Our Recent Question Contest ~ Answer to Michelle Bassett : I would really like more information on bowel endometriosis and what happens when its found on the ureter? I know Fallopian tubes can be removed but what about ureters in the future? Endometriosis can involve the bowels, the bladder and in some cases even the ureters. Depending on the severity of the disease in these areas, different surgical procedures can be performed to fully remove the diseased tissue. Firstly, a word on endometriosis of the fallopian tubes. While in some cases the tubes are removed (such as when a hysterectomy is performed or if there is a significant problem with the tubes that is causing pain, such as fluid or blood in the tube (hydrosalpinx and hematosalpinx / or an ectopic pregnancy), in many cases disease involving the tubes can actually be treated without having to remove the tubes. For example, if superficial endometriosis is found on the tubes it can be excised or laser vaporized (depending on how large an area is involved and which part of the tube is involved). If invasive disease of the tubes is found (which is rare), then the area can be resected and the damage to the tube repaired via sutures. In some cases a segment of tube may need to be removed in order to remove the disease, and then the two ends can be reattached and sutured back together (re-anastomosis of the fallopian tube). This technique has been used in women who have undergone tubal ligation and who later wanted to regain their fertility and reverse the procedure. So basically, there are several ways of approaching a problem, some more radical than others and the end point is to resolve the problem while preserving the structures as much as possible. Now lets apply this concept to endometriosis of the bowel. Endometriosis can affect the bowels to differing extents. Superficial disease only affects the serosa of the bowel (the thin saran-like wrap that cloaks the bowel). If disease is superficial then the serosa (or peritoneum) can be grasped, lifted and excised and the tissue carefully excised, just like superficial disease involving any other area of the pelvis. If bowel disease is invasive, however, the diseased tissue may actually involve part of the bowel wall. The bowel wall consists of several layers, including the muscularis (muscular layer) and the mucosa (the inner lining of the bowel). Rarely a bowel nodule will invade through to the lumen (the inside of the bowel) but in most cases even with invasive disease, only a portion of the bowel wall is involved. If a patient has invasive bowel disease the surgeon has to make a decision as to how best to remove it. If the nodule only involves a portion of the muscular layer of the bowel wall then the surgeon may be able to perform a partial-thickness discoid resection. This is when a disc of tissue is cut out of the bowel wall without cutting right the way through to the inside of the bowel. Once the disc has been removed (resected) the hole in the wall is repaired with sutures. If the nodule involves the majority of the muscular layer or has invaded through to the mucosal layer then a full-thickness discoid resection may well be necessary. This is similar to a partial thickness discoid bowel resection but this time the surgeon does have to cut right the way through the full thickness of the bowel wall. Once the disc of tissue has been removed, the hole in the bowel wall has to be carefully repaired, layer by layer, with sutures. Sometimes a patient has such severe bowel disease (i.e. several nodules that are close together or a very big nodule) that performing disc resections would leave too big a hole to safely repair. In these situations the decision is made to perform a segmental bowel resection. This is when the entire segment of affected bowel is removed, leaving two loose ends behind. The two loose ends are then reconnected back together using a stapler device (re-anastomosis). Typically this procedure requires that one of the laparoscopy incisions be extended slightly in order to pass the one section of bowel out of the body so that the stapling device can be inserted and the two ends reconnected. Patients who undergo a segmental bowel resection usually have to stay in the hospital slightly longer than other patients in order to be monitored closely during their initial healing process. We find that our intestinal endometriosis patients do very well and we are able to operate on all severities of intestinal disease with good results. Many surgeons, however, are nervous about working on the bowel and may tell their patients that the surgery is too dangerous, impossible or will result in a colostomy bag (a “poop bag”). In reality, however, if the surgical team is sufficiently experienced, resection of bowel endometriosis is safe and highly effective with minimal risk of complications. If you suspect you have bowel endometriosis, it is important to consult with a specialist surgeon who understands this disease and who can safely remove it. As for the ureters, endometriosis involving the ureter is actually quite rare. More common disease is found nearby the ureters and the tissue surrounding the disease can become fibrotic (scarred) as a result of the disease process. The fibrosis can then begin to encroach upon the ureter, in some cases strangling it over time, which can cause damage to the kidney on that side (hydronephrosis). This would be an example of severe endometriosis, however, and most patients do not have problems with their ureters due to the disease. If endometriosis if found involving the tissue overlying the ureters, an experienced excision surgery can carefully excise this tissue, without damaging the ureters. If scar tissue is found in the space surrounding the ureters, again careful excision is usually possible and in some cases laser vaporization may be appropriate to carefully strip the scar tissue from the outside of the ureter. In rare cases, endometriosis itself invades the ureter or scar tissue actually wraps around the ureter and strangles it. In these cases, if the disease/scarring cannot be excised from the outside of the ureter a segmental resection of the ureter may be performed. Just like with bowel surgery, this is when a segment of ureter is removed and the two ends are then reconnected. Sutures are used to reconnect the two ends and then a stent is passed through the affected ureter from the bladder to the kidney in order to allow urine to continue passing from the kidney to bladder while the ureter is healing. After 6 weeks, the stent can be removed. Thank you for your patience, and thanks for a great question !
Posted on: Sat, 28 Jun 2014 00:11:32 +0000
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