be associated with major perioperative complications. From general surgery experience, intraoperative proctosigmoidoscopy has shown encouraging results as a feasible, safe, and effective technique in reducing the risk of complications related to intestinal anastomosis after segmental resection. Unfortunately, there are no studies evaluating its role after discoid resection for rectosigmoid endometriosis. A pilot, multicentric, observational, prospective, cohort study. Two academic hospitals, from March 1 to December 31, 2022. We enrolled all consecutive fertile-age patients affected by symptomatic endometriosis scheduled for laparoscopic discoid bowel resection. Inclusion criteria were (1) age between 18 and 50 years, (2) diagnosis of rectosigmoid endometriosis performed by transvaginal ultrasound and/or magnetic resonance imaging, and (3) women scheduled for laparoscopic discoid bowel resection of endometriosis at low risk of segmental resection. During data analysis, enrolled patients were divided into 2 study groups for comparisons based on whether or not the intraoperative proctosigmoidoscopy was performed upon surgeons' discretion after discoid resection for treating endometriosis, in addition to standard integrity tests. Primary outcome was the rate of intraoperative proctosigmoidoscopy success. Secondary study outcomes were the differences between the intraoperative proctosigmoidoscopy group and the nonintraoperative proctosigmoidoscopy group in (1) mean of total operative time and (2) rate of perioperative complications. A total of 28 patients were enrolled and equally distributed in the 2 groups. The rate of intraoperative proctosigmoidoscopy success was 86%. No significant difference was reported between the 2 groups in terms of total operative time (p = .1) and intraoperative and postoperative complications (p = .5 and p = 1, respectively), with no surgical complication related to intraoperative proctosigmoidoscopy. Intraoperative proctosigmoidoscopy seems as a feasible and non-time-consuming intraoperative procedure in women undergone discoid resection for rectosigmoid endometriosis. Larger studies with longer follow-up period are necessary to confirm our findings and assess clinical benefits over standard procedure.

Current and Future Role of HIFU in Obstetric Gynaecology

Obstetric gynaecology, as a field in which diagnostic ultrasound has quickly found its place, especially in screening for birth defects and monitoring pregnancies, is also a speciality in which therapeutic ultrasound is used extensively.In pelvic gynaecology, HIFU therapy is used more specifically in two types of uterine conditions: fibroids and adenomyosis. In both cases, studies have shown significant efficacy in reducing pain and bleeding associated with the conditions, secondarily (more moderately but still significantly) reducing the volume of the lesions. Impact on fertility has yet to be demonstrated.In rectosigmoid endometriosis, clinical data indicates good treatment feasibility and significant efficacy on digestive and gynaecologic pain symptoms, as well as on quality of life, with no associated severe complications. Should the efficacy of HIFU in treating endometriosis be confirmed over time, it could revolutionise the management of digestive endometriosis by offering a valid minimally invasive alternative to rectosigmoid surgery.In senology, where visible scars have a particularly significant psychological impact, several teams have been researching the use of HIFU for the destruction of some types of breast lesions (fibroadenomas and breast tumours).In obstetrics, HIFU could become a treatment of choice for vascular anomalies such as twin-to-twin transfusion syndrome in twin pregnancies. Promising studies are also available regarding the use of HIFU in the treatment of post-partum placenta accreta.

Treatment of rectosigmoid endometriosis by laparoscopic reverse submucosal dissection (LRSD): TheSydney partial thickness discoid excision technique.

Laparoscopic reverse submucosal dissection (LRSD) is a standardised surgical technique for removal of rectosigmoid endometriosis which optimises the anatomical dissection plane for excision of endometriotic nodules. This cohort study assesses the outcomes of the first cohort of women treated by LRSD, for deeply infiltrating rectosigmoid endometriosis. Primary outcomes assessed were complication rate as defined by the Clavien-Dindo system, and completion of the planned LRSD. Secondary outcomes include mucosal breach, specimen margin involvement, length of hospital admission, and a comparison of pre-operative and post-operative pain, bowel function and quality of life surveys. These included the Endometriosis Health Profile Questionnaire (EHP-30), the Knowles-Eccersley-Scott Symptom Questionnaire (KESS) and the Wexner scale. Of 19 patients treated, one required a segmental resection. The median length of hospital admission was two days (range 1-5) and no post-operative complications occurred. Median pain visual analogue scales (scale 0-10) were higher prior to surgery (dysmenorrhoea 9.0, dyspareunia 7.5, dyschezia 9.0, pelvic pain 6.0) compared to post-surgical median scores (dysmenorrhoea 5.0, dyspareunia 4.0, dyschezia 2.0, pelvic pain 4.0) at a median of six months (range 4-32). Quality of life studies suggested improvement following surgery with pre-operative median EHP-30 and KESS scores (EHP-30: 85 (5-106), KESS score 9 (0-20)) higher than post-operative scores (EHP-30: 48.5 (0-80), KESS score: 3 (0-19)). This series highlights the feasibility of LRSD with low associated morbidity as a progression of partial thickness discoid excision (rectal shaving) for the treatment of rectosigmoid deep infiltrating endometriosis.

Not All Bad Comes to Harm: Enhanced Recovery After Surgery for Rectosigmoid Endometriosis

To assess the impact of implementing an enhanced recovery after surgery (ERAS) protocol on the length of hospitalization in women undergoing laparoscopy for rectosigmoid deep infiltrating endometriosis (DIE). A retrospective cohort study. An academic referral center for endometriosis and minimally invasive gynecologic surgery. Women aged between 18 and 50 years scheduled for laparoscopic excision (shaving, full-thickness anterior wall resection, segmental resection) of rectosigmoid endometriosis between February 2017 and February 2023. We divided patients into 2 groups (non-ERAS and ERAS) based on the timing of surgery (before or after March 5, 2020). Starting from this day, restrictions were issued to limit the spread of the coronavirus disease 2019 pandemic, inducing our group to implement an ERAS protocol for patients hospitalized after surgery for posterior DIE. We included 579 patients in the analysis, 316 (54.6%) in the non-ERAS group and 263 (45.4%) in the ERAS group. In the ERAS group, we observed a shorter length of hospital stay (5.8 ± 3.1 days vs 4.8 ± 2.9 days; p <.001) and lower complications rates (33, 12.5% vs 60, 19.0%; p=.04), despite a decreased frequency of conservative surgical approaches (shaving procedures 121 vs 196; p <.001). Repeated surgery or hospital readmissions owing to postdischarge complications were infrequent, with no significant differences between the 2 groups. The multiple linear regression analysis strengthened our results given the higher prevalence of bowel resection surgeries (both full-thickness anterior wall or segmental), showing that patients managed with a multimodal protocol had an overall reduction of hospital stay by 1.5 days. The implementation of an ERAS program in patients undergoing laparoscopic surgery for DIE is associated with a significant reduction in hospital stay, without an increase in perioperative or postoperative complication rates.

Fertility sparing double discoid excision of rectosigmoid deep endometriosis under robotic-integrated ultrasound guidance

ObjectiveTo present the use of robotic-integrated ultrasound in performing a double discoid excision of multifocal rectosigmoid endometriosis. DesignVideo article Statement of ConsentThe patient included in this video gave consent for publication of the video and posting of the video online including social media, the journal website, scientific literature websites (such as PubMed, ScienceDirect, Scopus, etc.) and other applicable sites. SubjectsA 26 year-old G0 with chronic pelvic pain, dyschezia and dysmenorrhea refractory to medical management who desires future fertility. Imaging was suggestive of deep infiltrating endometriosis involving the rectosigmoid colon. Exposuren/a Main Outcome MeasuresDouble Discoid Excision of multifocal rectosigmoid endometriosis using robotic integrated ultrasound. Resultsn/a ConclusionPerforming a complete pre-operative evaluation in patient’s with suspected endometriosis is important in determining the extent of disease and the necessity of a multidisciplinary approach. Robotic-integrated ultrasound can provide additional information including size and depth of bowel endometriosis lesions, which can play a role in surgical decision making. Performing a double discoid excision of multifocal rectosigmoid endometriosis with the use of robotic-integrated ultrasound is a technique that can avoid the need for a segmental bowel resection.

The implications of the anatomy of the nerves and vessels in the treatment of rectosigmoid endometriosis.

Endometriosis is a common benign gynecological disease characterized by the presence of endometrial glands and stroma outside the uterus. It can be defined as endometrioma, superficial peritoneal endometriosis or deep infiltrating endometriosis (DIE) depending on the location and the depth of infiltration of the organs. In 5%-12% of cases, DIE affects the digestive tract, frequently involving the distal part of the sigmoid colon and rectum. Surgery is generally recommended in cases of obstructive symptoms and in cases with pain that is non-responsive to medical treatment. Selection of the most optimal surgical technique for the treatment of bowel endometriosis must consider different variables, including the number of lesions, eventual multifocal lesions, as well as length, width and grade of infiltration into the bowel wall. Except for some major and widely accepted indications regarding bowel resection, established international guidelines are not clear on when to employ a more conservative approach like rectal shaving or discoid resection, and when, instead, to opt for bowel resection. Damage to the pelvic autonomic nervous system may be avoided by detection of the middle rectal artery, where its relationship with female pelvic nerve fibers allows its use as an anatomical landmark. To reduce the risk of potential vascular and nervous complications related to bowel resection, a less invasive approach such as shaving or discoid resection can be considered as potential treatment options. Additionally, the middle rectal artery can be used as a reference point in cases of upper bowel resection, where a trans mesorectal technique should be preferred to prevent devascularization and denervation of the bowel segments not affected by the disease.

Laparoscopic shaving of rectosigmoid deep infiltrating endometriosis under laparoscopic ultrasound guidance

To present laparoscopic shaving of rectosigmoid endometriosis using the novel approach of laparoscopic ultrasound guidance to enhance complete excision. The intervention performed includes excision of rectosigmoid deep infiltrating endometriosis under guidance of laparoscopic ultrasound. NA RESULTS & CONCLUSION: It is important to perform a complete pre-operative evaluation to determine the extent of disease and the necessity of a multidisciplinary approach. Intraoperative laparoscopic ultrasound can provide additional information including size and depth of lesions, which could play a role in surgical decision making. Laparoscopic ultrasound may enhance complete excision of DIE lesions and decrease the incidence of recurrence.

Impact of surgery on fertility among patients with deep infiltrating endometriosis

ObjectiveThe aim of the study was to investigate pregnancy and live birth rate after surgical resection of rectosigmoid deep infiltrating endometriosis (DIE), and study if complications affect these rates. Study designHistorical case series. 193 patients with rectosigmoid DIE and pregnancy intention undergoing a rectosigmoid resection for DIE from January 2009 to May 2019. All operations were performed at the Department of Obstetrics and Gynecology, Aarhus University Hospital, Denmark. Surgical and fertility outcome data were obtained through patient files. Anonymized data was analyzed statistically. Normally distributed continuous variables are stated as means, categorical data as percentages and time to pregnancy as Kaplan-Meier failure function. Live birth rates stratified on complications were tested with chi2 test. Results117 patients became pregnant postoperatively with a pregnancy and live birth rate of 60.6% and 53.9%, respectively. 39 patients (20.2%) became pregnant spontaneously and 78 patients (40.4%) by intrauterine insemination or assisted reproductive technologies. Median time to pregnancy after surgery was 12.4 months (range: 0.4–58). Clavien-Dindo complication grade III (none grade IV) was registered among 16.6%. These patients had pregnancy and live birth rates of 50%, not statistically significantly different from those without complications. ConclusionsPostoperative pregnancy and live birth rates after resection of rectosigmoid endometriosis in this study are in line with conservative treatment, when comparing with the literature. Interestingly, complications (Clavien-Dindo grade III) did not affect live birth rate or time to pregnancy.

Laparoscopic Shaving of Rectosigmoid Deep Infiltrating Endometriosis Under Laparoscopic Ultrasound Guidance

<h3>Study Objective</h3> Our study objectives include presenting laparoscopic shaving of rectosigmoid endometriosis and describing the novel approach of using laparoscopic ultrasound guidance to enhance complete excision. <h3>Design</h3> Laparoscopic ultrasound during rectosigmoid deep infiltrating endometriosis excision. <h3>Setting</h3> Tertiary care center. <h3>Patients or Participants</h3> Patient presenting for multidisciplinary surgical excision of DIE. <h3>Interventions</h3> The intervention performed includes excision of rectosigmoid deep infiltrating endometriosis with use of laparoscopic ultrasound. <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> It is important to perform a complete pre-operative evaluation to determine the extent of disease and the necessity of a multidisciplinary approach. Laparoscopic ultrasound can provide additional information including size and depth of lesions, which could play a role in surgical decision making. Laparoscopic ultrasound may enhance complete excision of DIE lesions and decrease the incidence of recurrence.

S2023 Endometrioma Presenting as a Sigmoid Colon Polyp

Introduction: Endometriosis refers to inflammation caused by active endometrium outside of the uterus. Colonic involvement can give rise to various complications, such as luminal narrowing, obstruction, and even perforation; all which can be avoided with endoscopic mucosal resection (EMR). Our case shows that endometrial implants in the colon can present similarly to colon cancer and should be considered as a potential etiology of findings on colonoscopy. Case Description/Methods: A 45-year-old female (G4P3) presented with a several month history of left lower quadrant abdominal pain, bloating and multiple episodes of blood per rectum. Past medical history was significant for endometriosis with hysterectomy, tubal ligation, and idiopathic thrombocytopenic purpura. She was referred for a rectosigmoid polyp concerning for malignancy. The mass found was a firm, rubbery, 15mm, exophytic sessile polyp positioned on the acute fold of the sigmoid colon. Using an underwater technique, piecemeal EMR was performed. Argon plasma coagulation (APC) ablation was performed on residual adjacent tissue and the resection bed. Histopathology showed endometriosis involving the muscularis propria and submucosa negative for hyperplastic polyp, adenoma or malignancy. Endometriosis stain was positive for CK7 and PAX-8 and negative for CK20 and CDX-2 confirming the diagnosis. Hormone therapy was initiated and showed significant improvement in symptoms (Figure). Discussion: Endometriosis can affect essentially any organ. Intestinal involvement usually presents with symptoms and gross appearance similar to many disorders including cancer or leiomyoma, such as in our case. Endometriosis usually involves serosa and subserosa. When there is deep invasion into the muscularis propria and submucosa, it can be mistaken for colon cancer, delaying and complicating diagnosis. The gold standard for diagnosing endometriosis is laparoscopy, but colonoscopy can provide direct visualization of lesions with the opportunity for EMR and confirmatory biopsy. As rectosigmoid endometriosis surgery is associated with high rates of complication when compared to other parts of the colon, EMR was preferred in our case. Hormone therapy can help prolong the recurrence interval between resection and recurrence, but has no effect on lesion size. A multidisciplinary approach to intestinal endometriomas with hormone therapy combined with EMR can lower recurrence, remove lesions completely, and help patients avoid endometrioma complications and high-risk surgical procedures.Figure 1.: a: Lesion development prior to EMR. b: Cap-assisted underwater technique piecemeal EMR performed using hot 20 mm and 10 mm snares. c: Lesion was completely removed, retrieved, and APC ablation was performed on residual tissue adjacent to the resection site, as well as resection bed.

Evaluation of an e-learning program for the diagnosis of rectosigmoid endometriosis with rectal water contrast transvaginal ultrasonography (rectosonography)

This study aimed to evaluate the value of an e-learning program for the diagnosis of rectosigmoid endometriosis lesions using rectal water contrast transvaginal ultrasonography (rectosonography/RSG). Theoretical RSG training using videos with a commentary was offered online to healthcare professionals involved in ultrasound screening for endometriosis. A test (without correction) with 24 RSG video loops was used to assess the participants’ baseline level before the training and their improvement afterwards. If the success rate post-training was below 80 %, the participant could start over with another series of 24 videos. Between February and June 2020, thirty participants took the training course (of which 80 % were obstetrics-gynaecology residents). The e-learning program resulted in a significant performance increase in the diagnosis of rectosigmoid endometriosis lesions, with a higher test success rate after the training compared to before (74.4 % and 63.6 % respectively; +10.8 %; 95 % CI [6,6; 15]; p < 0.001). Significant improvement was also observed regarding the overall skills involved in the ultrasound diagnosis of deep infiltrating endometriosis (+9.2 %; p < 0.001), the accurate diagnosis of the height of bowel lesions (+14.7 %; p < 0.001) and uterosacral ligament lesions (+8%; p < 0.005). In conclusion, our e-learning program led to a significant improvement of the diagnostic performance of digestive endometriosis using transvaginal ultrasound with intrarectal water contrast (rectosonography). Adding feedback to the post-test video loops could further increase the efficacy of the e-learning training.

O-309 Surgery versus IVF/ICSI in infertile women with rectosigmoid endometriosis: the FERTILITY-RECTOSIGMOID study

Abstract Study question To compare the live birth rate in infertile patients with rectosigmoid endometriosis treated by surgery or IVF/ICSI. Summary answer In infertile women with rectosigmoid endometriosis, IVF/ICSI is associated with a higher live birth rate and a shorter time to conceive than first-line surgery. What is known already The choice between surgery and IVF/ICSI is based on several variables including concomitant infertility factors, presence of (sub)occlusive symptoms, preference of patients. Until now, there is no evidence to favor first-line IVF/ICSI or first-line surgery in women affected by rectosigmoid endometriosis wishing to conceive. Study design, size, duration This was a prospective patient’s preference study enrolling infertile women with rectosigmoid endometriosis who underwent first-line surgery or IVF/ICSI. Symptoms and fertility outcomes were compared between the two groups. Participants/materials, setting, methods Rectosigmoid endometriosis was diagnosed by transvaginal ultrasonography and magnetic resonance enema. All study patients underwent computed tomographic colonography (CTC) to assess the degree of stenosis of the intestinal lumen. Inclusion criteria were infertility; bilateral tubal patency; age &amp;lt; 40 years. Exclusion criteria were history of surgery for endometriosis; previous IVF/ICSI cycles; oocyte donation or vitrified oocyte procedures; poor ovarian reserve; estimated bowel stenosis &amp;gt; 70% at CTC; (sub)occlusive symptoms; oligospermia (sperm count &amp;lt; 15 million/mL). Main results and the role of chance Two hundred twenty-nine patients underwent IVF/ICSI. Patients underwent up to 4 IVF/ICSI cycles. Overall, 128 women had a live birth (55.9%; 95% C.I., 49.2%-62.4%). Two bowel sub occlusions occurred during IVF-ICSI. 198 patients underwent surgical treatment of rectosigmoid endometriosis. Nine patients have postoperative complications: four rectovaginal fistula, two anastomotic leakage, two pelvic abscess and one postoperative bleeding. At a median follow-up of 23 months after surgery (range, 12-56 months), 91 women had a live birth (44.9%; 95% C.I., 38.0%-56.1%). The live-birth rate was significantly higher in patients who underwent IVF/ICSI than in those who underwent surgery (p = 0.047). The time to conception that resulted in live birth was significantly shorter in patients who underwent IVF/ICSI (mean ± SD, 11.9 ± 7.6 months) than in those who underwent surgery (18.5 ± 8.1 months; p = 0.037). Six months after surgery or first IVF/ICSI cycle, there was a higher improvement of pain (p &amp;lt; 0.001) and intestinal symptoms (p &amp;lt; 0.001) in women surgically treated. No bowel endometriosis-related complication occurred during pregnancy. There was no difference in perinatal outcomes between the two groups. Limitations, reasons for caution The nonrandom allocation to treatments and the relatively small sample sized limits the strength of our results. Wider implications of the findings IVF/ICSI is associated with a higher live birth rate and a shorter time to conceive than surgery. The disadvantages of IVF/ICSI are potential endometriosis-related complications during the procedure and persistence of symptoms. Surgery improves symptoms but it has a higher risk of postoperative complications, which may negatively impact spontaneous conception. Trial registration number CE Liguria - ID 10766 - n. 394 (Approval: 10/2020)

The Use of near Infra-Red Radiation Imaging after Injection of Indocyanine Green (NIR-ICG) during Laparoscopic Treatment of Benign Gynecologic Conditions: Towards Minimalized Surgery. A Systematic Review of Literature.

Background and Objectives: To assess the use of near infrared radiation imaging after injection of indocyanine green (NIR–ICG) during laparoscopic treatment of benign gynecologic conditions. Materials and Methods: A systematic review of the literature was performed searching 7 electronic databases from their inception to March 2022 for all studies which assessed the use of NIR–ICG during laparoscopic treatment of benign gynecological conditions. Results: 16 studies (1 randomized within subject clinical trial and 15 observational studies) with 416 women were included. Thirteen studies assessed patients with endometriosis, and 3 studies assessed non-endometriosis patients. In endometriosis patients, NIR–ICG use appeared to be a safe tool for improving the visualization of endometriotic lesions and ureters, the surgical decision-making process with the assessment of ureteral perfusion after conservative surgery and the intraoperative assessment of bowel perfusion during recto-sigmoid endometriosis nodule surgery. In non-endometriosis patients, NIR–ICG use appeared to be a safe tool for evaluating vascular perfusion of the vaginal cuff during total laparoscopic hysterectomy (TLH) and robotic-assisted total laparoscopic hysterectomy (RATLH), and intraoperative assessment of ovarian perfusion in adnexal torsion. Conclusions: NIR–ICG appeared to be a useful tool for enhancing laparoscopic treatment of some benign gynecologic conditions and for moving from minimally invasive surgery to minimalized surgery. In particular, it might improve treatment of endometriosis (with particular regard to deep infiltrating endometriosis), benign diseases requiring TLH and RATLH and adnexal torsion. However, although preliminary findings appear promising, further investigation with well-designed larger studies is needed.

Mushroom Cap a Sign of Rectosigmoid Deep Infiltrating Endometriosis on MRI Corresponding to Surgical Specimen

Rectosigmoid deep infiltrating endometriosis accounts for 75% to 90% of cases of intestinal endometriosis [1]. Most cases with rectosigmoid involvement are identified within the serosa; the lesions may infiltrate deeply into the intestinal wall to produce a nodular mass [2]. Deep rectosigmoid endometriosis often leads to severe intestinal symptoms including hematochezia and dyschezia [2]. The ectopic endometrial glands in deep pelvic endometriosis are surrounded by fibrous tissue and smooth muscle proliferation.

3D Patient-Specific Virtual Models for Presurgical Planning in Patients with Recto-Sigmoid Endometriosis Nodules: A Pilot Study.

Background and Objective: In recent years, 3D printing has been used to support surgical planning or to guide intraoperative procedures in various surgical specialties. An improvement in surgical planning for recto-sigmoid endometriosis (RSE) excision might reduce the high complication rate related to this challenging surgery. The aim of this study was to build novel presurgical 3D models of RSE nodules from magnetic resonance imaging (MRI) and compare them with intraoperative findings. Materials and Methods: A single-center, observational, prospective, cohort, pilot study was performed by enrolling consecutive symptomatic women scheduled for minimally invasive surgery for RSE between November 2019 and June 2020 at our institution. Preoperative MRI were used for building 3D models of RSE nodules and surrounding pelvic organs. 3D models were examined during multi-disciplinary preoperative planning, focusing especially on three domains: degree of bowel stenosis, nodule’s circumferential extension, and bowel angulation induced by the RSE nodule. After surgery, the surgeon was asked to subjectively evaluate the correlation of the 3D model with the intra-operative findings and to express his evaluation as “no correlation”, “low correlation”, or “high correlation” referring to the three described domains. Results: seven women were enrolled and 3D anatomical virtual models of RSE nodules and surrounding pelvic organs were generated. In all cases, surgeons reported a subjective “high correlation” with the surgical findings. Conclusion: Presurgical 3D models could be a feasible and useful tool to support surgical planning in women with recto-sigmoidal endometriotic involvement, appearing closely related to intraoperative findings.

Preoperative Imaging in Patients with Deep Infiltrating Endometriosis: An Important Aid in Predicting Depth of Infiltration in Rectosigmoid Disease

To determine the diagnostic accuracy of specialist-performed transvaginal ultrasound (TVUS) and pelvic magnetic resonance imaging (MRI) modalities in predicting depth of deep infiltrating endometriosis (DIE) of the rectosigmoid by comparison with histologic specimens obtained at surgery. A retrospective analysis, which met the Standards for Reporting of Diagnostic Accuracy Studies (2015) guidelines for a diagnostic accuracy study. Tertiary teaching hospital. A total of 194 cases who underwent preoperative discussion at the gynecologic endosurgery unit multidisciplinary meeting between January 2012 and December 2019 were eligible for inclusion. Retrospective assessment of the accuracy of TVUS and MRI in predicting histologic depth of rectosigmoid DIE after operative management. Al total of 135 surgeries were performed for DIE; 20 underwent a rectal shave, 14 had a disc/wedge resection, 38 an anterior/segmental resection, and 63 had no rectosigmoid surgery. Of the 52 patients with full-thickness rectal wall excision, all patients had at least one imaging modality available for review; 42 (81%) had both. At least one imaging modality was in agreement with histologic depth in 48 cases (92%) (sensitivity, 94%; specificity, 50%; positive predictive value [PPV], 97.9%; negative predictive value [NPV], 25.0%; area under the receiver operating curve, 0.720; 95% confidence interval, 0.229-1.000). When TVUS was assessed in isolation, the test remained sensitive for any rectal wall involvement (sensitivity, 93.6%; specificity, 50.0%; PPV, 97.8%; NPV, 25.0%; area under the receiver operating curve, 0.718; 95% confidence interval, 0.227-1.000). When only MRI was assessed, the test demonstrated both high sensitivity and specificity for rectal wall disease (sensitivity, 86.4%; specificity, 100%; PPV, 100%; NPV, 14.2). Specialist-performed TVUS and MRI are accurate in predicting depth of disease in rectosigmoid endometriosis. These modalities were similar in their diagnostic performance at assessing depth of rectal wall involvement, and their use is justified in the preoperative planning of these gynecologic surgeries.

A Rare Cause of Bowel Obstruction Mimicking Colon Cancer: Endometriosis

Intestinal involvement is observed in a significant portion of patients diagnosed with endometriosis. Involvement is often on the serosal surface of the sigmoid colon. Rarely, it takes place in the colonic mucosa and lymph nodes, causing lumen obstruction. Colonoscopic biopsies may be insufficient in the differential diagnosis of malignancy and diverticulitis. We report a case of a 41-year-old premenopausal female patient with endometriosis located in the ampulla recti causing complete intestinal obstruction. Although having a significant rectal mucosal mass, the diagnosis could not be made with tissue samples taken by endoscopy. During the examination, the patient developed ileus. With the preliminary diagnosis of rectal cancer, surgical intervention was applied with oncological principles, and its treatment was performed with opening a diverting ileostomy. Diagnosis of rectosigmoid endometriosis is difficult. In women of childbearing age, rectosigmoid endometriosis should be kept in mind in lower gastrointestinal tract obstructions.

Indocyanine green fluorescence angiography after full-thickness bowel resection for rectosigmoid endometriosis: Amulticentric experience with quantitative analysis.

To evaluate effectiveness and reproducibility of qualitative and quantitative near-infrared indocyanine green (NIR-ICG) analyses as a tool for anastomotic perfusion assessment after full-thickness bowel resection for rectosigmoid endometriosis (RSE). Symptomatic women with RSE undergoing minimally invasive full-thickness surgical excision of RSE and NIR-ICG evaluation from November 2019 to July 2020 were included. Study outcomes were the accuracy of qualitative and quantitative NIR-ICG analyses in predicting bowel fistula and their reproducibility. NIR-ICG predictive accuracy was assessed by calculating sensitivity, specificity, and area under the curve on receiver operating characteristic curves with 95% confidence intervals (CI). NIR-ICG reproducibility was assessed through Cohen's k coefficient to determine interoperator agreement between two observers. Of 33 patients, 2 (6%) developed bowel fistula. In predicting bowel fistula, qualitative and quantitative NIR-ICG evaluations showed sensitivity of 100% and 100%, specificity of 71% and 93%, and area under the curve of 0.86 (95% CI 0.67-1.00) and 0.96 (95% CI 0-1.00), respectively. Regarding interoperator agreement rate, it was reported as excellent for the qualitative analysis and very good for the quantitative analysis. Qualitative and quantitative NIR-ICG evaluations might be effective and reproducible tools for anastomotic perfusion assessment after discoid or segmental resection for RSE. Quantitative evaluation might be even more effective than qualitative evaluation in predicting bowel fistula.