Bowel function and quality of life following surgery for deep endometriosis

Pregnancy and Neonatal Outcomes in Women Treated for Bowel Endometriosis: A Seven-Year Single-Centre Retrospective Matched Cohort Study

Background/Objectives: Deep infiltrating endometriosis has been linked to worsened maternal and neonatal outcomes. However, reports regarding bowel endometriosis are still scanty. We aimed to evaluate pregnancy, delivery, and newborn adverse outcomes in women after laparoscopic-assisted surgery for bowel endometriosis. Methods: A single-center retrospective cohort study was conducted at a tertiary-care university hospital. From January 2015 to December 2021, pregnant women who were diagnosed and treated for bowel endometriosis were matched using a 1:3 ratio with pregnant women with no history of endometriosis. Patients were matched using the Cox proportional hazards model to determine parity, age, BMI and gestational age-adjusted relative risk (aRR) with a 95% confidence interval (CI). Co-primary outcomes were the incidence of labor abnormalities and cesarean section (CS) rate. Co-secondary outcomes were incidence of complications related to pregnancy, delivery, and newborn. Results: A total of 71 pregnancies among women treated for bowel endometriosis and 213 from healthy controls were included. Patients requiring IVF/ET for getting pregnant were in the bowel endometriosis group relative to controls (43.7% vs. 11.7%; p < 0.001). Increased risk of labor abnormalities was present for bowel endometriosis relative to controls (21.1% vs. 17.4%; p = 0.040; aRR 1.39 [95% CI 1.06-2.05]). Risk of non-cephalic fetal presentation (14.1% vs. 6.1%; p = 0.016; aRR 3.08 [95% CI 2.03-4.68]), CS rate (43.7% vs. 24.9%; p = 0.003; aRR 1.75 [95% CI 1.23-2.49]), and emergent CS rate (19.7% vs. 8.5%; p = 0.009; aRR 2.21 [95% CI 1.55-3.16]) were significantly higher in women treated for colorectal endometriosis compared with controls. Moreover, placenta previa (9.9% vs. 0.0%; p < 0.001; aRR 21.82 [95% CI 2.19-116.40]), second-trimester hemorrhage (5.6% vs. 0.9%; p = 0.017; aRR 6.00 [95% CI 1.12-32.06]), postpartum hemorrhage (15.5% vs. 3.3%; p < 0.001; aRR 4.71 [95% CI 1.90-11.70]), and the need for transfusion during labor (5.6% vs. 0.5%; p = 0.004; aRR 12.00 [95% CI 1.36-105.60]) were increased in treatments vs. controls. Concerning neonatal outcomes, an increased risk for neonatal intensive care unit admission was seen in postsurgical endometriotic women relative to healthy controls (26.0% vs. 6.9%; p < 0.001; aRR 3.75 [2.04-3.86]). Conclusions: Women treated for bowel endometriosis seem more exposed to adverse pregnancy and neonatal outcomes relative to healthy controls. However, additional prospective and comparative studies are needed to validate the available evidence.

Totally intracorporeal colorectal anastomosis (TICA) versus classical mini-laparotomy for specimen extraction, after segmental bowel resection for deep endometriosis: a single-center experience

PURPOSE

The surgical approach to bowel endometriosis is still unclear. The aim of the study is to compare TICA to conventional specimen extractions and extra-abdominal insertion of the anvil in terms of both complications and functional outcomes.

METHODS

This is a single-center, observational, retrospective study conducted enrolling symptomatic women underwent laparoscopic excision of deep endometriosis with segmental bowel resection between September 2019 and June 2022. Women who underwent TICA were compared to classical technique (CT) in terms of intra- and postoperative complications, moreover, functional outcomes relating to the pelvic organs were assessed using validated questionnaires [Knowles-Eccersley-Scott-Symptom (KESS) questionnaire and Gastro-Intestinal Quality of Life Index (GIQLI)] for bowel function. Pain symptoms were assessed using Visual Analogue Scale (VAS) scores.

RESULTS

The sample included 64 women. TICA was performed on 31.2% (n = 20) of the women, whereas CT was used on 68.8% (n = 44). None of the patients experienced rectovaginal, vesicovaginal, ureteral or vesical fistula, or ureteral stenosis and uroperitoneum, and in no cases was it necessary to reoperate. Regarding the two surgical approaches, no significant difference was observed in terms of complications. As concerns pain symptoms at 6-month follow-up evaluations on stratified data, except for dysuria, all VAS scales reported showed significant reductions between median values, for both surgery interventions. As well, significant improvements were further observed in KESS scores and overall GIQLI. Only the GIQLI evaluation was significantly smaller in the TICA group compared to CT after the 6-month follow-up.

CONCLUSIONS

We did not find any significant differences in terms of intra- or post-operative complications compared TICA and CT, but only a slight improvement in the Gastro-Intestinal Quality of Life Index in patients who underwent the CT compared to the TICA technique.

Measurement properties of sexual function assessment questionnaires in women with endometriosis: A systematic review following COSMIN guidelines

INTRODUCTION

Sexual function of patients with endometriosis should be assessed by patient-reported outcome measures (PROMs) that present high reliability and validity. The objective was to study the PROMs used to assess sexual function for patients with endometriosis to improve their selection for research and clinical practice.

MATERIAL AND METHODS

We performed a systematic literature review from January 2000 to September 2023. All studies including women with confirmed endometriosis and assessing sexual quality of life or sexual function or sexual distress were retrieved. Different properties of PROMs used for sexual dysfunction were assessed according to the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) recommendations. Properties evaluated were: structural validity, internal consistency, cross-cultural validity, reliability, measurement error, criterion validity, construct validity, and responsiveness. This literature review was registered on Prospero as 2018 CRD42018102278.

RESULTS

Seventy-four articles with evaluation of sexual function were included. Of the 25 PROMs assessing sexual function, the Female Sexual Function Index (FSFI) was the most frequently used (34/74 [45.9%] items), followed by the Female Sexual Distress Scale (9/74 [12.2%] items) and the Sexual Activity Questionnaire (SAQ) (8/74 [10.8%] items). The most commonly used measurement properties were "hypothesis testing" and "responsiveness". The PROMs with a high level of evidence for these two measurement properties were the FSFI, the SAQ, the Short Sexual Functioning Scale, the Sexual Satisfaction Scale for Women, Sexual Quality of Life-Female, the Brief Profile of Female Sexual Function, and the Sexual Health Outcomes in Women Questionnaire. The FSFI questionnaire appeared to be more relevant for evaluating medical treatment, and the SAQ for evaluating surgical treatment. Only one instrument was specific to endometriosis (the Subjective Impact of Dyspareunia Inventory [SIDI]).

CONCLUSIONS

In this systematic literature review of sexual function assessment questionnaires in endometriosis, the FSFI and the SAQ questionnaires emerged as having the best measurement properties according to the COSMIN criteria. The FSFI questionnaire appears to be suited for evaluating medical treatment, and the SAQ for surgical treatment. The SIDI is the only specific questionnaire, but its responsiveness remains to be defined.

Early Quality of Life Assessment After Segmental Colorectal Resection for Deep Infiltrating Endometriosis

STUDY OBJECTIVE

Endometriosis is a benign condition afflicting women of reproductive age that significantly impacts their quality of life (QoL). Given its debilitating symptoms and prevalence, it is essential to define its proper management. In this study, we have assessed patient-reported outcomes among women having undergone segmental colorectal resection for deep infiltrating endometriosis. Any correlation between preoperative nutritional status and overall postoperative complications has also been analyzed.

STUDY DESIGN

Prospective observational study.

SETTING

Public medical center.

PATIENTS

One hundred forty consecutive patients that had undergone segmental colorectal resection for DIE between November 2020 and October 2021 at IRCCS Sacro Cuore Don Calabria Hospital of Negrar of Valpolicella (Verona, Italy).

INTERVENTIONS

Patient-reported outcomes were measured using data collected from the MD Anderson Symptom Inventory for gastrointestinal surgery patients and Euro-QoL Group EQ-5D-5L (EQ-5Q-5L) questionnaires, which were administered preoperatively (T0), at discharge (T1) and at 4 to 6 weeks after surgery (T2). Nutritional status was examined through the Mini Nutritional Assessment Short form and Prognostic Nutritional Index.

MEASUREMENTS AND MAIN RESULTS

A significant improvement in the EQ-5Q-5L and MDASI-GI scores was noted between T0 and T2 (p <. 001 and p <. 001, respectively.) No statistically significant differences were found in scores at T2 between patients who had experienced postoperative complications and those who had not. No statistically significant association was observed between the presence of malnutrition and overall postoperative complications and their severity.

CONCLUSION

This study confirms, through patient-reported outcomes, the pivotal role of surgery in improving the QoL at 4 to 6 weeks of women affected by endometriosis who have previously been unresponsive to medical therapy.

Faecal incontinence-a comprehensive review

Introduction

Faecal incontinence (FI) is a distressing and often stigmatizing condition characterised as the recurrent involuntary passage of liquid or solid faeces. The reported prevalence of FI exhibits considerable variation, ranging from 7 to 15% in the general population, with higher rates reported among older adults and women. This review explores the pathophysiology mechanisms, the diagnostic modalities and the efficiency of treatment options up to date.

Methods

A review of the literature was conducted to identify the pathophysiological pathways, investigation and treatment modalities.

Result and discussion

This review provides an in-depth exploration of the intricate physiological processes that maintain continence in humans. It then guides the reader through a detailed examination of diagnostic procedures and a thorough analysis of the available treatment choices, including their associated success rates. This review is an ideal resource for individuals with a general medical background and colorectal surgeons who lack specialized knowledge in pelvic floor disorders, as it offers a comprehensive understanding of the mechanisms, diagnosis, and treatment of faecal incontinence (FI).

Vascular- and nerve-sparing bowel resection for deep endometriosis: A retrospective single-center study

OBJECTIVE

Surgical management of bowel endometriosis is still controversial. Recently, many authors have pointed out the potential benefits of preserving the superior rectal artery, thus ensuring better perfusion of the anastomosis. The aim of this study was to evaluate the complication rate and functional outcomes of a bowel resection technique for deep endometriosis (DE) involving a nerve- and vascular-sparing approach.

METHODS

A single-center retrospective study was conducted by enrolling patients who underwent segmental resection of the rectus sigmoid for DE in our department between September 2019 and April 2022. Intraoperative and postoperative complications were recorded for each woman, and functional outcomes relating to the pelvic organs were assessed using validated questionnaires (Knowles-Eccersley-Scott-Symptom [KESS] questionnaire and Gastro-Intestinal Quality of Life Index [GIQLI] for bowel function, Bristol Female Lower Urinary Tract Symptoms [BFLUTS] for urinary function, and Female Sexual Function Index [FSFI] for sexual function). These were evaluated preoperatively and postoperatively after 6 months from surgery.

RESULTS

Sixty-one patients were enrolled. No patients had Clavien-Dindo grade 3 or 4 complications, there were no rectovaginal fistulas or ureteral lesions, and in no cases was it necessary to reoperate. Temporary bladder voiding deficits were reported in 8.2% of patients, which were treated with self-catheterizations, always resolving within 45 days of surgery. Gastrointestinal function evaluated by KESS and GIQLI improved significantly after surgery, whereas sexual function appeared to worsen, although without reaching the level of statistically significant validity.

CONCLUSION

Our vascular- and nerve-sparing segmental bowel resection technique for DE had a low intraoperative and postoperative complication rate and produced an improvement in gastrointestinal function after surgery.

Sacral Neuromodulation for defecation disorders after non oncologic pelvic surgery

PURPOSE

Defecation disorders (DD) can sometimes affect the outcomes of pelvic or colorectal surgery. The aim of the present study is to evaluate the role of sacral neuromodulation for the treatment of constipation and other evacuation disorders after surgery.

METHODS

A retrospective analysis in all the consecutive patients that underwent sacral nerve modulation (SNM) for DD arisen or worsened after pelvic or colorectal surgery was performed from January 2010 to December 2020. DD were defined starting from Rome IV Criteria, and according to manometric results, all patients were further divided into the two subgroups: inadequate defecatory propulsion and dyssynergic defecation. Cleveland Clinic Constipations Score (CCCS) and SF-36 have been evaluated in the time.

RESULTS

Thirty-seven patients have been included in the study. Twenty-seven out of thirty-seven (73.3%) patients had experienced sufficient benefits to implant the definitive device, and 22 patients (59.4% of tested and 81.5% of permanently implanted) still had the device functioning after a mean follow-up of 6.3 years. The most represented manometric pattern was inadequate propulsive function (59% of patients). CCCS at preoperative assessment for all patients was 17.5 with a reduction to 10.4 at the first year of follow-up (p < 0.001).

CONCLUSION

SNM appears to be a feasible, safe, and well-tolerated procedure with durable benefit in the long-term treatment of defecatory dysfunction after pelvic or colorectal surgery for benign diseases.

Evaluation of Bowel Function of Women with Colorectal Endometriosis: a Cross-Sectional Study

The objective was to evaluate bowel function in women with colorectal endometriosis according to treatment type. Cross-sectional study, carried out with 141 women with endometriosis, followed by the University of Campinas from May 2020 to April 2021. Women were divided into 3 groups according to the kind of treatment: 16 women with conservative surgery, 35 women with radical surgery treatment, and 90 women with clinical treatment. The clinical and sociodemographic characteristics of these women were evaluated. To access bowel outcome, we used the following questionnaires: the Bristol Stool Scale, the Bowel Function in the Community, the Gastrointestinal Quality of Life Index (GIQLI), and the Pelvic Floor Distress Inventory (PFDI-20). The mean treatment time was 32.24 ± 29.37 months. The women of the three groups had similar gastrointestinal quality of life index scores (p = 0.27) and pelvic floor distress inventory scores (p = 0.23). Women in the radical surgery group had a higher frequency of evacuatory effort and change in posture to evacuate (p = 0.01 and 0.009, respectively) than did those in the other groups. Women with constipation had worse quality of life and more pain than those without constipation. In conclusion, women with endometriosis treated with radical surgery (segmental resection) had a higher frequency of constipation. In addition, women with endometriosis and constipation had a worse quality of life and higher pain scores compared to those without constipation.

Segmental Rectum Resection for Deep Endometriosis and Excision Similarly Improve Sexual Function and Pain

Segmental rectum resections for indications other than endometriosis were reported to result in up to 40% sexual dysfunctions. We, therefore, evaluated sexual function after low bowel resection (n = 33) for deep endometriosis in comparison with conservative excision (n = 23). Sexual function was evaluated with the FSFI-19 (Female Sexuality Functioning Index) and EHP 30 (Endometriosis Health Profile). The pain was evaluated with visual analogue scales. Linear excision and bowel resections improved FSFI, EHP 30, and postoperative pain comparably. By univariate analysis, a decreased sexual function was strongly associated with pain both before (p < 0.0001) and after surgery (p = 0.0012), age (p = 0.05), and duration of surgery (p = 0.023). By multivariate analysis (proc logistic), the FSFI after surgery was predicted only by FSFI before or EHP after surgery. No differences were found between low bowel segmental resection and a more conservative excision. In conclusion, improving pain after surgery can explain the improvement in sexual function. A deleterious effect of a bowel resection on sexual function was not observed for endometriosis. Sexual function in women with endometriosis can be evaluated using a simplified questionnaire such as FSFI-6.

Comprehensive surgical treatment for obstructive rectal endometriosis: a case report and review of the literature

Background

Intestinal obstruction caused by endometriosis maybe easily misdiagnosed as a tumor or other occupying disease in emergency condition. How to deal with it depending on the clarity of the preoperative diagnosis and the experience of the surgeon.

Case presentation

A 47-year-old woman, admitted to our emergency service with abdominal pain and distension for 5 days, anal stop exhausting and defecating for 3 days. Based on imaging and laboratory examination, we made a preoperative diagnosis of rectal endometriosis probably. After 7 days of colon decompression with a intestinal obstruction catheter, an operation of laparoscopic partial rectal and sigmoid resection without protective stoma and total hysterectomy was performed successfully. The patient obtained a smooth postoperative course and doing well after 12-weeks follow up.

Conclusions

Obstruction caused by rectal endometriosis is very rare and easily overlooked by surgeon and gynecologist. Appropriate preoperative diagnosis and preoperative management can reduce the trauma and incidence of complications.

Conservative versus Radical Surgery for Women with Deep Infiltrating Endometriosis: Systematic Review and Meta-analysis of Bowel Function

OBJECTIVE

To assess bowel function in women with deep infiltrating endometriosis according to surgical approach (radical vs conservative).

DATA SOURCES

Five databases were searched from 1970 to September 2021 to retrieve studies comparing radical (colorectal segmental resection) and conservative (shaving or discoid excision) surgery for bowel function in women with deep infiltrating endometriosis.

METHODS OF STUDY SELECTION

No language restriction was applied. Two reviewers extracted and combined data from the included studies, applying a meta-analytic model with random effects in all calculations. Results are expressed in risk ratio (RR) with 95% confidence interval (CI). Assessment of risk of bias and quality of evidence was performed by the Newcastle-Ottawa and Grading of Recommendations, Assessment, Development and Evaluation, respectively.

TABULATION, INTEGRATION, AND RESULTS

We included 13 studies in our meta-analysis, and most of them were of nonrandomized design. Conservative surgery had fewer events of constipation and frequent bowel movements when compared with radical surgery (RR, 2.31; 95% CI, 1.21-4.43; I2 = 0%; 3 studies; RR, 2.80; 95% CI 1.17-6.75; I2 = 0%; 2 studies, respectively). Defecation pain, anal incontinence loss, minor and major lower anterior resection syndrome, and Clavien-Dindo complications grade I to IV showed no statistically significant difference between surgeries. Grading of Recommendations, Assessment, Development and Evaluation assessment was low to very low for all outcomes.

CONCLUSION

Conservative surgery (shaving or discoid excision) presented fewer events of constipation and frequent bowel movements than colorectal segmental resection. There was a very low quality of evidence to provide recommendations regarding bowel function.

Anorectal dysfunction after radical cystectomy for bladder cancer

Objective: To prospectively assess anorectal dysfunction using patient-reported outcomes using validated questionnaires, manovolumetry and endoanal ultrasound before and 12 months after RC.Patients and methods: From 2014 to 2019, we prospectively included 44 patients scheduled for RC. Preoperatively and 12 months after surgery, 41 patients filled in a low anterior resection syndrome score (LARS-score) to assess fecal incontinence, increased frequency, urgency and emptying difficulties and a St Mark's score to assess fecal incontinence in conjunction with manovolumetry and endoanal ultrasound examinations. Pre- and postoperative patient-reported anorectal dysfunction were assessed by LARS-score and St Marks's score. At the same time-points, anorectal function was evaluated by measuring mean anal resting and maximal squeeze pressures, volumes and pressures at first desire, urgency to defecate and maximum toleration during manovolumetry. Wilcoxon's signed rank test was used to compare pre- and postoperative outcomes by questionnaires.Results: Postoperatively 6/41 (15%) patients reported flatus incontinence assessed by the LARS-questionnaire, and correspondingly the St Mark's score increased postoperatively. The median anal resting pressure decreased from 57 mmHg preoperatively to 46 mmHg after RC, but without any postoperative anatomic defects detected by endoanal ultrasound. Volumes and pressures at first desire, urgency to defecate and maximum toleration during manovolumetry all increased after RC, indicating decreased postoperative rectal sensation, as rectal compliance was unaltered.Conclusions: Postoperative flatus incontinence is reported by one out of seven patients after RC, which corresponds to decreased anal resting pressures. The finding of decreased rectal sensation might also contribute to patient-reported symptoms and anorectal dysfunction after RC.