Published online Feb 14, 2019. doi: 10.3748/wjg.v25.i6.696
Peer-review started: December 8, 2018
First decision: December 28, 2018
Revised: January 14, 2018
Accepted: January 18, 2019
Article in press: January 18, 2019
Published online: February 14, 2019
Rectosigmoid endometriosis is an underdiagnosed disease responsible for digestive disorders. Two surgical approaches, rectosigmoid bowel resection (segmental or patch) or intramuscular layer dissection (shaving), are available. Nowadays, the choice is led by a conjunction of clinical and radiological findings without strict criteria. A recent study has shown that a pre-operative magnetic resonance imaging (MRI) colonography might predict the need for bowel resection in rectosigmoid endometriosis. However, it has previously been demonstrated that rectosigmoid endoscopic ultrasonography (RS-EUS) exhibits better sensitivity and negative predictive value than MRI in the diagnosis of rectosigmoid endometriosis.
To assess whether the characteristics of endometriosis lesions evaluated on a preoperative RS-EUS could predict the need for bowel resection in rectosigmoid endometriosis for a better optimization of the preoperative management of the patient.
To assess whether the lesion features observed via preoperative RS-EUS might predict the need for bowel resection.
This multicentric retrospective study was conducted on a cohort of patients with rectosigmoid endometriosis who underwent a curative surgical procedure, evaluated by RS-EUS performed by two trained operators, between January 2012 and March 2018. In this cohort, data were collected prospectively when patients were suspected of having endometriosis. RS-EUS features evaluated were thickness, width, infiltration of the submucosae, presence of a bump into the digestive lumen and presence of multiple rectosigmoid localizations All the surgical interventions were performed by one well trained gynecologic surgeon via open laparoscopy. Shaving was preferred any time it was possible based on the nodule characteristics. This procedure was typically performed on unique and small lesions without submucosae involvement. A univariate statistical analysis was performed on nodules’ RS-EUS features followed by multivariate logistic regression on significant results.
In total, 367 women were followed for endometriosis and included in the cohort between January 2012 and March 2018. 73 patients met the inclusion criteria and were included in the analysis, in two groups: Shaving (36 patients) and bowel resection (37 patients). In univariate analysis thickness (P < 0.001), width P < 0.001) and infiltration of the submucosae (P = 0.007) experienced significant results. After multivariate logistic regression only thickness appeared to be significant with an odds ratio (OR) = 1.49 [95% confidence interval (CI) 1.04-2.12, P = 0.028]. Nevertheless, a sensible trend regarding width was identified. Specifically, width was increased in the resection group compared with the shaving group (OR 1.12, CI95% 1.00-1.26, P = 0.054). Based on receiver operating characteristic analysis, a thickness greater than 5.20 mm was the best threshold to determine the need for digestive resection with a sensitivity of 76%, a specificity of 81%, and a positive predictive value and negative predictive value of 0.80 and 0.76, respectively.
We found that an endometriosis nodule greater than 5.20 mm thick might predict the need for bowel resection in rectosigmoid endometriosis. This is the first study to evaluate the accuracy of RS-EUS before surgical procedure in rectosigmoid endometriosis. It has some implications as it reveals new interest in the realization of preoperative RS-EUS in deep infiltrating endometriosis. This information might help surgeons to organize procedures in a multidisciplinary team. Although, our work has also some limitations, mainly because of its retrospective design with small patient samples.
Further investigations, such as prospective, multicentric studies, have to be conducted to confirm our results.