Severe endometriosis: laparoscopic rectum resection

Different segmental resection techniques and postoperative complications in patients with colorectal endometriosis: A systematic review

INTRODUCTION

The aim of this study was to analyze the available literature by conducting a systematic review to assess the possible effects of nerve-sparing segmental resection and conventional bowel resection on postoperative complications for the treatment of colorectal endometriosis.

MATERIAL AND METHODS

Pubmed, Clinical Trials.gov, Cochrane Library, and Web of Science were comprehensively searched from 1997 to 2021 in order to perform a systematic review. Studies including patients undergoing segmental resection for colorectal endometriosis including adequate follow-up, data on postoperative complications and postoperative sequelae were enrolled in this review. Selected articles were evaluated and divided in two groups: Nerve-sparing resection (NSR), and conventional segmental resection not otherwise specified (SRNOS). Within the NSRs, studies mentioning preservation of the rectal artery supply (artery and nerve-sparing SR - ANSR) and not reporting preservation of the artery supply (NSR not otherwise specified - NSRNOS) were further analyzed.

PROSPERO ID

CRD42021250974.

RESULTS

A total of 7549 patients from 63 studies were included in the data analysis. Forty-three of these publications did not mention the preservation or the removal of the hypogastric nerve plexus, or main rectal artery supply and were summarized as SRNOS. The remaining 22 studies were listed under the NSR group. The mean size of the resected deep endometriosis lesions and patients' body mass index were comparable between SRNOS and NSR. A mean of 3.6% (0-16.6) and 2.3% (0-10.5%) of rectovaginal fistula development was reported in patients who underwent SRNOS and NSR, respectively. Anastomotic leakage rates varied from 0% to 8.6% (mean 1.7 ± 2%) in SRNOS compared with 0% to 8% (mean 1.7 ± 2%) in patients undergoing NSR. Urinary retention (4.5% and 4.9%) and long-term bladder catheterization (4.9% and 5.6%) were frequently reported in SRNOS and NSR. There was insufficient information about pain or the recurrence rates for women undergoing SRNOS and NSR.

CONCLUSIONS

Current data describe the outcomes of different segmental resection techniques. However, the data are inhomogeneous and not sufficient to reach a conclusion regarding a possible advantage of one technique over the other.

Laparoscopic Surgery for Colorectal Endometriosis and its Impact upon Fertility: An Updated Australian Series of 307 Cases

Introduction

Colorectal involvement occurs in up to 12% of cases of endometriosis. Various surgical options for its management have been described, including segmental resection and disc excision, with debate surrounding indications for surgery and the impact of such procedures. The current study aimed to describe the experiences of three Australian gynaecologists regarding laparoscopic bowel surgery for colorectal endometriosis.

Methods

The records of three gynaecological surgeons were analysed for patients who underwent surgical removal of colorectal endometriosis by way of appendicectomy, bowel disc excision and/or segmental resection, between 1999 and 2012.

Results

A total of 307 patients were identified. Sixteen (5.2%) underwent appendicectomy, 146 (47.6%) underwent disc excision, 126 (41.0%) underwent segmental resection and 19 (6.2%) underwent simultaneous procedures. The majority of procedures were performed laparoscopically (265 of 307; 86.3%). Nineteen procedures (6.2%) were planned laparotomies due to the known extent of disease. Twenty-three procedures were converted from laparoscopy to laparotomy (conversion rate of 7.5%). Complications occurred in 35 of the 307 cases (11.4%). Sixty-seven women amongst the 122 wishing to conceive post-operatively achieved at least one pregnancy (pregnancy rate of 54.9%). Of the 84 pregnancies achieved amongst the 67 women who conceived, 49 (58.3%) were achieved through assisted reproductive technologies, and 31 pregnancies (36.9%) were conceived spontaneously. This information was unavailable for 4 pregnancies (4.8%).

Conclusions

The current series demonstrates that laparoscopic surgery for severe disease is feasible in specialised centres. Furthermore, such surgery may have a positive impact upon post-operative fertility.

Endometriosis: Survey of Current Diagnostic and Therapeutic Options and Latest Research Work

Endometriosis is one of the most frequent benign diseases in women of child-bearing age. The main symptoms are chronic upper abdominal pain and infertility. However, the aetiology and pathogenesis of endometriosis are as yet insufficiently clarified. Thus, therapy is mainly symptomatic with laparoscopic surgery being the gold standard. The aim of drug therapy is to achieve a hypo-oestrogenic condition. In cases of severe endometriosis and a desire to have children there is often an indication for assisted reproduction. The present article illustrates almost all current aspects on the diagnosis of and therapy of endometriosis. From the clinical viewpoint, emphasis is placed on the rare cases of deeply infiltrating endometriosis that are, however, accompanied with a high morbidity. Current therapeutic options in cases of infertility are also presented in more detail. Furthermore, special attention is paid to the latest research results from both clinical and basic research fields in order to demonstrate our current knowledge on the pathogenesis and, where possible, potentially related therapeutic options.

Bowel and bladder function after resection of deeply infiltrating endometriosis

AIMS

To compare bowel and bladder function following uterosacral or rectovaginal excision of endometriosis with excision of endometriosis from other sites of the pelvis.

METHODS

A retrospective cohort study was performed via a questionnaire derived from validated questionnaires in the literature. This was applied to the two groups of women who have had endometriosis resected in the last 15 years--those with deeply infiltrating endometriosis (DIE) and those with endometriosis from other sites. In the questionnaire, voiding dysfunction, urinary stress incontinence, urinary urge incontinence, stool evacuation and overall symptoms post-surgery were investigated. The higher the score, the higher the level of dysfunction.

RESULTS

Women with DIE had higher levels of urinary stress dysfunction than the control group (mean 1 vs 0, IQR 3 vs 2, P = 0.047). Women with DIE also expressed a higher level of bowel dysfunction (mean 2 vs 2, IQR 1 vs 0, P = 0.002). However, women with DIE also reported significant improvement in urinary and bowel dysfunction postoperatively. There were no significant differences between the other variables.

CONCLUSION

The study demonstrated no clear association between the depth of excision of endometriosis with urinary and bowel dysfunction. The differences in urinary stress incontinence and bowel dysfunction may be explained by DIE itself causing damage to the hypogastric plexus.

Long Term Surgical Outcomes after Segmental Colorectal Resection in Women with Severe Endometriosis

Purpose

The aim of this study is to assess post-operative complications, symptoms, patient satisfaction, and fertility outcome after a long-term follow-up period in patients with severe intestinal endometriosis.

Methods

In this retrospective study (January 1998 - December 2008) patients scheduled for a segmental colorectal resection by laparotomy were identified. Surgery was performed by a multidisciplinary team. Data were obtained from medical records and supplemented by a questionnaire.

Results

A total of 41 patients (median age 30 years [24–45]) were included with a mean follow-up of 50 months. Three patients were lost to follow-up. Chronic pelvic pain, dysmenorrhea, dyschezia, hematochezia, constipation, pencil like stool, diarrhea, and tenesmus decreased, respectively, in 24, 16, 31, 25, 26, 12, 11, and 21 patients. Post-operatively, one patient conceived naturally and eleven out of fifteen patients conceived after in vitro fertilization. The post-operative patient satisfaction rate (mean 7.4) was significantly higher compared to prior to surgery (mean 4.6). Four major complications were reported in the first year after surgery. The cumulative complication rate was 12%.

Conclusions

Segmental colorectal resection by laparotomy in patients with severe intestinal endometriosis effectively reduces symptoms and increases patient satisfaction with an acceptable risk on treatable complications.

Effect of patient selection on estimate of reproductive success after surgery for rectovaginal endometriosis: literature review

The effect of rectovaginal endometriosis on fertility is unclear. Several authors foster radical surgery, including colorectal resection, as a fertility-enhancing procedure. However, interpretation of data is difficult, as the baseline fertility status is often undefined and it is not always possible to discriminate between spontaneous conceptions and those resulting from IVF. A systematic literature review was performed with the aim of defining the pregnancy rate specifically in patients who were infertile before surgery and who sought spontaneous pregnancy. A PubMed search was conducted to identify English language studies published between 2005 and 2011 evaluating reproductive performance after surgery for rectovaginal and rectosigmoid endometriosis. According to the results of the 11 selected studies, the mean post-operative conception rate in all women seeking pregnancy independently of preoperative fertility status and IVF performance was 39% (95% CI 35-43%; 223/571), but dropped to 24% (95% CI 20-28%; 123/510) in infertile patients who sought spontaneous conception (odds ratio 0.50, 95% CI 0.38-0.65%). Patients' selection significantly influences the estimate of the effect of rectovaginal endometriosis excision on infertility. This should be carefully taken into consideration at preoperative counselling. Rectovaginal endometriosis usually is associated with pain symptoms, but the effect of this disease form on fertility is uncertain, as burial of foci beneath rectouterine adhesions with exclusion of the deepest part of the pelvis may limit interference with fertilization processes. Several authors foster radical surgery, including colorectal resection, as a fertility-enhancing procedure. However, interpretation of data is difficult, as the baseline fertility status is often undefined and it is not always possible to discriminate between spontaneous conceptions and those resulting from IVF. A systematic literature review was performed with the aim of defining the pregnancy rate specifically in patients who were infertile before surgery and who sought pregnancy spontaneously. A PubMed search was conducted to identify English language studies published between 2005 and 2011 evaluating reproductive performance after surgery for rectovaginal and rectosigmoid endometriosis. According to the results of the 11 selected studies, the mean post-operative conception rate in all women seeking pregnancy independently of preoperative fertility status and IVF performance was 39% (223/571), but dropped to 24% (123/510) in infertile patients who sought conception spontaneously. The 15% difference is statistically significant. Infertile patients with rectovaginal endometriosis considering surgery, should be carefully informed of the real probability of post-operative conception avoiding generic overestimations.

The treatment of rectal endometriosis and the role of laparoscopic surgery

PURPOSE OF REVIEW

Rectal endometriosis is a very indolent disease whose treatment has been debated by a range of competing schools. Meanwhile, not all audiences in the scientific community are entirely familiar with the full aspects of the disease. Hence, the purpose of this review is to outline the basic as well as the recent literature pertaining to the disease, thus offering a broader view to the interested reader.

RECENT FINDINGS

Laparoscopic shaving or disc excision for rectal endometriotic nodules may be simple, safe options of controlling the disease. On the contrary, laparoscopic rectal resections, originally reserved for more extensive disease, are now more skillfully mastered by surgeons and gynecologists. Meta-analyses, retrospective, and prospective studies are being published frequently supporting one form of therapy at a time and discrediting another at other times.

SUMMARY

Laparoscopic shaving or disc excisions for rectal endometriotic foci or rectal resections are feasible and efficient methods for treating rectal endometriosis. More complex surgery to the bowel means more risk for complications. With the rising learning curve of the operators, laparoscopic rectal resections have become a safe option that should be offered to patients. The patient's preference to a particular treatment option should be central to the type of surgery to be elected.

Laparoscopic rectal resection of deep infiltrating endometriosis

PURPOSE

Deep infiltrating endometriosis with colorectal involvement is a complex disorder, often requiring segmental bowel resection. Complete removal of all visible lesions is considered the adequate treatment of infiltrating endometriosis in order to reduce recurrence. In this article, we describe our experience with laparoscopic management of deep infiltrating endometriosis with involvement of the rectum.

METHODS

A retrospective analysis of data from patients with deep infiltrating endometriosis with rectal involvement who underwent a laparoscopic surgery in the years 2002-2009 at the Department of Obstetrics and Gynecology at our institution was done.

RESULTS

Between 2002 and 2009, a laparoscopic partial rectal resection was performed in 52 patients, and laparoscopic disk resection was performed in 4 cases with deep infiltrating endometriosis. The mean age of patients was 34.4 years (range, 22-62 years). Preoperative symptoms included dysmenorrhea, dyspareunia, chronic pelvic pain, and infertility. The laparoscopic procedure was converted to formal laparotomy in 3 patients (5.4%). The mean duration of surgery was 145 minutes. Postoperative complications included 3 cases of anastomotic leakage with rectovaginal fistula in two cases and intraabdominal bleeding in 1 case. The mean hospital stay was 7 days. Postoperatively, nine patients had a normal delivery, two of them after in vitro fertilization treatment.

CONCLUSION

Laparoscopic rectal resection for deep infiltrating endometriosis is a relatively safe procedure, when performed by a surgeon and a gynecologist with sufficient experience in laparoscopic colorectal surgery.