Bowel Function not Affected by Type of Surgery in Deep Rectal Endometriosis, Clinical Trial Shows

Women should be informed that there is a risk of abnormal bowel movements regardless of the type of surgery for deep rectal endometriosis

Key Points

Highlights:

• Conservative surgery and radical rectal surgery to manage deep rectal endometriosis seem to have the same functional digestive and urinary outcome.

Importance:

• Women undergoing surgery to treat deep rectal endometriosis should be informed that they have a risk of abnormal bowel movement following surgery regardless of the type of surgery.

What’s done here?

• Researchers conducted a randomized clinical trial in 60 women with endometriosis infiltrating the rectum. Half of the women underwent radical rectal surgery while the other half had a more conservative surgery involving shaving or disc excision only. 

Key results:

• 48.1 percent of women who underwent conservative surgery and 39.4 percent of those who had radical surgery had at least one functional problem two years later.
• There was no differences in the overall score in the Knowles Eccersley Scott Symptom (KESS) questionnaire, the Gastrointestinal Quality of Life Index (GIQLI), the Wexner scale, the Urinary Symptom Profile (USP), or the Short Form 36 Health Survey (SF36) between women who underwent conservative surgery and those who had a radical surgery.
• Women who underwent radical surgery had an increased risk of rectal stenosis requiring additional endoscopic or surgical procedures compared to women who had conservative surgery.

Limitations of the study:

• Only women who had large infiltrations of the rectum were included in the trial meaning that it is not known whether the same results are valid for small nodules.
• The presumption of a 40% difference favorable to conservative surgery in terms of postoperative functional outcomes resulted in a lack of power to demonstrate the difference for the primary endpoint. 

Lay Summary

Conservative surgery for the management of deep rectal endometriosis does not seem to improve the function of the digestive and urinary system compared to more radical surgery according to a new study by French researchers published in the scientific journal Human Reproduction. 

According to the researchers, patients should, therefore, be informed that there is a risk of abnormal bowel movements regardless of the type of surgery.

There are two surgical approaches that doctors usually use to treat deep infiltrating endometriosis of the rectum: a radical approach where a whole section of the colon and rectum are removed, and a more conservative approach that aims to leave the rectum untouched. 

It was always thought, based on case studies and comparative observational studies that a conservative approach yielded a better functional outcome following surgery. However, these studies were not randomized meaning that they could be biassed towards the benefits of conservative surgery since only more severe cases of deep endometriosis would be operated using the more radical approach and being more severe to start with would be more likely to have a worse outcome.

To establish whether there is a real difference regarding functional outcome between conservative and radical rectal surgery in patients with sizeable deep endometriosis, researchers led by Dr. Jean-Jaques Tuech at Rouen University Hospital conducted a two-arm randomized clinical trial (NCT 01291576). 

They enrolled 60 women with endometriosis infiltrating the rectum at three French university hospitals. The women were randomly divided into two groups to undergo either conservative surgery or radical rectal surgery. 

Two years after surgery, the researchers assessed the proportion of women experiencing constipation, frequent bowel movements, pain during defecation, anal incontinence, and difficulty urinating. 

They used the Knowles Eccersley Scott Symptom (KESS) questionnaire, an 11-item tool for diagnosing constipation, the Gastrointestinal Quality of Life Index (GIQLI), an instrument designed to measure the quality of life, specifically of patients with gastrointestinal disease, the Wexner scale to assess fecal incontinence, the Urinary Symptom Profile (USP) to determine the degree of the women’s urinary symptoms, and the Short Form 36 Health Survey (SF36), a measure of the quality of life.

The results showed that there were no differences in the overall score in any of the tests and questionnaires used. A total of 13 women in each group (corresponding to 48.1 percent of the conservative surgery group and 39.4 percent of the radical surgery group) had at least one functional problem two years after surgery. The only difference between the two groups was that women who underwent radical surgery had an increased risk of rectal stenosis, or narrowing of the rectum and anus due to the build-up of scar tissue, requiring additional endoscopy or surgery.

“No evidence was found that functional outcomes differed when conservative surgery was compared to radical rectal surgery for deeply invasive endometriosis involving the bowel,” the researchers wrote. They added that these findings could help estimate the sample size of future randomized clinical trials and may be used in future meta-analyses focusing on the functional outcomes of colorectal surgery for endometriosis.

Research Source: https://www.ncbi.nlm.nih.gov/pubmed/29194531