后盆腔深部浸润型子宫内膜异位症的临床病理特点及腹腔镜手术治疗效果

Clinico-pathologic characteristics of posterior deeply infiltrating endometriosis lesions, pain symptoms and its treatment using laparoscopic surgery

目的探讨后盆腔深部浸润型子宫内膜异位症（PDIE）疼痛症状的特点、临床分型和腹腔镜手术治疗效果。方法以2003年2月至2008年2月在北京协和医院就诊、经腹腔镜手术和病理检查证实为PDIE的176例患者为研究对象，以179例非PDIE的内异症患者为对照，PDIE患者按照是否侵犯阴道穹隆或直肠分为单纯型（144例）、穹隆型（18例）和直肠型（14例）；分析患者的临床病理资料。结果PDIE患者91．5％（161／176）有不同程度的痛经，中度痛经（36．4％，64／176）、重度痛经的比例（42．0％，74／176）均高于非PDIE患者，痛经风险的OR值为6．73（95％CI为3．66～12．40）。PDIE患者中，慢性盆腔痛的发生率（33．0％，58／176）、性交痛的发生率（45．5％，80／176）、肛门坠胀的发生率（58．0％，102／176）及大便痛的发生率（22．7％，40／176）均高于非PDIE患者，其OR值分别为1．90、3．09、3．11和4．90（95％C1分别为1．17—3．05、1．94～4．92、2．10～4．81和2．07～8．11）。3种类型PDIE患者中，直肠型患者大便痛的发生率（50．0％）增加；穹隆型患者发生性交痛（72．2％）和肛门坠胀（88．9％）的比率也高于另外两种类型；分别比较，差异均有统计学意义（P〈0．05）。直肠型PDIE患者腹腔镜手术时间[（82±31）min]、术后住院时间[（7．7±2．1）d]明显延长；穹隆型患者术中出血量增加[（99±24）ml]；分别比较，差异均有统计学意义（P〈0．01）。3种类型PDIE患者中，直肠型腹腔镜手术完全切净率（28．6％）最低，其次为穹隆型（83．3％），单纯型达到了95．1％。3种类型PDIE的手术有效率分别为99．3％、94．4％、100．0％，分别比较，差异无统计学意义（P〉0．05）。手术切净程度是影响术后疼痛缓解时间的主要因素（P〈0．05）。结论PDIE与各种子宫内膜异位症疼痛症状的关系密切，不同类型的PDIE腹腔镜保守性手术后能获得较满意的疼痛缓解，术后疼痛缓解时间与手术切净程度相关。

Objective To investigate the characteristics of the anatomical distribution of posterior deeply infiltrating endometriosis （PDIE） lesions, pain symptoms and effects of laparoscopic surgery. Methods Clinical data of 176 PDIE patients with laparoscopically diagnosed and histologically confirmed were analyzed and compared with data of 179 cases with non-PDIE. According to the invasion of rectum or vaginal fornix, 176 PDIE cases were divided into three groups： simple （144 cases）, fornix （18 cases） or rectum group （14 cases）. Results Compared with the non-PDIE patients, the risk of pain symptoms in PDIE patients were significantly increased, OR for dysmenorrhea, chronic pelvic pain, deep dyspareunia, dyschezia were 6. 73 （95% CI, 3.66 - 12.40）, 1.90 （95% CI, 1.17 -3.05）, 3.09 （95% CI, 1.94 - 4. 92） and 4. 90 （95% CI, 2. 07 -8.11 ）, respectively （all P 〈0. 05）. The highest incidence of dyschezia was observed in rectum group （50. 0%, P 〈0. 05）, while deep dyspareunia in fornix group （72. 2%, P 〈 0. 05）. The longest operative duration （82 ± 31 ） minutes and the postoperative hospitalization （7. 7 ± 2. 1 ） days were observed in rectum group （P 〈 0. 01 ）. The median pain relief time was 56 months in the patients with complete excision of PDIE lesions, which was significantly longer than that in patients with incomplete excision （25 months, P 〈 0. 01 ）. Multivariate analysis demonstrated that only incomplete excision of PDIE lesions was the risk factor for shorter pain relief time （P 〈 0. 05）. Conclusion Conservative laparoscopie surgery may effectively relieve pelvic pain symptoms in patients with PDIE, while incomplete excision of PDIE lesions was the only significant predictor of shorter pain relief time.