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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. 

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.

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.

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.

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. 

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). 

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).

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.