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Crestani A, Merlot B, Goualard PH, Grigoriadis G, Chanavaz Lacheray I, Dennis T, Roman H. Bowel endometriosis: Surgical customization is demanding. Best Pract Res Clin Obstet Gynaecol 2024; 94:102495. [PMID: 38593673 DOI: 10.1016/j.bpobgyn.2024.102495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 02/20/2024] [Accepted: 03/20/2024] [Indexed: 04/11/2024]
Abstract
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.
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Affiliation(s)
- Adrien Crestani
- Institut Franco-Europeen Multidisciplinaire d'Endometriose (IFEMEndo), Endometriosis Centre, CliniqueTivoli-Ducos, 33000, Bordeaux, France.
| | - Benjamin Merlot
- Institut Franco-Europeen Multidisciplinaire d'Endometriose (IFEMEndo), Endometriosis Centre, CliniqueTivoli-Ducos, 33000, Bordeaux, France; Franco-European Multidisciplinary Endometriosis Institute (IFEMEndo), Middle East Clinic, Burjeel Medical City, Abu Dhabi, 7400, United Arab Emirates
| | - Paul-Henri Goualard
- Institut Franco-Europeen Multidisciplinaire d'Endometriose (IFEMEndo), Endometriosis Centre, CliniqueTivoli-Ducos, 33000, Bordeaux, France
| | | | - Isabelle Chanavaz Lacheray
- Institut Franco-Europeen Multidisciplinaire d'Endometriose (IFEMEndo), Endometriosis Centre, CliniqueTivoli-Ducos, 33000, Bordeaux, France
| | - Thomas Dennis
- Institut Franco-Europeen Multidisciplinaire d'Endometriose (IFEMEndo), Endometriosis Centre, CliniqueTivoli-Ducos, 33000, Bordeaux, France
| | - Horace Roman
- Institut Franco-Europeen Multidisciplinaire d'Endometriose (IFEMEndo), Endometriosis Centre, CliniqueTivoli-Ducos, 33000, Bordeaux, France; Franco-European Multidisciplinary Endometriosis Institute (IFEMEndo), Middle East Clinic, Burjeel Medical City, Abu Dhabi, 7400, United Arab Emirates; Department of Obstetrics and Gynecology, Aarhus University, 8000, Aarhus, Denmark
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Excision of Deep Rectovaginal Endometriosis Nodules with Large Infiltration of Both Rectum and Vagina: What Is a Reasonable Rate of Preventive Stoma? A Comparative Study. J Minim Invasive Gynecol 2023; 30:147-155. [PMID: 36402380 DOI: 10.1016/j.jmig.2022.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 11/04/2022] [Accepted: 11/09/2022] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVE To compare postoperative complications and rectovaginal fistula rate in women undergoing excision of large rectovaginal endometriosis requiring concomitant excision of rectum and vagina during 2 time periods with differing policies for preventive stoma confection. DESIGN Retrospective before-and-after comparative cohort study on data prospectively recorded in a database. Patients managed from September 2018 to March 2020 (first period) were compared with those managed from April 2020 to June 2022 (second period). SETTING Endometriosis Institute. PATIENTS One hundred sixty-eight patients presenting with deep endometriosis infiltrating the rectum and vagina, with lesions more than 3 cm in diameter during 2 consecutive time periods with differing policies regarding use of preventive stoma. INTERVENTIONS Rectal disc excision or colorectal resection, concomitantly with large vaginal excision. MEASUREMENTS AND MAIN RESULTS A total of 87 and 81 women received surgery during the first and the second period, respectively, during which the rate of preventive stoma was, respectively, 32.2% and 8.6%. Deep rectovaginal nodule characteristics were comparable. The mean height (SD) of rectal sutures after disc excision and colorectal resection were, respectively, 6.5 cm (2.3 cm) and 7.2 cm (3.8 cm). Rectovaginal fistula was recorded in 17 patients, corresponding to an overall rate of 10.1%. The rates of rectovaginal fistula in the group of patients with and without preventive stoma, regardless of the period in which surgery was performed, were 11.4% and 9.8%, respectively (p = .76). The rates of fistula recorded during the first and the second period were, respectively, 9.2% and 11.1% (p = .80), and that of overall early main complications were 31% and 29.6% (p = .84). Regression logistic model identified an independent relationship between smoking and rectovaginal fistula (adjusted odds ratio [OR] 3.9, 95% confidence interval [CI] 1.1-14) after adjustment for the period (adjusted OR 1.4, 95% CI 0.4-4.9 related to the second period), stoma confection (adjusted OR 1.8, 95% CI 0.5-7.1 related to stoma confection), robotic surgery (adjusted OR 1.7, 95% CI 0.3-10.1 related to robotic assistance), and type of rectal surgery (adjusted OR 0.4, 95% CI 0.1-1.4 related to disc excision when compared with colorectal resection). CONCLUSION No statistically significant differences were found concerning risk of rectovaginal fistula in women with rectovaginal endometriosis requiring large rectal and vaginal excision after a decision to no longer routinely perform preventive stoma.
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Grigoriadis G, Dennis T, Merlot B, Forestier D, Noailles M, François MO, Hajdinák A, Roman H. Natural Orifice Specimen Extraction (NOSE) colorectal resection for deep endometriosis: A 50 case series: NOSE resection for DIE: 50 cases. J Minim Invasive Gynecol 2022; 29:1054-1062. [PMID: 35595229 DOI: 10.1016/j.jmig.2022.05.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 05/07/2022] [Accepted: 05/11/2022] [Indexed: 11/27/2022]
Abstract
STUDY OBJECTIVE To describe our experience with the use of Natural Orifice Specimen Extraction (NOSE) technique for segmental bowel resection in patients with colorectal endometriosis. DESIGN Retrospective, observational study. SETTING Single tertiary referral centre PATIENTS: 50 consecutive patients undergoing NOSE colectomy for colorectal endometriosis in our centre, between March 2021 and November 2021. INTERVENTIONS NOSE colectomy for colorectal endometriosis with removal of the excised colorectal specimen through the vagina or the anus. MEASUREMENT AND MAIN RESULTS 45 procedures were performed laparoscopically and 5 procedures were carried out robotically. All interventions were carried out by 3 endometriosis surgeons in a multi-disciplinary fashion, with involvement of a colorectal surgeon. There were no cases of conversion to laparotomy. Concomitant surgical procedures were performed in all cases. 11 patients had concomitant interventions on the digestive tract. 5 patients had concomitant interventions on the sacral plexus or sciatic nerve. All anastomoses were latero-terminal. The mean height of colorectal anastomosis was 12 centimetres (SD= +/- 4), and the mean length of the excised colorectal specimen was 9 centimetres (SD= +/- 4). In 29 cases, the specimen was extracted through the vagina and in 21 cases through the anus. 5 patients required a re-operation in the early post-operative period: We identified 1 case of anastomotic leak, 1 case of post-operative bowel obstruction, 1 case of haemorrhage and 2 cases of pelvic collection (no macroscopic evidence of pus). No patient received blood transfusion. The mean operative time was 158 minutes (SD=+/- 70) and mean hospital stay was 4 days (SD=+/- 1). CONCLUSION NOSE colectomy is a reproducible surgical technique for the management of colorectal endometriosis. The complication rate appears comparable with the conventional (mini-laparotomy) surgical approach. In experienced hands, this technique has a short learning curve, both in laparoscopy as well as in robotic surgery.
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Affiliation(s)
| | - Thomas Dennis
- IFEMEndo Endometriosis Centre, Clinique Tivoli-Ducos, Bordeaux, 33000, France
| | - Benjamin Merlot
- IFEMEndo Endometriosis Centre, Clinique Tivoli-Ducos, Bordeaux, 33000, France
| | - Damien Forestier
- IFEMEndo Endometriosis Centre, Clinique Tivoli-Ducos, Bordeaux, 33000, France
| | - Myriam Noailles
- IFEMEndo Endometriosis Centre, Clinique Tivoli-Ducos, Bordeaux, 33000, France
| | | | - Adrienn Hajdinák
- IFEMEndo Endometriosis Centre, Clinique Tivoli-Ducos, Bordeaux, 33000, France
| | - Horace Roman
- IFEMEndo Endometriosis Centre, Clinique Tivoli-Ducos, Bordeaux, 33000, France.
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Roman H, Prosszer M, Marabha J, Merlot B, Forestier D, Noailles M, Marpeau L, Tuech JJ. Live surgery of colorectal endometriosis broadcasted from a surgeon's routine operating theater is not associated with higher complications rate. Acta Obstet Gynecol Scand 2021; 100:2176-2185. [PMID: 34546562 DOI: 10.1111/aogs.14264] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 08/02/2021] [Accepted: 08/30/2021] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Although live surgeries are routinely included in surgical congress programs, they are the subject of an ongoing debate in terms of patient safety and teaching value. The goal of our study was to assess the risk of postoperative complications related to live surgery broadcast from the surgeon's routine theater, in patients managed for deep endometriosis infiltrating the digestive tract. MATERIAL AND METHODS We report a retrospective comparative study, enrolling women managed for colorectal endometriosis by a gynecologic surgeon, from September 2013 to March 2020 in two referral centers. We compared the rate of postoperative bowel fistula in women managed during live surgery in the routine operating theater, with that observed in women for whom surgery was not broadcast. RESULTS Among 813 women, 33 (4.1% of cases) underwent surgical procedures transmitted live to various conference rooms located outside the hospital and were compared with 780 patients who underwent non-broadcast surgery. Women's age, body mass index, past surgical and obstetrical history, and major preoperative complaints were comparable. Cases presented with impaired constipation score, more frequent sciatic pain, and infiltration of the vagina, whereas overall revised American Fertility Society classification scores were more severe in controls. The rate of rectal nodules over 3 cm in size was comparable between the two groups (72.7% in cases vs. 72.1% in controls). Operative time was also comparable (153 ± 52 minutes vs. 148 ± 79 minutes). Cases were more frequently managed by disk excision of rectal nodules (63.7% vs. 30.3%), and more frequently involved the sacral plexus (18.2% vs. 7.3%). Postoperative complications were comparable between the two groups, in terms of bowel fistula (3% in the live surgery group vs. 4.1% in controls), pelvic abscess requiring secondary laparoscopy (3% vs. 4.9%), or bladder dysfunction requiring self-catheterization after discharge (6.1% vs. 5.3%). CONCLUSIONS Performing laparoscopic management of colorectal endometriosis with live transmission of surgery from a surgeon's routine operating theater, is not related to a higher risk of major postoperative complications.
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Affiliation(s)
- Horace Roman
- IFEMEndo, Endometriosis Center, Clinique Tivoli-Ducos, Bordeaux, France.,Department of Gynecology and Obstetrics, University Hospital Aarhus, Aarhus, Denmark
| | - Maria Prosszer
- IFEMEndo, Endometriosis Center, Clinique Tivoli-Ducos, Bordeaux, France
| | - Jamil Marabha
- IFEMEndo, Endometriosis Center, Clinique Tivoli-Ducos, Bordeaux, France
| | - Benjamin Merlot
- IFEMEndo, Endometriosis Center, Clinique Tivoli-Ducos, Bordeaux, France
| | - Damien Forestier
- IFEMEndo, Endometriosis Center, Clinique Tivoli-Ducos, Bordeaux, France
| | - Myriam Noailles
- IFEMEndo, Endometriosis Center, Clinique Tivoli-Ducos, Bordeaux, France
| | - Loïc Marpeau
- Expert Center in the Diagnosis and Multidisciplinary Management of Endometriosis, Rouen University Hospital, Rouen, France
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Serial assessment of inflammatory parameters for prediction of septic complications following surgery for colorectal endometriosis : A descriptive, retrospective study. Wien Klin Wochenschr 2021; 134:118-124. [PMID: 34338850 PMCID: PMC8857128 DOI: 10.1007/s00508-021-01916-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/30/2021] [Indexed: 12/03/2022]
Abstract
Purpose To assess whether C‑reactive protein (CRP), white blood cell count (WBC) and body temperature changes are suitable parameters for the early detection of septic complications following resection of colorectal deep endometriosis (DE). Methods Retrospective data analysis of CRP, WBC and body temperature courses following colorectal surgery for DE at a tertiary referral center for endometriosis. Results Out of 183 surgeries performed, 10 major surgical complications were observed, including 4 anastomotic leakages (AL 2%) and 2 rectovaginal fistulae (RVF 1%). In the presence of a lower gastrointestinal tract (GIT)-related septic complication or abdominal wall abscess, serum CRP levels were increased starting at postoperative day 2–3. A cut-off value of 10 mg/dl on day 4 for prediction of early septic complications could be verified (area under the curve 0.94, obtained by receiver operating characteristics analysis, sensitivity 88%, specificity 90%, positive predictive value 32%, negative predictive value 99%). Additionally, most patients with early septic complications exhibited increased WBC levels starting mainly from day 3–4; however, increased inflammatory parameters could not be observed in one patient with an RVF. Body temperature did not prove useful for early discrimination between uncomplicated cases and those with early septic complications. Conclusion Relevant elevations of serum CRP and WBC levels were demonstrated in patients with early septic complications following surgery for colorectal DE starting at postoperative day 2–4. The cut-off value of 10 mg/dl for CRP levels may serve as an early predictor for lower GIT-related septic complications but should be used with caution in women with suspected RVF development. Supplementary Information The online version of this article (10.1007/s00508-021-01916-w) contains supplementary material, which is available to authorized users.
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Raimondo D, Raffone A, Aru AC, Salucci P, Travaglino A, Maletta M, Ambrosio M, Borghese G, Iodice R, Casadio P, Seracchioli R. C-reactive Protein for Predicting Early Postoperative Complications in Patients Undergoing Laparoscopic Shaving for Deep Infiltrating Endometriosis. J Minim Invasive Gynecol 2021; 29:135-143. [PMID: 34280565 DOI: 10.1016/j.jmig.2021.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 07/02/2021] [Accepted: 07/11/2021] [Indexed: 10/20/2022]
Abstract
STUDY OBJECTIVE To assess the accuracy of C-reactive protein (CRP) in predicting early postoperative complications in patients undergoing elective laparoscopic shaving for rectosigmoid deep infiltrating endometriosis (DIE). DESIGN A single-center observational retrospective cohort study. SETTING Third-level referral center for endometriosis. PATIENTS A total of 294 patients were included in the study. All of them underwent elective laparoscopic shaving for rectosigmoid DIE. INTERVENTIONS Postoperative CRP levels (assessed from day 3 onward, every 48 hours, until hospital discharge) and early postoperative complications were reviewed to assess CRP as a predictive marker of postoperative complications. MEASUREMENTS AND MAIN RESULTS The study outcomes were the association between early postoperative complications and CRP levels, the optimal CRP cutoff, and its predictive accuracy. Twenty-five patients (8.5%) experienced early postoperative complications. Five patients with postoperative complications within 2 days of surgery were excluded from the analysis. On postoperative day 3 the difference in the means of CRP levels between patients with and without complications was 2.5 mg/dL (95% CI, 1.0-4.1), whereas on day 5 the difference was 5.3 mg/dL (95% CI, 3.3-7.5), with a significant increase of 2.8 mg/dL (95% CI, 0.2-5.5). On postoperative day 7 the difference was 11.4 mg/dL (95% CI, 8.2-14.6), with an increase of 6.1 mg/dL (95% CI, 2.2-9.9) from day 5. The mean CRP level in the group with complications showed an increase of 1.2 mg/dL (95% CI, -1.3 to 3.8) from day 3 to day 5 and of 6.2 mg/dL (95% CI, 2.6-9.8) from day 5 to day 7. The optimal cutoff for the CRP level in predicting early postoperative complications was 3.1 mg/dL on postoperative day 3 and 5.2 mg/dL on postoperative day 5, with a sensitivity of 87.5% (95% CI, 52.9-97.8) and 80% (95% CI, 37.6-96.4), a specificity of 62.5% (95% CI, 52.1-71.9) and 91.2% (95% CI, 81.1-96.2), a positive predictive value of 17.5% (95% CI, 8.7-31.9) and 44.4% (95% CI, 18.9-73.3), a negative predictive value of 98.2% (95% CI, 90.6-99.7) and 98.1% (95% CI, 90.1-99.7), and an area under the receiver operating characteristic curve of 75.0% (95% CI, 61.9-80.1) and 85.6% (95% CI, 74.1-96.5), respectively. CONCLUSION CRP on postoperative day 5 seemed to be a moderately accurate predictive marker of early postoperative complications in the patients who had undergone elective laparoscopic shaving for rectosigmoid DIE.
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Affiliation(s)
- Diego Raimondo
- Division of Gynaecology and Human Reproduction Physiopathology, Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, University of Bologna (Drs. Raimondo, Raffone, Aru, Salucci, Maletta, Ambrosio, Borghese, Iodice, Casadio, and Seracchioli), Bologna, Italy
| | - Antonio Raffone
- Division of Gynaecology and Human Reproduction Physiopathology, Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, University of Bologna (Drs. Raimondo, Raffone, Aru, Salucci, Maletta, Ambrosio, Borghese, Iodice, Casadio, and Seracchioli), Bologna, Italy; Gynaecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II (Dr. Raffone), Naples, Italy
| | - Anna Chiara Aru
- Division of Gynaecology and Human Reproduction Physiopathology, Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, University of Bologna (Drs. Raimondo, Raffone, Aru, Salucci, Maletta, Ambrosio, Borghese, Iodice, Casadio, and Seracchioli), Bologna, Italy.
| | - Paolo Salucci
- Division of Gynaecology and Human Reproduction Physiopathology, Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, University of Bologna (Drs. Raimondo, Raffone, Aru, Salucci, Maletta, Ambrosio, Borghese, Iodice, Casadio, and Seracchioli), Bologna, Italy.
| | - Antonio Travaglino
- Anatomic Pathology Unit, Department of Advanced Biomedical Sciences, School of Medicine, University of Naples Federico II (Dr. Travaglino), Naples, Italy
| | - Manuela Maletta
- Division of Gynaecology and Human Reproduction Physiopathology, Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, University of Bologna (Drs. Raimondo, Raffone, Aru, Salucci, Maletta, Ambrosio, Borghese, Iodice, Casadio, and Seracchioli), Bologna, Italy
| | - Marco Ambrosio
- Division of Gynaecology and Human Reproduction Physiopathology, Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, University of Bologna (Drs. Raimondo, Raffone, Aru, Salucci, Maletta, Ambrosio, Borghese, Iodice, Casadio, and Seracchioli), Bologna, Italy
| | - Giulia Borghese
- Division of Gynaecology and Human Reproduction Physiopathology, Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, University of Bologna (Drs. Raimondo, Raffone, Aru, Salucci, Maletta, Ambrosio, Borghese, Iodice, Casadio, and Seracchioli), Bologna, Italy
| | - Raffaella Iodice
- Division of Gynaecology and Human Reproduction Physiopathology, Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, University of Bologna (Drs. Raimondo, Raffone, Aru, Salucci, Maletta, Ambrosio, Borghese, Iodice, Casadio, and Seracchioli), Bologna, Italy
| | - Paolo Casadio
- Division of Gynaecology and Human Reproduction Physiopathology, Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, University of Bologna (Drs. Raimondo, Raffone, Aru, Salucci, Maletta, Ambrosio, Borghese, Iodice, Casadio, and Seracchioli), Bologna, Italy
| | - Renato Seracchioli
- Division of Gynaecology and Human Reproduction Physiopathology, Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, University of Bologna (Drs. Raimondo, Raffone, Aru, Salucci, Maletta, Ambrosio, Borghese, Iodice, Casadio, and Seracchioli), Bologna, Italy
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Roman H, Bridoux V, Merlot B, Noailles M, Magne E, Resch B, Forestier D, Tuech JJ. Risk of Rectovaginal Fistula in Women with Excision of Deep Endometriosis Requiring Concomitant Vaginal and Rectal Sutures, with or without Preventive Stoma: A Before-and-after Comparative Study. J Minim Invasive Gynecol 2021; 29:56-64.e1. [PMID: 34175463 DOI: 10.1016/j.jmig.2021.06.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 06/14/2021] [Accepted: 06/20/2021] [Indexed: 01/28/2023]
Abstract
STUDY OBJECTIVE To assess whether a liberal policy of preventive stoma (LPS) reduces the rate of rectovaginal fistulas in women with excision of deep endometriosis requiring concomitant vaginal and rectal sutures in comparison with a more restrictive policy of preventive stoma (RPS) and to assess the risk factors for rectovaginal fistula. DESIGN Retrospective before-and-after comparative study. SETTING Two referral centers, one with an LPS and the other with an RPS. PATIENTS A total of 363 patients with deep endometriosis infiltrating the rectum and the vagina. INTERVENTIONS Rectal disc excision or colorectal resection concomitantly with vaginal excision. MEASUREMENTS AND MAIN RESULTS Two hundred forty-one and 122 women received surgery at the LPS and RPS centers, respectively. The rate of preventive stomas was 71.4% at the LPS center (n = 172) and 30.3% at the RPS center (N = 37). Rectovaginal fistula was recorded in 31 cases (8.5%): nineteen women were managed at the LPS center, and 12 women underwent surgery at the RPS center. It occurred in, respectively, 9.4%, 10.8%, 10.1%, and 7% of the women managed without and with a stoma at the RPS center and of those managed without and with a stoma at the LPS center (p = .72). The height of the rectal stapled line was significantly lower in the women undergoing a stoma, particularly in those managed at the RPS center (5.4 ± 1.8 cm). Performing rectal sutures within 8 cm from the anal verge increased the risk of rectovaginal fistula more than 3-fold, independently of stoma creation, surgical procedure carried out on the rectum, size of vaginal infiltration, or associated excision of deep endometriosis involving the pelvic nerves (odds ratio 3.4; 95% confidence interval, 1.3-9.1). CONCLUSION No statistically significant differences were found in terms of the risk of rectovaginal fistula between women with rectovaginal endometriosis managed by either an LPS or an RPS; however, these findings need to be confirmed by a randomized trial.
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Affiliation(s)
- Horace Roman
- Endometriosis Center, Clinique Tivoli-Ducos (Drs. Roman, Merlot, Noailles, Magne, and Forestier), Bordeaux; Department of Gynecology and Obstetrics, Aarhus University Hospital, Aarhus, Denmark (Dr. Roman).
| | - Valérie Bridoux
- Department of Digestive Surgery, Rouen University Hospital (Drs. Bridoux and Tuech)
| | - Benjamin Merlot
- Endometriosis Center, Clinique Tivoli-Ducos (Drs. Roman, Merlot, Noailles, Magne, and Forestier), Bordeaux
| | - Myriam Noailles
- Endometriosis Center, Clinique Tivoli-Ducos (Drs. Roman, Merlot, Noailles, Magne, and Forestier), Bordeaux
| | - Eric Magne
- Endometriosis Center, Clinique Tivoli-Ducos (Drs. Roman, Merlot, Noailles, Magne, and Forestier), Bordeaux
| | - Benoit Resch
- Expert Center for the Diagnosis and Multidisciplinary Management of Endometriosis, Rouen University Hospital (Dr. Resch), Rouen, France
| | - Damien Forestier
- Endometriosis Center, Clinique Tivoli-Ducos (Drs. Roman, Merlot, Noailles, Magne, and Forestier), Bordeaux
| | - Jean-Jacques Tuech
- Department of Digestive Surgery, Rouen University Hospital (Drs. Bridoux and Tuech)
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Roman H, Bridoux V, Merlot B, Resch B, Chati R, Coget J, Forestier D, Tuech JJ. Risk of bowel fistula following surgical management of deep endometriosis of the rectosigmoid: a series of 1102 cases. Hum Reprod 2021; 35:1601-1611. [PMID: 32619233 PMCID: PMC7368398 DOI: 10.1093/humrep/deaa131] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 05/06/2020] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Horace Roman
- Endometriosis Center, Clinique Tivoli-Ducos, Bordeaux, France.,Department of Gynecology and Obstetrics, Aarhus University Hospital, Aarhus, Denmark
| | - Valérie Bridoux
- Department of Digestive Surgery, Rouen University Hospital, Rouen, France
| | - Benjamin Merlot
- Endometriosis Center, Clinique Tivoli-Ducos, Bordeaux, France
| | - Benoit Resch
- Department of Gynecology and Obstetrics, Rouen University Hospital, Rouen, France.,Clinique Mathilde, Rouen, France
| | - Rachid Chati
- Department of Digestive Surgery, Rouen University Hospital, Rouen, France
| | - Julien Coget
- Department of Digestive Surgery, Rouen University Hospital, Rouen, France
| | | | - Jean-Jacques Tuech
- Department of Digestive Surgery, Rouen University Hospital, Rouen, France
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Predictive value of 4th post-operative-day CRP in the early detection of complications after laparoscopic bowel resection for endometriosis. J Gynecol Obstet Hum Reprod 2021; 50:102148. [PMID: 33872816 DOI: 10.1016/j.jogoh.2021.102148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 03/23/2021] [Accepted: 04/15/2021] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Post-operative CRP on postoperative day 4 (POD) is used for the early detection of complications after colorectal surgery for cancer, but there is no evidence yet that justifies the use of this marker for bowel resection in case of endometriosis. STUDY DESIGN We retrospectively included 66 consecutive patients who underwent bowel resection for endometriosis (stage 4) in Lille university hospital, France, from August 1, 2015 until January 31, 2017. The composite endpoint of our study included anastomotic leakages, infectious or thrombo-embolic complications, hematomas, bowel stenosis, rectorrhagia, voiding dysfunction, and rehospitalization for related symptoms. RESULTS CRP on POD 4 presents a satisfying area under the curve of 0.85, for the composite endpoint. A CRP cut off value of 56 mg/L yielded a sensitivity of 0.61 (IC95%: 0.36 to 0.83) and a specificity of 0.98 (IC95%: 0.89 to 1). The negative and positive predictive values were 0.87 and 0.92. CONCLUSION The negative predictive value of the CRP on POD 4 after bowel resection for endometriosis is a useful early indicator for detecting a complication. Therefore, this biomarker might be safely used as an additional criterion for a safe discharge from hospital after colorectal resection in endometriosis.
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Bertocchi E, Barugola G, Ceccaroni M, Guerriero M, Rossini R, Gentile I, Ruffo G. Laparoscopic colorectal resection for deep infiltrating endometriosis: can we reliably predict anastomotic leakage and major postoperative complications in the early postoperative period? Surg Endosc 2021; 36:422-429. [PMID: 33523269 DOI: 10.1007/s00464-021-08301-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 01/09/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Anastomotic leakage (AL) and major complications after colorectal resection for deep infiltrating endometriosis (DIE) have a remarkable impact on patient outcomes. The aim of this study is to assess the predictive value of C-reactive protein (CRP), procalcitonin (PCT), white blood cell count (WBCs) and the Dutch Leakage Score (DLS) as reliable markers in the early diagnosis of AL and major complications after laparoscopic colorectal resection for DIE. METHODS 262 consecutive women undergoing laparoscopic colorectal resection for DIE between September 2017 and September 2018 were prospectively enrolled. WBCs, CRP, PCT and DLS were recorded at baseline and on postoperative day (POD) 2, 3 and 6 then statistically analyzed as predictors of AL and severe postoperative complications. RESULTS The AL rate was 3.2%. The major morbidity rate was 11.2%. No postoperative mortality was recorded. The postoperative trend of DLS and serum levels of CRP and PCT, but not WBCs, were significantly higher in women developing AL and severe complications. DLS had better sensitivity and specificity than biomarkers on all postoperative days as a predictor of AL and major complications. CRP and PCT have a low positive predictive value (PPV) and a high negative predictive value (NPV) for AL and major complications on POD3 and POD6. The risk of malnutrition was significantly related to AL. CONCLUSIONS The combination of DLS as a standardized postoperative clinical monitoring system and CRP and PCT as serum biomarkers, allows the exclusion of AL and major complications in the early postoperative period after laparoscopic colorectal resection for DIE, thus ensuring a safe patient discharge.
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Affiliation(s)
- Elisa Bertocchi
- General Surgery Unit, IRCCS Sacro Cuore Don Calabria Hospital, Via Don A. Sempreboni 5, 37024, Negrar di Valpolicella, Verona, Italy.
| | - Giuliano Barugola
- General Surgery Unit, IRCCS Sacro Cuore Don Calabria Hospital, Via Don A. Sempreboni 5, 37024, Negrar di Valpolicella, Verona, Italy
| | - Marcello Ceccaroni
- Department of Obstetrics and Gynecology, Gynecology Oncology and Minimally-Invasive Pelvic Surgery, International School of Surgical Anatomy (ISSA), IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, Italy
| | - Massimo Guerriero
- Clinical Research Unit, IRCCS Sacro Cuore Don Calabria Hospital and University of Verona, Verona, Italy
| | - Roberto Rossini
- General Surgery Unit, IRCCS Sacro Cuore Don Calabria Hospital, Via Don A. Sempreboni 5, 37024, Negrar di Valpolicella, Verona, Italy
| | - Irene Gentile
- General Surgery Unit, IRCCS Sacro Cuore Don Calabria Hospital, Via Don A. Sempreboni 5, 37024, Negrar di Valpolicella, Verona, Italy
| | - Giacomo Ruffo
- General Surgery Unit, IRCCS Sacro Cuore Don Calabria Hospital, Via Don A. Sempreboni 5, 37024, Negrar di Valpolicella, Verona, Italy
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Roman H, Marabha J, Polexa A, Prosszer M, Huet E, Hennetier C, Tuech JJ, Marpeau L. Crude complication rate is not an accurate marker of a surgeon's skill: A single surgeon retrospective series of 1060 procedures for colorectal endometriosis. J Visc Surg 2021; 158:289-298. [PMID: 33451966 DOI: 10.1016/j.jviscsurg.2020.08.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the relationship between the rate of postoperative bowel fistula and surgeon experience. DESIGN Retrospective study. SETTING Two referral centers. PATIENTS 1060 women managed for colorectal deep endometriosis by one gynecologist surgeon from January 2005 to March 2020. INTERVENTIONS Shaving, disc excision and segmental colorectal resection. MAIN OUTCOME MEASURES Rate of bowel fistula stratified according to 4 time periods: P1 from 2005 to 2009, P2 from 2010 to 2014, P3 from 2015 to June 2018 and P4 from September 2018 to March 2020. RESULTS 68 patients (6.4%) were managed during P1, 299 patients (28.2%) during P2, 422 patients (39.8%) during P3 and 271 patients (25.6%) during P4. Both diameter of rectal infiltration and rate of complex surgical procedures progressively increased from P1 to P4. Bowel fistula rate was comparable between all 4 time periods, respectively 2.9, 3.3, 4 and 4.4%. Logistic regression model revealed that risk of fistula decreased when shaving was performed when compared to segmental resection (adj OR 0.1, 95% CI 0-0.5) and increased when deep endometriosis nodules also involved sacral roots (adjOR 4.9, 95%CI 1.8-13.3) and infiltration of the vagina (adj OR 3, 95%CI 1.3-7). No statistically significant relationship was found between surgery time period and risk of fistula. CONCLUSION Crude rates of bowel fistula following surgical management of deep endometriosis infiltrating the colon and the rectum are not an accurate marker of surgeon expertise and should be considered in conjunction with expected higher risks related to challenging procedures performed by experienced surgeons.
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Affiliation(s)
- H Roman
- Endometriosis centre, clinique Tivoli-Ducos, Bordeaux, France; Department of gynaecology and obstetrics, university hospital Aarhus, Aarhus, Denmark.
| | - J Marabha
- Endometriosis centre, clinique Tivoli-Ducos, Bordeaux, France
| | - A Polexa
- Endometriosis centre, clinique Tivoli-Ducos, Bordeaux, France
| | - M Prosszer
- Endometriosis centre, clinique Tivoli-Ducos, Bordeaux, France
| | - E Huet
- Department of surgery, Rouen university hospital, Rouen, France
| | - C Hennetier
- Expert center in the diagnosis and multidisciplinary management of endometriosis, Rouen university hospital, Rouen, France
| | - J-J Tuech
- Department of surgery, Rouen university hospital, Rouen, France
| | - L Marpeau
- Expert center in the diagnosis and multidisciplinary management of endometriosis, Rouen university hospital, Rouen, France
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