Portal de Periódicos da CAPES

Bowel Invisible Microscopic Endometriosis: Leave It Alone

2018; Elsevier BV; Volume: 25; Issue: 3 Linguagem: Inglês

10.1016/j.jmig.2018.01.017

1553-4669

David B. Redwine, Elizabeth Hopton,

Intestinal and Peritoneal Adhesions

Severe endometriosis associated with infertility, pain, uterine retroversion, and nodularity has vexed women and the physicians caring for them at least since the time of Hippocrates. Intestinal involvement is a frequent finding in tertiary endometriosis surgical centers. Badescu et al [ 1 Badescu A. Roman H. Barsan I. et al. Patterns of bowel invisible microscopic endometriosis reveal the goal of surgery: removal of visual lesions only. J Minim Invasive Gynecol. 2017; (Epub ahead of print)https://doi.org/10.1016/j.jmig.2017.10.026 Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar ] deserve congratulations for conducting such an Herculean study using a detailed intestinal mapping technique. They have confirmed and expanded on the findings of Remorgida et al [ 2 Remorgida V. Ragni N. Ferrero S. Anserini P. Torelli P. Fulcheri E. How complete is full-thickness disc resection of bowel endometriotic lesions? A prospective surgical and histological study. Hum Reprod. 2005; 20: 2317-2320 Crossref PubMed Scopus (147) Google Scholar ] and their own previous work [ 3 Badescu A. Roman H. Aziz M. et al. Mapping of bowel occult microscopic endometriosis implants surrounding deep endometriosis nodules infiltrating the bowel. Fertil Steril. 2016; 105: 430-434 Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar ]: Small deposits of nonapparent endometriosis can be found in the bowel muscularis up to several centimeters from an obvious intestinal nodule of endometriosis. The possibility therefore exists of tiny lesions of endometriosis buried in the colonic muscularis that were not removed by surgery. This is termed by the authors “bowel invisible microscopic endometriosis” (BIME). This term and that of “bowel occult microscopic endometriosis,” used by Badescu et al previously [ 4 Hopton E.N. Redwine D.B. Eyes wide shut. The illusory tale of invisible microscopic endometriosis. Hum Reprod. 2013; 29: 384-387 Crossref PubMed Scopus (11) Google Scholar ], invite strained analogies with the terms invisible [ 5 Redwine D.B. Is “microscopic” peritoneal endometriosis invisible?. Fertil Steril. 1988; 50: 665-666 Abstract Full Text PDF PubMed Scopus (22) Google Scholar ] or occult [ 6 Khan K.N. Fujishita A. Kitajima M. Hiraki K. Nakashima M. Masuzaki H. Occult microscopic endometriosis: undetectable by laparoscopy in normal peritoneum. Hum Reprod. 2014; 29: 462-472 Crossref PubMed Scopus (50) Google Scholar ] microscopic endometriosis of the peritoneal surface, which could be termed “peritoneal invisible/occult microscopic endometriosis.” The strained analogy results from the fact that the peritoneal surface has reliable visible surface changes [ 5 Redwine D.B. Is “microscopic” peritoneal endometriosis invisible?. Fertil Steril. 1988; 50: 665-666 Abstract Full Text PDF PubMed Scopus (22) Google Scholar ] associated with endometriosis, and although those surface changes may be very subtle, they are detectable by visual inspection during surgery [ 7 Redwine D.B. “Invisible” microscopic endometriosis: a review. Gynecol Obstet Invest. 2003; 55: 63-67 Crossref PubMed Scopus (43) Google Scholar ], resulting in the possibility of identifying and removing 100% of peritoneal endometriosis by excising peritoneum that is not visually normal [ 8 Yeung Jr, P. Sinervo K. Winer W. Albee Jr, R.B. Complete laparoscopic excision of endometriosis in teenagers: is postoperative hormonal suppression necessary?. Fertil Steril. 2011; 95: 1909-1912 Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar ]. No one who has studied the peritoneum while using both strict criteria of normal peritoneum and using near-contact laparoscopy has found evidence of endometrium attached to, invading, or proliferating within visually normal peritoneum. In contrast, small nonfibrotic lesions of BIME within the colonic muscularis seem to be ubiquitous and well hidden, so the possibility of histologic cure of intestinal endometriosis by surgery approaches 0% if these little islands of occult endometriosis remain behind despite any type of colonic resection. BIME more closely resembles diffuse uterine adenomyosis, which can be cured by hysterectomy, although no one is suggesting that total colectomy be used to cure BIME.