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Schneyer RJ, Hamilton KM, Meyer R, Nasseri YY, Siedhoff MT. Surgical treatment of colorectal endometriosis: an updated review. Curr Opin Obstet Gynecol 2024; 36:239-246. [PMID: 38743685 DOI: 10.1097/gco.0000000000000960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
PURPOSE OF REVIEW This review aims to summarize recent literature on the surgical treatment of colorectal endometriosis. RECENT FINDINGS The last decade has seen a surge in the number of studies on bowel endometriosis, with a focus on preoperative evaluation, perioperative management, surgical approach, and surgical outcomes. Many of these studies have originated from large-volume referral centers with varying surgical approaches and philosophies. Colorectal surgery for endometriosis seems to have a positive impact on patient symptoms, quality of life, and fertility. However, these benefits must be weighed against a significant risk of postoperative complications and the potential for long-term bowel or bladder dysfunction, especially for more radical procedures involving the lower rectum. Importantly, most studies regarding surgical technique and outcomes have been limited by their observational design. SUMMARY The surgical management of bowel endometriosis is complex and should be approached by a multidisciplinary team. Methodical preoperative evaluation, including appropriate imaging, is vital for surgical planning and patient counseling. The decision to perform a more conservative or radical excision is nuanced and remains an area of controversy. High quality studies in the form of multicenter randomized controlled trials are needed before clear recommendations can be made.
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Affiliation(s)
- Rebecca J Schneyer
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Kacey M Hamilton
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Raanan Meyer
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California, USA
- The Dr. Pinchas Bornstein Talpiot Medical Leadership Program, Sheba Medical Center, Tel Hashomer, Ramat-Gan, Israel
| | - Yosef Y Nasseri
- Department of General Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Matthew T Siedhoff
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Djemouai S, Agostini A, Loubière S, Auquier P, Pirro N, Netter A, Pivano A. Enhanced recovery after surgery (ERAS) for deep infiltrating endometriosis surgery: Experience of a French center. J Gynecol Obstet Hum Reprod 2024; 53:102771. [PMID: 38513805 DOI: 10.1016/j.jogoh.2024.102771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 03/03/2024] [Accepted: 03/18/2024] [Indexed: 03/23/2024]
Abstract
OBJECTIVE The objective of the study was to evaluate the implementation of an ERAS programme for deep pelvic endometriosis (DPE) surgery in terms of length of stay (LOS), postoperative complications (POC) and rehospitalisation rate. METHODS This was a comparative retrospective monocentric study in the Gynaecologic Department of the La Conception Hospital in Marseille, France. We compared a 'conventional' group, with classic perioperative management corresponding to patients undergoing DPE surgery between April 8, 2014 and January 23, 2018, and an 'ERAS' group after setting up the ERAS protocol from February 6, 2018 to March 6, 2020. RESULTS A total of 101 patients with DPE surgery were included, with 39 in the conventional group and 53 in the ERAS group. The LOS decreased by 1.91 days (p < 0.001). During the 45 postoperative days, no difference was found in rehospitalised rate (p = 1). The POC rate was 15/39 (38.5 %) in the conventional group and 12/53 (22.6 %) in the ERAS group (p = 0.1). CONCLUSION The implementation of an ERAS programme for DPE surgery is an effective strategy because it can reduce the LOS without increasing the POC rate.
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Affiliation(s)
- Sara Djemouai
- Department of Obstetrics and Gynecology, Hôpital La Conception, Aix-Marseille University, 147 Bd Baille, Marseille 13005, France.
| | - Aubert Agostini
- Department of Obstetrics and Gynecology, Hôpital La Conception, Aix-Marseille University, 147 Bd Baille, Marseille 13005, France
| | - Sandrine Loubière
- CEReSS - Health Services and Quality of Life Research, Department of Epidemiology, Aix-Marseille University, Marseille, France
| | - Pascal Auquier
- CEReSS - Health Services and Quality of Life Research, Department of Epidemiology, Aix-Marseille University, Marseille, France
| | - Nicolas Pirro
- Department of Digestive Surgery, Hôpital Timone, Aix-Marseille University, Marseille, France
| | - Antoine Netter
- Department of Obstetrics and Gynecology, Hôpital La Conception, Aix-Marseille University, 147 Bd Baille, Marseille 13005, France
| | - Audrey Pivano
- Department of Obstetrics and Gynecology, Hôpital La Conception, Aix-Marseille University, 147 Bd Baille, Marseille 13005, France
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Arena A, Degli Esposti E, Pazzaglia E, Orsini B, Cau I, Govoni F, Raimondo D, Palermo R, Lenzi J, Casadio P, Seracchioli R. Not All Bad Comes to Harm: Enhanced Recovery After Surgery for Rectosigmoid Endometriosis. J Minim Invasive Gynecol 2024; 31:49-56. [PMID: 37839779 DOI: 10.1016/j.jmig.2023.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 10/04/2023] [Accepted: 10/08/2023] [Indexed: 10/17/2023]
Abstract
STUDY OBJECTIVE To assess the impact of implementing an enhanced recovery after surgery (ERAS) protocol on the length of hospitalization in women undergoing laparoscopy for rectosigmoid deep infiltrating endometriosis (DIE). DESIGN A retrospective cohort study. SETTING An academic referral center for endometriosis and minimally invasive gynecologic surgery. PATIENTS Women aged between 18 and 50 years scheduled for laparoscopic excision (shaving, full-thickness anterior wall resection, segmental resection) of rectosigmoid endometriosis between February 2017 and February 2023. INTERVENTIONS We divided patients into 2 groups (non-ERAS and ERAS) based on the timing of surgery (before or after March 5, 2020). Starting from this day, restrictions were issued to limit the spread of the coronavirus disease 2019 pandemic, inducing our group to implement an ERAS protocol for patients hospitalized after surgery for posterior DIE. MEASUREMENTS AND MAIN RESULTS We included 579 patients in the analysis, 316 (54.6%) in the non-ERAS group and 263 (45.4%) in the ERAS group. In the ERAS group, we observed a shorter length of hospital stay (5.8 ± 3.1 days vs 4.8 ± 2.9 days; p <.001) and lower complications rates (33, 12.5% vs 60, 19.0%; p = .04), despite a decreased frequency of conservative surgical approaches (shaving procedures 121 vs 196; p <.001). Repeated surgery or hospital readmissions owing to postdischarge complications were infrequent, with no significant differences between the 2 groups. The multiple linear regression analysis strengthened our results given the higher prevalence of bowel resection surgeries (both full-thickness anterior wall or segmental), showing that patients managed with a multimodal protocol had an overall reduction of hospital stay by 1.5 days. CONCLUSION The implementation of an ERAS program in patients undergoing laparoscopic surgery for DIE is associated with a significant reduction in hospital stay, without an increase in perioperative or postoperative complication rates.
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Affiliation(s)
- Alessandro Arena
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti, 13, Bologna 40138, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Govoni, Raimondo, Palermo, Casadio, and Seracchioli); Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Cau, Palermo, Seracchioli)
| | - Eugenia Degli Esposti
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti, 13, Bologna 40138, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Govoni, Raimondo, Palermo, Casadio, and Seracchioli); Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Cau, Palermo, Seracchioli)
| | - Enrico Pazzaglia
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti, 13, Bologna 40138, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Govoni, Raimondo, Palermo, Casadio, and Seracchioli); Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Cau, Palermo, Seracchioli).
| | - Benedetta Orsini
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti, 13, Bologna 40138, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Govoni, Raimondo, Palermo, Casadio, and Seracchioli); Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Cau, Palermo, Seracchioli)
| | - Irene Cau
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Cau, Palermo, Seracchioli)
| | - Francesca Govoni
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti, 13, Bologna 40138, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Govoni, Raimondo, Palermo, Casadio, and Seracchioli)
| | - Diego Raimondo
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti, 13, Bologna 40138, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Govoni, Raimondo, Palermo, Casadio, and Seracchioli)
| | - Roberto Palermo
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti, 13, Bologna 40138, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Govoni, Raimondo, Palermo, Casadio, and Seracchioli); Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Cau, Palermo, Seracchioli)
| | - Jacopo Lenzi
- Department of biomedical and neuromotor sciences, Alma mater Studiorum, University of Bologna, Bologna, Italy (Dr. Lenzi)
| | - Paolo Casadio
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti, 13, Bologna 40138, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Govoni, Raimondo, Palermo, Casadio, and Seracchioli)
| | - Renato Seracchioli
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti, 13, Bologna 40138, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Govoni, Raimondo, Palermo, Casadio, and Seracchioli); Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy (Drs. Arena, Degli Esposti, Pazzaglia, Orsini, Cau, Palermo, Seracchioli)
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Falcone F, Laganà AS, Casarin J, Chiofalo B, Barra F, Garzon S, Ghezzi F, Vizza E, Malzoni M. Evaluation of Peri-Operative Management in Women with Deep Endometriosis Who are Candidates for Bowel Surgery: A Survey from the Italian Society of Gynecologic Endoscopy. J Minim Invasive Gynecol 2023; 30:462-472. [PMID: 36754274 DOI: 10.1016/j.jmig.2023.01.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/28/2023] [Accepted: 01/31/2023] [Indexed: 02/09/2023]
Abstract
STUDY OBJECTIVE There is great consensus that the implementation of the enhanced recovery after surgery (ERAS) approach is beneficial for surgical patients, but there is a paucity of data concerning its application in women with deep endometriosis (DE) who are candidates for bowel surgery. The survey described herein was aimed at gathering detailed information on perioperative management of DE patients who were undergoing sigmoid/rectal (discoid or segmental) resection within the Italian Society of Gynecologic Endoscopy (SEGI) group. DESIGN Baseline survey. SETTING National survey conducted within the main Italian cooperative group in minimally invasive gynecologic surgery (SEGI). PATIENTS The study did not involve patients. INTERVENTIONS A 63-item questionnaire covering ERAS items for gynecologic/elective colorectal surgery was sent to SEGI centers. Only questionnaires from centers that reported performing ≥10 sigmoid/rectal resections per year were considered for this analysis. MEASUREMENTS AND MAIN RESULTS Thirty-three of 38 (86.8%) of the questionnaires were analyzed. The rates of concordance with the ERAS guidelines were 40.4%, 64.4%, and 62.6% for preoperative, intraoperative, and postoperative items, respectively. The proportion of overall agreement was 56.6%. Preoperative diet, fasting and bowel preparation, correction of anemia, avoidance of peritoneal drains, postoperative feeding, and early mobilization were the most controversial items. Comparative analysis revealed that the referred rates of complete disease removal and conversion to open surgery were significantly different depending on case volume (p = .044 and p = .003, respectively) and gynecologist's/surgeon's experience (p = .042 and p = .022, respectively), with higher chances of obtaining a complete laparoscopic/robotic excision of endometriosis in centers that reported ≥30 DE surgeries performed per year and/or ≥90% of bowel resections performed by a gynecologist/general surgeon specifically dedicated to DE management. In contrast, the rates of concordance with the ERAS guidelines were not significantly different according to case volume (p = .081) or gynecologist's/surgeon's experience (p = .294). CONCLUSION This is the first study on DE conducted on a national scale. The current survey results revealed suboptimal compliance with the ERAS recommendations and underline the need to improve the quality of perioperative care in DE patients undergoing sigmoid/rectal resection. This study is a first step toward building a consistent, structured reporting platform for the SEGI units and facilitating wide implementation and standardization of the ERAS protocol for DE patients in Italy.
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Affiliation(s)
- Francesca Falcone
- Endoscopica Malzoni, Center for Advanced Endoscopic Gynecologic Surgery, Avellino, Italy (Dr. Falcone and Dr. Malzoni).
| | - Antonio Simone Laganà
- Unit of Gynecologic Oncology, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, ARNAS "Civico-Di Cristina-Benfratelli," University of Palermo, Palermo, Italy (Dr. Laganà)
| | - Jvan Casarin
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy (Dr. Casarin and Dr. Ghezzi)
| | - Benito Chiofalo
- Gynecologic Oncology Unit, Department of Experimental Clinical Oncology, IRCCS "Regina Elena" National Cancer Institute, Rome, Italy (Dr. Chiofalo and Dr. Vizza)
| | - Fabio Barra
- Unit of Obstetrics and Gynecology, P.O. "Ospedale del Tigullio"-ASL4, Metropolitan Area of Genoa, Genoa, Italy (Dr. Barra); Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy (Dr. Barra)
| | - Simone Garzon
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy (Dr. Garzon)
| | - Fabio Ghezzi
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy (Dr. Casarin and Dr. Ghezzi)
| | - Enrico Vizza
- Gynecologic Oncology Unit, Department of Experimental Clinical Oncology, IRCCS "Regina Elena" National Cancer Institute, Rome, Italy (Dr. Chiofalo and Dr. Vizza)
| | - Mario Malzoni
- Endoscopica Malzoni, Center for Advanced Endoscopic Gynecologic Surgery, Avellino, Italy (Dr. Falcone and Dr. Malzoni)
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