Bowel Endometriosis Surgical Treatment

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There are different approaches to the surgical management of bowel endometriosis, such as shaving, excision, and resection. Different studies reveal the advantages and disadvantages of the different techniques. Most experts express using a team approach (such as involving a colorectal surgeon), using imaging to help guide planning before surgery (with preference for MRI), and decisions based on each individual. Those with more advanced skill in working with bowel endometriosis cite low complication rates. (You can find more on the experts’ opinions in Nancy’s Nook Facebook Group in Unit 2: Surgery).

Studies:

  • Bendifallah, S., Puchar, A., Vesale, E., Moawad, G., Daraï, E., & Roman, H. (2020). Surgical outcomes after colorectal surgery for endometriosis: Systematic Review and Meta-Analysis. Journal of Minimally Invasive Gynecology. Retrieved from https://pubmed.ncbi.nlm.nih.gov/32841755/

“Colorectal surgery for endometriosis exposes patients to a risk of severe complications such as rectovaginal fistula, anastomotic leakage, anastomotic stenosis and voiding dysfunction. Rectal shaving appears to be less associated with postoperative complications than disc excision and segmental colorectal resection. However, this technique is not suitable in all patients with large bowel infiltration. Compared to segmental colorectal resection, disc excision has several advantages including shorter operating time, shorter hospital stay and lower risk of postoperative bowel stenosis.”

“For these reasons, surgeons should consider rectal shaving as a first-line surgical treatment of rectovaginal DE, regardless of nodule size or association with other digestive localizations. When the result of rectal shaving is unsatisfactory (rare cases), disc excision may be performed either exclusively by laparoscopy or by using transanal staplers. Segmental resection may ultimately be reserved for advanced lesions responsible for major stenosis or for several cases of multiple nodules infiltrating the rectosigmoid junction or sigmoid colon.”

  • Afors, K., Centini, G., Fernandes, R., Murtada, R., Zupi, E., Akladios, C., & Wattiez, A. (2016). Segmental and discoid resection are preferential to bowel shaving for medium-term symptomatic relief in patients with bowel endometriosis. Journal of Minimally Invasive Gynecology, 23(7), 1123-1129. Retrieved from https://www.sciencedirect.com/science/article/pii/S1553465016310032

“All 3 treatment modalities are effective in terms of immediate symptom relief with acceptable complication rates. However, significantly higher rates of symptom recurrence and reintervention were noted in the shaving group, whereas segmental resection is more likely to be indicated in cases of large nodules.”

  • Kent, A., Shakir, F., Rockall, T., Haines, P., Pearson, C., Rae-Mitchell, W., & Jan, H. (2016). Laparoscopic surgery for severe rectovaginal endometriosis compromising the bowel: a prospective cohort study. Journal of minimally invasive gynecology, 23(4), 526-534. Retrieved from https://www.sciencedirect.com/science/article/pii/S1553465015017100

“Our aim was to determine the quality of life after radical excision of rectovagina endometriosis compromising the bowel….Severe rectovaginal endometriosis compromising the bowel can be treated surgically with experienced combined gynecologic and colorectal input with a low serious complication rate. Surgery by an experienced multidisciplinary team results in significant improvement in pain, sexual function, and quality of life up to 1 year postoperatively. Pelvic clearance improves outcome and patients should be counseled accordingly. There is no difference in outcome between the types of bowel surgery undertaken as long as all visible/palpable endometriosis is removed.”

  • Riiskjaer, M., Greisen, S., Glavind‐Kristensen, M., Kesmodel, U. S., Forman, A., & Seyer‐Hansen, M. (2016). Pelvic organ function before and after laparoscopic bowel resection for rectosigmoid endometriosis: a prospective, observational study. BJOG: An International Journal of Obstetrics & Gynaecology, 123(8), 1360-1367. Retrieved from https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/1471-0528.13975

“A significant and clinically relevant improvement in urinary and sexual function 1 year after laparoscopic bowel resection for endometriosis was found. Except for anastomotic leakage, this could be observed independent of any patient‐ or treatment‐related factor. Apprehension about impairment of urinary and sexual function should not be a contraindication for bowel resection in endometriosis patients.”

  • Wolthuis, A. M., Meuleman, C., Tomassetti, C., D’Hooghe, T., van Overstraeten, A. D. B., & D’Hoore, A. (2014). Bowel endometriosis: colorectal surgeon’s perspective in a multidisciplinary surgical team. World Journal of Gastroenterology: WJG, 20(42), 15616. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4229526/

“A precise diagnosis about the presence, location, and extent of endometriosis is necessary to plan surgical treatment. Multidisciplinary laparoscopic treatment has become the standard of care. Depending on the size of the lesion and site of involvement, full-thickness disc excision or bowel resection needs to be performed by an experienced colorectal surgeon. Long-term outcomes, following bowel resection for severe endometriosis, regarding pain and recurrence rate are good with a pregnancy rate of 50%.”

“Some experts have argued that a more conservative surgery, in which the endometriotic nodule is shaved or removed, may reduce the risk for complications associated with the more radical bowel resection, according to Mads Riiskjær, MD, of the department of obstetrics and gynecology at Aarhus University Hospital in Denmark, and colleagues.

‘The surgical strategy in this group of patients has been subject to debate in endometriosis circles for many years,” Riiskjær said in a video abstract. “Indeed, rectal resection is a procedure that carries a substantial risk of short- and long-term complications, and it has been argued that it is too radical an approach for a benign condition.’

“Given this controversy, evaluated prospectively collected data on women who underwent laparoscopic bowel resection for rectosigmoid endometriosis between February 2011 and November 2015. ‘Indication for surgery included severe pain and obstructive bowel symptoms unresponsive to medical treatment.’

“Most of the patients (97.1%) completed questionnaires for pelvic pain and quality-of-life both before and 1 year after surgery, which showed significant reductions in all pelvic pain parameters (P = .0001), especially dyschezia, and significant improvements in quality-of-life scores (P = .0001). Notably, significantly more patients did not require hormone therapy (19% vs. 44%) or pain medication (6% vs. 38%) after surgery. Patients who experienced a surgical complication reported no negative impact on their outcome. Riiskjær and colleagues also noted that they previously showed this procedure results in positive effects on urinary and sexual function.

“’No two patients are identical and all factors including age, wish for pregnancy, and other personal and social factors should be taken into account in each case, but we strongly believe that our study supports a more aggressive surgical strategy in case of failed medical therapy, and apprehension about impairment of urinary and sexual function should not be a contraindication for bowel resection,’ Riiskjær said in the video abstract.

“Due to a lack of randomized studies comparing different surgical approaches, there remains no consensus on the best surgery for rectosigmoid endometriosis, and providers should therefore take a ‘patient-tailored approach,’ and choose ‘the least invasive radical option,’ according to a related editorial by Jean-Jacques Tuech, MD, PhD, and Horace Roman, MD, PhD, of Rouen, France.”

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