Conservative surgery of deep bowel endometriosis

Abstract

The management of deep endometriosis of the bowel remains debated. A discussion of the management needs to define deep endometriosis, to understand the accuracy and pitfalls of the diagnosis, and to consider postoperative complications, for the rest of the life bladder, bowel and sexual problems together with the results concerning pain, infertility and quality of life. It is well established that the recurrence rates and complication rates after conservative excision and after a bowel resection are not obviously different notwithstanding remaining nests of endometrium like cells up to 5 cm from a nodule. Considering the genetic-epigenetic pathophysiology of endometriosis, we explain this apparent discrepancy in recurrence rates by postulating that deep endometriosis is composed of an inner core of endometriotic cells with stable genetic-epigenetic alterations, surrounded by metaplastic endometrium like cells with reversible epigenetic alterations and a fibrotic zone. With our knowledge of today we suggest that for deep endometriosis of the sigmoid, short bowel resections should be liberally used. A sigmoid bowel resection is associated with little postoperative and for the rest of the life complications, and is technically much easier than a conservative excision, which moreover is often not feasible. For rectum and low rectum deep endometriosis lesions a conservative excision is the preferred technique and a rectum resection should be avoided. Today almost all deep endometriosis lesions of the rectum can be treated conservatively by excision, eventually by a discoid excision. It is discussed why rectum resections should be avoided. Rectum resections have progressively become obsolete except for the very large lesions, for which a short resection should be performed.