Lower endoscopic ultrasound in preoperative evaluation of rectosigmoid endometriosis

Abstract

Background and study aims Endometriosis affects a significant proportion of reproductive-aged women and involves the bowel in up to one-third of patients with the condition. Lower endoscopic ultrasound (LEUS) in assessment of endometriosis of the rectosigmoid colon was first described 20 years ago in European populations. The current study aimed to describe the diagnostic characteristics of this imaging modality at a tertiary US referral center in a large cohort and its impact on surgical planning.

Patients and methods This was a retrospective cohort study of adult women evaluated for rectosigmoid endometriosis by LEUS at an American tertiary referral center between January 2003 through June 2017. The reference standard for rectosigmoid endometriosis was surgical evaluation regardless of whether tissue was obtained for histologic evaluation. Two separate analyses were run; one comparing EUS to laparoscopic findings and another comparing EUS to histologic findings.

Results LEUS demonstrated a positive predictive value (PPV) of 93.8 % (CI:68.1,99.1) and negative predictive value (NPV) of 96.4 % (CI:87.8,99.0) in the diagnosis of rectosigmoid endometriosis. Test sensitivity was 88.2 % (CI:63.6,98.5) and specificity was 98.2 % (CI:90.1,99.9). Overall diagnostic accuracy of the test was 95.8 % (CI:88.1,99.1).

Conclusions In this large cohort of women at an American tertiary referral center undergoing evaluation for rectosigmoid endometriosis, LEUS demonstrated high PPV and NPV as well as excellent diagnostic accuracy. In addition, the LEUS findings provided important information to the referring gynecologic surgeon. This minimally-invasive imaging modality should be utilized in preoperative evaluation of women undergoing surgery for suspected or known endometriosis.

• References

• 1 Chapron C, Fauconnier A, Dubuisson JB. et al. Deep infiltrating endometriosis: Relation between severity of dysmenorrhoea and extent of disease. Hum Reprod 2003; 18: 760-766
• 2 Parasar P, Ozcan P, Terry KL. Endometriosis: epidemiology, diagnosis and clinical management. Curr Obstet Gynecol Rep 2017; 6: 34-41
• 3 Remorgida V, Ferrero S, Fulcheri E. et al. Bowel endometriosis: Presentation, diagnosis, and treatment. Obstet Gynecol Surv 2007; 62: 461-470
• 4 Seracchioli R, Mabrouk M, Guerrini M. et al. Dyschezia and posterior deep infiltrating endometriosis: analysis of 360 cases. J Minim Invasive Gynecol 2008; 15: 695-699
• 5 Ferrero S, Camerini G, Ragni N. et al. Endometriosis and irritable bowel syndrome: Co-morbidity or misdiagnosis?. BJOG An Int J Obstet Gynaecol 2009; 116: 129
• 6 Schröder J, Löhnert M, Doniec JM. et al. Endoluminal ultrasound diagnosis and operative management of rectal endometriosis. Dis Colon Rectum 1997; 40: 614-617
• 7 Chapron C, Dumontier I, Dousset B. et al. Results and role of rectal endoscopic ultrasonography for patients with deep pelvic endometriosis. Hum Reprod 1998; 13: 2266-2270
• 8 Roseau G, Dumontier I, Palazzo L. et al. Rectosigmoid endometriosis: Endoscopic ultrasound features and clinical implications. Endoscopy 2000; 32: 525-530
• 9 Rossi L, Palazzo L, Yazbeck C. et al. Can rectal endoscopic sonography be used to predict infiltration depth in patients with deep infiltrating endometriosis of the rectum?. Ultrasound Obstet Gynecol 2014; 43: 322-327
• 10 Gauche CC, Koskas M, Martin B. et al. Preoperative imaging of deeply infiltrating endometriosis in: Transvaginal sonography, rectal endoscopic sonography and magnetic resonance imaging. Gynecol Obstet Fertil 2012; 40: 634-641
• 11 Koga K, Osuga Y, Yano T. et al. Characteristic images of deeply infiltrating rectosigmoid endometriosis on transvaginal and transrectal ultrasonography. Hum Reprod 2003; 18: 1328-1333
• 12 Cotton PB, Eisen GM, Aabakken L. et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010; 71: 446-454
• 13 Bazot M, Lafont C, Rouzier R. et al. Diagnostic accuracy of physical examination, transvaginal sonography, rectal endoscopic sonography, and magnetic resonance imaging to diagnose deep infiltrating endometriosis. Fertil Steril 2009; 92: 1825-1833
• 14 Chapron C, Vieira M, Chopin N. et al. Accuracy of rectal endoscopic ultrasonography and magnetic resonance imaging in the diagnosis of rectal involvement for patients presenting with deeply infiltrating endometriosis. Ultrasound Obstet Gynecol 2004; 24: 175-179
• 15 Alborzi S, Rasekhi A, Shomali Z. et al. Diagnostic accuracy of magnetic resonance imaging, transvaginal, and transrectal ultrasonography in deep infiltrating endometriosis. Medicine 2018; 97
• 16 Scardapane A, Lorusso F, Bettocchi S. et al. Deep pelvic endometriosis: accuracy of pelvic MRI completed by MR colonography. La Radiol Med 2013; 118: 323-338
• 17 Centers for Medicare & Medicaid Services. Physician Fee Schedule. 2018 Available at https://www.cms.gov/apps/physician-fee-schedule/
• 18 Ballard K, Lane H, Hudelist G. et al. Can specific pain symptoms help in the diagnosis of endometriosis? A cohort study of women with chronic pelvic pain. Fertil Steril 2010; 94: 20-27
• 19 Melton LJ. Selection bias in the referral of patients and the natural history of surgical conditions. Mayo Clin Proc 1985; 60: 880-885
• 20 Hegedus EJ, Moody J. Clinimetrics corner: the many faces of selection bias. J Man Manip Ther 2010; 18: 69-73