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Copenhagen,
Denmark
19 - 22 June 2005
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How
radical is nodulectomy in bowel endometriosis?
V Remorgida
[1], N Ragni [1], S Ferrero [1], P Anserini
[1], P Torelli [2], E Fulcheri [3]
[1] San Martino Hospital and University
of Genoa
Department of Obstetrics and Gynaecology
Genoa, Italy
[2] San Martino Hospital and University of
Genoa
Department of General Surgery and Transplant
Genoa, Italy
[3] University of Genoa
Department of Anatomy and Histopathology
Genoa, Italy
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Introduction
When surgical treatment of colorectal endometriosis
is judged to be required, deep endometriotic lesions
of the bowel can be removed either by full thickness
disc resection or by segmental resection. The choice
between these two techniques is often based on the
considerations concerning the reconstruction of
bowel wall continuity, rather than on the radicality
of treatment. This study aims to evaluate the radicality
of disc resection in the treatment of deep endometriotic
lesions of the bowel.
Materials and methods
This study comprised 16 women with bowel endometriotic
lesions requiring segmental resection on the basis
of the following criteria: single lesion larger
than 3 cm in diameter, single lesion infiltrating
50%
of the bowel wall and three lesions infiltrating
the muscular layer. For the purpose of the study,
before intestinal resection, nodulectomy was performed
by laparoscopy (n=10) or laparotomy (n=6).
Nodulectomy was performed with electrosurgery cutting
the serosa around the tip of the nodule leaving
at least 1 cm of macroscopically ‘healthy’
tissue; after the first incision, the nodule was
removed following the ‘cleavage plane’.
When the surgeons were satisfied with the radicality
of the nodulectomy, bowel resection was performed
through a sovrapubic incision after the laparoscopic
mobilisation of the bowel segment(s) involved (an
automatic stapler was used).
Both the nodule and the resected bowel segment were
histopathologically studied in a standardised fashion;
the presence of endometriotic infiltration in direct
continuity with the removed nodule was evaluated.
The purified murine monoclonal antibody against
muscle-specific actin (Biogenex, USA) was used to
recognise smooth muscle cells. The presence of fibrosis
was evaluated in all bowel wall layers
surrounding the resected nodule; the degree of fibrosis
in the muscular layer was divided into 5 grades
according to the ratio of the fibrotic area to the
entire tissue area: grade G0, no fibrosis; G1, <25%;
G2, 25–49%; G3, 50–75%; G4, >75%.
Statistical analysis was performed using Fisher’s
exact test.
Results
The mean (±SD) larger diameter of the resected
nodule was 2.9±0.7 cm; the mean (±SD)
length of the resected segments was 17.0±9.2
cm. In 7 out of 16 cases (43.8%), endometriosis
was still present in the bowel wall adjacent to
the site of nodulectomy (incomplete nodulectomy);
the infiltration reached the muscular layer in all
these cases. No significant difference was observed
in the presence of persistent disease after laparoscopic
(40.0%) and laparotomic (50.0%) nodulectomy (p=0.549).
The endometriotic lesions spread laterally in the
bowel wall up to 2.6 cm beyond the limit of nodulectomy
(mean±SD, 1.6±0.6 cm). In case of
incomplete nodulectomy, the muscular layer of the
bowel segment surrounding the endometriotic nodule
contained G2 fibrosis in one case, G1 fibrosis in
three cases and no fibrosis (G0) in three cases.
Fibrosis in the submucosal layer was found in five
cases (71.4%); of those two were in the G0 group.
Conclusions
Full thickness disc resection is not radical in
at least 40% of women with bowel endometriosis independent
of the surgical technique (laparoscopy or laparotomy).
Our finding that fibrosis in the muscular layer,
the main landmark during surgical resection, does
not always surround bowel endometriotic lesions
might explain why incomplete resections occur.
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