Background
Two surgical approaches usually are used in the surgical management of deep infiltrating endometriosis of the rectum: the radical approach that mainly is based on colorectal resection and the conservative or symptom-guided approach that prioritizes conservation of the rectum. There are no data available that compare long-term functional digestive outcomes of 1 approach to the other.
Objective
The purpose of this study was to compare long-term digestive outcomes in women who were treated by either rectal shaving or colorectal resection for deep endometriosis infiltrating the rectum.
Study Design
A retrospective comparative study was performed. All women who were treated with surgery for deep endometriosis infiltrating the rectum by either shaving or colorectal resection at the University Hospital of Rouen from January 2005 to January 2010 were enrolled. Follow-up evaluation was carried out for a minimum of 5 years. Postoperative evaluation of digestive symptoms was performed by 4 standardized gastrointestinal questionnaires: the Gastrointestinal Quality of Life Index, the Knowles-Eccersley-Scott-Symptom score for constipation, the Wexner score for anal continence, and the Bristol Stool Score. Symptoms that were related to endometriosis, fertility, and disease recurrence were obtained from a specific questionnaire.
Results
A total of 77 women were included. Three women were lost to follow up (3.9%), and 3 were treated by disc excision (3.9%). The mean follow-up time was 80±19 months. Forty-six women underwent conservative rectal shaving, and 25 women underwent colorectal resection. Patient characteristics and the severity of the disease were comparable in both groups. Patients who were treated by rectal shaving had significantly better Gastrointestinal Quality of Life Index values, lower Knowles-Eccersley-Scott-Symptom scores for postoperative constipation, and better anal continence. No statistically significant differences were revealed for postoperative pelvic pain. Rectal recurrence occurred in 8.7% of patients who were treated by conservative surgery: 4.3% underwent secondary colorectal resection and 4.3% were treated secondarily by rectal shaving. Consequently, avoiding a recurrence for merely 1 patient would have required 11 patients to undergo colorectal resection instead of shaving.
Conclusion
Our data suggest that, in patients who are treated for rectal endometriosis, colorectal resection does not improve long-term postoperative functional outcomes when compared with rectal shaving.
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Two surgical approaches usually are used in the management of deep infiltrating endometriosis of the rectum: the radical approach is based mainly on colorectal resection, and the conservative or symptom-guided approach prioritizes conservation of the rectum. The latter may be performed without opening the rectum (shaving) or by removing the nodule along with surrounding rectal wall (full-thickness or disc excision). It has been suggested that adoption of a conservative approach may improve digestive functional outcomes and reduce the risk of immediate postoperative complications. However, because of the scarcity of comparative studies, available data are provided mainly by retrospective series (that are reported by surgeons who generally perform only 1 technique and in which patients are treated by 1 surgical procedure); it can be unclear whether only patients who have benefited from this procedure are included or whether surgeons simply routinely performed the procedure. Consequently, recommendations concerning surgical management of rectal endometriosis are based on meager evidence and tend to reflect the personal convictions and experience of the experts who edit the guidelines.
Two recent studies evaluated outcomes of colorectal resection by comparing them with those after surgery for stage 3 and 4 endometriosis without bowel involvement. However, the use control subjects without bowel endometriosis may jeopardize the study’s conclusion while failing to provide information on digestive outcomes that are related to various procedures on the digestive tract. Furthermore, focusing only on patients with long-term follow-up periods allows for a more accurate evaluation of recurrence risk in patients who are treated with or without rectal resection.
The aim of our study was to compare long-term outcomes in patients who were treated by either rectal shaving or colorectal resection for rectal endometriosis in terms of digestive function, pelvic complaints, rectal recurrence, and patient satisfaction.
Materials and Methods
All patients who were treated for rectal endometriosis in the Department of Obstetrics and Gynecology at Rouen University Hospital (France) between January 2005 and January 2010 were enrolled. Inclusion criteria were women who were treated surgically for deep endometriosis of the rectum that was located within 15 cm from the anal verge, by either rectal shaving or colorectal resection. Exclusion criterion was superficial infiltration of the rectum that involved only the serosa and surgical treatment with disc excision. Rectal endometriosis was diagnosed by clinical examination, magnetic resonance imaging, and/or endorectal ultrasound scanning and was confirmed intraoperatively. Surgical technique was decided preoperatively on the basis of preoperative assessment and in agreement with patient informed choice. The follow-up period was superior to 60 months.
The protocol for treatment of patients with rectal endometriosis in our department has been described previously. Patients underwent preoperative assessment of deep endometriosis that included clinic examination, magnetic resonance imaging, endorectal ultrasound scanning, and computed tomography–based virtual colonoscopy that was performed exclusively by experienced operators.
Two senior gynecologic surgeons (H.R. and B.R.) with extensive experience in surgery of deep endometriosis performed the shaving. The rectal shaving surgical procedure is similar to that performed by other surgical teams ( Video ), as described by Donnez et al. Digestive surgeons who were experienced in colorectal surgery performed colorectal resections. The segmental colorectal resection procedure that was used was similar to that described in the literature by other teams and was performed by either open or laparoscopic route ( Video ). Diverting temporary stoma frequently was performed in patients with concomitant rectal and vaginal sutures to avoid the risk of complications because of rectovaginal fistula or leakages. Despite a lack of evidence, colostoma usually was preferred to ileostoma, with the consideration that it would lead to better patient adaptation and comfort. As opposed to liquid stools, solid stools would lower the risk of appliance leakage, result in fewer appliance changes required per day, and reduce diet restrictions.
Postoperative treatment by continuous contraceptive pill intake in women who did not intend to conceive was recommended systematically. The surgeon kept contact with his patients at yearly follow- up visits or by email exchange with women who lived far from the hospital.
Before November 2007, segmental colorectal resection was performed in most cases, which was a choice that was justified by the aim of achieving microscopically complete removal of digestive nodules, which was expected to ensure a decrease in the risk of rectal recurrences. November 2007 marked a change in our surgical preference and general convictions concerning the disease. From this date onward, we considered that, although with nodule excision the removal of microscopic rectal implants might be microscopically incomplete, a thorough relief of symptoms could be obtained by shaving that was associated with prolonged postoperative amenorrhea. Moreover, we believed that colorectal segmental resection was an overly complex procedure that was followed in some cases by unpleasant functional digestive symptoms in young patients. As a result, after December 2007, colorectal resection rates decreased from 73.9 to 16.7%.
Postoperative evaluation of digestive symptoms was performed from January to November 2015, respecting a minimum follow-up period of 60 months. Patients received a questionnaire that focused on pelvic pain, fertility, reinterventions, and satisfaction and 4 standardized gastrointestinal questionnaires (the Gastrointestinal Quality of Life Index [GIQLI], the Knowles-Eccersley-Scott-Symptom [KESS] score, the Wexner score, and the Bristol Stool Score). Medical charts were used to record preoperative patient characteristics and details of the surgical procedures.
To evaluate digestive outcomes, 4 standardized gastrointestinal questionnaires were used. Their usefulness has been discussed previously. These questionnaires allow an accurate evaluation of digestive function and comparison among patients who undergo surgical management of bowel diseases. For the diagnosis of constipation, the KESS questionnaire was used, which was comprised of 11 individual items with a maximum possible 39 points. Lower scores represent symptom-free states; higher scores represent increased symptom severity. The KESS total score differentiates patients with constipation for whom overall values are >10 from healthy control subjects for whom the median value averages 2 (range, 0–6).
The GIQLI includes 36 questions that concern digestive symptoms, physical status, emotions, social dysfunction, and effects of medical treatment. Consequently, it not only includes questions on gastrointestinal symptoms but also on other aspects of quality of life and has been validated for various gastrointestinal diseases. Total scores range from 0 (worst) to 144 (best quality of life); median values vary around 126 for healthy control subjects.
The Wexner scale is used to measure the functional impact of fecal incontinence. It has 5 items (solid, liquid, gas, wears pad, and lifestyle alteration) and is scored 0-4. The score 0 corresponds to perfect continence; 20 represents complete anal incontinence.
The Bristol Stool Chart was designed to classify feces into 7 categories of stool: types 1–2 indicate constipation; types 3–4 indicate ideal stools that are easier to pass; types 5–7 may indicate diarrhea and urgency.
We were unable to use the more recent low anterior rectal resection syndrome score because the French version is awaiting validation.
Statistical analysis was performed with Stata software (version 11.0; Stata Corporation, College Station, TX). Median values, percentiles, ranges, mean values, and standard deviations were calculated for continuous variables and percentages for the qualitative variables. Variable distributions that depended on groups were compared by univariate analysis (Fischer’s exact test in qualitative parameters and the analysis of variance test, Kruskall-Wallis test, and Mann and Whitney test in continuous variables). Comparison was performed first between patients who had undergone shaving and colorectal resection, respectively. Supplemental comparison was carried out between patients who were treated before and after November 2007, respectively, as in our previous study. The multiple regression model was used to estimate beta coefficients; the 95% confidence interval characterized the relationship between score overall values and those covariates for which the relationship with postoperative digestive function was clinically relevant (such as, height and diameter of rectal nodules, postoperative complications, recurrences and associated hysterectomy because of symptomatic adenomyosis). A probability value of <.05 was considered statistically significant. No preplanned calculation of statistical power was carried out. Our retrospective data analysis received institutional review board approval.
Results
Seventy-seven women underwent surgical treatment for deep endometriosis that was infiltrating the rectum up to 15 cm above the anus from January 2005 to 2010. Three patients were lost from follow up (3.9%). Three other patients were treated by rectal disc excision (3.9%). Seventy-one patients answered the follow- up questionnaire and were enrolled in the present study.
Twenty-five patients (35.2%) were treated by colorectal resection, and 46 patients (64.8%) were treated by rectal shaving. Patient characteristics and associated localization of endometriosis were comparable between the 2 groups ( Table 1 ), with the exception of lower and deeper infiltration of the rectal wall in nodules that were managed by colorectal resection and more frequent involvement of the bladder.
| Endometriosis localizations | Shaving (n=46; 64.2%) | Colorectal resection (n=25; 35.8%) | P value |
|---|---|---|---|
| Rectal nodules (up to 15 cm from the anus), n (%) | .32 | ||
| 1 | 33 (71.7) | 21 (84) | |
| 2 | 12 (26.1) | 3 (12) | |
| 3 | 1 (2.2) | 1 (4) | |
| Median diameter of rectal nodule (of the largest, when multiple), mm (minimum–maximum) | 30 (15–60) | 30 (15–65) | .31 |
| Median height of the rectal nodules (measured from the anus, of the lowest rectal nodule when multiple), cm (minimum–maximum) | 12 (5–21) | 10 (5–15) | .05 |
| Depth of the rectal nodule (using endorectal ultrasound, in 72 women), n (%) | .006 | ||
| Muscular layer | 35 (79.5) | 13 (52) | |
| Submucosa | 9 (19.1) | 8 (32) | |
| Mucosa | — | 4 (16) | |
| Total number of colorectal nodules (caecum, colon and rectum), n (%) | .59 | ||
| 1 | 31 (67.4) | 14 (56) | |
| 2 | 12 (24.5) | 8 (32) | |
| 3 | 3 (6.1) | 3 (12) | |
| Associated endometriosis localizations, n (%) | |||
| Appendix | 2 (4.4) | 2 (8) | .61 |
| Small bowel | 4 (8.7) | 5 (20) | .26 |
| Diaphragm | 11 (23.9) | 4 (16) | .55 |
| Ureteral stenosis | 9 (19.6) | 8 (32) | .26 |
| Bladder | 1 (2.17) | 4 (16) | .05 |
| Ovary | 35 (76.1) | 23 (92) | .12 |
| Uterosacral ligaments | 33 (71.7) | 15 (60) | .43 |
| Rectovaginal septum | 41 (89.1) | 24 (96) | .41 |
| Vagina | 34 (73.9) | 21 (84) | .39 |
Open surgery was more frequent in colorectal resection, because this was performed more often during the first period ( Table 2 ). The length of colorectal specimen removed by colorectal resection was 11.4±4.8 cm (range, 6–26 cm). Additional procedures were comparable, apart from confectioning temporary stoma and bladder resection, which were more frequent in the colorectal resection group. There were no differences between major postoperative complications, with the exception of rectorrhagia that originated from the anastomosis stapled line and delayed stoma-related complications, the latter being more frequent after colorectal resection. No rectovaginal fistula was recorded in our series; however, 2 patients had rectal fistula after rectal shaving and colorectal resection, respectively.
| Surgical procedures | Shaving (n=46; 64.2%), n (%) | Colorectal resection (n=25; 35.8%), n (%) | P value |
|---|---|---|---|
| Operative route | .02 | ||
| Laparoscopy | 39 (84.8) | 14 (56) | |
| Open route exclusively | 2 (4.4) | 7 (28) | |
| Laparoscopy followed by open digestive procedure | 5 (10.9) | 4 (16) | |
| Adnexal surgery | .99 | ||
| Unilateral ovarian cystectomy | 15 (32.6) | 8 (32) | |
| Bilateral ovarian cystectomy | 4 (8.7) | 3 (12) | |
| Unilateral ovarian endometriomas ablation with the use of plasma energy | 1 (2.2) | 0 | |
| Bilateral ovarian endometriomas ablation with the use of plasma energy | 1 (2.2) | 1 (4) | |
| Unilateral oophorectomy (conservation of contralateral ovary) | 6 (13) | 3 (12) | |
| Bilateral oophorectomy | 8 (17.4) | 3 (12) | |
| Hysterectomy | 15 (32.6) | 7 (28) | .69 |
| Additional procedures | |||
| Cystectomy for bladder nodule | 1 (2.2) | 4 (16) | .05 |
| Management of ureteral endometriosis | .36 | ||
| Complete ureterolysis | 7 (15.2) | 7 (28) | |
| Resection of the ureter | 2 (4.4) | 1 (4) | |
| Resection of sigmoid colon | 2 (4.4) | — | .54 |
| Resection of small bowel | 1 (2.2) | 3 (12) | .12 |
| Stoma | 2 (4.4) | 16 (64) | <.001 |
| Resection of vaginal fornix | .57 | ||
| Isolated | 26 (56.5) | 17 (68) | |
| Along with hysterectomy | 8 (17.4) | 4 (16) | |
| Postoperative complications | |||
| Rectal fistulae (necrosis of shaved rectum and anastomotic leakage) | 1 (2.2) | 1 (4) | 1 |
| Ureteral suture leakage | 1 (2.2) | 0 | 1 |
| Bladder suture leakage | 0 | 1 (4) | .35 |
| Secondary surgery for presumed pelvic abscess | 5 (10.9) | 3 (12) | 1 |
| Urinary infection | 5 (10.9) | 6 (24) | .18 |
| Stenosis of colorectal anastomosis | 0 | 2 (8) | .11 |
| Rectorrhagia that originated on rectal wall suture | 0 | 3 (12) | .04 |
| Stoma-related complications | 0 | 4 (16) | .01 |
| Fever before day 7 managed by antibiotics | 10 (21.7) | 6 (24) | 1 |
| Somatic motor nerve injuries | 1 (2.2) a | 2 (8) b | .28 |
| Bladder atony >1 month that required daily catheterization | 1 (2.2) | 3 (12) | .12 |
| Stenosis of ureters | 0 | 1 (4) | .34 |
| Clavien Dindo complications | |||
| 1 | 6 (13) | 4 (16) | .73 |
| 2 | 11 (23.9) | 10 (40) | .20 |
| 3a | 0 | 1 (4) | .34 |
| 3b | 6 (13) | 5 (20) | .35 |
| 4a | 1 (2.2) c | 0 | 1 |
| 4b | 1 (2.2) d | 0 | 1 |
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