Dumontier I, Roseau G, Vincent B, Chapron C, Dousset B, Chaussade S, Moreau J F, Dubuisson J B, Couturier D
Services d'Hépato-Gastroentérologie, Hôpital Cochin, 27, rue du Faubourg Saint-Jacques, 75014 Paris, France.
Gastroenterol Clin Biol. 2000 Dec;24(12):1197-204.
Deep pelvic endometriosis may lead to severe pain, the treatment of which may require complete surgical resection of lesions. Digestive infiltration is a difficult therapeutic problem. Preoperative diagnosis is difficult and digestive infiltration may remain unknown with incomplete resection and sometimes repeated surgery. Both magnetic resonance imaging (MRI) and endoscopic ultrasonography are able to detect rectosigmoid infiltration but their usefulness in the preoperative staging is still to be evaluated. The aim of this work was to evaluate and compare both techniques in the preoperative detection of deep pelvic endometriosis, particularly digestive infiltration.
From 1996 to 1998, 48 women with painful deep pelvic endometriosis had preoperative imaging exploration with endoscopic ultrasonography and MRI, and were operated on in order to attempt complete endometriosis resection. Patients were proposed for laparoscopic resection if endoscopic ultrasonography and/or MRI did not reveal digestive infiltration or for open resection if endoscopic ultrasonography and/or MRI were positive for digestive infiltration.
Endoscopic ultrasonography and/or MRI led to suspicion of digestive endometriosis in 16 patients. Surgical resection was performed in 12 and digestive wall invasion was histologically demonstrated. At final follow-up, all patients had a dramatic decrease of their symptoms. The remaining 4 patients refused digestive resection and had only laparoscopic gynecologic resection. Infiltration although not histologically proven was very likely both on operative findings and clinical evolution. Digestive infiltration was preoperatively excluded in the 32 other patients. All had a laparoscopic treatment without digestive resection and pain diminished in all patients. In the 12 patients group who had digestive resection, digestive infiltration was correctly diagnosed by endoscopic ultrasonography in all cases (no false negative) whereas MRI, even with the use of endocoil antenna, led to correct diagnosis in 8 out of 12 cases. When endoscopic ultrasonography was negative for digestive infiltration, laparoscopic resection of lesions at surgery appeared complete in all cases. For the 16 patients with presumed digestive infiltration, sensitivity of endoscopic ultrasonography and MRI was 100 and 75% respectively, with a 100% specificity in both cases. MRI appeared very accurate for the detection of ovarian endometriotic locations. MRI was more sensitive but less specific than endoscopic ultrasonography for the diagnosis of isolated endometriotic recto-vaginal septum and utero-sacral ligaments lesions.
Endoscopic ultrasonography was the best technique for the diagnosis of digestive endometriotic infiltration, which complicates the therapeutic strategy. MRI, however, allows more complete staging of other pelvic endometriotic lesions.
深部盆腔子宫内膜异位症可能导致严重疼痛，其治疗可能需要对病变进行彻底手术切除。消化器官浸润是一个棘手的治疗难题。术前诊断困难，且消化器官浸润在切除不完全及有时重复手术的情况下可能仍未被发现。磁共振成像（MRI）和内镜超声检查均能够检测直肠乙状结肠浸润，但它们在术前分期中的作用仍有待评估。本研究的目的是评估和比较这两种技术在术前检测深部盆腔子宫内膜异位症，尤其是消化器官浸润方面的效果。
1996年至1998年期间，48例患有深部盆腔疼痛性子宫内膜异位症的女性患者在术前接受了内镜超声检查和MRI成像检查，并接受了手术，以期彻底切除子宫内膜异位症病灶。如果内镜超声检查和/或MRI未显示消化器官浸润，则建议患者进行腹腔镜切除；如果内镜超声检查和/或MRI显示消化器官浸润呈阳性，则建议进行开放手术切除。
内镜超声检查和/或MRI使16例患者怀疑有消化器官子宫内膜异位症。其中12例患者接受了手术切除，组织学证实有消化壁侵犯。在最后的随访中，所有患者的症状均显著减轻。其余4例患者拒绝进行消化器官切除，仅接受了腹腔镜妇科手术切除。尽管未得到组织学证实，但从手术发现和临床进展来看，消化器官浸润的可能性很大。另外32例患者术前排除了消化器官浸润。所有患者均接受了腹腔镜治疗，未进行消化器官切除，所有患者的疼痛均减轻。在接受消化器官切除的12例患者组中，内镜超声检查在所有病例中均正确诊断出消化器官浸润（无假阴性），而MRI即使使用了腔内线圈天线，在12例病例中也仅8例诊断正确。当内镜超声检查显示消化器官浸润为阴性时，手术中病变的腹腔镜切除在所有病例中均看似完整。对于16例疑似消化器官浸润的患者，内镜超声检查和MRI的敏感性分别为100%和75%，两者的特异性均为100%。MRI在检测卵巢子宫内膜异位症位置方面似乎非常准确。对于孤立的子宫内膜异位症直肠阴道隔和子宫骶韧带病变的诊断，MRI比内镜超声检查更敏感，但特异性较低。
内镜超声检查是诊断消化器官子宫内膜异位症浸润的最佳技术，消化器官浸润会使治疗策略复杂化。然而，MRI能够对其他盆腔子宫内膜异位症病变进行更全面的分期。
