Functional Outcomes After Rectal Resection for Deep Infiltrating Pelvic Endometriosis: Long-term Results

Bowel endometriosis: Surgical customization is demanding

Bowel endometriosis is the most common form of severe deep endometriosis. Surgery is an option in case of infertility and/or chronic pain or in the presence of a stenotic lesion. Clinical examination and preoperative imaging must provide an identity card of the lesion so that customized surgery can be proposed. The primary objective of this tailor-made surgery will always be to preserve the organ. The surgeon then has three options: shaving, discoid resection and segmental resection. The more extensive the resection, the greater the risk of severe short- and long-term complications. Surgery must therefore be adapted to the patient's specific situation and needs. Moreover, personalized care must extend beyond surgery. It must begin before the operation, preparing the patient for the operation like an athlete before a race, and continue afterwards by adapting the follow-up to the surgery performed.

Vascular- and nerve-sparing bowel resection for deep endometriosis: A retrospective single-center study

OBJECTIVE

Surgical management of bowel endometriosis is still controversial. Recently, many authors have pointed out the potential benefits of preserving the superior rectal artery, thus ensuring better perfusion of the anastomosis. The aim of this study was to evaluate the complication rate and functional outcomes of a bowel resection technique for deep endometriosis (DE) involving a nerve- and vascular-sparing approach.

METHODS

A single-center retrospective study was conducted by enrolling patients who underwent segmental resection of the rectus sigmoid for DE in our department between September 2019 and April 2022. Intraoperative and postoperative complications were recorded for each woman, and functional outcomes relating to the pelvic organs were assessed using validated questionnaires (Knowles-Eccersley-Scott-Symptom [KESS] questionnaire and Gastro-Intestinal Quality of Life Index [GIQLI] for bowel function, Bristol Female Lower Urinary Tract Symptoms [BFLUTS] for urinary function, and Female Sexual Function Index [FSFI] for sexual function). These were evaluated preoperatively and postoperatively after 6 months from surgery.

RESULTS

Sixty-one patients were enrolled. No patients had Clavien-Dindo grade 3 or 4 complications, there were no rectovaginal fistulas or ureteral lesions, and in no cases was it necessary to reoperate. Temporary bladder voiding deficits were reported in 8.2% of patients, which were treated with self-catheterizations, always resolving within 45 days of surgery. Gastrointestinal function evaluated by KESS and GIQLI improved significantly after surgery, whereas sexual function appeared to worsen, although without reaching the level of statistically significant validity.

CONCLUSION

Our vascular- and nerve-sparing segmental bowel resection technique for DE had a low intraoperative and postoperative complication rate and produced an improvement in gastrointestinal function after surgery.

Postoperative Complications and Stoma Rates After Laparoscopic Resection of Deep Infiltrating Endometriosis with Bowel Involvement

OBJECTIVE

 The purpose was to assess the rates of postoperative complications and the need of temporary stoma of laparoscopic surgical treatment for bowel endometriosis in a referral center.

METHODS

 The surgical indication, type of operation, operative time, length of hospital stay, need for a temporary stoma, rate of conversion to open surgery, postoperative complications were evaluated.

RESULTS

 One-hundred and fifty patients were included. The average duration of surgery was significantly longer for segmental resection (151 minutes) than for disc excision (111.5 minutes, p < 0.001) and shaving (96.8 minutes, p < 0.001). Patients with segmental resection had longer postoperative lengths of hospital stay (1.87 days) compared with patients with disc excision (1.43 days, p < 0.001) and shaving (1.03 days, p < 0.001). A temporary stoma was performed in 2.7% of patients. Grade II and III postoperative complications occurred in 6.7% and 4.7% patients, respectively.

CONCLUSION

 Laparoscopic intestinal resection has an acceptable postoperative complication rate and a low need for a temporary stoma.

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

INTRODUCTION

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

MATERIAL AND METHODS

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

PROSPERO ID

CRD42021250974.

RESULTS

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

CONCLUSIONS

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

Effect of Surgical Treatment for Deep Infiltrating Endometriosis on Pelvic Floor Disorders: A Systematic Review with Meta-analysis

OBJECTIVES

 To evaluate the impact of surgical treatment of deep infiltrative endometriosis (DIE) on pelvic floor dysfunction (urinary incontinence [UI], pelvic organ prolapse [POP], fecal incontinence [FI)] or constipation, and sexual function [dyspareunia]).

DATA SOURCE

 The present systematic review was performed in the PubMed database. For the selection of studies, articles should be published by January 5, 2021, without language restriction.

STUDY SELECTION

 Six randomized controlled studies that evaluated surgical treatment for DIE and the comparison of different surgical techniques were included.

DATA COLLECTION

 The studies were selected independently by title and abstract by two authors. Disagreements were resolved by a third author. All included studies were also evaluated according to the Cochrane risk of bias tool and the quality of the evidence was analyzed using the GRADE criteria. Subgroup analysis by different treatments and follow-up periods was also performed.

RESULTS

 Six studies were included in the quantitative analysis. The risk of bias between studies showed an uncertain risk of bias for most studies, with concealment of allocation being the least reported category. The quality of the evidence was considered low. High heterogeneity was found between the studies. No study has evaluated UI or POP comparatively before and after surgery.

CONCLUSION

 Dyspareunia and FI have improved after the surgical procedure, but it was not possible to demonstrate which surgical technique was related to these outcomes as there was surgical heterogeneity. This diversity was found across data, with the recommendation of future prospective studies addressing pelvic floor disorders with DIE.

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.

Impact of Nerve-Sparing Postero-Lateral Parametrial Excision for Deep Infiltrating Endometriosis on Postoperative Bowel, Urinary and Sexual Function

OBJECTIVE

To evaluate the functional outcomes of nerve-sparing surgery for deep infiltrating endometriosis (DIE) with or without postero-lateral parametrectomy.

METHODS

A multicenter, observational, retrospective, cohort study was performed including all symptomatic women who underwent nerve-sparing laparoscopic excision of DIE and preoperative and postoperative assessment of functional outcomes through validated questionnaires between April 2019 and March 2020. Women with postero-lateral parametrial DIE (P-group) and women with no parametrial involvement (NP-group) were compared in term of preoperative and postoperative: functional outcomes related to pelvic organs assessed through validated questionnaires (KESS and GIQLI for bowel function, BFLUTS for urinary function, and FSFI for sexual function); pain symptoms at 3-month follow-up assessed through a 11-points Visual Analogue Scales (VAS) for dyschezia, dysmenorrhea, dyspareunia and chronic pelvic pain; surgical outcomes; rate of urinary voiding dysfunction at 3-month follow-up.

RESULTS

One-hundred patients were included: 69 in the P-group and 31 in the NP-group. Preoperative and postoperative values of questionnaires, pain symptoms and postoperative complications rates were comparable between the two groups, except for postoperative dyspareunia and sexual dysfunction, which were statistically higher in the P-group. Only patients in the P-group experienced urinary voiding dysfunction, but no statistical significance was reached (p=.173).

CONCLUSION

Postero-lateral parametrectomy for DIE appears associated to a higher risk of post-operative dyspareunia and sexual dysfunction.

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

STUDY OBJECTIVE

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

DESIGN

Retrospective study of a prospective database.

SETTING

University hospital.

PATIENTS

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

INTERVENTIONS

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

MEASUREMENTS AND MAIN RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Laparoscopic bowel resection of deep infiltrating endometriosis. Comparative outcomes of a public teaching hospital and a referral private hospital

PURPOSE

To compare the operative outcomes of laparoscopic surgical treatment for bowel endometriosis in a public teaching hospital versus in a private referral hospital.

METHODS

The indications for surgery, type and time of operation, length of hospital stay, need for a temporary stoma, rate of conversion to open surgery, and postoperative complications were evaluated.

RESULTS

One hundred eighty-one patients were included (150 patients, 82.9%, in a private hospital). In the private hospital, there were more patients with infertility [56% vs. 29%; P=0.01] as an indication for surgery) and segmental resection was more common in the private hospital (48% vs. 29%, p=0.05). The average operative time (211.9±83.4 minutes vs. 128 ± 55 minutes, p<0.001) as well as the length of hospital stay (3.97±1.7 days vs. 1.56±0.85 days, p<0.001) was higher in the public hospital; the rate of conversion to open surgery was significantly lower in the private hospital (2% vs. 32.3%, p<0.001). Operations performed at the public hospital were associated with higher rates of postoperative complications (Clavien-Dindo II and II) (38.7% x 11.3%, p=0.021; OR 3.2, CI 95% 1.2-8.0).

CONCLUSION

Laparoscopic surgery in private centers was associated with reductions in major complications, surgical times, lengths of stay and rates of conversion to open surgery compared to that in public teaching hospitals.

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.

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.

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.

Identification of a group with high risk of postoperative complications after deep bowel endometriosis surgery: a retrospective study on 164 patients

PURPOSE

Identify a group with a high risk of postoperative complications after deep bowel endometriosis surgery.

METHODS

We conducted a retrospective study on patients treated from 2012 to 2018 in two departments of gynecological surgery at the Toulouse University Hospital, France. The postoperative complications were evaluated in relation to the surgical management, associated with or without non-digestive surgical procedures, initial disease and patient's characteristics.

RESULTS

164 patients were included. A postoperative complication occurred in 37.8% (n = 62) of the cases and required a secondary surgery in 18.3% (n = 30) of the cases. In the univariate analysis, the risk of postoperative complications increased significantly in the presence of segmental resection, disease progression, and associated urinary tract procedure or vaginal incision. In the multivariate analysis, the risk of overall postoperative complications was associated with the surgical management (p = 0.013 and 0.017) and particularly in the presence of segmental resection [Odds Ratio (OR): 20.87; CI 95% (1.96-221.79)]. The risk of rectovaginal fistula increased in the presence of segmental resection [OR: 22.71; CI 95% (2.74-188.01)] as well as in vaginal incision [OR: 19.67; CI 95% (2.43-159.18); p = 0.005].

CONCLUSION

The risk of overall postoperative complications and rectovaginal fistula in particular increases significantly in the presence of vaginal incision, segmental resection and urinary tract procedures after deep bowel endometriosis surgery.

Post-operative complications and recurrence rate after treatment of bowel endometriosis: Comparison of three techniques

Objective

The aim of the present study was to compare post-operative complications and recurrence of three surgical techniques: segmental resection, discoid excision and nodule shaving.

Study design

From January 2014 to December 2017, 143 patients who underwent segmental bowel resections for endometriosis at “La Paz” University Hospital, were enrolled and grouped by different techniques. We compared post-operative complications and recurrence rate in three groups: 76 (53%) patients underwent segmental resection (group I), 20 (14%) patients underwent discoid resection (group II) and 47 (33%) patients underwent rectal shaving (group III).

Qualitative data was defined by absolute values and percentages, and quantitative data by mean and standard deviation. Qualitative variables between groups were compared using Chi- squared test. While quantitative data between groups was performed by means of t-test and ANOVA test. For all statistical tests a value of p < 0.05 will be considered statistically significant.

Result

Segmental resection was associated with higher rate of severe post-operative complications in comparison with discoid resection or shaving technique (23.5% versus 5% versus 0% respectively) (p = 0.005). We showed statistical differences among the three study groups for nodule size (p < 0.001) and localization (p = 0.02). Our analysis showed statistical differences among the three groups in term of additional procedures performed at the same time of bowel surgery, in particular in case of endometriosis of the ureter (p = 0.001) and the parametrium (p = 0.04).

After a long follow-up (46.4 ± 0.5 months for the group I, 42.2 ± 1.6 months for the group II, 39.7 ± 1.8 months for the group III), the shaving group was associated to higher recurrence rate (12.7%) in comparison with the discoid group (5%) and the segmental resection group (1.3%) (p = 0.01).

Conclusion

We showed that segmental resection is associated with high rate of postoperative complications. Conversely, this strategy should avoid the need of further interventions in young patients. Conservative surgery, such as discoid resection and shaving, revealed a higher recurrence rate and could be more appropriate in women approximating menopause because of the lower possibility of recurrence.