Surgery-related complications and long-term functional morbidity after segmental colo-rectal resection for deep infiltrating endometriosis (ENDO-RESECT morb)

[Interdisciplinary surgical spectrum in cooperation of abdominal surgery and gynecology : What must the (general/abdominal) surgeon know?]

AIM

This short overview aims to concisely outline the most important gynecological issues from a predominantly operative point of view, which could also be relevant for general and abdominal surgeons as well as important gynecological aspects of primarily visceral surgical pathologies.

METHOD

Narrative review on the topic of interdisciplinary cooperation in gynecological/general and abdominal surgery through the use of PubMed® as well as the Cochrane Library with search terms, such as "operative profile of abdominal surgery and gynecology", "interdisciplinary surgery aspects of gynecology/abdominal surgery" as well as "interdisciplinary surgical approach-surgical complication".

RESULTS (MAIN POINTS)

As the close anatomical relationship suggests, numerous primarily gynecological pathologies can also occur in abdominal organs. Likewise, predominantly surgical pathologies can result in involvement of gynecological organs. This can make an intraoperative collaboration necessary. In addition, as a result of diagnostic uncertainty or within the context of complications, interdisciplinary collaboration can also be required preoperatively and postoperatively. Multidisciplinary knowledge as well as close cooperation of the involved specialties can improve the outcome of affected patients.

CONCLUSION

Many pathologies extend not only to the boundaries of an individual discipline but can also affect physiological systems exceeding those limits. Therefore, for an optimal treatment it is necessary to be aware of such aspects of the diseases and to establish structured procedures for interdisciplinary cooperation.

Robotic surgery for deep-infiltrating endometriosis: is it time to take a step forward?

Endometriosis is a chronic debilitating disease that affects nearly 10% of women of the reproductive age. Although the treatment modalities of endometriosis are numerous, surgical excision of the endometriotic implants and nodules remains the sole cytoreductive approach. Laparoscopic excision of endometriosis was proven to be beneficial in improving the postoperative pain and fertility. Moreover, it was also proved to be safe and efficient in treating the visceral localization of deep endometriosis, such as urinary and colorectal endometriosis. More recently, robotic-assisted surgery gained attention in the field of endometriosis surgery. Although the robotic technology provides a 3D vision of the surgical field and 7-degree of freedom motion, the safety, efficacy, and cost-effectiveness of this approach are yet to be determined. With this paper, we aim to review the available evidence regarding the role of robotic surgery in the management of endometriosis along with the current practices in the field.

Pilot study of treatment of patients with deep infiltrative endometriosis with methotrexate carried in lipid nanoparticles

OBJECTIVE

Previously, lipid nanoparticles (LDE) injected in women with endometriosis were shown to concentrate in the lesions. Here, the safety and feasibility of LDE carrying methotrexate (MTX) to treat deep infiltrating endometriosis was tested.

DESIGN

Prospective pilot study.

SETTING

Perola Byington Hospital Reference for Women's Health.

SUBJECTS

Eleven volunteers (aged 30-47 years, BMI 26.15 ± 6.50 kg/m2) with endometriosis with visual analog scale pelvic pain scores (VAS) > 7 and rectosigmoid lesions were enrolled in the study.

INTERVENTION

Three patients were treated with LDE-MTX at single intravenous 25 mg/m2 dose of MTX and eight patients with two 25 mg/m2 doses with 1-week interval.

MAIN OUTCOME MEASURES

Clinical complaints, blood count, and biochemistry were analyzed before treatment and on days 90, 120, and 180 after LDE-MTX administration. Endometriotic lesions were evaluated by pelvic and transvaginal ultrasound (TVUS) before treatment and on days 30 and 180 after LDE-MTX administration.

RESULTS

No clinical complaints related with LDE-MTX treatment were reported by the patients, and no hematologic, renal, or hepatic toxicities were observed in the laboratorial exams. FSH, LH, TSH, free T4, anti-Müllerian hormone, and prolactin levels were also within normal ranges during the observation period. Scores for deep dyspareunia (p < 0.001), chronic pelvic pain (p = 0.008), and dyschezia (p = 0.025) were improved over the 180-day observation period. There was a non-significant trend for reduction of VAS scores for dysmenorrhea. Bowel lesions by TVUS were unchanged. No clear differences between the two dose levels in therapeutic responses were observed.

CONCLUSION

Results support the safety and feasibility of using LDE-MTX in women with deep infiltrating endometriosis as a novel and promising therapy for the disease. More prolonged treatment schemes should be tested in future placebo-controlled studies aiming to establish the usefulness of this novel nanomedicine approach.

Colorectal endometriosis: Diagnosis, surgical strategies and post-operative complications

Objective

The present work aimed to investigate the feasibility, complications, recurrence rate, and infertility outcomes of the radical and conservative surgical methods for colorectal endometriosis in short- and long-term follow-ups.

Methods

In this prospective study, the patients with confirmed diagnosis of colorectal DIE were included from March 2015 to March 2021, who were referred to an Endometriosis Surgery Center affiliated with Shiraz University of Medical Sciences (SUMS). Information on demographics, surgical approaches, intra-operative, and post-operative findings as well as complications were collected and compared. Six- and 12-month interviews were conducted to evaluate the functional outcomes of all the procedures.

Results

Out of 3,111 patients who underwent endometriosis surgery, 837 (28.19%) with the average age of 34.2 ± 5.9 years and average ASRM score of 102.1 ± 36.8 had rectosigmoid endometriosis. Laparoscopic rectal shaving was performed in 263(30.0%) patients while 326 (37.2%) underwent segmental bowel resection, and 248 (28.30%) were treated with disc excision. Prophylactic ileostomy was performed in six (0.68%) patients and peritonitis was reported in four (0.45%). Five (0.58%) subjects developed rectovaginal fistula and one (0.11%) was diagnosed with bladder atonia. The recurrence rate was 3.8%, 1.2%, and 0.3% in rectal shaving, disc, and segmental bowel resection techniques, respectively. Dysmenorrhea, dyspareunia, and dyschezia were improved after surgery by 7.3, 9.4, and 12.5 times, respectively. We observed 25.2% of total pregnancy following the operation, the majority of which occurred in the first year after the surgery.

Conclusion

There were very few short-term or long-term complications in the three different techniques when the choice was correct.

Combination of laparoscopic side-to-end colorectal anastomosis and vaginal nose (natural orifice specimen extraction) surgery for colorectal endometriosis: Technique and outcomes

Objective:

To investigate the effectiveness of combining side-to-end anastomosis and vaginal NOSE (Natural orifice specimen extraction) surgery in colorectal endometriosis.

Material and methods:

We included 11 patients treated with laparoscopic side-to-end colorectal anastomosis and vaginal NOSE surgery between January 2019 and May 2021. We questioned the visual analog score (VAS) for pain symptoms, the short form-36 (SF-36) for health survey questionnaire, The Female Sexual Function Index (FSFI), EHP-5 for endometriosis health profile, The Hospital Anxiety and Depression Scale (HADS), OAB-V8 for overactive bladder symptoms and Constipation Severity Instrument (CSI).

Results:

VAS, EHP-5, and SF-36 scores were better at postoperative third and sixth months than preoperative values ( p < 0.05). There were no statistically significant differences in terms of FSFI, OAB-V8, HADS, and the CSI.

Conclusions:

Laparoscopic side-to-end anastomosis with vaginal NOSE surgery is feasible, scarless, and could be offered to patients with deep symptomatic bowel endometriosis.

Long-term surgical outcomes of nerve-sparing discoid and segmental resection for deep endometriosis

INTRODUCTION

The aim of this study was to investigate long-term outcomes in terms of pain, quality of life (QoL), and gastrointestinal symptoms in women following colorectal surgery for deep endometriosis.

MATERIAL AND METHODS

In this historical cohort, women who underwent surgical treatment for deep endometriosis by either nerve-sparing full-thickness discoid resection (DR) or colorectal segmental resection (SR) between March 2011 and August 2016 were re-evaluated through telephone interviews about their long-term pain symptoms, subjective overall QoL as rated using a score from 0 (worst) to 10 (optimal), and gastrointestinal outcomes reflected by lower anterior resection syndrome (LARS) following a first postsurgical evaluation (visit 1) published previously and a long-term follow-up evaluation (visit 2).

RESULTS

The median long-term follow-up time was 35.4 months at visit 1 and 86 months at visit 2. Of 134 patients, 77 were eligible for final analysis and 57 were lost to follow-up. Compared with presurgical values, QoL scores were significantly increased at both postsurgical evaluation visits in both the SR cohort (scores of 3, 8.5, and 10 at the presurgical visit, visit 1, and visit 2, respectively; p < 0.001) and the DR cohort (scores of 3, 9, and 10, respectively; p < 0.001). Pain scores for dysmenorrhea (SR group scores of 8, 2, and 2, respectively; p < 0.001; DR group scores of 9, 2, and 1, respectively; p < 0.001), dyspareunia (SR group scores of 4, 0, and 0, respectively; p < 0.001; DR group scores of 5, 0, and 1, respectively; p = 0.003), and dyschezia (SR group scores of 8, 2, and 2, respectively; p < 0.001; DR group scores of 9, 2, and 1, respectively; p < 0.001) significantly decreased after surgery and remained stable in both cohorts over the follow-up period. Minor and major LARS, reflecting gastrointestinal function, was observed in 6.5% and 8.1% of the SR group and in 13.3% and 6.7% of the DR group, respectively, at visit 1 and in 3.2% and 3.2% of the SR group and 0% and 0% of the DR group, respectively, at visit 2, without significant differences between the SR and DR groups.

CONCLUSIONS

Colorectal surgery for deep endometriosis, either by DR or SR, provides stable and long-term pain relief with low rates of permanent gastrointestinal function impairment.

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.

Sexual Function of Women With Deep Endometriosis Before and After Surgery: A Prospective Study

BACKGROUND

Deep endometriosis (DE) may significantly affect women's quality of life. Limited data exists on the effect of surgery on the several domains of sexual function.

AIM

To prospectively compare various domains of sexual function before and after laparoscopic surgery for DE.

METHODS

A prospective observational cohort study in a tertiary university-affiliated referral center. Patients with suspected DE who were planned to undergo laparoscopic surgery completed the Female Sexual Function Index questionnaire before surgery. The same questionnaire was completed by the participants 6 weeks, 6 months, and 12 months after surgery. Rate of sexual dysfunction over time was compared using multilevel logistic regression. Summary scores were then compared at each time point to the corresponding score before surgery using multilevel linear regression. Multivariable analysis was performed of potential confounders.

OUTCOMES

Change in desire, arousal, orgasm, lubrication, satisfaction and pain summary scores as well as in the full-scale score between before and after surgery.

RESULTS

We followed 149 patients with surgically confirmed DE. Sexual dysfunction rate as per the full-scale score was 75.5% before surgery and remained over 60% to 12 months after. The full-scale sexual function score improved at 6 (change in score = 2.8 ± 9.5, P = .004) and 12 months (change in score = 2.1 ± 9.9, P = .03). None of the summary scores improved at 6 weeks. Desire score (P < .001), arousal score (P = .02), and pain score (P = .01) improved at 6 months. Desire score (P = .03) and pain score (P = .01) also improved at 12 months, as compared to before surgery. On multivariable multilevel analysis, scores before surgery significantly contributed to the scores after surgery (P < .001).

CLINICAL TRANSLATION

While sexual function improved after surgery, dysfunction rate remained substantial. Proper preoperative counseling should address sexual function measures and clinical and research attention should be given to seek ways to further reduce sexual dysfunction.

STRENGTHS AND LIMITATIONS

The main strengths of our study are the prospective design, the relatively long follow-up and the use of a detailed validated questionnaire allowing assessment of a large variety of clinically relevant sexual function domains and scores as well as a full-scale score. Among our limitations are the lower response rate at 12 months and the limited generalizability as this is a single center study.

CONCLUSION

Sexual function is a major and often under reported domain of quality of life. Further research is needed to identify the specific populations who may improve, not change or experience deterioration in their sexual functioning after surgery. Dior UP, Reddington C, Cheng C, et al. Sexual Function of Women With Deep Endometriosis Before and After Surgery: A Prospective Study. J Sex Med 2022;19:280-289.

Quality of Life in Patients With Rectal Resections and End-to-End Primary Anastomosis Using a Standardized Perioperative Pathway

Objectives: Lower rectal resection is associated with a high rate of postoperative complications and, therefore, adversely impacts the postoperative health-related quality of life (QoL). Though sporadically practiced in different centers, there is no standard perioperative protocol for the management of patients with rectal growths. The aim of this analysis is to evaluate the patient-reported outcomes after low rectal resections followed by an end-to-end-reconstruction and temporary covering ileostomy using a multidisciplinary fail-safe-concept.

Methods: Between 2015 and 2020, we evaluated patient reported outcomes after open and laparoscopic rectal resections with end-to-end reconstruction with a primary straight anastomosis using a standardized perioperative pathway All patients with stoma were excluded from the study. The data for the QoL of patients was collected using the established Low Anterior Resection Syndrome (LARS)-score and the EORTC-C30 and CR-29 questionnaires at a single postoperative timepoint.

Results: We recruited 78 stoma-free patients for this analysis. Of 78 patients included in the study, 87.2% were operated laparoscopically and the mean global health status was 67.95 points, while a major LARS was detected in 48 (61.5%) patients. No anastomotic leakage (AL) occurred within the study cohort. There was no significant change in the LARS-score or the global health status depending on the follow-up-period.

Conclusion: This study shows that good QoL and functional outcomes with no AL are achievable following end-to-end straight anastomosis using a standardized perioperative surgical fail-safe protocol procedure.

Near-Infrared Imaging With Indocyanine Green for the Treatment of Endometriosis: Results From the Gre-Endo Trial

Introduction

A current challenge for endometriosis surgery is to correctly identify the localizations of disease, especially when small or hidden (occult endometriosis), and to exactly define their real extension. The use of near-infrared radiation imaging (NIR) after injection of indocyanine green (ICG) represents one of the most encouraging method. The aim of this study is to assess the diagnostic value of NIR-ICG imaging in the surgical treatment of endometriosis compared with the standard of treatment.

Material and Methods

The Gre-Endo trial is a prospective, single-arm study (NCT03332004). After exploring the operatory field using the white light (WL) mode, patients were injected with ICG and then observed in NIR mode. All suspected areas were classified and chronicled according to lesions visualized only in WL, NIR-ICG, or in the combination of both. Lesion not visualized in WL was considered as suspect occult lesion (s-OcL). In addition, a random control biopsy from an apparent negative peritoneum visualized in WL and NIR-ICG imaging was taken for all patients (control cases). All lesions removed were considered “suspect endometriosis” until pathology.

Results

Fifty-one patients were enrolled between January 2016 and October 2019. A total of 240 suspected lesions have been identified with both methods (WL + NIR-ICG). Two hundred and seven (86.2%) lesions out of the overall 240 were visualized with WL imaging, and 200 were confirmed to be pathologic (true positive for WL). The remaining 33/240 (13.75%) (false negative for WL) lesions were identified only with NIR-ICG imaging and collected as s-OcL. All 33 s-OcLs removed were confirmed to be pathologic (c-OcL = 100%). NIR-ICG vision showed PPV of 98.5%, NPV of 87.1%, Se of 87%, and Sp of 98.5%, confirming that this kind of imaging is an excellent diagnostic and screening test (p = 0.001 and p = 0.835, according to McNemar’s and Cohen’s kappa tests, respectively).

Conclusions

The use of NIR-ICG vision alone and combined with WL showed good results in intraoperative detection rate and fluorescence-guided surgery of endometriosis. Furthermore, NIR-ICG allowed surgeons to remove occult lesions that otherwise would remain, leading to possible greater postoperative pain and a higher risk of persistence and relapse.

Urinary Function after Surgery for Deep Endometriosis: A Prospective Study

STUDY OBJECTIVE

To compare urinary function before and after surgery in patients undergoing laparoscopy for deep endometriosis and to measure the rate of postoperative deterioration in urinary function after surgery.

DESIGN

Prospective questionnaire-based observational cohort study.

SETTING

Tertiary university-affiliated hospital.

PATIENTS

Included were 149 women who underwent surgery for deep endometriosis.

INTERVENTIONS

Participants completed the international consultation on incontinence female lower urinary tract symptoms long-form questionnaire before surgery and 6 weeks, 6 months, and 12 months after surgery.

MEASUREMENTS AND MAIN RESULTS

Bladder filling, voiding, and urinary incontinence summary scores were compared before and after surgery with mixed-effects linear regression analysis (correlated observations). Individual domains comprising the summary scores and their bother scores were also compared before and after surgery. Filling score at 6 weeks (3.7 ± 2.6), 6 months (3.2 ± 2.2), and 12 months (3.4 ± 2.2) improved from presurgery scores (4.2 ± 2.6) (p-value for the difference between before and after surgery: p <.001, p = .009, and p = .02 for 6 weeks, 6 months, and 12 months, respectively). No change was observed after surgery in bladder voiding score. Incontinence score improved at 6 weeks after surgery (presurgery and 6-week scores: 2.5 ± 3.3 and 1.6 ± 2.2, respectively, p <.001) but not thereafter. Patients with low preoperative summary scores had higher summary scores (worse function) after surgery, and patients with high preoperative scores had lower summary scores (improved function) after surgery.

CONCLUSION

Urinary function improved after laparoscopy for deep endometriosis. Greatest improvement was found in patients with worse preoperative function, whereas postoperative deterioration in urinary function was found for patients with initially normal function. More research is needed to better identify the subpopulations in whom surgical intervention provides symptomatic benefit or deterioration.

Six-month follow-up of minimally invasive nerve-sparing complete excision of endometriosis: What about dyspareunia?

STUDY OBJECTIVE

To assess individual changes of deep dyspareunia (DDyspareunia) six months after laparoscopic nerve-sparing complete excision of endometriosis, with or without robotic assistance.

METHODS

This preplanned interdisciplinary observational study with a retrospective analysis of intervention enrolled 126 consecutive women who underwent surgery between January 2018 and September 2019 at a private specialized center. Demographics, medical history and surgery details were recorded systematically. DDyspareunia (primary outcome), dysmenorrhea and acyclic pelvic pain were assessed on self-reported 11-point numeric rating scales both preoperatively and at six-month follow-up. Cases with poor prognosis in relation to dyspareunia were described individually in greater detail.

RESULTS

Preoperative DDyspareunia showed weak correlation with dysmenorrhea (rho = .240; P = .014) and pelvic pain (rho = .260; P = .004). Although DDyspareunia improved significantly (P < .001) by 3 points or more in 75.8% (95%CI: 64.7-86.2) and disappeared totally in 59.7% of cases (95%CI:47.8-71.6), individual analysis identified different patterns of response. The probability of a preoperative moderate/severe DDyspareunia worsening more than 2 points was 4.8% (95%CI: 0.0-10.7) and the probability of a woman with no DDyspareunia developing "de novo" moderate or severe DDyspareunia was 7.7% (95%CI: 1.8-15.8) and 5.8% (95%CI: 0.0-13.0), respectively. In a qualitative analysis, several conditions were hypothesized to impact the post-operative DDyspareunia response; these included adenomyosis, mental health disorders, lack of hormone therapy after surgery, colporrhaphy, nodule excision in ENZIAN B compartment (uterosacral ligament/parametrium), the rectovaginal septum or the retrocervical region.

CONCLUSION

Endometriosis surgery provides significant improvement in DDyspareunia. However, patients should be alerted about the possibility of unsatisfactory results.