Endofound’s Sixth Annual Medical Conference: Ending Endometriosis Starts at the Beginning
Ken Sinervo, MD
I am going to talk about endometriosis involving the bowel. I am going to briefly talk a little bit of working up patients and the kind of symptomatology that they usually have. I will go over three different techniques for trying to deal with endometriosis involving the rectosigmoid endo. I do not think I will have time for the small bowel endometriosis at the end.
Endometriosis has varying incidents ranging from 3.7 to 38 percent depending on which studies you look at. In my particular group of patients it is somewhere in the 30 percent range with close to a third having endometriosis involving the bowel. To some extent patients usually present with pelvic pain but they also have typically bowel symptoms associated with that as well. They will have painful bowel movements. They will often have intestinal cramping. But if they have more of an obstructive type pattern they will often present with intermittent constipation and alternating diarrhea where once they have a bowel movement they will have this reflux diarrhea afterwards because the stool that has been sitting above there will often not have had a chance to have the water reabsorbed from it so they will tend to have this alternating pattern.
In terms of trying to diagnose these patients there are a lot of different modalities that have been talked about today. The best evidence that we have right now is that transvaginal ultrasound is probably the best with an enema an hour beforehand. That has sensitivities above and specificity above 95 percent. MRI as the data today was reflective, unfortunately there is not a lot of – there is so much variability between interpreters that a lot of disease can easily be missed or over-called as well. So, MRI is not great. Virtual colonoscopy is something that has come out over the last five years or so which also offers promise. The advantage of that is it can show lesions at any point in the bowel. So it can often show small bowel lesions which you probably would not be able to pick up with transvaginal ultrasound unless you have the bowel itself drawn down into the pelvis. Small bowel lesions make up about 10 percent of all bowel endometriosis cases that I run into and would often be missed. Colonoscopy is probably the poorest thing that we can have our patients do even with invasive disease where it is invading into the muscularis of the bowel. They only pick up between five and ten percent of those cases. While most of our patients end up going to see a gastroenterologist the fact that they do not see anything is not reassuring at all because most of the time it will be missed.
In terms of medical treatments most of the patients that I see have been on three or four different medical treatments, usually they have had three or four surgeries beforehand. They are the patients who are having persistent symptoms despite having undergone medical treatments. There is some evidence that smaller lesions where there is less than 60 percent stenosis may respond well to medical treatments but again in patients with recalcitrant disease they are going to be the ones who are going to need surgical manipulation before they are going to get better.
This is a video of a 47-year-old lady. She is actually someone who came for a hysterectomy and treatment of her obliterated cul-de-sac. We had the bowel there drawn up into a posterior aspect of the uterus. You can see that the bowel is being drawn up. Here we are mobilizing the bowel. Basically initially we tried to mobilize the bowel as well as we can medially. Then we go into the pararectal spaces and we work in between the uterosacral ligaments and the bowel. I am kind of a little bit younger but I am kind of old school as well. I trained with Tom Lyons who used the Yag laser originally and then I joined my partner who uses the CO2 laser and I am very comfortable with the CO2 laser. I like the tissue effect that it has because as you are dissecting other modalities I think sometimes remove too much healthy tissue. If you look at the data of specifically looking at rectosigmoid disease and disease infiltrating the uterosacral ligaments there can be a lot of patients who have urinary problems afterwards because too much of the tissue lateral to the uterosacral ligaments is removed. And those patients can have both defecatory and voiding dysfunction afterwards.
Here we are working to remove all of the disease that is stuck to the uterosacral ligaments as well. We want to make sure we are not leaving any disease behind because if there is disease that is left on the uterosacral ligaments or anywhere else it is going to – the bowel can fall back onto those tissues and then set yourself up for a recurrence. All the other disease has to be meticulously removed as well. Here what we are doing is we are shaving. We are basically making an incision at the junction between the normal bowel and the nodule itself. We are working our way, this lesion is not invasive, and we are working our way basically at the junction between normal tissue. The good thing about when you are working on the bowel there is a protective layer of fat, even in the thinnest patients. Usually you are going to have a little bit of a margin of error. I use a little 3 mm bipolar that goes through the suction irrigator here. That allows us to coagulate any small bleeders that we have as well. I also have a 3 mm grasper that I can use for smaller lesions as well. Then we basically work our way around the lesion, really at the junction between the fat and the nodule itself. We continue our dissection working deeper into the pelvis. That way we can see and undermine the lesion completely.
As you can see – again we are controlling any bleeding. There is a lot of lateral blood vessels coming into these nodules often. Anything like a Gyrus or a LigaSure with a Maryland type tip is very good or small bipolar in this case is very good for controlling those bleeders as well.
We continued working our way circumferentially so that when we are done we completely excised the nodule. We are getting deeper into the rectovaginal space or the lower part of the rectum and the complete nodule is removed. This is just showing a little superficial nodulectomy or shaving technique where once we are done there are still a little bit of cleaning up to do distally and proximally but we have removed the majority of the nodule and it did not penetrate into the rectum itself.
This we like to call a Harry Reich technique because Harry was the first one to describe it for my partner and we have used it dozens of times. It is really good. There is a lot of evidence from Mauricio Abräo that for smaller lesions less than 3 cm involving less than 40 percent of the circumference of the bowel a discoid technique like this is very useful. Here you can see the nodule itself. It is probably around 2.5 to 3 cm in size. What we do is we initially take the suture and we place it proximally to the lesion and then we will place the same suture distally and then we put a circular stapler into the rectum. We open up the stapler and then we draw the tissue, which is…by the upper and lower margins into the stapling device and then we close the stapler. That way we can incorporate that lesion into the stapling device completely. You can do this multiple times into the bowel if you have a larger lesion that you feel you might not have been able to completely get with the first excision. Re-firing it does not seem to affect the integrity of the bowel.
Here we are inserting the circular stapler. We try to insert the largest stapler that we can get usually it is a 31 or 33 mm stapler, circular stapler. Here he has overshot the runway and he is drawing back the stapling device. Now that we have got right over the lesion he is opening up the stapler and then we draw the bowel nodule into the stapling device and then we can close. You can see right at the margins here we have got nice healthy tissue here, nice healthy tissue there. You want to try to line up the bowel so that you do not have any – so the bowel is not twisted, so that you are not getting the mesentery too much into the nodule. It freaks patients out if they have corkscrew poo because it turns in their – they can get pencil stools and stuff like that. You want to make sure that you are lining it up properly. Here you can see the nodule has been removed and when you look at it it is about a 3 cm nodule. The margins are clear so this is a very good technique for isolated lesions that are below 3 cm in size. Then what we do as with any bowel procedure we clamp the bowel. We fill the pelvis with fluid and then test the bowel as well.
So this is the third scenario that we run into where we have a completely obliterated cul-de-sac and a lesion that is invading into the bowel. It is much larger than 3 cm and usually we are having a significant obstruction or narrowing of the bowel.
I am just going to show you a little bit of the initial dissection here. Here you can see that the cul-de-sac is completely obliterated. The bowel is extending to the uterosacral ligaments. The approach is the same. I basically follow my way along the uterosacral ligaments working from, again, there are differences in technique, working from a healthy area. I know the uterosacrals are fine. I will go and I will dissect out the ureters as well but working our way along the uterosacral. It is kind of you do not necessarily find the plane right away initially so sometimes it is a process of slowing chipping your way into the tissue. Again, the thing I like about the laser is that it is very meticulous. I know how deep the laser is penetrating as I move it at a certain pace over those tissues, working from side to side until we can completely mobilize the lesion.
At this point we have completely mobilized the bowel and we have done a hysterectomy on this patient as well. You can see the opening of the vagina, which we will close up afterwards. I have a general surgeon who I work with, I do not actually have a colorectal surgeon but we have done about 250 to 280 bowel resections together and we probably have more experience than the colorectal docs at the hospital we work at.
Here we go across the distal margin of the lesion with a linear stapler, usually a 60 mm stapler. You can see the lesion. We then mobilized the mesentery of the bowel so that we could bring the lesion up through the abdominal wall. We enlarge our lateral left lower quadrant trocar site because that way we just have one more incision by adding a little bit higher trocar on the left hand side, we keep the larger one still around the bikini line. Here you can see we are deflating the bulb, we are going to come through, he is going to enlarge the incision a little bit. We basically use the LigaSure to make an incision in the subcutaneous tissues. We then bring up the lesion. We have cut away the abnormal part of the bowel and we have put in the anvil. We then take the suture off the anvil. We always put a suture on the anvil so that you do not lose the anvil. Trying to get that anvil out of the bowel after it has gotten in there is very difficult. I have had that happen once. Then what we do is coming from below we advance the distal portion of the stapler. This we have to mobilize the vaginal cuff a little bit as well so it is not pulling on the vagina. Then we come through. We reconnect the bowel, fire the stapler, make sure it is lined up properly and then again, afterwards, once we have fired the bowel then we can check to make sure that it is water tight.
The patient is usually in the hospital for about five days on average. The great majority of these patients do extremely well. We have had between 250 and 280 we have had one recurrence. That was a discoid case. It was probably one of the first ones we did. In all the bowel resections we have never had a recurrence where we have done a segmental resection.
Harry Reich, MD: Very nice demonstration. I love the CO2 laser, again, I keep telling everybody it is not used enough today. Somehow, everybody forgot about it. CY would probably vouch for that too. It is a great…
Audience Member: It is expensive Harry,
Ken Sinervo, MD: We use one from 1993.
Audience Member: It is more expensive than a scissor.
Harry Reich, MD: You think? Especially those scissors you are using. I just want to make one comment, personal, from the technique. The discoid, the anterior discoid, we use one curved suture right through the nodule instead of going on each side anteriorly, posteriorly or superiorly, inferiorly one through it then you have the two ends of the suture, dip your nodule right into the stapler then the person standing between the legs pushes way down so you do not catch any posterior wall of the rectum, which you could certainly do otherwise.
Ken Sinervo, MD: Yes, that is very true. You want to make sure you are just getting the anterior wall of the bowel. The good thing about that is you do not affect the blood supply. Theoretically you are going to have a lower risk of complication from that because you are not affecting it.
Harry Reich, MD: Do you use Ethicon or the Covidien?
Ken Sinervo, MD: We have used both. We have kind of used more the Covidien one lately.
Harry Reich, MD: We have found that Ethicon was a lot better, 29 or 33.
Ken Sinervo, MD: Try using the largest one possible.
Harry Reich, MD: Plus, we thank them for helping us out at this meeting too.
Ken Sinervo, MD: Here you can see in this picture the lesion itself, you can see how much the lumen is compromised. This is a normal lumen and this is the other lumen. You can see how much of the bowel is compromised by all the fibrosis here so you see how obstructive that could be.
Harry Reich, MD: Very good.
- What is your criteria for the segmental resection…including suture rupture…it is about seven percent. … If possible…unless like this case do you have any criteria that you use?
Ken Sinervo, MD: If you look at Abräo suggested – if you have got greater than a 40 percent lesion then a discoid resection is not possible. You can go old school where you do a nodulectomy where you resect the nodule and do a two…closure. You do have probably a little bit lower risk of some of those complications, in particular bleeding. We have had two cases of bleeding, three fistulas...(CY makes a comment that cannot be heard)…only one or two. So you know, seven out of 280 those are the major complications. It is still a fairly low percentage, probably in the three to four percent rate of major complications perioperatively. It is something that we are going to be presenting or finishing up…
Harry Reich, MD: I will say this, I have never seen a leak with an anterior discoid resection. I have not seen a leak. The patients go home the next day. And are OR teams really happy when we decide to use it? It means they are going to save an hour of operating time.
Ken Sinervo, MD: We usually keep them in two or three days. We advance their diet from clear liquids once they start passing gas with the anterior discoid resection. They probably could go home earlier. I think we just want to be conservative.
Tamer Seckin, MD: I am just curious I think we are going to come back to the same, 250 is an incredibly high number. That is a great number of bowel resections and you say the leak rate and everything is less than three percent?
Ken Sinervo, MD: No, the major complication rate – yes, probably somewhere between three and four percent, that includes leaks, fistulas, abscess…
Tamer Seckin, MD: That is…when they have 1200 to…
Ken Sinervo, MD: Well, you know one of the problems with some of the studies in Europe is they do, they remove the whole posterior vaginal wall. So they have a 12 or 14 percent fistula rate just alone. And that is because I think most of the time you do not have to resect the posterior vaginal wall.
Tamer Seckin, MD: When do you guys do nodulectomy? How do you draw the line between segmental resection…
Ken Sinervo, MD: It comes down to size.
Tamer Seckin, MD: I personally do tons of nodulectomies and avoid segmental resection because the complication rates are so high and we have been seeing it reported so that is incredible. This is out of how many cases or how many years 250 segmental resections?
Ken Sinervo, MD: Probably my partner had done maybe 20 before I joined him and since we have been together in 2001 probably 230 to 260. Last year I did 44.
Tamer Seckin, MD: Harry, how many bowel resections have you done in your life?
Harry Reich, MD: In my life? Forty.
Ken Sinvero, MD: We get a lot of patients with bowel disease. That is part of it.
Tamer Seckin, MD: Not every bowel disease means you have to do bowel resection.
Ken Sinervo, MD: Well, we are talking probably 250 to 280 out of 12 or 1400 obliterated cul-de-sacs. Again, the great majority of them do not need that. Most of them are getting shaving or partial nodulectomies involving partial invasion where there is over sewing.
Tamer Seckin, MD: …discussions in Europe Koninckx and the rest of them and finally Koninckx made his point over the Austrian guy.
Ken Sinervo, MD: Over Wattiez?
Tamer Seckin, MD: Yes, no, not Arnaud Wattiez…
Harry Reich, MD: Let me make one point and that is that in many of these cases I will dissect, I hug the lesion. I hug the fibrosis, I get into the rectum. I get into the rectum so you debulk most of the mass. Most of your deep fibrotic nodule is gone and then I put a suture across the hole. I dip the hole into the circular stapler.
Ken Sinervo, MD: Yes, or when you are shaving a lot of times you are doing a combination of shaving and a discoid because you can debulk a lot of it by shaving, getting rid of all the fibrosis and then it collapses on itself and you can make it amenable to a discoid or nodulectomy.
Tamer Seckin, MD: …significant…Everybody has a different technique obviously. Personally I do pure…scissors, feel the lesion and do meticulous nodulectomy and you do not need to do in my cases many times a bowel resection. I think it is a matter of choice.
Audience Member: Do you bowel prep your patients?
Ken Sinervo, MD: I bowel prep all my patients.
Audience Member: So everybody gets a bowel prep because you do not know what you are going to do.
Audience Member: If the nodule has penetrated the vaginal wall you said you…
Ken Sinervo, MD: No, no but most of the time. Most of the time it does not penetrate all the way through the vaginal wall. I would say the minority of cases involving rectal cervical disease or rectovaginal disease, whatever you want to call it, actually penetrate through the whole vaginal wall. There can be a lot of inflammatory changes but the endo itself does not necessarily go through all the way.
Audience Member: We have seen so many….see the nodule.
Ken Sinervo, MD: Maybe you are having a different disease. I do not know but total vaginal wall involvement – sometimes we are doing a hysterectomy and sometimes we may take a little bit more off the posterior vaginal wall to make sure we are not leaving anything. But, again, it is probably much less than 10 percent of the bowel resections we do.
Tamer Seckin, MD: How much concomitant disease do you have on the ureter and pelvic sidewall? …15 percent are associated with ureter disease and sidewalls.
Ken Sinervo, MD: A large number because the ureters, uterosacral ligaments, everything is being drawn into the whole cul-de-sac inflammatory mass. But actual disease that penetrates in the ureter, again, is very, very…