GYNECOLOGY

Calitatea vieţii la pacientele cu endometrioză şi rezecţie colorectală laparoscopică

 Quality of life in patients with deep endometriosis and laparoscopic colorectal resection

First published: 15 aprilie 2021

Editorial Group: MEDICHUB MEDIA

DOI: 10.26416/Gine.32.2.2021.5001

Abstract

Objective. The aim of this paper is to evaluate the effective­ness of laparoscopic colorectal resection in cases of deep en­do­metriosis, as well as the impact on the quality of life, on gynecological and digestive symptoms. Materials and method. Following the preoperative evaluation (MRI, trans­va­gi­nal ultrasound, endorectal ultrasound, hydro-colon CT), 42 cases with deep endometriosis were included in the studied group. All patients included in the study com­ple­ted a questionnaire on preoperative endometriosis symp­toms and quality of life (SF-36 Questionnaire). The status and qua­lity of life were assessed. Gynecological and di­ges­tive symp­toms, as well as the rate of perioperative com­pli­ca­tions were also assessed. Laparoscopic surgeries were per­formed by the same operating team (E.B., C.C.B., R.M., A.I., L.R.). Results. The average age of the patients was 34 years old. The conversion rate to laparotomy was zero. Fol­lowing surgery, there was a significant improvement re­gar­ding dysmenorrhea, dyspareunia, chronic pelvic pain, defe­ca­tion pain, and lower abdominal pain. In cases with deep endometriosis and colorectal resection, an im­prove­ment in the score for the quality of life, assessed by the SF-36 Questionnaire, was observed. One patient (2.38%) refused the colorectal resection for objective reasons. The rate of perioperative complications was 4.76%, including an inadvertent cystotomy (2.38%) and a reintervention (2.38%) at five days postoperatively – protective ileo­sto­my. The rate of hemoperitoneum, rectovaginal fistula, uro­pe­ri­to­neum and pelvic abscess was zero. Conclusions. La­pa­roscopic segmental colorectal resection for endome­trio­sis significantly improves the quality of life and the gy­ne­co­lo­gical and digestive symptoms. However, women should be informed about the risk of complications, in­clu­ding rec­to­va­ginal fistula. The need to adhere to a guide­line on the therapeutic conduct in cases of deep en­do­me­trio­sis and the standardization of treatment allow to obtain sa­tis­fac­tory results in terms of improving the quality of life in patients with colorectal resection. Preoperative investigations allow the planning of surgery and the formation of a multi­dis­ci­pli­nary team for the correct management and the complete ex­ci­sion of endometriotic lesions.
 

Keywords
minimally invasive surgery, laparoscopy, deep endometriosis, superficial endometriosis, rectosigmoid resection, mechanical end-to-end anastomosis

Rezumat

Obiectiv. Scopul acestei lucrări este de a evalua eficacitatea rezecţiei colorectale laparoscopice în cazurile de endometrioză profundă, precum şi impactul asupra calităţii vieţii şi asupra simptomatologiei ginecologice şi digestive. Materiale şi me­to­dă. În urma evaluării preoperatorii (RMN, ecografie trans­va­ginală, ecografie endorectală, hidro-colono-CT), în lotul studiat au fost incluse 42 de paciente cu endometrioză profundă. Toate pacientele incluse în studiu au completat un chestionar privind simptomele preoperatorii ale endometriozei şi calitatea vieţii (chestionarul SF-36). Au fost evaluate statusul şi calitatea vieţii. De asemenea, au fost evaluate simptomele ginecologice şi digestive, precum şi rata de complicaţii perio­pe­ra­torii. Intervenţiile chirurgicale laparoscopice au fost efec­tua­te de aceeaşi echipă operatorie (E.B., C.C.B., R.M., A.I., L.R.). Rezultate. Vârsta medie a pacientelor a fost de 34 de ani. Rata de conversie la laparotomie a fost nulă. În ur­ma in­ter­ven­ţiei chirurgicale s-a observat o ameliorare sem­ni­fi­ca­ti­vă a dismenoreei, dispareuniei, a durerilor pelviene cronice, a durerilor la defecaţie şi a durerilor în etajul abdominal in­fe­rior. În cazurile cu endometrioză profundă şi rezecţie co­­lo­rec­tală, s-a observat o îmbunătăţire a scorului pentru ca­li­ta­tea vieţii, evaluată prin chestionarul SF-36. O pacientă (2,38%) a refuzat rezecţia colorectală, din motive obiective. Ra­ta de complicaţii perioperatorii a fost de 4,76%, incluzând o cistotomie inadvertentă (2,38%) şi o reintervenţie (2,38%) la cinci zile postoperatoriu – ileostomă de protecţie. Rata de hemoperitoneu, fistulă rectovaginală, uroperitoneu şi de ab­ces pelvian a fost nulă. Concluzii. Rezecţia colo­rec­tală seg­men­tară laparoscopică pentru endometrioză îm­bu­nă­tă­ţeş­te semnificativ calitatea vieţii şi simptomele ginecologice şi di­ges­ti­ve. Cu toate acestea, femeile trebuie să fie informate cu pri­vi­re la riscul unor complicaţii, inclusiv fistula rectovaginală. Ne­ce­si­ta­tea aderării la un ghid privind conduita terapeutică în cazurile de endometrioză profundă şi standardizarea tra­ta­men­tului permit obţinerea unor rezultate satisfăcătoare în ceea ce priveşte ameliorarea calităţii vieţii la pacientele cu rezecţie colorectală. Investigaţiile preoperatorii permit pla­ni­fi­carea intervenţiei chirurgicale şi formarea unei echipe mul­ti­dis­ci­pli­nare, pentru managementul corect şi excizia completă a leziunilor endometriozice. 
 

Introduction

Deep infiltrating endometriosis of the bowel re­pre­sents a major challenge for the gynecologists, general sur­geons and patients. The incidence regarding deep infil­tra­ting endometriosis affecting the bowel is estimated at 5-12% of the patients with deep endometriosis(1). Endometriosis has a high impact on the life of the patient, leading to chronic non-menstrual pelvic pain, dysmenorrhea, dyspareunia and infertility. Deep infiltrating endometriosis affecting the intestinal tract generates digestive symptoms, such as diarrhea, constipation, painful defecation, rectal ble­eding or even occlusion(2).

Deep endometriosis is defined as the presence of endometrial tissue infiltrating more than 5 mm of the peritoneum. Deep endometriosis of the bowel represents the endometriosis that affects the muscular layer(3,4). The endometriosis can spread from the small bowel to the anus, but the most frequent sites are the rectum and sigmoid colon (74%), cecum and appendix(5).

Once the diagnosis of bowel endometriosis has been made, the management plan must be established and the colorectal resection procedure – with its advantages and disadvantages – must be discussed with the patient. Once the surgery is established, a complete resection of all endometriotic lesions must be performed(6). There has to be a specialized multidisciplinary team in charge of these cases, in order to reduce the negative outcomes while maintaining good results(7).

Alike any other surgical procedure, the surgical treat­ment of deep infiltrating endometriosis of the bowel has also some downsides besides the expected favourable out­come. Postprocedural complications depend on dif­ferent surgical approaches, and the number of com­pli­ca­tions can sum up when more than one technique is per­formed. Both major and minor surgical complications have been reported after the surgical excision of deep en­do­me­triosis. The complications that need to be men­tio­ned are: pelvic abscess, cutaneous abscesses, peri­to­ni­tis, stenosis of colorectal anastomosis, anastomotic leak­age(8), rectovaginal fistula(9-11), haemorrhage(12), lapa­ro­con­ver­sion(13), bladder atony and bowel dysfunction(14). How­ever, some studies suggested that the risk of un­fa­vourable outcomes is higher when segmental colorectal re­section is performed, but we also have to reckon with the patient’s overall health condition(15).

The aim of this paper is to present the direct ob­ser­va­tion of the authors and to evaluate the effectiveness of laparoscopic colorectal resection in cases of deep en­do­me­triosis, as well as the impact on life’s quality, gyne­co­lo­gical symptoms and digestive symptoms.

Materials and method

We conducted a prospective study, from January 2019 to December 2019, in the Department of Obstetrics and Gynecology of the Monza Hospital, Bucharest, and the “Prof. Dr. Panait Sîrbu” Clinical Hospital of Obstetrics and Gynecology. We enrolled patients with deep in­fil­tra­ting endometriosis symptoms. Following the pre­ope­rative evaluation (magnetic resonance imaging [MRI], transvaginal ultrasound, endorectal ultrasound, hydro-colo computed tomography), forty-two cases with deep endometriosis were included in the studied group. From this group, we choose the patients with bowel endometriosis, and the study will focus on them.

All patients included in this study completed a questionnaire regarding preoperative endometriosis symptoms and the quality of life (SF-36 Questionnaire) and six-month postoperative symptoms, in order to evaluate the impact of symptoms on life before and after the colorectal resection. All patients gave their informed consent. The purpose of the questionnaire is twofold: to provide a complete clinical picture of the symptoms, and to objectify the improvement of the quality of life. The questionnaire consists of multiple variables that quantify various dimensions of health, that can be associated into two measures, the physical and mental scores. Patients also filled in data regarding the presence of dysmenorrhea, dyspareunia and of chronic non-menstrual pelvic pain. Status and quality of life were assessed. Quality of life assessment in patients with deep endometriosis is an integral part of both preoperative and postoperative assessment, in order to objectify the benefit of surgery. Gynecological and digestive symptoms, as well as the rate of perioperative complications were also assessed.

The operative strategy was discussed in the mul­ti­dis­ci­plinary team which consisted of gynecology spe­cia­lists and general surgeons. The management plan was also discussed with the patient. The 28 procedures were performed as a segmental laparoscopic bowel re­sec­tion with end-to-end anastomosis. All of the visible en­do­me­triosis was excised, including infiltrating nodules of the sacrouterine ligaments, parametrial nodules and peritoneum lesions. In those cases with ovarian endometriomas, unilateral or bilateral laparoscopic cystectomy was performed. For the transection of the rectosigmoid below the endometriotic lesion a linear stapler was used, after which the bowel was exteriorized through an extension of the umbilical incision. The end-to-end anastomosis was completed using a circular stapler (33 mm). Laparoscopic surgeries were performed by the same ope­rating team (E.B., C.C.B., R.M., A.I., L.R.).

To assess the comparisons between preoperative and postoperative scores, the Student t test and Pearson correlation were performed for continuous data. For all comparisons, a p<0.05 was considered to define statistical significance. All data were analyzed in SPSS 23.0.

Results

Twenty-eight patients (67%) received laparoscopic segmental rectosigmoid resection with mechanical end-to-end anastomosis. Thirteen patients (31%) with deep endometriosis benefited from laparoscopic excision of deep endometriosis nodules and one (2%) patient with bowel endometriosis refused the rectosigmoid resection – Figure 1. The histopathologic exam confirmed in all cases that the bowel nodules were endometriotic. 

Figure 1. Comple­men­tary procedures performed along with colorectal resection
Figure 1. Comple­men­tary procedures performed along with colorectal resection

From now on, we will focus on the 28 patients who underwent laparoscopic segmental rectosigmoid resection with mechanical end-to-end anastomosis. In Figure 2, we illustrate the complementary procedures that were performed beside colorectal resection.

The mean age of the 28 patients included in the study was 34.1 years old. The demographic characteristics of the patients is presented in Table 1.

Table 1. Social and demographic characteristics of the patients
Table 1. Social and demographic characteristics of the patients

All patients presented preoperatively with dys­me­nor­rhea (100%) and 19 (67.9%) with dyspareunia. Re­gar­ding the pelvic non-menstrual pain, 20 patients (71.4%) presented the aforementioned symptom. Six months after surgery, at the follow-up, the number of patients who presented with the symptoms described before was lower compared to preoperative numbers. Following surgery, there was a significant improvement (p<0.05) in dysmenorrhea, dyspareunia and chronic non-menstrual pelvic pain, as it can be observed in Table 2.

Table 2. Comparison between the main symptoms of the patients, preoperatively and at six months postoperatively
Table 2. Comparison between the main symptoms of the patients, preoperatively and at six months postoperatively

The quality of life, evaluated with SF-36 Questionnaire, is summarized in two elements: physical health and mental health, each with four aspects. Dysmenorrhea and dyspareunia affect the quality of life, as we notice from Table 3.

Table 3. The influence of the intensity of dysmenorrhea and dyspareunia on the quality of life – preoperatively
Table 3. The influence of the intensity of dysmenorrhea and dyspareunia on the quality of life – preoperatively

We found out that, preoperatively, there is an inverse statistic correlation between the intensity of both dysmenorrhea and dyspareunia and some variables regarding life’s quality. This statistically negative correlation proves that, the higher the intensity of dysmenorrhea, the lower the physical functioning, the bodily pain, the general health, the social functioning, the physical health and the mental health. Also, the higher the intensity of dyspareunia, the lower the level of physical functioning and physical health.

As we can notice in Table 4 and Table 5, a significant im­provement was observed in all eight aspects and both ele­ments (p<0.05) of the quality of life after the bowel resection. 

Table 4. The evaluation of the physical health (SF-36) – pre- and postoperatively, at 6 months
Table 4. The evaluation of the physical health (SF-36) – pre- and postoperatively, at 6 months
Table 5. The evaluation of the mental health (SF-36) – pre- and postoperatively, at 6 months
Table 5. The evaluation of the mental health (SF-36) – pre- and postoperatively, at 6 months

Patients’ age correlated statistically significantly with the intensity of postoperative dysmenorrhea at 6 months (p=0.030). The Visual Analogue Scale was used in order to assess the intensity of dysmenorrhea. The older the patients, the higher the intensity of dysmenorrhea (Figure 2). 

Figure 2. The correlation between the intensity of dysmenorrhea and the age of the patients at 6 months postoperatively
Figure 2. The correlation between the intensity of dysmenorrhea and the age of the patients at 6 months postoperatively

The Body Mass Index (BMI) of the patients had a positive statistical correlation with the intensity of the preoperative dyspareunia (p=0.020). The higher the BMI, the higher the intensity of the preoperative dyspareunia (Figure 3).

Figure 3. The correlation between the BMI of the  patient and the intensity of the dyspareunia (preoperatively)
Figure 3. The correlation between the BMI of the patient and the intensity of the dyspareunia (preoperatively)

The rate of perioperative complications was 4.76%, including an inadvertent cystotomy (2.38%) and a reintervention (2.38%) at five days postoperatively –protective ileostomy. Two patients (4.76%) benefited from double resection – rectosigmoid segmental re­sec­tion and segmented enterectomy with manual ana­sto­mosis. The protective ileostoma was due to the enteral ana­sto­mo­sis (short distance from the ileocecal valve). The rate of hemoperitoneum, rectovaginal fistula, uro­pe­ri­toneum and pelvic abscess was zero.

Discussion

The present study brings preoperative and post­ope­ra­tive information on pelvic pain and quality of life in a group of women who underwent rectosigmoid resection for deep infiltrating endometriosis. Our study shows that laparoscopic colorectal resection has a statistically sig­ni­fi­cant positive effect on pain symptoms and life’s qua­li­ty in these patients. For all elements of the mental and physical health, a highly significant improvement was observed. All of the comparisons presented had highly significant p values, minimizing the risk of mul­ti­ple comparison problems.

Even though large studies regarding deep infiltrating endometriosis surgeries with colorectal segmental resection are needed, several studies, retrospective, with limited number of patients, were published and revealed similar findings with the ones of our study. Bailey et al. reported that 86% of the patients who underwent colorectal resection had symptoms improvement at 6 months postoperatively. In a study of 50 patients, Kavallaris et al. noted that 72% of the women, at 32 months postlaparoscopic segmental bowel resection, were symptom-free or nearly symptom-free. An improvement regarding dysmenorrhea and dyspareunia was noticed by Thomassin et al. in a study in which 27 patients were followed-up after bowel resection(16-18).

Some authors believe that segmental rectosigmoid resection should be avoided due to short- and long-term complications. Our rate of postoperative complications was low and we didn’t report any fistula or leakage, despite large studies, like the one published in France, which reported a rate of these complications at 4.7% after laparoscopic segmental resection of bowel endometriosis(19).

Conclusions

Bowel involvement with endometriosis is a new frontier for the gynecologists, general surgeons and patients. We have shown that laparoscopic segmental colorectal resection for endometriosis significantly improves gynecological symptoms – dysmenorrhea, dyspareunia and non-menstrual pelvic pain. The aforementioned improvements had a positive effect on life’s quality for these patients. Rectosigmoid resection is a feasible and safe technique for treating bowel endometriosis.  

Conflict of interests: The authors declare no con­flict of interests.

Bibliografie

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