Which surgical approach for bowel endometriosis?

An endometriotic bowel nodule with similar characteristics may be managed by different strategies following a “patient-oriented treatment”.

Key Points

Highlights:

• Segmental resection may be a feasible option in young patients with a desire to conceive to prevent a recurrence.
• Conservative surgery, such as discoid resection and shaving, which revealed a higher recurrence rate, may be more appropriate in women approximating menopause since the recurrence possibility of endometriosis is lower in them.

Importance:

• Achieving a low recurrence rate of disease with a reasonable postoperative complication rate is challenging.

What’s done here?

• The researchers compared postoperative complications and recurrence rates of three surgical techniques: segmental bowel resection, discoid excision and rectal nodule shaving in 143 patients with bowel endometriosis.

Key Points:

• A higher rate of severe postoperative complications was observed in endometriosis patients who underwent segmental resection in comparison with discoid resection or shaving. The authors explained the higher rate of complications by the performance of additional severe procedures (esp. for endometriosis infiltrating the ureter or the parametrium).
• In contrast to the segmental resection group, no case of severe organ dysfunction occurred in the group of shaving and discoid resections.
• Shaving group had a higher recurrence rate (12.7%) in comparison with the discoid group (5%) and the segmental resection group

Limitations:

• Since 86.8% of patients who underwent segmental resection had previous surgery for endometriosis, it is difficult to distinguish between residual and recurrent disease. This may create a bias in this analysis. However, after all of the surgical procedures performed in the study, no patients showed macroscopic disease.

Lay Summary

A group of researchers from Spain, led by Dr. Alicia Hernández Gutiérrez, conducted a retrospective study to compare postoperative complications and recurrence of three surgical techniques: segmental bowel resection (group I), discoid excision (group II), and rectal nodule shaving (group III). They analyzed 143 patients who underwent surgical treatment for symptomatic bowel endometriosis.

Endometriosis patients who underwent segmental resection revealed a higher rate of severe postoperative complications in comparison with discoid resection or shaving groups. The authors explained the higher rate of complications by the performance of additional severe procedures (esp. for endometriosis infiltrating the ureter or the parametrium).

The recto-vaginal fistula was seen in 5.2% of segmental resection patients, while no rectovaginal fistula occurred in the groups of shaving and discoid resections. According to the researchers, the higher rate of partial colpectomy in the group of segmental resection (31.5%) in comparison with the other groups (25% in the discoid group; 23.4% in the shaving group) may explain this.

Researchers showed that the shaving group was associated with a higher recurrence rate (12.7%) in comparison with the discoid group (5%) and the segmental resection group (1.3%) which is in concordance with the literature. On the contrary, no case of severe organ dysfunction was seen in the group of shaving and discoid resections.

There were significant differences among the three groups, but they did not seem to affect the final prognosis of the patients.

One of the strengths of this retrospective study is that it has a longer follow-up of patients (approximately 46 months for the group I, 42 months for the group II, 39 months for the group III) when compared to the literature.

Authors suggested segmental resection for young patients with a desire to conceive to prevent a recurrence, and conservative surgery for women approximating menopause since the recurrence possibility of endometriosis is lower in them.

This article has been recently published in the European Journal of Obstetrics Gynecology and Reproductive Biology.

Research Source: https://www.ncbi.nlm.nih.gov/pubmed/31517307