Laparoscopic treatment of deep infiltrating endometriosis: results of the combined laparoscopic gynecologic and colorectal surgery

Natural Orifice Specimen Extraction as a Promising Alternative for Minilaparotomy in Bowel Resection Due to Endometriosis: A Systematic Review and Meta-Analysis

OBJECTIVE

This study focuses on evaluating the effectiveness, safety and efficacy of 2 surgical tissue extraction methods for treating bowel endometriosis: natural orifice specimen extraction (NOSE) and minilaparotomy.

DATA SOURCES

A systematic search was conducted in MedLine, Embase, and Cochrane Library databases in October 2023, without date restrictions.

METHODS OF STUDY SELECTION

This study included studies that directly compared NOSE and minilaparotomy in colectomy patients due to endometriosis. Primary outcomes were defined as operation duration, length of hospital stay, intraoperative blood loss, and major postoperative complication rates. The Clavien-Dindo classification was used to categorize complications. Statistical analysis was performed using Review Manager Software by Cochrane, with a DerSimonian and Laird random-effects model to account for anticipated high heterogeneity. Subgroup analysis was conducted for patients undergoing full laparoscopic (L/S) resection.

TABULATION, INTEGRATION AND RESULTS

Out of 1236 identified studies, 6 met the inclusion criteria, comprising 372 patients. One study was a randomized controlled trial, and 5 were observational. Operation duration did not significantly differ between NOSE and minilaparotomy (MD: -10.85 min; 95% CI: [-23.33, 1.63]; p = .09). NOSE was associated with a significantly reduced length of hospital stay (MD: -0.76 day; 95% CI: [-1.21, -0.31]; p = .008). The major postoperative complication rates were 3.77% for NOSE and 5.55% for minilaparotomy, with no significant difference (OR: 0.84; 95% CI: [0.27, 2.60]; p = .76). Subgroup analysis revealed that Full L/S had significantly shorter operation duration (MD: -26.06 min; 95% CI: [-45.85, -6.27]; p = .01), reduced length of stay (MD: -0.75 day; 95% CI: [-1.25, -0.25]; p = .003), and lower blood loss (MD: -15.01 mL; 95% CI: [-29.64, -0.37]; p = .04).

CONCLUSION

NOSE emerged as a potentially safer alternative to minilaparotomy for tissue extraction in colectomy for bowel endometriosis. However, standardization of the procedure and additional randomized controlled trials are needed to validate these findings.

Totally intracorporeal colorectal anastomosis (TICA) versus classical mini-laparotomy for specimen extraction, after segmental bowel resection for deep endometriosis: a single-center experience

PURPOSE

The surgical approach to bowel endometriosis is still unclear. The aim of the study is to compare TICA to conventional specimen extractions and extra-abdominal insertion of the anvil in terms of both complications and functional outcomes.

METHODS

This is a single-center, observational, retrospective study conducted enrolling symptomatic women underwent laparoscopic excision of deep endometriosis with segmental bowel resection between September 2019 and June 2022. Women who underwent TICA were compared to classical technique (CT) in terms of intra- and postoperative complications, moreover, functional outcomes relating to the pelvic organs were assessed using validated questionnaires [Knowles-Eccersley-Scott-Symptom (KESS) questionnaire and Gastro-Intestinal Quality of Life Index (GIQLI)] for bowel function. Pain symptoms were assessed using Visual Analogue Scale (VAS) scores.

RESULTS

The sample included 64 women. TICA was performed on 31.2% (n = 20) of the women, whereas CT was used on 68.8% (n = 44). None of the patients experienced rectovaginal, vesicovaginal, ureteral or vesical fistula, or ureteral stenosis and uroperitoneum, and in no cases was it necessary to reoperate. Regarding the two surgical approaches, no significant difference was observed in terms of complications. As concerns pain symptoms at 6-month follow-up evaluations on stratified data, except for dysuria, all VAS scales reported showed significant reductions between median values, for both surgery interventions. As well, significant improvements were further observed in KESS scores and overall GIQLI. Only the GIQLI evaluation was significantly smaller in the TICA group compared to CT after the 6-month follow-up.

CONCLUSIONS

We did not find any significant differences in terms of intra- or post-operative complications compared TICA and CT, but only a slight improvement in the Gastro-Intestinal Quality of Life Index in patients who underwent the CT compared to the TICA technique.

Routine use of ICG to enhance operative safety in emergency laparoscopic cholecystectomy: a randomized controlled trial

OBJECTIVE

To test the hypothesis that ICG fluorescence cholangiography (ICG-FC) helps to identify critical structures during laparoscopic cholecystectomy (LC) and hence reduce biliary injuries and conversions. In LC, biliary injury and conversion often happen if the biliary anatomy is misidentified.

METHODS

This was a single-center randomized controlled trial from 2017 to 2019. Patients with acute cholecystitis requiring LC were assessed for eligibility for the trial. Patients in the trial were randomized to undergo either conventional LC (conventional arm) or LC with ICG-FC (ICG arm). Conversion rate and biliary injury incidence were outcome measures.

RESULTS

Totally 92 patients participated (46 patients in each arm). The median age was 61 years in both arms (p = 0.472). The conventional arm had 22 men and 24 women; the ICG arm had 24 men and 22 women (p = 0.677). The two arms were comparable in all perioperative parameters. The time from ICG injection to surgery was 67 (16-1150) min. Both arms had an 8.7% conversion rate (p = 1.000). The median operative time was 140.5 min in the conventional arm and 149.5 min in the ICG arm (p = 0.086). The complication rate was 15.2% in the former and 10.9% in the latter (p = 0.536), and both had a 2.2% bile leakage rate. The median hospital stay was 3.5d in the former and 4.0d in the latter (p = 0.380).

CONCLUSION

ICG-FC did not make any difference in conversion or complication rate. Its routine use in LC is questionable. However, it may be helpful in difficult cholecystectomies and may be used as an adjunct.

TRIAL REGISTRATION

The trial was registered with the Institutional Review Board of University of Hong Kong/Hospital Authority Hong Kong West Cluster ( http://www.med.hku.hk/en/research/ethics-and-integrity/human-ethics ). Registration number: UW17-492.

Endometriosis and adverse pregnancy outcome

INTRODUCTION

Endometriosis is a gynecologic disease affecting approximately 10% of reproductive age women, around 21-47% of women presenting subfertility and 71-87% of women with chronic pelvic pain. Main symptoms are chronic pelvic pain, dysmenorrhea, dyspareunia and infertility that seem to be well controlled by oral contraceptive pill, progestogens, GnRh antagonists. The aim of this review was to illustrate the modern diagnosis of endometriosis during pregnancy, to evaluate the evolution of endometriotic lesions during pregnancy and the incidence of adverse outcomes.

EVIDENCE ACQUISITION

Published literature was retrieved through searches of the database PubMed (National Center for Biotechnology Information, US National Library of Medicine, Bethesda, MD, USA). We searched for all original articles published in English through April 2020 and decided to extract every notable information for potential inclusion in this review. The search included the following MeSH search terms, alone or in combination: "endometriosis" combined with "endometrioma," "biomarkers," "complications," "bowel," "urinary tract," "uterine rupture," "spontaneous hemoperitoneum in pregnancy" and more "adverse pregnancy outcome," "preterm birth," "miscarriage," "abruption placentae," "placenta previa," "hypertensive disorder," "preeclampsia," "fetal grow restriction," "small for gestation age," "cesarean delivery."

EVIDENCE SYNTHESIS

Pregnancy in women with endometriosis does not always lead to disappearance of symptoms and decrease in the size of endometriotic lesions, but it may be possible to observe a malignant transformation of ovarian endometriotic lesions. Onset of complications may be caused by many factors: chronic inflammation, adhesions, progesterone resistance and a dysregulation of genes involved in the embryo implantation. As results, the pregnancy can be more difficult because of endometriosis related complications (spontaneous hemoperitoneum [SH], bowel complications, etc.) or adverse outcomes like preterm birth, FGR, hypertensive disorders, obstetrics hemorrhages (placenta previa, abruptio placenta), miscarriage or cesarean section. Due to insufficient knowledge about its pathogenesis, currently literature data are contradictory and do not show a strong correlation between endometriosis and these complications except for miscarriage and cesarean delivery.

CONCLUSIONS

Future research should focus on the potential biological pathways underlying these relationships in order to inform patients planning a birth about possible complications during pregnancy.

Feasibility and safety of transvaginal specimen extraction in deep endometriosis colorectal resectional surgery and analysis of risk factors for postoperative complications

BACKGROUND

The aim of the present study was to demonstrate that transvaginal specimen extraction is a feasible and safe approach in colorectal resection for deep endometriosis (DE) and to assess the risk factors for postoperative complications.

METHODS

This retrospective cohort study included all the consecutive patients undergoing segmental bowel resection for symptomatic endometriosis at "La Paz" University Hospital (Madrid, Spain) and at "Hospital General Universitario de Valencia" (Valencia, Spain) from January 2014 to December to 2017. Patients were grouped according to specimen extraction approach into those who had transvaginal extraction (Group I) and those who had suprapubic extraction (Group II). Clinic-demographical, surgical and post-surgical data were recorded. Intra- and postoperative complications were classified according to Clavien-Dindo criteria. Postoperative data were compared between groups. Risk factors associated with surgery were investigated.

RESULTS

Out of 99 female patients included (average age 36.91 ± 5.36 years), 23 patients (23.2%) had transvaginal and 76 (76.8%) had suprapubic specimen extraction. The groups were comparable regarding operative time, nodule size, level of anastomosis, hospital stay and intraoperative complications. We observed no statistically significant differences in postoperative complications and rectovaginal fistula rate between the groups. Binary logistic regression analyses determined that vaginal endometriosis is an independent risk factor for postoperative complications (OR: 2.63, 95% CI [1.10-6.48], p = 0.03).

CONCLUSIONS

Transvaginal specimen extraction is a safe and feasible technique in DE colorectal surgery and should be taken into consideration whenever vaginal endometriosis exists. Nevertheless, vaginal endometriosis can be an independent risk factor for postoperative complications in DE surgery.

Laparoscopic adenomyomectomy combined with levonorgestrel-releasing intrauterine system in the treatment of adenomyosis: Feasibility and effectiveness

AIM

To evaluate the clinical efficacy and safety of laparoscopic adenomyomectomy combined with intraoperative replacement of levonorgestrel-releasing intrauterine system (LNG-IUS) in the treatment of symptomatic adenomyosis.

METHODS

This is a case-series study in a university medical center. A total of 52 patients with symptomatic adenomyosis were treated by laparoscopic adenomyomectomy combined with intraoperative replacement of LNG-IUS from January 2015 to July 2018. Visual analog scale, menstrual flow and uterine volume were compared before and after the surgery (3, 12 and 24 months). Meanwhile, LNG-IUS-induced adverse reactions (e.g. irregular vaginal bleeding, amenorrhea, expulsion, and perforation) were also recorded.

RESULTS

All operations were successfully completed via laparoscopy without conversion to laparotomy. No severe complications were noted during the surgical procedure or follow-up period. The mean postoperative visual analog scale and menstrual flow scores and the volume of the uterus were significantly decreased (all P < 0.001) at 3, 12, and 24 months postoperatively, compared with preoperative scores. The clinical effective rates among the patients with dysmenorrhea were 98%, 96% and 96% at 3, 12 and 24 months after the operation, respectively. And the clinical effectiveness rate of menorrhagia was 97.6%, 95.2% and 95.2% at 3, 12 and 24 months after treatment, respectively. Among all related adverse reactions, amenorrhea was the most common (n = 12, 23.1%). There was one case of LNG-IUS perforation (1.9%) and two cases of expulsion (3.8%).

CONCLUSION

Laparoscopic adenomyomectomy combined with intraoperative replacement of LNG-IUS is a novel and effective conservative surgical procedure for symptomatic adenomyosis treatment.

Nanotechnology for the treatment of deep endometriosis: uptake of lipid core nanoparticles by LDL receptors in endometriotic foci

OBJECTIVE

Rapidly dividing cells in multiple types of cancer and inflammatory diseases undergo high low density lipoprotein (LDL) uptake for membrane synthesis, and coupling an LDL-like nanoemulsion, containing lipid nanoparticles (LDE) to a chemotherapeutic agent efficiently targets these cells without significant systemic effects. This was a prospective exploratory study that evaluated the uptake of a radioactively labeled LDE emulsion by receptors of endometriotic foci and the capacity of the LDE for cellular internalization.

METHODS

The lipid profile of each patient was determined before surgery, and labeled LDE were injected into fourteen patients with intestinal or nonintestinal endometriosis. The radioactivity of each tissue sample (intestinal endometriosis, nonintestinal endometriosis, healthy peritoneum, or topical endometrium) was measured.

RESULTS

The group with intestinal endometriosis presented higher levels of plasma LDL but lower LDE uptake by foci than the nonintestinal group, suggesting less cell division and more fibrosis. The uptake of LDE was highest in the topical endometrium, followed by the healthy peritoneum, and lowest in the endometriotic lesion. Since the endometriotic foci showed significant LDE uptake, there was likely increased consumption of LDL by these cells, similar to cells in cancers and inflammatory diseases. Plasma cholesterol levels had no influence on LDE uptake, which showed that the direct delivery of the nanoemulsion to target tissues was independent of serum lipoproteins. There were no significant differences in the parameters (p>0.01) because of the small sample size, but the findings were similar to those of previous studies.

CONCLUSION

Nanotechnology is a promising therapeutic option for surgery and hormonal blockage for deep endometriosis, with a lower complication rate and no systemic side effects.

Functional outcomes of nerve-sparing laparoscopic eradication of deep infiltrating endometriosis: a prospective analysis using validated questionnaires

PURPOSE

Radical eradication of deep infiltrating endometriosis (DIE) is associated with a high risk of iatrogenic autonomic denervation and pelvic dysfunction. Our aim was to prospectively analyze peri-operative details and post-operative functional outcomes (in terms of pain relief and bladder, rectal, and sexual function) among women operated for DIE of the posterior compartment with nerve-sparing technique, using the visual analogue scale and validated questionnaires.

METHODS

All women undergoing laparoscopic nerve-sparing eradicative surgery for DIE nodules of the posterior compartment ≥ 4 cm ± bowel resection were included. Pain scores [using Visual Analogue Scale (VAS) scores] were collected before surgery and 6 and 12 months after surgery. Functional outcomes in terms of bladder, rectal, and sexual function, were evaluated using validated questionnaires (i.e., ICIQ-UISF, NBD score, and FSFI) administered pre-operatively and 6 months after surgery.

MAIN RESULTS

A total of 34 patients were included. Twenty-eight (82.4%) of them had already undergone a previous abdominal surgery for endometriosis. Bowel resection was performed in 16 (47.1%) patients. Median VAS score levels of pelvic pain were significantly decreased after surgery both at 6 (median 3, range 0-7 and 2, 0-7, respectively) and at 12 months (3, 0-8 and 2, 0-7), compared to pre-operative levels (9, 1-10 and 3, 0-7, respectively) (p < 0.0001). No differences were found in terms of urinary function between pre- and post-operative ICIQ-SF questionnaires. In no cases, bladder self-catheterization was needed at the 6-and 12-month follow-up. Median NBD score was 3.5 (0-21) pre-operatively and 2 (0-18) after 6 months (p = 0.72). The pre-operative total FSFI score was 19.1 (1.2-28.9) vs. 22.7 (12.2-31) post-operatively (p = 0.004).

CONCLUSIONS

The nerve-sparing approach is effective in eradicating DIE of the posterior compartment, with satisfactory pain control, significant improvement of sexual function, and preservation of bladder and rectal function.

Outcomes after rectosigmoid resection for endometriosis: a systematic literature review

PURPOSE

"Endometriosis" is defined such as the presence of endometrial glands and stroma outside the uterine cavity. This ectopic condition may develop as deeply infiltrating endometriosis (DIE) when a solid mass is located deeper than 5 mm underneath the peritoneum including the intestinal wall. The ideal surgical treatment is still under search, and treatment may range from simple shaving to rectal resection. The aim of the present systematic review is to report and analyze the postoperative outcomes after rectosigmoid resection for endometriosis.

METHODS

We performed a systematic review according to Meta-analysis of Observational Studies in Epidemiology guidelines. The search was carried out in the PubMed database, using the keywords: "rectal resection" AND "endometriosis" and "rectosigmoid resection" AND "endometriosis." The search revealed 380 papers of which 78 were fully analyzed.

RESULTS

Thirty-eight articles published between 1998 and 2017 were included. Three thousand seventy-nine patients (mean age 34.28 ± 2.46) were included. Laparoscopic approach was the most employed (90.3%) followed by the open one (7.9%) and the robotic one (1.7%). Overall operative time was 238.47 ± 66.82. Conversion rate was 2.7%. In more than 80% of cases, associated procedures were performed. Intraoperative complications were observed in 1% of cases. The overall postoperative complications rate was 18.5% (571 patients), and the most frequent complication was recto-vaginal fistula (74 patients, 2.4%). Postoperative mortality rate was 0.03% and mean hospital stay was 8.88 ± 3.71 days.

CONCLUSIONS

Despite the large and extremely various number of associated procedures, rectosigmoid resection is a feasible and safe technique to treat endometriosis.

Left colon resection with transrectal specimen extraction: current status

BACKGROUND

Full laparoscopic left colectomy with transrectal specimen extraction is proposed as an improvement of the minimally invasive surgical technique. This paper reviews in detail the current status of left-sided colectomy and upper rectum resection with transrectal specimen extraction.

METHODS

A systematic review was performed of all types of publications on colorectal resection with natural orifice specimen extraction (NOSE). We only included studies reporting on left colectomy, sigmoidectomy, and high anterior resection with transrectal specimen extraction (TRSE), excluding transanal (TASE), transvaginal, or transcolonic specimen extraction. Surgical techniques, patient characteristics, and outcomes were reviewed in detail.

RESULTS

Thirty-five papers reported on TRSE (2 randomized clinical trials, 7 case-matched series, 19 case series, 5 case reports, and 2 articles on surgical technique). We found a wide variety of innovative anastomotic and specimen extraction techniques. After excluding duplicates and papers reporting mixed TRSE and TASE results, outcomes in patients undergoing TRSE from 23 publications showed a conversion rate to conventional laparoscopy of 3.7% (21/559), overall morbidity 9.5% (53/559) [major in 2.9% (16/559), intra-abdominal infection in 2.1% (12/559)]. No mortality was reported. Postoperative anal incontinence was rarely reported. Several studies showed a decrease in postoperative pain and some in length of hospital stay.

CONCLUSIONS

Colectomy with TRSE is feasible and seems safe in selected patients. Reported outcomes seem in general similar to conventional laparoscopic colectomy with a possible benefit in postoperative pain and length of hospital stay. Obvious selection bias and lack of high quality trials do not allow firm conclusions to be drawn.

Impact of endometriosis on surgical outcomes and complications of total laparoscopic hysterectomy

PURPOSE

Total laparoscopic hysterectomy (TLH) in the case of endometriosis may be extremely challenging. Our aim has been to analyze perioperative details and complications of TLH in women with vs. women without endometriosis.

METHODS

Consecutive women who underwent TLH for endometriosis (endometriosis group) were compared with consecutive patients who had TLH for other conditions (controls) in terms of perioperative outcomes. Patients in the endometriosis group were analyzed, according to the severity of the disease.

RESULTS

One-hundred and twelve women in the endometriosis group, 29 (25.9 %) with minimal-mild, and 83 (74.1 %) with moderate-severe stage disease (rAFS score), respectively, were compared with 572 controls. Conversion rate was 0.8 vs. 0.5 % (P = 0.51), and median operative time was 75 vs. 55 min (pxxx = x) in the endometriosis group vs.

CONTROLS

Intraoperative complications were similar between groups (P = 0.56). Postoperative complications occurred in 10 (12.3 %) women in the endometriosis group vs. 12 (3.3 %) among the controls (P = 0.002). The severity of complications according to Clavien-Dindo classification system was higher in the endometriosis group (Clavien-Dindo >2: 7.5 vs. 1.9 %). The risk of organ lesions, urinary lesions, postoperative complications, and severe adverse events was significantly higher in women with moderate-severe endometriosis vs.

CONTROLS

No differences between patients with minimal-mild endometriosis and controls were found.

CONCLUSION(S)

TLH in the case of endometriosis is associated with longer operative time and an almost fourfold increase in the risk and severity of complications compared with controls. In particular, the adjunctive risk of adverse events is specific for moderate/severe-stage disease but not for minimal/mild endometriosis.

Full-Thickness Excision versus Shaving by Laparoscopy for Intestinal Deep Infiltrating Endometriosis: Rationale and Potential Treatment Options

Endometriosis is defined as the presence of endometrial mucosa (glands and stroma) abnormally implanted in locations other than the uterine cavity. Deep infiltrating endometriosis (DIE) is considered the most aggressive presentation of the disease, penetrating more than 5 mm in affected tissues, and it is reported in approximately 20% of all women with endometriosis. DIE can cause a complete distortion of the pelvic anatomy and it mainly involves uterosacral ligaments, bladder, rectovaginal septum, rectum, and rectosigmoid colon. This review describes the state of the art in laparoscopic approach for DIE with a special interest in intestinal involvement, according to recent literature findings. Our attention has been focused particularly on full-thickness excision versus shaving technique in deep endometriosis intestinal involvement. Particularly, the aim of this paper is clarifying from the clinical and methodological points of view the best surgical treatment of deep intestinal endometriosis, since there is no standard of care in the literature and in different surgical settings. Indeed, this review tries to suggest when it is advisable to manage the full-thickness excision or the shaving technique, also analyzing perioperative management, main complications, and surgical outcomes.