Surgical treatment of symptomatic colorectal endometriosis

Evolution of bowel complaints after laparoscopy endometriosis surgery: a 1497 women comparative study

STUDY OBJECTIVE

To assess what degree can digestive symptoms improve after endometriosis surgery for different localisations?

DESIGN

A comparative retrospective study employing data prospectively recorded in The North-West Inter-Regional Female Cohort for Patients with Endometriosis (CIRENDO) from June 2009 to November 2018.

SETTING

Two referral centres Patients: 1,497 women undergoing surgery due to pelvic endometriosis were divided into three groups: superficial endometriosis (Group 1, n=396), deep endometriosis sparing the bowel (Group 2, n=337), and deep endometriosis involving the bowel (Group 3, n=764).

INTERVENTIONS

Surgery for endometriosis.

MEASUREMENTS AND MAIN RESULTS

Preoperative and postoperative gastrointestinal symptoms were evaluated with standardised questionnaires, including the Gastrointestinal Quality of Life Index (GIQLI) and Knowles-Eccersley-Scott-Symptom questionnaire (KESS). The degree of postoperative improvement in digestive symptoms was compared between the groups. The women in Group 3 were significantly symptomatic in terms of cycle-related gastrointestinal symptoms and scores of standardised questionnaires GIQLI, KESS. According to the 1-year postoperative evaluation, women in Group 3 experienced the most significant improvement in their gastrointestinal symptoms.

CONCLUSION

Women with severe bowel symptoms and deep endometriosis infiltrating the bowel should be informed about the high probability of symptom improvement after the removal of bowel nodules. Conversely, in women without deep endometriosis, postoperatively, there is less improvement in baseline digestive complaints.

Rectal endometriosis presenting as toxic megacolon

Background

The bowel is the most common site of extragenital endometriosis, with involvement of the locoregional sigmoid colon and anterior rectum seen most often. The clinical presentation varies depending on how soon patients seek medical care, thus requiring changes in management strategies. Endometriosis can cause a life-threatening surgical emergency with progressive obliteration of the bowel lumen leading to obstruction and late complications including toxic megacolon and transmural necrosis.

Case presentation

We report the case of a 41-year-old woman presenting with an acute abdomen and complete large bowel obstruction complicated by sepsis and toxic megacolon. The patient underwent emergency total colectomy with ileostomy. Medical history was significant for chronic, vague, and episodic lower abdominal pain self-medicated with herbal tea and laxatives. Pathologic examination demonstrated colonic endometriosis within the bowel wall as the cause of obstruction, ischemia, and transmural necrosis.

Conclusions

Although a rare clinical entity, this case highlights two important points. First, it demonstrates the value of performing proper and complete clinical work up to rule out or in all possible causes of colonic obstruction, including intestinal endometriosis. Second, it suggests a potential benefit of a formalized multidisciplinary approach, including surgery, in the management of medically unresponsive endometriosis. In conclusion, this case shows that endometriosis can cause life-threatening colonic obstruction in women of childbearing age. Prompt early intervention is warranted, particularly when obstruction is only partial and ischemia has not supervened, to conceivably prevent the development of a toxic megacolon requiring colectomy and avoid late complications.

Surgical Management by Disk Excision or Rectal Resection of Low Rectal Endometriosis and Risk of Low Anterior Resection Syndrome: A Retrospective Comparative Study

STUDY OBJECTIVE

To assess the risk of low anterior resection syndrome (LARS) between women managed by either disk excision or rectal resection for low rectal endometriosis.

DESIGN

Retrospective study of a prospective database.

SETTING

University hospital.

PATIENTS

One hundred seventy-two patients managed by disk excision or rectal resection for deep endometriosis infiltrating the rectum <7 cm from the anal verge.

INTERVENTIONS

Rectal disk excision and/or segmental resection using transanal staplers.

MEASUREMENTS AND MAIN RESULTS

One hundred eight patients (62.8%) were treated by disk excision (group D) and 64 (37.2%) by rectal resection (group R). All patients answered the LARS score questionnaire. Follow-up was 33.3 ± 22 months for group D (range 12-108 months) and 37.3 ± 22.1 months (range 12-96 months) for group R (p = .25). The rates of rectovaginal fistula and pelvis abscess requiring radiologic drainage and surgery in the D and R groups were, respectively, 7.4% and 8.3% vs 7.8% and 9.3%. The rate of women with normal bowel movements postoperatively was higher in group D (61.1% vs 42.8%, p = .05). Women enrolled in group R reported higher frequency of stools (p <.001), clustering of stools (p = .02), and fecal urgency (p = .05). Regression logistic model revealed 2 independent risk factors for minor/major LARS: performing low rectal resection (adjusted odds ratio 2.28; 95% confidence interval, 1.1-4.7) and presenting with bladder atony requiring self-catheterization beyond postoperative day 7 (adjusted odds ratio 2.52; 95% confidence interval, 1.1-5.8).

CONCLUSION

The probability of normal bowel movements is higher after disk excision than after low rectal resection in women with deep endometriosis infiltrating the low rectum.

Deep endometriosis: medical or surgical treatment?

Deep endometriosis (DE) is classically defined as disease that infiltrates structures by more than 5 mm, such as bowel, ureters, bladder and vagina. The two major symptoms related to DE are pain and infertility. A lot of debate goes on upon the best treatment choice for DE. Treatments include medical therapy with oral progestins or combined contraceptives, and surgery for resection of DE nodules. In this review we focus on the best option treatment for the symptomatic patients with DE not seeking conception. We performed a narrative review of literature searching for the latest evidence on efficacy and outcomes of medical and surgical treatment of DE patients. Results showed that 2/3 of patients with DE will be satisfied with hormonal treatment, and surgery will be effective in improving QoL in most patients with DE. Most studies published regarding surgical outcomes involve bowel endometriosis, and their complication rates should not be extrapolated to all DE. DE that does not infiltrate pelvic viscera accounts for most cases of DE. Together with DE affecting the urinary tract, a much lower rate of severe complications is reported when compared to bowel endometriosis. This distinction should influence decision making. Medical treatment should be first option for non-complicated DE patients not seeking conception. Surgery should be indicated for those who do not tolerate nor improve with medical treatment, as well as those cases complicated by visceral impairment.

Conservative vs radical bowel surgery for endometriosis: A systematic analysis of complications

BACKGROUND

Endometriosis of the bowel can be associated with significant morbidity. Surgery to remove it carries risks. Options include conservative shaving or discoid resection and more radical segmental bowel resection.

AIMS

To determine if more conservative shaving or discoid bowel resection is associated with fewer risks than more radical segmental resection.

MATERIAL AND METHODS

This study is a systematic review. We considered eligible any cohort, observational or randomised controlled trial (RCT) study of at least ten women per arm comparing conservative vs radical bowel surgery for endometriosis. We divided complications into two groups, major and minor. One additional article was added due to its significance in answering our study question as well as the high quality of the study design as an RCT.

RESULTS

There were 3041 studies screened. Eleven studies were included (n = 1648). For major complications, the risk ratio for shaving and disc excision vs segmental resection is 0.31 (95% CI 0.21-0.46), while the risk difference is -0.25 (95% CI -0.41 to 0.10). For minor complications, the risk ratio is 0.63 (95% CI 0.36-1.09), while the risk difference is -0.03 (95% CI -0.12 to 0.05).

CONCLUSIONS

Conservative shaving or discoid excision surgery is associated with reduced complications. Previous studies demonstrated a trend toward this finding, but suffered from relatively low participant numbers, increasing the risk of type one statistical error. Our results allow surgeons to make informed choices about potential complications when deciding how to approach bowel endometriosis. The results also allow patients to have more information about the risks. However, outcomes in the studies analysed are heterogenous and are from low-quality evidence.

Comparison of robotic versus conventional laparoscopy for the treatment of colorectal endometriosis: Pilot study of an expert center

INTRODUCTION

Surgical management of deep endometriosis with colorectal involvement remains an option after failure of medical treatments. Conventional laparoscopy is currently considered the standard approach for surgical treatment. Recently, assisted-robotic laparoscopy emerged as an alternative to conventional laparoscopy but with low evidence.

METHODS

From March 2019 to September 2019, we conducted a prospective cohort study of 48 patients undergoing a surgical treatment for colorectal endometriosis (rectal shaving, discoid excision or segmental resection). The interventions were either performed by robotic or conventional laparoscopy. Patients' characteristics, operative and post-operative data were compared between the robotic and the conventional laparoscopic group.

RESULTS

48 patients were included, 25 in the conventional laparoscopy group and 23 in the robotic group. Patients' characteristics and operative findings were similar between the two groups, except for a trend in a higher incidence of associated surgical urinary or digestive procedures in the robotic group (p = 0.06). The mean total surgical room occupancy time and operating time were longer in the in the robotic group (281 ± 97 min vs 208 ± 85 min; p = 0.008) and (221 ± 94 min vs 163 ± 83 min (p = 0.03), respectively. The mean intra operative blood loss, the incidence of intra operative, post-operative complication (according to Clavien-Dindo classification) rates and voiding dysfunction were similar in the two groups. The rate of grade III complication was higher in the robotic group (13 % vs 0%) without reaching a significance (p = 0.17). The mean hospital stay was 8 ± 4.4 days in the robotic group and 6.5 ± 2.6 days in the conventional laparoscopy group (p = 0.18).

CONCLUSION

Despite our initial experience in robotic surgery, our results support that robotic surgery is an adequate alternative to conventional laparoscopy for endometriosis colorectal resection.

Identification of a group with high risk of postoperative complications after deep bowel endometriosis surgery: a retrospective study on 164 patients

PURPOSE

Identify a group with a high risk of postoperative complications after deep bowel endometriosis surgery.

METHODS

We conducted a retrospective study on patients treated from 2012 to 2018 in two departments of gynecological surgery at the Toulouse University Hospital, France. The postoperative complications were evaluated in relation to the surgical management, associated with or without non-digestive surgical procedures, initial disease and patient's characteristics.

RESULTS

164 patients were included. A postoperative complication occurred in 37.8% (n = 62) of the cases and required a secondary surgery in 18.3% (n = 30) of the cases. In the univariate analysis, the risk of postoperative complications increased significantly in the presence of segmental resection, disease progression, and associated urinary tract procedure or vaginal incision. In the multivariate analysis, the risk of overall postoperative complications was associated with the surgical management (p = 0.013 and 0.017) and particularly in the presence of segmental resection [Odds Ratio (OR): 20.87; CI 95% (1.96-221.79)]. The risk of rectovaginal fistula increased in the presence of segmental resection [OR: 22.71; CI 95% (2.74-188.01)] as well as in vaginal incision [OR: 19.67; CI 95% (2.43-159.18); p = 0.005].

CONCLUSION

The risk of overall postoperative complications and rectovaginal fistula in particular increases significantly in the presence of vaginal incision, segmental resection and urinary tract procedures after deep bowel endometriosis surgery.

Double Disk Excision of Large Deep Endometriosis Nodules Infiltrating the Low and Mid Rectum: A Pilot Study of 20 Cases

STUDY OBJECTIVE

To report the technique of double disk excision of deep endometriosis nodules infiltrating the mid or low rectum and surgical outcomes.

DESIGN

A retrospective case series using data prospectively recorded in the North-West Inter Regional Female Cohort for Patients with Endometriosis database.

SETTING

University tertiary referral center.

PATIENTS

Twenty women managed for large deep endometriosis nodules infiltrating the mid or low rectum.

INTERVENTIONS

Double disk excision using transanal end-to-end anastomosis circular stapler.

MEASUREMENTS AND MAIN RESULTS

Twenty women managed by double disk excision from May 2016 to September 2019 were included in the study. The mean time of intervention was 149 ± 74 minutes. The cumulated mean diameter of the excised rectal disks was 53.4 ± 19.1 mm, whereas in 85% of the women, it was ≥50 mm. The mean distance between the lowest margin of the disk and the anal verge was 66 mm. Vaginal infiltration was removed in 15 patients (75%), and in 6 patients (30%) it exceeded 30 mm in diameter. Owing to the presence of sigmoid colon nodules, 2 patients (10%) underwent concomitant segmental sigmoid resection of 4 cm and 6 cm in length, respectively. Transitory stoma was performed in 8 patients (40%) owing to concomitant vaginal excision >3 cm in size. After a follow-up varying from 3 months to 42 months, no digestive fistula was recorded. The rate of Clavien-Dindo 3 complications was 15%.

CONCLUSION

Double disk excision is suitable for excising large deep endometriosis nodules infiltrating the mid or low rectum and is associated with a low severe complication rate with good functional outcomes in women. Further studies are required to assess the improvement of functional outcomes in deep endometriosis nodules infiltrating the mid or low rectum in comparison with colorectal resection.

[Anatomic reports of vegetative nerves within para rectal fossa, to the rectal endometriosis surgery application]

OBJECTIVES

The objective of the study was to describe the inferior hypogastric plexus and nerves constituting the para-rectal fossa in order to study the importance of anatomical knowledge in rectal endometriosis surgery.

METHODS

In order to discover the complete anatomy of the study area, we carried out a review of the literature and relied on dissection of a female cadaver and operative dissections in patients treated for rectal endometriosis.

RESULTS

The inferior hypogastric plexus, the hypogastric nerve and the pelvic splanchnic nerves are the nervous elements component the para-rectal fossa. These nerves were important urinary, digestive and sexual functions. The dissection of the Okabayashi and the Latzko spaces within the para-rectal fossa and sparing nerve within this zone is more important for the prevention of traumatic nervous sequelae during rectal endometriosis surgery. The pelvic anatomy can be by attraction and sheathing nerve structures by endometriosis lesions which can complicate preservation techniques.

CONCLUSION

Lesions of pelvic vegetative nerves running through the para-rectal fossa can be responsible for urinary, digestive and sexual disorders that can affect patients quality of life. There is currently only one standardized "nerve sparing" technique in pelvic endometriosis surgery. Knowledge of the anatomy of the nerves making up the para-rectal fossa helps to orient the operative dissection and prevent postoperative nerve complications after surgery for rectal endometriosis.

Discoid resection for colorectal endometriosis: results from a prospective cohort from two French tertiary referral centres

AIM

Using a prospective database of discoid resection performed in two tertiary referral centres, the aim of this study is to assess the feasibility, short-term complication rates and clinical outcomes, including voiding dysfunction, of the procedure.

METHOD

A retrospective analysis of a prospective cohort database was conducted from February 2010 to October 2017 in two tertiary referral centres. One hundred and forty-eight consecutive patients scheduled for colorectal endometriosis by discoid resection were enrolled. The median follow-up was 21 months. All the women underwent complete preoperative assessment (MRI, transvaginal ultrasonography and rectal echo-endoscopy) before the removal of colorectal endometriosis. Postoperative complications were classified according to the Clavien-Dindo classification system as minor (grades I and II) or major (grades IIIA, IIIB and IV). Cases of voiding dysfunction were also noted.

RESULTS

The procedure was abandoned in seven patients. In 91 (64.5%) of the remaining 141 patients, the diameter of discoid resection removed was ≥ 30 mm. Surgery was performed by laparoscopy in 137/141 cases (92.7%). Grade I-III complications were observed in 37 patients (26.2%) with 11 grade IIIb (7.8%). Postoperative voiding dysfunction occurred in 16 patients (11.3%), 11 of whom required self-catheterization for < 1 month. In a multivariate analysis including age, body mass index, lesion size and history of previous surgery for endometriosis, a history of previous surgery was independently correlated to complication outcome (P = 0.043).

CONCLUSIONS

This analysis suggests that discoid resection is associated with good short-term results for women with colorectal endometriosis in a tertiary referral centre as it is associated with a low rate of postoperative complications.

Feasibility, Complications, and Recurrence after Discoid Resection for Colorectal Endometriosis: A Series of 93 Cases

Laparoscopic discoid colorectal resection is a surgical option for bowel endometriosis, 1 of the most severe forms of endometriosis. However, no study has clearly analyzed the feasibility or the complication and recurrence rates of the procedure in a homogeneous population with specific criteria for discoid resection. The aims of this study were to evaluate the rate of conversion to segmental resection, the need for double discoid resection, and the complication and recurrence rates. We conducted a prospective study of 93 consecutive patients who underwent discoid resection in Tenon University Hospital, Paris, France. The median follow-up was 20 months. We included patients with colorectal endometriosis (≤3 cm long and <90° of bowel circumference) experiencing failure of medical treatment or associated infertility. All the patients underwent a discoid colorectal resection using a transanal circular stapler. The primary end point was the rate of conversion to segmental resection (3.2%). The secondary end point was the rate of double discoid resection (6.5%). The overall complication rate was 24%, and the severe complication rate (i.e., Clavien-Dindo IIIB) was 3% (n = 4). Postoperative voiding dysfunction requiring bladder self-catheterization was observed in 16% (n = 15). The mean duration of bladder self-catherization was 30 days (range, 15-90) including 11 cases (74%) lasting less than 30 days and 4 cases lasting more than 30 days. No patients required bladder self-catheterization over 3 months. No difference in the complication rate or in voiding dysfunction was observed between double and single discoid resection. The low rate of conversion to radical resection confirms the satisfactory preoperative evaluation of bowel endometriosis. Few publications report the rate of conversion to radical surgery. This raises the crucial issue of the right indications for discoid resection. The present study confirms that discoid resection is probably the best option for small lesions because of its high feasibility and low complication rate. Further studies are required to evaluate the technique for larger colorectal endometriotic lesions.

Bowel endometriosis: diagnosis and management

The most common location of extragenital endometriosis is the bowel. Medical treatment may not provide long-term improvement in patients who are symptomatic, and consequently most of these patients may require surgical intervention. Over the past century, surgeons have continued to debate the optimal surgical approach to treating bowel endometriosis, weighing the risks against the benefits. In this expert review we will describe how the recommended surgical approach depends largely on the location of disease, in addition to size and depth of the lesion. For lesions approximately 5-8 cm from the anal verge, we encourage conservative surgical management over resection to decrease the risk of short- and long-term complications.

Gastrointestinal and Urinary Tract Endometriosis: A Review on the Commonest Locations of Extrapelvic Endometriosis

Extrapelvic endometriosis is a rare entity that presents serious challenges to researchers and clinicians. Endometriotic lesions have been reported in every part of the female human body and in some instances in males. Organs that are close to the uterus are more often affected than distant locations. Extrapelvic endometriosis affects a slightly older population of women than pelvic endometriosis. This might lead to the assumption that it takes several years for pelvic endometriosis to "metastasize" outside the pelvis. All current theories of the pathophysiology of endometriosis apply to some extent to the different types of extrapelvic endometriosis. The gastrointestinal tract is the most common location of extrapelvic endometriosis with the urinary system being the second one. However, since sigmoid colon, rectum, and bladder are pelvic organs, extragenital pelvic endometriosis may be a more suitable definition for endometriotic implants related to these organs than extrapelvic endometriosis. The sigmoid colon is the most commonly involved, followed by the rectum, ileum, appendix, and caecum. Most lesions are confined in the serosal layer; however, deeper lesion can alter bowel function and cause symptoms. Bladder and ureteral involvement are the most common sites concerning the urinary system. Unfortunately, ureteral endometriosis is often asymptomatic leading to silent obstructive uropathy and renal failure. Surgical excision of the endometriotic tissue is the ideal treatment for all types of extrapelvic endometriosis. Adjunctive treatment might be useful in selected cases.

Diagnostic and treatment guidelines for gastrointestinal and genitourinary endometriosis

Endometriosis is commonly misdiagnosed, even among many experienced gynecologists. Gastrointestinal and genitourinary endometriosis is particularly difficult to diagnose, and is commonly mistaken for other pathologies, such as irritable bowel syndrome, interstitial cystitis, and even psychological disturbances. This leads to delays in diagnosis, mismanagement, and unnecessary testing. In this review, we will discuss the diagnosis and management of genitourinary and gastrointestinal endometriosis. Medical management may be tried first, but often fails in cases of urinary tract endometriosis. This is particularly important in cases of ureteral endometriosis because silent obstruction can lead to eventual kidney failure. Thus, we recommend complete surgical treatment in these cases. Bladder endometriosis may be managed more conservatively, and only if symptomatic, because these rarely lead to significant morbidity. In cases of bowel endometriosis, we recommend medical management first in all cases, and the least invasive surgical management only if medical treatment fails. This is due to the extensive nervous and vasculature supply to the lower rectum. Injury to these nerves and vessels can cause significant complications and postoperative morbidity.

From Endometriosis to Pregnancy: Which is the “Road-Map”?

In the last decade, pregnancy was considered as a therapeutic period for patients affected by endometriosis and painful symptoms. However, several studies have taken into consideration how endometriosis affects pregnancy achievement and pregnancy development, including obstetric complications. The adverse effects of endometriosis on the development of pregnancy include miscarriage, hypertensive disorders and pre-eclampsia, placenta previa, obstetric hemorrhages, preterm birth, small for gestational age, and adverse neonatal outcomes. The aim of this review is to analyze the current literature regarding the relationship between different forms of endometriosis (endometrioma, peritoneal endometriosis, deep endometriosis) and infertility, and the impact of endometriosis on pregnancy outcomes.

Is ileostomy always necessary following rectal resection for deep infiltrating endometriosis?

OBJECTIVE

To verify the hypothesis that in most patients bowel segmental resection to treat endometriosis can be safely performed without creation of a stoma and to discuss the limitations of this statement.

DESIGN

Retrospective study (Canadian Task Force classification III).

SETTING

Tertiary referral center.

PATIENTS

Forty-one women with sigmoid and rectal endometriotic lesions who underwent segmental resection.

INTERVENTION

Segmental resection procedures performed between 2004 and 2011. Patient demographic, operative, and postoperative data were compared.

MEASUREMENTS AND MAIN RESULTS

Sigmoid resection was performed in 6 patients (15%), and rectal anterior resection in 35 patients (high in 21 patients [51%], and low, i.e., <10 cm from the anal verge, in 14 [34%]). In 4 patients a temporary ileostomy was created. There was 1 anastomotic leak (2.4%), in a patient with an unprotected anastomosis, which was treated via laparoscopic surgery and creation of a temporary ileostomy. Other postoperative complications included hemoperitoneum, pelvic abscess, pelvic collection, and a ureteral vaginal fistula, in 1 patient each (all 2.4%).

CONCLUSION

A protective stoma may be averted in low anastomosis if it is >5 cm from the anal verge and there are no adverse intraoperative events.

Clinical outcome after radical excision of moderate-severe endometriosis with or without bowel resection and reanastomosis: a prospective cohort study

OBJECTIVE

To assess the clinical outcome of women requiring laparoscopic excision of moderate-severe endometriosis in women with and without bowel resection and reanastomosis.

METHODS

Two hundred three patients with laparoscopically excised moderate (n = 67) or severe (n = 136) endometriosis (rAFS: revised endometriosis classification of the American Fertility Society) were prospectively followed during a median of 20 months (1-45 months) using a CONSORT-inspired checklist. Patients completed the EHP30 Quality-of-Life Questionnaire and visual analogue scales (VAS) for dysmenorrhea, chronic pelvic pain, and deep dyspareunia and answered questions about postoperative complications, reinterventions/recurrences, and fertility outcome 1 month before and 6, 12, 18, and 24 months after surgery. Clinical outcome was compared between women with deeply infiltrative endometriosis undergoing CO2 laser ablative surgery with bowel resection (study group, 76/203; 37%) and without bowel resection (control group, 127/203; 63%).

RESULTS

Both groups were similar with respect to population characteristics and clinical outcome, except for mean rAFS score [higher in study group (73 ± 31) than in control group (48 ± 26)] and minor complication rate [higher in study group (11%) than in control group (1%)]. In both groups, mean VAS and EHP30 scores improved significantly and remained stable for 24 months after surgery, with a pregnancy rate of 51%. Within 1, 2, and 3 years follow-up, the cumulative reintervention rate was 1%, 7%, and 10%, respectively, and the cumulative endometriosis recurrence rate was 1%, 6%, and 8%, respectively.

CONCLUSIONS

Clinical outcome after CO2 laser laparoscopic excision of moderate-severe endometriosis was comparable in women with or without bowel resection and reanastomosis, except for a higher minor complication rate occurring in women with bowel resection and reanastomosis (NCT00463398).

The outcomes of laparoscopic resection of bowel endometriosis

PURPOSE OF REVIEW

To present the outcome of laparoscopic resection for bowel endometriosis.

RECENT FINDINGS

In the last 12 months, numerous articles have been published to demonstrate and underline the efficiency and feasibility of the laparoscopic approach in the treatment of bowel endometriosis.

SUMMARY

Endometriosis is a common condition that can affect women in their reproductive age. It can have an intestinal involvement, and when it occurs rectum and rectosigmoid junction are the most frequent sites; other lesser frequent sites are the appendix, the distal ileum, and the cecum. It is widely agreed that surgical management is the primary treatment for symptomatic bowel endometriosis. Laparoscopic bowel resection has become increasingly popular because it represents a well tolerated and feasible technique.

[Experience with multidisciplinary laparoscopic surgery in patients with deep infiltrating colorectal endometriosis]

INTRODUCTION

Deep infiltrating endometriosis is a particular form of endometriosis that penetrates the peritoneal surface or it reaches the subserosal neurovascular plexus.

AIM

The aim of the authors was to analyze the results of segmental colorectal resections performed for deep infiltrating endometriosis.

METHOD

Between 2009 and 2012, 50 patients underwent segmental rectum or/and sigmoid resection for endometriosis.

RESULTS

21 patients had ultralow rectal resection and 29 patients had low colorectal anastomosis or anterior resection. Concomitant intervention in other organs was required in all cases, including gynecologic procedures (n = 50), additional gynecologic (n = 47), vesical (n = 9) and ureteral (n = 18) resections. The mean number of endometriosis lesions was 2.4±1.8 per patient. In all patients fertility was preserved. Severe surgical complications (Clavien-Dindo stage III or more severe) occurred in 3 patients (6%).

CONCLUSIONS

The results confirm that segmental bowel resection is an efficient and safe method for the treatment of deep infiltrating colorectal endometriosis. Orv. Hetil., 2014, 155(5), 182-186.

Multidisciplinary laparoscopic treatment for bowel endometriosis

Endometriosis is a handicapping disease affecting young females in the reproductive period. It mainly occurs in the pelvis and affects the bowel in 3-37%. Endometriosis can cause menstrual and non-menstrual pelvic pain and infertility. Colorectal involvement results in alterations of bowel habit such as constipation, diarrhoea, tenesmus, and rarely rectal bleeding. A precise diagnosis about the presence, location and extent is necessary. Based on clinical examination, the diagnosis of bowel endometriosis can be made by transvaginal ultrasound, barium enema examination and magnetic resonance imaging. Multidisciplinary laparoscopic treatment has become the standard of care and depending on size of the lesion and site of involvement full-thickness disc excision or bowel resection is performed by an experienced colorectal surgeon. Anastomotic complications occur around 1%. Long-term outcome after bowel resection for severe endometriosis is good with a pregnancy rate of 50%.

Bowel dysfunction before and after surgery for endometriosis

The relationship between deep fibrotic endometriosis of the rectum and digestive symptoms as well as the impact of surgical treatment on digestive complaints appears increasingly complex. With the exception of cases in which the disease leads to rectal stenosis, it seems likely that certain digestive symptoms are a result of cyclic inflammatory phenomena leading to irritation of the digestive tract and not necessarily the result of actual involvement of the rectum by the disease itself because they frequently occur in women free of rectal nodules. Functional or inflammatory bowel diseases and rectal hypersensitivity may be associated with pelvic endometriosis and consequently joepardize the hypothetical causal relationship between the presence of a rectal nodule and digestive complaints. Women treated surgically for rectal endometriosis may continue to experience postoperative digestive complaints, such as constipation. Despite successful surgery free of intra- and postoperative complications and significant improvement in well-being and pelvic pain, several unpleasant digestive symptoms may be incompletely cured by the surgery. Furthermore, de novo postoperative digestive complaints may occur after rectal surgery. Retrospective data suggest that performing colorectal resection is related to less favorable digestive functional outcomes than the use of conservative procedures such as shaving or full-thickness disc excision. These hypotheses need to be confirmed by prospective randomized trials comparing rectal radical and conservative approaches. Bearing in mind the complex relationship between rectal nodules, digestive symptoms and rectal surgery, particular care must be taken in the preoperative assessment of digestive function and in choosing the most suitable surgical procedure.

Deep infiltrating colorectal endometriosis treated with robotic-assisted rectosigmoidectomy

Robotic-assisted surgery for the treatment of deep infiltrating bowel endometriosis appears to be feasible, effective, and safe.

Background and Objective:

Deep infiltrating pelvic endometriosis with bowel involvement is one of the most aggressive forms of endometriosis. Nowadays, robotic technology and telemanipulation systems represent the latest developments in minimally invasive surgery. The aim of this study is to present our preliminary results and evaluate the feasibility of robotic-assisted laparoscopic colorectal resection for severe endometriosis.

Methods:

Between September 2009 and December 2011, 10 women with colorectal endometriosis underwent surgery with the da Vinci robotic surgical system (Intuitive Surgical, Sunnyvale, CA, USA). We evaluated the following parameters: short-term complications, clinical outcomes and long-term follow-up, pain relief recurrence rate, and fertility outcomes.

Results:

Extensive ureterolysis was required in 8 women (80%). Ovarian cystectomy with removal of the cystic wall was performed in 7 women (70%). Torus resection was performed in all women, with unilateral and bilateral uterosacral ligament resection in 1 woman (10%) and 8 women (80%), respectively. In addition to segmental colorectal resection in all cases, partial vaginal resection was necessary in 2 women (20%). An appendectomy was performed in 2 patients (20%). The mean operative time with the robot was 157 minutes (range, 90–190 minutes). The mean hospital stay was 3 days. Six patients had infertility before surgery, with a mean infertility time of 2 years. After a 12-month follow-up period, 4 women (67%) conceived naturally and 2 (33%) underwent in vitro fertilization.

Conclusion:

We show that robotic-assisted laparoscopic surgery for the treatment of deep infiltrating bowel endometriosis is feasible, effective, and safe.

Effect of laparoscopic surgery for moderate and severe endometriosis on depression, relationship satisfaction and sexual functioning: comparison of patients with and without bowel resection

STUDY QUESTION

Is there a difference between women with endometriosis who underwent laparoscopic surgery with bowel resection or without bowel resection regarding depressive symptoms, relational adjustment and sexual functioning?

SUMMARY ANSWER

Radical surgery for endometriosis in both groups improved the levels of depression and sexual functioning, but only the bowel resection patients showed improvements in relationship satisfaction. WHAT IS KNOWN ALREADY?: The frequent pain symptoms in endometriosis patients can have an impact on psychological issues, relationships and sexual functioning. There are no data available on depression and relationship adjustment after endometriosis surgery. Sexual dysfunction problems have been described after bowel resection for rectal cancer, but no data are available for endometriosis surgery.

STUDY DESIGN, SIZE, DURATION

This prospective cohort study included 203 consecutive women operated at the Leuven University Fertility Center (LUFC) between 1 September 2006 and 30 September 2008 for moderate (n = 67) or severe (n = 136) endometriosis. The preoperative response rate was respectively 84% in the bowel resection group and 79% in the no bowel resection group.

PARTICIPANTS, SETTING, METHODS

The beck depression inventory (BDI) measured depression, the dyadic adjustment scale (DAS) measured relationship satisfaction and the short sexual functioning scale (SSFS) measured sexual functioning before and 6, 12 and 18 months after women had laparoscopic surgery at the LUFC, a tertiary referral centre for fertility exploration, treatment and surgery.

MAIN RESULTS AND THE ROLE OF CHANCE

Both groups had better post-operative outcomes when compared with the preoperative assessments. Mean BDI and DAS levels were comparable with the normal population. Overall assessment points, the bowel resection patients had better outcomes for DAS (P < 0.05) and SSFS 'arousal' (P < 0.05) than the no bowel resection patients. At 6 months after the operation, when compared with the no bowel resection group, the bowel resection group reported lower mean levels of BDI (P < 0.05), a lower incidence of SSFS 'pain during intercourse' and 'orgasm problems' (P < 0.05), and a lower proportion of patients with severe orgasm problems (P < 0.05). The data show that radical but fertility sparing surgery, with or without bowel resection, for the treatment of endometriosis results in comparable and good psychological outcomes concerning depression levels, relationship satisfaction and sexual functioning.

LIMITATIONS, REASONS FOR CAUTION

Although the initial response rate was good, response dropped over time and was significantly higher for bowel resection patients compared with the no bowel resection patients (P = 0.05). A responder/non-responder analysis for the whole study population showed no significant differences concerning pain problems. This reduces the possible risk of (positive) bias in the results.

WIDER IMPLICATIONS OF THE FINDINGS

Endometriosis is a complex condition and the focus should not be on a one-dimensional end-organ gynaecological outcome, but should take into account the role of psychological factors in pain-related outcome. To this end, more prospective data are needed on sexual functioning and psychological outcomes.

Clinical outcome after laparoscopic radical excision of endometriosis and laparoscopic segmental bowel resection

PURPOSE OF REVIEW

To present the clinical outcome after laparoscopic radical excision of deeply infiltrative endometriosis (DIE) with colorectal extension and laparoscopic segmental bowel resection.

RECENT FINDINGS

In three different studies including mostly patients with recurrent DIE with colorectal extension, we showed that radical reconstructive CO2 laser laparoscopic resection of DIE with colorectal extension in a multidisciplinary setting resulted in a low complication rate, a low cumulative reintervention and recurrence rate and a high cumulative pregnancy rate, also when bowel resection reanastomosis was performed. In a systematic review to assess the clinical outcome of surgical treatment of DIE with colorectal involvement, data were reported in such a way that comparison of different surgical techniques was not possible. A checklist is proposed to achieve standardized reporting of presenting symptoms, preoperative tests, inclusion criteria, preoperative and postoperative care, complications, follow-up, patient-centered assessment of pain and quality of life, fertility and recurrence corrected for postoperative use of hormonal suppression or infertility treatment.

SUMMARY

CO2 laser laparoscopic radical excision of DIE with colorectal extension and laparoscopic segmental bowel resection in centers of expertise is associated with good clinical outcome. To make real progress, international agreement is needed on terms and definitions used in surgical endometriosis research.

Robotic surgery and standard laparoscopy: a surgical hybrid technique for use in colorectal endometriosis

AIM

The aim of our work was to assess the feasibility and possible benefits of a novel hybrid surgical technique in rectosigmoidal resection in patients with bowel endometriosis.

MATERIAL AND METHODS

A total of seven symptomatic and infertile women with severe bowel endometriosis underwent segmental bowel resection using the da Vinci surgical system and conventional laparoscopy. Statistical analysis was performed by Friedman test for non-parametric multiple comparisons.

RESULTS

The surgical procedure has a determined short mean operative time (210min) and short postoperative hospitalization (five days). In 100% of patients, the resected area showed disease-free margins. Follow-up, carried out at three, six and 12months after operation, showed a regression of painful symptoms in all operated patients (100%). Two patients (28.6%) aged≥35years eventually had natural pregnancies.

CONCLUSION

To the best of our knowledge, this report is the first concerning the use of a hybrid technique for intestinal resection in severe endometriosis, and comparing our data with that in the literature, its methodological and clinical advantages are evident. Moreover, the complete removal of endometriotic implants seems to offer good results in terms of postoperative fertility, although the study data do not allow us to draw definitive conclusions on the management of fertility.

Robotic treatment of colorectal endometriosis: technique, feasibility and short-term results

BACKGROUND

Deep infiltrating endometriosis (DIE) is a complex disease that impairs the quality of life and the fertility of women. Since a medical approach is often insufficient, a minimally invasive approach is considered the gold standard for complete disease excision. Robotic-assisted surgery is a revolutionary approach, with several advantages compared with traditional laparoscopic surgery.

METHODS

From March 2010 to May 2011, we performed 22 consecutive robotic-assisted complete laparoscopic excisions of DIE endometriosis with colorectal involvement. All clinical data were collected by our team and all patients were interviewed preoperatively and 3 and 6 months post-operatively and yearly thereafter regarding endometriosis-related symptoms. Dysmenorrhoea, dyschezia, dyspareunia and dysuria were evaluated with a 10-point analog rating scale.

RESULTS

There were 12 patients, with a median larger endometriotic nodule of 35 mm, who underwent segmental resection, and 10 patients, with a median larger endometriotic nodule of 30 mm, who underwent complete nodule debulking by colorectal wall-shaving technique. No laparotomic conversions were performed, nor was any blood transfusion necessary. No intra-operative complications were observed and, in particular, there were no inadvertent rectal perforations in any of the cases treated by the shaving technique. None of the patients had ileostomy or colostomy. No major post-operative complications were observed, except one small bowel occlusion 14 days post-surgery that was resolved in 3 days with medical treatment. Post-operatively, a statistically significant improvement of patient symptoms was shown for all the investigated parameters.

CONCLUSIONS

To our knowledge, this is the first study reporting the feasibility and short-term results and complications of laparoscopic robotic-assisted treatment of DIE with colorectal involvement. We demonstrate that this approach is feasible and safe, without conversion to laparotomy.

[Intestinal endometriosis]

Endometriosis affects 6 to 10 % of all women of childbearing age. Intestinal involvement is defined by muscularis infiltration and has been estimated to occur in 8 % to 12 % of women with endometriosis. The most common sites are rectum, sigmoid and ileocaecal junction. In most cases, intestinal endometriosis is associated with deep infiltrating endometriosis, multifocal and aggressive form of endometriosis, responsible for refractory pelvic pain and infertility. The symptoms are nonspecific but are characterized by cyclic exacerbation of pain. The preoperative work-up includes a rectal endoscopic ultrasonography, a transvaginal ultrasonography, a pelvic magnetic resonance imaging and a multidetector CT scan. There is currently no cure other than surgical removal of lesions. Medical treatments are based on a hormone used to block ovarian function.

Clinical outcome after CO₂ laser laparoscopic radical excision of endometriosis with colorectal wall invasion combined with laparoscopic segmental bowel resection and reanastomosis

BACKGROUND

Laparoscopic segmental bowel resection and reanastomosis for endometriosis with colorectal wall invasion can be associated with high complication rates. This study was performed to test the hypothesis that this high complication rate can be prevented and combined with a good clinical outcome, following a multidisciplinary surgical approach.

METHODS

A retrospective cohort study of all patients with deep endometriosis and colorectal invasion treated by CO₂ laser laparoscopic radical excision between September 2004 and September 2006 (n = 45) to document the clinical outcome: complications, recurrence and fertility (life table analysis), pain, quality of life (QOL) and sexual function.

RESULTS

No immediate major post-operative complications requiring surgical reintervention were recorded. Gynaecological pain (P < 0.0001), sexual function (P < 0.03) and QOL (P< 0.0001), improved significantly after a median follow-up period of 27 (range: 16-40) months. Although five patients (11%) had a surgical reintervention, histologically proven recurrent endometriosis was observed in only two (4%), with a cumulative endometriosis recurrence rate of 2.2 and 4.4% after 1 and 3 years, respectively. Thirteen of 28 patients who wanted to become pregnant conceived after surgery. One patient delivered twice. These 14 pregnancies were achieved spontaneously (n = 9) or after IVF (n = 5). The cumulative pregnancy rate was 47% after 3 years.

CONCLUSION

Pain, sexual function and QOL improved significantly and were associated with a good fertility rate and a low complication and recurrence rate after a CO₂ laser laparoscopic radical excision of endometriosis with colorectal wall invasion combined with laparoscopic segmental bowel resection and reanastomosis.

Symptomatic intestinal endometriosis requiring surgical resection: clinical presentation and preoperative diagnosis

OBJECTIVES

Intestinal endometriosis (IE) can present with varied symptoms, making the diagnosis difficult. Modalities have been described to evaluate IE, but few can provide a confirmatory diagnosis. A preoperative diagnosis of IE may help guide management. We sought to describe the presentation, diagnostic evaluation, histology and operative management of 89 patients with tissue-confirmed symptomatic IE.

METHODS

The records of 89 patients from a single institution with histologically confirmed, symptomatic IE from 1 January 1994 to 30 September 2009 were reviewed.

RESULTS

Abdominal pain was the most common symptom in patients with IE; however, rectal bleeding was significantly associated with IE of the distal colon (P=0.02), while dysfunctional uterine bleeding was seen more in patients with proximal IE (P=0.01). Preoperative confirmation of IE was uncommon; colonoscopy with biopsy confirmed the diagnosis in 29.6% of patients tested and only 15% of patients with IE had histologic lesions involving mucosa. In the five patients who underwent endoscopic ultrasound (EUS), the diagnosis of IE was established in all cases (n=4) where histology or cytology was obtained. Malignancy was considered nearly as frequently as IE preoperatively, and 90.4% of patients underwent laparotomy as the initial surgical approach.

CONCLUSIONS

IE can present with a variety of manifestations, which may provide clues to location of bowel affected. Patients with known pelvic endometriosis and rectal bleeding are more likely to have distal bowel affected; EUS with tissue sampling may play a role if routine endoscopy fails to reveal the diagnosis. Making a diagnosis of IE preoperatively may allow for less invasive surgical approaches and better patient outcomes.

Preoperative assessment of intestinal endometriosis: A comparison of transvaginal sonography with water-contrast in the rectum, transrectal sonography, and barium enema

To evaluate the accuracy of Transrectal Sonography (TRS) and a new technique, Transvaginal Sonography with Water-Contrast in the Rectum (RWC-TVS), in the diagnosis of rectosigmoid endometriosis, and the accuracy of Barium Enema (BE) and RWC-TVS in the detection of intestinal stenosis due to endometriosis. In a prospective study, we compared the findings of TRS and RWC-TVS performed before surgery with the operative and pathologic findings in 61 consecutive patients who underwent laparoscopy or laparotomy for suspected rectosigmoid endometriosis. The accuracy of BE and RWC-TVS in the detection of intestinal stenosis was evaluated comparing the radiologic and ultrasonographic results with the macroscopic findings at surgery and pathology. RWC-TVS diagnosed rectosigmoid endometriosis with the same accuracy of TRS and was equally efficient as BE in the detection of a significant intestinal lumen stenosis. For the diagnosis of rectosigmoid endometriosis the sensitivity, specificity, positive and negative predictive values of TRS and RWC-TVS were 88.2% and 96%, 80%, and 90%, 95.7%, and 98%, and 57.1% and 81.8%, respectively. For the detection of intestinal stenosis the sensitivity, specificity, positive and negative predictive values of BE and RWC-TVS were 93.7% and 87.5%, 94.2% and 91.4%, 88.2% and 82.3%, and 97% and 94.1%, respectively. RWC-TVS is a new, simple technique for a single-step and accurate preoperative assessment of rectosigmoid endometriosis.

Fertility after colorectal resection for endometriosis: results of a prospective study comparing laparoscopy with open surgery

OBJECTIVE

To determine whether the surgical route of colorectal resection for endometriosis is a determinant factor for fertility.

DESIGN

Prospective study.

SETTING

Tertiary-care university hospital.

PATIENT(S)

Fifty-two patients with endometriosis were randomly assigned to laparoscopic or open surgery.

INTERVENTION(S)

Laparoscopically assisted vs. open colorectal resection.

MAIN OUTCOME MEASURE(S)

Evaluation of fertility outcomes spontaneously and after assisted reproductive therapy.

RESULT(S)

The mean follow-up was 29 months. Among the 28 patients wishing to conceive, 11 (39.3%) became pregnant. Overall cumulative pregnancy rate at 52 months for these patients was 45.1%. For patients with or without infertility, the cumulative pregnancy rate was 37.6% and 55.6%, respectively, and the cumulative spontaneous pregnancy rate 13.3% and 36.5%, respectively. All the spontaneous pregnancies were observed in the laparoscopy group.

CONCLUSION(S)

This study demonstrates that spontaneous pregnancy is more frequent after laparoscopy compared with open surgery for colorectal endometriosis.