The postoperative functional outcomes of deep infiltrating endometriosis

The achievement of normal bowel movements after deep infiltrating endometriosis surgery is less likely for women with severe preoperative constipation,

Key Points

Highlights:

• Deep infiltrating endometriosis of rectum is associated with gastrointestinal and urinary dysfunction symptoms that severely impair patients’ health-related quality of life. 

Importance:

• Women with deep infiltrating endometriosis benefit from laparoscopic surgery with functional postoperative outcomes resulting in improvement of the quality of life.

 What’s done here?

• This study was conducted as a 2-arm randomized trial in three French university hospitals from 2011 to 2013.
• Women >18 and <45 years of age and managed for deep infiltrating endometriosis of the rectum up to 15 cm from the anus, measuring >20 mm in length, involving at least the muscular layer in depth, and up to 50% of rectal circumference included in the study.
• Either conservative rectal surgery (shaving or disc excision), or radical rectal surgery (segmental resection) were performed.
• The postoperative symptoms evaluated at 24 months are constipation, frequent bowel movements, anal incontinence, dysuria or bladder atony requiring bladder voiding by self-catheterization.
• The scales applied to investigate postoperative secondary endpoints are KESS, the GIQLI, the Wexner scale, the Urinary Symptom Profile, and the SF36 Health Survey.
• Patients were followed-up at 6,12,18 and 24-month visits postoperatively. Same examinations and questionnaires were applied to compare pre- and postoperative digestive and urinary functions. 

Key results:

• A total of 60 women who met the criteria included in the study; 27 underwent conservative surgery and 33 underwent segmental colorectal resection.
• There were no follow-up losses or no exclusions, and all 60 patients were analyzed. Only in women whose stoma was not closed, functional outcomes could not be evaluated during the assessment.
• In the conservative group, 11.1% reported constipation, 7.4% reported frequent bowel movements, 18.5% reported defecation pain and 11.1% of patients reported involuntary loss of gas. In the radical surgery group, constipation was recorded in 9.1%, frequent bowel movements in 21.2%, defecation pain in 18.2% and involuntary loss of gas or stools in 27.3%.
• As a primary endpoint, patients with severe preoperative constipation are less likely to achieve normal bowel functions postoperatively.
• As secondary endpoints, scores and proportions of questionnaires were comparable between two groups of women who underwent conservative or radical surgery over the whole period.
• Except for KESS score, no evidence of postoperative change was found.

Strengths and Limitations

• The strength of the study is the prospective, randomized and rigorous design.
• All operations were performed by the experienced gynecologic and general surgeons. Conservative procedures allowed for systemic preservation of the mesorectum.
• The limitations are, the inclusion of only women with large rectum infiltration, irregular distribution of the participants among institutions, and the study being unblinded and small sample size.

Lay Summary

Rectosigmoid endometriosis is defined as the infiltration of the bowel wall with the endometrial-like glands and stroma, reaching at least the muscular layer. The most commonly involved sites are the rectum and sigmoid colon. For the management of deep infiltrating endometriosis, conservative rectal surgery by shaving or disc excision, or radical rectal surgery by segmental resection should be performed. However, there is no study identifying the predictive factors of postoperative functional outcomes in these patients.

Roman et al, a group of scientists from France, published a study titled as “Baseline severe constipation negatively impacts functional outcomes of surgery for deep endometriosis infiltrating the rectum: Results of the ENDORE randomized trial” in the journal named "Journal of Gynecology Obstetrics and Human Reproduction".

The authors aimed to evaluate the functional outcomes in patients managed by conservative or radical rectal surgery for deep infiltrating rectal endometriosis.

They found that patients with severe preoperative constipation are less likely to achieve normal bowel functions postoperatively. Rectal surgery provides significant improvement in pelvic pain, gastrointestinal complaints, and discomfort related to subjective bladder voiding, except constipation. This improvement remained stable up to 24 months postoperatively.

“Symptomatic patients may benefit from laparoscopic surgery for deep endometriosis infiltrating the rectum with favorable functional outcomes,” they added.

Research Source: https://www.ncbi.nlm.nih.gov/pubmed/30902761