{"paper_id":"e006c7a5-27ba-4611-8049-f7261298f303","body_text":"j coloproctol (rio j). 2 0 2 0; 4 0(3) :243–246\nwww.jcol.org.br\nJournal of\nColoproctology\nOriginal Article\nCorrelation between findings  of nuclear magnetic\nresonance and 3D anorectal ultrasound in patients\nwith suspected deep endometriosis\nMurilo Masanobu Tomiyoshi a,∗, Doryane Maria dos Reis Lima b, Gustavo Kurachic,\nUnivaldo Etsuo Sagaec,d, Fabiano Emori e, Barbara Bazzano a\na Hospital São Lucas, Cascavel, PR, Brazil\nb Faculdade Medicina Assis Gurgaz (FAG), Curso de Medicina, Cascavel, PR, Brazil\nc Centro Universitário Fundac¸ão Assis Gurgacz, Curso de Medicina, Cascavel, PR, Brazil\nd Universidade Estadual do Oeste do Paraná, Curso de Medicina, Cascavel, PR, Brazil\ne Hospital São Lucas, Imaging Department, Cascavel, PR, Brazil\na r t i c l e i n f o\nArticle history:\nReceived\n 11 February 2020\nAccepted 10 May 2020\nAvailable online 11 June 2020\nKeywords:\nEndometriosis\nNuclear\n magnetic resonance\n3D anorectal ultrasound\nIntestinal endometriosis\na b s t r a c t\nIntroduction: Endometriosis is defined  as endometrial glands and stroma that occur outside\nthe\n uterine cavity. Although not malignant, ectopic endometrial tissue and the result-\ning\n inflammation  can cause dysmenorrhea, dyspareunia, chronic pain, and infertility. The\ndiagnostic\n imaging tests most used are nuclear magnetic resonance imaging (NMR) and\nultrasonography\n (USG).\nMethods:\n Correlate the findings  of three-dimensional anorectal ultrasound with the NMR\nfindings\n of the pelvis with intestinal preparation in women with deep endometriosis,\nthrough a retrospective, observational, cross-sectional study, evaluating 63 female patients\nwith\n suspected deep endometriosis with probable involvement intestinal. The evaluation\nperiod\n was from March 2016 to April 2018. Statistical analysis was performed using the\nkappa\n agreement to assess the degree of agreement between 3D NMR and USG in relation to\nthe\n degree of infiltration  in the rectal muscle layer, with a confidence  interval of 0.272–0.579,\np\n < 0.001.\nResults\n and conclusion: According to the results presented, three-dimensional anorectal ultra-\nsonography\n proved to be a good diagnostic test in the evaluation of the middle and posterior\ncompartments\n of deep lesions of endometriosis, and there was a correlation between the\nNMR\n findings  of the pelvis with intestinal preparation in relation to injuries that invade the\nmuscularis\n propria of the rectum.\n© 2020 Sociedade Brasileira de Coloproctologia. Published by Elsevier Editora Ltda. This\nis\n an open access article under the CC BY-NC-ND license (http://creativecommons.org/\nlicenses/by-nc-nd/4.0/).\n∗ Corresponding author.\nE-mail:\n murilo tomiyoshi@hotmail.com (M.M. Tomiyoshi).\nhttps://doi.org/10.1016/j.jcol.2020.05.015\n2237-9363/© 2020 Sociedade Brasileira de Coloproctologia. Published by Elsevier Editora Ltda. This is an open access article under the CC\nBY-NC-ND\n license (http://creativecommons.org/licenses/by-nc-nd/4.0/).\nArticle published online: 2021-03-08\n\n244 j coloproctol (rio j). 2 0 2 0; 4 0(3) :243–246\nCorrelac¸ão entre achados de ressonância magnética nuclear e\nultrassonografia\n anorretal 3D em pacientes com suspeita de\nendometriose\n profunda\nPalavras-chave:\nEndometriose\nRessonância\n nuclear magnética\nUltrassonografia  anorretal 3D\nEndometriose intestinal\nr e s u m o\nIntroduc¸ão: A endometriose ’e definida  como glaˆndulas  endometriais e estroma que ocorrem\nfora\n da cavidade uterina. Embora na˜o maligno, tecido endometrial ect ´opico e a inflamac¸a˜o\nresultante\n podem causar dismenorreia, dispareunia, dor croˆnica  e infertilidade. Exames de\ndiagnóstico por imagem mais utilizados são Ressonância Nuclear Magnética e ultrassono-\ngrafia.\nMétodos:\n Correlacionar os achados da ultrassonografia  anorretal tridimensional com os\nachados\n da ressonaˆncia  magn´etica nuclear de pelve com preparo intestinal em mulheres\nportadoras de endometriose profunda, através de um estudo retrospectivo, observacional,\ntransversal,\n avaliou 63 pacientes do sexo feminino com suspeita de endometriose profunda\ncom\n prov´avel acometimento intestinal. O per´iodo de avaliac¸ão  foi Marc¸o  de 2016 a Abril\nde\n 2018. Foi\n realizada\n análise estatística por meio do Coeficiente  de Concordância de Kappa\npara se avaliar o grau de concordância entre RNM × USG 3D em relac¸ão  ao grau de infiltrac¸ão\nna\n camada muscular retal com cálculo de intervalo de confianc¸a  de 0,272–0,579;  p < 0,001.\nResultados\n e conclusão: Segundo os resultados apresentados a ultrassonografia  anorretal\ntridimensional\n mostrou-se um bom exame diagnóstico na avaliac¸ão  dos compartimentos\nmédio\n e posterior\n de lesões profundas de endometriose e há correlac¸ão  entre os achados\nda ressonaˆncia  magn´etica nuclear de pelve com preparo intestinal em relac¸ão  a lesões que\ninvadem\n a muscular própria do reto.\n©\n 2020 Sociedade Brasileira de Coloproctologia. Publicado por Elsevier Editora Ltda. Este\n´e\n um artigo Open Access sob uma licenc¸a  CC BY-NC-ND (http://creativecommons.org/\nlicenses/by-nc-nd/4.0/).\nIntroduction\nEndometriosis\n is defined  as the presence of endometrial\nglands and stroma outside the uterine cavity. They are usu-\nally\n located in\n the pelvis, but can occur in several places,\nincluding\n the intestine, diaphragm, and pleural cavity. Studies\nreport that between 15% and 30% of women with endometrio-\nsis will have a profound infiltrative  disease,1–3 and pregnancy\ncan often be difficult  and challenging. One study reported\nan incidence of intestinal involvement of 3%–37%, 1 while\nother authors reported an incidence of up to 80%.4 The most\ncommon\n areas of intestinal involvement are the rectum and\nsigmoid colon. When the gastrointestinal tract is involved, the\nfoci are more commonly located in the sigmoid and rectum,\nstarting from the uterosacral ligament and/or the rectovaginal\nseptum.1 The imaging exam must be able to indicate the num-\nber of foci present, the size and depth of the lesion, as well as\nits distance from the anal margin.5,6 With this information, it\nis possible to determine the most efficient  surgical procedure\nfor each case.\nCurrently, the main role of nuclear magnetic resonance\nimaging (NMR) in deep pelvic endometriosis lies in the\ndiagnosis and thorough lesion mapping.7 Anorectal ultra-\nsonography\n has high sensitivity and specificity  (97%–100%\nand 97%–100%,  respectively) for the diagnosis of rectal\ninvolvement in patients with endometriosis.8 It also allows\nmeasuring the distance from the endometriotic focus to the\nsphincter apparatus, suggesting which anastomosis will be\nthe most appropriate in each case, as well as the possible need\nfor a stoma. Therefore, it is possible to plan the appropriate\nsurgical approach for each case.9\nObjective\nCorrelate the findings  of three-dimensional anorectal ultra-\nsound (USG) with the findings  of pelvic NMR with intestinal\npreparation in women with deep endometriosis.\nMethods\nThis was a retrospective, observational, cross-sectional study\nthat evaluated 63 female patients with suspected deep\nendometriosis and probable intestinal involvement. The eval-\nuation period was from March 2016 to April 2018. Patients\nwere selected at gynecology service that is a reference in the\nscreening of patients with deep endometriosis for colorectal\nsurgery.\nThe patients were initially submitted to three-dimensional\nanorectal USG with the BK device with three-dimensional\nacquisitions. After fasting for six hours, patients underwent\na rectal enema with 125 mL of sodium phosphate two hours\nbefore the exam and another one hour before the ultrasound.\nThe patients were placed in lateral decubitus (Sims’ position)\nand underwent anesthetic sedation performed by an anes-\nthesiologist with propofol and 1 mL of fentanyl. The following\nvariables were analyzed in 3D rectal USG: lesions in perirectal\nfat, invasion of the muscularis propria, and distance from the\nlesion to the sphincter apparatus.\n\n\nj coloproctol (rio j). 2 0 2 0; 4 0(3) :243–246  245\nThe resonance was performed by a radiologist trained in\nthe assessment of patients with deep endometriosis with a\nhigh field  device (1.5 T) with multiplanar slices of high spatial\nresolution for fat-suppressed T1- and T2-weighted imaging.\nAll patients underwent intestinal preparation, and vaginal and\nrectal contrasts were used. The NMR assessed the presence\nof lesions in the bladder, cervix, uterus, ovaries, round and\nuterosacral ligaments, rectum, and sigmoid. Patients who did\nnot undergo one of the exams, those in whom cancer was\ndetected at any time during the evaluation, or those who did\nnot have a properly completed medical record were excluded.\nAn Excel spreadsheet was used for data analysis. The data\nevaluated on NMR were the presence of lesions in the blad-\nder, cervix, right ovary, left ovary, round ligament, uterosacral\nligament, and uterus, and description of the location and size\nof the lesion in sigmoid and rectum. In 3D anorectal USG, the\npresence of\n the size of the lesion, the location of the lesion and\nwhether\n it invaded the muscularis propria, and the distance\nfrom the lesion of the sphincter were assessed.\nStatistical analysis was performed using the kappa\nagreement coefficient  to assess the degree of agreement\nbetween\n NMR and 3D USG regarding the degree of infil-\ntration\n in the rectal muscle layer with a confidence\ninterval of 0.272–0.579  (p < 0.001). The calculation was per-\nformed using an agreement analysis device available at\nwww.lee.dante.com.br/pesquisa.html.\nResults\nNMR indicated that six (9.5%) patients had lesions suggestive\nof bladder\n endometriosis, one (1.5%) patient had a lesion in\nthe\n cervix, eight (12%) patients had endometrioma in the left\novary, 11 (17%) patients had endometrioma in the right ovary,\neight (12%) patients had lesions in the round ligament, 11 (17%)\npatients had lesions in the uterosacral ligament, 25 (39%) had\nlesions suggestive of adenomyosis, 30 (47%) patients had rectal\nlesions, and 16 (25%) had sigmoid lesions.\nThe analysis of 3D anorectal USG data indicated that nine\n(14.28%) patients had no lesions, 20 (31.74%) patients had\nlesions of the perirectal fat, and 28 (44.44%) patients had\nlesions that invaded the muscularis propria. In this analysis,\nsix (9.52%) patients were excluded from the study due to lack\nof data.\nWhen comparing NMR with 3D USG, it was observed that\nNMR diagnosed 20 (31%) patients without lesion suggestive\nof endometriosis, while anorectal USG identified  only nine\n(14%) patients. When comparing the presence of lesion until\nthe perirectal fat, USG identified  20 (31%) patients, while\nNMR identified  12 (19%) patients. In the comparison between\nlesions that invaded the muscularis propria, 3D USG diag-\nnosed 28 (44%), while NMR diagnosed 30 (47%) patients.\nStatistical analysis was performed using Kappa’s Agree-\nment Coefficient  to assess the degree of agreement between\nNMR and 3D USG regarding the degree of infiltration  in the\nrectal muscle layer.\nThe kappa value can be interpreted as follows: <0 —  no\nagreement; 0.0–0.19  —  poor; 0.20–0.39  —  regular; 0.40–0.59  —\nmoderate; 0.60–0.79  —  substantial; 0.80–1.0  —  near perfect\nagreement\nIn patients without lesions, the kappa value was 0.349 (95%\nCI 0.542–0.155);  in the evaluation of lesions in perirectal fat,\nthe kappa value was 0.064 (95% CI: 0.119 to −0.248) and, in\nlesions that invaded the muscularis propria, the kappa value\nwas 0.864 (95% CI 1–0.611).\nDiscussion\nEndometriosis is characterized by the presence of endome-\ntrial tissue outside the uterine cavity. The theory of retrograde\nmenstruation is accepted as the most likely etiology, but there\nappears to be other etiological associations, such as molec-\nular biology.10 It affects 10%–15%  of women of childbearing\nage. Intestinal involvement occurs in 3%–7%  of these women,\nwith the rectum,\n sigmoid, or both affected in 90% of these\ncases.11 The clinical picture is varied; the main complaints,\nwhen present, are dyspareunia, dysmenorrhea, chronic pelvic\npain, and infertility.10\nThe definitive  diagnosis is made through a surgical\nprocedure\n with resection of the lesion and subsequent\nanatomopathological analysis.10 Some studies indicate pelvic\nultrasound as a first-line  diagnostic test, leaving NMR and\nendoscopic USG of the rectosigmoid as second and third lines\nof diagnosis,12 although some systematic reviews demon-\nstrated\n that both NMR and transvaginal pelvic USG have\nsimilar sensitivity and specificity  in the diagnosis of deep\nendometriosis.13\nSome studies14 compared the accuracy of two-dimensional\nvs. three-dimensional USG diagnosis and showed no sig-\nnificant  difference between positive and negative predictive\nvalues; however, this comparison was made with the use of\ntransvaginal\n USG rather than rectal USG.12\nSurgical treatment of deep endometriosis involves surgical\ntechniques known as muscle layer dissection (shaving), disc\nresection, and intestinal resection (segmental or patch). The\nadvantages of the first  and second techniques include a pro-\ncedure with shorter operative time, shorter hospital stay, and\nfewer complications. In turn, the resection technique can lead\nto longer surgical time and hospital stay, paralytic ileum, and\nintestinal complications such as fistulas.  The choice of the sur-\ngical technique depends on the number of lesions observed in\nimaging exams, their location, and the surgeon’s experience;\nhowever, the shaving technique is chosen whenever possible,\nespecially\n in cases of single and small lesions without invasion\nof the submucosa.12\nRecent systematic reviews indicated that the sensitivity\nof transvaginal USG ranges from 73.3% to 98.1%, while the\nNMR sensitivity varies from 73.3% to 100%. The specificity\nof transvaginal USG ranges from 66.7% to 100%, while that\nof NMR ranges from 50% to 100%.13 In the present study, 3D\nanorectal USG had almost perfect agreement, according to the\nkappa coefficient,  when comparing lesions that invade the\nmuscularis propria; however, such expressive agreement val-\nues were not observed in patients without lesions or those\nwith\n lesions in the perirectal fat. In this service, 3D anorec-\ntal USG showed a significant  correlation in the diagnosis of\ndeep intestinal pelvic endometriosis and involvement of the\nmuscularis propria.\n\n\n246 j coloproctol (rio j). 2 0 2 0; 4 0(3) :243–246\nDespite the small number of studies retrieved in the inter-\nnational literature, 3D anorectal USG, despite requiring further\nstudies, can be used as a parameter of choice for surgical treat-\nment, and can be used (in combination with the experience\nof the service/surgeon and/or associated with other imaging\nexams such as NMR) to define  the best surgical technique\n(shaving or segmental resection).12\nConclusions\n3D anorectal USG is a good diagnostic test for the evaluation of\nthe middle and posterior compartments of deep endometrio-\nsis lesions; a correlation was observed between the findings\nof NMR of the pelvis with intestinal preparation in relation to\ninjuries that invade the muscularis propria.\nConflicts  of interest\nThe authors declare no conflicts  of interest.\nr e f e r e n c e s\n1. 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Guerriero S, Ajossa S, Gerada M, Virgilio B, Angioni S, Melis\nGB.\n Diagnostic value of transvaginal ‘tenderne.ss-guided’\nultrasonography\n for the prediction of location of deep\nendometriosis.\n Hum Reprod. 2008;23:2452–7.","source_license":"CC0","license_restricted":false}