What is deep endometriosis?

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Deep endometriosis is a severe form characterized by the presence of endometriotic tissue more than 5 mm deep outside the uterine cavity. These lesions usually appear as nodules and are rich in fibrosis, a hardened connective tissue similar to a scar. It can affect any organ in the pelvis, especially the uterine ligaments, intestine, rectum, vagina, bladder and ureters.

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intestinal endometriosis

Intestinal endometriosis is defined as the disease affecting the muscular layer of the intestine. If there are only adhesions, the disease is considered superficial. Bowel endometriosis is the second most common form of deep endometriosis, second only to endometriosis located in the retrocervical region, including the uterosacral ligaments.

The most common sites of endometriosis in the bowel are:

• Straight 70%;

• 15% Sigmoid;

• Appendix 6%;

• 5% ileum;

• Cecum 4%

What are Symptoms of Bowel Endometriosis?

• Pain to evacuate during menstrual period (most common symptom);

• Diarrhea or constipation during menstruation;

• Feeling of incomplete evacuation;

• bleeding from feces  in the menstrual period (uncommon and usually in cases of very advanced disease).

How to diagnose bowel endometriosis?

The best test for the diagnosis of bowel endometriosis is transvaginal ultrasound with bowel preparation, which, when performed by a trained professional, can detect almost 100% of the lesions. However, this exam is dependent on the examining physician and is not readily available.

The second best exam is MRI, which must also be performed with bowel preparation and by a radiologist specializing in endometriosis, otherwise the results are poor. The advantage of transvaginal ultrasound with bowel preparation over magnetic resonance imaging is its greater capacity to detect the different layers affected by the disease.

Another exam of fundamental importance is colonoscopy. This test allows you to diagnose endometrial damage inside the intestine and identify strictures caused by the disease.

Indications for Endometriosis Surgery

One of the great challenges of treating endometriosis is deciding when to operate. Surgery may not resolve all of the patient's symptoms, and in particular situations these symptoms may even get worse. Therefore, the treatment must be individualized and discussed with the patient.  

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Often an intestinal endometriosis lesion causes narrowing of the bowel and causes pain during the menstrual period. These symptoms can cause a significant decrease in quality of life. In these cases, surgery may be an option.  

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When the patient undergoes surgery for deep endometriosis with intestinal invasion, the immediate postoperative period is performed in the Intensive Care Unit (ICU). This care is necessary due to the surgical time (duration of the surgery) and the risks of bleeding and other complications that can occur in the postoperative period. Usually this stay in the ICU is 1 to 2 days.

After discharge to the room, the patient is hospitalized for an average of 3 days until complete acceptance and tolerance of a light pasty diet. 

After surgery, a drain may be left in the patient to control bleeding and aspiration of residual fluids that accumulate in the pelvis due to extensive surgical dissection. Eventually, a temporary ostomy (ileostomy) may be performed for the intestinal diversion of feces in more severe and higher-risk cases.

The main risks and complications after deep endometriosis are:

• intestinal or intra-abdominal bleeding;

• bladder dysfunction such as urinary incontinence;

• difficulty to evacuate;

• fistulas or bowel leaks where a surgical re-approach and making a temporary ostomy will be necessary;

• disease recurrence;

• lower limb venous thrombosis;

• pulmonary embolism.

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Below is an edited video of an endometriosis surgery with robotic bowel resection using the Da Vinci Xi system.