title: Deep endometriosis infiltrating the recto-sigmoid: critical factors to consider before management.
abstract: BACKGROUND
  Deep endometriosis invading the bowel constitutes a major challenge for the gynecologist. In addition to the greater impact on pain, the high incidence of surgical morbidity involved with bowel endometriosis poses a therapeutic dilemma for the surgeon. Intestinal involvement by deep endometriotic nodules has been estimated to occur in 8-12% of women with endometriosis. Individual and clinical factors, pre-operative morphologic characteristics from imaging, surgical considerations and impact on quality of life are critical variables that should be considered in determining the best therapeutic strategy for a patient with deep endometriosis involving the sigmoid and/or the rectum. Pre-operative planning is fundamental for defining the optimal therapeutic strategy; patient counseling of treatment options, and when surgery is indicated, involvement of a multidisciplinary surgical team is required.
  
  
  METHODS
  The PubMed and Cochrane database were searched for all original and review articles published in English, French and Italian, until June 2014. Search terms included 'deep endometriosis', 'surgical and clinical approach', 'bowel disease', 'quality of life', 'management of deep endometriosis'. Special attention was paid to articles comparing features of discoid and segmental resection.
  
  
  RESULTS
  The rationale for the best therapeutic options for patients with deep endometriosis has been shown and an evidence-based treatment algorithm for determining when and which surgical intervention may be required is proposed. In deciding the best treatment option for patients with deep endometriosis involving the sigmoid and rectum, it is important to understand how the different clinical factors and pre-operative morphologic imaging affect the algorithm. Surgery is not indicated in all patients with deep endometriosis, but, when surgery is chosen, a complete resection by the most appropriate surgical team is required in order to achieve the best patient outcome.
  
  
  CONCLUSIONS
  In women with deep endometriosis, surgery is the therapy of choice for symptomatic patients when deep lesions do not improve with a medical treatment.
authors.affiliation: Endometriosis Division, Obstetrics and Gynecological Department - Sao Paulo University, Sao Paulo, Brazil msabrao@mac.com.
authors.forename: Mauricio Simões
authors.initials: MS
authors.lastname: Abrão
authors.affiliation: Obstetrics and Gynecology, Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy.
authors.forename: Felice
authors.initials: F
authors.lastname: Petraglia
authors.affiliation: Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Tommaso
authors.initials: T
authors.lastname: Falcone
authors.affiliation: Department of Obstetrics and Gynecology, Center for Endometriosis, Villach Hospital, Villach, Austria.
authors.forename: Joerg
authors.initials: J
authors.lastname: Keckstein
authors.affiliation: Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tokyo, Hongo, Bunkyo, Tokyo, Japan.
authors.forename: Yutaka
authors.initials: Y
authors.lastname: Osuga
authors.affiliation: Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, Assistance Publique - Hôpitaux de Paris (AP- HP), Groupe Hospitalier Universitaire (GHU) Ouest, Centre Hospitalier Universitaire (CHU) Cochin, Department of Gynecology Obstetrics II and Reproductive Medicine, 75679 Paris, France Institut Cochin, Université Paris Descartes, Sorbonne Paris Cité CNRS (UMR 8104), Paris, France Inserm, Université Paris Descartes, Sorbonne Paris Cité, Unité de recherche U1016, Paris, France.
authors.forename: Charles
authors.initials: C
authors.lastname: Chapron
mesh_terms: D012809:Colon, Sigmoid / Q000000981:diagnostic imaging / Q000473:pathology* / Q000601:surgery; D004715:Endometriosis / Q000000981:diagnostic imaging / Q000473:pathology* / Q000601:surgery*; D005260:Female; D006801:Humans; D008198:Lymph Nodes / Q000473:pathology; D019060:Minimally Invasive Surgical Procedures; D011788:Quality of Life; D012002:Rectal Diseases / Q000000981:diagnostic imaging* / Q000601:surgery; D012007:Rectum / Q000000981:diagnostic imaging / Q000473:pathology* / Q000601:surgery; D014463:Ultrasonography
keywords: MRI; deep endometriosis; minimally invasive surgery; recurrence; ultrasound