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Laparoscopic treatment of deep endometriosis with segmental colorectal resection: Short-term morbidity
Journal of Minimally Invasive Gynecology (2007) 14, 463– 469
Laparoscopic treatment of deep endometriosis with segmental colorectal resection: Short-term morbidity Liliana Mereu, MD, Giacomo Ruffo, MD, Stefano Landi, MD, Fabrizio Barbieri, MD, Riccardo Zaccoletti, MD, Andrea Fiaccavento, MD, Ania Stepniewska, MD, Giovanni Pontrelli, MD, and Luca Minelli, MD From the Departments of Obstetrics and Gynecology and General Surgery, Ospedale Sacro Cuore, Negrar-Verona, Italy (all authors). KEYWORDS: Deep endometriosis; Colorectal endometriosis; Colorectal resection; Laparoscopy; Endometriosis
Abstract STUDY OBJECTIVE: Adequate surgical treatment of severe deep endometriosis requires complete excision of all implants, but the modality of bowel resection is still debated. We describe the results of our experience as a tertiary care endometriosis referral center in complete laparoscopic management of deep pelvic endometriosis with bowel involvement. DESIGN: A prospective single-center study (Canadian Task Force classification II-1). SETTING: In Sacro Cuore General Hospital of Negrar, Italy. PATIENTS: One hundred ninety-two women treated with laparoscopic excision of deep endometriosis and segmental colorectal resections were evaluated. INTERVENTION: From January 2003 through December 2005 we registered all consecutive patients laparoscopically treated for deep endometriosis who also were having segmental bowel resection. MEASUREMENTS AND MAIN RESULTS: Data analysis included age, weight, body mass index, history of endometriosis, preoperative symptoms, parity, infertility, operative procedures, operating time, conversion, intraoperative and postoperative morbidity, recovery of bladder and bowel function, and discharge from hospital. We report our results in terms of feasibility and short-term morbidity. Radicality was achieved in 91.5% of patients. Laparoconversion occurred in 5 cases (2.6%). Major complications that required repeat operation occurred in 20 cases (10.4%): Nine anastomosis leakages (4.7%), 3 uroperitoneum (1.6%), 4 hemoperitoneum (2.1%), 1 pelvic abscess (0.5%), 1 bowel perforation, 1 intestinal obstruction, and 1 sepsis. Minor complications occurred in 50 patients (26%). CONCLUSION: Laparoscopic segmental colorectal resection for endometriosis is feasible and, in hospitals with necessary experience, can be proposed to selected patients who are informed of the risk of complications. © 2007 AAGL. All rights reserved.
The authors have no commercial, proprietary, or financial interest in the products or companies described in this article. Corresponding author: Liliana Mereu, MD, Department of Obstetrics and Gynecology, Ospedale Sacro Cuore, 37024 Negrar (VR) Italy. E-mail: [email protected] Submitted October 26, 2006. Accepted for publication February 10, 2007.
1553-4650/$ -see front matter © 2007 AAGL. All rights reserved. doi:10.1016/j.jmig.2007.02.008
Deep infiltrating endometriosis and bowel involvement are less frequent than peritoneal and ovarian endometriosis. The incidence of bowel localization is estimated to be between 3% and 37% among women with endometriosis,1–3 and the rectum and the rectosigmoid junction together account for 70% to 93% of all intestinal lesions.2,4,5 In these cases, medical treatment could be insufficient, and the condition is often refractory to medical management. For these reasons,
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bowel surgical treatment is frequently needed, even if surgical removal of colorectal endometriosis has been debated because of risk of complications and unproved long-term efficacy. Numerous advances have been made with regard to laparoscopy in the management of endometriosis. Previous studies have demonstrated the feasibility of laparoscopic treatment of deep infiltrating endometriosis with good results in terms of improvement in symptoms, infertility, and quality of life.2,6 –10 There are many published studies on laparoscopic colorectal resection for endometriosis, but all are retrospective with a small number of cases.5,9 –21 In this prospective study, we analyzed the feasibility and associated morbidity of laparoscopic management of deep infiltrating endometriosis with colorectal involvement, treated by segmental colorectal resection in a tertiary care endometriosis referral center.
Materials and methods Beginning January 1, 2003, at Sacro Cuore General Hospital in Negrar (Verona, Italy), we initiated a single-center, prospective study of surgery complications, efficacy, and rate of recurrence after laparoscopic excision of endometriosis with colorectal involvement. Through December 31, 2005, we enrolled 192 patients who underwent laparoscopic segmental colorectal resection. Inclusion criteria for surgery were age of at least 18 years, signed written informed consent, severe pain syndrome resulting from rectosigmoid endometriosis, or asymptomatic endometriotic bowel localization with ureteral stenosis unresponsive to hormonal or previous surgical therapy, colorectal involvement detected by barium enema,22 endometriotic lesions with diameter greater than 2 cm infiltrating the bowel, or circumferential involvement more than 180 degrees, or with multiple lesions. Exclusion criteria were absence of written informed consent to bowel resection, laparotomic approach, and presence of conditions potentially preventing compliance with follow-up schedule. Data on patient age, body mass index, weight, previous surgery or medical therapy for endometriosis, parity, infertility status, intraoperative disease localizations, operative procedures, total operative time, amount of blood loss, conversion to laparotomy, intraoperative and postoperative complications, hemoglobin variation, recovery of bladder and bowel function, discharge from hospital, and 30-day readmission were prospectively recorded in a computed database. In particular, major complications were considered reintervention, blood heterologous transfusion, and bowel, urinary, or peripheral nerve dysfunction longer than 30 days. Before surgery, each patient underwent a routine examination, a rectovaginal examination, abdominal and pelvic ultrasound scanning, and double-contrast barium enema and provided signed written informed consent. Preoperative pain symptoms (dysmenorrhea, nonmenstrual pelvic pain, dyspareunia, dysuria, and dyschezia) were evaluated with a
10-point analog rating scale (0 ⫽ absent, 10 ⫽ unbearable). Hormonal therapy was stopped 3 months before surgery. Patients with severe ureteral stenosis underwent double-J catheter placement before surgery. The day before surgery, all patients received mechanical bowel preparation; antithrombotic prophylaxis with lowmolecular-weight heparin was administered from the evening before the operation until mobilization, and prophylactic antibiotic therapy with cefazolin and metronidazole was given at the beginning of the operation until bowel function recovery following our internal protocol. The operation time was calculated from anesthesia induction to patient awakening, including the surgeons’ change time. Blood loss during surgery was estimated by measuring aspirated blood volume, and hemoglobin variation was calculated by the difference between blood sampling 1 day before and 1 day after surgery. Surgery was carried out with an indwelling Foley catheter in situ that was removed as soon as the patient could independently reach the toilet. A drainage catheter was left near the anastomosis, and it was withdrawn after first bowel function recovery. For 24 hours after surgery, all patients received postoperative analgesia via continuous intravenous infusion with an elastomeric reservoir pump. Data on suspension of antibiotic therapy, removal of bladder catheter and intraperitoneal drainage, duration of significant residual urine volume (⬎100 mL), and bowel movement were collected. Clear fluids were allowed the day after surgery, and oral intake began the next day, followed by a graduated diet. Before the procedure, all patients were counseled regarding the potential risks and benefits of the intervention before signing written informed consent. All patients were clinically evaluated 1 month after surgery. Follow-up consisted of pelvic examination, a questionnaire to determine time to reach subjective well-being and the presence of complications. Institutional review board permission was obtained by the ethical committee of our hospital.
Operative technique The laparoscopic procedure was performed with the patient in the modified dorsolithotomy position under endotracheal general anesthesia; nasogastric suctioning was not routinely used. After pneumoperitoneum induction with a Veress needle and introduction of the 10-mm laparoscope in the standard umbilical position, three 5-mm trocars were placed: suprapubic, left iliac fossa, and right iliac fossa. Complete excision of pelvic endometriosis lesions was performed with 5-mm bipolar scissors working retroperitoneally in healthy tissue and following the surgical technique previously described by our group:17 (1) lysis of adhesions; (2) bilateral ureterolysis starting from healthy tissue at the pelvic brim to the level of the crossing with uterine vessels; (3) stripping of endometriomas and temporary ovarian suspension; (4) excision of the bladder or other pelvic side-wall endometriosis; (5) exposition of both pararectal spaces me-
Mereu et al Table 1
Deep endometriosis with segmental colorectal resection
465
Statistical methods
Patient characteristics
Variable
N ⫽ 192
Median age, year (range) Mean body mass index (SD) Parity 0 1 2 Infertility Previous surgery for endometriosis Previous medical therapy Ureteral stenosis Ureteral stent placement before surgery Colorectal lesions ⬎2 cm Multiple colorectal lesions Colorectal stenosis Acute intestinal obstruction*
32 (32–43) 21.6 (3.2) 167 20 5 61 91 80 55 12 182 29 136 2
(31.7%) (47.4%) (41.6%) (28.6%) (6.2%) (94.8%) (15.1%) (70.8%) (1%)
*Rectosigmoid stenosis for endometriosis.
dial to the ureters; (6) intrafascial dissection down the posterior cervix to the rectovaginal septum; (7) opening of the vaginal wall, if involved; and (8) unification of both pararectal spaces with the retrorectal space by mobilizing the rectosigmoid colon from the pelvic floor. All endometriotic implants were removed en bloc. The intestinal surgery was performed by a colorectal surgeon after the placement of a fourth trocar on the right part of the abdomen and the substitution of the 5-mm trocar in the right iliac fossa with a 12-mm trocar for the harmonic scalpel used to mobilize and isolate the rectosigmoid colon. A linear endoscopic stapler was used to staple the area of normal bowel 1 cm distal from the nodule; the proximal abnormal bowel segment was transected more than 1 cm proximal to the mass through the vagina or through a miniPfannenstiel and returned to the abdomen. The T-T stapled colorectal anastomosis was performed transanally with a 28- or 32-mm circular anastomosis following the double stapling technique described by Griffen et al.23 The integrity of the anastomosis was observed by a proctosigmoidoscope with air test in water-filled pelvis.24 When bowel and vagina anastomoses were at the same level, an omental flap was placed between the two sutures. A drain was left in place until the spontaneous release of flatus. All excised specimens were sent for histological examination. Colorectal anastomoses were classified as very low (⬍4 cm from the anal verge), low (4 – 8 cm from the anal verge), and high (⬎8 cm from the anal verge). In some cases (very low colorectal anastomosis, positive air leak test, incomplete doughnut ring, excessive intraoperative bleeding) the colorectal surgeon opted for protective ileostomy usually converted 1 month later by end-to-end anastomosis after Gastrografin enema to confirm an intact anastomosis.25,26 Beginning in April 2004, we initiated use of the nervesparing technique already described by Landi et al17 in an attempt to preserve the rectal sympathetic fibers of the upper mesorectum, the sympathetic fibers of the lower mesorectum, and the pelvic splanchnic nerves.
Normally distributed data are presented as mean ⫾ SD and confidence interval while skewed data are presented as median and range. Categorical variables are reported as absolute values and percentages. Continuous variables were compared by use of Student’s t test. Categorical variables were compared using the 2 test, as appropriate. The p value ⬍.05 was considered statistically significant.
Results Characteristics of the 192 patients analyzed in this study are shown in Table 1. Preoperative symptoms included pelvic pain (70.4%), dysmenorrhea (96.3%), dyspareunia (71.3%), dysuria (24.5%), and intestinal symptoms (78.1%), which included diarrhea, constipation pain on bowel movement, intestinal cramping, pain on defecation, and cyclic rectal bleeding. In 2 cases, the double-contrast barium enema did not detect colorectal involvement; in 182 (94.8%), the lesion was more than 2 cm. Two (1%) patients had temporary colostomy after presenting to the hospital emergency department with clinical and radiologic evidence of acute intestinal obstruction because of rectosigmoid endometriotic lesion. Laparoscopic procedures concomitant to bowel resection are given in Table 2. One hundred seventyfive (91.6%) patients had complete excision of deep endometriosis. Table 3 describes intraoperative and early postoperative findings, including mean operation time. Laparoconversion occurred in 5 (2.6%) cases; the indication was massive hemorrhage in 1 case, difficulty in endometriosis resection at the level of the coccygeal bone in 1 case, severe adhesions in 2 cases, and colorectal surgeon decision in 1 pa-
Table 2
Concomitant procedures (N ⫽ 192 patients)
Procedure
No. (%)
Adhesiolysis Cystectomy Unilateral adnexectomy Bilateral adnexectomy Monolateral salpingectomy Salpingostomy Total hysterectomy Partial vaginal resection Myomectomy Full-thickness bladder resection Bilateral ureteral lysis Ureteral anastomosis Ureteral stenting Appendectomy Ileocolic resection Ileo resection Defunctioning loop-ileostomy
192 87 13 4 10 60 2 60 2 20 192 13 15 9 4 9 20
(100) (45.3) (6.7) (2) (5) (31.2) (1) (31.2) (1) (10.4) (100) (6.7) (7.8) (4.7) (2) (4.7) (10)
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Table 3
Intraoperative and early postoperative findings
Variable
Median
Range
Blood loss (mL) Hemoglobin variation (g/dL) Operation time, min Drainage, days Foley catheter, days Antibiotics, days Time to resume urinary function, days Time to resume bowel function, days Time to discharge, days
300
50–5500
4.6 2.2 5.5 2.4
3.9–4.4 1.9–2.5 4.9–6.1 2–2.8
9.4
8.8–10.1
Mean (SD)
95% CI
2.5 (1.3) 326.7 (97.7)
2.1–2.9 312.8–340.5
4.1 (1.8)
tient. Seventy-two (38%) women had temperatures ⬎ 38°C for more than 2 days. Table 4 lists the major complications; 20 cases (10.4%) required reoperation. Median time at which major complications occurred was 9 days (range 2–30). There were 4 anastomotic fistulas: none ⬍ 4 cm from the anus; in 1 case a positive pneumatic test result led to performance of manual resuture on mechanical anastomosis and defunctioning ileostomy at the initial surgery. The anastomotic fistulas required the following procedures: 1 laparotomic manual resuture of the anastomosis and protective colostomy; 1 Hartman procedure followed by a coloanal anastomosis with defunctioning ileostomy; 2 laparoscopic manual sutures, 1 of which needed further rectal resection. Five rectovaginal fistulas occurred; 2 after very low anastomosis and loop ileostomy; the same 2 patients received blood transfusion for hemorrhagic complication. In these 5 cases no omental flap was performed at the initial surgery and hydropneumatic test was negative. The rectovaginal fistulas were treated as follows: 2 with loop ileostomy (1 laparoscopically and 1 laparotomically), in which the fistulas healed without further complications; 2 by laparotomic resuture of the bowel anastomosis and of the vagina; 1 with
Table 4 Major complications of colorectal resection for endometriosis Complication
No. (%)
Reintervention
Anastomotic leakage Rectovaginal fistula Anastomotic fistula Perforation Bowel obstruction Uroperitoneum Ureteral fistula Bladder fistula Pelvic abscess Sepsis Hemoperitoneum Heterologous blood transfusion Urinary retention after 30 days Constipation after 30 days Peripheral sensory disturbance after 30 days
9 5 4 1 1 3 2 1 1 1 4 12 9 5 3
9 5 4 1 1 3 2 1 1 1 4
(4.7) (2.7) (2) (0.5) (0.5) (1.5) (1) (0.5) (0.5) (0.5) (2) (6) (4.7) (2.6) (1.5)
3.9–4.4
temporary ileostomy, subsequent bowel resection and vaginal resuture. No permanent colostomies were necessary. The bowel perforation occurred 3 days after initial surgery, localization was far away from the anastomosis and probably because of mechanical lesion; treatment required laparoscopic suture of the bowel and protective colostomy. The 2 ureteral fistulas were treated with stent placement and then laparoscopic ureteral anastomosis. The bladder fistula was managed by laparoscopic cystorrhaphy. The 4 hemoperitoneum cases were resolved by laparoscopic drainage and coagulation. The episode of abscess required laparoscopic toilette. The sepsis and the bowel obstruction required only diagnostic laparoscopy that excluded abscess and mechanical ileus. In 5 cases, there was bowel anastomotic stenosis recovered by mechanical dilation; in all these patients a 28-mm circular anastomosis was used, and in 1 case very low anastomosis was performed. One patient had rectal bleeding. Other complications included peripheral sensorial disturbances in 3 patients, 2 cases of pneumonia, and 1 case of bipolar disorder. There was no death. Every year, the mean operative time (2003–2005, p ⬍.05) and the number of major complications (p ⬎.05) decreased (Figure 1). We had 3/132 (2.2%) bowel anastomotic fistulas in women who did not undergo vaginal resection and 6/60 (10%) with vaginal suture (p ⬎.05). Anas-
Figure 1 Major complications that required reintervention, per year (p ⬎.05)
Mereu et al Table 5
Deep endometriosis with segmental colorectal resection
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Incidence of major complications with laparoscopic segmental colorectal resections for endometriosis
Series, year
No. of patients
Anastomotic leakage No. (%)
Abscess No. (%)
Hemoperitoneum No. (%)
Uroperitoneum No. (%)
Redwine et al18 Possover et al11 Darai et al9 Keckstein et al13 Campagnacci et al15 Dubernard et al14 Langebrekke et al16 Mohor et al19 Ribeiro et al20 Present study
8 34 40 142 7 58 8 48 125 192
0 2 3 6 0 6 0 1 2 9
— — 1 (2.5) 2 (1.4)† 0 1 (1.7) 0 — 0 1 (0.5)
— — — — 0 1 (1.7) 0 — — 4 (2)
— — — — 0 1 (1.7) 0 1 (2) — 3 (1.5)
(5.8)* (7.5) (4.2)† (10.3) (2) (1.6) (4.7)
*Minor anastomotic leakage. †Referred to 202 patients undergoing bowel resection with stapler anastomosis, sigmoid resection with hand-sewn anastomosis, small intestine resection with hand-sewn anastomosis, appendectomy with stapler technique, or cecal pole resection.
tomotic level classification was as follows: high 1/16 (6%), low 6/152 (4%), and very low 2/17 (12%), p ⬎.05.
Discussion Complete excision of endometriosis seems to provide long-term pain relief, improved quality of life, and a low rate of recurrent disease in most patients with deeply infiltrating endometriosis10,27–29 and in cases of bowel involvement.4,6,13,14,19,30 Thanks to advances in laparoscopic technology over the past 10 years, endometriosis can now be managed laparoscopically, even when bowel resection is indicated. Considering that endometriosis is a benign disease that affects young women, it is extremely important to know the risks and the postoperative morbidity rate of this kind of surgery. In the literature, we find only small retrospective series on the feasibility and morbidity of laparoscopic digestive surgery, making precise assessment virtually impossible.5,9 –20,31,32 To our knowledge, our series is the largest single-center prospective study on laparoscopic bowel resection for endometriosis. In our department double-contrast barium enema is the method used to identify bowel involvement. As shown in previous study in our center the sensitivity is 100% and the specificity is 98% for this kind of technique with an accuracy of 99%.22 We achieved complete excision of deep endometriosis in 91.6% of patients; in 17 cases, total excision was not possible because endometriosis deeply embedded the lateral parametrium on both sides of the pelvis, the nodule excision could have resulted in bilateral damage to the nerves and, hence, to permanent bladder dysfunction. There are no data for comparison in the literature, probably because of the highly selective nature of the published series. The operative time calculated from anesthesia induction to patient awakening (median 5 hours) was in keeping with those reported previously on laparoscopic segmental colorectal resection.5,9,11–18,20,30,31 Campagnacci et al15 and
Langebrekke et al16 reported a median operating time of 3.4 hours but in series where only few patients underwent bowel resection. Our operative time is still higher than those reported with a laparotomic approach.2,4,33 This difference can be explained by the slowness of the laparoscopic technique, and by the presence in our series of cases that required extensive surgery. Of the 192 patients, only 5 required laparoconversion; this rate of conversion (3%) is low, especially if we compare it with previous reports in which the incidence was as high as 12.5% to 20%,5,11,12,14,18,31 and if we consider that 48% of the patients had previously had at least one operation for endometriosis. In our experience, median intraoperative blood loss was 300 mL with a mean hemoglobin variation of 2.6 g/dL; 6% of patients required heterologous blood transfusion, reflecting the complexity of this kind of surgery. There are few data on minor complications such as bleeding and transfusion rate in the literature, probably because of the retrospective nature of most studies, but our results are similar to those reported by Darai et al.9 Major complications requiring further surgery occurred in 10.4% of patients. These data are in agreement with the data reported by Darai et al9 (10%), by Duepree et al12 (11.1%), and by Dubernard14 (15.5%). Analyzing previous studies on laparoscopic segmental colorectal resection (Table 5), Redwine et al18 (6 cases) did not report any rectovaginal fistulae, Possover et al11 reported 2/34 women with minimal anastomotic leakage detected by sigmoidoscopy that healed spontaneously. Rectovaginal fistulas associated with vaginal resection were reported by Darai et al9 (6.3%), Dubernard et al14 (10.3%), and Jerby et al5 (14.3%). We found no statistically significant difference between occurrence of a concomitant and nonconcomitant vaginal opening probably because of our habit of placing an omental flap between the vaginal suture and the bowel anastomosis if both were performed at the same level. In addition, the comparison of bowel fistulas between the different levels of anastomosis did not reach statistical significance, possibly because of the potential bias of protective ileostomy that was
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present in 20 (10%) of patients (12 with very low rectal anastomosis). If we consider only very low anastomosis, rectovaginal fistula occurred in 2 patients of 12 with ileostomy; we did not have fistulas in 6 patients without diverting stoma. Our data support the evidence that defunctioning ileostomy has no influence over whether a low rectal anastomosis will leak after surgery.25,26 We identified 4 cases of anastomotic leakage; Possover et al11 and Duepree et al12 reported 2 and 1 cases, respectively. Keckstein and Wiesinger13 found an anastomotic leakage incidence of 3% among women who underwent different types and levels of bowel resections whereas Darai et al,9 Campagnacci et al,15 and Langebrekke et al16 observed no anastomotic dehiscence. In our series, there was systematic use of drainage, even though there is insufficient evidence showing that routine drainage after colorectal anastomoses prevents anastomotic and other complications.34 In considering data from colorectal resection performed via laparotomy for endometriosis, we note that the results are similar to ours; in fact, Fleisch et al35 and Urbach et al36 reported respectively a 13% and 10% rate of complications leading to repeat surgery, and Urbach et al36 described a rectovaginal fistula in 29 patients (3.3%); however, Bailey et al4 observed no cases of bowel fistula. The complication incidence in this study is also in agreement with the rate (4.4%) reported by Griffen et al23 in a collected series of 10 reports of laparotomic stapled colorectal anastomoses. Although constipation and urinary retention were not mentioned by most centers, we found these respectively in 4.2% and 10% of our cases at hospital discharge. Only Darai et al9 have reported similar data on digestive and urinary morbidity but with higher percentages—37.5% and 17.5%—and in the same report they recommended the nerve sparing technique. These data led us to use this nervesparing technique from April 2004 onward, which could explain our improved results. The median length of the hospital stay in our study was 8 days, which is comparable with the findings of Marpeau et al,31 Ribeiro et al,20 and Urbach et al36; Redwine et al,18 Mohor et al,19 and Duepree et al,12 however, reported a median hospitalization of 5 and 4 days, respectively. It is interesting to note that analysis of the data year by year showed a reduction in mean operating time and in the number of major complications. These improvements may be the result of a long learning curve for this kind of surgery. Ten percent of complications that required reintervention is high, but we have to consider that the patients eligible to undergo this kind of surgery are selected women with a severe grade of deep endometriosis involving bowel and often bladder and ureters. Results have to be proved, but conservative radical surgical treatment in patients not responsive to medical treatment or less extensive surgery at the moment seems to be the only option for young patients.
Conclusion The data indicate that the laparoscopic approach to severe pelvic endometriosis with segmental colorectal resection is feasible, with morbidity rates similar to those achieved by laparotomy. In a laparoscopic referral center with a multidisciplinary team (gynecologist, surgeon, urologist and radiologist), this kind of procedure can be proposed to selected patients. However, every woman should be carefully informed of the risks and possible complications. Data from our study on long-term efficacy and rate of recurrence are ongoing.
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27. Donnez J, Nisolle M, Gillerot S, et al. Rectovaginal septum endometriotic or adenomyotic nodules: a series of 500 cases. Br J Obstet Gynecol. 1997;104:1014 –1018. 28. Busacca M, Bianchi S, Agnoli B, et al. Follow up of laparoscopic treatment of stage III-IV endometriosis. J Am Assoc Gynecol Laparosc. 1999;6:55–58. 29. Chapron C, Dubuisson JB, Fritel X, et al. Operative management of deep endometriosis infiltrating the uterosacral ligaments. J Am Assoc Gynecol Laparosc. 1999;6:31–37. 30. Redwine DB, Sharpe DR. Laparoscopic segmental resection of the sigmoid colon. J Laparoendosc Surg. 1991;1:217–220. 31. Marpeau O, Thomassin I, Barranger E, Detchev R, Bazot M, Darai E. Resection coelioscopique du colon-rectum pour endometriose: resultants preliminaries. J Gynecol Obstet Biol Reprod. 2004;33:600 – 606. 32. Nezhat C, Nezhat F, Pennington E. Laparoscopic treatment of infiltrative rectosigmoid colon and rectovaginal septum endometriosis by the technique of videolaparoscopy and CO2 laser. Br J Obstet Gynecol. 1992;99:664 – 667. 33. Tran KT, Kuijpers HC, Willemsen WN, Bulten H. Surgical treatment of symptomatic rectosigmoid endometriosis. Eur J Surg. 1996;162: 139 –141. 34. Karliczek A, Jesus EC, Matos D, Castro AA, Atallah AN, Wiggers T. Drainage or nondrainage in elective colorectal anastomosis: a systematic review and meta-analysis. Colorectal Dis. 2006;8:259 –265. 35. Fleisch MC, Xafis D, Bruyne FD, Hicke J, Bender HG, Dall P. Radical resection of invasive endometriosis with bowel or bladder involvement–Long term results. Eur J Obstet Gynecol. 2005;123: 224 –239. 36. Urbach DR, Reedijk M, Richard CS, Lie KI, Ross TM. Bowel resection for intestinal endometriosis. Dis Colon Rectum. 1998;41:1158 – 1164.
Laparoscopic treatment of deep endometriosis with segmental colorectal resection: Short-term morbidity Liliana Mereu, MD, Giacomo Ruffo, MD, Stefano Landi, MD, Fabrizio Barbieri, MD, Riccardo Zaccoletti, MD, Andrea Fiaccavento, MD, Ania Stepniewska, MD, Giovanni Pontrelli, MD, and Luca Minelli, MD From the Departments of Obstetrics and Gynecology and General Surgery, Ospedale Sacro Cuore, Negrar-Verona, Italy (all authors). KEYWORDS: Deep endometriosis; Colorectal endometriosis; Colorectal resection; Laparoscopy; Endometriosis
Abstract STUDY OBJECTIVE: Adequate surgical treatment of severe deep endometriosis requires complete excision of all implants, but the modality of bowel resection is still debated. We describe the results of our experience as a tertiary care endometriosis referral center in complete laparoscopic management of deep pelvic endometriosis with bowel involvement. DESIGN: A prospective single-center study (Canadian Task Force classification II-1). SETTING: In Sacro Cuore General Hospital of Negrar, Italy. PATIENTS: One hundred ninety-two women treated with laparoscopic excision of deep endometriosis and segmental colorectal resections were evaluated. INTERVENTION: From January 2003 through December 2005 we registered all consecutive patients laparoscopically treated for deep endometriosis who also were having segmental bowel resection. MEASUREMENTS AND MAIN RESULTS: Data analysis included age, weight, body mass index, history of endometriosis, preoperative symptoms, parity, infertility, operative procedures, operating time, conversion, intraoperative and postoperative morbidity, recovery of bladder and bowel function, and discharge from hospital. We report our results in terms of feasibility and short-term morbidity. Radicality was achieved in 91.5% of patients. Laparoconversion occurred in 5 cases (2.6%). Major complications that required repeat operation occurred in 20 cases (10.4%): Nine anastomosis leakages (4.7%), 3 uroperitoneum (1.6%), 4 hemoperitoneum (2.1%), 1 pelvic abscess (0.5%), 1 bowel perforation, 1 intestinal obstruction, and 1 sepsis. Minor complications occurred in 50 patients (26%). CONCLUSION: Laparoscopic segmental colorectal resection for endometriosis is feasible and, in hospitals with necessary experience, can be proposed to selected patients who are informed of the risk of complications. © 2007 AAGL. All rights reserved.
The authors have no commercial, proprietary, or financial interest in the products or companies described in this article. Corresponding author: Liliana Mereu, MD, Department of Obstetrics and Gynecology, Ospedale Sacro Cuore, 37024 Negrar (VR) Italy. E-mail: [email protected] Submitted October 26, 2006. Accepted for publication February 10, 2007.
1553-4650/$ -see front matter © 2007 AAGL. All rights reserved. doi:10.1016/j.jmig.2007.02.008
Deep infiltrating endometriosis and bowel involvement are less frequent than peritoneal and ovarian endometriosis. The incidence of bowel localization is estimated to be between 3% and 37% among women with endometriosis,1–3 and the rectum and the rectosigmoid junction together account for 70% to 93% of all intestinal lesions.2,4,5 In these cases, medical treatment could be insufficient, and the condition is often refractory to medical management. For these reasons,
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bowel surgical treatment is frequently needed, even if surgical removal of colorectal endometriosis has been debated because of risk of complications and unproved long-term efficacy. Numerous advances have been made with regard to laparoscopy in the management of endometriosis. Previous studies have demonstrated the feasibility of laparoscopic treatment of deep infiltrating endometriosis with good results in terms of improvement in symptoms, infertility, and quality of life.2,6 –10 There are many published studies on laparoscopic colorectal resection for endometriosis, but all are retrospective with a small number of cases.5,9 –21 In this prospective study, we analyzed the feasibility and associated morbidity of laparoscopic management of deep infiltrating endometriosis with colorectal involvement, treated by segmental colorectal resection in a tertiary care endometriosis referral center.
Materials and methods Beginning January 1, 2003, at Sacro Cuore General Hospital in Negrar (Verona, Italy), we initiated a single-center, prospective study of surgery complications, efficacy, and rate of recurrence after laparoscopic excision of endometriosis with colorectal involvement. Through December 31, 2005, we enrolled 192 patients who underwent laparoscopic segmental colorectal resection. Inclusion criteria for surgery were age of at least 18 years, signed written informed consent, severe pain syndrome resulting from rectosigmoid endometriosis, or asymptomatic endometriotic bowel localization with ureteral stenosis unresponsive to hormonal or previous surgical therapy, colorectal involvement detected by barium enema,22 endometriotic lesions with diameter greater than 2 cm infiltrating the bowel, or circumferential involvement more than 180 degrees, or with multiple lesions. Exclusion criteria were absence of written informed consent to bowel resection, laparotomic approach, and presence of conditions potentially preventing compliance with follow-up schedule. Data on patient age, body mass index, weight, previous surgery or medical therapy for endometriosis, parity, infertility status, intraoperative disease localizations, operative procedures, total operative time, amount of blood loss, conversion to laparotomy, intraoperative and postoperative complications, hemoglobin variation, recovery of bladder and bowel function, discharge from hospital, and 30-day readmission were prospectively recorded in a computed database. In particular, major complications were considered reintervention, blood heterologous transfusion, and bowel, urinary, or peripheral nerve dysfunction longer than 30 days. Before surgery, each patient underwent a routine examination, a rectovaginal examination, abdominal and pelvic ultrasound scanning, and double-contrast barium enema and provided signed written informed consent. Preoperative pain symptoms (dysmenorrhea, nonmenstrual pelvic pain, dyspareunia, dysuria, and dyschezia) were evaluated with a
10-point analog rating scale (0 ⫽ absent, 10 ⫽ unbearable). Hormonal therapy was stopped 3 months before surgery. Patients with severe ureteral stenosis underwent double-J catheter placement before surgery. The day before surgery, all patients received mechanical bowel preparation; antithrombotic prophylaxis with lowmolecular-weight heparin was administered from the evening before the operation until mobilization, and prophylactic antibiotic therapy with cefazolin and metronidazole was given at the beginning of the operation until bowel function recovery following our internal protocol. The operation time was calculated from anesthesia induction to patient awakening, including the surgeons’ change time. Blood loss during surgery was estimated by measuring aspirated blood volume, and hemoglobin variation was calculated by the difference between blood sampling 1 day before and 1 day after surgery. Surgery was carried out with an indwelling Foley catheter in situ that was removed as soon as the patient could independently reach the toilet. A drainage catheter was left near the anastomosis, and it was withdrawn after first bowel function recovery. For 24 hours after surgery, all patients received postoperative analgesia via continuous intravenous infusion with an elastomeric reservoir pump. Data on suspension of antibiotic therapy, removal of bladder catheter and intraperitoneal drainage, duration of significant residual urine volume (⬎100 mL), and bowel movement were collected. Clear fluids were allowed the day after surgery, and oral intake began the next day, followed by a graduated diet. Before the procedure, all patients were counseled regarding the potential risks and benefits of the intervention before signing written informed consent. All patients were clinically evaluated 1 month after surgery. Follow-up consisted of pelvic examination, a questionnaire to determine time to reach subjective well-being and the presence of complications. Institutional review board permission was obtained by the ethical committee of our hospital.
Operative technique The laparoscopic procedure was performed with the patient in the modified dorsolithotomy position under endotracheal general anesthesia; nasogastric suctioning was not routinely used. After pneumoperitoneum induction with a Veress needle and introduction of the 10-mm laparoscope in the standard umbilical position, three 5-mm trocars were placed: suprapubic, left iliac fossa, and right iliac fossa. Complete excision of pelvic endometriosis lesions was performed with 5-mm bipolar scissors working retroperitoneally in healthy tissue and following the surgical technique previously described by our group:17 (1) lysis of adhesions; (2) bilateral ureterolysis starting from healthy tissue at the pelvic brim to the level of the crossing with uterine vessels; (3) stripping of endometriomas and temporary ovarian suspension; (4) excision of the bladder or other pelvic side-wall endometriosis; (5) exposition of both pararectal spaces me-
Mereu et al Table 1
Deep endometriosis with segmental colorectal resection
465
Statistical methods
Patient characteristics
Variable
N ⫽ 192
Median age, year (range) Mean body mass index (SD) Parity 0 1 2 Infertility Previous surgery for endometriosis Previous medical therapy Ureteral stenosis Ureteral stent placement before surgery Colorectal lesions ⬎2 cm Multiple colorectal lesions Colorectal stenosis Acute intestinal obstruction*
32 (32–43) 21.6 (3.2) 167 20 5 61 91 80 55 12 182 29 136 2
(31.7%) (47.4%) (41.6%) (28.6%) (6.2%) (94.8%) (15.1%) (70.8%) (1%)
*Rectosigmoid stenosis for endometriosis.
dial to the ureters; (6) intrafascial dissection down the posterior cervix to the rectovaginal septum; (7) opening of the vaginal wall, if involved; and (8) unification of both pararectal spaces with the retrorectal space by mobilizing the rectosigmoid colon from the pelvic floor. All endometriotic implants were removed en bloc. The intestinal surgery was performed by a colorectal surgeon after the placement of a fourth trocar on the right part of the abdomen and the substitution of the 5-mm trocar in the right iliac fossa with a 12-mm trocar for the harmonic scalpel used to mobilize and isolate the rectosigmoid colon. A linear endoscopic stapler was used to staple the area of normal bowel 1 cm distal from the nodule; the proximal abnormal bowel segment was transected more than 1 cm proximal to the mass through the vagina or through a miniPfannenstiel and returned to the abdomen. The T-T stapled colorectal anastomosis was performed transanally with a 28- or 32-mm circular anastomosis following the double stapling technique described by Griffen et al.23 The integrity of the anastomosis was observed by a proctosigmoidoscope with air test in water-filled pelvis.24 When bowel and vagina anastomoses were at the same level, an omental flap was placed between the two sutures. A drain was left in place until the spontaneous release of flatus. All excised specimens were sent for histological examination. Colorectal anastomoses were classified as very low (⬍4 cm from the anal verge), low (4 – 8 cm from the anal verge), and high (⬎8 cm from the anal verge). In some cases (very low colorectal anastomosis, positive air leak test, incomplete doughnut ring, excessive intraoperative bleeding) the colorectal surgeon opted for protective ileostomy usually converted 1 month later by end-to-end anastomosis after Gastrografin enema to confirm an intact anastomosis.25,26 Beginning in April 2004, we initiated use of the nervesparing technique already described by Landi et al17 in an attempt to preserve the rectal sympathetic fibers of the upper mesorectum, the sympathetic fibers of the lower mesorectum, and the pelvic splanchnic nerves.
Normally distributed data are presented as mean ⫾ SD and confidence interval while skewed data are presented as median and range. Categorical variables are reported as absolute values and percentages. Continuous variables were compared by use of Student’s t test. Categorical variables were compared using the 2 test, as appropriate. The p value ⬍.05 was considered statistically significant.
Results Characteristics of the 192 patients analyzed in this study are shown in Table 1. Preoperative symptoms included pelvic pain (70.4%), dysmenorrhea (96.3%), dyspareunia (71.3%), dysuria (24.5%), and intestinal symptoms (78.1%), which included diarrhea, constipation pain on bowel movement, intestinal cramping, pain on defecation, and cyclic rectal bleeding. In 2 cases, the double-contrast barium enema did not detect colorectal involvement; in 182 (94.8%), the lesion was more than 2 cm. Two (1%) patients had temporary colostomy after presenting to the hospital emergency department with clinical and radiologic evidence of acute intestinal obstruction because of rectosigmoid endometriotic lesion. Laparoscopic procedures concomitant to bowel resection are given in Table 2. One hundred seventyfive (91.6%) patients had complete excision of deep endometriosis. Table 3 describes intraoperative and early postoperative findings, including mean operation time. Laparoconversion occurred in 5 (2.6%) cases; the indication was massive hemorrhage in 1 case, difficulty in endometriosis resection at the level of the coccygeal bone in 1 case, severe adhesions in 2 cases, and colorectal surgeon decision in 1 pa-
Table 2
Concomitant procedures (N ⫽ 192 patients)
Procedure
No. (%)
Adhesiolysis Cystectomy Unilateral adnexectomy Bilateral adnexectomy Monolateral salpingectomy Salpingostomy Total hysterectomy Partial vaginal resection Myomectomy Full-thickness bladder resection Bilateral ureteral lysis Ureteral anastomosis Ureteral stenting Appendectomy Ileocolic resection Ileo resection Defunctioning loop-ileostomy
192 87 13 4 10 60 2 60 2 20 192 13 15 9 4 9 20
(100) (45.3) (6.7) (2) (5) (31.2) (1) (31.2) (1) (10.4) (100) (6.7) (7.8) (4.7) (2) (4.7) (10)
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Table 3
Intraoperative and early postoperative findings
Variable
Median
Range
Blood loss (mL) Hemoglobin variation (g/dL) Operation time, min Drainage, days Foley catheter, days Antibiotics, days Time to resume urinary function, days Time to resume bowel function, days Time to discharge, days
300
50–5500
4.6 2.2 5.5 2.4
3.9–4.4 1.9–2.5 4.9–6.1 2–2.8
9.4
8.8–10.1
Mean (SD)
95% CI
2.5 (1.3) 326.7 (97.7)
2.1–2.9 312.8–340.5
4.1 (1.8)
tient. Seventy-two (38%) women had temperatures ⬎ 38°C for more than 2 days. Table 4 lists the major complications; 20 cases (10.4%) required reoperation. Median time at which major complications occurred was 9 days (range 2–30). There were 4 anastomotic fistulas: none ⬍ 4 cm from the anus; in 1 case a positive pneumatic test result led to performance of manual resuture on mechanical anastomosis and defunctioning ileostomy at the initial surgery. The anastomotic fistulas required the following procedures: 1 laparotomic manual resuture of the anastomosis and protective colostomy; 1 Hartman procedure followed by a coloanal anastomosis with defunctioning ileostomy; 2 laparoscopic manual sutures, 1 of which needed further rectal resection. Five rectovaginal fistulas occurred; 2 after very low anastomosis and loop ileostomy; the same 2 patients received blood transfusion for hemorrhagic complication. In these 5 cases no omental flap was performed at the initial surgery and hydropneumatic test was negative. The rectovaginal fistulas were treated as follows: 2 with loop ileostomy (1 laparoscopically and 1 laparotomically), in which the fistulas healed without further complications; 2 by laparotomic resuture of the bowel anastomosis and of the vagina; 1 with
Table 4 Major complications of colorectal resection for endometriosis Complication
No. (%)
Reintervention
Anastomotic leakage Rectovaginal fistula Anastomotic fistula Perforation Bowel obstruction Uroperitoneum Ureteral fistula Bladder fistula Pelvic abscess Sepsis Hemoperitoneum Heterologous blood transfusion Urinary retention after 30 days Constipation after 30 days Peripheral sensory disturbance after 30 days
9 5 4 1 1 3 2 1 1 1 4 12 9 5 3
9 5 4 1 1 3 2 1 1 1 4
(4.7) (2.7) (2) (0.5) (0.5) (1.5) (1) (0.5) (0.5) (0.5) (2) (6) (4.7) (2.6) (1.5)
3.9–4.4
temporary ileostomy, subsequent bowel resection and vaginal resuture. No permanent colostomies were necessary. The bowel perforation occurred 3 days after initial surgery, localization was far away from the anastomosis and probably because of mechanical lesion; treatment required laparoscopic suture of the bowel and protective colostomy. The 2 ureteral fistulas were treated with stent placement and then laparoscopic ureteral anastomosis. The bladder fistula was managed by laparoscopic cystorrhaphy. The 4 hemoperitoneum cases were resolved by laparoscopic drainage and coagulation. The episode of abscess required laparoscopic toilette. The sepsis and the bowel obstruction required only diagnostic laparoscopy that excluded abscess and mechanical ileus. In 5 cases, there was bowel anastomotic stenosis recovered by mechanical dilation; in all these patients a 28-mm circular anastomosis was used, and in 1 case very low anastomosis was performed. One patient had rectal bleeding. Other complications included peripheral sensorial disturbances in 3 patients, 2 cases of pneumonia, and 1 case of bipolar disorder. There was no death. Every year, the mean operative time (2003–2005, p ⬍.05) and the number of major complications (p ⬎.05) decreased (Figure 1). We had 3/132 (2.2%) bowel anastomotic fistulas in women who did not undergo vaginal resection and 6/60 (10%) with vaginal suture (p ⬎.05). Anas-
Figure 1 Major complications that required reintervention, per year (p ⬎.05)
Mereu et al Table 5
Deep endometriosis with segmental colorectal resection
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Incidence of major complications with laparoscopic segmental colorectal resections for endometriosis
Series, year
No. of patients
Anastomotic leakage No. (%)
Abscess No. (%)
Hemoperitoneum No. (%)
Uroperitoneum No. (%)
Redwine et al18 Possover et al11 Darai et al9 Keckstein et al13 Campagnacci et al15 Dubernard et al14 Langebrekke et al16 Mohor et al19 Ribeiro et al20 Present study
8 34 40 142 7 58 8 48 125 192
0 2 3 6 0 6 0 1 2 9
— — 1 (2.5) 2 (1.4)† 0 1 (1.7) 0 — 0 1 (0.5)
— — — — 0 1 (1.7) 0 — — 4 (2)
— — — — 0 1 (1.7) 0 1 (2) — 3 (1.5)
(5.8)* (7.5) (4.2)† (10.3) (2) (1.6) (4.7)
*Minor anastomotic leakage. †Referred to 202 patients undergoing bowel resection with stapler anastomosis, sigmoid resection with hand-sewn anastomosis, small intestine resection with hand-sewn anastomosis, appendectomy with stapler technique, or cecal pole resection.
tomotic level classification was as follows: high 1/16 (6%), low 6/152 (4%), and very low 2/17 (12%), p ⬎.05.
Discussion Complete excision of endometriosis seems to provide long-term pain relief, improved quality of life, and a low rate of recurrent disease in most patients with deeply infiltrating endometriosis10,27–29 and in cases of bowel involvement.4,6,13,14,19,30 Thanks to advances in laparoscopic technology over the past 10 years, endometriosis can now be managed laparoscopically, even when bowel resection is indicated. Considering that endometriosis is a benign disease that affects young women, it is extremely important to know the risks and the postoperative morbidity rate of this kind of surgery. In the literature, we find only small retrospective series on the feasibility and morbidity of laparoscopic digestive surgery, making precise assessment virtually impossible.5,9 –20,31,32 To our knowledge, our series is the largest single-center prospective study on laparoscopic bowel resection for endometriosis. In our department double-contrast barium enema is the method used to identify bowel involvement. As shown in previous study in our center the sensitivity is 100% and the specificity is 98% for this kind of technique with an accuracy of 99%.22 We achieved complete excision of deep endometriosis in 91.6% of patients; in 17 cases, total excision was not possible because endometriosis deeply embedded the lateral parametrium on both sides of the pelvis, the nodule excision could have resulted in bilateral damage to the nerves and, hence, to permanent bladder dysfunction. There are no data for comparison in the literature, probably because of the highly selective nature of the published series. The operative time calculated from anesthesia induction to patient awakening (median 5 hours) was in keeping with those reported previously on laparoscopic segmental colorectal resection.5,9,11–18,20,30,31 Campagnacci et al15 and
Langebrekke et al16 reported a median operating time of 3.4 hours but in series where only few patients underwent bowel resection. Our operative time is still higher than those reported with a laparotomic approach.2,4,33 This difference can be explained by the slowness of the laparoscopic technique, and by the presence in our series of cases that required extensive surgery. Of the 192 patients, only 5 required laparoconversion; this rate of conversion (3%) is low, especially if we compare it with previous reports in which the incidence was as high as 12.5% to 20%,5,11,12,14,18,31 and if we consider that 48% of the patients had previously had at least one operation for endometriosis. In our experience, median intraoperative blood loss was 300 mL with a mean hemoglobin variation of 2.6 g/dL; 6% of patients required heterologous blood transfusion, reflecting the complexity of this kind of surgery. There are few data on minor complications such as bleeding and transfusion rate in the literature, probably because of the retrospective nature of most studies, but our results are similar to those reported by Darai et al.9 Major complications requiring further surgery occurred in 10.4% of patients. These data are in agreement with the data reported by Darai et al9 (10%), by Duepree et al12 (11.1%), and by Dubernard14 (15.5%). Analyzing previous studies on laparoscopic segmental colorectal resection (Table 5), Redwine et al18 (6 cases) did not report any rectovaginal fistulae, Possover et al11 reported 2/34 women with minimal anastomotic leakage detected by sigmoidoscopy that healed spontaneously. Rectovaginal fistulas associated with vaginal resection were reported by Darai et al9 (6.3%), Dubernard et al14 (10.3%), and Jerby et al5 (14.3%). We found no statistically significant difference between occurrence of a concomitant and nonconcomitant vaginal opening probably because of our habit of placing an omental flap between the vaginal suture and the bowel anastomosis if both were performed at the same level. In addition, the comparison of bowel fistulas between the different levels of anastomosis did not reach statistical significance, possibly because of the potential bias of protective ileostomy that was
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present in 20 (10%) of patients (12 with very low rectal anastomosis). If we consider only very low anastomosis, rectovaginal fistula occurred in 2 patients of 12 with ileostomy; we did not have fistulas in 6 patients without diverting stoma. Our data support the evidence that defunctioning ileostomy has no influence over whether a low rectal anastomosis will leak after surgery.25,26 We identified 4 cases of anastomotic leakage; Possover et al11 and Duepree et al12 reported 2 and 1 cases, respectively. Keckstein and Wiesinger13 found an anastomotic leakage incidence of 3% among women who underwent different types and levels of bowel resections whereas Darai et al,9 Campagnacci et al,15 and Langebrekke et al16 observed no anastomotic dehiscence. In our series, there was systematic use of drainage, even though there is insufficient evidence showing that routine drainage after colorectal anastomoses prevents anastomotic and other complications.34 In considering data from colorectal resection performed via laparotomy for endometriosis, we note that the results are similar to ours; in fact, Fleisch et al35 and Urbach et al36 reported respectively a 13% and 10% rate of complications leading to repeat surgery, and Urbach et al36 described a rectovaginal fistula in 29 patients (3.3%); however, Bailey et al4 observed no cases of bowel fistula. The complication incidence in this study is also in agreement with the rate (4.4%) reported by Griffen et al23 in a collected series of 10 reports of laparotomic stapled colorectal anastomoses. Although constipation and urinary retention were not mentioned by most centers, we found these respectively in 4.2% and 10% of our cases at hospital discharge. Only Darai et al9 have reported similar data on digestive and urinary morbidity but with higher percentages—37.5% and 17.5%—and in the same report they recommended the nerve sparing technique. These data led us to use this nervesparing technique from April 2004 onward, which could explain our improved results. The median length of the hospital stay in our study was 8 days, which is comparable with the findings of Marpeau et al,31 Ribeiro et al,20 and Urbach et al36; Redwine et al,18 Mohor et al,19 and Duepree et al,12 however, reported a median hospitalization of 5 and 4 days, respectively. It is interesting to note that analysis of the data year by year showed a reduction in mean operating time and in the number of major complications. These improvements may be the result of a long learning curve for this kind of surgery. Ten percent of complications that required reintervention is high, but we have to consider that the patients eligible to undergo this kind of surgery are selected women with a severe grade of deep endometriosis involving bowel and often bladder and ureters. Results have to be proved, but conservative radical surgical treatment in patients not responsive to medical treatment or less extensive surgery at the moment seems to be the only option for young patients.
Conclusion The data indicate that the laparoscopic approach to severe pelvic endometriosis with segmental colorectal resection is feasible, with morbidity rates similar to those achieved by laparotomy. In a laparoscopic referral center with a multidisciplinary team (gynecologist, surgeon, urologist and radiologist), this kind of procedure can be proposed to selected patients. However, every woman should be carefully informed of the risks and possible complications. Data from our study on long-term efficacy and rate of recurrence are ongoing.
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