{"paper_id":"92566e47-1cf3-44d9-9f94-f8b6124438cf","body_text":"Biomed Transl Sci. 2022; 2(4):1-4\nPage 1 of 4\n                      Original ArticleBiomedical & Translational Science\nCitation: Demetrius G. Quality of life after videolaparoscopic segmentary colectomyfor intestinal \nendometriosis Biomed Transl Sci. 2022; 2(4):1-4\nBiomedical & \nTranslational Science\nScience Excel\nQuality of Life After Video Laparoscopic Segmentary \nColectomy For Intestinal Endometriosis\nDemetrius Germini \nState Civil Servant Hospital (IAMSPE), São Paulo, Brazil.\nCorrespondence\nDemétrius Germini\nState Civil Servant Hospital (IAMSPE), São \nPaulo, Brazil.\n•\t Received Date:  20 Jun 2022\n•\t Accepted Date: 28 Aug 2022\n•\t Publication Date: 01 Nov 2022\nKeywords\nColorectal resection in deep pelvic \nendometriosis, Colorectal resection/shaving/\ndisc excision, Deep endometriosis, Quality of \nlife \nCopyright\n© 2022 Science Excel. This is an open- \naccess article distributed under the terms \nof the Creative Commons Attribution 4.0 \nInternational license.\nIntroduction\nEndometriosis is a chronic disease \ndependent on the action of estrogen, in the \nendometrium stroma outside the uterine \ncavity, mainly in the pelvic peritoneum, \novaries, colon, rectum and bladder [1]. It is \nestimated that 176 million women worldwide \nsuffer from endometriosis [2], representing \nup to 15% of women at a reproductive age. \nEndometriosis is associated with pelvic pain, \ndysmenorrhea, dyspareunia, and infertility \n[3,4]; these symptoms worsen the quality of \nlife and work [5,6], causing financial losses \ndue to absenteeism and decreased productivity \n[7].\nIntestinal endometriosis (IE) is a type \nof deep endometriosis characterized by \nendometrioma implants in the colon and \nrectum. It is estimated that 20% of women \nwith endometriosis have an intestinal form \nand 90% have colorectal involvement [8]. \nThere is still no consensus on the treatment \noption for IE [4].\nIn addition to low recurrence rate, but a \nhigher rate of complications is also observed \nin up to 18% of the operated patients, such as \nanastomotic dehiscence or stenosis, fistulas, \nand pelvic collections [9].\nThe treatment of IE in some cases is \nsurgical and is associated with different levels \nof morbidity [10-12].  Several have shown \nsignificant results in symptom resolution \nand improvement in quality of life [13], in \naddition to low recurrence rate. However, a \nhigher complication rate, up to 18% of patients \noperated, has been observed in some studies; \ncomplications include anastomotic dehiscence \nor stenosis, fistulas, or pelvic collections [9].\nVideolaparoscopic segmental colectomy \n(VSC) is usually indicated for larger \nendometriomas, measuring 2 cm, with \ninfiltrative capsules that go beyond the muscular \nlayer of the intestine, that go beyond the main \naxis, or that affect more than one-third of the \nintestinal lumen, which can lead to intestinal \nlumen stenosis [9,14,15].\nAbstract\nBackground: Intestinal endometriosis (IE) is a chronic estrogen-dependent disease \ncharacterized by endometrial stroma outside the uterine cavity. It affects 10 to 15% of \nwomen and may present with pelvic pain and worsening quality of life. Treatment can be \nsurgical, such as videolaparoscopic segmental colectomy (VSC). Objective: To evaluate \nthe quality of life of patients after VSC for treatment of intestinal endometriosis. Method: \nThis is an observational, longitudinal, and retrospective study carried out through a review \nof medical records and a telephone interview with patients who underwent laparoscopic \nsegmental colectomy in a private hospital between 2016 and 2020. Results: 43 patients were \nstudied, of whom 30 (70%) complained of having impaired daily activities. Before surgery, \ndysmenorrhea intensity was classified as mild, moderate, severe, and very severe pain, with \none patient (2.33%) classified as mild, three patients (6.98%) as moderate, 16 patients (37.2%) \nas severe, and 23 (53.49%) as very severe. As for pain during sexual intercourse, 13 patients \n(30%) reported dyspareunia. After surgery, 100% of the patients reported improvement in the \ncomplaint, referring to maintaining a normal routine after the VSC; of the 13 patients who \ndid not feel that they had any impairment in their daily activities before the surgery, 2 still \nreported feeling more lively in their routine after having undergone surgery (P<.05). As for \nthe intensity of dysmenorrhea after surgery, one (2.33%) patient classified it as moderate and \n42 (97.67%) as mild (P<.05), indicating that there is a difference in pain intensity before and \nafter surgery. Of the patients who previously reported dyspareunia, it was observed that 100% \nof them reported improvement after VSC with P=.0002 . Conclusion: CSV can improve the \nquality of life of patients with intestinal endometriosis.. \n\nPage 2 of 4\nDemetrius Germini. Biomedical and Translational Science. 2022; 2(4):1-4\nBiomed Transl Sci. 2022; 2(4):1-4\nEI can worsen women’s quality of life. Disabling pain leads \nto a reduction in happiness rates, absence from daily activities, \nand decreased performance at work. The indirect costs of the \nmost severe cases in terms of productivity are twice the costs of \ntreatment [16,17].\nPurpose\nThe purpose of this study is to evaluate the quality of life of \npatients after surgical treatment by videolaparoscopic segmental \ncolectomy (VSC) for intestinal endometriosis.\nMethod\nThe study was observational, longitudinal, and \nretrospective; it was carried out at Hospital São Luiz Jabaquara \nRede D’Or (São Paulo, Brazil) with patients undergoing VSC \nperformed by the same surgical team between January 2016 and \nOctober 2020 and was conducted from January 2016 to October \n2020 in accordance with the ethical standards determined by \nthe Declaration of Helsinki of the World Medical Association, \nadopted in 1964 and reformulated in 1996.\nThe patients included in the study had undergone VSC, \nhad a clinical and radiological diagnosis of IE, and were over \n18 years of age, of reproductive age, female, and of various \nethnicities. All patients operated on for a cause other than \nIE, patients whose medical records were not located, and all \npatients who refused to participate in the study were excluded \nfrom this study.\nA review of the patients’ charts and a telephone interview \nwere carried out in the late postoperative period, with at least 3 \nmonths between the surgery and the telephone contact, for the \nadministration of a standardized questionnaire with the patient \nto inquire about the quality of life after surgery for intestinal \nendometriosis.\nDescription of the cases\nWe retrospectively analyzed the data of 51 patients with \nIE undergoing VSC. Eight patients were excluded due to the \nimpossibility of telephone contact, resulting in a total of 43 \npatients studied.\nIn these patients, the mean age was 36.9 years (24 to 52 \nyears), with symptom duration predominantly from 3 to 10 \nyears in 21 patients (48%). Each patient in the study had several \ncomplaints, among which the most prevalent symptoms were \npelvic pain (dysmenorrhea), intestinal bleeding, tenesmus, \ndyspareunia, diarrhea, and anal pain. Infertility was an associated \ncondition in 10 patients (20.9%). As for pain symptoms, the \nmost prevalent period was the perimenstrual period, and the \nmost reported pain intensity was very intense in 23 patients \n(50.49%). Among the patients evaluated, it was possible to \nevaluate the size of the endometrioma in 31 patients, among \nwhom they ranged from 1 to 6 cm with a median of 3 cm. It \nwas possible to determine the distance from the anal edge in \n33 patients; this distance varied between 6 and 18 centimeters \nfrom the anal edge. It was not necessary to perform protective \nostomies in any of the cases.\nAs for the quality of life of patients in the preoperative \nperiod, complaints were analyzed regarding the impairment of \ndaily activities due to symptoms; it was found that 30 (70%) of \nthe patients involved in the study reported limitations in their \ndaily activities (home care, shopping, studying), 27 (63%) had \nalready been away from work for a certain period, 13 (30%) \nrevealed having difficulties in sexual relations, and 13 (30%) \nreported difficulties in leisure activities (sports practice, travel, \ntraining).\nStatistical analysis\nFor continuous variables, the median and interquartile \nrange were calculated; when there is no normal distribution and \nthe mean is a confidence interval for the age variable, it has \na normal distribution. For categorical variables, the number of \npatients in each category and their percentage are presented. The \ntest applied to verify the association of the variables before and \nafter the surgery was the exact McNemar test. For all analyses, \nthe significance level considered is .05. R software version 4.0.3 \n(2020-10-10) was used to perform the analyses.\nResults\nBefore VSC, patients classified the intensity of \ndysmenorrhea as mild, moderate, severe, and very severe, with \none patient (2.33%) classified as mild, three patients (6.98%) as \nmoderate, 16 patients (37.2%) as intense, and 23 (53.49%) as \nvery intense. After VSC, one (2.33%) patient classified the pain \nas moderate and 42 (97.67%) as mild (P<.05), indicating that \nthere is a difference in pain intensity before and after surgery.\nOf the 43 patients whose data were analyzed, 30 (70%) \ncomplained of having impaired daily activities. Of these, 100% \nreported improvement in the complaint, referring to maintaining \na normal routine after VSC. Of the 13 patients who did not feel \nthat they had any impairment in daily activities before surgery, \n2 still reported feeling better than before in their routine after \nhaving undergone surgery (P<.05).\nAmong the 13 patients who complained of having difficulties \nin leisure activities (physical activities, entertainment, travel), \n12 reported improvement in this aspect after VSC, and 1 patient \nA B C\nFigure 1. A- Surgical specimen with evidence of IE in sigmoid serosa. B- Surgical specimen with evidence of IE causing intestinal obliteration. \nC- Surgical specimen with evidence of IE affecting the serous and muscular layers of the rectum.\n\nPage 3 of 4\nDemetrius Germini. Biomedical and Translational Science. 2022; 2(4):1-4\nBiomed Transl Sci. 2022; 2(4):1-4\nreported not noticing improvement. Among the 29 patients who \ndid not complain of impairment in leisure activities, one patient \nwith a previous complaint expressed feeling better after surgery \nwhen performing these activities (P<.05).\nRegarding work performance, 27 (63%) of the patients had \nbeen absent from work at some point due to the intensity of the \nsymptoms; of these, 25 patients reported improved performance \nat work on a daily basis and did not suffer more absences after \nthe surgery. Of the 16 patients who did not complain of absence \nfrom work, 1 patient reported improved performance. In relation \nto this data, P>.05, which does not show statistical significance.\nOf the patients analyzed, 13 (30%) reported dyspareunia; \n100% of them reported improvement after VSC, with P=.0002.\nIn relation to patients who complained of infertility, the \noccurrence or nonoccurrence of pregnancy after surgery was \nanalyzed. Initially, 10 patients (23.26%) reported that infertility \nwas really a problem that influenced their quality of life, with \nfailure after some treatment attempts. Another two (4.65%) \nreported having undergone treatment unsuccessfully, but they \ndid not see infertility as a problem in their lives. Of the patients \nwith complaints, 6 (14%) managed to conceive and four (9.3%) \nwere still unsuccessful (P>.05).\nAmong the 43 patients involved in the study, 7 (16%) \ndeveloped mild complaints in the late postoperative period, \n4 of them due to changes in usual bowel habits (constipation \nor diarrhea) but without significant impact on quality of life. \nOf the others, 1 (2.33%) developed anastomotic stricture and \nunderwent endoscopic dilation, showing improvement, and 2 \nother patients complained of sporadic tenesmus.\nDiscussion\nIE affects women in the most productive phase of their \nlives. The symptoms, especially intense and disabling pain, \nnegatively impact the quality of life of these patients.\nThe present study sought to analyze the impact of VSC on \nthe quality of life of patients with IE. We understand that there \nare some limiting factors, such as the retrospective nature of the \nanalysis and the lack of a second group of patients undergoing a \nsurgical technique different from the one adopted. A comparison \nbetween surgical techniques could have broadened the \ndiscussions on the impact of surgeries in the treatment of this \ncondition. However, we chose to use the preoperative status of \neach patient as a control to measure the results, and we believe \nthis is also an adequate way to study the initial objective.\nAlthough part of the published studies show a high number \nof postoperative complications in VSC, this study showed a \nsmall number of complications in the operated patients, most \nof them mild complications such as changes in bowel habits \nwithout significant impact on the patients’ quality of life.\n Bassi et al, [8] in a study with 151 patients of reproductive \nage with IE and symptoms of chronic pelvic pain, a questionnaire \nwas administered before segmental colon resection and 1 year \nafter. After segmental intestinal resection, there was a significant \nimprovement in gastrointestinal, gynecological, and emotional \nsymptoms, leading to an improvement in the quality of life \nof 90% of these patients, proving its effectiveness. This study \npresented results in agreement with those observed by Bassi \net al. We observed that, of the 27 patients (63%) who reported \nabsence from work due to the intensity of symptoms, 25 patients \nreported improvement in their daily work performance and did \nnot suffer more absences after the surgery. Regarding other \nfactors that contribute to quality of life, of the total number of \npatients analyzed, 13 (30%) reported difficulty in their sexual \nrelations, and 100% of these patients improved in this aspect \nafter surgery, which shows a robust improvement in a quality \nof life parameter.\nTurco et al, [18] in a study with 50 patients with a mean age \nof 38 years with symptoms of dysmenorrhea, dyschezia, and \ndyspareunia submitted to segmental colon resection and filled \nout a questionnaire assessing their quality of life before and after \nthe operation. After surgery, using the visual pain scale, pain \nimprovement was noted in 74% of patients, as well as greater in \nself-confidence and improvement in interpersonal relationships, \nsex life, and work performance. In the current study, where the \nseries was equivalent, with 43 patients undergoing a surgical \napproach, the response was even more impressive, showing a \nreduction in perimenstrual pain complaints to physiological \nlevels in 42 patients, more than 97% of the women studied.\nIn this study, it was observed that 14% of the patients who had \nundergone surgery became pregnant in the postoperative period. \nThis result did not reach significant relevance in the comparison \nbetween pre- and postoperative periods. Stepniewska et al, [19] \nin a study with women who underwent colectomy, observed \na spontaneous fertility rate of 35% in the evaluation after \nfour years of surgery (P<.05). We believe that, with a longer \ntime segment, the fertility rate in the women operated on in \nthe current study should still increase substantially, since the \ninterval between surgery and the interview with the patients \nwas, in some cases, quite short.\nThis study, as well as others, suggests that the gynecological \nand intestinal symptoms of endometriosis, especially its \ncolorectal infiltrative form, have a significant impact on patients’ \nlives, affecting daily routine, leisure activities, employment, and \neven sexual intercourse. Although VSC is still considered an \napproach subject to a higher rate of postoperative complications, \na significant improvement in the symptoms and in the routine of \nthe patients involved after this surgery is evident.\nConclusion\nWithin the context in which this study was carried out, \none can conclude that VSC for the treatment of intestinal \nendometriosis can improve the quality of life of patients.\nReferences\n1. Milone M, Vignali A, Milone F , et al. Endometriosis, technique \nand complications. World J Gastroenterol. 2015;21(47):13345-51.\n2. Adamson GD, Kennedy SH, Hummelshoj L. Creating solutions \nin endometriosis: global collaboration through the World \nEndometriosis Research Foundation. J Endometr. 2010;2:4–6.\n3. Olive DL, Schwartz LB. Endometriosis. N Engl J Med. \n1993;328:1759-68.\n4. Charatsi D, Koukoura O, Ntavela IG, et al. Gastrointestinal and \nurinary tract endometriosis: a review on the commonest locations \nof extrapelvic endometriosis. Adv Med. 2018;2018:3461209. \n5. Abrao MS, Petraglia F , Falcone T, Keckstein J, Osuga Y , Chapron \nC. Deep endometriosis infiltrating the recto-sigmoid: critical \nfactors to consider before management. Hum Reprod Update. \n2015;21:329–39. \n6. Setubal A, Sidiropoulou Z, Torgal M, Casal E, Lourenço C, \nKoninckx P . Bowel complications of deep endometriosis during \npregnancy or in vitro fertilization. Fertil Steril. 2014;101:442–6. \n7. Simoens S, Dunselman G, Dirksen C, et al. The burden \nof endometriosis: costs and quality of life of women with \n\nPage 4 of 4\nDemetrius Germini. Biomedical and Translational Science. 2022; 2(4):1-4\nBiomed Transl Sci. 2022; 2(4):1-4\nendometriosis and treated in referral centres. Hum Reprod. \n2012;27(5):1292-9.\n8. Bassi MA, Podgaec S, Dias JA Jr, et al. Quality of life after segmental \nresection of the rectosigmoid by laparoscopy in patients with deep \ninfiltrating endometriosis in bowel. Obstet. 2020;301:217–28. \n9. Y oung S, Burns MK, Di Francesco L, Nezhat A, Nezhat C. \nDiagnostic and treatment guidelines for gastrointestinal and \ngenitourinary endometriosis. J Turk Ger Gynecol Assoc. \n2017;18(4):200-9. \n10. De Cicco C, Corona R, Schonman R, Mailova K, Ussia A, Koninckx \nP . Bowel resection for deep endometriosis: a systematic review. \nBJOG. 2011;118:285–91.\n11. Douay-Hauser N, Y azbeck C, Walker F , Luton D, Madelenat \nP , Koskas M. Infertile women with deep and intraperitoneal \nendometriosis: comparison of fertility outcome according to the \nextent of surgery. J Minim Invasive Gynecol. 2011;18:622–8. \n12. Becker CM, Gattreall WT, Gude K, Singh SS. Reevaluating \nresponse and failure of medical treatment of endometriosis: a \nsystematic review. Fertil Steril 2017;108:125-36.\n13. Byrne D, Curnow T, Smith P , Cutner A, Saridogan E, Clarck TJ. \nLaparoscopic excision of deep rectovaginal endometriosis in \nBSGE endometriosis centres: a multicenter prospective cohort \nstudy. BMJ Open. 2018;8:e018924.\n14. Wolthuis AM, Meuleman C, Tomassetti C, D’Hooghe T, de Buck \nvan Overstraeten A, D’Hoore A. Bowel endometriosis: colorectal \nsurgeon's perspective in a multidisciplinary surgical team. World J \nGastroenterol. 2014;20(42):15616-23. \n15. Milone M, Vignali A, Milone F , et al. Colorectal resection in \ndeep pelvic endometriosis: surgical technique and post-operative \ncomplications. World J Gastroenterol. 2015;21(47-51)\n16. Nnoaham K, Hummelshoj L, Webster P , et al. Impact of \nendometriosis on quality of life and work productivity: a multicenter \nstudy across ten countries. Fertil Steril. 2019;112(4):137-52.\n17. Simoens S, Dunselman G, Dirksen C, et al. The burden \nof endometriosis: costs and quality of life of women with \nendometriosis and treated in referral centres. Hum Reprod. \n2012;27(5):1292–9.\n18. Turco LC, Scaldaferri F , Chiantera V et al. Long-term evaluation \nof quality of life and gastrointestinal well-being after segmental \ncolo-rectal resection for deep infiltrating endometriosis (ENDO-\nRESECT QoL). Arch Gynecol Obstet. 2020;301:217–228. \n19. Stepniewska A, Pomini P , Bruni F , et al. Laparoscopic treatment \nof bowel endometriosis in infertile women. Hum Reprod. \n2009;24(7):1619-25.","source_license":"CC0","license_restricted":false}