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Roman H, Dennis T, Forestier D, François MO, Assenat V, Tuech JJ, Hennetier C, Merlot B. Disk Excision Using End-to-End Anastomosis Circular Stapler for Deep Endometriosis of the Rectum: A 492-Patient Continuous Prospective Series. J Minim Invasive Gynecol 2023; 30:122-130. [PMID: 36334913 DOI: 10.1016/j.jmig.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 10/25/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022]
Abstract
STUDY OBJECTIVE To report a large series including women managed by disk excision using end-to-end anastomosis (EEA) circular transanal stapler to assess the feasibility of the technique, the features of nodules suitable for removal by disk excision, and the rate of major early complications. DESIGN Retrospective study on data prospectively recorded in 2 databases. SETTING Two tertiary referral centers. PATIENTS A total of 492 patients undergoing surgery for rectal endometriosis from May 2011 to June 2022. INTERVENTIONS Rectal disk excision using the EEA stapler. MEASUREMENT AND MAIN RESULTS Disk excision using EEA was performed in 492 patients (24.2%) of 2,029 women receiving surgery for deep endometriosis infiltrating the rectum during the 11-year study period. Deep endometriosis involved low rectum in 11% and mid rectum in 55.3%. The diameter of rectal nodules exceeded 3 cm in 65.9%. Mean operative time was 2 hours, mean diameter of rectal patches removed was 41 ± 11 mm, and the mean rectal suture height was 9.2 ± 5.5 cm. The presence of microscopic foci on the edges of rectal patches was identified in 30.2% of cases. Rectal fistula was recorded in 20 patients (4%). The distance from the anal verge was significantly lower in patients with fistula than women with no fistula (5.9 ± 2 cm vs 9.2 ± 5.6 cm, p = .027). Follow-up ranged from 1 to 120 months, with a median value of 36 months. Magnetic resonance imaging in 3 patients during follow-up revealed a recurrent nodule infiltrating the previous stapled line (0.6%) after a postoperative delay of, respectively, 36, 48, and 84 months. CONCLUSION Disk excision using the EEA stapler is suitable in nodules >3 cm if surgeons ensure deep shaving of the rectum, to allow complete inclusion of the shaved area into the stapler jaws. Postoperative rectal recurrences seem incidental, whereas bowel leakage rate is comparable with that after colorectal resection. This technique is suitable in almost a quarter of patients managed for rectal endometriosis nodules and is therefore a valuable technique that warrants more widespread use.
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Affiliation(s)
- Horace Roman
- Franco-European Multidisciplinary Endometriosis Institute (IFEMEndo), Clinique Tivoli-Ducos, Bordeaux, France (Drs. Roman, Dennis, Forestier, François, Assenat, and Merlot); Department of Gynecology and Obstetrics, Aarhus University Hospital, Aarhus, Denmark (Dr. Roman, Dr. Tuech, Dr. Hennetier).
| | - Thomas Dennis
- Franco-European Multidisciplinary Endometriosis Institute (IFEMEndo), Clinique Tivoli-Ducos, Bordeaux, France (Drs. Roman, Dennis, Forestier, François, Assenat, and Merlot)
| | - Damien Forestier
- Franco-European Multidisciplinary Endometriosis Institute (IFEMEndo), Clinique Tivoli-Ducos, Bordeaux, France (Drs. Roman, Dennis, Forestier, François, Assenat, and Merlot)
| | - Marc Olivier François
- Franco-European Multidisciplinary Endometriosis Institute (IFEMEndo), Clinique Tivoli-Ducos, Bordeaux, France (Drs. Roman, Dennis, Forestier, François, Assenat, and Merlot)
| | - Vincent Assenat
- Franco-European Multidisciplinary Endometriosis Institute (IFEMEndo), Clinique Tivoli-Ducos, Bordeaux, France (Drs. Roman, Dennis, Forestier, François, Assenat, and Merlot)
| | - Jean Jacques Tuech
- Department of Surgery, Rouen University Hospital, Rouen, France (Dr. Tuech)
| | - Clotilde Hennetier
- Department of Gynecology and Obstetrics, Rouen University Hospital, Rouen, France (Dr. Hennetier)
| | - Benjamin Merlot
- Franco-European Multidisciplinary Endometriosis Institute (IFEMEndo), Clinique Tivoli-Ducos, Bordeaux, France (Drs. Roman, Dennis, Forestier, François, Assenat, and Merlot)
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Altomare DF, Pecorella G, Tegon G, Aquilino F, Pennisi D, De Fazio M. Does a more extensive mucosal excision prevent haemorrhoidal recurrence after stapled haemorrhoidopexy? Long-term outcome of a randomized controlled trial. Colorectal Dis 2017; 19:559-562. [PMID: 27801539 DOI: 10.1111/codi.13549] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 08/11/2016] [Indexed: 02/08/2023]
Abstract
AIM The study aimed in a multicentric randomized controlled trial to define the role of a more extensive mucosal resection on recurrence of mucosal prolapse in patients with Stage III haemorrhoids undergoing stapled haemorrhoidopexy. METHOD In all, 135 patients were randomized to treatment with a PPH-01/03 (Ethicon EndoSurgery) or an EEA (Covidien) stapler. They were reviewed after a minimum follow-up of 4 years to determine the rate of recurrent mucosal prolapse and general condition (wellness evaluation score). Postoperative bowel dysfunction was assessed using the Rome III criteria. RESULTS Eighty-seven (65%) of the 135 patients (48 in the EEA stapler group and 37 in the PPH group) were available for long-term follow-up. The two groups were comparable for age, gender and duration of follow-up (mean 49.3 ± 5.4 months and 49.0 ± 5.3 months respectively). In the EEA group, 11 (23%) patients had some degree of recurrent prolapse compared with 12 (32%) in the PPH group (P = 0.409). Persistence of anal bleeding was significantly higher in the PPH group (P = 0.04) while the postoperative Haemorrhoid Symptom Score was significantly better in the EEA group (1.73 ± 1.65 vs 3.17 ± 1.94, P < 0.001). The wellness evaluation score was significantly better in the EEA group (1.2 ± 1.27 vs 0.6 ± 1.0, P = 0.028). Furthermore, 7 (15%) of the patients in the EEA group complained of some evacuation disturbance compared with 13 (36%) in the PPH group (P = 0.021). CONCLUSION The study failed to demonstrate any significant difference in the long-term recurrence rate of Stage III haemorrhoids using EEA or PPH. Nevertheless, use of the larger volume EEA provides better symptom resolution compared with PPH.
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Affiliation(s)
- D F Altomare
- Department of Emergency and Organ Transplantation, University Aldo Moro of Bari, Bari, Italy
| | - G Pecorella
- Colorectal Unit, Surgical Clinic, University of Catania, Catania, Italy
| | - G Tegon
- Colorectal Unit, 'San Camillo' Hospital, Treviso, Italy
| | - F Aquilino
- Department of Emergency and Organ Transplantation, University Aldo Moro of Bari, Bari, Italy
| | - D Pennisi
- Colorectal Unit, Surgical Clinic, University of Catania, Catania, Italy
| | - M De Fazio
- Department of Emergency and Organ Transplantation, University Aldo Moro of Bari, Bari, Italy
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Abstract
The introduction of circular end-to-end stapling devices (CEEA OR EEA stapler) into colorectal surgery have revolutionised anastomotic techniques. The EEA stapler is generally regarded as an instrument that is safe, reliable, and simple to operate. Despite it’s popularity, very little information is available regarding the technical difficulties encountered during surgery. The routine technique to perform an end-to-end circular colonic anastomosis is to introduce the instrument distally through the anus (transrectal/transanal approach) and attach it to the anvil which is purse stringed at the distal end of the proximal bowel to be anastomosed. Two cases of reversal of Hartmann’s procedure for perforated diverticulitis are described in the present study, where difficulty was experienced while using the EEA stapler in the routine method. Hence, an alternative reverse technique which was used is presented.
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