Laparoscopic mesenteric vascular and nerve sparing surgery as a tool for DIE resection

Analysis of a safer, more effective surgical technique to treat deeply-infiltrating endometriosis.

Key Points

Highlights:

• Segmental intestinal resection with "mesenteric vascular and nerve sparing surgery" has been found to reduce post-operative complications for deep iniltrating endometriosis surgery.

What’s done here?

• Researchers aim to analyze the reproducibility, safety, and efficacy of segmental intestinal resection for DIE performed with mesenteric vascular and nerve sparing surgery (MSS).

Key Results:

• Out of 62 patients who underwent laparoscopic segmental intestinal resection with MSS, only 4 (6.5%) with major complications required repeat operation.
• During post-operative follow-up, patients experienced statistically significant improvement in dysmenorrhea, dyspareunia, dyschezia, and dysuria. 
• After an average of 33.1 months from surgery, severe constipation as a complication was reported only by 2 patients (3.6%). Additionally, the prevalence of the post-operative constipation decreased by time after surgery, however post-operative constipation increased as the distance of primary anastomosis from the anal verge shortens.

Limitations:

• Lack of a control group for comparison and small sample size prevents a definitive conclusion regarding the safety and efficacy of this surgical technique.

Lay Summary

Endometriosis can be characterized by a wide range of clinical aggressiveness based upon the location, character, and growth of ectopic endometrial implants. As one of the most aggressive forms of endometriosis, deep infiltrating endometriosis (DIE) is known to involve the colon and bladder. Surgery in these patients may lead to complications such as urinary retention, constipation and sexual dysfunction. Surgical techniques aimed at minimizing these complications are being developed such as pelvic nerve-sparing surgery. 

The researchers from the Department of Gynecology in Verona, Italy have recently published a paper in the European Journal of Obstetrics & Gynecology and Reproductive Biology aimed to investigate mesenteric vascular and nerve sparing surgery (MSS) as a laparoscopic surgical technique for the resection of deeply infiltrating endometriosis (DIE). 

            From January 2013 to December 2016, 75 consecutive women with suspected clinical intestinal DIE in the University of Verona and who underwent clinical and diagnostic imaging including pelvic examination, transvaginal ultrasound (TVUS), and magnetic resonance imaging (MRI) followed by shaving or intestinal resection with MSS were included in the study’s results. CT-based colonoscopy, otherwise known as CT colonography, was used to assess the length and height of DIE nodules and assess the extent of intestinal involvement as part of the surgical pre-operative evaluation. Depending on the depth of intestinal DIE involvement, segmental intestinal resection with primary anastomosis or shaving was performed. Post-surgical data including post-op recovery (and after 30-60 days), complications such as dysmenorrhea, dyspareunia, dyschezia, and dysuria were evaluated.

            Of the 75 women who were diagnosed with confirmed intestinal DIE, thirteen patients were excluded because they were ultimately treated with shaving versus MSS. Thus, 62 patients ultimately underwent laparoscopic segmental intestinal resection for DIE with MSS. The vast majority of patients (96.8%) underwent single segmental intestinal resection due to a solitary DIE lesion and only 8.1% required a temporary colostomy or ileostomy but was ultimately closed within 32-95 days. In terms of post-operative characteristics of the surgery in this institution, most patients were able to urinate freely, have a bowel motion, and eat per orally within the first post-operative day. Median follow-up was 45 days at which point subjective pain, dyspareunia, dysmenorrhea, and dyschezia were significantly reduced (p<.001). Using logistic regression analysis, the prevalence of constipation was found to decrease after surgery and increased as the distance of the primary intestinal resection shortens from the anal verge.

            Further understanding of the disease process underlying DIE and a standard technique to perform segmental intestinal resection and MSS continues to be elucidated. Improvement of DIE-associated symptoms has been clearly shown to be reduced in this study using segmental intestinal resection with MSS.

Research Source: https://www.ncbi.nlm.nih.gov/pubmed/?term=30415128