Rectal endometriosis: high sensitivity and specificity of endorectal ultrasound with an impact for the operative management.

PURPOSE: In patients with histopathologically proven or suspected endometriosis with possible involvement of the rectum, endorectal ultrasound was performed to determine the sensitivity and specificity of this method with regard to rectal wall involvement and the impact on the following operation. METHODS: In an historical cohort analysis, 85 females with histopathologically proven or suspected endometriosis with possible involvement of the rectum were treated between 1992 and 2001. Endorectal ultrasound was performed with a 7.5 MHz real-time unit, and results of endorectal ultrasound were compared with intraoperative findings and histopathologic diagnosis of 65 patients undergoing operation. A questionnaire was used to evaluate postoperative signs and symptoms. RESULTS: Of 65 patients undergoing surgery, 37 underwent laparotomy with 25 resections of the bowel and 28 laparoscopy. In 31 of 32 patients with suspected rectal wall infiltration, preoperative endorectal ultrasound diagnosis was confirmed. In patients in whom endorectal ultrasound showed no rectal wall involvement, histopathology revealed infiltration in one patient, leading to sensitivity of 97 percent and specificity of 97 percent with regard to rectal wall involvement. In terms of the deepness of rectal wall infiltration, endorectal ultrasound had a sensitivity of 76 percent with regard to infiltration of the muscularis propria and 66 percent for infiltration of the submucosa. Operations led to a significant (P < 0.05) reduction of preoperative symptoms by approximately 60 percent. CONCLUSIONS: Endorectal ultrasound is a useful, noninvasive technique for preoperative evaluation of possible rectal wall involvement in endometriosis. Based on the high sensitivity and specificity, recommendation for laparotomy and bowel resection in cases with suspected rectal involvement can be facilitated.

Endoscopic removal of large colorectal polyps: prevention of unnecessary surgery?

PURPOSE: Because of the potential risk of malignancy and technical difficulties in achieving complete removal, large colorectal polyps represent a special problem for the endoscopist. The aim of this study was to evaluate the capabilities and risks of endoscopy in complete removal of large colorectal polyps. METHODS: Endoscopic polypectomy of 186 colorectal polyps larger than 3 cm in diameter (range, 3-13 cm) was performed; 141 were sessile and 45 pedunculated. Most of the polyps were located in the rectum (n = 88), sigmoid (n = 63), and cecum (n = 9). The remaining adenomas were situated in other parts of the colon. Sessile polyps were removed using the piecemeal technique. RESULTS: Histology results showed an adenoma in 167 cases, and invasive carcinoma was present in the adenoma in 19 patients. Of the adenomas, 29 were tubulous, 118 tubulovillous, and 20 villous; adenoma with severe dysplasia was found in 49 cases. Complete endoscopic removal was achieved in all sessile and pedunculated polyps. None of the patients with invasive carcinoma who underwent surgical resection (n = 10) had any evidence of tumor in the resected specimen. Bleeding occurred in 4 patients after polypectomy (2 percent). Perforation occurred in 1 patient (0.5 percent), who had an invasive carcinoma of the cecum. There was no procedure-related mortality. During a mean follow-up period of 40 (range, 3-87) months, 6 patients presented with recurrence of a benign adenoma (3 percent), which was treated endoscopically, and 1 patient presented with a recurrent invasive carcinoma, which was treated surgically. CONCLUSIONS: Endoscopic polypectomy is a safe and effective method of treating large colorectal polyps.