Long-term functional outcomes following colorectal resection versus shaving for rectal endometriosis

Long-term gastrointestinal function outcomes of women undergoing nerve-vessel sparing segmental or full-thickness discoid resection for deep colorectal endometriosis

INTRODUCTION

Patients undergoing colorectal surgery for symptomatic deep endometriosis may experience postoperative impairment of gastrointestinal function. However, there is limited information on long-term follow-up of this surgical sequela. We aimed to analyze 5-year postsurgical outcomes of gastrointestinal function in these patients, reflected by lower anterior resection syndrome (LARS) scores and gastrointestinal quality of life index (GIQLI).

MATERIAL AND METHODS

This prospective study included patients who either underwent nerve-vessel-sparing segmental resection (NVSSR) or full-thickness discoid resection (FTDR) for symptomatic colorectal deep endometriosis from April 2017 to May 2022 at two tertiary referral centers. As published previously, gastrointestinal function was evaluated by LARS and GIQLI scores pre- and postsurgically (postoperative visit 1) and was now re-evaluated (postoperative visit 2) to gain information on long-term outcomes.

RESULTS

Out of 121 patients, 92 were eligible for the final analysis at postoperative visit 2. The mean follow-up interval was 58.5 ± 17.9 months in the NVSSR group and 61.6 ± 10.7 months in the FTDR group. As published previously, presurgical LARS-like symptoms were observed in 42/92 (45.7%) of patients, including 37/76 (48.7%) in the NVSSR group and 5/16 (31.3%) in the FTDR group. Compared to preoperative LARS scores, patients in the NVSSR group showed a significant reduction of LARS scores at long-term postoperative visit 2 (p = <0.001), with LARS scores remaining stable over postoperative visit 1 and visit 2 (p = 0.09) at 5 years postoperatively. In women following FTDR, presurgical and long-term postoperative visit 2 LARS scores remained statistically unchanged (p < 0.73), with worsening of LARS scores between postoperative visit 1 and visit 2 (p = 0.02). In contrast, significant improvement of GIQLI was observed between the preoperative visit and postoperative visit 2 at 5 years follow-up in both NVSSR and FTDR groups (p ≤ 0.001 and p = 0.001, respectively).

CONCLUSIONS

Compared to presurgical values, long-term gastrointestinal function reflected by LARS scores remains improved following NVSSR, whereas it remains unchanged following FTDR. However, when GIQLI is applied as patient-reported outcome measurement (PROM), patients show permanent, long-term improvement of gastrointestinal function following either NVSSR or FTDR for symptomatic colorectal endometriosis.

Gastrointestinal function outcomes following radical and conservative colorectal surgery for deep endometriosis: A systematic review and meta-analysis

INTRODUCTION

Patients who have undergone colorectal surgery for symptomatic deep endometriosis may still encounter persistent or worsening digestive complaints. The aim of the present work was to analyze gastrointestinal function outcomes after radical and conservative colorectal surgery to further elucidate the effect of surgery on postoperative bowel function.

MATERIAL AND METHODS

PubMed, EMBASE, Web of Science, Clinical Trials.gov and the Cochrane Database databases were searched from January 1, 2010 until April 1, 2024. The quality of included studies was assessed by the Downs and Black quality checklist. Studies including patients with colorectal endometriosis who either underwent segmental resection (SR) or conservative approaches and reported data on bowel function were included.

RESULTS

From the initial pool of 55 studies, 14 reported patient reported outcome measures eligible to be pooled in the meta-analysis. Conservative surgery was less associated with constipation and increased number of daily stool (>3/day) when compared to SR (p = 0.02 and p = 0,0004, respectively). No difference was found in the occurrence of gas and stool incontinence (p = 0.72), postsurgical defecation pain (p = 0.44) and time to defer defecation (≤ 15 min; p = 0.64). Patients in the conservative surgery group reported higher postoperative Gastrointestinal Quality of Life Index (GIQLI) when compared to SR (p = 0.01). However, when comparing changes between pre- and postsurgical patient reported outcome measures within the respective groups, rather than evaluating postsurgical outcomes alone, none of the intervention groups showed significant changes between pre- and postsurgical GIQLI, Knowles Eccersley Scott Symptom Score(KESS) and Wexner scores (p = 0.28, p = 0.94 and p = 0.78, respectively).

CONCLUSIONS

Segmental resection seems to be associated with higher rates of post-operative constipation and lower GIQLI scores when compared to conservative surgery. However, when comparing the change of gastrointestinal function symptoms reflected by changes of gastrointestinal function parameters from pre- to postoperative rather than focusing on purely postoperative parameters alone, no significant difference of these parameters was observed between surgical techniques.

Voiding dysfunction after surgery for colorectal deep infiltrating endometriosis: an updated systematic review and meta-analysis

To define the risk factors of post-operative voiding dysfunction according to the type of surgical procedure performed. A systematic review through PubMed, the Cochrane Library, and Web of Science databases was performed. The Medical Subject Headings terms aimed for English articles about colorectal endometriosis surgery and voiding dysfunction published until December 26, 2022 were used. The primary outcome was the occurrence of post-operative voiding dysfunction. Secondary outcome was the presence of a persistent voiding dysfunction at 1 month. MeSH terms included ''deep endometriosis'', ''surgery'', or ''voiding dysfunction''. Two reviewers (AM, PE) assessed the quality of each article independently. A Study Quality Assessment Tool was used to provide rating of the quality of the included studies. 22 studies were included in the final analysis. Rectal shaving was associated with less voiding dysfunction than segmental resection (OR 0.33; 95%CI [0.20: 0.54]; I2 = 0%; p < 10-3). No difference was found between rectal shaving and discoid excision (OR 0.44; 95%CI [0.07: 2.84]; I2 = 55%; p = 0.39), nor between discoid excision and segmental resection (OR 0.44; 95%CI [0.18: 1.09]; I2 = 49%; p = 0.08). Conservative surgery (i.e., shaving and discoid) was associated with less voiding dysfunction than radical surgery (i.e., segmental resection) (OR 0.37; 95%CI [0.25: 0.55]; I2 = 0%; p < 10-3). Regarding persistent voiding dysfunction, rectal shaving and discoid excision were less associated with voiding dysfunction than segmental resection (respectively, OR 0.30; 95%CI [0.14: 0.66]; I2 = 0%; p = 0.003 and OR 0.13; 95%CI [0.03: 0.57]; I2 = 0%; p = 0.007). Conservative bowel procedures are associated with lower rates of persistent post-operative voiding dysfunction and should be considered first when possible.Trial registration: Our meta-analysis was registered under the PROSPERO number: CRD42023395356.

Comprehensive Management of Bowel Endometriosis: Surgical Techniques, Outcomes, and Best Practices

Bowel endometriosis is a complex condition predominantly impacting women in their reproductive years, which may lead to chronic pain, gastrointestinal symptoms, and infertility. This review highlights current approaches to the diagnosis and management of bowel endometriosis, emphasizing a multidisciplinary strategy. Diagnostic methods include detailed patient history, physical examination, and imaging techniques like transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI), which aid in preoperative planning. Management options range from hormonal therapies for symptom relief to minimally invasive surgical techniques. Surgical interventions, categorized as shaving excision, disc excision, or segmental resection, depend on factors such as lesion size, location, and depth. Shaving excision is preferred for its minimal invasiveness and lower complication rates, while segmental resection is reserved for severe cases. This review also explores nerve-sparing strategies to reduce surgical morbidity, particularly for deep infiltrative cases close to the rectal bulb, anal verge, and rectosigmoid colon. A structured, evidence-based approach is recommended, prioritizing conservative surgery to avoid complications and preserve fertility as much as possible. Comprehensive management of bowel endometriosis requires expertise from both gynecologic and gastrointestinal specialists, aiming to improve patient outcomes while minimizing long-term morbidity.

Impact of Endometriosis Surgery on In Vitro Fertilization/Intracytoplasmic Sperm Injection Outcomes: a Systematic Review and Meta-analysis

Endometriosis-related infertility remains a therapeutic challenge. A burning issue in this field of research is determining whether pre-assisted reproductive technology (ART) surgery may be of some benefit in terms of reproductive outcomes. This systematic review and meta-analysis aimed at comparing ongoing pregnancy rates (OPR) and/or live birth rates (LBR) in patients who underwent endometriosis surgery before ART (IVF/ICSI) in comparison with patients who underwent first-line ART (IVF/ICSI). Searches were conducted from January 1990 to June 2021 on PubMed, Embase, and Cochrane Library using the following search terms: endometriosis, surgery, reproductive outcomes, and IVF/ICSI. The primary outcomes were OPR or LBR. A total of 19 studies were included in the meta-analysis. No statistically significant differences in LBR [0.91[0.63, 1.30]; I2 = 66%; n = 11], OPR [1.28[0.66, 2.49]; I2 = 60%; n = 3], and early pregnancy loss rate [0.88[0.62, 1.25]; I2 = 0%; n = 7] per cycle were found when comparing patients who underwent endometriosis surgery before IVF/ICSI and those who did not. After the exclusion of the studies with high risks of bias, the LBR per cycle was significantly reduced in the case of surgical treatment before IVF/ICSI [0.53[0.33, 0.86]; I2 = 30%; n = 4]. These data urge the clinician to carefully weigh the pros and cons before referring infertile patients with endometriosis to surgery before IVF, highlighting the key role of multidisciplinary referral centers.

Discoid excision for colorectal endometriosis associated infertility: A balance between fertility outcomes and complication rates

OBJECTIVE

The objective of our study was to study the impact of discoid excision for deep endometriosis (DE) with colorectal involvement on fertility outcomes.

METHODS

49 patients with a desire for pregnancy treated with discoid excision for colorectal endometriosis in our endometriosis expert center between January 2015 and August 2020 were selected from our prospectively maintained database. Indications for surgery were either infertility and / or pelvic pain. Postoperative complications were graded according to the Clavien-Dindo classification. Fertility outcomes, both spontaneous and post-ART pregnancies, were analyzed.

RESULTS

Among the 49 patients who underwent discoid excision exclusively (no other digestive resection) with a desire to conceive, 25 had a pregnancy after surgery and 24 did not. Double discoid excision was performed in 6.1 % of the cases (3/49). A colpectomy was performed in 12.2 % of the patients (6/49), and a protective stoma in 12.2 % (6/49). Fenestration of endometriomas was performed in 28.6 % of the patients (14/49), and parametrectomy in 40.8 % (20/49). The postoperative complication rate was 24.5 % (12/49) including 10.2 % (5/49) grade I, 12.2 % (6/49) grade II, and 2 % (1/49) grade III. Prior to surgery, 28 (57.1 %) patients had infertility including 13 (52 %) that successfully conceived following surgery and 15 (62.5 %) that remain infertile. Spontaneous pregnancy was achieved in 60 % (15/25) of infertile patients' prior surgery. The live-birth rate in patients conceiving spontaneously was 75 % (12/16).

CONCLUSION

Our results support that discoid excision is safe and associated with good fertility outcomes. Whether first-line surgery using discoid excision is superior to first-line ART remains to be determined.

Minimally invasive surgery for deep endometriosis

Deep endometriosis (DE) is endometriotic tissue that invades the peritoneum by >5 mm. Surgery is the treatment of choice for symptomatic DE, and laparoscopic surgery is preferred over laparotomy due to better vision and postoperative pain. In this review, we aimed to collect and summarize recent literature on DE surgery and share laparoscopic procedures for rectovaginal and bowel endometriosis.

Evaluation of Bowel Function of Women with Colorectal Endometriosis: a Cross-Sectional Study

The objective was to evaluate bowel function in women with colorectal endometriosis according to treatment type. Cross-sectional study, carried out with 141 women with endometriosis, followed by the University of Campinas from May 2020 to April 2021. Women were divided into 3 groups according to the kind of treatment: 16 women with conservative surgery, 35 women with radical surgery treatment, and 90 women with clinical treatment. The clinical and sociodemographic characteristics of these women were evaluated. To access bowel outcome, we used the following questionnaires: the Bristol Stool Scale, the Bowel Function in the Community, the Gastrointestinal Quality of Life Index (GIQLI), and the Pelvic Floor Distress Inventory (PFDI-20). The mean treatment time was 32.24 ± 29.37 months. The women of the three groups had similar gastrointestinal quality of life index scores (p = 0.27) and pelvic floor distress inventory scores (p = 0.23). Women in the radical surgery group had a higher frequency of evacuatory effort and change in posture to evacuate (p = 0.01 and 0.009, respectively) than did those in the other groups. Women with constipation had worse quality of life and more pain than those without constipation. In conclusion, women with endometriosis treated with radical surgery (segmental resection) had a higher frequency of constipation. In addition, women with endometriosis and constipation had a worse quality of life and higher pain scores compared to those without constipation.

Long-term risk of repeated surgeries in women managed for endometriosis: a 1,092 patient-series

OBJECTIVE

To assess the long-term risk of repeated surgery in women undergoing complete excision of endometriosis by an experienced surgeon and to identify circumstances leading up to repeat surgery.

DESIGN

Retrospective study based on data recorded in a large prospective database.

SETTING

University Hospital.

PATIENT(S)

A total of 1,092 patients managed for endometriosis, from June 2009 to June 2018, by one surgeon.

INTERVENTION(S)

Complete excision of endometriosis lesions.

MAIN OUTCOME MEASURE(S)

The recording of a repeated surgery linked to endometriosis performed during follow-up.

RESULT(S)

Endometriosis was exclusively superficial in 122 patients (11.2%) and 54 women (5%) had endometriomas without associated deep endometriosis nodules. Deep endometriosis was managed in 916 women (83.9%), leading to infiltration or not of the bowel in 688 (63%) and 228 (20.9%) patients, respectively. A majority of patients were managed for severe endometriosis infiltrating the rectum (58.4%). Mean and median follow-up was 60 months. A total of 155 patients underwent a repeated surgery relating to endometriosis; 108 procedures were required because of recurrences (9.9%), 39 surgeries were related to the management of infertility by assisted reproductive techniques (3.6%), and in 8 surgeries, a direct relationship between surgery and endometriosis was probable but not certain (0.8%). The majority of procedures involved hysterectomy for adenomyosis (n=45, 4.1%). The probability of requiring repeated surgery at 1, 3, 5, 7, and 10 years was 3%, 11%, 18%, 23%, and 28%, respectively. Cox's multivariate model identified postoperative pregnancy and hysterectomy as being statistically significant independent predictors for a reduction in the probability of having a repeated surgery, after adjustment on continuous postoperative amenorrhea, the main localization of the disease, and management for endometriosis infiltrating the rectum during the first surgery.

CONCLUSION(S)

Up to 28% of patients may require a repeated surgical procedure during the 10 years after complete excision of endometriosis. Conservation of the uterus is followed by an increased risk of repeated surgery. The study is based on outcomes resulting from a single surgeon, which limits the generalizability of results.

Pain, gastrointestinal function and fertility outcomes of modified nerve-vessel sparing segmental and full thickness discoid resection for deep colorectal endometriosis - A prospective cohort study

INTRODUCTION

There is an ongoing debate on surgical techniques for colorectal deep endometriosis (DE) and their effects on gastrointestinal (GI) function. The aim of this study was to prospectively investigate the differences in pre- and postsurgical GI function, health profiles and pain symptoms in women undergoing colorectal surgery for symptomatic DE either with a modified segmental resection technique, so-called nerve-vessel sparing segmental resection (NVSSR), or full thickness discoid resection (FTDR). Complication rates and fertility outcomes were also evaluated.

MATERIAL AND METHODS

A total of 162 consecutive patients, 125 (77.2%) of whom underwent NVSSR and 37 (22.8%) FTDR, were evaluated regarding complication rates. Furthermore a lower anterior resection syndrome (LARS) scores, gastrointestinal function-related quality of life index (GIQLI), pain symptoms, endometriosis health profile (EHP-30) parameters were analyzed pre- and post-surgery in a final cohort of 121 patients.

RESULTS

There was no difference between postsurgical prevalence of LARS in either surgery group (14/98, 14.1% NVSSR; 2/23, 8.6% FTDR), with significantly decreased LARS scores and increased GIQLI values before vs after surgery in both groups (P < 0.001). The overall grade III complication rate was 7/162 (4.3%) with no significant differences between NVSSR and FTDR groups. Overall, EHP-30 and pain scores significantly decreased after a median follow-up of 41 (± 17.6) months (EHP-30 51.1, SD 21.5 vs 12.7, SD 19.3, P < 0.001; dysmenorrhea, dyspareunia, dyschezia all P < 0.001 both cohorts, respectively). The overall life birth rate and postsurgical pregnancy in infertile patients undergoing NVSSR and FTDR was respectively 58.1% in 25/43 patients; 55.6% in 5/9 patients; 56.0% in 14/25 patients and 100% in 5/5 patients.

CONCLUSIONS

NVSSR and FTDR for symptomatic colorectal DE confer a significant amelioration of GI function reflected by decreased LARS symptoms and increased GIQLI scores with no differences in postsurgical function in between the two techniques. Both techniques confer similar complication rates and effects on pain reduction and health profiles.

Oocyte donation outcomes in endometriosis patients with multiple IVF failures

RESEARCH QUESTION

What are the reproductive outcomes and the prognostic factors of live birth rates in patients with endometriosis referred to oocyte donation after multiple IVF failures?

DESIGN

Observational cohort study including all women with endometriosis-related infertility and two or more failed IVF/intracytoplasmic sperm injection (ICSI) cycles referred to oocyte donation between January 2013 and June 2022. Endometriosis was diagnosed based on published imaging criteria, and was confirmed histologically in women who had a history of surgery for endometriosis. The main outcome measured was the cumulative live birth rate (CLBR). The characteristics of women who had a live birth were compared with those who did not using univariate and multivariate analysis to identify determinant factors of fertility outcome.

RESULTS

Fifty-seven patients underwent 90 oocyte donation cycles after 244 failed autologous IVF cycles. The mean ± SD age of the population was 36.8 ± 3.3 years, with a mean duration of infertility of 3.6 ± 2.2 years, and a mean number of autologous IVF/ICSI cycles of 4.4 ± 2.3 cycles per patient. Three patients (5.3%) had superficial peritoneal endometriosis, two patients (3.5%) had ovarian endometriomas, and 52 patients (91.2%) had deep infiltrating endometriosis, among which 30 patients (57.7%) had bowel lesions. Thirty patients (52.6%) had associated adenomyosis. Overall, CLBR per patient was 36/57 (63.2%). After multivariate analysis, only being nulligravida (P=0.002) remained an independent negative predictive factor of the live birth rate. Previous surgery did not impact reproductive outcomes.

CONCLUSION

This study suggests that oocyte donation appears to be a viable option to optimize the live birth rate in women with endometriosis-related infertility and recurrent IVF failures.

Conservative surgery versus colorectal resection for endometriosis with rectal involvement: a systematic review and meta-analysis of surgical and long-term outcomes

PURPOSE

The optimal surgical approach for removal of colorectal endometrial deposits is unclear. Shaving and discoid excision of colorectal deposits allow organ preservation but risk recurrence with associated functional issues and re-operation. Formal resection risks potential higher complications but may be associated with lower recurrence rates. This meta-analysis compares peri-operative and long-term outcomes between conservative surgery (shaving and disc excision) versus formal colorectal resection.

METHODS

The study was registered with PROSPERO. A systematic search was performed on PubMed and EMBASE databases. All comparative studies examining surgical outcomes in patients that underwent conservative surgery versus colorectal resection for rectal endometrial deposits were included. The two main groups (conservative versus resection) were compared in three main blocks of variables including group comparability, operative outcomes and long-term outcomes.

RESULTS

Seventeen studies including 2861 patients were analysed with patients subdivided by procedure: colorectal resection (n = 1389), shaving (n = 703) and discoid excision (n = 742). When formal colorectal resection was compared to conservative surgery there was lower risk of recurrence (p = 0.002), comparable functional outcomes (minor LARS, p = 0.30, major LARS, p = 0.54), similar rates of postoperative leaks (p = 0.22), pelvic abscesses (p = 0.18) and rectovaginal fistula (p = 0.92). On subgroup analysis, shaving had the highest recurrence rate (p = 0.0007), however a lower rate of stoma formation (p < 0.00001) and rectal stenosis (p = 0.01). Discoid excision and formal resection were comparable.

CONCLUSION

Colorectal resection has a significantly lower recurrence rate compared to shaving. There is no difference in complications or functional outcomes between discoid excision and formal resection and both have similar recurrence rates.

Surgical Treatment of Deep Endometriosis

In deep endometriosis (DE), clusters of endometrium-like cells penetrate more than 5 mm below the peritoneum: The affected organs and tissue structures can eventuate in an alteration of the anatomy with eliminated organ boundaries, which in some cases can pose a real surgical challenge, even for experienced surgeons. A comprehensive description of the different manifestations of the disease can be found in the #Enzian classification. Since the operation is usually the foundation for the successful treatment of DE, what is important are conclusive indications, appropriate preoperative preparation and, above all, appropriate experience on the part of the surgical team. This article aims to provide a review of the surgical options that are currently available.

Expert opinion on the use of transvaginal sonography for presurgical staging and classification of endometriosis

Gynecological ultrasonography plays a central role in the management of endometriosis. The rapid technical development as well as the currently increasing evidence for non-invasive diagnostic methods require an updated compilation of recommendations for the use of ultrasound in the management of endometriosis. The present work aims to highlight the accuracy of sonography for diagnosing and classifying endometriosis and will formulate the present list of key messages and recommendations. This paper aims to demonstrate the accuracy of TVS in the diagnosis and classification of endometriosis and to discuss the clinical applications and consequences of TVS findings for indication, surgical planning and assessment of associated risk factors. (1) Sophisticated ultrasound is the primary imaging modality recommended for suspected endometriosis. The examination procedure should be performed according to the IDEA Consensus. (2) Surgical intervention to confirm the diagnosis alone is not recommended. A preoperative imaging procedure with TVS and/or MRI is strongly recommended. (3) Ultrasound examination does not allow the definitive exclusion of endometriosis. (4) The examination is primarily transvaginal and should always be combined with a speculum and a bimanual examination. (5) Additional transabdominal ultrasonography may enhance the accuracy of the examination in case of extra pelvic disease, extensive findings or limited transvaginal access. (6) Sonographic assessment of both kidneys is mandatory when deep endometriosis (DE) and endometrioma are suspected. (7) Endometriomas are well defined by sonographic criteria. When evaluating the ovaries, the use of IOTA criteria is recommended. (8) The description of sonographic findings of deep endometriosis should be systematically recorded and performed using IDEA terminology. (9) Adenomyosis uteri has sonographically well-defined criteria (MUSA) that allow for detection with high sensitivity and specificity. MRI is not superior to differentiated skilled ultrasonography. (10) Classification of the extent of findings should be done according to the #Enzian classification. The current data situation proves the best possible prediction of the intraoperative situs of endometriosis (exclusive peritoneum) for the non-invasive application of the #Enzian classification. (11) Transvaginal sonographic examination by an experienced examiner is not inferior to MRI diagnostics regarding sensitivity and specificity in the prediction of the extent of deep endometriosis. (12) The major advantage of non-invasive imaging and classification of endometriosis is the differentiated planning or possible avoidance of surgical interventions. The recommendations represent the opinion of experts in the field of non-invasive and invasive diagnostics as well as therapy of endometriosis. They were developed with the participation of the following national and international societies: DEGUM, ÖGUM, SGUM, SEF, AGEM/DGGG, and EEL.

Comprehensive surgical treatment for obstructive rectal endometriosis: a case report and review of the literature

Background

Intestinal obstruction caused by endometriosis maybe easily misdiagnosed as a tumor or other occupying disease in emergency condition. How to deal with it depending on the clarity of the preoperative diagnosis and the experience of the surgeon.

Case presentation

A 47-year-old woman, admitted to our emergency service with abdominal pain and distension for 5 days, anal stop exhausting and defecating for 3 days. Based on imaging and laboratory examination, we made a preoperative diagnosis of rectal endometriosis probably. After 7 days of colon decompression with a intestinal obstruction catheter, an operation of laparoscopic partial rectal and sigmoid resection without protective stoma and total hysterectomy was performed successfully. The patient obtained a smooth postoperative course and doing well after 12-weeks follow up.

Conclusions

Obstruction caused by rectal endometriosis is very rare and easily overlooked by surgeon and gynecologist. Appropriate preoperative diagnosis and preoperative management can reduce the trauma and incidence of complications.

Long term outcomes following surgical management of rectal endometriosis: 7-year follow-up of patients enrolled in a randomized trial

STUDY OBJECTIVE

To compare functional outcomes, recurrence rate and pregnancy likelihood in patients undergoing conservative or radical surgery in patients with deep rectal endometriosis 7 years post-operatively.

DESIGN

Prospective study in a cohort of patients enrolled in a 2-arm randomized trial from March 2011 to August 2013.

SETTING

A tertiary referral center.

PATIENTS

55 patients with deep endometriosis infiltrating the rectum.

INTERVENTIONS

Patients underwent either segmental resection or nodule excision by shaving or disc excision, depending on a randomization which was performed preoperatively using sequentially numbered, opaque sealed envelopes.

MEASUREMENT AND MAIN RESULTS

The primary endpoint was the number of patients experiencing one of the following symptoms: constipation, frequent bowel movements, anal incontinence or bladder dysfunction 24 months postoperatively. Secondary endpoints were values of gastrointestinal and overall quality of life scores. The 7 year-recurrence rates (new deep endometriosis nodule infiltrating the rectum) in the excision vs. the segmental resection arms were 7.4 % vs. 0% (P=.24). One of more symptoms included in the definition of the primary outcomes were recorded in 55.6% vs. 60.7% of patients (P=0.79). However, 51.9% vs. 53.6% of patients considered their bowel movements as normal (P=.99). An intention-to-treat comparison of overall quality of life scores did not find differences between the two groups 7 years postoperatively. At the end of the 7-year study period, 31 of the 37 patients who tried to conceive were successful (83.8%) including: 27 (57.4%) natural conceptions and 20 (42.6%) pregnancies resulting from ART procedures. Pregnancy rate was 82.4% vs. 85% in the two arms (P=.99). A 75.7% live birth rate was recorded. At the end of the follow up there were 15 women with one child (40.5%) and 13 women with 2 children (35.1%). During the 7-year follow- up, the reoperation rate was respectively 37% and 35.7% in each arm, P=0.84). Among the 27 reoperation procedures during the follow up period, 11 were postoperative complications (40.7%), 7 were necessary prior to ART management (25.9%), 8 were for recurrent abdominal or pelvic pain (29.6%) and one for midline ventral hernia following pregnancy (3.7%).

CONCLUSIONS

Our study did not reveal a significant difference in terms of digestive functional outcomes, recurrence rate, reoperation risk and pregnancy likelihood when conservative and radical rectal surgery for deep endometriosis were compared 7 years postoperatively. Postoperative pregnancy rate observed in our series is high.

SURGICAL TECHNIQUES FOR THE TREATMENT OF RECTAL ENDOMETRIOSIS: A SYSTEMATIC REVIEW OF RANDOMIZED CONTROLLED TRIALS AND OBSERVATIONAL STUDIES

BACKGROUND

Endometriosis is a common disease in reproductive-age women and it is estimated to occur in up to 50% of those with infertility. Intestinal involvement is reported in up to a third of the cases. This condition is related to chronic pain and loss of quality of life, resulting in emotional, social and economic costs. Treatment consists of hormonal block and surgical resection, with variable side effects and efficacy. The best choice for surgical treatment for rectal endometriosis is a matter of discussion regarding the indication and the best technique to be employed.

OBJECTIVE

To summarize data on indications, results and complications of surgical techniques for the treatment of rectal endometriosis.

METHODS

This comprehensive systematic review is a compilation of the available literature and discussion, carried out by a team with experience in the surgical treatment of intestinal endometriosis. Data regarding indications, results and complications of conservative and radical techniques for the surgical treatment of rectal endometriosis was carefully reviewed. Searches of PubMed, EMBASE, and CENTRAL up to May 2021 were performed to identify randomized controlled trials (RCTs) and observational studies that compared at least two of the three surgical techniques of interest (i.e., shaving, discoid resection, segmental resection).

RESULTS

One RCT and nine case series studies with a total of 3,327 patients met the eligibility criteria. Participants ages ranged from a mean of 30.0 to 37.9 years old. Mean follow-up ranged from 1.2 to 42.76 months. With regards the methodological quality, overall the included studies presented a low risk of bias in the majority of the domains. Surgical treatment of rectal endometriosis is indicated for patients with obstructive symptoms and those with pain scores above 7/10. Patients with disease involving beyond muscularis propria of the rectum, documented in magnetic resonance imaging or transvaginal pelvic ultrasound with intestinal preparation, are candidates for discoid or segmental resection. The presence of multifocal disease, extension greater than 3 cm and infiltration greater than 50% of the loop circumference favor the radical technique. The distance from the lesion to the anal verge, age, symptoms and reproductive desire are other factors that influence the choice of the technique to be employed. The risk of complications and unfavorable functional results seems to be directly related to the complexity of the procedure.

CONCLUSION

The choice of surgical technique performed for the treatment of rectal endometriosis is a matter of discussion and depends not only on the preoperative staging, but also on the patient's expectations, risks and potential complications, recurrence rates and the expertise of the multidisciplinary team.

Conservative Management of Rectovaginal Deep Endometriosis: Shaving Should Be Considered as the Primary Surgical Approach in a High Majority of Cases

Deep endometriosis infiltrating the rectum remains a challenging situation to manage, and it is even more important when ureters and pelvic nerves are also infiltrated. Removal of deep rectovaginal endometriosis is mandatory in case of symptoms strongly impairing quality of life, alteration of digestive, urinary, sexual and reproductive functions, or in case of growing. Extensive preoperative imaging is required to choose the right technique between laparoscopic shaving, disc excision, or rectal resection. When performed by skilled surgeons and well-trained teams, a very high majority of cases of deep endometriosis nodule (>95%) is feasible by the shaving technique, and this is associated with lower complication rates regarding rectal resection. In most cases, removing a part of the rectum is questionable according to the risk of complications, and the rectum should be preserved as far as possible. Shaving and rectal resection are comparable in terms of recurrence rates. As shaving is manageable whatever the size of the lesions, surgeons should consider rectal shaving as first-line surgery to remove rectal deep endometriosis. Rectal stenosis of more than 80% of the lumen, multiple bowel deep endometriosis nodules, and stenotic sigmoid colon lesions should be considered as indication for rectal resection, but this represents a minority of cases.

Surgical management of deep pelvic endometriosis in France: Do we need to be a pelvic surgeon to deal with DPE?

INTRODUCTION

Endometriosis is a common disease in women, which requires a medical and surgical approach. Surgical societies recommend a multidisciplinary management in tertiary referral centers. The objective of our study is to assess the surgical management of endometriosis in France by studying the surgeons' attitude for bowel and urinary endometriosis.

METHODS

We sent a survey to french endometriosis surgeons. We did a descriptive analysis and a comparative analysis between surgeons who believe endometriosis surgeons should be considered as "pelvic surgeons", able to treat bowel and urinary involvement.

RESULTS

We included 90 answers, from gynaecologic surgeons from all over France. Gynaecologic surgeons perform minor bowel and urinary tract surgery, and more complex procedures are performed with digestive or urological surgeon (bowel resection 85% of cases, ureteric resection-anastomosis 84% of cases, ureteric reimplantation 91% of cases). Surgeons considering that gynaecologists should be able to deal with urinary and bowel endometriosis carry out more bowel and urinary procedures. They have an additional training in surgery and perform more endometriosis surgery every year. However, bowel and urinary endometriosis management by gynaecologic surgeons is contested amongst gynaecologists.

CONCLUSION

To this day, there is no dedicated training in France to coach gynaecologist to perform such procedures. Multidisciplinary approach is essential for quality care, in expert centers. The basic education of gynaecologic surgeons does not allow them to perform complex pelvic surgeries, but qualifications can be gained for these interventions with a special training, and perform a greater number of surgeries.

Patient-Reported Outcome Measures in Endometriosis

Patient Reported Outcome Measures (PROM) evoke measurements that allow capturing patients’ perspectives on their condition. In endometriosis care, physicians’ understanding of the effect of the disease and the treatment on patients is often poor. The use of PROMs in endometriosis clinical practice can facilitate patient-provider communication and the implementation of patient-centered care, improve patients’ quality of life, as well as provide a tool for patients’ self-management of the disease. Today, PROMs are extensively used in research and clinical trials, however they are barely used in clinical practice. The development of digital tools facilitating capturing PROMs can contribute to their use by physicians in routine endometriosis care. However, all PROMs are not adapted to be used in routine care in the context of endometriosis. The objective of this study was to present a catalogue of available PROMs for routine endometriosis care and evaluate them according to selected criteria. To do so, we explored the different PROMs currently in the literature. Consequently, 48 PROM were identified as tools used to evaluate various dimensions of the impact of endometriosis on patients. The selected PROMs were evaluated for their potential to be used as a standard in clinical practice in endometriosis. The selected catalogue of PROMs is the starting point for the integration of digital tools to capture PROMs and the development of patient-centered dashboards to be used by patients and clinicians in endometriosis care and self-management to improve care processes, patient satisfaction, quality of life, and outcomes.

Evaluation of Bowel Function After Surgical Treatment for Intestinal Endometriosis: A Prospective Study

BACKGROUND

Defecation symptoms related to intestinal deep infiltrative endometriosis are caused by anatomical and functional disorders and are probably linked to the course of the disease and surgical treatment.

OBJECTIVE

The primary aim of this study was to assess bowel function before and after intestinal deep infiltrative endometriosis surgery. Secondarily, we sought to correlate defecatory symptoms with preoperative risk factors.

DESIGN/SETTINGS

This is a single-center prospective cohort study, using the low anterior resection syndrome score to evaluate bowel function 4 weeks before, as well as at 6 months and 1 year after surgery. The Wilcoxon signed-rank test and logistic multiple regression analyses were performed to compare preoperative and postoperative scores. The level of significance was set at <0.05 for all comparisons.

PATIENTS

Thirty-seven adult female patients who underwent intestinal resection for deep infiltrative endometriosis between 2015 and 2017 were included.

MAIN OUTCOME MEASURES

The primary outcome was bowel function appraisement in deep infiltrative endometriosis intestinal surgery.

RESULTS

During the preoperative evaluation, 48.6% of patients reported low anterior resection syndrome score ≥21. This group presented a mean score of 17.9 ± 13.7, with a median of 20 and a range of 5 to 30. After 1 year, the mean score was decreased to 9.6 ± 11.1, with a median of 4 and a range of 0 to 22. A significant difference was detected when comparing the post- and preoperative scores (p = 0.0006). Improvements in defecatory symptoms such as reduced fecal incontinence for flatus (p = 0.004) and liquid stools (p = 0.014) were also reported. The clustering of stools (p = 0.005) and fecal urgency (p = 0.001) also improved 1 year after surgery. The preoperative multiple logistic regression showed that dyschezia was the only independent variable associated with bowel symptoms.

LIMITATIONS

This is a well-documented prospective study, but the data presented have a relatively small population.

CONCLUSIONS

This study provides evidence that intestinal deep infiltrative endometriosis surgery improves bowel function and has a positive impact on evacuation symptoms. See Video Abstract at http://links.lww.com/DCR/B534.

EVALUACIN DE LA FUNCIN INTESTINAL DESPUS DEL TRATAMIENTO QUIRRGICO PARA LA ENDOMETRIOSIS INTESTINAL UN ESTUDIO PROSPECTIVO

ANTECEDENTES:Se considera que los síntomas defecatorios relacionados con la endometriosis intestinal infiltrativa profunda, son causados por trastornos anatómicos y funcionales, y probablemente estén relacionados con el curso de la enfermedad y tratamiento quirúrgico.OBJETIVO:El objetivo principal fue evaluar la función intestinal antes y después de la cirugía por endometriosis intestinal infiltrativa profunda. En segundo lugar, correlacionar los síntomas defecatorios con los factores de riesgo preoperatorios.DISEÑO / AJUSTES:Es un estudio de cohorte prospectivo de un solo centro, utilizando la puntuación del síndrome de resección anterior baja (LARS Score) para evaluar la función intestinal 4 semanas antes, 6 meses y un año después de la cirugía. Se realizaron pruebas de rango firmado de Wilcoxon y análisis de regresión logística múltiple para comparar puntuaciones preoperatorias y postoperatorias. Para todas las comparaciones, el nivel de significancia se estableció en <0.05.ENTORNO CLINICO:Se incluyeron 37 mujeres adultas sometidas a resección intestinal por endometriosis infiltrativa profunda entre 2015 y 2017.PRINCIPALES MEDIDAS DE VALORACION:El resultado principal, fue la evaluación de la función intestinal en cirugía de endometriosis infiltrativa profunda intestinal.RESULTADOS:Durante la evaluación preoperatoria, el 48,6% de los pacientes reportaron Síndrome de Resección Anterior Baja ≥ 21. Este grupo presentó una puntuación media de 17,9 ± 13,7, con una mediana de 20 y un rango de 5 a 30. Después de un año, la puntuación media se redujo a 9,6 ± 11,1, con una mediana de 4 y un rango de 0 a 22 Se detectó una diferencia significativa al comparar las puntuaciones postoperatorias y preoperatorias (p = 0,0006). Se informó de mejoras en los síntomas defecatorios como la reducción de la incontinencia fecal por flatos (p = 0,004) y heces líquidas (p = 0,014). La agrupación de heces (p = 0,005) y la urgencia fecal (p = 0,001) presentaron mejoría a un año después de la cirugía. La regresión logística múltiple preoperatoria mostró que la disquecia fue la única variable independiente asociada con los síntomas intestinales.LIMITACIONES:A pesar de que es un estudio prospectivo bien documentado, los datos presentados son de una población relativamente pequeña.CONCLUSIONES:El estudio proporciona evidencia de que la cirugía intestinal por endometriosis infiltrativa profunda, mejora la función intestinal y tiene un impacto positivo en los síntomas de evacuación. Consulte Video Resumen en http://links.lww.com/DCR/B534.

Urinary Function after Surgery for Deep Endometriosis: A Prospective Study

STUDY OBJECTIVE

To compare urinary function before and after surgery in patients undergoing laparoscopy for deep endometriosis and to measure the rate of postoperative deterioration in urinary function after surgery.

DESIGN

Prospective questionnaire-based observational cohort study.

SETTING

Tertiary university-affiliated hospital.

PATIENTS

Included were 149 women who underwent surgery for deep endometriosis.

INTERVENTIONS

Participants completed the international consultation on incontinence female lower urinary tract symptoms long-form questionnaire before surgery and 6 weeks, 6 months, and 12 months after surgery.

MEASUREMENTS AND MAIN RESULTS

Bladder filling, voiding, and urinary incontinence summary scores were compared before and after surgery with mixed-effects linear regression analysis (correlated observations). Individual domains comprising the summary scores and their bother scores were also compared before and after surgery. Filling score at 6 weeks (3.7 ± 2.6), 6 months (3.2 ± 2.2), and 12 months (3.4 ± 2.2) improved from presurgery scores (4.2 ± 2.6) (p-value for the difference between before and after surgery: p <.001, p = .009, and p = .02 for 6 weeks, 6 months, and 12 months, respectively). No change was observed after surgery in bladder voiding score. Incontinence score improved at 6 weeks after surgery (presurgery and 6-week scores: 2.5 ± 3.3 and 1.6 ± 2.2, respectively, p <.001) but not thereafter. Patients with low preoperative summary scores had higher summary scores (worse function) after surgery, and patients with high preoperative scores had lower summary scores (improved function) after surgery.

CONCLUSION

Urinary function improved after laparoscopy for deep endometriosis. Greatest improvement was found in patients with worse preoperative function, whereas postoperative deterioration in urinary function was found for patients with initially normal function. More research is needed to better identify the subpopulations in whom surgical intervention provides symptomatic benefit or deterioration.

Robotic-assisted laparoscopy is a feasible method for resection of deep infiltrating endometriosis, especially in the rectosigmoid area

OBJECTIVE

This study aimed to compare outcomes of mini-invasive surgical treatment of endometriosis, especially conventional laparoscopy with robotic-assisted laparoscopy, and to evaluate the quality of life.

METHODS

One hundred three consecutive patients with endometriosis who had surgery from 2014 to 2017 owing to an indication of pain were enrolled in this retrospective study. The majority (n = 77, 75%) of patients underwent conventional laparoscopy and 18 (17%) had robotic-assisted laparoscopy. The quality of life was postoperatively assessed with a questionnaire.

RESULTS

The rates of parametrectomy (76% vs. 45%,) and rectovaginal resection (28% vs. 4%) were significantly higher in robotic-assisted laparoscopy than in laparoscopy. Additionally, the rate of bowel operations (50% vs. 17%), especially the shaving technique, was higher in robotic-assisted laparoscopy surgery than in laparoscopy (39% vs. 8%). There was no difference in the rate of postoperative complications between laparoscopy and robotic-assisted laparoscopy. Most (91%) of the patients who answered the questionnaire felt that surgical treatment had relieved their pain. In the laparoscopic and robotic-assisted groups, 88% of respondents felt that their quality of life had improved after surgery.

CONCLUSIONS

This study suggests that robotic-assisted laparoscopy is a feasible method to resect deep infiltrating endometriosis, especially in the rectosigmoid area.

"The Sword in the Stone": radical excision of deep infiltrating endometriosis with bowel shaving-a single-centre experience on 703 consecutive patients

BACKGROUND

Laparoscopic segmental bowel resection, disc excision and rectal shaving are described as surgical options for the treatment of bowel endometriosis, but the gold standard has not yet established. The aim of the study is to investigate the efficacy of the laparoscopic bowel shaving technique in terms of pain symptomatology and to analyse early and late postoperative complications.

METHODS

Retrospective cohort study of a series of 703 consecutive patients treated between January 2014 and December 2019 in a tertiary care referral centre. All patients underwent laparoscopic bowel shaving with concomitant radical excision of DIE.

RESULTS

Bilateral posterolateral parametrectomy and ureterolysis were performed, respectively, in 314 (44.7%) and 318 cases (45.2%). A radical hysterectomy was performed in 107 cases (82.9%). Postoperative complications were infrequent: 17 patients required a reoperation (2.4%) and in this subgroup we registered 2 rectovaginal fistulas (0.3%), 4 patients received blood transfusion (0.6%), 12 patients (1.7%) experienced postoperative fever, 6 patients experienced impaired bladder voiding (0.9%) after 6 months. Median follow-up was 14 months. The study reported good clinical and surgical results, with a regression of symptoms (p < 0.0001) and an overall rate of recurrence of 6.5%. Clinical and instrumental criteria of bowel endometriosis relapse were exclusively detected in 5 patients (0.8%). Eleven patients (1.7%) with relapsed endometriosis were reoperated.

CONCLUSIONS

Bowel shaving is a feasible and valuable surgical procedure. It is only the last step of a complex surgery which is aimed to minimize the residual quote of infiltrating nodule and requires a multidisciplinary team to achieve optimal treatment preoperatively, intraoperatively and postoperatively.

Transvaginal Ultrasound Findings After Laparoscopic Rectosigmoid Segmental Resection for Deep Infiltrating Endometriosis

OBJECTIVES

To evaluate transvaginal ultrasound (TVUS) findings in patients who underwent segmental rectosigmoid resection for deep infiltrating endometriosis (DIE) and to correlate postsurgical ultrasound findings with symptoms.

METHODS

A retrospective study including 50 premenopausal women with bowel endometriosis who underwent segmental rectosigmoid resection was conducted. Within 12 months after surgery, a TVUS examination was conducted in all patients to evaluate the presence of postsurgical endometriosis locations and symptoms, including dysmenorrhea, dyspareunia, dysuria, dyschezia, and chronic pelvic pain. Pelvic pain was assessed in all women by a visual analog scale.

RESULTS

At the follow-up 32 of 50 patients were receiving medical treatment, whereas 18 women declined postsurgical medical therapy and tried to conceive. A high percentage of adhesions (90%) was found. A negative sliding sign (a simple diagnostic sign that can be performed during a TVUS examination, consisting of gentle pressure applied by both the vaginal transducer and the examiner's hand on the abdomen; if the uterus does not glide freely along with the rectum and posterior fornix, the sign is considered negative, and adhesions can be suspected) was found in 29 (58%) women and was associated with bowel symptoms. Recurrence of posterior DIE was found in 9 cases (18%) and endometriomas in 8 cases (16%). Adenomyosis was observed in 80% of women and was present in all symptomatic patients.

CONCLUSIONS

After rectosigmoid segmental resection patients with DIE may continue to be symptomatic, and postoperative TVUS may reveal foci of disease or pelvic adhesions. Moreover, adenomyosis could be linked to symptoms experienced during follow up. Women should be aware that painful symptoms and alterations of pelvic organs could still be present after surgery and be detectable by TVUS.

Role of surgical treatment in endometriosis

Endometriosis can take one of three forms depending on its clinical presentation and management: endometriotic ovarian cyst (ovarian endometrioma), superficial or peritoneal endometriosis and deep infiltrating endometriosis (DIE).¹Among them, DIE is considered the most aggressive, and the patient is often affected by more than one type together. The therapeutic methodology should not be influenced by a combination of different types of endometriotic lesion. According to the clinical context and the patient's needs, the treatment of this pathology can be medical or surgical. Although medical therapy could improve endometriosis-associated symptoms, it never offers a definite treatment for symptomatic patients, who often require surgical treatment. The rationale behind endometriosis surgical treatment is to achieve the complete removal of all lesions through a one-step surgical procedure; to obtain promising long-term results for pelvic pain, recurrence rate, and fertility; and to protect the functionality of the involved organs. Achieving these results depends on the total removal of the pathology from the pelvis, in an attempt to preserve, as much as possible, the healthy tissues surrounding the site of the disease. The choice of a surgical approach rather than medical therapy is subject to the patient's expectations, such as pregnancy desire, the effectiveness of treatment compared to possible complications, the type of pain and its intensity, and the location and severity of the disease. In this context, surgical management using a multidisciplinary endometriosis team is an important factor for achieving good outcomes.

Risk of bowel fistula following surgical management of deep endometriosis of the rectosigmoid: a series of 1102 cases

STUDY QUESTION

What are the risk factors and prevalence of bowel fistula following surgical management of deep endometriosis infiltrating the rectosigmoid and how can it be managed?

SUMMARY ANSWER

In patients managed for deep endometriosis of the rectosigmoid, risk of fistula is increased by bowel opening during both segmental colorectal resection and disc excision and rectovaginal fistula repair is more challenging than for bowel leakage.

WHAT IS KNOWN ALREADY

Bowel fistula is known to be a severe complication of colorectal endometriosis surgery; however, there is little available data on its prevalence in large series or on specific management.

STUDY DESIGN, SIZE, DURATION

A retrospective study employing data prospectively recorded in the North-West Inter Regional Female Cohort for Patients with Endometriosis (CIRENDO) from June 2009 to May 2019, in three tertiary referral centres.

PARTICIPANTS/MATERIALS, SETTING, METHODS

One thousand one hundred and two patients presenting with deep endometriosis infiltrating the rectosigmoid, who were managed by shaving, disc excision or colorectal resection. The prevalence of bowel fistula was assessed, and factors related to the complication and its surgical management.

MAIN RESULTS AND THE ROLE OF CHANCE

Of 1102 patients enrolled in the study, 52.5% had a past history of gynaecological surgery and 52.7% had unsuccessfully attempted to conceive for over 12 months. Digestive tract subocclusion/occlusion was recorded in 12.7%, hydronephrosis in 4.5% and baseline severe bladder dysfunction in 1.5%. An exclusive laparoscopic approach was carried out in 96.8% of patients. Rectal shaving was performed in 31.9%, disc excision in 23.1%, colorectal resection in 35.8% and combined disc excision and sigmoid colon resection in 2.9%. For various reasons, the nodule was not completely removed in 6.4%, while in 7.2% of cases complementary procedures on the ileum, caecum and right colon were required. Parametrium excision was performed in 7.8%, dissection and excision of sacral roots in 4%, and surgery for ureteral endometriosis in 11.9%. Diverting stoma was performed in 21.8%. Thirty-seven patients presented with bowel fistulae (3.4%) of whom 23 (62.2%) were found to have rectovaginal fistulae and 14 (37.8%) leakage. Logistic regression model showed rectal lumen opening to increase risk of fistula when compared with shaving, regardless of nodule size: adjusted odds ratio (95% CI) for disc excision, colorectal resection and association of disc excision + segmental resection was 6.8 (1.9–23.8), 4.8 (1.4–16.9) and 11 (2.1–58.6), respectively. Repair of 23 rectovaginal fistulae required 1, 2, 3 or 4 additional surgical procedures in 12 (52.2%), 8 (34.8%), 2 (8.7%) and 1 patient (4.3%), respectively. Repair of leakage in 14 patients required 1 procedure (stoma) in 12 cases (85.7%) and a second procedure (colorectal resection) in 2 cases (14.3%). All patients, excepted five women managed by delayed coloanal anastomosis, underwent a supplementary surgical procedure for stoma repair. The period of time required for diverting stoma following repair of rectovaginal fistulae was significantly longer than for repair of leakages (median values 10 and 5 months, respectively, P = 0.008)

LIMITATIONS, REASONS FOR CAUTION

The main limits relate to the heterogeneity of techniques used in removal of rectosigmoid nodules and repairing fistulae, the lack of accurate information about the level of nodules, the small number of centres and that a majority of patients were managed by one surgeon.

WIDER IMPLICATIONS OF THE FINDINGS

Deep endometriosis infiltrating the rectosigmoid can be managed laparoscopically with a relatively low risk of bowel fistula. When the type of bowel procedure can be chosen, performance of shaving instead of disc excision or colorectal resection is suggested considering the lower risk of bowel fistula. Rectovaginal fistula repair is more challenging than for bowel leakage and may require up to four additional surgical procedures.

STUDY FUNDING/COMPETING INTEREST(S)

CIRENDO is financed by the G4 Group (The University Hospitals of Rouen, Lille, Amiens and Caen) and the ROUENDOMETRIOSE Association. No financial support was received for this study. H.R. reports personal fees from ETHICON, Plasma Surgical, Olympus and Nordic Pharma outside the submitted work. The other authors declare no conflict of interests related to this topic.

Management Challenges of Deep Infiltrating Endometriosis

Deep infiltrating endometriosis (DIE) is the most aggressive of the three phenotypes that constitute endometriosis. It can affect the whole pelvis, subverting the anatomy and functionality of vital organs, with an important negative impact on the patient's quality of life. The diagnosis of DIE is based on clinical and physical examination, instrumental examination, and, if surgery is needed, the identification and biopsy of lesions. The choice of the best therapeutic approach for women with DIE is often challenging. Therapeutic options include medical and surgical treatment, and the decision should be dictated by the patient's medical history, disease stage, symptom severity, and personal choice. Medical therapy can control the symptoms and stop the development of pathology, keeping in mind the side effects derived from a long-term treatment and the risk of recurrence once suspended. Surgical treatment should be proposed only when it is strictly necessary (failed hormone therapy, contraindications to hormone treatment, severity of symptoms, infertility), preferring, whenever possible, a conservative approach performed by a multidisciplinary team. All therapeutic possibilities have to be explained by the physicians in order to help the patients to make the right choice and minimize the impact of the disease on their lives.

Conservative vs radical bowel surgery for endometriosis: A systematic analysis of complications

BACKGROUND

Endometriosis of the bowel can be associated with significant morbidity. Surgery to remove it carries risks. Options include conservative shaving or discoid resection and more radical segmental bowel resection.

AIMS

To determine if more conservative shaving or discoid bowel resection is associated with fewer risks than more radical segmental resection.

MATERIAL AND METHODS

This study is a systematic review. We considered eligible any cohort, observational or randomised controlled trial (RCT) study of at least ten women per arm comparing conservative vs radical bowel surgery for endometriosis. We divided complications into two groups, major and minor. One additional article was added due to its significance in answering our study question as well as the high quality of the study design as an RCT.

RESULTS

There were 3041 studies screened. Eleven studies were included (n = 1648). For major complications, the risk ratio for shaving and disc excision vs segmental resection is 0.31 (95% CI 0.21-0.46), while the risk difference is -0.25 (95% CI -0.41 to 0.10). For minor complications, the risk ratio is 0.63 (95% CI 0.36-1.09), while the risk difference is -0.03 (95% CI -0.12 to 0.05).

CONCLUSIONS

Conservative shaving or discoid excision surgery is associated with reduced complications. Previous studies demonstrated a trend toward this finding, but suffered from relatively low participant numbers, increasing the risk of type one statistical error. Our results allow surgeons to make informed choices about potential complications when deciding how to approach bowel endometriosis. The results also allow patients to have more information about the risks. However, outcomes in the studies analysed are heterogenous and are from low-quality evidence.

Infertility in women with bowel endometriosis: first-line assisted reproductive technology results in satisfactory cumulative live-birth rates

OBJECTIVE

To evaluate the assisted reproductive technology (ART) cumulative live-birth rate (LBR) in a cohort of bowel endometriosis patients with no prior history of surgery for endometriosis.

DESIGN

Prospective cohort study.

SETTING

University hospital.

PATIENT(S)

One hundred and one consecutive infertile bowel-endometriosis patients with no prior history of surgery for endometriosis in whom the diagnosis of endometriosis was based on published imaging criteria using transvaginal sonography and magnetic resonance imaging.

INTERVENTION(S)

First-line ART.

MAIN OUTCOME MEASURE(S)

Cumulative LBR, with statistical analysis via Kaplan Meier method with a "conservative" method, whereby it was assumed that no live births took place for patients who did not return.

RESULT(S)

Between January 2016 and December 2018, 101 bowel endometriosis patients underwent 176 ART cycles. The mean number of deep-infiltrating endometriosis lesions per patient was 3 ± 0.9, with a mean number of bowel lesions of 1.3 ± 0.6. Seventy-three percent of the patients had associated endometriomas, and 88.1% had associated adenomyosis. Overall, the cumulative LBR after four ART cycles was 64.4%, using the conservative Kaplan-Meier method.

CONCLUSION(S)

The ART cumulative LBR was very satisfactory (64.4%) in bowel endometriosis patients with no prior history of surgery for endometriosis. In light of these data, clinicians should carefully weigh the pros and cons before systematically referring infertile bowel endometriosis patients to fertility-preserving surgery because as first-line ART appears to offer satisfactory results.

Systematic Nerve Sparing during Surgery for Deep-infiltrating Posterior Endometriosis Improves Immediate Postoperative Urinary Outcomes

STUDY OBJECTIVE

Evaluate the feasibility and risk-benefit ratio of systematic nerve sparing by complete dissection of the inferior hypogastric nerves and afferent pelvic splanchnic nerves during surgery for deep-infiltrating endometriosis (DIE) on the basis of complication rates and postoperative bladder morbidity.

DESIGN

Observational before (2012-2014)-and-after (2015-2017) study based on a prospectively completed database of all patients treated medically or surgically for endometriosis.

SETTING

Unicentric study at the Centre Hospitalier Intercommunal de Poissy-St-Germain-en-Laye.

PATIENTS

This study included patients undergoing laparoscopic surgery for DIE (pouch of Douglas resection with or without colpectomy or bilateral uterosacral ligament resection), with complete excision of all identifiable endometriotic lesions, with or without an associated digestive procedure, between 2012 and 2017. The exclusion criteria included prior history of surgery for DIE or colorectal DIE excision, unilateral uterosacral ligament resection, and bladder endometriotic lesions.

INTERVENTIONS

For the patients in group 1 (2012-2014, n = 56), partial dissection of the pelvic nerves was carried out only if they were macroscopically caught in endometriotic lesions, without dissection of the pelvic splanchnic nerves. The patients in group 2 (2015-2017, n = 65) systematically underwent nerve sparing during DIE surgery, with dissection of the inferior hypogastric nerves and pelvic splanchnic nerves.

MEASUREMENTS AND MAIN RESULTS

Both groups were comparable in terms of patient age, parity, body mass index, and previous abdominal surgery. The operating times were similar in both groups (228 ± 105 minutes in group 2 vs 219 ± 71 minutes in group 1), as were intra- and postoperative complication rates. Time to voiding was significantly longer in the patients in group 1 (p <.01), with 7 (12.9%) patients requiring self-catheterization in this group compared with no patients (0%) in group 2. The duration of self-catheterization for the 7 patients in group 1 was 28, 21, 3, 60, 21, 1 (stopped by the patient), and 28 days, respectively. Uroflowmetry on postoperative day 10 was abnormal in 5/25 patients in group 1 compared with 1/33 in group 2 (p = .031).

CONCLUSION

Systematic and complete nerve sparing, including pelvic splanchnic nerve dissection, during surgery for posterior DIE improves immediate postoperative urinary outcomes, reducing the need for self-catheterization without increasing operating time or complication rates.

Successful detection of rectal injury during laparoscopic surgery using a rectal probe in a patient with deep endometriosis

Laparoscopic surgery has become the gold standard treatment for endometriosis. Surgical treatment of deep endometriosis with colorectal involvement is challenging. It requires complete surgical excision of lesions despite a high risk of complications that include rectal injury, rectovaginal fistula and pelvic abscess. An intraoperative air leak test allows detection of rectal injury and reduces postoperative complications. We report a case of successful management of rectal injury during laparoscopic surgery using a rectal probe even though air leak tests were negative. A 45-year-old woman with severe endometriosis and rectal involvement underwent total laparoscopic hysterectomy combined with rectal shaving. A pinhole injury that reached the rectal muscularis layer without breaching the mucosal layer was identified using a rectal probe after negative air leak tests. The injury was repaired uneventfully. Our experience suggests that using a rectal probe could be helpful for early detection and safe repair of rectal injury during surgery.

Tools for fecal incontinence assessment: lessons for inflammatory bowel disease trials based on a systematic review

BACKGROUND

Fecal incontinence is a disabling condition affecting up to 20% of women.

OBJECTIVE

We investigated fecal incontinence assessment in both inflammatory bowel disease and non-inflammatory bowel disease patients to propose a diagnostic approach for inflammatory bowel disease trials.

METHODS

We searched on Pubmed, Embase and Cochrane Library for all studies on adult inflammatory bowel disease and non-inflammatory bowel disease patients reporting data on fecal incontinence assessment from January 2009 to December 2019.

RESULTS

In total, 328 studies were included; 306 studies enrolled non-inflammatory bowel disease patients and 22 studies enrolled inflammatory bowel disease patients. In non-inflammatory bowel disease trials the most used tools were the Wexner score, fecal incontinence quality of life questionnaire, Vaizey score and fecal incontinence severity index (in 187, 91, 62 and 33 studies). Anal manometry was adopted in 41.2% and endoanal ultrasonography in 34.0% of the studies. In 142 studies (46.4%) fecal incontinence evaluation was performed with a single instrument, while in 64 (20.9%) and 100 (32.7%) studies two or more instruments were used. In inflammatory bowel disease studies the Wexner score, Vaizey score and inflammatory bowel disease quality of life questionnaire were the most commonly adopted tools (in five (22.7%), five (22.7%) and four (18.2%) studies). Anal manometry and endoanal ultrasonography were performed in 45.4% and 18.2% of the studies.

CONCLUSION

Based on prior validation and experience, we propose to use the Wexner score as the first step for fecal incontinence assessment in inflammatory bowel disease trials. Anal manometry and/or endoanal ultrasonography should be taken into account in the case of positive questionnaires.

Endometriosis within the sigmoid colon: A rare cause of bowel obstruction

Endometriosis is a common gynecological disease, ectopic endometrium can invade any part of the body, usually in the ovary and uterine sacral ligament, while endometriosis invades the intestinal wall to cause intestinal obstruction is very rare, which easily leads to misdiagnosis. In this case report, we present a case of sigmoid endometriosis with bowel obstruction. Pathological examination is the main basis for the diagnosis of intestinal endometriosis, and the comprehensive treatment of surgery and hormonal therapy is an effective method for the treatment of intestinal endometriosis.

Excision versus colorectal resection in deep endometriosis infiltrating the rectum: 5-year follow-up of patients enrolled in a randomized controlled trial

STUDY QUESTION

Is there a difference in functional outcomes and recurrence rate between conservative versus radical rectal surgery in patients with large deep endometriosis infiltrating the rectum 5 years postoperatively?

SUMMARY ANSWER

No evidence was found that long-term outcomes differed when nodule excision was compared to rectal resection for deeply invasive endometriosis involving the bowel.

WHAT IS KNOWN ALREADY

Functional outcomes of nodule excision and rectal resection for deeply invasive endometriosis involving the bowel are comparable 2 years after surgery. Despite numerous previously reported case series enrolling patients managed for colorectal endometriosis, long-term data remain scarce in the literature.

STUDY DESIGN, SIZE, DURATION

From March 2011 to August 2013, we performed a two-arm randomized trial, enrolling 60 patients with deep endometriosis infiltrating the rectum up to 15 cm from the anus, measuring >20 mm in length, involving at least the muscular layer in depth, and up to 50% of rectal circumference. Among them, 55 women were enrolled at one tertial referral centre in endometriosis, using a randomization list drawn up separately for this centre. Institute review board approval was obtained to continue follow-up to 10 years postoperatively. One patient requested to stop the follow-up 2 years after surgery.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Patients underwent either nodule excision by shaving or disc excision, or segmental resection. Randomization was performed preoperatively using sequentially numbered, opaque, sealed envelopes, and patients were informed of randomization results. The primary endpoint was the proportion of patients experiencing one of the following symptoms: constipation (1 stool/>5 consecutive days), frequent bowel movements (≥3 stools/day), anal incontinence, dysuria or bladder atony requiring self-catheterization 24 months postoperatively. Secondary endpoints were values taken from the Knowles–Eccersley–Scott-symptom questionnaire (KESS), the gastrointestinal quality of life index (GIQLI), the Wexner scale, the urinary symptom profile (USP) and the Short Form 36 Health Survey (SF36).

MAIN RESULTS AND THE ROLE OF CHANCE

Fifty-five patients were enrolled. Among the 27 patients in the excision arm, two were converted to segmental resection (7.4%). One patient managed by segmental resection withdrew from the study 2 years postoperatively, presuming that associated pain of other aetiologies may have jeopardized the outcomes. The 5 year-recurrence rate for excision and resection was 3.7% versus 0% (P = 1), respectively. For excision and resection, the primary endpoint was present in 44.4% versus 60.7% of patients (P = 0.29), respectively, while 55.6% versus 53.6% of patients subjectively reported normal bowel movements (P = 1). An intention-to-treat comparison of overall KESS, GIQLI, Wexner, USP and SF36 scores did not reveal significant differences between the two arms 5 years postoperatively. Statistically significant improvement was observed shortly after surgery with no further improvement or impairment recorded 1–5 years postoperatively. During the 5-year follow-up, additional surgical procedures were performed in 25.9% versus 28.6% of patients who had undergone excision or resection (P = 0.80), respectively.

LIMITATIONS, REASONS FOR CAUTION

The presumption of a 40% difference concerning postoperative functional outcomes in favour of nodule excision resulted in a lack of power for demonstration of the primary endpoint difference.

WIDER IMPLICATIONS OF THE FINDINGS

Five-year follow-up data do not show statistically significant differences between conservative and radical rectal surgery for long-term functional digestive and urinary outcomes in this specific population of women with large involvement of the rectum.

STUDY FUNDING/COMPETING INTEREST(S)

No specific funding was received. Patient enrolment and follow-up until 2 years postoperatively was supported by a grant from the clinical research programme for hospitals in France. The authors declare no competing interests related to this study.

TRIAL REGISTRATION NUMBER

This randomized study is registered with ClinicalTrials.gov, number NCT 01291576.

TRIAL REGISTRATION DATE

31 January 2011.

DATE OF FIRST PATIENT’S ENROLMENT

7 March 2011.

Surgical Outcomes after Colorectal Surgery for Endometriosis: A Systematic Review and Meta-analysis

OBJECTIVE

To assess the impact of type of surgery for colorectal endometriosis-rectal shaving or discoid resection or segmental colorectal resection-on complications and surgical outcomes.

DATA SOURCES

We performed a systematic review of all English- and French-language full-text articles addressing the surgical management of colorectal endometriosis, and compared the postoperative complications according to surgical technique by meta-analysis. The PubMed, Clinical Trials.gov, Cochrane Library, and Web of Science databases were searched for relevant studies published before March 27, 2020. The search strategy used the following Medical Subject Headings terms: ("bowel endometriosis" or "colorectal endometriosis") AND ("surgery for endometriosis" or "conservative management" or "radical management" or "colorectal resection" or "shaving" or "full thickness resection" or "disc excision") AND ("treatment", "outcomes", "long term results" and "complications").

METHODS OF STUDY SELECTION

Two authors conducted the literature search and independently screened abstracts for inclusion, with resolution of any difference by 3 other authors. Studies were included if data on surgical management (shaving, disc excision, and/or segmental resection) were provided and if postoperative outcomes were detailed with at least the number of complications. The risk of bias was assessed according to the Cochrane recommendations.

TABULATION, INTEGRATION, AND RESULTS

Of the 168 full-text articles assessed for eligibility, 60 were included in the qualitative synthesis. Seventeen of these were included in the meta-analysis on rectovaginal fistula, 10 on anastomotic leakage, 5 on anastomotic stenosis, and 9 on voiding dysfunction <30 days. The mean complication rate according to shaving, disc excision, and segmental resection were 2.2%, 9.7%, and 9.9%, respectively. Rectal shaving was less associated with rectovaginal fistula than disc excision (odds ratio [OR] = 0.19; 95% confidence interval [CI], 0.10-0.36; p <.001; I² = 33%) and segmental colorectal resection (OR = 0.26; 95% CI, 0.15-0.44; p <.001; I² = 0%). No difference was found in the occurrence of rectovaginal fistula between disc excision and segmental colorectal resection (OR = 1.07; 95% CI, 0.70-1.63; p = .76; I² = 0%). Rectal shaving was less associated with leakage than disc excision (OR = 0.22; 95% CI, 0.06-0.73; p = .01; I² = 86%). No difference was found in the occurrence of leakage between rectal shaving and segmental colorectal resection (OR = 0.32; 95% CI, 0.10-1.01; p = .05; I² = 71%) or between disc excision and segmental colorectal resection (OR = 0.32; 95% CI, 0.30-1.58; p = .38; I² = 0%). Disc excision was less associated with anastomotic stenosis than segmental resection (OR = 0.15; 95% CI, 0.05-0.48; p = .001; I² = 59%). Disc excision was associated with more voiding dysfunction <30 days than rectal shaving (OR = 12.9; 95% CI, 1.40-119.34; p = .02; I² = 0%). No difference was found in the occurrence of voiding dysfunction <30 days between segmental resection and rectal shaving (OR = 3.05; 95% CI, 0.55-16.87; p = .20; I² = 0%) or between segmental colorectal and discoid resections (OR = 0.99; 95% CI, 0.54-1.85; p = .99; I² = 71%).

CONCLUSION

Colorectal surgery for endometriosis exposes patients to a risk of severe complications such as rectovaginal fistula, anastomotic leakage, anastomotic stenosis, and voiding dysfunction. Rectal shaving seems to be less associated with postoperative complications than disc excision and segmental colorectal resection. However, this technique is not suitable for all patients with large bowel infiltration. Compared with segmental colorectal resection, disc excision has several advantages, including shorter operating time, shorter hospital stay, and lower risk of postoperative bowel stenosis.

Voiding Dysfunction after Colorectal Surgery for Endometriosis: A Systematic Review and Meta-analysis

OBJECTIVE

Surgical management of deep endometriosis is associated with a high incidence of lower urinary tract dysfunction. The aim of the current systematic review and meta-analysis was to assess the rates of voiding dysfunction according to colorectal shaving, discoid excision, and segmental resection for deep endometriosis.

DATA SOURCES

We performed a systematic review using bibliographic citations from PubMed, Clinical Trials.gov, Embase, Cochrane Library, and Web of Science databases. Medical Subject Headings terms for colorectal endometriosis and voiding dysfunction were combined and restricted to the French and English languages. The final search was performed on August 28, 2019. The outcome measured was the occurrence of postoperative voiding dysfunction.

METHODS OF STUDY SELECTION

Study Quality Assessment Tools were used to assess the quality of included studies. Studies rated as good and fair were included. Two reviewers independently assessed the quality of each included study, discrepancies were discussed; if consensus was not reached, a third reviewer was consulted.

TABULATION, INTEGRATION AND RESULTS

Out of 201 relevant published reports, 51 studies were ultimately reviewed systematically and 13 were included in the meta-analysis. Rectal shaving was statistically less associated with postoperative voiding dysfunction than segmental colorectal resection (Odds ratio [OR] 0.34; 95% confidence intervals [CI], 0.18-0.63; I² = 0%; p <.001) or discoid excision (OR 0.22; 95% CI, 0.09-0.51; I² = 0%; p  <.001). No significant difference was noted when comparing discoid excision and segmental colorectal resection (OR 0.74; 95% CI, 0.32-1.69; I² = 29%; p = .47). Similarly, rectal shaving was associated with a lower risk of self-catheterization >1 month than segmental colorectal resection (OR 0.3; 95% CI, 0.14-0.66; I² = 0%; p = .003). This outcome was no longer significant when comparing discoid excision and segmental colorectal resection (OR 0.72; 95% CI, 0.4-1.31; I² = 63%; p = .28).

CONCLUSION

Colorectal surgery for endometriosis has a significant impact on urinary function regardless of the technique. However, rectal shaving causes less postoperative voiding dysfunction than discoid excision or segmental resection.

Predictive approach in managing voiding dysfunction after surgery for deep endometriosis: a personalized nomogram

INTRODUCTION AND HYPOTHESIS

The aim was to develop a nomogram based on clinical and surgical factors to predict the likelihood of voiding dysfunction after surgery for deep endometriosis.

METHODS

This was a retrospective study of 789 patients (training set) who underwent surgery for deep endometriosis with colorectal involvement from January 2005 through December 2017 at Tenon University Hospital. A multivariate logistic regression analysis of selected risk factors was performed to construct a nomogram to predict postoperative voiding dysfunction. The nomogram was externally validated in 333 patients (validation set) from Rouen University Hospital.

RESULTS

Postoperative voiding dysfunction occurred in 23% of the patients (180/789) in the training set. Age, colorectal involvement/management, colpectomy and parametrectomy were the main factors associated with an increased risk of voiding dysfunction and were included in the nomogram. The predictive model had an internal concordance index of 0.79 (95% CI: 0.77-0.81) after the 200 repetitions of bootstrap sample corrections and showed good calibration. The ROC area related to the nomogram for external validation was 0.74 (95% CI: 0.72-0.76).

CONCLUSIONS

The nomogram we present here, based on four clinical and imaging characteristics, could be useful in predicting postoperative voiding dysfunction for women undergoing surgery for deep endometriosis. Patients could thus be better informed about this postoperative risk and the surgical strategy adapted according to individual risk. The accuracy of the tool was validated externally but additional validation is required.

Colon resection for endometriosis

Endometriosis affects the women during reproductive period and can cause functional disorders. Sometimes general surgical intervention is necessary because of disease boundary. Especially the sigmoid colon and rectum are affected due to the close neighboring. In such a case, treatment must be individualized according to the patient and symptoms. If the lesion has penetrated the entire bowel wall, bowel resection may be inevitable. Laparoscopic resection of the sigmoid colon or rectum can be performed safely in this situation. When laparoscopic resection cannot be possible because of technical difficulties, open resection may be performed for treatment. Here we present two cases, one open and one laparoscopic colon resection performed due to endometriosis.

Bowel surgery for endometriosis: A practical look at short- and long-term complications

Endometriosis involving the bowel requires a thorough evaluation prior to deciding upon surgical treatment. Patient symptoms, treatment goals, extent and location of disease, surgeon experience, and anticipated risks all play a part in the preoperative decision-making process. Short- and long-term complications after bowel surgery for endometriosis are the focus of this article. Unfortunately, the literature to date has inherent limitations that prevent generalizability. Most studies are retrospective or prospective single-center case series. Publication bias is unavoidable with mainly large volume experts sharing their experience. As a result, there is a need for high-quality prospective studies that standardize inclusion criteria and outcome measures among various centers with an aim to present long-term outcomes. In the meantime, care for those with endometriosis involving the bowel requires a thorough preoperative plan to minimize risks and a need for early diagnosis and management of complications unique to bowel surgery.

Deep endometriosis: The place of laparoscopic shaving

Deep endometriosis (DE) is considered to be one of the most challenging conditions to manage, especially when it invades surrounding organs like the rectum. Surgical excision of deep rectovaginal endometriosis is required when lesions are symptomatic, impairing bowel, urinary, sexual, and reproductive functions, or if they evolve. Preoperative radiological examination should be extensive to determine the appropriate surgery: laparoscopic shaving, disc excision, or rectal resection. We demonstrated that in the hands of experienced surgeons, rectal shaving is possible for DE in more than 95% of cases, with low complication rates compared to rectal resection. Shaving and bowel resection are associated with comparable recurrence rates. As shaving is indicated whatever the size of deep lesions, surgeons should first consider rectal shaving to remove DE. Bowel resection should only be performed in case of major rectal stenosis (>80%), multiple and/or posterior rectal lesions and stenotic sigmoid colon lesions.

Outcome after surgery for deep endometriosis infiltrating the rectum

OBJECTIVE

To evaluate the rate of postoperative complications between conservative surgery and segmental resection in patients with rectal endometriosis.

DESIGN

Single-center retrospective study.

SETTING

University hospital.

PATIENT(S)

A total of 232 women undergoing surgery for deep endometriosis infiltrating the rectum up to 15 cm from the anus with at least involvement of the muscularis layer, stratified into two arms according to surgical technique. Subgroup analysis was performed in patients without previous therapeutic laparoscopy for endometriosis (n = 108). A propensity-score approach was used to correct for group differences.

INTERVENTION(S)

All patients underwent CO₂-laser laparoscopic surgery: 61 underwent conservative surgery, and 171 had a segmental resection.

MAIN OUTCOME MEASURE(S)

Postoperative complication rate (Clavien-Dindo classification).

RESULT(S)

Clavien-Dindo type 1 and 2 complications did not differ between both groups. Clavien-Dindo type 3 complications were more frequent in the segmental resection group (1/61 [1.6%] conservative vs. 18/171 [10.5%] segmental), after propensity analysis only a trend was retained. In the subgroup analysis, no difference or trend was found (1/27 [3.7%] conservative vs. 5/81 [6.2%] segmental). A low rate of temporary diverting stoma was recorded: 24/232 (10.3%).

CONCLUSION(S)

A higher major complication (Clavien-Dindo ≥3) rate for segmental resections compared with conservative surgical treatment was shown in the overall population, although after correction for group differences this was attenuated to a trend only. However, in patients without previous therapeutic laparoscopy no significant difference or trend was found regardless of the surgical technique used. This not only suggests that redo/repeated surgery has a potentially increased morbidity, but also emphasizes the importance of a well executed primary surgery.

Levator ani evaluation at transperineal elastography in women with deep infiltrating endometriosis postoperatively

OBJECTIVE

To explore whether operation can change the elasticity of levator ani in deep infiltrating endometriosis (DIE) with operation and pharmacotherapy using transperineal elastography.

METHODS

Total thirty-four patients who were diagnosed as DIE were included in the study. Transperineal elastography were performed in all cases preoperatively and postoperatively. The levator ani was evaluated by means of the scoring system and strain ratio (SR) values on maximal Valsalva and quiescent condition, respectively.

RESULTS

On quiescent condition, the preoperative mean elastography scores and SR of the levator ani were statistically significantly higher than the postoperative ones in both shaving technique group and segmental colorectal resection group. And on maximal Valsalva, the preoperative mean elastography scores and SR of the levator ani were statistically significantly lower than the postoperative ones in both groups. After surgery and 6 cycles of GnRHa therapy, the mean elastography score and SR of the levator ani were statistically significantly lower than before GnRHa therapy in shaving technique group on quiescent condition. And on maximal Valsalva, the mean elastography score and SR were statistically higher than before GnRHa therapy. However, in segmental colorectal resection group, the differences were not observed before and following 6 cycles of GnRHa therapy.

CONCLUSION

The elasticity of levator ani of DIE was changed by both shaving technique and segmental colorectal resection. And transperineal elastography could access the alterations.

Bowel surgery as a fertility-enhancing procedure in patients with colorectal endometriosis: methodological, pathogenic and ethical issues

Bowel surgery for colorectal endometriosis is being promoted to infertile women without severe sub-occlusive symptoms, with the objective of improving the likelihood of conception. Contrary to rectal shaving, bowel surgery involving full-thickness disk excision and segmental resection entails opening of the intestinal lumen thus increasing the risk of postoperative infectious complications. About 1 in 10 patients undergoing colorectal resection for intestinal endometriosis will experience severe sequelae, including anastomotic dehiscence, rectovaginal fistula formation, and bladder and bowel denervation. Similar to other surgical procedures aiming at enhancing fertility in women with endometriosis, bowel surgery has been introduced into clinical practice without adequate evaluation through randomized controlled trials. According to systematic literature reviews based mainly on case series, the incremental gain of adding bowel procedures to standard surgery appears uncertain in terms of pregnancy rate after both natural attempts and IVF. Considering the methodological drawbacks and the high risk of bias in the available observational studies, it is not possible to exclude the suggestion that the benefit of colorectal surgery has been overestimated. Given the risk of harms to women's health and the important ethical implications, less emphasis should be put on strict statistical significance and more emphasis should be placed on the magnitude of the effect size. In this regard, the published data may not be generalizable, as the surgeons publishing their results may not be representative of all surgeons. Until the results of adequately designed and conducted RCTs are available, colorectal surgery with the sole intent of improving the reproductive performance of infertile patients with intestinal endometriosis should be performed exclusively within research settings and by highly experienced surgeons. Women should be informed about the uncertainties regarding the harms and benefits of bowel surgery in different clinical conditions, and preoperative counselling must be conducted impartially with the objective of achieving a truly shared medical decision.