{"paper_id":"7d4ccca3-de06-45a7-b3d7-f7ecfee38ddf","body_text":"Abstract\nPurpose\nThe optimal surgical approach for removal of colorectal endometrial deposits is unclear. Shaving and discoid excision of colorectal deposits allow organ preservation but risk recurrence with associated functional issues and re-operation. Formal resection risks potential higher complications but may be associated with lower recurrence rates. This meta-analysis compares peri-operative and long-term outcomes between conservative surgery (shaving and disc excision) versus formal colorectal resection.\nMethods\nThe study was registered with PROSPERO. A systematic search was performed on PubMed and EMBASE databases. All comparative studies examining surgical outcomes in patients that underwent conservative surgery versus colorectal resection for rectal endometrial deposits were included. The two main groups (conservative versus resection) were compared in three main blocks of variables including group comparability, operative outcomes and long-term outcomes.\nResults\nSeventeen studies including 2861 patients were analysed with patients subdivided by procedure: colorectal resection (n = 1389), shaving (n = 703) and discoid excision (n = 742). When formal colorectal resection was compared to conservative surgery there was lower risk of recurrence (p = 0.002), comparable functional outcomes (minor LARS, p = 0.30, major LARS, p = 0.54), similar rates of postoperative leaks (p = 0.22), pelvic abscesses (p = 0.18) and rectovaginal fistula (p = 0.92). On subgroup analysis, shaving had the highest recurrence rate (p = 0.0007), however a lower rate of stoma formation (p < 0.00001) and rectal stenosis (p = 0.01). Discoid excision and formal resection were comparable.\nConclusion\nColorectal resection has a significantly lower recurrence rate compared to shaving. There is no difference in complications or functional outcomes between discoid excision and formal resection and both have similar recurrence rates.\nSimilar content being viewed by others\nData availability\nThe data that support the findings of this study are available on request from the corresponding author, [SM].\nReferences\nWolthuis AM, Meuleman C, Tomassetti C, D'Hooghe T, de Buck van Overstraeten A, D'Hoore A (2014) Bowel endometriosis: colorectal surgeon's perspective in a multidisciplinary surgical team. World J Gastroenterol 20(42):15616–23\nAbrao MS, Petraglia F, Falcone T, Keckstein J, Osuga Y, Chapron C (2015) Deep endometriosis infiltrating the recto-sigmoid: critical factors to consider before management. Hum Reprod Update 21:329–339\nSurrey E, Soliman AM, Trenz H, Blauer-Peterson C, Sluis A (2020) Impact of endometriosis diagnostic delays on healthcare resource utilization and costs. Adv Ther 37(3):1087–1099\nGhai V, Jan H, Shakir F, Haines P, Kent A (2020) Diagnostic delay for superficial and deep endometriosis in the United Kingdom. J Obstet Gynaecol 40(1):83–89\nFalcone T, Flyckt R (2018) Clinical management of endometriosis. Obstet Gynecol 131(3):557–571\nVercellini P, Facchin F, Buggio L, Barbara G, Berlanda N, Frattaruolo MP, Somigliana E (2018) Management of endometriosis: Toward value-based, cost-effective. affordable care. J Obstet Gynaecol Can 40(6):726–749\nHabib N, Centini G, Lazzeri L, Amoruso N, El Khoury L, Zupi E, Afors K (2020) Bowel endometriosis: Current perspectives on diagnosis and treatment. Int J Womens Health 29(12):35–47\nRoman H, Ness J, Suciu N et al (2012) Are digestive symptoms in women presenting with pelvic endometriosis specific to lesion localizations? A preliminary prospective study Hum Reprod 27(12):3440–3449\nBecker CM, Bokor A, Heikinheimo O, Horne A, Jansen F, Kiesel L, King K, Kvaskoff M, Nap A, Petersen K, Saridogan E, Tomassetti C, van Hanegem N, Vulliemoz N, Vermeulen N, ESHRE Endometriosis Guideline Group (2022) ESHRE guideline: endometriosis. Hum Reprod Open 2022(2):hoac009. https://doi.org/10.1093/hropen/hoac009\nLiberati A, Altman DG, Tetzlaff J et al (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 339:b2700\nSterne JA, Hernán MA, Reeves BC et al (2016) ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 355:i4919\nMorarasu S, O’Brien L, Clancy C, Dietrich D, Maurer CA, Frasson M, Garcia-Granero E, Martin ST (2021) A systematic review and meta-analysis comparing surgical and oncological outcomes of upper rectal, rectosigmoid and sigmoid tumours. Eur J Surg Oncol 47(9):2421–2428\nMorarasu S, Clancy C, Cronin CT, Matsuda T, Heneghan HM, Winter DC (2021) Segmental versus extended colectomy for tumours of the transverse colon: a systematic review and meta-analysis. Colorectal Dis 23(3):625–634\nMorarasu S, Clancy C, Ghetu N, Musina AM, Velenciuc N, Iacob S, Frunza T, Roata CE, Lunca S, Dimofte GM (2022) Impact of quilting sutures on surgical outcomes after mastectomy: A systematic review and meta-analysis. Ann Surg Oncol 29(6):3785–3797\nDerSimonian R, Laird N (1986) Meta-analysis in clinical trials. Control Clin Trials 7(3):177–188\nAbo C, Moatassim S, Marty N, Saint Ghislain M, Huet E, Bridoux V, Tuech JJ, Roman H (2018) Postoperative complications after bowel endometriosis surgery by shaving, disc excision, or segmental resection: a three-arm comparative analysis of 364 consecutive cases. Fertil Steril 109(1):172-178.e1. https://doi.org/10.1016/j.fertnstert.2017.10.001\nAfors 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. J Minim Invasive Gynecol 23(7):1123–1129. https://doi.org/10.1016/j.jmig.2016.08.813\nBafort C, van Elst B, Neutens S, Meuleman C, Laenen A, d’Hoore A, Wolthuis A, Tomassetti C (2020) Outcome after surgery for deep endometriosis infiltrating the rectum. Fertil Steril 113(6):1319-1327.e3. https://doi.org/10.1016/j.fertnstert.2020.02.108\nBokor A, Hudelist G, Dobó N, Dauser B, Farella M, Brubel R, Tuech JJ, Roman H (2021) Low anterior resection syndrome following different surgical approaches for low rectal endometriosis: A retrospective multicenter study. Acta Obstet Gynecol Scand 100(5):860–867. https://doi.org/10.1111/aogs.14046\nBonin E, Bridoux V, Chati R, Kermiche S, Coget J, Tuech JJ, Roman H (2019) Diverting stoma-related complications following colorectal endometriosis surgery: a 163-patient cohort. Eur J Obstet Gynecol Reprod Biol 232:46–53. https://doi.org/10.1016/j.ejogrb.2018.11.008\nBraund S, Hennetier C, Klapczynski C, Scattarelli A, Coget J, Bridoux V, Tuech JJ, Roman H (2021) Risk of postoperative stenosis after segmental resection versus disk excision for deep endometriosis infiltrating the rectosigmoid: A retrospective study. J Minim Invasive Gynecol 28(1):50–56. https://doi.org/10.1016/j.jmig.2020.04.034\nFanfani F, Fagotti A, Gagliardi ML, Ruffo G, Ceccaroni M, Scambia G, Minelli L (2010) Discoid or segmental rectosigmoid resection for deep infiltrating endometriosis: a case-control study. Fertil Steril 94(2):444–449. https://doi.org/10.1016/j.fertnstert.2009.03.066\nFarella M, Tuech JJ, Bridoux V, Coget J, Chati R, Resch B, Marpeau L, Roman H (2021) Surgical management by disk excision or rectal resection of low rectal endometriosis and risk of low anterior resection syndrome: a retrospective comparative study. J Minim Invasive Gynecol 28(12):2013–2024. https://doi.org/10.1016/j.jmig.2021.05.007\nGornes H, Vaysse C, Leguevaque P, Gallini A, André B, Guerby P, Kirzin S, Suc B, Motton S, Rimailho J, Weyl A, Chantalat E (2020) Identification of a group with high risk of postoperative complications after deep bowel endometriosis surgery: a retrospective study on 164 patients. Arch Gynecol Obstet 302(2):383–391. https://doi.org/10.1007/s00404-020-05604-4\nHernández Gutiérrez A, Spagnolo E, Zapardiel I, Garcia-Abadillo Seivane R, López Carrasco A, Salas Bolívar P, Pascual Miguelañez I (2019) Post-operative complications and recurrence rate after treatment of bowel endometriosis: Comparison of three techniques. Eur J Obstet Gynecol Reprod Biol X 4:100083. https://doi.org/10.1016/j.eurox.2019.100083\nHudelist G, Aas-Eng MK, Birsan T, Berger F, Sevelda U, Kirchner L, Salama M, Dauser B (2018) Pain and fertility outcomes of nerve-sparing, full-thickness disk or segmental bowel resection for deep infiltrating endometriosis-A prospective cohort study. Acta Obstet Gynecol Scand 97(12):1438–1446. https://doi.org/10.1111/aogs.13436\nJayot A, Nyangoh Timoh K, Bendifallah S, Ballester M, Darai E (2018) Comparison of laparoscopic discoid resection and segmental resection for colorectal endometriosis using a propensity score matching analysis. J Minim Invasive Gynecol 25(3):440–446. https://doi.org/10.1016/j.jmig.2017.09.019\nMabrouk M, Raimondo D, Altieri M, Arena A, Del Forno S, Moro E, Mattioli G, Iodice R, Seracchioli R (2019) Surgical, clinical, and functional outcomes in patients with rectosigmoid endometriosis in the gray zone: 13-Year long-term follow-up. J Minim Invasive Gynecol 26(6):1110–1116. https://doi.org/10.1016/j.jmig.2018.08.031\nMoawad NS, Guido R, Ramanathan R, Mansuria S, Lee T (2011) Comparison of laparoscopic anterior discoid resection and laparoscopic low anterior resection of deep infiltrating rectosigmoid endometriosis. JSLS 15(3):331–8. https://doi.org/10.4293/108680811X13125733356431\nRoman H, Rozsnayi F, Puscasiu L, Resch B, Belhiba H, Lefebure B, Scotte M, Michot F, Marpeau L, Tuech JJ (2010) Complications associated with two laparoscopic procedures used in the management of rectal endometriosis. JSLS 14(2):169–77. https://doi.org/10.4293/108680810X12785289143800\nRoman H, Milles M, Vassilieff M, Resch B, Tuech JJ, Huet E, Darwish B, Abo C (2016) Long-term functional outcomes following colorectal resection versus shaving for rectal endometriosis. Am J Obstet Gynecol 215(6):762.e1-762.e9. https://doi.org/10.1016/j.ajog.2016.06.055\nRoman H, Bubenheim M, Huet E, Bridoux V, Zacharopoulou C, Daraï E, Collinet P, Tuech JJ (2018) Conservative surgery versus colorectal resection in deep endometriosis infiltrating the rectum: a randomized trial. Hum Reprod 33(1):47–57. https://doi.org/10.1093/humrep/dex336\nBendifallah S, Puchar A, Vesale E, Moawad G, Daraï E, Roman H (2021) Surgical outcomes after colorectal surgery for endometriosis: A systematic review and meta-analysis. J Minim Invasive Gynecol 28(3):453–466. https://doi.org/10.1016/j.jmig.2020.08.015\nBendifallah S, Vesale E, Daraï E, Thomassin-Naggara I, Bazot M, Tuech JJ, Abo C, Roman H (2020) Recurrence after surgery for colorectal endometriosis: A systematic review and meta-analysis. J Minim Invasive Gynecol 27(2):441-451.e2. https://doi.org/10.1016/j.jmig.2019.09.791\nHeinz-Partington S, Costa W, Martins WP, Condous G (2021) Conservative vs radical bowel surgery for endometriosis: A systematic analysis of complications. Aust N Z J Obstet Gynaecol 61(2):169–176. https://doi.org/10.1111/ajo.13311\nAuthor information\nAuthors and Affiliations\nContributions\nAll authors contributed to the study conception and design. Luke O’Brien, Stefan Morarasu, Cillian Clancy, Paul C Near, Mihail Gabriel Dimofte, Sorinel Lunca designed the study and approved the study protocol. Luke O’Brien, Stefan Morarasu, Bianca Codrina Morarasu, Ana Maria Musina, Natalia Velenciuc, Cristian Ene Roata performed the literature search. Luke O’Brien, Stefan Morarasu, Cillian Clancy analysed the data. Luke O’Brien, Stefan Morarasu, Cillian Clancy, Bianca Codrina Morarasu, Ana Maria Musina, Natalia Velenciuc, Cristian Ene Roata, Diego Raimondo, Renato Seracchioli, Paolo Casadio prepared the manuscript. Diego Raimondo, Renato Seracchioli and Paolo Casadio provided raw patient data for subgroup analysis. Cillian Clancy, Paul C Neary, Mihail Gabriel Dimofte, Sorinel Lunca, Diego Raimondo, Renato Seracchioli and Paolo Casadio critically reviewed the final manuscript. All authors read and approved the final manuscript.\nCorresponding author\nEthics declarations\nConsent for publication\nThe results of this study were never published or presented elsewhere.\nConflict of interest\nThe authors have no conflicts of interest to disclose.\nAdditional information\nPublisher's Note\nSpringer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.\nRights and permissions\nSpringer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.\nAbout this article\nCite this article\nO’Brien, L., Morarasu, S., Morarasu, B.C. et al. Conservative surgery versus colorectal resection for endometriosis with rectal involvement: a systematic review and meta-analysis of surgical and long-term outcomes. Int J Colorectal Dis 38, 55 (2023). https://doi.org/10.1007/s00384-023-04352-6\nAccepted:\nPublished:\nVersion of record:\nDOI: https://doi.org/10.1007/s00384-023-04352-6","source_license":"CC0","license_restricted":false}