Intestinal endometriosis combined with colorectal cancer: a case series | Journal of Medical Case Reports

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Endometriosis is histologically defined as the presence of endometrial glands and stroma outside the uterus [14]. It is a common benign disease among menstruating women [14]. The frequency of intestinal endometriosis is estimated to be approximately 3–34% of endometriosis [14]. Endometriosis is estimated to affect the intestinal tract in 15–37% of patients with pelvic endometriosis [57]. Many theories regarding the pathogenesis of this benign gynecological disease have been proposed. The most widely accepted theory proposes retrograde menstruation and subsequent implantation of regurgitated endometrial cells on the peritoneum and pelvic viscera, which appears to be facilitated by alterations in cell-mediated and humoral immunity [5]. This pathology occurs in women of childbearing age and can be located in various anatomic sites including the peritoneum, ovary, fallopian tubes, cervix, vagina, vulva, rectovaginal septum, uterosacral ligaments, rectosigmoid bowel, bladder, uterus, and skin [5]. Intestinal endometriosis often presents as bowel obstruction due to a submucosal tumor or luminal stenosis because endometrial tissue usually involves the outer walls of the intestinal tract such as the serosal or submucosal layer. In that case, preoperative diagnosis of intestinal endometriosis is very difficult despite the use of CT or magnetic resonance imaging (MRI), and it is important to differentially diagnose intestinal endometriosis from advanced colorectal cancer such as invasion of adjacent organs (T4) [8].

In general, in almost all cases, intestinal endometriosis is diagnosed by histological findings after surgical resection [5]. Actually, in our series, there were no cases of preoperatively diagnosed intestinal endometriosis.

Operation is the basic treatment when treatment is needed for intestinal endometriosis. For surgical treatment of intestinal endometriosis, early detection, resection of endometrial tissue, and relief of symptoms are important. Although lymph node involvement by endometriosis is considered to be uncommon, there are a few reports of endometrial cells in the lymph nodes, despite intestinal endometriosis itself not being considered a malignant disease [9]. Therefore, lymph node dissection is required as well as resection of primary endometrial tissue.

In cases of T4 malignant tumor, intestinal resection with a safety margin and dissection along with a salpingo-oophorectomy and hysterectomy may be necessary [10]. However, in cases of intestinal endometriosis, which is a benign disease in reproductive women with the full thickness of the intestinal wall with no evidence of malignancy, preserving the uterus and ovary is very important and a laparoscopic approach has great potential as a diagnostic tool [10].

In recent years, laparoscopic surgery for colorectal disease has been appreciated and this technique has been improved; the procedure is also effective for distinguishing intestinal endometriosis from colorectal cancer [11]. Because of the ability of the laparoscope to zoom in and out in the pelvic space, it is possible to diagnose intestinal endometriosis during surgery. Therefore, laparoscopic surgery has great potential to contribute to preserving fertility and reducing invasiveness.

Several studies have shown that laparoscopic colorectal resection for endometriosis is feasible and safe, including a randomized prospective study by Darai and colleagues [12]. We should consider the patient’s age and fertility, and complications of the disease. Pelvic endometriosis sometimes involves the intestinal tract and a malignant tumor. When an unexpected pelvic mass lesion is found during surgery, an intraoperative histological examination should be considered for conclusive diagnosis.

In all of our cases, patients were not diagnosed preoperatively. In case 1, preoperative diagnosis was GIST, and it caused severe stenosis of the intestinal tract. In the other cases, preoperative diagnoses were colon cancer; however, they were diagnosed with intestinal endometriosis histologically. In case 7, we were able to preserve the uterus as rapid diagnosis and laparoscopic observation revealed that there was no invasion by T4 tumor. Furthermore, a previous study described that early diagnosis by intensive endoscopic examination could improve the number of curative colorectal resections [13]. In addition, the use of intraoperative colonoscopy is also very useful in that an adequate cutting line can be obtained by checking mucosal findings.

In our group, we performed laparoscopic surgery for 1433 colorectal cancer cases from November 2003 to June 2010. We consider laparoscopic surgery to be valid for observation of the affected part and pelvic space; therefore, it represents a safe approach for the treatment of intestinal endometriosis or colorectal cancer. Our postoperative morbidity and mortality rate is in accordance with many recent reports [1417]. Our experience will be related to a suitable intraoperative decision for preserving fertility and preventing excessive surgical stress.

We have performed laparoscopic surgery in combination with intraoperative endoscopy, which discloses the safety margin and other masses of the intestine. Especially in the case of laparoscopic low or super-low anterior resection, the edge of the incision line could be determined correctly using this technique in combination with intraoperative endoscopy.

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