Surgical techniques for rectosigmoid endometriosis, and functional outcomes

Conservative surgery including rectal shaving and disc excision can be preferred in patients with intermediate risk for bowel endometriosis due to similarities in improvements of symptoms and recurrence rates with fewer short-term complications.

Key Points

Highlights:

• Rectosigmoid endometriosis is encountered in approximately 8-12% of patients with a diagnosis of endometriosis and there is still no clear consensus about the management.

 Importance:

• The surgical techniques developed for the management of rectosigmoid endometriosis have similar surgical, clinical, and functional outcomes. The decision about the type of surgery depends on the center’s policy and the surgeon’s preference and experience.

What’s done here?

• This retrospective cohort study evaluates surgical, clinical, functional outcomes in patients underwent bowel surgery for rectosigmoid endometriosis through the medical records (2004-2017). Only patients in the intermediate risk group for rectosigmoid segmental resection were included in this study.
• All patients were evaluated by bimanual and speculum examination, transvaginal (TV-US) and transabdominal ultrasound (TA-US) before surgery.
• Those patients with large bowel nodules, rectal implants involving the inner propria muscle at TV-US or severe bowel symptoms, underwent further evaluation for the stenosis.
• The surgical method was decided after discussing with the patient preoperatively, and all were performed by two experienced gynecologic surgeons:
  • Rectal shaving (SG) (the careful dissection of only endometriotic nodule from the bowel wall).
  • Discoid resection (DG) of the rectal wall was preferred when bowel implants smaller than 3 cm located on the ventral surface of the rectum and within 15 cm from the anal verge.
  • Segmental rectosigmoid resection (RG) was applied if the bowel implants were larger than 3 cm or impacting the sigmoid tract.
• The short-term postoperative complications including rectal fistula, urinary fistula, rectal bleeding, hemoperitoneum requiring reintervention, anemia and fever were recorded in each surgical route. Pain improvement was evaluated based on a visual analog scale (VAS).
• The long-term postoperative complications such as de novo chronic constipation, urinary retention were also recorded at the 1st,3rd, 6th, and 12th-month follow-up controls.  

 Key results:

• 392 women were included: Rectal shaving [292 women (75.8%)], discoid resection [33 women (8.4%), and segmental resection [62 women (15.8%)] met the criteria.
• The patients were followed with a median duration of 43 months.
• The duration of surgery and the hospitalization were significantly shorter in the rectal shaving group than the other two groups.
• The overall rate of short-term complications was significantly higher in the segmental rectosigmoid resection, compared to the others.
• There was no statistically significant difference among the three groups regarding the suspected and proven recurrence rate, pain improvement, and long-term complications. However, the suspected and proven recurrence rates were higher in women managed with shaving and discoid resection.    

Strengths and Limitations

• The big sample size and extensive long follow-up duration represent the strengths of this study.
• The retrospective design and failure to evaluate confounding factors were the limitations.  

Lay Summary

Rectosigmoid endometriosis is defined as the infiltration of bowel wall with the endometrial-like glands and stroma, reaching at least the muscular layer.

Rectosigmoid endometriosis is encountered in approximately 8-12% of patients with a diagnosis of endometriosis. The most commonly involved sites are the rectum and sigmoid colon. There is still no clear consensus about the management of rectosigmoid endometriosis, although there are different surgical methods including rectal shaving, discoid resection, and segmental rectosigmoid resection.

Mabrouk et al, a group of scientists from Italy, published a randomized clinical study titled as “Surgical, clinical, and functional outcomes in patients with rectosigmoid endometriosis in the gray zone: 13-year long-term follow-up” in the journal named Journal of Minimally Invasive Gynecology.

The authors sought to evaluate the short- and long-term complications, pain improvement and recurrence rates with a minimum follow-up of 12 months. They found that the overall rate of short-term complications was significantly higher in segmental rectosigmoid resection group when compared with the other two groups.

There was no statistically significant difference among the three groups regarding the suspected and proven recurrence rate, pain improvement, and long-term complications. However, the suspected and proven recurrence rates were higher in women managed with shaving and discoid resection.     

“Conservative surgery in patients diagnosed in the gray zone owing to similar results in terms of symptom severity improvement and recurrence rate, with fewer short-term complications,” they added.

Research Source: https://www.ncbi.nlm.nih.gov/pubmed/?term=30414996