Quality of life and low anterior resection syndrome before and after deep endometriosis surgery

PURPOSE

Deep endometriosis (DE) is defined by the presence of ectopic endometrial glands, with rectal involvement ranging from 5.3 to 12%. The prevalence of low anterior resection-like syndrome (LARS) in patients with DE, how it affects quality of life (QoL), and its evolution after surgery is unclear. The objective of this study was to assess the gastrointestinal functional outcomes and QoL in patients who underwent surgery for DE.

PATIENTS AND METHODS

A prospective study was conducted from 2017 to 2019, recruiting patients who underwent DE surgery with and without rectal resection. Patients completed LARS and SF-36 questionnaires before, at 6 months and at 1 year after surgery.

RESULTS

Eighty-two patients were enrolled. Rectal segmental resection was required in 16 (19.5%) patients, shaving in 16 (19.5%) and discoid resection in 8 (9.8%). All 8 domains of the SF-36 questionnaire showed improvement during follow-up, reflecting improved QoL after surgery (p ≤ 0.05) in all patients. Mean LARS scores for patients without rectal surgery were 7.5 ± 10.4 before and 13.7 ± 14.2 1 year after surgery; rectal surgery was 13.6 ± 13.6 and 14.6 ± 13.1, respectively (p = 0.17). No significant differences were found in the rectal surgery patients' postoperative LARS score among the 3 rectal DE surgical techniques (p = 0.97), and the SF-36 scores improved independent of the technique performed.

CONCLUSIONS

Patients with DE present a LARS-like syndrome before surgery that does not appear to be negatively affected after rectal surgery, independent of the technique performed. Rectal surgery improves the QoL of patients with DE patients as measured by the SF-36 questionnaire at 1 year of follow-up.

Short-term outcomes in patients undergoing laparoscopic surgery for deep infiltrative endometriosis with rectal involvement: a single-center experience of 168 cases

Purpose

The surgical management of deep infiltrative endometriosis (DE) involving the rectum remains a challenge. The objective of this study was to assess the outcomes from a single tertiary center over a decade with an emphasis on the role of a protective loop ileostomy (PI).

Methods

A retrospective review of outcomes for 168 patients managed between 2008 and 2018 is presented including 57 rectal shaves, 23 discoid excisions, and 88 segmental rectal resections.

Results

The nodule size (mean±standard deviation) in the segmental resection group was 32.7±11.2 mm, 23.4±10.5 mm for discoid excision, and 18.8±6.0 mm for rectal shaves. A PI was performed in 19 elective cases (11.3%) usually for an ultra-low anastomosis <5 cm from the anal verge. All Clavien-Dindo grade III/IV complications occurred after segmental resections and included 5 anastomotic leaks, 6 rectovaginal fistulas, 2 ureteric fistulas, and 1 ureteric stenosis. Of 26 stomas (15.5%), there were 19 PIs, 3 secondary ileostomies (after complications), and 4 end colostomies. The median time to PI closure was 5.8 months (range, 0.4-16.7 months) in uncomplicated disease compared with 9.2 months (range, 4.7-18.4 months) when initial postoperative complications were recorded (P=0.019). Only 1 patient with a recurrent rectovaginal fistula had a permanent colostomy.

Conclusion

In patients with DE and rectal involvement a PI is selectively used for low anastomoses and complex pelvic reconstructions. Protective stomas and those used in the definitive management of a major postoperative complication can usually be reversed.

Management of perianal fistula in inflammatory bowel disease: identification of prognostic factors associated with surgery

PURPOSE

As one of the clinical manifestations of inflammatory bowel disease (IBD), perianal fistula disease (PFD) can potentially impact the patient quality of life. The management of PFD employs a multidisciplinary approach which includes antibiotics, biological therapies, immunomodulators, and surgery. We analyzed the outcome and prognostic factors of anal fistula surgery in IBD patients.

METHODS

We conducted a retrospective study of IBD patients undergoing elective surgery for anal fistula between January 2015 and December 2018 at our University Department of Surgery. We collated demographic factors, disease activity, imaging (MRI and endoanal ultrasound), surgical interventions, and medical treatment assessing the rate of fistula closure and fecal incontinence, 2 months and 1 year after surgery.

RESULTS

Thirty-five IBD patients with anal fistula underwent surgery (28 Crohn's disease, four ulcerative colitis, and three indeterminate colitis). Twenty-seven patients presented with complex fistulas and eight with simple fistulas with 10 patients undergoing single-stage surgery. In 25 patients, a two-stage surgical approach was planned and performed (draining seton plus medical treatment and then second-stage surgery with curative intent). At 1 year of follow-up, the fistula healing rate was 50% for single-stage surgery and 60% for two-stage surgery (P = 0.09). Overall, 19.2% of patients developed postoperative fecal incontinence. A time interval greater than 12 months between surgeries is a favorable prognostic factor for fistula healing with the two-stage approach (P = 0.002).

CONCLUSIONS

In our retrospective study, two-stage surgery in IBD patients presenting with complex perianal fistulous disease results in a better medium-term outcome with a longer time interval between surgeries.

SARS-CoV-2 pandemic on the activity and professionals of a General Surgery and Digestive Surgery Service in a tertiary hospital

INTRODUCTION

The rapid spread of SARS-CoV-2 infection has led to a radical reorganization of healthcare resources. Surgical Departments need to adapt to this change.

METHODS

We performed a prospective descriptive observational study of the incidence of COVID-19 in patients and surgeons of a General Surgical Department in a high prevalence area, between the 1st and 31st of March 2020.

RESULTS

Patients: The incidence of SARS-CoV-2 infection in elective surgery patients was 7% (mean age 59.5 years). All survived. Of 36 patients who underwent emergency surgery, two of them were SARS-CoV-2 positive and one was clinically highly suspicious of COVID-19 (11.1%). All three patients died of respiratory failure (mean age 81 years). Surgeons: There were a total of 12 confirmed SARS-CoV-2+ cases among the surgical department staff (24.4%) (8 out of 34 consultants and 4 out of 15 residents). Healthcare activity: The average number of daily emergency surgical interventions declined from 3.6 in February to 1.16 in March. 42% of the patients who underwent emergency surgery had peritonitis upon presentation.

CONCLUSIONS

The fast pace of COVID-19 pandemia should alert surgical departments of the need of adopting early measures to ensure the safety of patients and staff.