Colorectal endometriosis: benefits of long-term follow-up in patients who underwent laparoscopic surgery

Surgery vs. hormone-based treatment for pain control in deep infiltrating endometriosis: a retrospective cohort study

OBJECTIVE

To evaluate the outcome of surgical or hormone-based pharmacological treatment for deep infiltrating endometriosis (DIE) in patients with pain symptoms.

STUDY DESIGN

A retrospective cohort study of 122 women with DIE of the bowel was conducted: 61 women underwent surgical treatment due to poor pain control and 61 received hormone-based treatment alone for at least six months. Chronic pelvic pain, dysmenorrhea, deep dyspareunia, dyschezia and dysuria were evaluated by a visual analog scale (VAS) to measure pain on a scale from 0 to 10. Dyspareunia was further evaluated using the Deep Dyspareunia Scale (scores of 0-3).

RESULTS

Surgery (n = 61 women) was performed at a mean of 3.3 ± 1.6 years previously, while hormone-based treatment alone (n = 61 women) was used for a mean of 3.0 ± 1.41 years. After surgery, women without a desire to procreate received hormone-based treatment. Before treatment, the most intense endometriosis-related pain in the surgical treatment group and hormone-based treatment group alone were chronic pelvic pain (VAS = 9.48 ± 1.49; 8.57 ± 2.22), dysmenorrhea (VAS = 9.61 ± 1.45; 9.02 ± 1.35) and deep dyspareunia (VAS = 8.04 ± 2.82; 7.47 ± 3.21, respectively), all with mean pain scores of around 8 (0-10) in both groups. Both treatments were effective at reducing all symptoms (p < .001). The surgical treatment proved to be more effective and more enduring at improving chronic pelvic pain (p < .001), dyschezia (p = .003) and deep dyspareunia (p < .001). Regarding deep dyspareunia, using the deep dyspareunia scale, ∼70% of surgically treated women scored 0 or 1 (absent or mild deep dyspareunia) after treatment, compared to scores 2 or 3 (intense dyspareunia) in about 70% of the group using hormone-based treatment (p < .001).

CONCLUSION

Both types of treatment, surgical and pharmacological, effectively improved pain symptoms associated with DIE. However, improvement in chronic pelvic pain, dyschezia and deep dyspareunia was greater and longer-lasting after surgery.

ESHRE guideline: endometriosis

STUDY QUESTION

How should endometriosis be diagnosed and managed based on the best available evidence from published literature?

SUMMARY ANSWER

The current guideline provides 109 recommendations on diagnosis, treatments for pain and infertility, management of disease recurrence, asymptomatic or extrapelvic disease, endometriosis in adolescents and postmenopausal women, prevention and the association with cancer.

WHAT IS KNOWN ALREADY

Endometriosis is a chronic condition with a plethora of presentations in terms of not only the occurrence of lesions, but also the presence of signs and symptoms. The most important symptoms include pain and infertility.

STUDY DESIGN SIZE DURATION

The guideline was developed according to the structured methodology for development of ESHRE guidelines. After formulation of key questions by a group of experts, literature searches and assessments were performed. Papers published up to 1 December 2020 and written in English were included in the literature review.

PARTICIPANTS/MATERIALS SETTING METHODS

Based on the collected evidence, recommendations were formulated and discussed within specialist subgroups and then presented to the core guideline development group (GDG) until consensus was reached. A stakeholder review was organized after finalization of the draft. The final version was approved by the GDG and the ESHRE Executive Committee.

MAIN RESULTS AND THE ROLE OF CHANCE

This guideline aims to help clinicians to apply best care for women with endometriosis. Although studies mostly focus on women of reproductive age, the guideline also addresses endometriosis in adolescents and postmenopausal women. The guideline outlines the diagnostic process for endometriosis, which challenges laparoscopy and histology as gold standard diagnostic tests. The options for treatment of endometriosis-associated pain symptoms include analgesics, medical treatments and surgery. Non-pharmacological treatments are also discussed. For management of endometriosis-associated infertility, surgical treatment and/or medically assisted reproduction are feasible. While most of the more recent studies confirm previous ESHRE recommendations, there are five topics in which significant changes to recommendations were required and changes in clinical practice are to be expected.

LIMITATIONS REASONS FOR CAUTION

The guideline describes different management options but, based on existing evidence, no firm recommendations could be formulated on the most appropriate treatments. Also, for specific clinical issues, such as asymptomatic endometriosis or extrapelvic endometriosis, the evidence is too scarce to make evidence-based recommendations.

WIDER IMPLICATIONS OF THE FINDINGS

The guideline provides clinicians with clear advice on best practice in endometriosis care, based on the best evidence currently available. In addition, a list of research recommendations is provided to stimulate further studies in endometriosis.

STUDY FUNDING/COMPETING INTERESTS

The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, with the literature searches and with the dissemination of the guideline. The guideline group members did not receive payments. C.M.B. reports grants from Bayer Healthcare and the European Commission; Participation on a Data Safety Monitoring Board or Advisory Board with ObsEva (Data Safety Monitoring Group) and Myovant (Scientific Advisory Group). A.B. reports grants from FEMaLE executive board member and European Commission Horizon 2020 grant; consulting fees from Ethicon Endo Surgery, Medtronic; honoraria for lectures from Ethicon; and support for meeting attendance from Gedeon Richter; A.H. reports grants from MRC, NIHR, CSO, Roche Diagnostics, Astra Zeneca, Ferring; Consulting fees from Roche Diagnostics, Nordic Pharma, Chugai and Benevolent Al Bio Limited all paid to the institution; a pending patent on Serum endometriosis biomarker; he is also Chair of TSC for STOP-OHSS and CERM trials. O.H. reports consulting fees and speaker's fees from Gedeon Richter and Bayer AG; support for attending meetings from Gedeon-Richter, and leadership roles at the Finnish Society for Obstetrics and Gynecology and the Nordic federation of the societies of obstetrics and gynecology. L.K. reports consulting fees from Gedeon Richter, AstraZeneca, Novartis, Dr KADE/Besins, Palleos Healthcare, Roche, Mithra; honoraria for lectures from Gedeon Richter, AstraZeneca, Novartis, Dr KADE/Besins, Palleos Healthcare, Roche, Mithra; support for attending meetings from Gedeon Richter, AstraZeneca, Novartis, Dr KADE/Besins, Palleos Healthcare, Roche, Mithra; he also has a leadership role in the German Society of Gynecological Endocrinology (DGGEF). M.K. reports grants from French Foundation for Medical Research (FRM), Australian Ministry of Health, Medical Research Future Fund and French National Cancer Institute; support for meeting attendance from European Society for Gynaecological Endoscopy (ESGE), European Congress on Endometriosis (EEC) and ESHRE; She is an advisory Board Member, FEMaLe Project (Finding Endometriosis Using Machine Learning), Scientific Committee Chair for the French Foundation for Research on Endometriosis and Scientific Committee Chair for the ComPaRe-Endometriosis cohort. A.N. reports grants from Merck SA and Ferring; speaker fees from Merck SA and Ferring; support for meeting attendance from Merck SA; Participation on a Data Safety Monitoring Board or Advisory Board with Nordic Pharma and Merck SA; she also is a board member of medical advisory board, Endometriosis Society, the Netherlands (patients advocacy group) and an executive board member of the World Endometriosis Society. E.S. reports grants from National Institute for Health Research UK, Rosetrees Trust, Barts and the London Charity; Royalties from De Gruyter (book editor); consulting fees from Hologic; speakers fees from Hologic, Johnson & Johnson, Medtronic, Intuitive, Olympus and Karl Storz; Participation in the Medicines for Women's Health Expert Advisory Group with Medicines and Healthcare Products Regulatory Agency (MHRA); he is also Ambassador for the World Endometriosis Society. C.T. reports grants from Merck SA; Consulting fees from Gedeon Richter, Nordic Pharma and Merck SA; speaker fees from Merck SA, all paid to the institution; and support for meeting attendance from Ferring, Gedeon Richter and Merck SA. The other authors have no conflicts of interest to declare.

DISCLAIMER

This guideline represents the views of ESHRE, which were achieved after careful consideration of the scientific evidence available at the time of preparation. In the absence of scientific evidence on certain aspects, a consensus between the relevant ESHRE stakeholders has been obtained. Adherence to these clinical practice guidelines does not guarantee a successful or specific outcome, nor does it establish a standard of care. Clinical practice guidelines do not replace the need for application of clinical judgement to each individual presentation, nor variations based on locality and facility type. ESHRE makes no warranty, express or implied, regarding the clinical practice guidelines and specifically excludes any warranties of merchantability and fitness for a particular use or purpose (Full disclaimer available at www.eshre.eu/guidelines.).

Role of ultrasonographic parameters for predicting tubal involvement in infertile patients affected by endometriosis: A retrospective cohort study

INTRODUCTION

Transvaginal ultrasound is fundamental for the mapping of endometriosis, and the imaging criteria have been clearly described for different organs study. However, no specific ultrasonographic signs of tubal endometriosis have been reported, with the exception of hydrosalpinx, which is the expression of an extreme tubal damage and obstruction. The detection of tubal pathology in infertile patients is fundamental, therefore the aim of the study was to evaluate incidence of tubal endometriosis in infertile patients, and to analyze ultrasonographic signs useful for detection of this condition.

MATERIAL AND METHODS

It is a single-center, retrospective cohort study. All 500 consecutive infertile women who underwent laparoscopic surgery for endometriosis were included. The preoperative workup included transvaginal ultrasound and was compared to intraoperative findings and histologic study.

RESULTS

The incidence of tubal endometriosis in our study was 8%. Using hydrosalpinx as the ultrasonographic marker for tubal involvement the overall pooled, sensitivity and specificity of TVU were 12% (95%CI, 5-23%) and 99% (95%CI, 98-100%), respectively. If at least one ultrasonographic parameter like hydrosalpinx, periadnexal adhesions or ovarian cyst was considered as a sign of tubal endometriosis, a sensitivity, VPN and specificity were 94% (95% IC, 85-98%), 97% (95%IC, 93-99%) and 31% (95%CI, 27-36%), respectively.

DISCUSSION

Hydrosalpinx as ultrasonographic sign alone is characterized by a high specificity but low sensitivity for detection of tubal endometriosis; its sensitivity can be improved by the addition of other markers such as endometrioma and/or periadnexal adhesions.

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.

Rectovaginal fistula following surgery for deep infiltrating endometriosis: Does lesion size matter?

Objective This study was performed to identify risk factors for postoperative rectovaginal fistula (PRF) in patients with deep infiltrating endometriosis (DIE). Methods Data were retrospectively obtained from the medical records of 104 patients with DIE, and statistical analysis was used to detect risk factors for PRF. Results Five of 104 (4.8%) patients developed PRF from 5 to 16 days postoperatively. The operative procedures included 84 (80.8%) superficial excisions, 6 (5.8%) full-thickness disc excisions, and 14 (13.5%) bowel resections. Most lesions were located in the cul-de-sac, and the mean lesion size was 2.6 cm (range, 0.5-7.0 cm). The univariate analysis showed that lesion location, larger lesion size, and surgical technique were statistically significant risk factors for PRF. Conclusion Surgical procedures should be very carefully executed in patients with DIE lesions of ≥4 cm.

Management of deep infiltrating endometriosis of the rectum: Is a systematic temporary stoma relevant?

STUDY OBJECTIVE

To assess the value of performing a protective stoma in patients operated for rectal endometriosis.

MATERIAL AND METHODS

From June 2009 to December 2011, 47 patients were operated for rectal endometriosis by segmental or discoid resection in 4 different centers. Two groups were formed: one with protective stoma (group S), n=33 and one without protective stoma (group NS), n=14. Data were collected from the CIRENDO database.

MEASUREMENTS AND MAIN RESULTS

Postoperative complication rate of group NS was 57% against 48% in group S (P=0.75). There was an increasing trend of the rate of anastomotic leakage in group S as compared to group NS: 21% against 3% (P=0.073). All 3 patients of group NS with an anastomotic leakage were reoperated and the group S patient had medical treatment. In a center, digestive operative time was not necessarily performed in association with a gastrointestinal surgeon. All patients in group S had a restoration of continuity in about 3 months. Two of them had dilation of anastomotic stricture and 3 others showed a transient postoperative ileus during this recovery. Quality of life was assessed by the MOS SF-36 and significantly improved in both groups thanks to the intervention.

CONCLUSION

Temporary digestive stoma in patients operated for rectal endometriosis has to be considered because in our study, it seems reducing complications such as anastomotic leakage. This must be confirmed with studies with larger numbers.

Complications and long-term follow-up on colorectal resections in the treatment of deep infiltrating endometriosis extending to bowel wall

OBJECTIVE

To evaluate the rate of complications, factors associated with complications and long-term results in colorectal resections for the treatment of deep infiltrating endometriosis of the bowel wall.

DESIGN

Retrospective study.

SETTING

Tertiary center in Finland.

METHODS

Medical charts were reviewed for 164 women undergoing colorectal resections for deep infiltrating endometriosis between June 2004 and December 2012 at the Department of Obstetrics and Gynecology, Helsinki University Central Hospital; in 112 women (68%) bowel resection was performed laparoscopically and in 52 women (32%) laparotomy was needed.

MAIN OUTCOME MEASURES

Complications, re-operations, fertility.

RESULTS

The rate of major complications was 12% for both laparoscopies and laparotomies. However, the rate of complications during laparoscopies decreased from 27% in 2004-06 to 8% between 2010 and 2012. Similarly, the complication rate in laparoscopies fell with increased personal experience of the operating surgeon. A greater size (≥4 cm) of the nodules in the resected bowel was significantly associated with the development of a major complication. During the median follow up of 61 months (range 16-116 months) 7% needed a re-operation due to recurrence. Forty-seven percent of those women who preoperatively desired a pregnancy, subsequently had a child.

CONCLUSIONS

Laparoscopy has become a feasible alternative to laparotomy for performing colorectal resection in cases of deep infiltrating endometriosis of the bowel wall. Moreover, colorectal resections seem to result in good long-term pain relief and fertility. With increasing experience the number of complications was reduced and therefore, the practice of centralizing these operations seems to be well justified.

[Urinary functional disorders bound to deep endometriosis and to its treatment: review of the literature]

Lower urinary tract disorders in case of deep endometriosis are common (up to 50% of patients), although often masked by pelvic pain. They result from damage to the pelvic autonomic nervous system by direct infiltration of these structures by endometriotic lesions or surgical trauma (especially in resection of the uterosacral ligaments, rectum or vagina). These are mainly sensory disturbances and bladder voiding dysfunction. They impact quality of life and could be responsible for long-term complications (recurrent urinary tract infections on a persistent residual urine or pelvic floor disorders due to chronic thrusting). It is therefore important to diagnose and treat early these troubles by well-conducted interviews or standardized questionnaires. Different drug treatments have been proposed, such as cholinergics or prokinetics, but their effectiveness has not been demonstrated yet. Neuromodulation of the superior hypogastric plexus for treatment of refractory atonic bladder with persistent urinary retention after surgery seems promising but should be confirmed by further studies. To date, standard treatment of urinary retention after surgery remains self-catheterization. In terms of prevention, surgical nerve sparing techniques have been developed in order to minimize intraoperative injury of pelvic nerve plexus and reduce postoperative morbidity.

Rectosigmoid endometriosis: Practical approaches to improve the possibility of obtaining a definite preoperative biopsy diagnosis

AIM: To discuss the methods for improving the accuracy of preoperative diagnosis of rectosigmoid endometriosis.

METHODS: From December 2002 up to now, six patients with intestinal endometriosis were treated at our hospital. The clinical manifestations, enteroscopic findings, and histopathological manifestations of preoperative biopsy specimens and postoperative specimens removed by laparotomy or laparoscope resection were analyzed. A review of the literature was also performed.

RESULTS: Four (66.7%) cases of the rectosigmoid endometriosis were misdiagnosed clinically, including 1 case misdiagnosed as glandular dysplasia and 3 cases as chronic inflammation (including 1 case as ulcers). Immunohistochemical staining for ER, PR, CK7, K20 and CD10 were performed. Normal colorectal epithelia were negative for CK7, ER, and PR, whereas rectosigmoid endometriosis was positive for CK7, ER, and PR and showed endometrial stromal expression of CD10.

CONCLUSION: Combination of clinical manifestations, colonoscopic findings, and immunohistochemistry can improve the accuracy of preoperative diagnosis of endometriosis.

Laparoscopic management of bowel endometriosis: predictors of severe disease and recurrence

This study suggests that laparoscopic management of bowel endometriosis can be safe and effective. Two statistically significant predictors of higher stage disease were identified that showed the need for careful surgical planning.

Background and Objectives:

The identification of high-stage and recurrent cases of bowel endometriosis is critical, because these cases require careful surgical planning. We aim to describe the clinical characteristics of women with bowel endometriosis, our principles in laparoscopic management of this pathology, and to identify predictors of severe disease and recurrence.

Methods:

This was a retrospective study of 193 patients with pathologically confirmed bowel endometriosis.

Results:

Predictors of higher-stage endometriosis include a history of previous laparoscopic surgery (P=.04) and a presenting complaint of abnormal uterine bleeding (P=.01). The higher the stage of endometriosis, the more likely there would be coexistent urinary tract endometriosis (P=.02), a need for enterolysis (P=.002), ovarian cystectomy (P<.001), and bowel resection (P=.01) performed during laparoscopy. Patients with higher body mass index (BMI) had significantly higher recurrence rates of endometriosis compared to those with lower BMI (P=.002). Within our cohort, 87% of our patients achieved amelioration of symptoms by the end of the first postoperative month.

Conclusions:

Our study confirms that laparoscopic management of bowel endometriosis is safe and effective. We found 2 statistically significant predictors of higher-stage disease that should prompt careful surgical planning. Obesity is associated with a higher rate of recurrence of endometriosis.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

[Laparoscopic colorectal resection for deep pelvic endometriosis: Evaluation of post-operative outcome]

OBJECTIVES

Evaluation of mid-term functional results and the quality of life after laparoscopic colorectal resection.

PATIENTS AND METHODS

Twenty-three consecutive patients were included in a retrospective monocentric study. Postoperative functional outcomes and quality of life were analyzed.

RESULTS

The median follow-up after colorectal resection was of 24±15.7 months (6-72). Major complications occurred in three cases (12,9%) including one anastomotic stenosis, one digestive and one bladder fistula. A significant improvement in pelvic pain symptoms was observed. De novo constipation and pain on defecation occurred in respectively 23% and 42% of the cases. Transient de novo dysuria occurred in 18% of the cases. The quality of life has been significantly improved.

CONCLUSION

Laparoscopic colorectal resection is associated with unfavourable postoperative digestive and urological outcomes, such as bladder and rectal dysfunction. Radical treatment should be limited to selected patients.

Laparoscopic ileocecal resection for bowel endometriosis

BACKGROUND

Ileocecal endometriosis is a very rare entity, and its diagnosis is usually made during surgery for other endometriosis sites or, rarely, because of direct complications of ileal involvement. This study was designed to analyze perioperative and long-term outcomes after bowel resection for ileocecal endometriosis.

METHODS

All patients who underwent surgery for ileocecal endometriosis between October 2004 and January 2008 were prospectively collected and analyzed.

RESULTS

Thirty-one women (median age, 34 (range, 25-40) years) were identified. Ileocecal endometriosis was diagnosed during surgery in all patients, and it was associated with colorectal endometriosis in 29 patients (94%). All patients underwent laparoscopic ileocecal resection with no laparotomic conversion. Rectosigmoid or rectal resections was associated in 28 patients (90%) and nodulectomy for sigmoid endometriosis in 1 patient. Median duration of surgery was 301 (range, 90-480) min. Other associated surgical procedures included total hysterectomy (n = 3, 14%), ureterolysis (n = 7, 23%), excision of vesical (n = 4, 13%), vaginal (n = 8, 26%), and parametrial (n = 3, 14%) nodules. There was no mortality. Four patients (13%) required blood transfusions and one a reoperation for bleeding. In a patient who performed ureterolysis, a ureteral fistula occurred. The median hospital stay was 7 (range, 5-18) days. Long-term (>12 months) follow-up data were available for 18 patients. After a median follow-up of 27 months, in 12 of 18 patients (67%) defecation after surgery was normal. Only one patient developed recurrence, which is under medical treatment.

CONCLUSIONS

Laparoscopic ileocecal resection is safe and feasible and should be considered as part of surgery for endometriosis with radical intent.