J.A. Dias

Transvaginal ultrasonography with bowel preparation is able to predict the number of lesions and rectosigmoid layers affected in cases of deep endometriosis, defining surgical strategy

BACKGROUND Successful surgical treatment of deep bowel endometriosis depends on obtaining detailed information about the lesions, prior to the procedure. The objective of this study was to determine the capability of transvaginal ultrasonography with bowel preparation (TVUS-BP) to predict the presence of one or more rectosigmoid nodules and the deepest bowel layer affected by the disease. METHODS A prospective study of 194 patients with clinical and TVUS-BP suspected deep endometriosis submitted to videolaparoscopy. Image data were compared with surgical and histological results. RESULTS With respect to bowel nodule detection and presence of at least two rectosigmoid lesions, TVUS-BP had a sensitivity of 97 and 81%, specificity 100 and 99%, positive predictive value (PPV) 100 and 93% and negative predictive value (NPV) 98 and 96%, respectively. Regarding diagnosis of infiltration of the submucosal/mucosal layer, TVUS-BP had a sensitivity of 83%, specificity 94%, PPV 77%, NPV 96%. CONCLUSIONS These findings show that TVUS-BP is an adequate exam for evaluating the presence of one or more rectosigmoid nodules and the deepest layer affected in deep infiltrating bowel endometriosis, confirming the importance of this technique for defining the most appropriate surgical strategy to be implemented.

Aspectos epidemiológicos e clínicos da endometriose pélvica: uma série de casos

OBJECTIVE: To describe clinical and epidemiological aspects of patients with pelvic endometriosis who were operated in our service. METHODS: A retrospective study was made of 892 patients submitted to laparoscopy with histological confirmation of diagnosis of endometriosis. RESULTS: The mean age was 33.2 ± 6.3 years and 78.7% were Caucasian. We found that 76.9% of women had higher education. 56.5% of patients were nulliparous and 62.2% reported dysmenorrhea as the main complaint. Chronic pelvic pain was the most prevalent symptom, followed by deep dyspareunia, mentioned by 56.8% and 54.7% of patients, respectively. Infertility was reported by 39.8% of the 892 patients. CONCLUSION: Endometriosis is a disease diagnosed in the 4th decade of life, of patients who have multiple complaints . They must always be questioned to properly orient diagnosis and monitor results of treatment.OBJECTIVE To describe clinical and epidemiological aspects of patients with pelvic endometriosis who underwent laparoscopy at our service. METHODS Retrospective study of 892 post-laparoscopy patients with histologically confirmed diagnosis of endometriosis. RESULTS Mean age was 33.2 ± 6.3 years, and 78.7% of patients were Caucasian. We found that 76.9% of women in the sample had a higher education. Most (56.5%) patients were nulliparous, and 62.2% reported dysmenorrhea as the chief complaint. Chronic pelvic pain was the most prevalent symptom, followed by deep dyspareunia, reported by 56.8% and 54.7% of patients respectively. Infertility was reported by 39.8% of the 892 patients in the sample. CONCLUSION Endometriosis is most often diagnosed in the fourth decade of life. Patients with this condition present with multiple complaints, and must always undergo thorough questioning to properly guide diagnosis and monitor treatment results.

Endometriosis Lesions That Compromise the Rectum Deeper Than the Inner Muscularis Layer Have More Than 40% of the Circumference of the Rectum Affected by the Disease

STUDY OBJECTIVE To estimate the relationship between the depth of lesions of rectal endometriosis and the percentage of the circumference of the bowel segment affected by the disease. DESIGN A prospective pathologic analysis of 45 surgical specimens of bowel endometriosis obtained by laparoscopic segmental resection of the rectosigmoid (Canadian Task Force classification II-1). SETTING Tertiary referral hospital. PATIENTS forty-five patients were submitted to a segmental resection of the rectum due to endometriosis between July 2004 and September 2006. INTERVENTIONS Morphometric aspects of endometriotic lesions were analyzed, such as size and thickness of the lesion, deepest layer of bowel affected by lesion, and percentage of circumference of bowel affected by endometriosis. MEASUREMENTS AND MAIN RESULTS Results showed that in lesions that reached the submucous layer of the bowel, the circumference affected was 31.6% greater than in lesions that reached only the outer muscular layer, whereas in lesions that reached the mucous layer, the circumference affected was 52.5% greater than in those that reached the outer muscular layer of the bowel. In addition, 89.3% of lesions with an affected circumference greater than 40% were those affecting the submucous or mucous layers of the bowel. These results suggest that when a lesion reaches these 2 deepest layers of the rectosigmoid, risk increases that the circumference affected will be greater than 40% (relative risk = 1.5; 95% CI: 1.0-2.3; p = .03). CONCLUSION In endometriotic lesions affecting the rectosigmoid beyond the inner muscular layer of the bowel wall, more than 40% of the circumference of the rectosigmoid is affected by the disease, confirming the recommendation of segmental resection of the bowel for this form of the disease.

Treatment of rectosigmoid endometriosis by laparoscopically assisted vaginal rectosigmoidectomy

Objective: To describe the use of mechanical anastomoses in cases of laparoscopically assisted vaginal rectosigmoidectomy for the treatment of rectosigmoid endometriosis. Methods: Pilot study evaluating eight patients with rectosigmoid endometriosis referred for surgical treatment. All patients were submitted to laparoscopically assisted vaginal segmental resection of the rectosigmoid with anastomoses performed using linear and circular staplers. Results: The average length of the surgical procedure was 177.5 min and average duration of hospitalization was 4.13 days. There were no intra‐operative complications and integrity of the anastomoses was confirmed in all patients. One patient reported partial improvement of symptoms and 7 patients presented complete clinical remission 12 months following surgery. Conclusion: Laparoscopically assisted vaginal segmental resection of the sigmoid infiltrated by endometriosis is a feasible surgical procedure. The technique combines transvaginal access with mechanical intestinal anastomoses performed using linear and circular staplers, and achieves good results with low morbidity.

Vascular endothelial growth factor concentrations in the serum and peritoneal fluid of women with endometriosis

Objectives: To investigate whether there is an association between vascular endothelial growth factor (VEGF) levels in serum and peritoneal fluid, and the presence of pelvic endometriosis and its clinical symptoms. Methods: Blood and peritoneal fluid sample levels of VEGF were measured in 46 women undergoing laparoscopy: 32 with suspected endometriosis and 14 with confirmed endometriosis. Data were analyzed according to phase of the menstrual cycle, symptoms, disease stage, and disease site. Results: There were no significant associations between serum and peritoneal fluid levels of VEGF and the presence of endometriosis, even when controlling for the menstrual phase. However, among the women with confirmed endometriosis, there was a significant increase (P = 0.002) in the mean peritoneal VEGF level in those in the late secretory phase compared with those in the proliferative and early secretory phases. Conclusions: Measuring VEGF levels in symptomatic patients is not helpful to differentiate those with endometriosis from those with a different condition. However, in the late secretory and menstrual phases, mean VEGF levels were higher in women with confirmed endometriosis than in those suspected of having the disease.

Transvaginal ultrasound for diagnosis of deeply infiltrating endometriosis

Deeply infiltrating endometriosis is the clinical form of the disease that is generally associated with conditions of more intense pain and may require more complex surgical management, consequently resulting in greater risks to the patient. In recent years, various investigators have confirmed the usefulness of methods such as magnetic resonance imaging (MRI), transrectal ultrasound and transvaginal ultrasound (TVUS) for the diagnosis of deep endometriotic lesions. The objectives of the present study are to describe the method used to perform TVUS for the detection of deeply infiltrating endometriosis, and to discuss the clinical benefits that the data obtained may offer clinicians providing care for patients suspected of having this type of endometriosis.

Endometriosis of the ureter and bladder are not associated diseases

OBJECTIVE To verify whether bladder and ureter endometriosis had the same clinical features and disease behavior. DESIGN Case-control study. SETTING Multidisciplinary group in Sao Paulo, Brazil. PATIENT(S) A total of 690 patients were submitted to laparoscopy with histologically diagnosis of endometriosis between July 1999 and December 2006. Twelve of these patients had lesions affecting the ureter and 26 had lesions affecting the bladder. A control group consisted of 652 patients in whom endometriosis was not affecting either the ureter or the bladder. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Clinical and surgical features of patients with ureteral or bladder endometriosis. RESULT(S) No patients with ureteral endometriosis had lesions affecting the bladder. Compared with the control group, patients with ureteral endometriosis had more advanced disease (Stages III and IV) according to the American Society of Reproductive Medicine (ASRM) staging classification (100% vs. 65.5%); they also had more retrocervical (83.3% vs. 21.6%) and rectum-sigmoid lesions (91.7% vs. 17.9%). Compared with the control group, more patients with bladder endometriosis had cyclic dysuria and/or hematuria (34.6% vs. 9.8%), more advanced stages of the disease (88.4% vs. 65.5%), and an association with endometriosis of the rectum-sigmoid (65.3% vs. 17.9%). CONCLUSION(S) Ureter endometriosis is not associated with the bladder disease; however, it is associated with advanced ASRM stages and with retrocervical and rectum-sigmoid lesions.

Interleukin-12 but not interleukin-18 is associated with severe endometriosis

OBJECTIVE To evaluate interleukin (IL)-12 and IL-18 levels in the serum and peritoneal fluid of women with and without endometriosis. DESIGN Cross-sectional survey. SETTING University hospital. PATIENTS Interleukin-12 and IL-18 levels were compared in 105 patients submitted to laparoscopy because of symptoms suggestive of endometriosis (pain and/or infertility). The disease was confirmed in 72 patients (study group), while in 33 patients findings were not compatible with endometriosis (control group). INTEVENTION(S): Blood sample and peritoneal fluid were obtained from patients during videolaparoscopy. MAIN OUTCOME MEASURE(S) The levels of IL-12 and IL-18 in peripheral blood and peritoneal fluid were determined and compared with the stage and site of the disease and histologic classification. RESULT(S) IL-12 levels measured in peritoneal fluid were higher in patients with endometriosis compared with the control group. A significant increase in IL-12 levels was found when the more advanced stages of the disease were compared with the initial stages. No statistically significant differences were found in IL-18 levels, either in serum or in peritoneal fluid samples. CONCLUSION(S) Patients with severe endometriosis have higher IL-12 levels irrespective of IL-18 levels, suggesting that in this disease an alternative pathway is involved in induction of the Th1 immune response.

Common chromosomal imbalances and stemness-related protein expression markers in endometriotic lesions from different anatomical sites: the potential role of stem cells

BACKGROUND Endometriosis is a multifactorial gynecological disease characterized by the presence of functional endometrium-like tissue in ectopic sites. Several studies have focused on elucidating the immunological, endocrine, environmental and genetic factors involved in endometriosis. However, its pathogenesis is still unclear. METHODS High-resolution comparative genomic hybridization was applied to screen for genomic imbalances in laser microdissected stromal and epithelial cells from 20 endometriotic lesions and three samples of eutopic endometrium derived from eight patients. The expression of seven stemness-related markers (CD9, CD13, CD24, CD34, CD133, CD117/c-Kit and Oct-4) in endometrial tissue samples was evaluated by immunohistochemistry. RESULTS Samples of eutopic endometrium showed normal genomic profiles. In ectopic tissues, an average of 68 genomic imbalances was detected per sample. DNA losses were more frequently detected and involved mainly 3p, 5q, 7p, 9p, 11q, 16q, 18q and 19q. Many of the genomic imbalances detected were common to endometriotic stroma and epithelia and also among different endometriotic sites from the same patient. These findings suggested a clonal origin of the endometriotic cells and the putative involvement of stem cells. Positive immunostaining for CD9, CD34, c-Kit and Oct-4 markers was detected in isolated epithelial and/or stromal cells in eutopic and ectopic endometrium in the majority of cases. CONCLUSIONS The presence of shared genomic alterations in stromal and epithelial cells from different anatomical sites of the same patient and the expression of stemness-related markers suggested that endometriosis arises as a clonal proliferation with the putative involvement of stem cells.

Patients with endometriosis of the rectosigmoid have a higher percentage of natural killer cells in peripheral blood.

STUDY OBJECTIVE To estimate the concentration of natural killer (NK) cells in the peripheral blood in patients with and without endometriosis. DESIGN Case-control study (Canadian Task Force classification II-2). SETTING Tertiary referral hospital. PATIENTS One hundred fifty-five patients who had undergone videolaparoscopy were divided into 2 groups: those with endometriosis (n = 100) and those without endometriosis (n = 55). INTERVENTIONS The percentage of NK cells relative to peripheral lymphocytes was quantified at flow cytometry in 155 patients who had undergone laparoscopy. In addition to verifying the presence of endometriosis, stage of disease and the sites affected were also evaluated. MEASUREMENTS AND MAIN RESULTS The mean (SD) percentage of NK cells was higher (15.3% [9.8%]) in patients with endometriosis than in the group without the disease (10.6% [5.8%]) (p < .001). The percentage of NK cells was highest (19.8 [10.3%]) in patients with advanced stages of endometriosis and in those in whom the rectosigmoid colon was affected. In a statistical model of probability, the association of this marker (NK cells ≥11%) with the presence of symptoms such as pain and intestinal bleeding during menstruation and the absence of previous pregnancy yielded a 78% likelihood of the rectosigmoid colon being affected. CONCLUSION Compared with patients without endometriosis, those with endometriosis demonstrate a higher concentration of peripheral NK cells. The percentage of NK cells is greater, primarily in patients with advanced stages of endometriosis involving the rectosigmoid colon. Therefore, it may serve as a diagnostic marker for this type of severe endometriosis, in particular if considered in conjunction with the symptoms.