Pain and fertility outcomes of nerve-sparing, full-thickness disk or segmental bowel resection for deep infiltrating endometriosis-A prospective cohort study.

Choosing the optimal treatment for bowel endometriosis, ie, conservative vs radical surgery, is under debate. We aimed to evaluate the surgical outcomes of segmental resection and disk resection regarding fertility, pain symptoms, and quality of life score of women with colorectal deep infiltrating endometriosis. From March 2011 to December 2016, 134 consecutive patients with symptomatic deep infiltrating endometriosis of the rectosigmoid up to 25 cm from the anal verge undergoing segmental resection or disk resection were prospectively evaluated regarding reduction in pain symptoms, fertility outcomes, and complication rates according to Clavien-Dindo classification. Of the 134 women included, segmental resection was performed in 102 (76.1%) women and disk resection was performed in 32 (23.9%) women. There was no difference in duration of surgery, complication rates, mean hospital stay, or discrepancy in hemoglobin level comparing the two groups. There was no significant difference regarding reduction of pain symptoms, fertility, and functional outcomes. One hundred and twelve (83.6%) women were followed up long-term. In both cohorts, there was a significant reported decrease in pain symptoms and increase in quality of life scores. Of all the 61 infertile women, 26 (42.6%) became pregnant spontaneously, and 13 (21.3%) by in vitro fertilization with an overall pregnancy rate of 63.4%. The overall complication rate (Clavien-Dindo III-IV) was 8 of 134 (5.9%) without statistically significant difference between the cohorts. Both conservative surgery with disk resection, and nerve- and vessel-sparing segmental resection reduce pain symptoms with equal morbidity. Fertility is improved with surgery with both techniques.

Hudelist G ，Aas-Eng MK ，Birsan T ，Berger F ，Sevelda U ，Kirchner L ，Salama M ，Dauser B ... -  《-》

Conservative surgery versus colorectal resection in deep endometriosis infiltrating the rectum: a randomized trial.

Is there a difference in functional outcome between conservative versus radical rectal surgery in patients with large deep endometriosis infiltrating the rectum 2 years postoperatively? No evidence was found that functional outcomes differed when conservative surgery was compared to radical rectal surgery for deeply invasive endometriosis involving the bowel. Adopting a conservative approach to the surgical management of deep endometriosis infiltrating the rectum, by employing shaving or disc excision, appears to yield improved digestive functional outcomes. However, previous comparative studies were not randomized, introducing a possible bias regarding the presumed superiority of conservative techniques due to the inclusion of patients with more severe deep endometriosis who underwent colorectal resection. From March 2011 to August 2013, we performed a 2-arm randomized trial, enroling 60 patients with deep endometriosis infiltrating the rectum up to 15 cm from the anus, measuring more than 20 mm in length, involving at least the muscular layer in depth and up to 50% of rectal circumference. No women were lost to follow-up. Patients were enroled in three French university hospitals and had either conservative surgery, by shaving or disc excision, or radical rectal surgery, by segmental resection. Randomization was performed preoperatively using sequentially numbered, opaque, sealed envelopes, and patients were informed of the results of randomization. The primary endpoint was the proportion of patients experiencing one of the following symptoms: constipation (1 stool/>5 consecutive days), frequent bowel movements (≥3 stools/day), defecation pain, anal incontinence, dysuria or bladder atony requiring self-catheterization 24 months postoperatively. Secondary endpoints were the values of the Visual Analog Scale (VAS), Knowles-Eccersley-Scott-Symptom Questionnaire (KESS), the Gastrointestinal Quality of Life Index (GIQLI), the Wexner scale, the Urinary Symptom Profile (USP) and the Short Form 36 Health Survey (SF36). A total of 60 patients were enroled. Among the 27 patients in the conservative surgery arm, two were converted to segmental resection (7.4%). In each group, 13 presented with at least one functional problem at 24 months after surgery (48.1 versus 39.4%, OR = 0.70, 95% CI 0.22-2.21). The intention-to-treat comparison of the overall scores on KESS, GIQLI, Wexner, USP and SF36 did not reveal significant differences between the two arms. Segmental resection was associated with a significant risk of bowel stenosis. The inclusion of only large infiltrations of the rectum does not allow the extrapolation of conclusions to small nodules of <20 mm in length. The presumption of a 40% difference favourable to conservative surgery in terms of postoperative functional outcomes resulted in a lack of power to demonstrate a difference for the primary endpoint. Conservative surgery is feasible in patients managed for large deep rectal endometriosis. The trial does not show a statistically significant superiority of conservative surgery for mid-term functional digestive and urinary outcomes in this specific population of women with large involvement of the rectum. There is a higher risk of rectal stenosis after segmental resection, requiring additional endoscopic or surgical procedures. This work was supported by a grant from the clinical research programme for hospitals (PHRC) in France. The authors declare no competing interests related to this study. This study is registered with ClinicalTrials.gov, number NCT 01291576. 31 January 2011. 7 March 2011.

Roman H ，Bubenheim M ，Huet E ，Bridoux V ，Zacharopoulou C ，Daraï E ，Collinet P ，Tuech JJ ... -  《-》

Excision versus colorectal resection in deep endometriosis infiltrating the rectum: 5-year follow-up of patients enrolled in a randomized controlled trial.

Roman H ，Tuech JJ ，Huet E ，Bridoux V ，Khalil H ，Hennetier C ，Bubenheim M ，Branduse LA ... -  《-》

Pain, gastrointestinal function and fertility outcomes of modified nerve-vessel sparing segmental and full thickness discoid resection for deep colorectal endometriosis - A prospective cohort study.

Hudelist G ，Pashkunova D ，Darici E ，Rath A ，Mitrowitz J ，Dauser B ，Senft B ，Bokor A ... -  《-》

Postoperative complications after bowel endometriosis surgery by shaving, disc excision, or segmental resection: a three-arm comparative analysis of 364 consecutive cases.

To assess the postoperative complications related to three surgical procedures used in colorectal endometriosis: rectal shaving, disc excision, and segmental resection. Retrospective comparative study using data prospectively recorded in the North-West Inter Regional Female Cohort for Patients with Endometriosis (CIRENDO) database. University tertiary referral center. A total of 364 consecutive patients with deep endometriosis infiltrating the rectosigmoid, were stratified into three arms according to the technique used. All patients had a laparoscopic surgical procedure to treat bowel endometriosis: rectal shaving (145 patients), disc excision (80 patients), or segmental colorectal resection (139 patients). Postoperative complication rate was assessed using Clavien-Dindo classification. Clavien 3b postoperative complications were recorded in 43 patients (11.8%), two thirds of whom were managed by segmental colorectal resection (P<.001). Fourteen cases of rectovaginal fistula (3.8%) were reported: three in the shaving arm (2.1%), three in the disc excision arm (3.7%), and eight in the segmental colorectal resection arm (5.8%) (P=.13). Twenty-four cases (6.6%) of pelvic abscess were recorded in patients free of fistula or leakage. One year after the surgery pregnancy rate (PRs) and delivery rate were comparable between patients with or without severe complications who intended to get pregnant. Three years postoperatively, the PR in infertile patients was 66.7%, with spontaneous conception in 50% of cases. Our data suggest that using a strategy prioritizing shaving, whenever it is possible, could be related to a reduction in severe complication rates. However, prudence is required before concluding that extensive disease should not be treated by segmental resection because of the risk of complications.

Abo C ，Moatassim S ，Marty N ，Saint Ghislain M ，Huet E ，Bridoux V ，Tuech JJ ，Roman H ... -  《-》