{"paper_id":"e8760f8d-f843-4218-8c7e-6badf8e2f48a","body_text":"Arch Med Case Rep. 2024\nVolume 6, Issue 1\nArchives of Medical Case Reports  Case Report\n1\nArch Med Case Rep. 2024;6(1):1-3.\nComplications of Endometriosis – Case Report of a Postoperative \nRecurrence of Rectovaginal Fistula\nIntroduction\nEndometriosis is considered a clinical condition that is \ndifficult to diagnose, but recurrent in the female population. \nKnown since the 17 th century, it was first described by Von \nRokitansky in 1860 and a new view emerged with Sampson \nin 1927, who suggested menstrual flow as a facilitator for \nendometrial tissue to implant in the peritoneal cavity [1]. \nIt is a gynecological disease characterized by the growth \nof endometrial tissue outside the uterine cavity, almost \nexclusively diagnosed in patients of reproductive age \nin organs such as ovaries, posterior and anterior cul-de-\nsac, posterior leaflet of the broad ligament, uterosacral \nligaments, uterus, fallopian tubes, sigmoid colon, appendix, \nand round ligaments [2]. More than 60 years have \npassed for the approach to the disease to change, thus \nestablishing the concept of lesion infiltration, determining \nthat retrograde menstruation causes the deep infiltrative \nform of endometriosis in the cavity [2,3].\nAs it progresses, the clinical presentation of endometriosis \nas signs and symptoms varies considerably, as it does \nnot present pathognomonic clinical features, which \nmakes it difficult to suspect and correctly diagnose [1]. \nPhysical examination and clinical history are of little help \nin concluding the diagnosis, depending on the stage of \nthe disease, thus requiring the use of diagnostic methods \nsuch as imaging tests, especially transvaginal and pelvic \nultrasound and magnetic resonance imaging [1,2].\nGoal\nThis is a case report of a patient with deep endometriosis \nwho underwent surgical procedures with complications \nand is still in the process of rehabilitation due to sequelae.\nMethods\nThe information contained in this clinical case description \nwas obtained through a review of medical records, patient \nreports, images of diagnostic tests, and literature review.\nRosimeire da Silva 1, Eduardo Delfino Bindi 1, Lucas Tonholo da Silva 1, Karoliny Moreira Gonçalves 1, Maíra \nSanti Orsi Climeni 1,*, Marcelo Vicentini de Azevedo 1, Mariana Loureiro Dias Michelin 1, Paulo Vitor Carvalho \nSouza1, Ricardo Freitas 1, Tatiana Cesário Fonseca 1\n1Universidade Brasil, São Paulo, Brazil\n*Correspondence should be addressed to Maíra Santi Orsi Climeni, santimaira@yahoo.com.br\nReceived date:  February 25, 2024 , Accepted date: March 15, 2024\nCitation:  da Silva R, Bindi ED, da Silva LT, Gonçalves KM, Climeni MSO, de Azevedo MV , et al. Complications of Endometriosis \n– Case Report of a Postoperative Recurrence of Rectovaginal Fistula. Arch Med Case Rep. 2024;6(1):1-3.\nCopyright:  © 2024 da Silva R, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution \nLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author  and source \nare credited.\nAbstract\nEndometriosis is a disease with a poorly known etiology, characterized by the presence of dysfunctional endometrial tissue, which \nevolves to chronic inflammatory reactions in women of reproductive age, causing a great impact on the quality of life of this population, \noften leading to infertility. This article aims to describe the impact of endometriosis on women’s health, as well as the complications \nit can cause. The information was obtained from interviews and access to the patient’s medical records, analyzing diagnosis, surgical \nprocedures, and complications. However, it is hoped to deepen the existing knowledge about endometriosis, emphasizing the \nimportance of correct and early diagnosis of this disease and the risks of complications related to diagnosis, surgery, and rehabilitation.\nKeywords: Endometriosis, Laparoscopy, Colostomy, Rectovaginal fistula\n\n \nda Silva R, Bindi ED, da Silva LT, Gonçalves KM, Climeni MSO, de Azevedo MV , et al. Complications of Endometriosis \n– Case Report of a Postoperative Recurrence of Rectovaginal Fistula. Arch Med Case Rep. 2024;6(1):1-3.\nArch Med Case Rep. 2024\nVolume 6, Issue 1\n2\nCase Report\nPatient M.S.O.C., 33 years old, sought outpatient health \nservice as a beneficiary of health insurance, on an elective \nbasis on August 17, 2021, at Hospital Ministro Costa \nCavalcanti in the city of Foz de Iguaçu-PR, for consultation \nwith a gynecologist. Previously, she had oophorectomy \non the left due to ectopic pregnancy in 2015. During her \nconsultation the following symptoms were reported, \ndysmenorrhea in the first three days, urinary urgency, and \ninfertility. On specular examination blackish nodules in the \nbottom of the sac, on touch retroverted uterus, totally fixed, \nretrocervical nodule with apparent invasion of the vagina \nwere observed. A complementary magnetic resonance \nimaging exam was recommended.\nShe returned on September 15, 2021, and was \ndiagnosed with complex endometriosis of the posterior \nand left lateral compartment, endometriosis of the \nlower rectum, sigmoid, appendix, vagina, rectovaginal \nseptum, adenomyosis, fibroid, left hematosalpinx, and \nleft hypogastric plexus involvement. She underwent \nelective surgery on November 4, 2021 at the same hospital, \nwhere rectosigmoidectomy, right colectomy, hypogastric \nplexus nodule resection, bilateral parametrectomy, \nadenomyomectomy, colpectomy, appendectomy and \nenterectomy, rectovaginal septum tumor resection, \nuterosacral lesions, round ligaments, bladder peritoneum \nand ovarian fossa, left salpingectomy, and vaginal \nnodule were performed, a nodule in the ileocecal valve \nwas identified during the intraoperative period and \nremoved due to the risk of obstruction, and a nodule of \nendometriosis in the left lower hypogastric plexus. On the \n5th postoperative day (PO) of endometriosis, the patient \npresented vomiting, abdominal distension, dehydration, \nand paralytic ileus. On 11/10/2021, a surgical reapproach \nof Laparostomy with colostomy was performed due to \nrectovaginal fistula, presenting vaginal bleeding three days \nlater, requiring blood transfusion. On the 5th postoperative \nday of Laparostomy with colostomy, she was presented with \nbilateral pleural effusion and was referred to the Intensive \nCare Unit, where she received intensive support for 4 days \nand returned to the clinic. On the 11 th postoperative day \nof Laparostomy with colostomy, the patient presented with \nprofuse vaginal bleeding and underwent a new approach of \nlaparotomy and colporrhaphy, and the bleeding persisted \nin the postoperative period, which was evaluated by the \nvascular surgeon, who opted for embolization of the right \ninternal iliac branch, and after 4 days she was discharged. \nHyperbaric treatment was indicated for fistula closure, and \nduring the 5th session there was barotrauma in the right ear, \nwhich contraindicated the continuation of the treatment. \nThe patient underwent medical follow-up for one year and \ntwo months by means of colonoscopy (Figure 1).\nA new medical evaluation was carried out and the re-\napproach was scheduled for January 30, 2023. A new \nsurgical approach was performed, with partial colectomy \nby colostomy, reducing surgery, posterior access surgery, \nenterorrhaphy and removal of adhesions from previous \nsurgery. She was discharged on the 3rd postoperative day, \nwith collection of subsequent tests (D4 and D7). On the \n14th postoperative day, she was presented with vaginal \nand rectal hemorrhage at home and was taken to the \nprimary care unit in her hometown, where she had to be \nreferred to the referral hospital in the neighboring city. \nShe was evaluated in the emergency room and requested \nfor a transfer to another hospital that had better facilities, \nduring the care she presented severe hypotension, and \nthe use of noradrenaline was necessary. The patient \nwas referred from SAMU to another hospital, where she \nunderwent computed tomography and red blood cell \nconcentrate was administered. On further evaluation \nby a surgeon and gynecologist she was diagnosed with \na new rectovaginal fistula. Patient continues to have a \ncolostomy (transversostomy) and rectovaginal fistula. \nRectal anastomotic stenosis was identified during control \ncolonoscopy (Figure 2).\n \n  \nFigure 1\n\n \nda Silva R, Bindi ED, da Silva LT, Gonçalves KM, Climeni MSO, de Azevedo MV , et al. Complications of Endometriosis \n– Case Report of a Postoperative Recurrence of Rectovaginal Fistula. Arch Med Case Rep. 2024;6(1):1-3.\nArch Med Case Rep. 2024\nVolume 6, Issue 1\n3\nCase Discussion\nRectovaginal fistula is an abnormal connection between \nthe lower gastrointestinal tract and the vagina. They pose \na great challenge to colorectal surgeons because of their \ncomplexity which depends on location, etiology and quality \nof the surrounding tissues. They are most often caused \nby obstetric trauma, gynecological surgeries, traumas, \ninflammatory diseases, among others. Small- diameter, \ndistal fistulas in the rectovaginal septum secondary \nto traumatic injury or infection are considered simple. \nThose with a larger diameter, closer to the rectovaginal \nseptum, and associated with underlying inflammatory \nbowel disease, radiation, neoplasia, or insufficient anterior \nrepairs are considered more complex. There are several \nwell-described surgical approaches that can be divided \ninto trans anal, trans vaginal, trans perineal, and trans \nabdominal repairs. The type of procedure will depend on \nthe quality of the surrounding tissues, the location, and the \netiology of the fistula. In the last decade there has been a \nrapid use of bioprostheses in the form of plugs and gloves \nin the treatment of fistulas. A small number of cases have \nshown promising results, but there is still a paucity of long-\nterm data. Therefore, we can verify the difficulty in the \nmanagement of rectovaginal fistulas, treatment success, \nand latent risk of recurrence [4,5,6].\nConclusion\nThe present work aims to contribute to a deeper \nknowledge about endometriosis and its complications, \nsince it is a topic of enormous relevance today, with the \nobjective of motivating new health professionals and \nresearchers to delve deeper into the pathology and its \nsequelae, encouraging them to produce new studies and \ndemonstrate the impact of endometriosis on the quality \nof life of patients. For this, it is necessary to recognize the \nimportance of early diagnosis and treatment of the disease, \nin order to avoid possible complications such as the one \ndescribed in this case report, which directly influences \nthe woman’s infertility and fertilization rate, and the \ndevelopment of public policies aimed at the prevention \nand/or early detection of endometriosis is essential.\nReferences\n1. Rosa e Silva JC, Valério FP , Herren H, Troncon JK, Garcia R, \nPoli Neto OB. Endometriosis – Clinical aspects from diagnosis to \ntreatment. Femina. 2021; 49(3):134-41. \n2. Ministry of Health; Clinical Protocol and Therapeutic Guidelines \nfor Endometriosis; Ordinance nº879 of 12 July 2016; Retrieved from \nwww.gov.br\n3. Podgaec, Sérgio Manual of endometriosis / Sérgio Podgaec. \n-- Sao Paulo : Brazilian Federation of Gynecology and Obstetrics \nAssociations (FEBRASGO), Manual Endometriosis 2015.pdf \nRetrieved from: (pucgoias.edu.br).\n4. Soares GdeQ., Camargo de Jesus E, Lacerda da Silva IV, Faria \nSarmento L. Fístula retovaginal: relato de caso clínico. Caminhos da \nClínica. 2023.\n5. Machado IB, Vieira MG, Rangel MP , Nishida FS. IMPACTO \nDA ENDOMETRIOSE NA SAÚDE DA MULHER: RELATO DE CASO. \nElectronic Annals XII EPCC, Unicesumar. 2021 (unicesumar.edu.br).\n6. Costa ATD, Barbosa JC, Delfino GFdeL, Westphalen AP , Cipriani \nRFF, Fracaro GB, et al. FÍSTULA RETOVAGINAL: DA COLOSTOMIA \nAO AVANÇO DE RETALHO DE MARTIUS. Journal of Coloproctology. \n2017; 37(Suppl 1):61.\n \n \n Figure 2","source_license":"CC0","license_restricted":false}