Bowel Endometriosis Excision: Approaches and Outcomes Including Hand Sewing of Discoid Excision.

STUDY OBJECTIVE: To examine the outcomes of surgery performed for bowel endometriosis including shaving, discoid resections with hand sewn closure, and segmental resection. DESIGN: Retrospective cohort study. SETTING: Large academic hospital PATIENTS: All patients with bowel wall endometriosis who underwent surgical excision with the Division of Minimally Invasive Gynecologic Surgery (MIGS) between 2009 and 2022. INTERVENTIONS: No interventions administered. MEASUREMENTS AND MAIN RESULTS: From 2009 to 2022, a total of 112 patients underwent laparoscopic excision of endometriosis involving the rectum. From this cohort, 82 underwent shaving, 23 underwent discoid excision, and 7 had segmental bowel resection. The discoid excisions were closed in multiple layers with hand sewing and were not closed with a staple device. Average lesion size on preoperative imaging was 20.9 mm in the shave group, 22.5 mm in the discoid group and 38.5 mm in the segmental group. Complication requiring reoperation for anastomotic leak occurred in 3 cases (3.66%) of the shave group and 1 case (4.35%) of the discoid excision group, but did not occur in any of the segmental resections. The number of layers of closure and type of suture used did not appear to have an effect on complication rate, however this study was not powered to detect a meaningful difference. CONCLUSION: Our data shows a similar rate of anastomotic leak complication for each closure type as that reported in the literature (2.2%, 9.7% and 9.9% reported for shave, discoid and segmental resection respectively). While our study is underpowered, these findings support that hand sewing for discoid excision is a safe and reasonable alternative to circular stapler closures and can be considered with an experienced surgeon. Further study is warranted to confirm safety and explore potential cost savings associated with this technique as well as applications in areas with less resources available.

Protective defunctioning stoma in bowel segmental resection at the time of total hysterectomy for endometriosis: when less is more.

PURPOSE: To compare postoperative complications in women undergoing total hysterectomy with segmental resection (TH-SR) for intestinal endometriosis with or without protective defunctioning stoma (PDS) confection. METHODS: Retrospective cohort study conducted at the Gynecologic department of University Hospital of Lille (France) from January 2008 to January 2022 in patients undergone TH-SR for bowel endometriosis. RESULTS: 100 women were considered for the analysis. PDS were performed in 56 women. The rate of rectal resections was significantly higher in the PDS group (p = 0.03). The mean operative time, AAGL scores and length of hospital stay were significantly higher in the PDS group (p = 0.002). The rate of grade III complication according to Clavien-Dindo classification was higher in the PDS group (p = 0.03). Among digestive complications, one case of anastomosis leakage (1.8%) and one case of recto-vaginal fistula (2.3%) was recorded in the non-PDS group, 4 cases of anastomosis stenosis were recorded in the PDS group (7.1%). Persisting bladder atony requiring self-catheterization over one month was the most common disturb (4.6% in the non-PDS group and 7.1% in the PDS group, p = 0.58). The distance of digestive lesion from anal margin was the only risk factor for digestive complications, persistent bladder atony, Clavien-Dindo IIIA and IIIB complications at the multivariate analysis (p = 0.04 and p = 0.06 respectively). CONCLUSION: No statistically significant differences were found in the rate of digestive complications in case of total hysterectomy and concomitant segmental resection when performing or not preventing stoma.

Totally intracorporeal colorectal anastomosis (TICA) versus classical mini-laparotomy for specimen extraction, after segmental bowel resection for deep endometriosis: a single-center experience.

PURPOSE: The surgical approach to bowel endometriosis is still unclear. The aim of the study is to compare TICA to conventional specimen extractions and extra-abdominal insertion of the anvil in terms of both complications and functional outcomes. METHODS: This is a single-center, observational, retrospective study conducted enrolling symptomatic women underwent laparoscopic excision of deep endometriosis with segmental bowel resection between September 2019 and June 2022. Women who underwent TICA were compared to classical technique (CT) in terms of intra- and postoperative complications, moreover, functional outcomes relating to the pelvic organs were assessed using validated questionnaires [Knowles-Eccersley-Scott-Symptom (KESS) questionnaire and Gastro-Intestinal Quality of Life Index (GIQLI)] for bowel function. Pain symptoms were assessed using Visual Analogue Scale (VAS) scores. RESULTS: The sample included 64 women. TICA was performed on 31.2% (n = 20) of the women, whereas CT was used on 68.8% (n = 44). None of the patients experienced rectovaginal, vesicovaginal, ureteral or vesical fistula, or ureteral stenosis and uroperitoneum, and in no cases was it necessary to reoperate. Regarding the two surgical approaches, no significant difference was observed in terms of complications. As concerns pain symptoms at 6-month follow-up evaluations on stratified data, except for dysuria, all VAS scales reported showed significant reductions between median values, for both surgery interventions. As well, significant improvements were further observed in KESS scores and overall GIQLI. Only the GIQLI evaluation was significantly smaller in the TICA group compared to CT after the 6-month follow-up. CONCLUSIONS: We did not find any significant differences in terms of intra- or post-operative complications compared TICA and CT, but only a slight improvement in the Gastro-Intestinal Quality of Life Index in patients who underwent the CT compared to the TICA technique.

Robotic surgery for bowel endometriosis: a multidisciplinary management of a complex entity.

BACKGROUND: Bowel endometriosis impacts quality of life. Treatment requires complex surgical procedures with associated morbidity. Precision approach with robotic surgery leads to organ preservation. Bowel endometriosis requires a multidisciplinary management to improve patient outcomes. This study evaluates perioperative outcomes of bowel endometriosis undergoing multidisciplinary planning and robotic surgery. METHODS: Consecutive cases of multidisciplinary robotic bowel endometriosis procedures (January 2021-December 2022) were evaluated from a prospectively maintained database in a national endometriosis accredited centre. Patients were managed through a multidisciplinary setting including gynaecologists, colorectal robotic surgeons, and other specialists. Dyschezia (menstrual and non-cyclical) and quality of life were assessed pre- and postoperatively (6 months) through validated questionnaires. RESULTS: Sixty-eight consecutive cases of robotic bowel endometriosis were included. Median age was 35.0 (30.2-42.0) years. Median body mass index was 24.0 (21.0-26.7) kg/m2. Procedures performed were 48 (70.6%) shavings, 11 (16.2%) deep shavings, 3 (4.4%) disc excisions, and 6 (8.8%) segmental resections. One (1.5%) patient required temporary stoma. Median operating time was 150 (120-180) min. There were no conversions/return to theatre postoperatively. Median endometriotic nodule size was 25.0 (15.5-40.0) mm. Two (2.9%) patients developed postoperative complications. Median length of postoperative stay was 2 (2-4) days. Median follow-up was 12 (7-17) months. One (1.5%) patient recurred. Median menstrual dyschezia score improved from 5.0 (2.0-8.0) to 1.0 (0.0-5.7). Median non-cyclical dyschezia significantly improved (p < 0.001) from 1.0 (0.0-5.7) to 0.0 (0.0-2.0). Median quality of life score improved from 52.5 (35.0-70.0) to 74.5 (60.0-80.0). CONCLUSIONS: Robotic multidisciplinary approach to bowel endometriosis provides good perioperative outcomes with improvement of dyschezia and quality of life.

Bowel endometriosis: Surgical customization is demanding.

Bowel endometriosis is the most common form of severe deep endometriosis. Surgery is an option in case of infertility and/or chronic pain or in the presence of a stenotic lesion. Clinical examination and preoperative imaging must provide an identity card of the lesion so that customized surgery can be proposed. The primary objective of this tailor-made surgery will always be to preserve the organ. The surgeon then has three options: shaving, discoid resection and segmental resection. The more extensive the resection, the greater the risk of severe short- and long-term complications. Surgery must therefore be adapted to the patient's specific situation and needs. Moreover, personalized care must extend beyond surgery. It must begin before the operation, preparing the patient for the operation like an athlete before a race, and continue afterwards by adapting the follow-up to the surgery performed.

Resección intestinal por endometriosis severa, diagnóstico y tratamiento luego de la introducción de la Unidad de Endometriosis: revisión de 18 años en el Hospital Clínico de la Universidad de Chile / Bowel resection for severe endometriosis, diagnosis and treatment after the introduction of Endometriosis Unit: 18 years review, Clinical Hospital of the University of Chile

INTRODUCCIÓN: La endometriosis intestinal afecta en gran medida la calidad de vida de una mujer joven y habitualmente requiere un tratamiento quirúrgico con resección intestinal. Esta cirugía es técnicamente compleja por las adherencias firmes del intestino a la vagina, el útero y los ovarios. OBJETIVO: Describir y analizar los resultados quirúrgicos e histopatológicos de las resecciones intestinales por endometriosis grave durante los últimos 18 años en el Hospital Clínico de la Universidad de Chile, en relación con la introducción de la unidad multidisciplinaria de endometriosis, a partir del año 2011, y las experiencias publicadas en la literatura chilena y extranjera. MÉTODO: Trabajo retrospectivo realizado en un hospital terciario desde el año 2001 hasta el año 2019. Las pacientes se asignaron a dos grupos según el período de cirugía: grupo 2001-2010 y grupo 2011-2019, luego de la introducción de la unidad de endometriosis. Se recopilaron todas las pacientes a las que se realizó una resección intestinal (discoidal o segmentaria) por endometriosis, por laparotomía o laparoscopía. Los datos distribuidos normalmente se presentan como promedio ± DE y los datos no paramétricos como mediana (rango). Las comparaciones demográficas de variables continuas se hicieron con la prueba t de Student y las de las variables categóricas con las pruebas de ji al cuadrado o de Fisher. La significación estadística se estableció en p < 0,05. RESULTADOS: Se recopilaron 52 casos. El 94,2% de las cirugías fueron electivas. El 5,8% fueron de urgencia por obstrucción intestinal (todas entre 2001 y 2010). Un 75% de las cirugías fueron laparoscópicas. Se realizó resección segmentaria en el 67,3%, resección discoidal simple en el 28,8%, resección discoidal doble en el 1,9% y resección segmentaria y una discoidal en el 1,9%. La histopatología demostró compromiso de la lesión hasta la mucosa intestinal en un 7,7%. Hubo franca disminución del dolor en el seguimiento de las pacientes. El 24% de las pacientes con deseo de embarazo y endometriosis intestinal lograron un parto de término mediante fecundación in vitro o espontáneamente. Hubo cuatro complicaciones posoperatorias, tres de ellas de categoría II según la clasificación de Clavien-Dindo y una de categoría IV A con reintervención a las 72 horas. Al comparar ambos periodos, en 2001-2010 los exámenes diagnósticos utilizados fueron ecografía transvaginal (0%), enema baritado (60%), tomografía computarizada de abdomen y pelvis (45%) y resonancia magnética pelviana (20%), mientras que en 2011-2019 fueron ecografía transvaginal (100%), enema baritado (3%), tomografía computarizada (3%) y resonancia magnética pelviana (66%). En 2001-2010, las lesiones fueron más más infiltrativas (mayor compromiso mucoso y submucoso) (75 vs. 16% de las resecciones intestinales; p < 0,05), estenóticas (cirugías de urgencia por obstrucción), con mayor porcentaje de resecciones segmentarias (100 vs. 46,9%; p < 0,05) y más días de hospitalización (5,8 ± 2,3 vs. 4,1 ± 0,9 días) que en 2011-2019. CONCLUSIONES: A nuestro entender, esta es la serie más grande publicada en Chile de resecciones intestinales por endometriosis. Estos hallazgos demuestran cómo la introducción de la unidad multidisciplinaria de endometriosis permite un diagnóstico precoz y un tratamiento quirúrgico eficaz y oportuno, tal como se decribe en la literatura.

INTRODUCTION: Bowel endometriosis severely affects a young woman's quality of life and often requires surgical treatment with bowel resection. This surgery is technically complex due to the tight adhesions of the intestine to the vagina, uterus, and ovaries. The objective of this work is to describe and analyze the surgical and histopathological results of intestinal resections for severe endometriosis during the last 18 years at the Clinical Hospital University of Chile, in relation to the implementation of the multidisciplinary endometriosis unit, based on the year 2011 and the experiences published in Chilean and foreign literature. METHOD: Retrospective work carried out in a tertiary hospital from 2001 to 2019. The patients were assigned to two groups according to the surgery period: group 2001-2010 and group 2011-2019, after endometriosis unit formation. All patients who underwent bowel resection (discoidal or segmental) for endometriosis by laparotomy or laparoscopy were collected. Normally distributed data are presented as mean ± SD and nonparametric data as median (range). Demographic comparisons of continuous variables are compared using Student's t test and categorical variables using chi squared or Fisher's test. Statistical significance was established at p < 0.05. RESULTS: 52 cases were collected. 94.2% of the surgeries were elective. 5.8% were urgent due to intestinal obstruction (all between 2001 and 2010). 75% of the surgeries were laparoscopic. Segmental resection 67.3%, simple discoidal resection 28.8%, double discoidal resection 1.9% and segmental resection and a discoidal resection 1.9%. Histopathology showed involvement of the lesion up to the intestinal mucosa in 7.7%. A marked decrease in pain in the follow-up of the patients. 24% of the patients with a desire for pregnancy and intestinal endometriosis achieved a full-term delivery by IVF or spontaneously. There were four postoperative complications, three of them category II according to the Clavien-Dindo classification, and one category IV A complication with reoperation at 72 h. When comparing both periods, between 2001-2010 the diagnostic tests used were: transvaginal ultrasound (ECO TV) (0%), barium enema (BE) (60%), abdomen pelvis CT (45%) and pelvic resonance (MRI) (20%). Between 2011 and 2019 ECO TV (100%), EB (3%), TAC (3%) RM (66%). In the period 2001 to 2010, the lesions were more infiltrative (greater mucosal and submucosal involvement) (75% vs 16% of intestinal resections (P <0.05)), stenotic (urgent surgery for obstruction), with a higher percentage of resections segmental (100% vs 46.9% (P <0.05) and more days of hospitalization (5.8 ± 2.3 SD vs 4.1 ± 0.9 SD) than in the period from 2011 to 2019. CONCLUSIONS: To our knowledge, this is the largest series published in Chile of intestinal resections for endometriosis. These findings demonstrate how the introduction of the multidisciplinary endometriosis unit allows early diagnosis and effective and timely surgical treatment as described in the literature.

Resonancia magnética en el estudio de dos pacientes con dolor pélvico crónico asociado a endometriosis de infiltración profunda / Magnetic resonance imaging in the study of two patients with chronic pelvic pain associated to infiltrating endometriosis deep

INTRODUCCIÓN: La endometriosis de infiltración profunda (EIP) es una enfermedad crónica de difícil diagnóstico, que frecuentemente es confundida con otras patologías pelvianas. OBJETIVO: Presentar dos casos de endometriosis de infiltración profunda, donde la resonancia magnética (RM) de pelvis, fue importante para el diagnóstico y planificación del tratamiento quirúrgico. CASO CLÍNICO: Se describe el caso de dos pacientes. La primera de 24 años afectada por un nódulo de EIP retrocervical con extensión intestinal sintomática y la segunda, una paciente de 37 años con una recidiva sintomática de EIP en la cúpula vaginal después de una histerectomía total. RESULTADOS: La RM de pelvis describe en ambos casos la extensión de las lesiones endometriósicas y presenta una excelente correlación con los hallazgos intra operatorios en la laparoscopía quirúrgica. CONCLUSIONES: La RM de pelvis es un excelente recurso en el estudio diagnóstico de las pacientes con dolor pélvico crónico, tanto en el caso de EIP retrocervical con extensión intestinal y también en la recidiva de EIP en la cúpula vaginal después de una histerectomía total

INTRODUCTION: Deep infiltration endometriosis (DIE) is a chronic disease of difficult diagnosis, which is frequently confused with other pelvic pathologies. OBJETIVE: To present two cases of deep infiltrating endometriosis, where the pelvic magnetic resonance imaging (MRI) was important in the diagnosis and surgical treatment planning. CLINICAL CASES: Two cases, one 24 years-old patient suffering from retrocervical DIE nodule with symptomatic bowel involvement, and a 37 years-old patient, with a symptomatic DIE at the vaginal cuff after total hysterectomy. RESULTS: Pelvic MRI describes in both cases the extension of the endometriotic lesions and presents an excellent correlation with the intra operatory findings during surgical laparoscopy. CONCLUSIONS: Pelvic MRI is an excellent diagnostic tool for patients with pelvic pain, in case of retrocervical DIE with bowel involvement, and also in recurrence of DIE at the vaginal cuff after total hysterectomy

Abdome agudo obstrutivo causado por endometriose intestinal: relato de caso / Acute abdomen obstructive by bowel endometriosis: case report

Endometriose é definida como a implantação de tecido endometrial funcionante fora da cavidade uterina. Quando afeta os intestinos, ela pode se manifestar por estenose, levando ao abdômen agudo. Trata-se de um estudo de caso de uma paciente com dor abdominal, constipação intestinal e queixas ginecológicas. A paciente evoluiu com obstrução intestinal aguda e foi submetida à laparoscopia. Identificou-se estenose no sigmoide sugestivo de malignidade. Foi submetida a tratamento cirúrgico com anastomose colorretal mecânica, colostomia temporária e o coto retal foi sepultado. O estudo histopatológico revelou endometriose em submucosa intestinal e muscular própria. Sem intercorrências até o quinto dia após a cirurgia quando a paciente apresentou dor abdominal, taquicardia, falta de ar, sinais de irritação peritoneal e pneumoperitônio. Formas ectópicas da endometriose são difíceis de diagnosticar. Abdômen agudo obstrutivo secundário à endometriose é complicação incomum e de difícil manejo. Portanto, considera-se importante a investigação clínica e laparoscópica de pacientes com patologias intestinais crônicas e quadro ginecológico sem causa etiológica aparente, a fim de diagnosticar formas ectópicas de endometriose.

Endometriosis is by the implantation of functioning endometrial tissue outside the uterine cavity. When it affects the intestines, it can manifest by stenosis, leading to acute abdomen. This is a case study of a patient with abdominal pain, chronic intestinal constipation and gynecological complaints. The patient developed acute intestinal obstruction and underwent laparoscopy. We identified stenosis in the sigmoid suggestive of malignancy. Underwent surgical treatment with mechanical colorectal anastomosis, temporary colostomy and the rectal stump was buried. Histopathological study revealed endometriosis in intestinal submucosa and muscularis propria. It was uneventful until the fifth day after surgery, when the patient presented abdominal pain, tachycardia, shortness of breath, signs of peritoneal irritation and pneumoperitoneum. Ectopic forms of endometriosis are difficult to diagnose. Acute abdomen secondary to obstructive endometriosis is rare, so clinical and laparoscopic investigation are of great importance in patients with chronic intestinal and gynecological complaints without apparent etiology, in order to diagnose ectopic forms of endometriosis.

Tratamento laparoscópico de 98 pacientes com endometriose intestinal / Laparoscopic treatment of 98 women with bowel endometriosis

OBJETIVO: Identificar os tipos de tratamento cirúrgico e a morbidade operatória na endometriose intestinal. MÉTODOS: Estudo retrospectivo de pacientes operadas no Biocor Instituto (Belo Horizonte, MG) por uma equipe multidisciplinar para tratamento de endometriose no período de janeiro de 2002 a junho de 2009. RESULTADO: Noventa e oito pacientes foram submetidas aos seguintes procedimentos para tratamento da endometriose intestinal: ressecção segmentar do reto (n 46; 45,5 por cento), ressecção em disco (n 25; 24,7 por cento), "shaving" (n 18; 17,8 por cento), apendicectomia (n 5; 5 por cento), liberação de aderências sem ressecção (n 5; 5 por cento), ressecção segmentar do sigmóide (n 1; 1 por cento) e ressecção segmentar do colo direito (n 1, 1 por cento). A cirurgia concomitante mais freqüente foi a ressecção de endometriomas ovarianos (n 45). A morbidade operatória foi de 9,2 por cento, sendo as complicações maiores uma fístula retovaginal (1 por cento) e uma deiscência de anastomose (1 por cento). Quarenta e duas pacientes tiveram seguimento médio de 14 meses com recidiva clínica em 8 casos (dor pélvica e dispareunia) e 4 recidivas de imagem à ultrassonografia em parede intestinal, assintomáticas. CONCLUSÃO: O tratamento da endometriose por laparoscopia é factível e seguro, com baixos índices de recidiva.

OBJECTIVE: The purpose of this study was to identify the types of surgical procedures performed and the operative morbidity in women with bowel endometriosis. METHODS: Retrospective evaluation of surgical records of women who underwent surgical treatment of endometriosis by a mutidisciplinar team at Biocor Instituto (Belo Horizonte, MG) from January 2002 to June 2009. RESULTS: Ninety-eight women underwent surgical treatment of bowel endometriosis during the study period. The following surgical procedures were performed: segmetnal rectal resection (n 46; 45,5 percent), intestinal disc excision (n 25; 24,7 percent), "shaving" (n 18; 17,8 percent), appendectomy (n 5; 5 percent), adhesiolysis without intestinal resection (n 5; 5 percent), segmental sigmoidectomy (n 1; 1 percent) e segmental right colon resection (n 1, 1 percent). The most frequent concomitant surgery performed was the removal of ovarian endometriomas (n 45). Operative morbity was observed in 9.2 percent and major complications were rectovaginal fistula (1 percent) and anastomosis dehiscence (1 percent). After a mean followup of 14 months that included 42 patients , recurrence of clinical symptoms (pelvic pain and dyspareunia) was observed in 8 cases as well as 4 cases of asymptomatic intestinal wall endometriosis recurrence which was identified by ultrasonography. CONCLUSION: Laparoscopic treatment of bowel endometriosis is feasible, safe and presents a low recurrence rate.