How complete is full thickness disc resection of bowel endometriotic lesions? A prospective surgical and histological study

doi:10.1093/humrep/dei047 Human Reproduction Vol.20, No.8 pp. 2317–2320, 2005 Advance Access publication May 5, 2005 How complete is full thickness disc resection of bowel endometriotic lesions? A prospective surgical and histological study V.Remorgida1,4, N.Ragni1, S.Ferrero1, P.Anserini1, P.Torelli2 and E.Fulcheri3 1 Department of Obstetrics and Gynaecology, 2Department of General Surgery and Transplant, San Martino Hospital and University of Genoa, Largo R. Benzi 1, 16132 Genoa and 3Di.C.M.I., Unit of Anatomy and Histopathology, San Martino Hospital and University of Genoa, Via De Toni 14, 16132 Genoa, Italy 4 To whom correspondence should be addressed. E-mail: Key words: bowel endometriosis/bowel resection/fibrosis/full thickness disc resection/laparoscopy Introduction Intestinal involvement occurs in five to 27% of women with pelvic endometriosis, usually affecting the rectosigmoid colon (Weed and Ray, 1987; Jerby et al., 1999; Redwine, 1999; Chapron et al., 2003). A distinction must be drawn between the presence of superficial endometriotic foci on the large bowel serosa which do not cause specific symptoms, and deep infiltrating lesions which can be associated with severe gastrointestinal symptoms (i.e. obstructive symptoms, severe pain and heavy transit disturbances) (Azzena et al., 1998; Mussa et al., 2001; Yantiss et al., 2001; Varras et al., 2002; Weizman and Sullivan, 2003) or less severe disturbances mimicking the irritable bowel syndrome (Kumar, 2004; Remorgida et al., 2005). The management of colorectal endometriosis is controversial. When surgery is judged to be required, deep infiltrating endometriotic lesions of the bowel can be removed either by full thickness disc resection or by segmental resection (Verspyck et al., 1997; Duepree et al., 2002; Redwine, 2004). For lesions producing partial obstruction, most authors advocate bowel resection (Weed and Ray, 1987; Prystowsky et al., 1988) while full thickness disc resection is the recommended approach to less extensive lesions (Redwine, 2004). Up to now, the choice between the two different approaches has been more focused on the considerations concerning the reconstruction of bowel wall, rather than on the completeness of surgery. The main aim of the current study is to evaluate the completeness of disc resection in the treatment of deeply infiltrating endometriotic bowel lesions. We also investigated whether laparotomy and laparoscopy yield a different effectiveness in the removal of bowel endometriotic lesions. Materials and methods Between October 2003 and December 2004 patients with bowel endometriotic lesions requiring segmental resection were asked to participate in this study. In order to classify patients’ bowel habits and complaints, the Rome II Criteria (Thompson et al., 1999) were used under the conditions previously described (Remorgida et al., 2005). The study included patients requiring bowel resection on the basis of the following criteria: single lesion $ 3 cm in diameter, single lesion infiltrating $ 50% of the bowel wall, and $ 3 lesions infiltrating the muscular layer. Bowel resection was performed through a laparotomic suprapubic incision after laparoscopic mobilization of the bowel segment(s) involved. For the purpose of the study, before intestinal resection, q The Author 2005. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. 2317 For Permissions, please email: BACKGROUND: This study aims to evaluate the completeness of full thickness disc resection in the treatment of deep endometriotic bowel lesions. METHODS: This study comprised 16 women with bowel endometriotic lesions requiring segmental resection. For the purpose of the study, before intestinal resection, nodulectomy was performed. The presence of endometriotic infiltration in direct continuity with the removed nodule and the presence of fibrosis in the area surrounding the nodule were histologically evaluated. RESULTS: In seven out of 16 cases (43.8%; 95% CI, 19.8–70.1), endometriosis was found in the bowel wall adjacent to the site of nodulectomy; the infiltration was visible in the muscular layer in all cases. In cases of incomplete nodulectomy, the muscular layer of the bowel segment surrounding the endometriotic nodule contained limited or no fibrosis. CONCLUSIONS: Full thickness disc resection is not complete in $40% of women with bowel endometriosis. 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 resection may occur. V.Remorgida et al. Histological and immunohistochemical evaluation All surgical specimens were histologically evaluated in a standardized fashion as previously described (Remorgida et al., 2005). The specimens were immediately fixed in 4% formaldehyde for 12 h. The nodules were macroscopically oriented along the intestinal wall (from the serosa towards the mucosa) and cut in macro-sections of 2 mm thickness. From each macrosection, tissue blocks of ^ 1.5 cm length were obtained in variable number according to the size of the lesion. Each tissue block was embedded in paraffin and a 5 mm section was obtained for microscopical evaluation. Bowel segments were opened longitudinally through their entire length. Two millimetre longitudinal bands of bowel wall, reaching the two resection margins, were cut (Figure 1). These bands were sampled in tissue blocks and 5 mm sections were obtained for microscopical evaluation. These sections were stained with haematoxylin and eosin and examined histologically. The purified murine monoclonal antibody against muscle-specific actin (clone HHF 35, dilution 1/50; Biogenex, USA) was used to recognize smooth muscle cells; this antibody does not recognize other muscle filament proteins and it is non-reactive for other mesenchymal or epithelial cells. Immunohistochemical staining was performed on formalin-fixed, paraffin-embedded sections. After overnight incubation with a 1:50 dilution of the murine monoclonal antibody against muscle-specific actin, slides were rinsed with phosphate-buffered saline (PBS) and incubated with a biotinylated antimouse immunoglobulin G (Dako, USA). After rinsing again with TBS, preformed avidin and biotinylated horseradish peroxidase macromolecular complex (Vectastain Elite ABC kit; Vector Laboratories, Inc., USA) was applied for 30 min at room temperature. The antigen – antibody reaction was visualized using diaminobenzidine. Negative control sections were processed by omitting the primary antibody. Positive controls consisted in uterine leiomyomas and normal myometrium. The histopathological criteria for determining the presence and extension of bowel endometriotic lesions were the presence of both ectopic endometrial glands and stroma. The presence of endometriotic infiltration in the bowel segment representing an extensi (...truncated)