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461
31 Colon ic Volvulus
If diagnostic doubt is present, CT is diagnostic.
31.23 What Do You Do When a Diagnosis Is Made?
The patient should be resuscitated and examined for peritonitis. Successful colono-
scopic decompression has been reported but has a high failure rate and may fatally
delay operation [ 14 ] . It should not be attempted. Urgent right hemicolectomy is indi-
cated [ 7, 39 ] in all patients, except those unfi t for any intervention. Primary anasto-
mosis should be done as long as standard prerequisites for a safe anastomosis are
met. Mortality is 4.5%. Operative de-rotation with caecostomy or fi xation has been
described, but 30% recur after caecopexy, and mortality is similar, or worse, than for
a right hemicolectomy [ 7, 39 ] . Operative mortality has been reported to be zero after
tube caecostomy which therefore could be an option in very frail patients [ 7 ] .
However, as the right colon is very mobile (by defi nition), a right hemicolectomy
should be quick and add little further to operative risk.
31.24 Caecal Bascule
In this variation, the caecum and terminal ileum fold up anterior to the ascending
colon, with the development of adhesions between the two (Fig. 31.4 ). This produces
a fl ap valve effect, and small-bowel obstruction may be absent. It may be these
cases where successful colonoscopic or even barium enema decompression has been
achieved.
31.25 Volvulus Elsewhere in the Colon
Other forms of colonic volvulus are very rare. The literature is so sparse that mean-
ingful conclusions cannot be drawn. Common sense and the management lessons
learned with sigmoid volvulus should apply.
Box 31.5: AXR Findings in Caecal Volvulus
Small bowel obstruction
Collapsed distal colon and rectum
(Often greatly) distended caecum
Caecum displaced (central, epigastric, LUQ)
Kidney bean sign
Comma sign
Caput caecum
Haustral pattern maintained
Small bowel lying to the right of the caecum
462
L.M. Hunt
31.26 Ethical Issues
The population at risk of sigmoid volvulus does raise ethical issues. In 2002, a case
scenario of an elderly, demented patient with sigmoid volvulus was presented to
surgical members of the Association of Coloproctology GBI Northern Chapter.
Sixty-fi ve percent of respondents felt that surgery was inappropriate, and 26% felt
all intervention was inappropriate. There was wide variation in surgeons’ approach
[ 40 ] , possibly refl ecting different interpretation of how morbid the patient was. This
survey took place prior to the wider availability of PEC. The medical literature
strongly supports intervention, but care must always be taken to ensure what is
being proposed is right for the individual patient.
Fig. 31.4 Line drawing of a caecal bascule
Key Points
Caecal volvulus
Urgent life-threatening condition •
Treated by right hemicolectomy •
Sigmoid volvulus
Urgent life-threatening condition •
463
31 Colon ic Volvulus
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2000;45:74–80.
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2007;50:489–97.
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gical therapy. St Louis: Decker Inc; 1992. p. 170–4.
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1961;101:70–7.
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1982;62:249–60.
Often poorly diagnosed (especially in elderly) •
Nonoperative de-rotation if safe •
Or emergency surgery •
Urgent surgery after successful de-rotation •
Percutaneous endoscopic colostomy gives alternative option in unfi t patients •
464
L.M. Hunt
25. Tsai MS, Lin MT, Chang KJ. Optimal interval from decompression to semi-elective operation
in sigmoid volvulus. Hepatogastroenterology. 2006;53:354–6.
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S.R. Brown et al. (eds.), Contemporary Coloproctology,
DOI 10.1007/978-0-85729-889-8_32, © Springer-Verlag London Limited 2012
32.1 Introduction
Endometriosis is a gynecological condition that affects 8–18% of women of
reproductive age [ 1 ] . First-line management is medical, with surgery reserved for
nonresponders [ 2 ] . In the majority of cases, the superfi cial nature of the serosal
endometrial deposits lends themselves to surface ablative surgery such as dia-
thermy, and as such, this is not an area of surgery that comes to the attention of the
colorectal surgeon.
In some cases, however, the endometrial deposits behave differently by invading
more deeply. Those invading 5 mm or more are defi ned as deeply invasive [ 3 ] . These
cases are associated with fi brosis and adhesions, leading to the formation of endo-
metriotic nodules [ 4 ] . Deeply invasive nodules have been described in up to 11% of
patients with endometriosis – and are most frequently found deep in the pelvis (55%
in the pouch of Douglas and 35% in the uterosacral ligaments) [ 3 ] . The fi brosis
associated with these nodules may be marked, and while complete bowel obstruc-
tion is very rare, cases may initially be mistaken for rectal cancer.
Symptoms associated with such rectovaginal deposits include periodic constipa-
tion, diarrhea, rectal bleeding, deep pelvic pain, dysmenorrhea, dyspareunia, and
rectal defecatory pain (dyschesia) [ 1 ] . However, there is poor correlation between
the extent of disease and symptoms [
3 ] , an important factor to remember when rec-
ommending treatment.
I. J. Adam , FRCS, M.B.Ch.B.
Department of Colorectal Surgery ,
Northern General Hospital, Sheffi eld Teaching Hospitals NHS Trust ,
Herries Rd. , Sheffi eld, S Yorks S5 7 AU , UK
e-mail: ian.adam@sth.nhs.uk
Chapter 32
Rectovaginal Endometriosis
Ian J. Adam
466
I.J. Adam
32.2 Conservative Surgical Management
There is a long history of surgical excision of rectovaginal endometriosis nodules in
the literature which is beyond the scope of this review. However, one key principle
developed over half a century of surgical management becomes readily apparent –
surgical excision should be conservative [
5 ] and tailored to the depth of penetration
of the nodule through the rectal wall.
Histological studies show that the depth of penetration of endometriosis into the
rectal wall is variable. For example, one study of 50 cases of rectovaginal endo-
metriosis showed that while all the nodules penetrated the muscularis propria, in
only 17 (34%) patients did the endometriosis extend to the submucosa and in only
5 (10%) did the endometriosis breech the mucosa [ 6 ] . As an aside, this fi gure of
10% presumably explains why colonoscopy has not proved particularly helpful in
the assessment of these cases. But these statistics also have relevance to the surgeon
adopting a conservative operative strategy [ 5 ] .
In the approximately two-thirds of cases where there is no deeper penetration,
the endometriotic nodule may be shaved off the anterior wall of rectum. Batt et al.
describe an open surgical technique of placing traction sutures in the exposed rectal
nodule, incising the normal bowel serosa around the endometrioma with diathermy,
and stripping the nodule off the underlying layers [ 5 ] . Should the depth of penetra-
tion be found to be deeper, the incision into the rectum can be extended into the
lumen so as to excise the endometrioma as a full thickness disk excision. Closure
should be transversely so as to avoid subsequent structuring.
As an alternative to an open rectal shave, Donnez et al. from Brussels developed
a laparoscopic rectal shave technique [ 7 ] . In their series of 497 patients, operative
perforation occurred in only four cases (0.8%).
From a practical perspective, once a rectovaginal endometrioma penetrating the
deeper layers exceeds 2 cm, disk excision becomes diffi cult, and anterior resection
is usually required. There are many reports of successful anterior resection in the
earlier literature, but as an illustration of just how effective open colorectal surgery
can be for endometriosis, one needs look no further than the impressive series of
Bailey and colleagues from Houston [ 8 ] , who document 109 open anterior resec-
tions over 15 years without an anastomotic leak or mortality.
Despite this background of surgery for rectovaginal endometriosis, it is only
recently that surgery for deeply invasive rectovaginal nodules has become more com-
monplace. Instrumental in the popularization of such surgery has been the laparo-
scopic surgical approach as of described by David Redwine, a gynecologist from St.
Charles Medical Center in Bend, Oregon [ 9 ] . His work demands close inspection.
32.3 The Oregon Series
Of all of Redwines’s publications, the paper of most relevance to the colorectal
surgeon details a series of 100 where investigation with digital pelvic and laparo-
scopic examinations had revealed complete obliteration of the rectovaginal septum
467
32 Rectovaginal Endometriosis
by endometriosis [ 9 ] . In the event, in 16 of the patients, the rectovaginal septum was
found to be obliterated by adhesions alone with no endometrioma – leaving 84
patients in the series – and suggesting that there might be room for improved preop-
erative staging in such patients.
The laparoscopic surgical technique used is the key to the Redwine approach [ 9 ] .
After defi ning the extent of the rectovaginal nodule, incisions were made in normal
peritoneum outside of the nodule lateral and parallel to the uterosacral ligaments.
After undermining the uterosacrals to achieve lateral mobilization of the nodule, a
transverse incision was made across the posterior cervix, and the nodule mobilized
off the cervix/posterior fornix – leaving the nodule on the front of the midrectum.
Dissection was then taken caudally until normal rectovaginal septum was entered.
Finally, attention was paid to excising the endometriotic nodule along the conserva-
tive principles outlined in the previous section as dictated by the depth of invasion
of the endometrioma (see Table 32.1 ).
The results from the Oregon series were good [ 9 ] . There was no mortality, no
reoperations for surgical complications, and no leaks. Signifi cant improvements
were documented in nonmenstrual and menstrual pain, dyspareunia, dyschesia,
constipation, and diarrhea. Of the 28 patients who tried to conceive following sur-
gery, 12 women were successful.
32.4 Other Centers
With time, other centers have gone on to report similar, favorable reductions in pain
and improvements in fertility using similar laparoscopic approaches. Detailed evalu-
ation of the literature is beyond this chapter, but comprehensive reviews of all pub-
lished studies are available for those requiring more thorough analysis [
4, 10, 11 ] .
Among these, the systematic review of 34 studies by De Cicco et al. in particular
provides a detailed insight into the advantages of excisional surgery [
11 ] . The
authors calculate that 81.5% of women are pain free 1 year postresection, with
62.0% reporting complete relief of deep dyspareunia, 54.9% reporting complete
relief of dysmenorrhea, and 46.3% reporting complete relief of deep dyschesia.
Perhaps less encouraging is the calculation or the rate of recurrence of endometrio-
sis requiring surgery at 19.4% of cases.
In terms of other outcomes, evaluation of quality of life using the ED-5Q and
SF-12 are favorable [ 12, 13 ] . While papers looking at longer term outcomes are few
Table 32.1 Oregon series:
operative techniques used
1987–1999 [
9 ]
Technique Numbers
Conservative surgical treatment
1,049
Obliteration of rectovaginal septum 100
Laparoscopic excisional surgery 84
Superfi cial shave 17
Deep partial thickness shave 11
Disk excision (nodulectomy) 26
Anterior resection 7
468
I.J. Adam
and far between, one small series of patients followed for 5 years suggests that
much of the benefi cial effect of surgery on dysmenorrhea, dyschesia, pelvic pain,
and dyspareunia continues long term [ 14 ] .
Despite a large body of published case-based evidence to support excision of
rectovaginal endometriosis, there are no randomized controlled trials of excisional
surgery, either for laparoscopic or open cases. Furthermore, there are no meta-anal-
yses because of the variability of the data collected in the published studies [ 4, 11 ] .
The available evidence is all from retrospective and prospective case studies only.
Despite this, the literature supporting excisional surgery for rectovaginal endometri-
osis is rapidly expanding [ 11 ] , and increasing numbers of colorectal surgeons are
being asked to join their gynecological colleagues for such cases.
32.5 Predicting When a Colorectal Surgeon Is Needed
In planning cases where surgeons of different disciplines might be required, accurate
evaluation is desirable. The Oregon series evaluated potential cases of deep pelvic
endometriosis with a combination of internal digital examination and laparoscopy but
overpredicted the presence of a nodule in 16/100 cases [ 9 ] . As indicated above, colonos-
copy, even if performed during the menstrual cycle, is similarly problematical.
Preoperative evaluation with transrectal and transvaginal ultrasound, as well as
magnetic resonance imaging, has been more promising. In order to determine which
of these modalities is most useful, Bazot et al. evaluated 92 patients considered for
rectovaginal endometriosis surgery by digital examination, transvaginal ultrasound,
transrectal ultrasound, and pelvic MRI [ 15 ] . All three modalities were superior to
digital evaluation, but none was particularly better than another (see Table 32.2 ).
The conclusion is that the surgeon should employ the technique for which there is
most expertise in their own institution.
However, it is perhaps wise not to exclude barium enema from the list of investiga-
tions for evaluating of such cases. From the perspective of a colorectal surgeon, it
provides a simple visual guide to whether or not there is distortion of the anterior
rectal wall regardless of whether or not the mucosa has been breached. If distortion is
present, then a colorectal surgeon may well be needed to assist their gynecological
colleague. In a study of 108 patients with suspected large-bowel endometriosis, Landi
et al. found that barium enema had a sensitivity of 85%, specifi city of 50%, positive
predictive value of 96%, and negative predictive value of 20% for involvement [ 16 ] .
Table 32.2 Comparison of different modalities of assessing intestinal endometriosis [ 15 ]
Digital exam TV USS TRUSS MRI
Sensitivity (%) 46 94 89
87
Likelihood ratio of positive test
being positive
1.67 – 12.89 12.66
Likelihood ratio of negative test
being negative
0.75 0.06 0.12 0.14
469
32 Rectovaginal Endometriosis
Such results, coupled with its ready availability, make barium enema the investigation
of choice in some units.
32.6 Evolving Technique
With the spread of excisional surgery for rectovaginal surgery, an important issue is
which of the available excisional techniques – rectal shave, disk excision, or seg-
mental resection – is best. From a technical standpoint, a laparoscopic sutured disk
excision is perhaps just as demanding to perform as a stapled segmental resection.
To counter this, a simplifi ed technique of disk excision using a circular stapler has
been widely adopted [ 17 ] . However, segmental anterior resection continues to gain
prominence in published reports [ 11 ] .
An important factor in this evolution has been the role of histological studies.
Kavallaris et al. looked at 50 anterior resection specimens for endometriosis, includ-
ing en bloc excision of the posterior vaginal fornix [ 6 ] . They found that the endo-
metriotic deposits were multicentric in 19 cases and multifocal in 31 cases – the
histological resection margins were found to be involved in 4 cases despite such
radical surgery, and none of the cases involved a single nodule. Remorgida et al.
studied 16 patients undergoing surgery for a rectovaginal endometriotic nodule with
a novel study design [ 18 ] . The surgeon was asked to perform a nodulectomy using
a disk excision technique to achieve apparent local clearance. An anterior resection
was then performed, and the two specimens compared histologically. Endometriosis
was found to be outside the nodule in 7 of the 16 cases. Faced with histological
evidence suggesting the superiority of anterior resection, it is perhaps unsurprising
that many surgeons favor this approach.
However, in understanding why standard anterior resection has come to pre-
dominate over a more traditional conservative approach for rectovaginal endometri-
osis, it would be wise to examine in detail the work of one of the preeminent
colorectal surgeons involved in the management of this gynecological disease –
Rodney Woods from St. Vincent’s Hospital, Melbourne [ 10 ] . Over 11 years, Woods
was involved in 556 operations for pelvic endometriosis, of which 213 involved
excisional surgery for a rectovaginal nodule. One signifi cant revelation in the dis-
cussion of this chapter is the documentation of a change in surgical philosophy
during the years that the study took place. Instead of a gynecological decision being
taken as to how much of the rectovaginal nodule was safe to excise, the authors
document evolution toward a specialist collaborative approach toward complete
excision – with decisions taken in a way not unlike a multidisciplinary approach to
colorectal cancer. This change led to a very different distribution in surgical tech-
nique used when compared to the Oregon series [
9 ] , with a higher number of ante-
rior resections performed (see Table 32.3 ). Despite this change, the improvements
the patients experienced in terms of resolution of symptoms are similar to the
Oregon series [ 9 ] . This increase in anterior resection over rectal shave or disk exci-
sion is mirrored in other series [ 11 ] .
470
I.J. Adam
32.7 Evolving Complications
As more series involving bowel resections for rectovaginal endometriosis are published
in the literature, one observation seems to be coming to the fore – bowel resections for
rectovaginal endometriosis are associated with the same rate of complications that
might be expected from other colorectal diseases [ 11 ] . This comes as no surprise to
colorectal surgeons – but worries gynecologists [ 19 ] .
The Guildford group provides a candid insight into this issue by comparing their
complication rates for anterior resection for rectovaginal endometriosis with their
complication rate for laparoscopic anterior resections for other diseases [ 4 ] . In just
over 4 years, the unit performed 27 anterior resections for endometriosis, in which
there were 3 anastomotic leaks (11%), one pelvic abscess, and 5 cases of subse-
quent anastomotic stenosis. In the same time period, 97 anterior resections were
performed for other conditions, with just 2 anastomotic leaks (2%), one pelvic
abscess, and one stenosis. Although making a valid comparison between the two
sets of patients if diffi cult, the young age and benign pathology in the endometriosis
group must be of concern. The Guildford group is not alone in such outcomes for
bowel resection in rectovaginal endometriosis. Analysis of the literature is con-
founded by the fact that in much of the published series, distinction has not been
made between open or laparoscopic cases, or between rectal shave, disk excision,
or anterior resection [ 4, 11 ] – but those studies that have reported complication
rates specifi cally for laparoscopic anterior resection for endometriosis are presented
in Table 32.4 .
Notable among these studies is the Melbourne series, with only 1 leak from 137
anterior resections [ 10 ] . In this series, a diverting stoma was created in seven patients
(5%). This begs the question as to whether there is a role for a diverting stoma in all
diffi cult cases.
As a last word on this diffi cult subject, it is perhaps best to refl ect on the advice
of David Redwine about these cases. In his seminal series where we started this
review [ 9 ] , he states that “the surgery described here is time consuming and
requires considerable training and experience, surpassing that of oncological sur-
gery.” Care should be taken to build up experience on less complex cases, leaving
recurrences until the learning curve is safely scaled. Any conclusion about higher
complication rates in laparoscopic anterior resection for endometriosis is better
put off until specialist units begin to publish data from beyond their initial
experiences.
Table 32.3 Melbourne
series: operative techniques
used 1995–2006 [
11 ]
Operations on patients with pelvic endometriosis 556
Rectal involvement by endometriosis 213
Rectal shave 18
Disk excision (nodulectomy) 58
Anterior resection 137
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