Available online 26 April 2023

Author links open overlay panel, , , , , , , , , , , , , , AbstractStudy objective

: to evaluate the feasibility of laparoscopic rectosigmoid resection for rectosigmoid endometriosis (RSE), reporting surgical and short-term postoperative outcomes in a consecutive large series of patients.

Design

: a retrospective cohort study.

Setting

: third level national referral center for Deep Endometriosis (DE).

Patients

: three thousand and fifty patients with symptomatic RSE addressed to surgical treatment.

Interventions

: nerve-sparing laparoscopic treatment for RSE in a multidisciplinary setting enhanced surgical results and patients’ quality of life diminishing post operative surgical complications.

Measurements and main results

: Clavien‒Dindo (CD) IIIb postoperative complications were noted in 13.1% of patients, with anastomotic leakage (AL) and rectovaginal fistula (RVF) accounting for 3.0% and 1.9%, respectively. Postoperative bladder impairment was observed in 13.9% of patients during hospital discharge but spontaneously decreased to 4.5% at the first evaluation after 30 days, alongside a statistically significant change toward global symptom improvement. Multivariate analyses were done to identify the risk factors for segmental bowel resection in terms of occurrence of postoperative major complications. Ultra-low (≤5 cm from anal verge) and low rectal anastomosis (<8cm, >5cm), parametrectomy, vaginal resection, and previous surgeries seemed more related to AL, RVF, and bladder retention.

Conclusions

: Laparoscopic rectosigmoid resection for DE seems an effective and feasible procedure. The surgical complication rate is not negligible but could be reduced by implementing a multidisciplinary approach, an endless improvement in nerve-sparing techniques, surgical anatomy, and technological enhancements. Real future challenges will be to reduce the time for the first diagnosis of DE and the likelihood of surgical indications.

Section snippetsINTRODUCTION

Bowel endometriosis is characterized by the presence of endometrial-like glands and stroma infiltrating at least the muscularis tunica of the intestinal wall [1], with an incidence of 8-12% [2]; the rectosigmoid is the most involved bowel tract, accounting for approximately 80-85% of all cases [3].

Clinical manifestations of rectosigmoid endometriosis (RSE) could differ greatly, including women completely asymptomatic and patients with mild/severe symptoms, usually related to other pelvic

MATERIALS AND METHODS

This was a retrospective study including consecutive patients who were referred to the Department of Obstetrics and Gynecology, Gynecologic Oncology and Minimally Invasive Pelvic Surgery of IRCCS “Sacro Cuore-Don Calabria” Hospital undergoing segmental bowel resection for suspected RSE from January 2004 to June 2021.

Patients with suspected RSE underwent surgical approach because of 1) symptoms refractory to multiple failures of medical treatment; 2) an absolute indication for surgery regardless

Demographic characteristics

From January 2004 to June 2021, among 210,000 patients treated at our institution for DE, 14,643 women (approximately 7%) underwent surgical treatment. Among them, the number of surgical procedures involving the bowel was 4,588 (31.3%); therefore, a total of 3,050 consecutive patients who underwent laparoscopic segmental rectosigmoid resection were included in our study (20.8%). Twenty-two patients were excluded because considered not suitable due to the isolated ileal localization of bowel

DISCUSSION

The optimal strategy for the treatment of RSE has not yet been standardized. Considering the absolute indications for surgery previously mentioned, medical and integrated treatment should be always the first therapeutic option proposed regarding RSE, balancing its efficacy with good tolerability [30]. This retrospective cohort study reports intraoperative characteristics and postoperative complications of patients undergoing laparoscopic segmental rectosigmoid resection for the treatment of

CONCLUSIONS

Our study highlights the importance of individual patient evaluation with careful preoperative work-up and a tailored surgical strategy, while adopting nerve-sparing techniques to reduce postoperative complications. We emphasize the need for a multidisciplinary approach and continuous improvement in surgical anatomy and laparoscopic surgical skills to enhance the surgical feasibility and safety of this approach. However, we also acknowledge that the decision to perform surgery must be weighed

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© 2023 Published by Elsevier Inc. on behalf of AAGL.