Surgical Management by Disk Excision or Rectal Resection of Low Rectal Endometriosis and Risk of Low Anterior Resection Syndrome: A Retrospective Comparative Study.

STUDY OBJECTIVE: To assess the risk of low anterior resection syndrome (LARS) between women managed by either disk excision or rectal resection for low rectal endometriosis. DESIGN: Retrospective study of a prospective database. SETTING: University hospital. PATIENTS: One hundred seventy-two patients managed by disk excision or rectal resection for deep endometriosis infiltrating the rectum <7 cm from the anal verge. INTERVENTIONS: Rectal disk excision and/or segmental resection using transanal staplers. MEASUREMENTS AND MAIN RESULTS: One hundred eight patients (62.8%) were treated by disk excision (group D) and 64 (37.2%) by rectal resection (group R). All patients answered the LARS score questionnaire. Follow-up was 33.3 ± 22 months for group D (range 12-108 months) and 37.3 ± 22.1 months (range 12-96 months) for group R (p = .25). The rates of rectovaginal fistula and pelvis abscess requiring radiologic drainage and surgery in the D and R groups were, respectively, 7.4% and 8.3% vs 7.8% and 9.3%. The rate of women with normal bowel movements postoperatively was higher in group D (61.1% vs 42.8%, p = .05). Women enrolled in group R reported higher frequency of stools (p <.001), clustering of stools (p = .02), and fecal urgency (p = .05). Regression logistic model revealed 2 independent risk factors for minor/major LARS: performing low rectal resection (adjusted odds ratio 2.28; 95% confidence interval, 1.1-4.7) and presenting with bladder atony requiring self-catheterization beyond postoperative day 7 (adjusted odds ratio 2.52; 95% confidence interval, 1.1-5.8). CONCLUSION: The probability of normal bowel movements is higher after disk excision than after low rectal resection in women with deep endometriosis infiltrating the low rectum.

Risk of bowel fistula following surgical management of deep endometriosis of the rectosigmoid: a series of 1102 cases.

STUDY QUESTION: What are the risk factors and prevalence of bowel fistula following surgical management of deep endometriosis infiltrating the rectosigmoid and how can it be managed? SUMMARY ANSWER: In patients managed for deep endometriosis of the rectosigmoid, risk of fistula is increased by bowel opening during both segmental colorectal resection and disc excision and rectovaginal fistula repair is more challenging than for bowel leakage. WHAT IS KNOWN ALREADY: Bowel fistula is known to be a severe complication of colorectal endometriosis surgery; however, there is little available data on its prevalence in large series or on specific management. STUDY DESIGN, SIZE, DURATION: A retrospective study employing data prospectively recorded in the North-West Inter Regional Female Cohort for Patients with Endometriosis (CIRENDO) from June 2009 to May 2019, in three tertiary referral centres. PARTICIPANTS/MATERIALS, SETTING, METHODS: One thousand one hundred and two patients presenting with deep endometriosis infiltrating the rectosigmoid, who were managed by shaving, disc excision or colorectal resection. The prevalence of bowel fistula was assessed, and factors related to the complication and its surgical management. MAIN RESULTS AND THE ROLE OF CHANCE: Of 1102 patients enrolled in the study, 52.5% had a past history of gynaecological surgery and 52.7% had unsuccessfully attempted to conceive for over 12 months. Digestive tract subocclusion/occlusion was recorded in 12.7%, hydronephrosis in 4.5% and baseline severe bladder dysfunction in 1.5%. An exclusive laparoscopic approach was carried out in 96.8% of patients. Rectal shaving was performed in 31.9%, disc excision in 23.1%, colorectal resection in 35.8% and combined disc excision and sigmoid colon resection in 2.9%. For various reasons, the nodule was not completely removed in 6.4%, while in 7.2% of cases complementary procedures on the ileum, caecum and right colon were required. Parametrium excision was performed in 7.8%, dissection and excision of sacral roots in 4%, and surgery for ureteral endometriosis in 11.9%. Diverting stoma was performed in 21.8%. Thirty-seven patients presented with bowel fistulae (3.4%) of whom 23 (62.2%) were found to have rectovaginal fistulae and 14 (37.8%) leakage. Logistic regression model showed rectal lumen opening to increase risk of fistula when compared with shaving, regardless of nodule size: adjusted odds ratio (95% CI) for disc excision, colorectal resection and association of disc excision + segmental resection was 6.8 (1.9-23.8), 4.8 (1.4-16.9) and 11 (2.1-58.6), respectively. Repair of 23 rectovaginal fistulae required 1, 2, 3 or 4 additional surgical procedures in 12 (52.2%), 8 (34.8%), 2 (8.7%) and 1 patient (4.3%), respectively. Repair of leakage in 14 patients required 1 procedure (stoma) in 12 cases (85.7%) and a second procedure (colorectal resection) in 2 cases (14.3%). All patients, excepted five women managed by delayed coloanal anastomosis, underwent a supplementary surgical procedure for stoma repair. The period of time required for diverting stoma following repair of rectovaginal fistulae was significantly longer than for repair of leakages (median values 10 and 5 months, respectively, P = 0.008). LIMITATIONS, REASONS FOR CAUTION: The main limits relate to the heterogeneity of techniques used in removal of rectosigmoid nodules and repairing fistulae, the lack of accurate information about the level of nodules, the small number of centres and that a majority of patients were managed by one surgeon. WIDER IMPLICATIONS OF THE FINDINGS: Deep endometriosis infiltrating the rectosigmoid can be managed laparoscopically with a relatively low risk of bowel fistula. When the type of bowel procedure can be chosen, performance of shaving instead of disc excision or colorectal resection is suggested considering the lower risk of bowel fistula. Rectovaginal fistula repair is more challenging than for bowel leakage and may require up to four additional surgical procedures. STUDY FUNDING/COMPETING INTEREST(S): CIRENDO is financed by the G4 Group (The University Hospitals of Rouen, Lille, Amiens and Caen) and the ROUENDOMETRIOSE Association. No financial support was received for this study. H.R. reports personal fees from ETHICON, Plasma Surgical, Olympus and Nordic Pharma outside the submitted work. The other authors declare no conflict of interests related to this topic.

Effectiveness of Fibrin Sealant Application on the Development of Staple Line Complications After Sleeve Gastrectomy: A Prospective Randomized Trial.

OBJECTIVES: Evaluate the effectiveness of the use of fibrin sealant (FS) for preventing the development of staple line complications (SLCs) after sleeve gastrectomy (SG). BACKGROUND: There is no consensus on the best means of preventing SLCs after SG. METHODS: This was a prospective, intention-to-treat, randomized, 2 center study of a group of 586 patients undergoing primary SG (ClinicalTrials.gov identifier: NCT01613664) between March 2014 and June 2017. The 1:1 randomization was stratified by center, age, sex, gender, and body mass index, giving 293 patients in the FS group and 293 in the control group (without FS). The primary endpoint (composite criteria) was the incidence of SLCs in each of the 2 groups. The secondary criteria were the mortality rate, morbidity rate, reoperation rate, length of hospital stay, readmission rate, and risk factors for SLC. RESULTS: There were no intergroup differences in demographic variables. In an intention-to-treat analysis, the incidence of SLCs was similar in the FS and control groups (1.3% vs 2%, respectively; P = 0.52). All secondary endpoints were similar: complication rate (5.4% vs 5.1%, respectively; P = 0.85), mortality rate (0.3% vs 0%, respectively; P = 0.99), GL rate (0.3% vs 1.3%, respectively; P = 0.18), postoperative hemorrhage/hematoma rate (1% vs 0.7%, respectively; P = 0.68), reoperation rate (1% vs 0.3%, respectively; P = 0.32). Length of stay was 1 day in both groups (P = 0.89), and the readmission rate was similar (5.1% vs 3.4%, respectively; P = 0.32). No risk factors for SLCs were found. CONCLUSION: The incidence of postoperative SLCs did not appear to depend on the presence or absence of FS.

Multiple Nodule Removal by Disc Excision and Segmental Resection in Multifocal Colorectal Endometriosis.

STUDY OBJECTIVE: To report postoperative outcomes after dual digestive resection for deep endometriosis infiltrating the rectum and the colon. DESIGN: A retrospective study using data prospectively recorded in the CIRENDO database (Canadian Task Force classification II-2). SETTING: A university tertiary referral center. PATIENTS: Twenty-one patients managed for multiple colorectal deep endometriosis infiltrating nodules. INTERVENTIONS: Concomitant disc excision and segmental resection of both the rectum and sigmoid colon. MEASUREMENTS AND MAIN RESULTS: The assessment of postoperative outcomes was performed. Rectal nodules were managed by disc excision and segmental resection in 20 patients and 1 patient, respectively. Sigmoid colon nodules were removed by short segmental resection and disc excision in 15 and 6 patients, respectively. The rectal nodule diameter was between 1 and 3 cm and over 3 cm in 33% and 67% of patients, respectively. Associated vaginal infiltration requiring vaginal excision was recorded in 76.2% of patients. The mean diameter of the rectal disc removed averaged 4.6 cm, and the mean height of the rectal suture was 5.8 cm. The length of the sigmoid colon specimen and the height of the anastomosis were 7.3 cm and 18.5 cm, respectively. The mean operative time was 290 minutes, and the mean postoperative follow-up averaged 30 months. Clavien-Dindo 3 complications occurred in 28% of patients, including 4 with rectal fistulae (19%). The pregnancy rate was 67% among patients with pregnancy intention. CONCLUSION: Our data suggest that combining disc excision and segmental resection to remove multiple deep endometriosis nodules infiltrating the rectum and the sigmoid colon can preserve the healthy bowel located between 2 consecutive nodules. However, the rate of postoperative complications is high, particularly in patients with large low rectal nodules.

Colorectal Endometriosis Responsible for Bowel Occlusion or Subocclusion in Women With Pregnancy Intention: Is the Policy of Primary in Vitro Fertilization Always Safe?

OBJECTIVE: To discuss the risk of bowel occlusion or subocclusion in patients with pregnancy wish and deep colorectal endometriosis, when surgery is postponed until after conception. DESIGN: A prospective series of consecutive patients managed for occlusion or subocclusion between January 2012 and January 2015 (Canadian Task Force classification II-2). Deep endometriosis had previously been diagnosed in all patients; however, they were advised to postpone surgery until after conception. SETTING: University tertiary referral center. PATIENTS: Twelve women with bowel occlusion or subocclusion due to deep endometriosis and desiring pregnancy. INTERVENTION: Surgical management including colorectal resection. MAIN OUTCOME MEASURES: Digestive symptoms, including standardized gastrointestinal questionnaires and preoperative imaging assessment of deep endometriosis. RESULTS: The patients enrolled in the series represent 5% of 241 patients with colorectal endometriosis managed over 37 consecutive months. Major digestive complaints were bloating, defecation pain, constipation, liquid stools, and a feeling of incomplete stool evacuation. The median length of digestive tract stenosis was 50 mm (range, 20-100 mm). In 8 patients (67%), computed tomography-based virtual colonoscopy revealed a virtual digestive lumen. The median length of colorectal specimen removed was 120 mm (range, 60-200 mm). Three patients (25%) had Clavien-Dindo IIIb and IVa postoperative complications with favorable outcomes within up to 20 days after surgery. CONCLUSION: Given the risk of bowel occlusion or subocclusion in young patients with colorectal endometriosis, an exhaustive assessment of deep disease and advice at a tertiary referral center appears to be mandatory before prioritizing primary in vitro fertilization instead of primary surgery.

When Gastroplasty Is Not Feasible in Ivor Lewis Esophagectomy: A Single-Center Study of Intrathoracic Esophagojejunostomy.

Objective: The surgical management of tumors of the esophagogastric junction is increasingly performed by minimally invasive Ivor Lewis esophagectomy. However, gastroplasty is not always feasible. The creation of a long loop is an alternative for esophageal reconstruction. The aim of this study was to evaluate the technical feasibility of using a minimally invasive thoracoscopic approach in esophagojejunostomy and to describe the contraindications for gastroplasty. Methods: All patients who had intrathoracic esophagojejunostomy in our center were identified in our database. Since 2016, the preferred approach for intrathoracic esophagojejunostomy is minimally invasive laparoscopy and thoracoscopy, using a long Roux-en-Y jejunal loop with a semimechanical triangular anastomosis technique. Results: Between January 1, 2012 and January 1, 2022, 12 patients who had esophagojejunostomy in our center were included in the study. Among them, 6 had thoracotomy and 6 had total minimally invasive thoracoscopy, representing 3.5% of surgical procedures for esophagogastric junction tumors since 2016. The mean operative time was 416.9 ± 107.47 minutes. No anastomotic leakage was observed in the minimally invasive group versus 2 leakages in the thoracotomy group. The main complication was pneumonia in 3 patients (27.3%). Finally, the main indication for intrathoracic esophagojejunostomy was tumor size with a mean of 4.72 ± 2.35 cm and the patient's surgical history. Conclusion: A total minimally invasive approach using a long jejunal loop with triangular anastomosis could be a feasible and reproducible alternative to gastroplasty to restore continuity in Ivor Lewis esophagectomy when the stomach cannot be used.

Diverting stoma-related complications following colorectal endometriosis surgery: a 163-patient cohort.

OBJECTIVE: Deep endometriosis may simultaneously infiltrate the vagina and the rectosigmoid, which associated resection may increase the risk of postoperative complications. Among these complications, rectovaginal fistula is one of the worst. To reduce the risk of rectovaginal fistula and related complications, surgeons may employ diverting stoma. The literature is rich in data concerning the usefulness of stoma in patients managed for low rectal cancer. However, extrapolation of these data to patients managed for rectal endometriosis is disputable. For this reason, there are no guidelines on the role of stoma in preventing rectovaginal fistula in patients managed for colorectal endometriosis. The objective of our study was to assess the risk of complications related to the use of stoma in patients managed for colorectal endometriosis. STUDY DESIGN: A retrospective comparative study has been performed using data prospectively recorded in the CIRENDO database. 163 consecutive women with colorectal endometriosis who had temporary stoma have been enrolled at the University Hospital of Rouen, from June 2009 to December 2016. The main outcome was stoma-related complications rate using Clavien-Dindo classification. No women were lost to follow-up. RESULTS: Among the 163 women, 158 (96.9%) had a primary diverting stoma and 5 women (3.1%) with an immediate post-surgical bowel fistula had a secondary diverting stoma. Stoma involved the ileum in 28 women (17.2%) and the colon in 135 (82.8%). Surgical management of the rectosigmoid junction was rectal shaving in 2 women (1.2%), disc excision in 62 (38%), colorectal resection in 87 (53.4%), and combined rectal disc excision and sigmoid colon segmental resection in 12 (7.4%). Clavien Dindo I stoma-related complications occurred in 38 patients (23.3%) and were related to abnormal healing of stoma scar. Most Clavien-Dindo II complications were wound or urinary infections following stoma closure. Clavien Dindo III complications occurred in 14 patients (8.6%) and were related to leakage, hemoperitoneum, hernia of the abdominal wall, subcutaneous abscess and bowel obstruction syndrome. CONCLUSION: Specific complications may occur directly related to the use of stoma in the surgery of deep endometriosis of the rectosigmoid. The risk of these complications should be taken into account and full preoperative information should be provided to patients and their family.

Factors associated With burnout among French digestive surgeons in training: results of a national survey on 328 residents and fellows.

BACKGROUND: Digestive surgery training is notoriously difficult and medical students choose this path less and less often leading to a veritable demographic crisis for this specialty in France. The aim of this study was to evaluate the working conditions to measure the prevalence of burnout syndrome (BOS) and to identify potential risk factors to implement preventive measures and appropriate support. METHODS: This was a multicenter, cross-sectional study. An anonymous questionnaire was sent by e-mail to 500 French digestive surgeons in training (residents and fellows). RESULTS: The response rate was 65.6%. The mean working week was 75.7 hours (±12) and the mean number of night shifts was 5.3 (±1.6)/month. Sixty-seven percent of respondents had trouble sleeping and 12% reported suicidal thoughts. High-emotional exhaustion, depersonalization, and personal accomplishment low scores were observed respectively in 24.7%, 44.6%, and 47%, corresponding to a high score of BOS in 52%. CONCLUSIONS: This study showed a high rate of BOS in French digestive surgeons in training and a worrying rate of suicide ideation.

Functional outcomes after disc excision in deep endometriosis of the rectum using transanal staplers: a series of 111 consecutive patients.

OBJECTIVE: To assess the postoperative outcomes of patients with rectal endometriosis managed by disc excision using transanal staplers. DESIGN: Prospective study using data recorded in the CIRENDO database (NCT02294825). SETTING: University tertiary referral center. PATIENT(S): A total of 111 consecutive patients managed between June 2009 and June 2016. INTERVENTION(S): We performed rectal disc excision using two different transanal staplers: [1] the Contour Transtar stapler (the Rouen technique); and [2] the end to end anastomosis circular transanal stapler. MAIN OUTCOMES MEASURE(S): Pre- and postoperative digestive function was assessed using standardized gastrointestinal questionnaires: the Gastrointestinal Quality of Life Index and the Knowles-Eccersley-Scott Symptom Questionnaire. RESULT(S): The two staplers were used in 42 (37.8%) and 69 patients (62.2%), respectively. The largest diameter of specimens achieved was significantly higher using the Rouen technique (mean ± SD, 59 ± 11 mm vs. 36 ± 7 mm), which was used to remove nodules located lower in the rectum (5.5 ± 1.3 cm vs. 9.7 ± 2.5 cm) infiltrating more frequently the adjacent posterior vaginal wall (83.3% vs. 49.3%). Associated nodules involving sigmoid colon were managed by distinct procedures, either disc excision (2.7%) or segmental resection of sigmoid colon (9.9%). Postoperative values for the Gastrointestinal Quality of Life Index increased 1 and 3 years after the surgery, but improvement in constipation was not significant. The probability of pregnancy at 1 year after the arrest of medical treatment was 73.3% (95% confidence interval 54.9%-88.9%), with a majority of spontaneous conceptions. CONCLUSION(S): Disc excision using transanal staplers is a valuable alternative to colorectal resection in selected patients presenting with rectal endometriosis, allowing for good preservation of rectal function.