Disk Excision Using End-to-End Anastomosis Circular Stapler for Deep Endometriosis of the Rectum: A 492-Patient Continuous Prospective Series.

STUDY OBJECTIVE: To report a large series including women managed by disk excision using end-to-end anastomosis (EEA) circular transanal stapler to assess the feasibility of the technique, the features of nodules suitable for removal by disk excision, and the rate of major early complications. DESIGN: Retrospective study on data prospectively recorded in 2 databases. SETTING: Two tertiary referral centers. PATIENTS: A total of 492 patients undergoing surgery for rectal endometriosis from May 2011 to June 2022. INTERVENTIONS: Rectal disk excision using the EEA stapler. MEASUREMENT AND MAIN RESULTS: Disk excision using EEA was performed in 492 patients (24.2%) of 2,029 women receiving surgery for deep endometriosis infiltrating the rectum during the 11-year study period. Deep endometriosis involved low rectum in 11% and mid rectum in 55.3%. The diameter of rectal nodules exceeded 3 cm in 65.9%. Mean operative time was 2 hours, mean diameter of rectal patches removed was 41 ± 11 mm, and the mean rectal suture height was 9.2 ± 5.5 cm. The presence of microscopic foci on the edges of rectal patches was identified in 30.2% of cases. Rectal fistula was recorded in 20 patients (4%). The distance from the anal verge was significantly lower in patients with fistula than women with no fistula (5.9 ± 2 cm vs 9.2 ± 5.6 cm, p = .027). Follow-up ranged from 1 to 120 months, with a median value of 36 months. Magnetic resonance imaging in 3 patients during follow-up revealed a recurrent nodule infiltrating the previous stapled line (0.6%) after a postoperative delay of, respectively, 36, 48, and 84 months. CONCLUSION: Disk excision using the EEA stapler is suitable in nodules >3 cm if surgeons ensure deep shaving of the rectum, to allow complete inclusion of the shaved area into the stapler jaws. Postoperative rectal recurrences seem incidental, whereas bowel leakage rate is comparable with that after colorectal resection. This technique is suitable in almost a quarter of patients managed for rectal endometriosis nodules and is therefore a valuable technique that warrants more widespread use.

Long-term Outcomes Following Surgical Management of Rectal Endometriosis: Seven-year Follow-up of Patients Enrolled in a Randomized Trial.

STUDY OBJECTIVE: To compare functional outcomes, recurrence rate, and pregnancy likelihood in patients undergoing conservative or radical surgery for deep rectal endometriosis followed up for 7 years. DESIGN: Prospective study in a cohort of patients enrolled in a 2-arm randomized trial from March 2011 to August 2013. SETTING: A tertiary referral center. PATIENTS: Fifty-five patients with deep endometriosis infiltrating the rectum. INTERVENTIONS: Patients underwent either segmental resection or nodule excision via shaving or disk excision, depending on randomization that was performed preoperatively using sequentially numbered, opaque sealed envelopes. MEASUREMENTS AND MAIN RESULTS: The primary end point was the number of patients experiencing one of the following symptoms: constipation, frequent bowel movements, anal incontinence, or bladder dysfunction 24 months after surgery. The secondary end points were values of gastrointestinal and overall quality of life scores. The 7-year recurrence rates (new deep endometriosis nodules infiltrating the rectum) in the excision vs segmental resection arms were 7.4 % vs 0% (p = .24). One of the symptoms included in the definition of the primary outcomes was recorded in 55.6% vs 60.7% of patients (p = .79). However, 51.9% vs 53.6% of patients considered their bowel movements as normal (p = .99). An intention-to-treat comparison of overall quality of life scores did not find a difference between the 2 groups 7 years after surgery. At the end of the 7-year study period, 31 of 37 patients who tried to conceive were successful (83.8%), including 27 pregnancies (57.4%) resulting from natural conception and 20 pregnancies (42.6%) resulting from assisted reproductive technology procedures. The pregnancy rate was 82.4% vs 85% in the 2 arms (p = .99). A 75.7% live birth rate was recorded. At the end of the follow-up, there were 15 women with 1 child (40.5%) and 13 women with 2 children (35.1%). During the 7-year follow-up, the reoperation rates were 37% and 35.7%, respectively, in each arm (p = .84). Among the 27 reoperation procedures during the follow-up period, 11 (40.7%) were for postoperative complications, 7 (25.9%) were necessary before assisted reproductive technology management, 8 (29.6%) were for recurrent abdominal or pelvic pain, and 1 (3.7%) was for midline ventral hernia after pregnancy. CONCLUSION: Our study did not reveal a considerable difference in terms of digestive functional outcomes, recurrence rate, reoperation risk, and pregnancy likelihood when conservative and radical rectal surgeries for deep endometriosis were compared 7 years after surgery. The postoperative pregnancy rate observed in our series was high.

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.

Double Disk Excision of Large Deep Endometriosis Nodules Infiltrating the Low and Mid Rectum: A Pilot Study of 20 Cases.

STUDY OBJECTIVE: To report the technique of double disk excision of deep endometriosis nodules infiltrating the mid or low rectum and surgical outcomes. DESIGN: A retrospective case series using data prospectively recorded in the North-West Inter Regional Female Cohort for Patients with Endometriosis database. SETTING: University tertiary referral center. PATIENTS: Twenty women managed for large deep endometriosis nodules infiltrating the mid or low rectum. INTERVENTIONS: Double disk excision using transanal end-to-end anastomosis circular stapler. MEASUREMENTS AND MAIN RESULTS: Twenty women managed by double disk excision from May 2016 to September 2019 were included in the study. The mean time of intervention was 149 ± 74 minutes. The cumulated mean diameter of the excised rectal disks was 53.4 ± 19.1 mm, whereas in 85% of the women, it was ≥50 mm. The mean distance between the lowest margin of the disk and the anal verge was 66 mm. Vaginal infiltration was removed in 15 patients (75%), and in 6 patients (30%) it exceeded 30 mm in diameter. Owing to the presence of sigmoid colon nodules, 2 patients (10%) underwent concomitant segmental sigmoid resection of 4 cm and 6 cm in length, respectively. Transitory stoma was performed in 8 patients (40%) owing to concomitant vaginal excision >3 cm in size. After a follow-up varying from 3 months to 42 months, no digestive fistula was recorded. The rate of Clavien-Dindo 3 complications was 15%. CONCLUSION: Double disk excision is suitable for excising large deep endometriosis nodules infiltrating the mid or low rectum and is associated with a low severe complication rate with good functional outcomes in women. Further studies are required to assess the improvement of functional outcomes in deep endometriosis nodules infiltrating the mid or low rectum in comparison with colorectal resection.