Ballester M, Roman H
Service de gynécologie-obstétrique et médecine de la reproduction, CHU de Tenon, AP-HP, 4, rue de la Chine, 75020 Paris, France.
Centre expert de diagnostic et prise en charge multidisciplinaire de l'endométriose, clinique gynécologique et obstétricale, CHU Charles-Nicolle, 1, rue de Germont, 76031 Rouen, France.
Gynecol Obstet Fertil Senol. 2018 Mar;46(3):290-295. doi: 10.1016/j.gofs.2018.02.003. Epub 2018 Mar 10.
Deep endometriosis with colorectal involvement is considered one of the most severe forms of the disease due to its impact on patients' quality of life and fertility but also by the difficulties encountered by the clinicians when proposing a therapeutic strategy. Although the literature is very rich, evidence based medicine remains poor explaining the great heterogeneity concerning the management of such patients. Surgery therefore remains a therapeutic option. It improves the intensity of gynecological, digestive and general symptoms and the quality of life. Concerning the surgical approach, it appears that laparoscopy should be the first option; the laparoscopic robot-assisted route can also be proposed. The techniques of rectal shaving, discoid resection and segmental resection are the three techniques used for surgical excision of colorectal endometriosis. The parameters taken into account for the use of either technique are: the surgeon's experience, the depth of infiltration of the lesion within the rectosigmoid wall, the lesion size and circumference, multifocality and the distance of the lesion from the anal margin. In the case of deep endometriosis with colorectal involvement, performing an incomplete surgery increases the rate of pain recurrence and decreases postoperative fertility. In case of surgery for colorectal endometriosis, pregnancy rates are similar to those obtained after ART in non-operated patients. Existing data are insufficient to formally recommend first line surgery or ART in infertile patients with colorectal endometriosis. The surgery for colorectal endometriosis exposes to a risk of postoperative complications and recurrence of which the patients should be informed preoperatively.
深部子宫内膜异位症累及结直肠被认为是该疾病最严重的形式之一，这不仅是因为它会影响患者的生活质量和生育能力，还因为临床医生在制定治疗策略时会遇到困难。尽管相关文献非常丰富，但循证医学依据仍然不足，这解释了在这类患者的管理方面存在巨大异质性的原因。因此，手术仍然是一种治疗选择。它可以改善妇科、消化系统和全身症状的严重程度以及生活质量。关于手术方式，腹腔镜手术似乎应作为首选；也可以考虑腹腔镜机器人辅助手术。直肠削除术、盘状切除术和节段切除术是用于手术切除结直肠子宫内膜异位症的三种技术。选择使用任何一种技术时考虑的参数包括：外科医生的经验、病变在直肠乙状结肠壁内的浸润深度、病变大小和周长、多灶性以及病变距肛缘的距离。对于累及结直肠的深部子宫内膜异位症，手术不彻底会增加疼痛复发率并降低术后生育能力。对于结直肠子宫内膜异位症患者进行手术，其妊娠率与未接受手术的患者接受辅助生殖技术（ART）后的妊娠率相似。现有数据不足以正式推荐对患有结直肠子宫内膜异位症的不孕患者首选手术或ART。结直肠子宫内膜异位症手术存在术后并发症和复发的风险，术前应告知患者。
