Long-term evaluation of quality of life and gastrointestinal well-being after segmental colo-rectal resection for deep infiltrating endometriosis (ENDO-RESECT QoL)

A quality-of-life meta-analysis comparing pre- and postoperative symptoms in women undergoing colorectal resection for deep infiltrating endometriosis

AIM

Deep infiltrating endometriosis (DIE) may involve the rectum or colon and is associated with pain, gastrointestinal dysfunction and reduced quality of life (QoL). While hormonal treatment may be effective, surgical intervention including colorectal resection can be required. Colorectal resection can result in functional changes and complications, which can also impair QoL. The aim of this study is to examine all available comparative pre- and postoperative data on QoL and symptom outcomes following colorectal resection for DIE.

METHOD

An electronic database search was conducted for studies reporting pre- and postoperative QoL and symptom outcomes following colorectal resection for DIE. The study was registered with PROSPERO and followed PRISMA (Preferred Reporting Items in Systematic Reviews and Meta-analyses) guidelines. Data were combined using random-effects models.

RESULTS

Fourteen studies including 1142 patients were included. Colorectal resection was associated with improved outcomes for all items in the SF-36 QoL questionnaire as well as symptom outcomes including dysmenorrhoea, chronic pelvic pain and deep dyspareunia. Importantly, the gastrointestinal QoL index was significantly improved (mean difference 24.50, 95% CI 15.93-33.08, p < 0.0001) as was dyschezia (mean difference -4.1, 95% CI -4.77 to -3.42, p < 0.0001). There was no change in low anterior resection syndrome scores (mean difference -5.28, 95% CI -11.65 to 1.10, p = 0.1046).

CONCLUSION

This study demonstrates a significant postoperative improvement in patient-reported QoL, pain symptoms and gastrointestinal function following colorectal resection for endometriosis.

Long-Term Follow-Up of the Quality of Life of Endometriosis Patients after Surgery: A Comparative Study

Background/Objectives: This study investigated the long-term effects of the surgical removal of endometriotic lesions on quality of life in endometriosis patients. A sub-analysis explored different subtypes of endometriosis, hormonal influence, and the need for reoperation. Methods: The study was conducted at the Certified Endometriosis Center of the Medical University of Vienna. Included in the study were patients who had undergone the complete surgical removal of endometriotic lesions between 2014 and 2018. Patients were asked to complete the Endometriosis Health Profile-30 preoperatively, at the short-term follow-up (six to ten weeks postoperatively), and at the long-term follow-up (median of 48 months postoperatively). Results: A total of 87 patients completed the Endometriosis Health Profile-30 at the three time points. At the long-term follow-up, the reoperation rate was 8.0%. Significant improvements in the overall quality of life (p < 0.001; median decrease from 45.0 to 11.7) and in the categories of "pain", "control and powerlessness", "social support", "emotional well-being", and "self-image" at the long-term follow-up compared to preoperative values were observed (p-values < 0.01). The sub-analysis showed that patients with deep-infiltrating endometriosis (p < 0.001; median decrease from 49.2 to 10.0) and adenomyosis (p < 0.02; median decrease from 37.5 to 0.0) had the most pronounced long-term postsurgical benefits in terms of quality of life. Patients with (p < 0.001; median decrease from 45.0 to 1.7) and without (p < 0.001; median decrease from 45.42 to 12.5) hormonal influence showed significant improvements in overall quality of life compared to preoperative values. Patients without reoperation demonstrated improved long-term quality of life compared to the preoperative (p < 0.001; median decrease from 45.8 to 9.6) and short-term follow-up results (p < 0.005; median decrease from 19.2 to 9.6). Participants who underwent reoperation showed no improvement in quality of life at the long-term follow-up. Conclusions: The surgical removal of endometriotic lesions has a positive long-term impact on the quality of life, as measured by Endometriosis Health Profile-30.

Recommendations for the implementation and conduct of multidisciplinary team meetings for those providing endometriosis and adenomyosis care - a Delphi consensus of the European Endometriosis League (EEL)

Background

The treatment of endometriosis and adenomyosis requires a complex, multidisciplinary approach. Some centres have established multidisciplinary teams (MDT) and regular meetings. There are currently no international data or recommendations.

Objectives

To examine existing MDT meetings and define consensus recommendations to support implementation and conduct.

Materials and Methods

Online questionnaires were sent through the European Endometriosis League (EEL) based on a Delphi protocol. After a literature review and assessment of existing MDT meetings, essential aspects for consensus statements were identified. The consensus statements were evaluated using a 5-point Likert scale with the possibility to modify them. Results were analysed between rounds and reported to the respondents. Consensus, defined as ≥70% agreement, concluded the Delphi process when achieved in the majority of statements.

Main outcome measures

Prevalence and type of existing MDT meetings and recommendations.

Results

In round 1, 69 respondents participated, with 49.3% (34) having an MDT meeting at their institutions, of which 97% are multidisciplinary. 50 % meet once a month and 64.7% indicated that less than 25% of their patients are discussed. Throughout the three rounds, 47 respondents from 21 countries participated. During the process, 82 statements were defined, with an agreement of 92.7% on the statements.

Conclusions

This study assessed existing MDT meetings for endometriosis and adenomyosis and developed recommendations for their implementation and conduct. The consensus group supports the strengths of MDT meetings, highlighting their role in offering guideline-based, multidisciplinary, and personalised care.

What is new?

This study presents the first international data and recommendations on MDT meetings for endometriosis and adenomyosis.

A systematic review to determine use of the Endometriosis Health Profiles to measure quality of life outcomes in women with endometriosis

BACKGROUND

The Endometriosis Health Profiles (EHPs), the EHP-30 and EHP-5, are patient-reported outcome measures that were developed to measure the health-related quality of life (HRQoL) of women living with endometriosis. Prior to their development, a systematic review was undertaken which identified that the HRQoL of women living with endometriosis was poorly understood, with only three medical and one surgical study identified.

OBJECTIVE AND RATIONALE

The 20-year anniversary of the EHP-30 provided a timely opportunity to assess how the tools have been used and explore what the findings tell us about the impact of endometriosis and its associated treatments upon women's QoL. Applying robust systematic review methodology, following PRISMA guidelines, we sought to answer: How many studies have used the EHP and for what purpose?; What are the demographic characteristics and international context of the studies?; What is the methodological nature and quality of the studies?; Which interventions have been assessed and what are the reported EHP outcomes?; and Can the EHP outcomes of these interventions be analysed using a meta-analysis and, if so, what do the results show?

SEARCH METHODS

The electronic databases MEDLINE, CINAHL, PsycINFO, PubMed, and Google Scholar were searched from the year the EHP was first published, in 2001 to 26 February 2020 using the search terms 'EHP30', 'EHP5', 'EHP-30', 'EHP-5', 'endometriosis health profile 30', and 'endometriosis health profile 5'. We updated the searches on 9 April 2021. All included studies were quality assessed using the Mixed Methods Appraisal Tool (MMAT).

OUTCOMES

The review included 139 papers. In clinical intervention studies, the EHPs were deployed most frequently to measure the outcomes of medical (n = 35) and surgical (n = 21) treatment. The EHPs were also used in 13 other intervention studies, 29 non-interventional studies, 32 psychometric/cross cultural validation studies; six diagnostic studies, and in three other studies to measure outcomes in related conditions. They were mainly deployed in studies undertaken in Europe and North America. Overall, regardless of the nature of the intervention, most women reported improvements in HRQoL after treatment. Surgical interventions generally resulted in significant improvements for the longest amount of time. There was also evidence that when participants stopped taking medication their EHP scores worsened, perhaps reinforcing the temporary impact of medical treatment. Younger patients reported more negative impact upon their HRQoL. Further evidence using classical test theory to support the EHPs' robust psychometric properties, including acceptability, dimensionality, reliability, validity (including cross-cultural), and responsiveness, was demonstrated, particularly for the EHP-30. Strikingly, using anchor-based methods, EHP-30 responsiveness studies demonstrate the largest mean changes in the 'control and powerlessness' domain post-intervention, followed by 'pain'. MMAT outcomes indicated the quality of the papers was good, with the exception of five studies. A meta-analysis was not undertaken owing to the heterogeneity of the interventions and papers included in this review.

WIDER IMPLICATIONS

Women with endometriosis face a lifetime of surgical and/or medical interventions to keep the condition under control. Less invasive treatments that can lead to improved longer term physical and psycho-social outcomes are needed. The EHPs are reliable, valid, acceptable, and responsive tools, but more assessment of EHP outcomes using modern psychometric methods and in the context of women from ethnically diverse backgrounds and in routine clinical care would be beneficial. Given the brevity of the EHP-5, it may be the most appropriate version to use in routine clinical practice, whereas the longer EHP-30, which provides more granularity, is more appropriate for research.

Early Quality of Life Assessment After Segmental Colorectal Resection for Deep Infiltrating Endometriosis

STUDY OBJECTIVE

Endometriosis is a benign condition afflicting women of reproductive age that significantly impacts their quality of life (QoL). Given its debilitating symptoms and prevalence, it is essential to define its proper management. In this study, we have assessed patient-reported outcomes among women having undergone segmental colorectal resection for deep infiltrating endometriosis. Any correlation between preoperative nutritional status and overall postoperative complications has also been analyzed.

STUDY DESIGN

Prospective observational study.

SETTING

Public medical center.

PATIENTS

One hundred forty consecutive patients that had undergone segmental colorectal resection for DIE between November 2020 and October 2021 at IRCCS Sacro Cuore Don Calabria Hospital of Negrar of Valpolicella (Verona, Italy).

INTERVENTIONS

Patient-reported outcomes were measured using data collected from the MD Anderson Symptom Inventory for gastrointestinal surgery patients and Euro-QoL Group EQ-5D-5L (EQ-5Q-5L) questionnaires, which were administered preoperatively (T0), at discharge (T1) and at 4 to 6 weeks after surgery (T2). Nutritional status was examined through the Mini Nutritional Assessment Short form and Prognostic Nutritional Index.

MEASUREMENTS AND MAIN RESULTS

A significant improvement in the EQ-5Q-5L and MDASI-GI scores was noted between T0 and T2 (p <. 001 and p <. 001, respectively.) No statistically significant differences were found in scores at T2 between patients who had experienced postoperative complications and those who had not. No statistically significant association was observed between the presence of malnutrition and overall postoperative complications and their severity.

CONCLUSION

This study confirms, through patient-reported outcomes, the pivotal role of surgery in improving the QoL at 4 to 6 weeks of women affected by endometriosis who have previously been unresponsive to medical therapy.

Horizontal versus vertical direction of posterior vaginal wall suture after eradication of rectovaginal endometriosis: A multicenter study

OBJECTIVE

To compare safety and effectiveness of two-different directions of suturing the posterior vaginal breach (horizontal [Ho] vs vertical [Ve]) in women undergoing recto-vaginal endometriosis (RVE) nodule resection.

METHODS

A multicenter, retrospective, observational, cohort study was performed including all women of reproductive age undergoing RVE nodule resection between March 2013 and December 2018 at our tertiary centers. Patients included in the present study were divided into two groups based on the direction in suturing the posterior vaginal fornix defect, for comparisons in terms of rate of postoperative complications, pain relief, pain and anatomical recurrence, and length of hospital stay. Univariate comparisons were performed adopting the t test or the Mann-Whitney test for continuous data and the chi-square test or the Fisher exact test for categorical data, with a significant P value set to <0.05.

RESULTS

A total of 101 women were included: 67 in the Ho-group and 34 in the Ve-group. The two groups did not significantly differ in length of hospital stay (6.7 ± 6.9 vs 6.6 ± 3.3 days; P = 0.95), overall postoperative complications (32.8% vs 14.7%; P = 0.05), pain recurrence (35.8% vs 26.5%; P = 0.34) and anatomical recurrence rate (19.4% vs 23.5%; P = 0.62). Conversely, grade III complications were significantly more common in the Ho-group than in the Ve-group (22.7% vs 20%, P = 0.009), while pain relief in terms of deep dyspareunia, dyschezia, dysuria and chronic pelvic pain was more consistent in the Ve-group patients (P = 0.04, 0.04, 0.05, 0.004, respectively).

CONCLUSION

In symptomatic women undergoing RVE nodule resection, Ho suturing of the vaginal breach appears more commonly associated with severe postoperative complications and a worse pain control.

Improved quality of life (EHP-30) in patients with endometriosis after surgical treatment

OBJECTIVE

This study aimed to evaluate the quality of life of patients with endometriosis before and after surgical treatment.

METHODS

An observational, longitudinal, and prospective study was conducted with 102 women with pelvic pain and endometriosis that was unimproved by clinical treatment and indicated for surgical treatment. The patients' quality of life was assessed using the 30-item Endometriosis Health Profile (EHP-30) questionnaire before and 3 and 6 months after surgery. The statistical tests were analyzed using the Statistical Package for Social Sciences version 17.0, and the Friedman test was used.

RESULTS

There was a reduction in EHP-30 scores 3 and 6 months after surgery compared to before surgery, as well as 6 months after surgery compared to 3 months after surgery, in the central questionnaire (PART 1) and in Sections A, B, C, E, and F (p<0.0001). For Section D, there was a reduction in scores 6 months after surgery compared to before surgery (p<0.0001).

CONCLUSION

Surgical treatment of endometriosis improves quality of life in several areas assessed by the EHP-30 questionnaire.

Colorectal endometriosis: Diagnosis, surgical strategies and post-operative complications

Objective

The present work aimed to investigate the feasibility, complications, recurrence rate, and infertility outcomes of the radical and conservative surgical methods for colorectal endometriosis in short- and long-term follow-ups.

Methods

In this prospective study, the patients with confirmed diagnosis of colorectal DIE were included from March 2015 to March 2021, who were referred to an Endometriosis Surgery Center affiliated with Shiraz University of Medical Sciences (SUMS). Information on demographics, surgical approaches, intra-operative, and post-operative findings as well as complications were collected and compared. Six- and 12-month interviews were conducted to evaluate the functional outcomes of all the procedures.

Results

Out of 3,111 patients who underwent endometriosis surgery, 837 (28.19%) with the average age of 34.2 ± 5.9 years and average ASRM score of 102.1 ± 36.8 had rectosigmoid endometriosis. Laparoscopic rectal shaving was performed in 263(30.0%) patients while 326 (37.2%) underwent segmental bowel resection, and 248 (28.30%) were treated with disc excision. Prophylactic ileostomy was performed in six (0.68%) patients and peritonitis was reported in four (0.45%). Five (0.58%) subjects developed rectovaginal fistula and one (0.11%) was diagnosed with bladder atonia. The recurrence rate was 3.8%, 1.2%, and 0.3% in rectal shaving, disc, and segmental bowel resection techniques, respectively. Dysmenorrhea, dyspareunia, and dyschezia were improved after surgery by 7.3, 9.4, and 12.5 times, respectively. We observed 25.2% of total pregnancy following the operation, the majority of which occurred in the first year after the surgery.

Conclusion

There were very few short-term or long-term complications in the three different techniques when the choice was correct.

Combination of laparoscopic side-to-end colorectal anastomosis and vaginal nose (natural orifice specimen extraction) surgery for colorectal endometriosis: Technique and outcomes

Objective:

To investigate the effectiveness of combining side-to-end anastomosis and vaginal NOSE (Natural orifice specimen extraction) surgery in colorectal endometriosis.

Material and methods:

We included 11 patients treated with laparoscopic side-to-end colorectal anastomosis and vaginal NOSE surgery between January 2019 and May 2021. We questioned the visual analog score (VAS) for pain symptoms, the short form-36 (SF-36) for health survey questionnaire, The Female Sexual Function Index (FSFI), EHP-5 for endometriosis health profile, The Hospital Anxiety and Depression Scale (HADS), OAB-V8 for overactive bladder symptoms and Constipation Severity Instrument (CSI).

Results:

VAS, EHP-5, and SF-36 scores were better at postoperative third and sixth months than preoperative values ( p < 0.05). There were no statistically significant differences in terms of FSFI, OAB-V8, HADS, and the CSI.

Conclusions:

Laparoscopic side-to-end anastomosis with vaginal NOSE surgery is feasible, scarless, and could be offered to patients with deep symptomatic bowel endometriosis.

Long-term surgical outcomes of nerve-sparing discoid and segmental resection for deep endometriosis

INTRODUCTION

The aim of this study was to investigate long-term outcomes in terms of pain, quality of life (QoL), and gastrointestinal symptoms in women following colorectal surgery for deep endometriosis.

MATERIAL AND METHODS

In this historical cohort, women who underwent surgical treatment for deep endometriosis by either nerve-sparing full-thickness discoid resection (DR) or colorectal segmental resection (SR) between March 2011 and August 2016 were re-evaluated through telephone interviews about their long-term pain symptoms, subjective overall QoL as rated using a score from 0 (worst) to 10 (optimal), and gastrointestinal outcomes reflected by lower anterior resection syndrome (LARS) following a first postsurgical evaluation (visit 1) published previously and a long-term follow-up evaluation (visit 2).

RESULTS

The median long-term follow-up time was 35.4 months at visit 1 and 86 months at visit 2. Of 134 patients, 77 were eligible for final analysis and 57 were lost to follow-up. Compared with presurgical values, QoL scores were significantly increased at both postsurgical evaluation visits in both the SR cohort (scores of 3, 8.5, and 10 at the presurgical visit, visit 1, and visit 2, respectively; p < 0.001) and the DR cohort (scores of 3, 9, and 10, respectively; p < 0.001). Pain scores for dysmenorrhea (SR group scores of 8, 2, and 2, respectively; p < 0.001; DR group scores of 9, 2, and 1, respectively; p < 0.001), dyspareunia (SR group scores of 4, 0, and 0, respectively; p < 0.001; DR group scores of 5, 0, and 1, respectively; p = 0.003), and dyschezia (SR group scores of 8, 2, and 2, respectively; p < 0.001; DR group scores of 9, 2, and 1, respectively; p < 0.001) significantly decreased after surgery and remained stable in both cohorts over the follow-up period. Minor and major LARS, reflecting gastrointestinal function, was observed in 6.5% and 8.1% of the SR group and in 13.3% and 6.7% of the DR group, respectively, at visit 1 and in 3.2% and 3.2% of the SR group and 0% and 0% of the DR group, respectively, at visit 2, without significant differences between the SR and DR groups.

CONCLUSIONS

Colorectal surgery for deep endometriosis, either by DR or SR, provides stable and long-term pain relief with low rates of permanent gastrointestinal function impairment.

The State of Health and the Quality of Life in Women Suffering from Endometriosis

Quality of life is related to good health, family relations, feeling of self-esteem, and ability to cope with difficult situations. Endometriosis is a chronic condition which affects different areas of life. The lack of satisfaction in everyday life is mainly due to constant pain. The process of adjusting to a life with illness is associated with negative emotions. The aim of the article is to review the current state of knowledge concerning the impact of social and medical factors on a population of women affected by endometriosis. Women with endometriosis have an impaired quality of life compared to the general female population. Psychological consequences of endometriosis include: depression, anxiety, powerlessness, guilt, self-directed violence, and deterioration of interpersonal relations. It may contribute to lower productivity at work and less satisfying intimate life. A multi-disciplinary, evidence-based care is needed. The disease can take away the ability to be physically active, obtain an education, work continuously, and interact with friends. Social support and cognitive-behavioral therapy are extremely important for healing.

Near-Infrared Imaging With Indocyanine Green for the Treatment of Endometriosis: Results From the Gre-Endo Trial

INTRODUCTION

A current challenge for endometriosis surgery is to correctly identify the localizations of disease, especially when small or hidden (occult endometriosis), and to exactly define their real extension. The use of near-infrared radiation imaging (NIR) after injection of indocyanine green (ICG) represents one of the most encouraging method. The aim of this study is to assess the diagnostic value of NIR-ICG imaging in the surgical treatment of endometriosis compared with the standard of treatment.

MATERIAL AND METHODS

The Gre-Endo trial is a prospective, single-arm study (NCT03332004). After exploring the operatory field using the white light (WL) mode, patients were injected with ICG and then observed in NIR mode. All suspected areas were classified and chronicled according to lesions visualized only in WL, NIR-ICG, or in the combination of both. Lesion not visualized in WL was considered as suspect occult lesion (s-OcL). In addition, a random control biopsy from an apparent negative peritoneum visualized in WL and NIR-ICG imaging was taken for all patients (control cases). All lesions removed were considered "suspect endometriosis" until pathology.

RESULTS

Fifty-one patients were enrolled between January 2016 and October 2019. A total of 240 suspected lesions have been identified with both methods (WL + NIR-ICG). Two hundred and seven (86.2%) lesions out of the overall 240 were visualized with WL imaging, and 200 were confirmed to be pathologic (true positive for WL). The remaining 33/240 (13.75%) (false negative for WL) lesions were identified only with NIR-ICG imaging and collected as s-OcL. All 33 s-OcLs removed were confirmed to be pathologic (c-OcL = 100%). NIR-ICG vision showed PPV of 98.5%, NPV of 87.1%, Se of 87%, and Sp of 98.5%, confirming that this kind of imaging is an excellent diagnostic and screening test (p = 0.001 and p = 0.835, according to McNemar's and Cohen's kappa tests, respectively).

CONCLUSIONS

The use of NIR-ICG vision alone and combined with WL showed good results in intraoperative detection rate and fluorescence-guided surgery of endometriosis. Furthermore, NIR-ICG allowed surgeons to remove occult lesions that otherwise would remain, leading to possible greater postoperative pain and a higher risk of persistence and relapse.

Subcutaneous Vulvar Flap Viability Evaluation With Near-Infrared Probe and Indocyanine Green for Vulvar Cancer Reconstructive Surgery: A Feasible Technique

Introduction: Vulvar cancer is a rare condition affecting older women and accounts for 3-5% of all gynecological cancers. Primary surgical treatment involves the removal of a large amount of tissue for which reconstructive surgery is often necessary with a high rate of postoperative complications. Despite several techniques for the evaluation of vulvar flap viability have been proposed, many methods cannot be performed during surgery and require expensive devices often missing in a gynecological clinic. This study aims to verify the feasibility and the safety of the vulvar flap viability evaluation through a near-infrared endoscopic probe and Indocyanine green (ICG) tracer in a small group of patients and to evaluate long-term vulvar flap outcomes. Methods: Patients with primary vulvar cancer who required surgical treatment and subsequent vulvar flap reconstructive surgery were prospectively included in the study. A 25 mg ICG vial diluted in 20 ml of saline solution was intravenously infused before closing the skin edges of the flaps. All patients were given 0.2 mg/kg body weight of intravenous ICG. After 10-15 min, a near-infrared endoscopic probe was used to evaluate the vulvar flap viability. Results: Of the 18 patients who underwent radical vulvectomy for vulvar cancer during the study period, 15 were included in the analysis. All packaged surgical flaps showed tracer uptake on the surgical margin. No intro-operative complications were recorded neither surgery-related nor to dye infusion. No surgical infection, dehiscence, or necrosis was recorded. Conclusions: Vulvar flap viability assessment using Indocyanine green and a laparoscopic infrared probe is a feasible method. All cases included in the analysis showed a dye uptake on the surgical edge of the flap. Further, prospective studies are needed to confirm the method in clinical practice and to evaluate its superiority over simple subjective clinical evaluation.

Depression, Anxiety, and Correlating Factors in Endometriosis: A Systematic Review and Meta-Analysis

Background: Endometriosis stage is not directly related to the burden of symptoms, and recurrence of symptoms occurs frequently. It is suggested that symptoms are associated with psychological distress, as in depression and anxiety disorders. Our aim was to explore the strength of the associations between endometriosis and depression or anxiety and to review correlating factors. Materials and Methods: A literature search was carried out using the electronic databases Embase, PubMed, Web-of-science, and PsycINFO. Search terms related to depression, anxiety, and endometriosis were combined resulting in 1,837 records. Articles were included when describing an association between patients with endometriosis and symptoms of depression or anxiety assessed by validated tools, structured psychiatric interviews, or a documented diagnosis. With 47 articles a systematic qualitative review was performed. Seventeen studies were eligible for meta-analysis. Results: Endometriosis patients experienced significantly more symptoms of depression (standardized mean difference [SMD] of 0.71 (95% confidence interval [CI] 0.36-1.06)) and anxiety (SMD 0.60 (95% CI 0.35-0.84)) compared with healthy controls, but no differences were found comparing endometriosis patients with other chronic pelvic pain patients (SMD -0.01 [95% CI -0.17 to 0.15] for depression and SMD -0.02 [95% CI -0.22 to 0.18] for anxiety). Besides the effect of pain, other correlating factors included age, quality of life, quality of sleep, fatigue, sexual function, gastrointestinal symptoms, comorbidity, self-esteem, emotional self-efficacy, coping style, social adjustment, pain imagery, and pain sensitization. Conclusion: This systematic review supports the assumption that symptoms of depression and anxiety occur frequently in endometriosis patients and are related to chronic pain. Correlating factors should further be investigated.

Surgical Management by Disk Excision or Rectal Resection of Low Rectal Endometriosis and Risk of Low Anterior Resection Syndrome: A Retrospective Comparative Study

STUDY OBJECTIVE

To assess the risk of low anterior resection syndrome (LARS) between women managed by either disk excision or rectal resection for low rectal endometriosis.

DESIGN

Retrospective study of a prospective database.

SETTING

University hospital.

PATIENTS

One hundred seventy-two patients managed by disk excision or rectal resection for deep endometriosis infiltrating the rectum <7 cm from the anal verge.

INTERVENTIONS

Rectal disk excision and/or segmental resection using transanal staplers.

MEASUREMENTS AND MAIN RESULTS

One hundred eight patients (62.8%) were treated by disk excision (group D) and 64 (37.2%) by rectal resection (group R). All patients answered the LARS score questionnaire. Follow-up was 33.3 ± 22 months for group D (range 12-108 months) and 37.3 ± 22.1 months (range 12-96 months) for group R (p = .25). The rates of rectovaginal fistula and pelvis abscess requiring radiologic drainage and surgery in the D and R groups were, respectively, 7.4% and 8.3% vs 7.8% and 9.3%. The rate of women with normal bowel movements postoperatively was higher in group D (61.1% vs 42.8%, p = .05). Women enrolled in group R reported higher frequency of stools (p <.001), clustering of stools (p = .02), and fecal urgency (p = .05). Regression logistic model revealed 2 independent risk factors for minor/major LARS: performing low rectal resection (adjusted odds ratio 2.28; 95% confidence interval, 1.1-4.7) and presenting with bladder atony requiring self-catheterization beyond postoperative day 7 (adjusted odds ratio 2.52; 95% confidence interval, 1.1-5.8).

CONCLUSION

The probability of normal bowel movements is higher after disk excision than after low rectal resection in women with deep endometriosis infiltrating the low rectum.

The impact of laparoscopic surgery on the symptoms and wellbeing of patients with deep infiltrating endometriosis and bowel involvement

BACKGROUND

The purpose of this study was to evaluate the symptoms and wellbeing of patients who underwent laparoscopic colorectal resection for deep endometriosis infiltrating the rectum and/or colon in a single reference center.

METHODS

We conducted a cross-sectional survey based on a structured questionnaire. All patients underwent laparoscopic discoid resection, segmental resection or shaving for deep endometriosis in a single reference center between October 2014 and October 2019. The following topics were addressed: symptoms related to endometriosis, fertility, disease recurrence and quality of life. The Institutional Review Board approved the study and signed informed consent was required before enrollment.

RESULTS

A total of 77 of 160 (48.1%) subjects agreed to answer the questionnaire and were enrolled in the study. The mean age was 36.4 years (range, 24-54 years), and 45.5% of the patients had previously undergone surgery for deep endometriosis. Complete resolution of abdominal pain was observed in 48.1% of subjects after surgery. Pelvic pain was rated on a scale of 0 (no pain) to 10 (worst pain) before and after the procedure. In this evaluation, mean pain scores were reduced after surgery (9.21 ± 1.53 × 3.99 ± 3.14; p < .001). Other positive aspects reported by interviewees were increased willingness to perform daily activities (66.2%), increased physical activity (70.1%), better work performance (72.7%), improved dyspareunia (77.9%) and increased sexual activity (71.4%). Some negative aspects reported after surgery were straining at stool (35.1%), nocturia (24.7%), liquid-feces incontinence (13%), mild urinary incontinence (13%), urinary urgency (11.7%) and flatus incontinence (7.8%). Regarding pregnancy, 59% of patients tried to conceive after surgery, and the success rate was 28.2% (46.2% spontaneous and 53.8% after in vitro fertilization or insemination).

CONCLUSIONS

Laparoscopic surgery was associated with pain reduction and improved general wellbeing in patients diagnosed with deep endometriosis and bowel involvement.

Laparoscopic colorectal resection for deep infiltrating endometriosis: can we reliably predict anastomotic leakage and major postoperative complications in the early postoperative period?

BACKGROUND

Anastomotic leakage (AL) and major complications after colorectal resection for deep infiltrating endometriosis (DIE) have a remarkable impact on patient outcomes. The aim of this study is to assess the predictive value of C-reactive protein (CRP), procalcitonin (PCT), white blood cell count (WBCs) and the Dutch Leakage Score (DLS) as reliable markers in the early diagnosis of AL and major complications after laparoscopic colorectal resection for DIE.

METHODS

262 consecutive women undergoing laparoscopic colorectal resection for DIE between September 2017 and September 2018 were prospectively enrolled. WBCs, CRP, PCT and DLS were recorded at baseline and on postoperative day (POD) 2, 3 and 6 then statistically analyzed as predictors of AL and severe postoperative complications.

RESULTS

The AL rate was 3.2%. The major morbidity rate was 11.2%. No postoperative mortality was recorded. The postoperative trend of DLS and serum levels of CRP and PCT, but not WBCs, were significantly higher in women developing AL and severe complications. DLS had better sensitivity and specificity than biomarkers on all postoperative days as a predictor of AL and major complications. CRP and PCT have a low positive predictive value (PPV) and a high negative predictive value (NPV) for AL and major complications on POD3 and POD6. The risk of malnutrition was significantly related to AL.

CONCLUSIONS

The combination of DLS as a standardized postoperative clinical monitoring system and CRP and PCT as serum biomarkers, allows the exclusion of AL and major complications in the early postoperative period after laparoscopic colorectal resection for DIE, thus ensuring a safe patient discharge.

Indocyanine Green Fluorescence Angiography after Full-thickness Bowel Resection for Rectosigmoid Endometriosis-A Feasibility Study

STUDY OBJECTIVE

To evaluate feasibility of near-infrared (NIR)-indocyanine green (ICG) imaging for bowel vascularization assessment after full-thickness bowel resection for rectosigmoid endometriosis (RSE).

DESIGN

This is a prospective, single-center, preliminary study on consecutive patients who were symptomatic submitted to discoid or segmental resection for RSE and NIR-ICG evaluation for vascular assessment of the anastomotic line from May 2018 to January 2020.

SETTING

Tertiary university hospital.

PATIENTS

Thirty-two women with RSE meeting eligibility criteria were included for study analysis.

INTERVENTIONS

NIR-ICG evaluation of anastomotic line vascularization after RSE removal.

MEASUREMENTS AND MAIN RESULTS

Fluorescence degree of the anastomotic line was assessed with a 0 to 2 Likert scale, as follows: 0 or "absent" (no fluorescence observed), 1 or "irregular" (not uniform distribution or weak fluorescence), and 2 or "regular" (uniform distribution of fluorescence and similar to the proximal colon). In all the patients included in the study (100%), NIR-ICG imaging allowed the evaluation of fluorescence degree of the anastomotic line. No adverse reaction related to ICG use was recorded. The protocol did not greatly lengthen operating time (median, 4 [range, 3-5] minutes). Excellent interoperator agreement was observed. Most of the patients (31 of 32, 96.9%) showed regular fluorescence on the anastomotic line; in 1 patient with irregular fluorescence at NIR-ICG after discoid excision, the anastomotic suture was reinforced through interrupted stitches. We had 1 case of anastomotic leakage after segmental resection with intraoperative good fluorescence at NIR-ICG evaluation.

CONCLUSION

NIR-ICG imaging for anastomotic perfusion assessment after discoid or segmental resection for RSE seems to be a feasible, safe, and reproducible method.

Effect of nodule size on symptoms and the choice of surgical technique in patients with bladder endometriosis

Introduction:

In this study, we evaluated the relationships between symptoms of bladder endometriosis (EDT), lesion size, and the subsequent surgical technique used to excise the lesion.

Methods:

This is retrospective observational study of patients who underwent surgery in the Gynecological Endoscopy and Endometriosis Section at Hospital da Santa Casa of São Paulo, Brazil. A sample population of 39 women diagnosed with bladder EDT was included from 463 women presenting with deep pelvic EDT between January 2010 and March 2017. Clinical evaluations and surgical treatments for each EDT were performed.

Results:

Of the 39 women, 43.58% had dysmenorrhea or dyspareunia and 2.56% had hematuria. Furthermore, 21.10% presented with dysuria and endometriotic nodules on the bladder ( p < 0.04). The nodules had reached the muscle layer in 97.30% of patients, and a further 2.60% had reached the mucosal layer. In addition to bladder involvement, other pelvic regions were affected, including the left (15.8%) and right (13.2%) round ligament, left (68.4%) and right (65.8%) uterosacral ligament, retrocervical region (84.20%), and ureter (45.71%).

Conclusion:

The patients’ pain symptoms were found to be associated with bladder endometriosis and nodule size. Partial cystectomy with complete lesion excision might be an effective treatment option to relieve these symptoms. A study with a larger sample population is needed to confirm these findings.

Long-Term Evolution of Quality of Life and Symptoms Following Surgical Treatment for Endometriosis: Different Trajectories for Which Patients?

Many studies have shown a global efficacy of laparoscopic surgery for patients with endometriosis in reducing painful symptoms and improving quality of life (QoL) in the short and long-term. The aim of this study was to analyze the different trajectories of long-term evolution in QoL and symptoms following surgical treatment for endometriosis, and to identify corresponding patient profiles. This prospective and multicenter cohort study concerned 962 patients who underwent laparoscopic treatment for endometriosis. QoL was evaluated using the Short Form (SF)-36 questionnaire and intensity of pain was reported using a visual analog scale prior to surgery and at 6, 12, 18, 24 and 36 months after surgery. Distinctive trajectories of pain and QoL evolution were identified using group-based trajectory modeling, an approach which gathers individuals into meaningful subgroups with statistically similar trajectories. Pelvic symptom trajectories (models of the evolution of dysmenorrhea, dyspareunia and chronic pelvic pain intensity over years) correspond to (1) patients with no pain or pain no longer after surgery, (2) patients with the biggest improvement in pain and (3) patients with continued severe pain after surgery. Our study reveals clear trajectories for the progression of symptoms and QoL after surgery that correspond to clusters of patients. This information may serve to complete information obtained from epidemiological methods currently used in selecting patients eligible for surgery.

Surgery-related complications and long-term functional morbidity after segmental colo-rectal resection for deep infiltrating endometriosis (ENDO-RESECT morb)

PURPOSE

Segmental resection has been generally associated with increased peri-operative risk of major complications. While major complications are widely acknowledged, minor complications, such as slight, to moderate infections, peripheral sensory disturbances, bladder voiding dysfunction, postoperative urinary obstruction, and sexual disorders are less reported. The aim of this study is to investigate the surgery-related complications and functional disorders, as well as to evaluate their persistence after long-term follow-up in women undergone segmental resection for deep infiltrating endometriosis. Special attention is given to evaluating impairments of bowel, bladder, and sexual function.

METHODS

All clinical data obtained from medical records of women who underwent segmental resection for intestinal endometriosis between October 2005, and November 2017, in Catholic University Institutions. Perioperative morbidity was classified by Extended Clavien-Dindo classification. Postoperative intestinal, voiding, and sexual morbidity was estimated by the compilation of specific questionnaires.

RESULTS

Fifty women were included in the study. Forty-three high colorectal resections (86%), 6 low resections (12%), and 1 ultra-low resection (2%) were performed, while in 3 cases (6%) multiple resections were needed. The overall complication rate was 44%. Nineteen women (38%) experienced early complications and 3 women (6%) late complications. Long-term functional postoperative complications were composed of intestinal in 30%, urinary in 50%, and sexual in 64% of the study population. Median follow-up was 55.5 months.

CONCLUSIONS

Segmental resection, when indicated, offers a radical and feasible approach for bowel deep infiltrating endometriosis, resulting in an improved general quality of life. The bowel and bladder complications appear to be acceptable and often reversible. Postoperative sexual dysfunctions, such as anorgasmia and insufficient vaginal lubrication, appear to persist over time. Surgeons and women have to be aware of the incidence of this kind of complications.

Bowel resection for intestinal endometriosis

Over the last twenty years, segmental resection (SR) has been the technique most frequently used to treat bowel endometriosis. Nowadays, it is most commonly performed by laparoscopy; however, there is evidence that it can be safely performed by robotic-assisted laparoscopic surgery. Rectovaginal fistula and anastomotic leakage are the two major complications of SR; other complications include pelvic abscess, postoperative bleeding, ureteral damage, and anastomotic stricture. Several studies showed that SR causes improvement in pain and intestinal symptoms; nerve-sparing SR may improve the functional outcomes. The rates of postoperative recurrence of bowel endometriosis vary across the studies, possibly because of the different definitions of recurrence.