Natural Orifice Specimen Extraction (NOSE) colorectal resection for deep endometriosis: A 50 case series: NOSE resection for DIE: 50 cases

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.

Live surgery of colorectal endometriosis broadcasted from a surgeon's routine operating theater is not associated with higher complications rate

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.

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

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.

Nonvisualized palpable bowel endometriotic satellites

STUDY QUESTION

What is the prevalence of laparoscopically nonvisualized palpable satellite bowel nodules at or near the planned stapler site in women undergoing segmental bowel resection for endometriosis?

SUMMARY ANSWER

Overall, 13 (25.5%) of 51 patients who underwent resection had nonvisualized palpable satellite lesions as small as 2 mm, including seven (14%) who had nonvisualized palpable lesions at or beyond the planned stapler site.

WHAT IS KNOWN ALREADY

Both laparoscopy and laparotomy for bowel resection are standard of care in Europe and the USA. Reoperation rates after laparoscopic bowel procedures are 1–16%. Endometriotic lesions at the stapler margin of bowel resections are associated with increased repeat surgery. Nodules of 0.1 mm to 1 cm in size were not recognized during laparoscopic bowel surgery but were recognized on histological examination. Up to 20 nodules not visualized at laparoscopy have been recognized and excised at laparotomy. Tenderness is found at up to 27 mm from a recognized lesion. The size of a lesion does not always predict its symptoms or behavior.

STUDY DESIGN, SIZE, DURATION

This single-arm, observational study focused on the presence of nonvisualized palpable satellite lesions of the bowel. Fifty-one patients scheduled for laparoscopic-assisted bowel resection for deep infiltrating endometriosis with suprapubic incision for placement of the stapler’s anvil and removal of the specimen in the course of routine clinical care were included. There were no additional inclusion or exclusion criteria.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Laparoscopic-assisted segmental bowel resection for endometriosis was performed in a private referral center on women aged 24–49 years.

MAIN RESULTS AND THE ROLE OF CHANCE

Forty-nine (96.1%) of the 51 patients underwent segmental resection of the sigmoid or rectum, and 14 (27.5%) underwent segmental resection of the ileum for large nodule(s) recognized on MRI. Twelve patients underwent both procedures. Eleven (22.4%) of the 49 patients with recognized sigmoid or rectal lesions and 5 (35.7%) of the 14 patients with recognized ileal lesions had nonvisualized, palpable, satellite lesions. All the large lesions and none of the satellite lesions had been recognized preoperatively on MRI. Five (10%) of 49 patients with lesions of the large bowel and 4 (28.6%) of the 14 patients with lesions of the ileum had nonvisualized palpable satellite lesions at or beyond the planned stapler site. Lesions as small as 2 mm were palpable.

LIMITATIONS, REASONS FOR CAUTION

This is an observational study. It is not known if the small lesions of this study contributed to the symptoms or were progressive, stable or regressive. This study analyzed lesions in the bowel segment proximal to the primary large bowel lesion, but not in the distal segment as that would have required a change in standard of care surgical technique. This study protocol did not include shaving or disk resection or patients in whom no lesions were visualized. The use of additional techniques for recognition, such as hand-assisted laparoscopy or rectal probes, was not investigated.

WIDER IMPLICATIONS OF THE FINDINGS

This study confirms that some nonvisualized satellite lesions as small as 2 mm are palpable and that an increased length of resection can be used to remove lesions recognized by palpation and to avoid lesions at and beyond the stapler site. This may decrease recurrent surgery in 1–16% of the women undergoing surgery for bowel endometriosis. Knowledge of the occurrence of these small lesions may also be particularly useful in plans for repeat surgery or for women with clinically significant bowel symptoms and no visible lesions at laparoscopy. Moreover, small lesions are considered to be important as there is no current technique to determine whether a large primary lesion, smaller lesions, an associated adjacent tissue reaction or a combination of those cause symptoms.

STUDY FUNDING/COMPETING INTEREST(S)

This CIRENDO cohort was supported by the G4 Group (the University Hospitals of Rouen, Lille, Amiens and Caen) and the ROUENDOMETRIOSE association. No specific funding was received for the study. H.R. reports receiving personal fees from Plasma Surgical Inc., Ethicon Endosurgery, Olympus and Nordic Pharma for presentations related to his experience with endometriosis surgery. D.C.M. reports being given access to Lumenis Surgical CO₂ Lasers’ lab at a meeting. None of the other authors have conflicts of interest to disclose.

TRIAL REGISTRATION NUMBER

N/A