Resección intestinal por endometriosis severa, diagnóstico y tratamiento luego de la introducción de la Unidad de Endometriosis: revisión de 18 años en el Hospital Clínico de la Universidad de Chile / Bowel resection for severe endometriosis, diagnosis and treatment after the introduction of Endometriosis Unit: 18 years review, Clinical Hospital of the University of Chile

INTRODUCCIÓN: La endometriosis intestinal afecta en gran medida la calidad de vida de una mujer joven y habitualmente requiere un tratamiento quirúrgico con resección intestinal. Esta cirugía es técnicamente compleja por las adherencias firmes del intestino a la vagina, el útero y los ovarios. OBJETIVO: Describir y analizar los resultados quirúrgicos e histopatológicos de las resecciones intestinales por endometriosis grave durante los últimos 18 años en el Hospital Clínico de la Universidad de Chile, en relación con la introducción de la unidad multidisciplinaria de endometriosis, a partir del año 2011, y las experiencias publicadas en la literatura chilena y extranjera. MÉTODO: Trabajo retrospectivo realizado en un hospital terciario desde el año 2001 hasta el año 2019. Las pacientes se asignaron a dos grupos según el período de cirugía: grupo 2001-2010 y grupo 2011-2019, luego de la introducción de la unidad de endometriosis. Se recopilaron todas las pacientes a las que se realizó una resección intestinal (discoidal o segmentaria) por endometriosis, por laparotomía o laparoscopía. Los datos distribuidos normalmente se presentan como promedio ± DE y los datos no paramétricos como mediana (rango). Las comparaciones demográficas de variables continuas se hicieron con la prueba t de Student y las de las variables categóricas con las pruebas de ji al cuadrado o de Fisher. La significación estadística se estableció en p < 0,05. RESULTADOS: Se recopilaron 52 casos. El 94,2% de las cirugías fueron electivas. El 5,8% fueron de urgencia por obstrucción intestinal (todas entre 2001 y 2010). Un 75% de las cirugías fueron laparoscópicas. Se realizó resección segmentaria en el 67,3%, resección discoidal simple en el 28,8%, resección discoidal doble en el 1,9% y resección segmentaria y una discoidal en el 1,9%. La histopatología demostró compromiso de la lesión hasta la mucosa intestinal en un 7,7%. Hubo franca disminución del dolor en el seguimiento de las pacientes. El 24% de las pacientes con deseo de embarazo y endometriosis intestinal lograron un parto de término mediante fecundación in vitro o espontáneamente. Hubo cuatro complicaciones posoperatorias, tres de ellas de categoría II según la clasificación de Clavien-Dindo y una de categoría IV A con reintervención a las 72 horas. Al comparar ambos periodos, en 2001-2010 los exámenes diagnósticos utilizados fueron ecografía transvaginal (0%), enema baritado (60%), tomografía computarizada de abdomen y pelvis (45%) y resonancia magnética pelviana (20%), mientras que en 2011-2019 fueron ecografía transvaginal (100%), enema baritado (3%), tomografía computarizada (3%) y resonancia magnética pelviana (66%). En 2001-2010, las lesiones fueron más más infiltrativas (mayor compromiso mucoso y submucoso) (75 vs. 16% de las resecciones intestinales; p < 0,05), estenóticas (cirugías de urgencia por obstrucción), con mayor porcentaje de resecciones segmentarias (100 vs. 46,9%; p < 0,05) y más días de hospitalización (5,8 ± 2,3 vs. 4,1 ± 0,9 días) que en 2011-2019. CONCLUSIONES: A nuestro entender, esta es la serie más grande publicada en Chile de resecciones intestinales por endometriosis. Estos hallazgos demuestran cómo la introducción de la unidad multidisciplinaria de endometriosis permite un diagnóstico precoz y un tratamiento quirúrgico eficaz y oportuno, tal como se decribe en la literatura.

INTRODUCTION: Bowel endometriosis severely affects a young woman's quality of life and often requires surgical treatment with bowel resection. This surgery is technically complex due to the tight adhesions of the intestine to the vagina, uterus, and ovaries. The objective of this work is to describe and analyze the surgical and histopathological results of intestinal resections for severe endometriosis during the last 18 years at the Clinical Hospital University of Chile, in relation to the implementation of the multidisciplinary endometriosis unit, based on the year 2011 and the experiences published in Chilean and foreign literature. METHOD: Retrospective work carried out in a tertiary hospital from 2001 to 2019. The patients were assigned to two groups according to the surgery period: group 2001-2010 and group 2011-2019, after endometriosis unit formation. All patients who underwent bowel resection (discoidal or segmental) for endometriosis by laparotomy or laparoscopy were collected. Normally distributed data are presented as mean ± SD and nonparametric data as median (range). Demographic comparisons of continuous variables are compared using Student's t test and categorical variables using chi squared or Fisher's test. Statistical significance was established at p < 0.05. RESULTS: 52 cases were collected. 94.2% of the surgeries were elective. 5.8% were urgent due to intestinal obstruction (all between 2001 and 2010). 75% of the surgeries were laparoscopic. Segmental resection 67.3%, simple discoidal resection 28.8%, double discoidal resection 1.9% and segmental resection and a discoidal resection 1.9%. Histopathology showed involvement of the lesion up to the intestinal mucosa in 7.7%. A marked decrease in pain in the follow-up of the patients. 24% of the patients with a desire for pregnancy and intestinal endometriosis achieved a full-term delivery by IVF or spontaneously. There were four postoperative complications, three of them category II according to the Clavien-Dindo classification, and one category IV A complication with reoperation at 72 h. When comparing both periods, between 2001-2010 the diagnostic tests used were: transvaginal ultrasound (ECO TV) (0%), barium enema (BE) (60%), abdomen pelvis CT (45%) and pelvic resonance (MRI) (20%). Between 2011 and 2019 ECO TV (100%), EB (3%), TAC (3%) RM (66%). In the period 2001 to 2010, the lesions were more infiltrative (greater mucosal and submucosal involvement) (75% vs 16% of intestinal resections (P <0.05)), stenotic (urgent surgery for obstruction), with a higher percentage of resections segmental (100% vs 46.9% (P <0.05) and more days of hospitalization (5.8 ± 2.3 SD vs 4.1 ± 0.9 SD) than in the period from 2011 to 2019. CONCLUSIONS: To our knowledge, this is the largest series published in Chile of intestinal resections for endometriosis. These findings demonstrate how the introduction of the multidisciplinary endometriosis unit allows early diagnosis and effective and timely surgical treatment as described in the literature.

Resonancia magnética en el estudio de dos pacientes con dolor pélvico crónico asociado a endometriosis de infiltración profunda / Magnetic resonance imaging in the study of two patients with chronic pelvic pain associated to infiltrating endometriosis deep

INTRODUCCIÓN: La endometriosis de infiltración profunda (EIP) es una enfermedad crónica de difícil diagnóstico, que frecuentemente es confundida con otras patologías pelvianas. OBJETIVO: Presentar dos casos de endometriosis de infiltración profunda, donde la resonancia magnética (RM) de pelvis, fue importante para el diagnóstico y planificación del tratamiento quirúrgico. CASO CLÍNICO: Se describe el caso de dos pacientes. La primera de 24 años afectada por un nódulo de EIP retrocervical con extensión intestinal sintomática y la segunda, una paciente de 37 años con una recidiva sintomática de EIP en la cúpula vaginal después de una histerectomía total. RESULTADOS: La RM de pelvis describe en ambos casos la extensión de las lesiones endometriósicas y presenta una excelente correlación con los hallazgos intra operatorios en la laparoscopía quirúrgica. CONCLUSIONES: La RM de pelvis es un excelente recurso en el estudio diagnóstico de las pacientes con dolor pélvico crónico, tanto en el caso de EIP retrocervical con extensión intestinal y también en la recidiva de EIP en la cúpula vaginal después de una histerectomía total

INTRODUCTION: Deep infiltration endometriosis (DIE) is a chronic disease of difficult diagnosis, which is frequently confused with other pelvic pathologies. OBJETIVE: To present two cases of deep infiltrating endometriosis, where the pelvic magnetic resonance imaging (MRI) was important in the diagnosis and surgical treatment planning. CLINICAL CASES: Two cases, one 24 years-old patient suffering from retrocervical DIE nodule with symptomatic bowel involvement, and a 37 years-old patient, with a symptomatic DIE at the vaginal cuff after total hysterectomy. RESULTS: Pelvic MRI describes in both cases the extension of the endometriotic lesions and presents an excellent correlation with the intra operatory findings during surgical laparoscopy. CONCLUSIONS: Pelvic MRI is an excellent diagnostic tool for patients with pelvic pain, in case of retrocervical DIE with bowel involvement, and also in recurrence of DIE at the vaginal cuff after total hysterectomy

Perioperative nursing care to 14 patients with bowel endometriosis / 现代临床护理

Objective To sum up the measures for nursing 14 patients with bowel endometriosis(BE).Method Toally 14 BE patients hospitalized in our hospital during January 2009 to January 2016 were treated,with nursing care including:preoperative mental care and bowel preparation,and postoperative close observations to the incisions,dieting guidance and observations and treatment of the complications,and corresponding health education.Result The incisions of all the patients were well healed and the bowel function was restored.Conclusion Such nursing measures as preoperative mental care and bowel preparation,and postoperative close observations to the incisions,dieting guidance and observations and treatment of the complications,and corresponding health education.

Abdome agudo obstrutivo causado por endometriose intestinal: relato de caso / Acute abdomen obstructive by bowel endometriosis: case report

Endometriose é definida como a implantação de tecido endometrial funcionante fora da cavidade uterina. Quando afeta os intestinos, ela pode se manifestar por estenose, levando ao abdômen agudo. Trata-se de um estudo de caso de uma paciente com dor abdominal, constipação intestinal e queixas ginecológicas. A paciente evoluiu com obstrução intestinal aguda e foi submetida à laparoscopia. Identificou-se estenose no sigmoide sugestivo de malignidade. Foi submetida a tratamento cirúrgico com anastomose colorretal mecânica, colostomia temporária e o coto retal foi sepultado. O estudo histopatológico revelou endometriose em submucosa intestinal e muscular própria. Sem intercorrências até o quinto dia após a cirurgia quando a paciente apresentou dor abdominal, taquicardia, falta de ar, sinais de irritação peritoneal e pneumoperitônio. Formas ectópicas da endometriose são difíceis de diagnosticar. Abdômen agudo obstrutivo secundário à endometriose é complicação incomum e de difícil manejo. Portanto, considera-se importante a investigação clínica e laparoscópica de pacientes com patologias intestinais crônicas e quadro ginecológico sem causa etiológica aparente, a fim de diagnosticar formas ectópicas de endometriose.

Endometriosis is by the implantation of functioning endometrial tissue outside the uterine cavity. When it affects the intestines, it can manifest by stenosis, leading to acute abdomen. This is a case study of a patient with abdominal pain, chronic intestinal constipation and gynecological complaints. The patient developed acute intestinal obstruction and underwent laparoscopy. We identified stenosis in the sigmoid suggestive of malignancy. Underwent surgical treatment with mechanical colorectal anastomosis, temporary colostomy and the rectal stump was buried. Histopathological study revealed endometriosis in intestinal submucosa and muscularis propria. It was uneventful until the fifth day after surgery, when the patient presented abdominal pain, tachycardia, shortness of breath, signs of peritoneal irritation and pneumoperitoneum. Ectopic forms of endometriosis are difficult to diagnose. Acute abdomen secondary to obstructive endometriosis is rare, so clinical and laparoscopic investigation are of great importance in patients with chronic intestinal and gynecological complaints without apparent etiology, in order to diagnose ectopic forms of endometriosis.

Tratamento laparoscópico de 98 pacientes com endometriose intestinal / Laparoscopic treatment of 98 women with bowel endometriosis

OBJETIVO: Identificar os tipos de tratamento cirúrgico e a morbidade operatória na endometriose intestinal. MÉTODOS: Estudo retrospectivo de pacientes operadas no Biocor Instituto (Belo Horizonte, MG) por uma equipe multidisciplinar para tratamento de endometriose no período de janeiro de 2002 a junho de 2009. RESULTADO: Noventa e oito pacientes foram submetidas aos seguintes procedimentos para tratamento da endometriose intestinal: ressecção segmentar do reto (n 46; 45,5 por cento), ressecção em disco (n 25; 24,7 por cento), "shaving" (n 18; 17,8 por cento), apendicectomia (n 5; 5 por cento), liberação de aderências sem ressecção (n 5; 5 por cento), ressecção segmentar do sigmóide (n 1; 1 por cento) e ressecção segmentar do colo direito (n 1, 1 por cento). A cirurgia concomitante mais freqüente foi a ressecção de endometriomas ovarianos (n 45). A morbidade operatória foi de 9,2 por cento, sendo as complicações maiores uma fístula retovaginal (1 por cento) e uma deiscência de anastomose (1 por cento). Quarenta e duas pacientes tiveram seguimento médio de 14 meses com recidiva clínica em 8 casos (dor pélvica e dispareunia) e 4 recidivas de imagem à ultrassonografia em parede intestinal, assintomáticas. CONCLUSÃO: O tratamento da endometriose por laparoscopia é factível e seguro, com baixos índices de recidiva.

OBJECTIVE: The purpose of this study was to identify the types of surgical procedures performed and the operative morbidity in women with bowel endometriosis. METHODS: Retrospective evaluation of surgical records of women who underwent surgical treatment of endometriosis by a mutidisciplinar team at Biocor Instituto (Belo Horizonte, MG) from January 2002 to June 2009. RESULTS: Ninety-eight women underwent surgical treatment of bowel endometriosis during the study period. The following surgical procedures were performed: segmetnal rectal resection (n 46; 45,5 percent), intestinal disc excision (n 25; 24,7 percent), "shaving" (n 18; 17,8 percent), appendectomy (n 5; 5 percent), adhesiolysis without intestinal resection (n 5; 5 percent), segmental sigmoidectomy (n 1; 1 percent) e segmental right colon resection (n 1, 1 percent). The most frequent concomitant surgery performed was the removal of ovarian endometriomas (n 45). Operative morbity was observed in 9.2 percent and major complications were rectovaginal fistula (1 percent) and anastomosis dehiscence (1 percent). After a mean followup of 14 months that included 42 patients , recurrence of clinical symptoms (pelvic pain and dyspareunia) was observed in 8 cases as well as 4 cases of asymptomatic intestinal wall endometriosis recurrence which was identified by ultrasonography. CONCLUSION: Laparoscopic treatment of bowel endometriosis is feasible, safe and presents a low recurrence rate.