Derin İnfiltratif Rektal Endometriozisin Yönetiminde Kullanılan Teknikler

Synopsis

Sindirim sistemi boyunca endometriotik odakların en sık görüldüğü yer olan rektum ve distal sigmoid kolon derin infiltratif endometriozisi yönetiminde; hastaların semptomlarının şiddetine göre medikal tedavi ile tedavi edilebilecek hasta popülasyonu dışında, bu anatomik lokalizasyonda endometriotik odaklar histolojik olarak over ve peritondaki endometriotik odaklardan farklı olarak ağırlıklı olarak fibröz konnektif doku ve düz kas lifleri içerdiğinden primer tedavide hormonal medikal  tedavilere yanıtsız olabilir ve yoğun semptomatik olabilir. Bu durumda cerrahi yönetilmesi gerekir. Literatürde tanımlanan derin infiltratif endometriozisin cerrahi yönetimi hastalıktan etkilenen rektal segmentin çıkarılmasını içeren kolorektal rezeksiyon ve rektum açılmadan endometriotik nodülün çıkarılması ( shaving) ya da rektum  açılarak nodülü çevreleyen rektal duvarla birlikte çıkarılmasıdır (tam kalınlık veya disk eksizyonu). Kolorektal rezeksiyon ciddi obstrüksiyon olan veya rezeksiyonunun mümkün olmadığı endometriotik odakların rezeksiyonu için küçük bir gruba uygulanması gerekirken ; nodül eksizyonu semptomatik rektal derin infiltratif endometriozisi olan daha geniş bir hasta grubunda daha az morbid olduğu için tercih edilmekte ve uygulanmaktadır. Cerrahi sonrası hastalarda ağrı yönetimi ve nüks riskini azaltmak adına uygun olan tüm hastalarda medikal tedavi kombine edilmelidir. Hastaya uygulanacak cerrahi tedavi yöntemlerinin riskleri avantaj ve dezavantajları hakkında bilgi verilmeli ve hastaya uygulanacak tedavi hakkında seçme hakkı tanınmalıdır.

In the management of deep infiltrative endometriosis of the rectum and distal sigmoid colon, which is the most common site of endometriotic foci throughout the digestive tract, except for the patient population that can be treated with medical treatment according to the severity of the symptoms of the patients, endometriotic foci in this anatomical localization may be unresponsive to hormonal medical treatments in primary treatment and may be intensely symptomatic because endometriotic foci in this anatomical localization histologically contain predominantly fibrous connective tissue and smooth muscle fibers unlike endometriotic foci in the ovary and peritoneum. In this case, surgical management is required. Surgical management of deep infiltrative endometriosis described in the literature includes colorectal resection, which involves removal of the affected rectal segment, and removal of the endometriotic nodule without opening the rectum (shaving) or opening the rectum and removing the nodule together with the surrounding rectal wall (full thickness or disc excision). Colorectal resection should be performed in a small group for resection of severe obstruction and unresectable endometriotic foci, whereas nodule excision is preferred and performed in a larger group of patients with symptomatic rectal deep infiltrative endometriosis because it is less morbid. Postoperative pain management and medical treatment should be combined in all suitable patients to reduce the risk of recurrence. The patient should be informed about the risks, advantages and disadvantages of the surgical treatment methods to be applied to the patient.

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January 21, 2025

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