Invariant Natural Killer T-cells and their subtypes may play a role in the pathogenesis of endometriosis

Abstract Objective To evaluate the frequencies of iNKT cells and their subsets in patients with deep endometriosis. Methods A case-control study was conducted between 2013 and 2015, with 73 patients distributed into two groups: 47 women with a histological diagnosis of endometriosis and 26 controls. Peripheral blood, endometriosis lesions, and healthy peritoneal samples were collected on the day of surgery to determine the frequencies of iNKT cells and subtypes via flow cytometry analysis. Results The authors observed a lower number of iNKT (p= 0.01) and Double-Negative (DN) iNKT cells (p= 0.02) in the blood of patients with endometriosis than in the control group. The number of DN iNKT IL-17+ cells in the secretory phase was lower in the endometriosis group (p= 0.049). There was an increase in the secretion of IL-17 by CD4+ iNKT cells in the blood of patients with endometriosis and severe dysmenorrhea (p= 0.038), and severe acyclic pelvic pain (p= 0.048). Patients with severe dysmenorrhea also had a decreased number of CD4+ CCR7+ cells (p= 0.022). Conclusion The decreased number of total iNKT and DN iNKT cells in patients with endometriosis suggests that iNKT cells play a role in the pathogenesis of endometriosis and can be used to develop new diagnostic and therapeutic agents.

Tratamiento quirúrgico de la endometriosis pélvica profunda con compromiso colorrectal / Surgical treatment of deep pelvic endometriosis with colorectal involvement

INTRODUCCIÓN: En la endometriosis el compromiso intestinal afecta hasta al 12% de las pacientes, comprometiendo al recto y a la unión rectosigmoidea en el 90% de los casos. OBJETIVO: Describir la experiencia del equipo de Coloproctología y Ginecología de Clínica Alemana de Santiago en el tratamiento quirúrgico de la endometriosis pélvica profunda con compromiso colorrectal. MATERIAL Y MÉTODOS: Estudio retrospectivo a partir de la base de datos de pacientes con endometriosis tratados entre enero del año 2015 y abril de 2018. Los criterios de inclusión fueron pacientes con clínica de endometriosis pélvica profunda, que tuviesen compromiso colorrectal y hayan sido tratados con shaving rectal, resección discoide o resección segmentaria. Se revisaron fichas clínicas electrónicas, protocolos operatorios y biopsias definitivas. RESULTADOS: Se reclutaron 25 pacientes con una mediana de edad de 35 años. El síntoma principal de consulta fue dismenorrea y el síntoma digestivo más frecuente fue disquecia. En 8 pacientes se realizó un shaving rectal, en 7 una sigmoidectomía, en 9 una resección discoide y en 1 paciente una tiflectomía. La complicación posoperatoria reportada fue la hemorragia digestiva baja en 4 pacientes (Clavien-Dindo I y IIIa). Con una mediana de seguimiento de 13 meses, a la fecha 3 pacientes se les ha diagnosticado algún tipo de recidiva. CONCLUSIÓN: Es importante que la cirugía a realizar, garantice una morbilidad y recurrencia baja. Los resultados en nuestro centro son alentadores, lo que nos hace creer que el tratamiento quirúrgico podría ser una buena alternativa en la endometriosis pélvica profunda con compromiso colorrectal.

INTRODUCTION: In endometriosis, intestinal involvement affects up to 12% of patients, compromising the rectum and the rectosigmoid junction in 90% of cases. AIM: Describe the experience of the Coloproctolgy and Gynecology Team of the Clínica Alemana de Santiago in the surgical treatment of deep pelvic endometriosis with colorectal involvement. MATERIAL AND METHODS: Retrospective study based on the database of patients with endometriosis treated between January 2015 and April 2018. The inclusion criteria were patients with deep pelvic endometriosis clinic, who had colorectal involvement and who had been treated with rectal shaving, discoid resection or segmental resection. Electronic clinical records, operative protocols and definitive biopsies were reviewed. RESULTS: Twenty-five patients with a median age of 35 years were recruited. The main symptom of consultation was dysmenorrhoea and the most frequent digestive symptom was dyschezia. In 8 patients a rectal shaving was performed, in 7 a sigmoidectomy, in 9 a discoid resection and in 1 patient a tiflectomy. The only reported post-operative complication was low gastrointestinal bleeding in 4 of the 25 patients (Clavien-Dindo I and IIIa). A median follow-up of 13 months was achieved, to date 3 patients have been diagnosed with some type of recurrence. CONCLUSION: It is important that the surgery to be performed guarantees low morbidity and recurrence. The results in our center are encouraging, which makes us believe that surgical treatment could be a good alternative in deep pelvic endometriosis with colorectal involvement.

Manejo laparoscópico multidisciplinario de la endometriosis profunda del 2010 al 2017: estudio de cohorte retrospectivo / Multidisciplinary laparoscopic management of deep infiltrating endometriosis from 2010 to 2017: A retrospective cohort study

INTRODUCCIÓN La laparoscopía es actualmente el estándar en el manejo de la endometriosis profunda. Sin embargo, requiere de un entrenamiento específico e involucra la realización de procedimientos complejos y asociados a una alta tasa de complicaciones. Por lo anterior en Chile y Latinoamérica, la endometriosis profunda es frecuentemente manejada de manera inadecuada. OBJETIVO Describir nuestra experiencia en el enfrentamiento clínico y manejo quirúrgico laparoscópico de la endometriosis profunda, durante los últimos siete años. MÉTODOS Estudio de cohorte retrospectivo de 137 pacientes consecutivas operadas y con confirmación histológica de endometriosis profunda. Se recolectaron los datos demográficos, datos quirúrgicos, complicaciones, resultados reproductivos y seguimiento. RESULTADOS Todas las cirugías fueron completadas por laparoscopía, sin conversión. La dismenorrea y la dispareunia fueron los síntomas más frecuentes en 85,4 y 56,9%, respectivamente. La localización más frecuente de endometriosis profunda fueron los ligamentos úterosacros, coexistiendo un endometrioma en 48,9% de los casos. La mediana de tiempo operatorio fue de 140 minutos, siendo significativamente más prolongado en casos con compromiso intestinal (p < 0,0001). Quince pacientes (10,9%) presentaron complicaciones. El seguimiento medio fue de 24,5 meses. La tasa de embarazo fue de 58,1% y 90% de las pacientes reportó una mejoría significativa de su sintomatología. CONCLUSIONES El manejo laparoscópico de la endometriosis profunda es efectivo y seguro, pero debe reservarse a centros especializados y con disponibilidad de equipo multidisciplinario.

BACKGROUND Laparoscopy has become the standard of care in the surgical management of deep infiltrating endometriosis (DIE). However, it is a challenging procedure with a high complication rate. Despite the benefits of the minimally invasive approach, DIE resection is often performed by surgeons without adequate training, especially in developing countries like Chile. OBJECTIVE To asses our experience in the diagnosis and laparoscopic management of DIE during seven years. METHODS A retrospective cohort study of data including 137 patients with pathology-proven DIE. Surgical and fertility outcomes were evaluated. RESULTS All procedures were performed laparoscopically without conversion. Dysmenorrhea and dyspareunia were the most common symptoms in 85.4% and 56.9%, respectively. Uterosacral ligaments were the most common DIE location. Endometrioma was present in 48.9% of cases. Median operative time was 140 minutes; however, it was longer in cases requiring bowel surgery (p < 0.0001). The complication rate was 10.9%. Median follow-up was 24.5 months. The pregnancy rate was 58.1% and 90% of patients reported significant symptom relief after surgery. CONCLUSION Laparoscopic surgical management of DIE is effective and safe but it must be performed in tertiary centers with the availability of multidisciplinary teams.

Manejo quirúrgico de la endometriosis vésico-ureteral y sus complicaciones / Surgical management of deep endometriosis

La endometriosis ureteral es una infrecuente localización de endometriosis profunda, que puede condicionar una grave disminución de la función renal de forma silenciosa. Se presenta el caso de una paciente con fibrosis peritoneal secundaria a endometriosis profunda, cuya inespecífica sintomatologia conllevó un retraso diagnóstico, permitiendo el desarrollo de hidronefrosis. Es necesario descartar la presencia de endometriosis profunda en mujeres en edad fértil con hidronefrosis de etiología desconocida.

Deep endometriosis rarely entails ureteral involvement. It may be responsible of asymptomatic loss of renal function. A 35-year-old woman, gravida 1, para 1, was managed for peritoneal fibrosis due to deep infiltrating endometriosis. The nonspecific symptoms let a delayed diagnosis and a subsequent hydronephrosis. It must be excluded the existence of deep endometriosis in women of childbearing age with hydronephrosis of unknown etiology.

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.

Assoalho pélvico e endometriose profunda / Pelvic floor and deep endometriosis

A endometriose profunda infiltrativa é uma forma complexa de endometriose que infiltra a profundidade do peritônio em mais de 5 mm e afeta cerca de 20% das mulheres com endometriose. O seu tratamento objetiva remover os implantes e, em muitos casos de acometimento do trato genital, urinário e/ou gastrointestinal, o tratamento radical é necessário e pode acarretar danos ao assoalho pélvico, cuja função é manter a continência urinária, os órgãos pélvicos e a atividade sexual. As principais disfunções do assoalho pélvico que podem ocorrer após a cirurgia são: a sua hipertonia, disfunções urinárias e anorretais. O tratamento conservador com abordagem multidisciplinar visa à recuperação cinética-funcional do assoalho pélvico, contribuindo para a qualidade de vida das pacientes.

Deep endometriosis is a complex form of endometriosis that infiltrates below the surface of the peritoneum in over 5 mm and affects approximately 20% of women with endometriosis. The goal of the treatment is to remove these implants and, in many cases of affection of urinary or gastrointestinal tracts, the radical treatment is required and can cause damage to the pelvic floor, whose function is to keep the urinary continence, the pelvic organs and the sexual function. The main pelvic floor dysfunctions that can occur after surgery are: pelvic floor hypertrophy, urinary and colorectal dysfunctions. The conservative treatment with multiprofessional care aims to the recovery of the pelvic floor functional kinetics, thus helping to improve the patient’s quality of life.

Avaliação da concordância entre a ultrassonografia transvaginal e a ressonância magnética da pelve na endometriose profunda, com ênfase para o comprometimento intestinal / Evaluation of agreement between transvaginal ultrasonography and magnetic resonance imaging of the pelvis in deep endometriosis with emphasis on intestinal involvement

OBJETIVO: Comparar achados ultrassonográficos e de ressonância magnética na endometriose profunda,com ênfase para o comprometimento intestinal. MATERIAIS E MÉTODOS: Dezoito pacientes entre 23 e 49 anos de idade, com suspeita clínica e exame ginecológico sugestivo de endometriose profunda, foram submetidas a ultrassonografia e ressonância magnética para correlação dos achados. RESULTADOS: A ultrassonografia detectou 40 lesões e a ressonância magnética detectou 53 lesões na pelve. O estudo comparativo entre ultrassonografia e ressonância magnética na detecção das lesões não mostrou diferença estatística significativa (p > 0,19 e p > 0,14, respectivamente). Considerando-se a junção retossigmoide, a ressonânciamagnética detectou uma lesão (5,6%) e a ultrassonografia apontou quatro lesões (22,2%). Nas lesões retais, a ultrassonografia apontou oito lesões (44,4%) e a ressonância magnética, sete lesões (38,9%). CONCLUSÃO: A concordância entre a ressonância magnética e a ultrassonografia não foi boa na junção retossigmoide e no reto, sendo que a ultrassonografia detectou um número maior de lesões nessas localizações, mas identificou número menor de lesões na pelve. Na análise comparativa global entre os dois métodos na detecção das lesões não houve diferença estatística significativa. O baixo custo, a boa tolerabilidadee o fácil acesso tornam a ultrassonografia instrumento diagnóstico valioso na endometriose profunda.

OBJECTIVE: To compare sonographic and magnetic resonance imaging findings in deep endometriosis withemphasis on intestinal involvement. MATERIALS AND METHODS: Eighteen women aged between 23 and 49 years with clinical suspicion and gynecological signs suggestive of deep endometriosis were submitted to ultrasonography and magnetic resonance imaging for correlation between findings. RESULTS:Ultrasonography detected 40 lesions while magnetic resonance imaging detected 53 lesions in the pelvis. A comparative study has not shown any statistically significant intermethod difference in the detection of lesions(respectively p > 0.19 and p > 0.14). In the rectosigmoid junction, magnetic resonance imaging has detected one (5.6%) lesion, while ultrasonography has detected four lesions (22.2%). In the rectum, ultrasonography has detected eight lesions (44.4%), and magnetic resonance imaging has detected seven lesions (38.9%). CONCLUSION: The intermethod agreement has not been good for lesions in the rectosigmoid junction, considering that ultrasonography has detected a higher number of lesions in this region, but a lower number of lesions in the pelvis as compared with magnetic resonance imaging. The global comparative analysis has demonstrated no statistically significant intermethod difference in the detection of lesions. Low cost, good tolerability and high availability make ultrasonography a valuable diagnostic tool in cases of deep endometriosis.

Afectación ganglionar en paciente con endometriosis profunda rectovaginal / Lymph node involvement in a patient with rectovaginal endometriosis

Se describe un raro caso de endometriosis rectovaginal con compromiso ganglionar en mujer de 33 años. La presencia de tejido endometrial en ganglios linfáticos pélvicos es rara y ha sido confirmada en la literatura en mujeres que han sido sometidas a cirugía por endometriosis. La presencia de endometriosis en los ganglios linfáticos pélvicos es muy improbable que surja de novo y sugiere extensión de la enfermedad.

A rare case of rectovaginal endometriosis with lymph node involvement is described in a 33-year-old patient. The presence of endometrial tissue in pelvic lymph nodes is rare and has been confirmed in the literature in subjects who underwent surgery for endometriosis. Involvement of pelvic lymph nodes by endometriosis seems unlikely to arise de novo and probably suggests lymphatic spread of the disease.

The Efficacy of Laparoscopic Surgery in the Treatment of Endometriosis, especially Deep Endometriosis / 대한산부인과학회잡지

OBJECTIVE: To evaluate the efficacy of laparoscopic surgery in the treatment of deep endomtriosis, we have studied 30 cases of deep endometriosis. Endometriosis is classified into superficial(5mm) and very deep(>10mm) endometriosis by the infiltration depth from the peritoneal surface. In the treatment of deep endometriosis, medical hormonal therapy is not effective, so surgical treatment is required. There are many difficulties in surgiacal treatment ; hard lesion to excise, ditsorted pelvic anatomy after excision, easy to damage to ureter and uterine artery, and limitation for potentially morbid procedure to whom wants to conceive. Especially laparoscopic surgery in the treatment of deep endometriosis is very difficult because it is impossible to know the depth by palpation. In deep endometriosis type II, the lesion is concealed due to rectal adhesion to cul de sac, uterosacral ligament and in type III, the lesion is regarded as a small lesion or missed due to invagination into pelvic floor. The authors compared the laparoscopic surgery with laparotomy to evaluate the efficacy of laparoscopic surgery in the treatment of deep endomtriosis. METHODS: Deep endometriosis, 30 cases out of 102 cases, which were histologically comfirmed as endometriosis were studied. The authors compared the laparoscopic surgery(15 cases) with laparotomy(15 cases) in the surgical treatment of deep endometriosis for operation procedure, operation time, hospital stay and symptoms improvement. RESULTS: The mean operation time of laparoscopic surgeries in deep endometriosis was 178.7(+/-43.1)min while type I, II and III in deep endometriosis took 148.5(+/-21.2)min, 162.0(+/-30.7)min and 245.0(+/-36.1)min respectively and took a little more time than laparotomy. Mean hospital stay in laparoscopic surgeries was 5.7(+/-1.8)days and laparotomy took 10.0(+/-2.3)days that was statistically significant. CONCLUSION: If patients are chosen adequately and operator's skills are satisfactory, laparoscopic surgery is very valuable in the treatment of deep endometriosis. More datas will be required to confirm the efficacy.