{"paper_id":"bab027a3-aeb6-4677-a767-560220e7cfcc","body_text":"CASE REPORT\nLarge bowel obstruction caused by endometriosis - Elective laparoscopic \nmanagement - Natural orifice surgery\nM.I Ismail, M.F Afdhaal\nColombo South Teaching Hospital, Kalubowila, Sri Lanka.\nKeywords: Endometriosis, Large bowel obstruction, \nLaparoscopic surgery, Natural Orifice Surgery, Case report\nIntroduction\nEndometriosis is characterized by the implantation of \nendometrial epithelium outside the uterus. In women with \nendometriosis, bowel involvement has been estimated to \nrange from 5% to 15% [1]. Notably, colonic endometriosis \nhas the potential to result in complete bowel obstruction [1].\nWe herein present a case of endometriosis with recto-sigmoid \ninvolvement causing complete large bowel obstruction \n(LBO) treated initially with defunctioning colostomy and \nsubsequently elective laparoscopic surgery.\nCase report\nA 45-year-old previously healthy female patient presented \nwith clinical and radiological features suggestive of LBO.\nShe was hemodynamically stable. Her WBC was 13,880/mm³ \nand CRP 18.2 mg/L.\nAn abdominal CECT revealed short-segment enhancing \nmural thickening at the distal sigmoid colon, causing \nproximal large bowel and distal small bowel obstruction, \nmore suggestive of tumour than inflammatory lesion.\nFlexible sigmoidoscopy revealed extreme luminal narrowing \nat the rectosigmoid junction, making it impossible to traverse \nthe obstruction. Mucosa normal.\nAfter initial resuscitation a midline laparotomy was \nperformed under GA. Dense adhesions of the recto-sigmoid \nto the posterior wall of a retroverted uterus, suggestive of \nsevere endometriosis was noted. Further dissection in the \npelvis not done as the anatomy was unclear. Minimal \nadhesiolysis and a transverse loop colostomy were then \nperformed.\nPostoperatively gynaecological opinion was taken. \nTransvaginal ultrasonography (TVUS) revealed \nendometriosis with a retroverted uterus with large bowel \nadhered to the posterior wall of the uterus. Pelvic MRI was \nadvised and a course of GnRH was initiated.\nAt the time of discharge patient was ambulant, colostomy \nfunctioning well and eating normally.\nSubsequent pelvic MRI revealed the presence of a right \novarian endometrioma with extrauterine endometriotic \ndeposits and circumferential mural thickening in the distal \nsigmoid colon.\nIt was then decided that total laparoscopic hysterectomy \n(TLH) and bilateral salpingo-oophorectomy (BSO) with \nbowel resection would be carried out in 3 months from the \nfirst surgery if there was no relief of LBO from hormonal \ntreatment. After 3 months, repeat endoscopy passed both \nrectally and through transverse colostomy showed persistent \nrecto-sigmoid narrowing. It was hence decided to proceed \nwith surgery.\nThe planned laparoscopic surgery was carried out in \ncollaboration with the Professorial Gynecological unit. The \nprocedure was TLH, BSO, and the intracorporeal resection \nand anastomosis of the rectosigmoid stricture utilising a 5-\nport technique. Left ureteric stenting done. Extensive \nadhesiolysis was performed. Following TLH and BSO, an on-\ntable colonoscopy was attempted, but the rectosigmoid \njunction proved impassable. Hence resection and anastomosis \nof the involved segment using a circular stapler was done with \nspeciment retrieval through vaginal opening. Intergrity of \nanastomosis was confirmed with both negative air leak test \nand retrieval of two intact donuts. \nPostoperative recovery was uneventful. Patient was \ndischarged on day 8, on a normal diet and a functioning \ncolostomy. Colostomy closure was planned after a loopogram \nlater.\nCorrespondence: I. Ismail\nE-mail: ismailwight@yahoo.com\n     https://orcid.org/0009-0003-7332-7960\nReceived: 24-01-2024    Accepted: 09-03-2024\nDOI: http://doi.org/10.4038/sljs.v42i01.9105\n49The Sri Lanka Journal of Surgery 2024; 42 (1): 49-51\n\nHistological examination identified the existence of \nendometrioid foci accompanied by inflammation and \nfibrosis.\nDiscussion\nColorectal malignancy is the commonest cause of LBO. \nBenign causes of LBO include strictures arising from \ndiverticular disease or inflammatory bowel diseases, volvulus \nparticularly affecting the sigmoid colon, internal or external \nherniae involving large bowel, etc.[2] Masses arising from the \npelvis/abdomen such as uterine/ovarian tumours, lymph node \nenlargement, etc. also are causative factors. Endometriosis is \na very rare cause of LBO but must be considered in a younger \nfemale, especially those with a history of recurrent lower \nabdominal pain.\nIntestinal localization of endometriosis occurs in 5-15% of \naffected females. Approximately 90% of such localization is \nlimited to the sigmoid and rectum. Only about 1% of patients \nwith intestinal endometriosis require bowel resection surgery \n[1,3]. \nThe CECT in this patient did not reveal endometriosis. \nHowever the specificity of CECT in detecting endometriosis \nis low [1]. As there were no features of endometriosis in this \npatient's history it was not considered in our initial differential \ndiagnosis.\nTransvaginal ultrasound (TVUS) has a reported sensitivity of \n91% and specificity of 98% in detecting bowel localizations \nof endometriosis [4].\nIn the few reported cases available of LBO due to \nendometriosis, surgical management has included procedures \nsuch as Hartmann's surgery or primary resection and \nanastomosis with defunctioning stoma - both open and \nlaparoscopically.\nGynaecological input was taken throughout as a combined \nsurgical/gyanecological approach is considered the best \noption. GnRH was advocated in between initial laparotomy \nand subsequent elective laparoscopy because studies have \nshown this to help lesion regression and symptomatic \nimprovement in endometriosis. However, inspite of GnRH \ntreatment, this patient's bowel obstruction didn't resolve [5].\nThe decision to do TAH and BSO was taken by the \ngynaecological team because of the severity of the \nendometriosis with extra pelvic deposits.\nLaparoscopic TAH & BSO with sigmoid bowel resection and \nanastomosis in large bowel obstruction with endometriosis is \nfeasible if the required expertise is available. The surgery is \ndifficult due to extensive inter-loop bowel and pelvic \nadhesions associated with endometriosis. As the ureters may \nbe difficult to identify/involved, it is advisable to stent the \nureters preoperatively. In this patient the uterus/ovaries and \nthe resected sigmoid stricture were removed through the \nvaginal orifice, thereby avoiding additional incisions - \nNatural Orifice Surgery.\n \nFigure 1. Resected rectosigmoid stricture\n50The Sri Lanka Journal of Surgery 2024; 42 (1): 49-51\n\nReference\n1. Calcagno P, Viti M, Alessandro Cornelli, Galli DE, C \nD'Urbano. Intestinal obstruction caused by endometriosis: \nEndoscopic stenting and expedited laparoscopic resection \navoiding stoma. A case report and review of the literature. \nInternational Journal of Surgery Case Reports [Internet]. \n2018 Jan 1 [cited 2023 Dec 21];44:75–7. DOI: \nhttps://doi.org/10.1016/j.ijscr.2018.02.012\n2. Lieske B, Meseeha M. Large Bowel Obstruction [Internet]. \nNih.gov. StatPearls Publishing; 2021. Available from: \nhttps://www.ncbi.nlm.nih.gov/books/NBK441888/\n3. Wolthuis AM. Bowel endometriosis: Colorectal surgeon’s \nperspective in a multidisciplinary surgical team. World \nJournal of Gastroenterology [Internet]. 2014;20(42):15616. \nDOI: http://dx.doi.org/10.3748/wjg.v20.i42.15616\n4. Hudelist G, English J, Thomas AE, Tinelli A, Singer CF, \nKeckstein J. Diagnostic accuracy of transvaginal ultrasound \nfor non-invasive diagnosis of bowel endometriosis: \nsystematic review and meta-analysis. Ultrasound in \nObstetrics & Gynecology. 2011 Feb 18;37(3):257–63. DOI: \nhttps://doi.org/10.1002/uog.8858\n5. Eric S. Surrey, M.D. GnRH agonists in the treatment of \nsymptomatic endometriosis: a review  November 20, 2022. \nDOI: https://doi.org/10.1016/j.xfre.2022.11.009\nLearning  Points:\nŸ Although not common, endometriosis should be considered as a cause of LBO in young females.\nŸ TVUS is readily available and useful imaging modality in confirming bowel endometriosis.\nŸ Laparoscopic TLH + bowel resection with Natural Orifice Surgery possible when expertise available.\n51The Sri Lanka Journal of Surgery 2024; 42 (1): 49-51","source_license":"CC0","license_restricted":false}