{"paper_id":"1c27bad5-f616-4ec8-85a8-05312bcc9d90","body_text":"Abstract\nSummary of background data\nNational and international guidelines recommend referring patients with severe forms of endometriosis to expert centers. However, there is a lack of clear criteria to define an expert center. We examined the roles of surgeon and hospital procedure volumes as determinants of morbidity in deep infiltrating endometriosis of the rectum and sigmoid colon (DIERS).\nMethods\nWe conducted a French retrospective multicenter study of hospital facilities performing colorectal surgery for DIERS in 2015. The primary end point was to analyze the relation between case volume and the incidence of complications. We estimated the optimal cut-off (OCO) determined by a minimal p-value approach.\nResults\nThe study included 56 hospital facilities and collected data of 1135 cases of surgical management of colorectal endometriosis. The mean and median number of procedures per year and per surgeon were 9.17 and 5.58, respectively. The overall rate of grade III–V complication was 7.6% (82/1135). One grade V complication occurred. The rates of rectovaginal fistula, anastomotic leakage, pelvic abscess, and ureteral fistula were: 2.7% (31/1135), 0.79% (9/1135), 3.4% (39/1135), and 0.70% (8/1135), respectively. An OCO of 20 procedures per center and per year (p < 0.001) was defined. The OCO per surgeon and per year varied between seven (p = 0.007) and 13 procedures (p = 0.03). In a multivariate analysis, we found that only the volume of activity was independently correlated to complication outcomes (p = 0.0013).\nConclusion\nOur results contribute to providing objective morbidity data to determine criteria for defining expert centers for colorectal surgery for endometriosis.\nSimilar content being viewed by others\nReferences\nGiudice LC, Kao LC (2004) Endometriosis. Lancet 364:1789–1799. doi:10.1016/S0140-6736(04)17403-5\nde Ziegler D, Borghese B, Chapron C (2010) Endometriosis and infertility: pathophysiology and management. Lancet 376:730–738. doi:10.1016/S0140-6736(10)60490-4\nKoninckx PR, Ussia A, Adamyan L, Wattiez A, Donnez J (2012) Deep endometriosis: definition, diagnosis, and treatment. Fertil Steril 98:564–571. doi:10.1016/j.fertnstert.2012.07.1061\nDonnez J, Squifflet J (2010) Complications, pregnancy and recurrence in a prospective series of 500 patients operated on by the shaving technique for deep rectovaginal endometriotic nodules. Hum Reprod 25:1949–1958. doi:10.1093/humrep/deq135\nDarai E, Ackerman G, Bazot M, Rouzier R, Dubernard G (2007) Laparoscopic segmental colorectal resection for endometriosis: limits and complications. Surg Endosc 21:1572–1577. doi:10.1007/s00464-006-9160-1\nAdamson GD, Pasta DJ (2010) Endometriosis fertility index: the new, validated endometriosis staging system. Fertil Steril 94:1609–1615. doi:10.1016/j.fertnstert.2009.09.035\nVercellini P, Barbara G, Buggio L, Frattaruolo MP, Somigliana E, Fedele L (2012) Effect of patient selection on estimate of reproductive success after surgery for rectovaginal endometriosis: literature review. Reprod Biomed Online 24:389–395. doi:10.1016/j.rbmo.2012.01.003\nVercellini P, Consonni D, Barbara G, Buggio L, Frattaruolo MP, Somigliana E (2014) Adenomyosis and reproductive performance after surgery for rectovaginal and colorectal endometriosis: a systematic review and meta-analysis. Reprod Biomed Online 28:704–713. doi:10.1016/j.rbmo.2014.02.006\nZegers-Hochschild F, Adamson GD, de Mouzon J, Ishihara O, Mansour R, Nygren K, Sullivan E, Vanderpoel S, International Committee for Monitoring Assisted Reproductive Technology, World Health Organization (2009) International Committee for Monitoring Assisted Reproductive Technology (ICMART) and the World Health Organization (WHO) revised glossary of ART terminology, 2009. Fertil Steril 92:1520–1524. doi:10.1016/j.fertnstert.2009.09.009\nMeuleman C, Tomassetti C, D’Hoore A, Van Cleynenbreugel B, Penninckx F, Vergote I, D’Hooghe T (2011) Surgical treatment of deeply infiltrating endometriosis with colorectal involvement. Hum Reprod Update 17:311–326. doi:10.1093/humupd/dmq057\nMeuleman C, Tomassetti C, D’Hooghe TM (2012) Clinical outcome after laparoscopic radical excision of endometriosis and laparoscopic segmental bowel resection. Curr Opin Obstet Gynecol 24:245–252. doi:10.1097/GCO.0b013e3283556285\nDubernard G, Piketty M, Rouzier R, Houry S, Bazot M, Darai E (2006) Quality of life after laparoscopic colorectal resection for endometriosis. Hum Reprod 21:1243–1247. doi: 10.1093/humrep/dei491\nVercellini P, Fedele L, Aimi G, De Giorgi O, Consonni D, Crosignani PG (2006) Reproductive performance, pain recurrence and disease relapse after conservative surgical treatment for endometriosis: the predictive value of the current classification system. Hum Reprod 21:2679–2685. doi:10.1093/humrep/del230\nDarai E, Thomassin I, Barranger E, Detchev R, Cortez A, Houry S, Bazot M (2005) Feasibility and clinical outcome of laparoscopic colorectal resection for endometriosis. Am J Obstet Gynecol 192:394–400. doi:10.1016/j.ajog.2004.08.033\nKoh CE, Cooper MJ, Solomon MJ (2013) Deeply infiltrating endometriosis of the rectum: shave, disc or segmental excision? Surg Endosc 27:2644–2645. doi:10.1007/s00464-012-2744-z\nDaraï E, Dubernard G, Coutant C, Frey C, Rouzier R, Ballester M (2010) Randomized trial of laparoscopically assisted versus open colorectal resection for endometriosis: morbidity, symptoms, quality of life, and fertility. Ann Surg 251:1018–1023. doi:10.1097/SLA.0b013e3181d9691d\nRogers PAW, Adamson GD, Al-Jefout M, Becker CM, D’Hooghe TM, Dunselman GAJ, Fazleabas A, Giudice LC, Horne AW, Hull ML, Hummelshoj L, Missmer SA, Montgomery GW, Stratton P, Taylor RN, Rombauts L, Saunders PT, Vincent K, Zondervan KT, WES/WERF Consortium for Research Priorities in Endometriosis (2016) Research priorities for endometriosis: recommendations from a global consortium of investigators in endometriosis. Reprod Sci. doi:10.1177/1933719116654991\nDunselman G a. J, Vermeulen N, Becker C, Calhaz-Jorge C, D’Hooghe T, De Bie B, Heikinheimo O, Horne AW, Kiesel L, Nap A, Prentice A, Saridogan E, Soriano D, Nelen W, European Society of Human Reproduction and Embryology (2014) ESHRE guideline: management of women with endometriosis. Hum Reprod 29:400–412. doi:10.1093/humrep/det457\nSchrag D, Earle C, Xu F, Panageas KS, Yabroff KR, Bristow RE, Trimble EL, Warren JL (2006) Associations between hospital and surgeon procedure volumes and patient outcomes after ovarian cancer resection. J Natl Cancer Inst 98:163–171. doi:10.1093/jnci/djj018\nCowan RA, O’Cearbhaill RE, Gardner GJ, Levine DA, Roche KL, Sonoda Y, Zivanovic O, Tew WP, Sala E, Lakhman Y, Vargas Alvarez HA, Sarasohn DM, Mironov S, Abu-Rustum NR, Chi DS (2016) Is it time to centralize ovarian cancer care in the United States? Ann Surg Oncol 23:989–993. doi:10.1245/s10434-015-4938-9\nBristow RE, Palis BE, Chi DS, Cliby WA (2010) The National Cancer Database report on advanced-stage epithelial ovarian cancer: impact of hospital surgical case volume on overall survival and surgical treatment paradigm. Gynecol Oncol 118:262–267. doi:10.1016/j.ygyno.2010.05.025\nRoman H, Abo C, Huet E, Bridoux V, Auber M, Oden S, Marpeau L, Tuech J-J (2015) Full-thickness disc excision in deep endometriotic nodules of the rectum: a prospective cohort. Dis Colon Rectum 58:957–966. doi:10.1097/DCR.0000000000000447\nRoman H, FRIENDS group (French coloRectal Infiltrating ENDometriosis Study group) (2017) A national snapshot of the surgical management of deep infiltrating endometriosis of the rectum and colon in France in 2015: a multicenter series of 1135 cases. J Gynecol Obstet Hum Reprod 46:159–165. doi:10.1016/j.jogoh.2016.09.004\nClavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, de Santibañes E, Pekolj J, Slankamenac K, Bassi C, Graf R, Vonlanthen R, Padbury R, Cameron JL, Makuuchi M (2009) The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 250:187–196. doi:10.1097/SLA.0b013e3181b13ca2\nCanlorbe G, Wang Z, Laas E, Bendifallah S, Castela M, Lefevre M, Chabbert-Buffet N, Daraï E, Aractingi S, Méhats C, Ballester M (2016) Identification of microRNA expression profile related to lymph node status in women with early-stage grade 1-2 endometrial cancer. Mod Pathol 29:391–401. doi:10.1038/modpathol.2016.30\nBelghiti J, Ballester M, Zilberman S, Thomin A, Zacharopoulou C, Bazot M, Thomassin-Naggara I, Daraï E (2014) Role of protective defunctioning stoma in colorectal resection for endometriosis. J Minim Invasive Gynecol 21:472–479. doi:10.1016/j.jmig.2013.12.094\nDousset B, Leconte M, Borghese B, Millischer A-E, Roseau G, Arkwright S, Chapron C (2010) Complete surgery for low rectal endometriosis: long-term results of a 100-case prospective study. Ann Surg 251:887–895. doi:10.1097/SLA.0b013e3181d9722d\nBendifallah S (2012) The forthcoming reforms of residency and post-residency in obstetrics and gynaecology: Why and how?. Gynécol Obstét Fertil 40:62\nQuerleu D, Ray-Coquard I, Classe JM, Aucouturier JS, Bonnet F, Bonnier P, Darai E, Devouassoux M, Gladieff L, Glehen O, Haie-Meder C, Joly F, Lécuru F, Lefranc JP, Lhommé C, Morice P, Salengro A, Stoeckle E, Taieb S, Zeng ZX, Leblanc E (2013) Quality indicators in ovarian cancer surgery: report from the French Society of Gynecologic Oncology (Societe Francaise d’Oncologie Gynecologique, SFOG). Ann Oncol 24:2732–2739. doi:10.1093/annonc/mdt237\nCohen J, Thomin A, Mathieu d’Argent E, Laas E, Canlorbe G, Zilberman S, Belghiti J, Thomassin-Naggara I, Bazot M, Ballester M, Daraï E (2014) Fertility before and after surgery for deep infiltrating endometriosis with and without bowel involvement: a literature review. Minerva Ginecol 66(6):575–587\nCohen J, Ballester M, Selleret L, Mathieu D’Argent E, Antoine JM, Chabbert-Buffet N, Darai E (2016) Finding the balance between surgery and medically assisted reproduction in women with deep endometriosis. Minerva Ginecol 68(6):642–652\nDaraï E, Cohen J, Ballester M (2016) Colorectal endometriosis and fertility. Eur J Obstet Gynecol Reprod Biol. doi:10.1016/j.ejogrb.2016.05.024\nThomin A, Belghiti J, David C, Marty O, Bornes M, Ballester M, Roman H, Daraï E (2016) Maternal and neonatal outcomes in women with colorectal endometriosis. BJOG Int J Obstet Gynaecol. doi:10.1111/1471-0528.14221\nRuffo G, Sartori A, Crippa S, Partelli S, Barugola G, Manzoni A, Steinasserer M, Minelli L, Falconi M (2012) Laparoscopic rectal resection for severe endometriosis of the mid and low rectum: technique and operative results. Surg Endosc 26:1035–1040. doi:10.1007/s00464-011-1991-8\nMeuleman C, Tomassetti C, Wolthuis A, Van Cleynenbreugel B, Laenen A, Penninckx F, Vergote I, DʼHoore A, DʼHooghe T (2014) Clinical outcome after radical excision of moderate-severe endometriosis with or without bowel resection and reanastomosis: a prospective cohort study. Ann Surg 259:522–531. doi:10.1097/SLA.0b013e31828dfc5c\nVanhie A, Meuleman C, Tomassetti C, Timmerman D, D’Hoore A, Wolthuis A, Van Cleynenbreugel B, Dancet E, Van den Broeck U, Tsaltas J, Renner SP, Ebert AD, Carmona F, Abbott J, Stepniewska A, Taylor H, Saridogan E, Mueller M, Keckstein J, Pluchino N, Janik G, Zupi E, Minelli L, Cooper M, Dunselman G, Koh C, Abrao MS, Chapron C, D’Hooghe T (2016) Consensus on recording deep endometriosis surgery: the CORDES statement. Hum Reprod. doi:10.1093/humrep/dew136\nAcknowledgements\nFRIENDS study group (List of gynecologist and colorectal surgeons who managed the patients enrolled in the study): CHU de Rouen: Pr Horace Roman, Dr Basma Darwish, Dr Julie Ness, Dr Gauthier Dietrich, Dr Benoit Resch, Pr Jean-Jacques Tuech, Dr Emmanuel Huet, Dr Rachid Chati, Dr Julien Coget, Dr Valérie Bridoux; CHU Lille: Dr Chrystèle Rubod, Pr Pierre Collinet, Pr Guillaume Piessen, Dr Thibaut Crombé, Dr Williams Tessier; CHU Toulouse: Pr Pierre Laguevaque; CHU Tenon: Pr Emile Daraï, Pr Marcos Ballester; Hôpital Privé Natécia, Lyon: Dr Antoine Watrelot, Dr Géraldine Chauvin, Dr Jean Sébastien Lanne; CHU Clermont Ferrand: Pr Michel Canis, Dr Nicolas Bourdel, Pr Jean-Luc Pouly, Dr Anne-Sophie Grémeau, Pr Benoit Rabischong, Pr Karem Slim; CHU Nantes: Dr Stéphane Ploteau, Pr Patrice Lopes, Dr Juliette Podevin; Clinique Bouchard, Marseille: Dr Jean Philippe Estrade, Dr Brice Gurriet, Dr Alexandre Lazard, Dr Antoine Camerlo, Dr Xavier Hanna; CHU Cochin: Pr Bertrand Dousset, Pr Charles Chapron, Dr Mahaut Leconte, Pr Bruno Borghese; Polyclinique Santamaria, Nice et Polyclinique Saint-Jean, Cagnes-sur-Mer: Dr Sylvain Tassy, Dr Frédéric de France; CHU de Strasbourg: Pr Arnaud Wattiez, Dr Emilie Faller, Dr Cherif Youssef Akladios, Pr Joël Leroy; GHSJ Paris: Dr Eric Sauvanet, Dr Astrid Mephon, Dr Benjamin Angliviel, Dr Jerome Loriau; CH Versailles: Dr Pierre Panel, Dr Julien Niro, Dr Arnaud Le Toheic; Clinique Millénaire de Montpellier: Pr Herve Dechaud, Dr Dominique Cresienzo; CHU Rennes: Pr Jean Leveque; CHU Besançon: Dr Rajeev Ramanah; Clinique de la Muette, Paris: Pr Patrick Madelenat; CHU de Bordeaux: Pr Hocke Claude, Dr Conri Vanessa, Pr Brun Jean-Luc, Dr Merlot Benjamin, Pr Eric Rullier, Dr Quentin Denost; Réunion Nord: Dr Julie Eggermont, Pr Peter von Theobald, Dr Christophe Duchamp; CHU Lyon Sud: Pr François Golfier; CHU Réunion Sud: Dr Gabriele Marc, Pr Malik Boukerrou; Clinique de la Sagesse, Rennes: Dr Jérôme Blanchot, Dr Jean Vialard; CHU Poissy: Pr Arnaud Fauconnier, Pr Elie Chouillard; CHU Croix Rouge Lyon: Pr Gil Dubernard; CHU Tours: Dr Thomas Hebert; CHU Bichat: Dr Carmen Chis, Dr Martin Koskas; Clinique Mathilde, Rouen: Dr Benoit Resch, Dr Olivier Foulatier, Dr Vianney Roger; CHU Amiens: Dr Sophie Sanguin, Dr Lionel Rebibo, Dr Charles Sabbagh; CHU Dijon: Dr Laurence Filipuzzi; CHU Angers: Pr Philippe Descamps; CHU Montpellier: Dr Claire Vincens; Clinique Sud Vendée, Fontenay le Comte: Dr Eric Hermouet, Dr Hervé Briandet, Dr Marc Guillaume; Polyclinique Kenval, Nîmes: Dr Grégory Triopon; CHU Caen: Dr Mélusine Turck, Pr Raffaèle Fauvet, Dr Thomas Sarcher; CHU Beaujon et Clinique Hartmann, Paris: Pr Nizar Aflak; CHU La Conception, Marseille: Pr Aubert Agostini, Dr Audrey Pivano, Dr Christelle Arbola, Pr Nicolas Pirro, Dr Le Huu Nho Remy; Clinique Brétéché, Nantes: Dr Pascal Guihard, Dr Benoit Dixneuf, Dr Jean-Philippe Arigon; CHU Nancy: Dr Cecile Mezan de Malartic, Pr Olivier Morel, Dr Laurent Bresler; Clinique Clementville Montpellier: Dr Vincent Deutsch; CHU Poitiers: Pr Xavier Fritel, Dr Marie-Line Barussaud; CHU Nîmes: Pr Renaud de Tayrac, Dr Vincent Letouzey, Dr Florent Masia, Pr Michel Prudhomme, Dr Jérémy Ripoche; Clinique de l’Europe, Rouen: Dr Juan Berrocal, Dr Jean Hugues Maillochaud; Clinique du Val d’Ouest, Ecully: Dr Benjamin Cotte, Dr Vincent Schreiber, Dr Philippe Guillem; Clinique du Parc Monceau, Paris: Dr Ludovic Friederich; CHU Kremlin Bicêtre: Pr Hervé Fernandez; CHU Limoges: Dr Tristan Gauthier, Pr Muriel Mathonnet; Clinique Belledonne Grenoble: Dr François Muet; Polyclinique du Parc Rambot, Aix-en-Provence: Dr François Guillibert; CHU Hôpital Privé de l’Estuaire, Le Havre: Dr Jean-François Le Digabel, Dr Philippe Chasserant; CHU Jean Verdier, Bondy: Dr Jeremy Boujenah; CH La Rochelle: Dr Philippe Ferry; CH du Havre: Dr Eric Legoupils; CHU Clamart: Pr Xavier Deffieux; Clinique des Franciscaines, Paris: Dr Deborah Apfelbaum.\nAuthor information\nAuthors and Affiliations\nCorresponding author\nEthics declarations\nDisclosures\nAuthors Sofiane Bendifallah, Horace Roman, Chrystel Rubod, Pierre Leguevaque, Antoine Watrelot, Nicolas Bourdel, Marcos Ballester, Emile Darai have no conflicts of interest or financial ties to disclose.\nRights and permissions\nAbout this article\nCite this article\nBendifallah, S., Roman, H., Rubod, C. et al. Impact of hospital and surgeon case volume on morbidity in colorectal endometriosis management: a plea to define criteria for expert centers. Surg Endosc 32, 2003–2011 (2018). https://doi.org/10.1007/s00464-017-5896-z\nReceived:\nAccepted:\nPublished:\nIssue date:\nDOI: https://doi.org/10.1007/s00464-017-5896-z","source_license":"CC0","license_restricted":false}