Актуальность. Глубокий инфильтративный эндометриоз (ГИЭ) является особой формой эндометриоза, отличающейся выраженной тяжестью симптомов и поражением функции соседних органов. Несмотря на то, что в последние годы много сделано для понимания патогенеза развития заболевания и ассоциированных с ним симптомов, остаются нерешенные вопросы. Цель. На основании современных данных осветить дискуссионные вопросы патогенеза и тактики ведения больных ГИЭ. Материалы и методы. Изучены зарубежные и отечественные научные стати, имеющиеся в базе PubMed и на ресурсах Интернета по данной теме за последние 5 лет. Результаты. Проведен системный анализ данных о механизмах развития болевого синдрома, бесплодия при ГИЭ, выборе консервативной и оперативной тактики при решении конкретных задач ведения пациенток с ГИЭ. Заключение. Несмотря на различные подходы к тактике, большинство специалистов согласны, что стратегия лечения должна исходить из того, что заболевание является хроническим и рецидивирующим. Выбор лечения должен быть индивидуальным в зависимости от выраженности клинических проявлений, характера пораженной эндометриозом функции смежных органов, таких как кишечник, мочевой пузырь, мочеточники, а также от возраста и репродуктивных планов женщины. В зависимости от клинической ситуации возможно применение различных схем консервативной терапии. Планирование оперативного лечения должно быть максимально взвешенным. Радикальная операция по удалению эндометриоидных очагов, выполненная опытным хирургом в специализированном стационаре, в сочетании с медикаментозной терапией и вспомогательными репродуктивными технологиями увеличивает шансы больной на беременность и вынашивание здорового ребенка, а последующая комбинированная терапия обеспечивает длительный безрецидивный период. Беременность и роды у пациенток при глубоких инфильтративных формах эндометриоза должны рассматриваться как состояние высокого риска по развитию тяжелых осложнений.
Relevance. Deep infiltrative endometriosis (DIE) is a particular form of endometriosis with a more severe symptoms and dysfunction of the neighboring organs. Inspite of the fact that in recent years, much had been done to understand the pathogenesis of the disease and its associated symptoms; there are still several unresolved issues. Aim. To describe debated issues of pathogenesis and management of patients with DIE using current data. Materials and methods. Foreign and domestic scientific articles on this topic that is available in PubMed database and on Internet resources have been examined over the past 5 years. Results. The review consisted of a system analysis of data on the pathogenesis of pain, infertility, the choice of conservative or surgical treatment in dealing with specific problems of managing patients with DIE. Conclusion. Despite there are different options of managing and treating, most specialists agree that the treatment strategy should be based on the assumption that it is a chronic recurrent disease. The treatment choice should be personal depending on the severity of symptoms, dysfunction of the neighboring organs affected by endometriosis, such as the intestines, bladder, ureters, as well as the woman's age and reproductive life plans. Depending on the clinical case, it is possible to use various regimens of conservative management. Surgical management planning should be highly balanced. A radical surgery with removing foci of endometriosis performed by an experienced surgeon in a specialized hospital in coupled with pharmacotherapy and assisted reproductive technologies increases the patient's chances of pregnancy, a healthy childbearing. Subsequent combination therapy provides a long-term remission. Pregnancy and childbirth in patients with deep infiltrative endometriosis should be considered as a high risk condition for the severe complications.
Key words: deep infiltrative endometriosis, pathogenesis, management.
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________________________________________________
1. Endometrioz. Klinicheskie rekomendatsii ministerstva zdravookhraneniia RF (in Russian).
2. Johnson NP, Hummelshoj L, Adamson GD et al. World Endometriosis Society consensus on the classification of endometriosis. Hum Reprod 2017; 32 (2): 315–24. DOI: 10.1093/humrep/dew293
3. Ruffo G, Scopelliti F, Manzoni A et al. Long-term outcome after laparoscopic bowel resections for deep infiltrating endometriosis: a single-center experience after 900 cases. Biomed Res Int 2014; 2014: 463058. DOI: 10.1155/2014/463058
4. 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 (2): 430–4.e26. DOI: 10.1016/j.fertnstert.2015.11.006
5. de Freitas Fonseca M, Aragao LC, Sessa FV et al. Interrelationships among endometriosis-related pain symptoms and their effects on health-related quality of life: a sectional observational study. Obstet Gynecol Sci 2018; 61 (5): 605–14. DOI: 10.5468/ogs.2018.61.5.605
6. Tosti C, Pinzauti S, Santulli P et al. Pathogenetic Mechanisms of Deep Infiltrating Endometriosis. Reprod Sci 2015; 22 (9): 1053–9. DOI: 10.1177/1933719115592713
7. Gordts S, Koninckx P, Brosens I. Pathogenesis of deep endometriosis. Fertil Steril 2017; 108 (6): 872–85.e1. DOI: 10.1016/j.fertnstert.2017.08.036
8. Sel'kov S.A., Iarmolinskaia M.I., Pavlov O.V. Sistemnye i lokal'nye urovni reguliatsii immunopatogeneticheskikh protsessov u patsientok s naruzhnym genital'nym endometriozom. Zhurn. akusherstva i zhenskikh boleznei. 2005; 54 (1): 20–8 (in Russian).
9. Tsitskarava D.Z., Iarmolinskaia M.I., Seliutin A.V. et al. Otsenka soderzhaniia i patogeneticheskoi roli tsitokinov peritoneal'noi zhidkosti u patsientok s glubokim infil'trativnym endometriozom. Zhur. akusherstva i zhenskikh boleznei. 2017; 66 (1): 38–45. DOI: 10.17816/jоwд66138-45 (in Russian).
10. Kogan E.A., Khachatrian A.M., Paramonova N.B. et al. Prognozirovanie razvitiia rasprostranennykh form infil'trativnogo endometrioza na osnovanii otsenki ekspressii CD15 v bioptatakh endometriia. Patent RF na izobretenie №2634263/24.10.2017 (in Russian).
11. Toullec L, Batteux F, Santulli P et al. High Levels of Anti-GM-CSF Antibodies in Deep Infiltrating Endometriosis. Reprod Sci 2020; 27 (1): 211–17. DOI: 10.1007/s43032-019-00021-8
12. Avila I, Filogonio IDS, Costa LMP et al. Anatomic distribution of deep infiltrating endometriosis and its relationship to pelvic pain. J Gynecol Surg 2016; 32: 99–103. DOI: 10.1089/gyn.2015.0092
13. Nnoaham KE, Hummelshoj L, Webster P et al. Reprint of: Impact of endometriosis on quality of life and work productivity: a multicenter study across ten countries. Fertil Steril 2019; 112 (4 Suppl. 1): e137–52. DOI: 10.1016/j.fertnstert.2019.08.082
14. Comptour A, Pereira B, Lambert C et al. Identification of Predictive Factors in Endometriosis for Improvement in Patient Quality of Life.
J Min Invasive Gynecol 2020; 27 (3): 712–20. DOI: 10.1016/j.jmig.2019.05.013
15. Yela DA, Quagliato IP, Benetti-Pinto CL. Quality of Life in Women with Deep Endometriosis: A Cross-Sectional Study. Qualidade de vida de mulheres com endometriose profunda: Estudo de corte transversal. Rev Bras Ginecol Obstet 2020; 42 (2): 90–5. DOI: 10.1055/s-0040-1708091
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1 ФГБНУ «Научно-исследовательский институт акушерства, гинекологии и репродуктологии им. Д.О. Отта», Санкт-Петербург, Россия;
2 ФГБОУ ВО «Северо-Западный государственный медицинский университет им. И.И. Мечникова» Минздрава России, Санкт-Петербург, Россия
*pismo_rusina@mail.ru
________________________________________________
Elena I. Rusina*1, Maria I. Yarmolinskaya1,2, Valeriia O. Piankova1
1 Ott Research Institute of Obstetrics, Gynecology and Reproductology, Saint Petersburg, Russia
2 Mechnikov North-Western State Medical University, Saint Petersburg, Russia
*pismo_rusina@mail.ru