{"paper_id":"9952af63-4393-4921-80dd-88c96055fdab","body_text":"j coloproctol (rio j). 2 0 1 9; 3 9(3) :191–196\nwww.jcol.org.br\nJournal of\nColoproctology\nOriginal Article\nStandardization of endometriosis surgery –  the\ncoloproctologist’s vision\nBarbara Pereira Laraa, Karina Correa Ebrahima, Univaldo Etsuo Sagaea,b,c,d,\nGustavo Kurachi a,b,c, Francisco Sérgio Pinheiro Regadas e,f,g,h,\nSthela Maria Murad Regadas e, Doryane Maria dos Reis Lima a,b,c,∗\na Fundac¸ão Hospitalar São Lucas, Cascavel, PR, Brazil\nb Gastroclinica Cascavel, Cascavel, PR, Brazil\nc Centro Universitário da Fundac¸ão Assis Gurgacz, Cascavel, PR, Brazil\nd Universidade do Oeste do Paraná, Cascavel, PR, Brazil\ne Universidade Federal do Ceará (UFC), Faculdade de Medicina, Fortaleza, CE, Brazil\nf Sociedade Brasileira de Coloproctologia, Rio de Janeiro, RJ, Brazil\ng Colégio Brasileiro de Cirurgia Digestiva (CBCD), Colégio Brasileiro de Cirurgiões (CBC), São Paulo, SP , Brazil\nh American Society of Colon and Rectal Surgeons, York Township, United States\na r t i c l e i n f o\nArticle history:\nReceived\n 28 August 2018\nAccepted 10 February 2019\nAvailable\n online 12 April 2019\nKeywords:\nEndometriosis\nUltrasonography\nLaparoscopy\nColorectal\n surgery\na b s t r a c t\nObjective: To demonstrate the standardization of deep endometriosis surgery with intestinal\ninvolvement.\nMethods:\n Prospective study evaluating 74 women undergoing standardized surgery for deep\nintestinal\n endometriosis. Divided into two groups, according to the findings  of three-\ndimensional\n anorectal ultrasound, Group I with lesions affecting perirectal fat and Group II\nwith\n lesions affecting at least the muscular layer of the rectum.\nResults:\n There was no statistically significant  difference between the groups in relation to\nthe\n size of the focus and the distance of the lesion to the puborectalis muscle (p > 0.05).\nThe\n type of surgery performed was laparoscopy without lesions in one patient (1.35%), disk\nresection\n in 13 patients (17.56%), shaving in 45 patients (60.81%), and rectosigmoidectomy\nin\n 15 patients (20.27%). The complications were bleeding from the drain with conserva-\ntive\n treatment in three patients (4.05%), fistula  in two patients submitted to the shaving\nmethod\n (2.70%), and three patients (4.05%) with lower anterior recession syndrome (LARS),\nwith\n improvement\n from conservative treatment. Lesions in other organs were also observed\nduring\n videolaparoscopy.\nConclusion:\n Surgical standardization is important to guide the general/colorectal surgeon in\nthe\n effective approach of intestinal endometriosis.\n©\n 2019 Published by Elsevier Editora Ltda. on behalf of Sociedade Brasileira de\nColoproctologia.\n This is an open access article under the CC BY -NC-ND license (http://\ncreativecommons.org/licenses/by-nc-nd/4.0/).\n∗ Corresponding author.\nE-mail:\n doryane@gmail.com (D.M. Lima).\nhttps://doi.org/10.1016/j.jcol.2019.02.003\n2237-9363/© 2019 Published by Elsevier Editora Ltda. on behalf of Sociedade Brasileira de Coloproctologia. This is an open access article\nunder\n the CC BY -NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).\nArticle published online: 2021-03-08\n\n192 j coloproctol (rio j). 2 0 1 9; 3 9(3) :191–196\nPadronizac¸ão da cirurgia da endometriose –  visão do coloproctologista\nPalavras-chave:\nEndometriose\nUltrassonografia\nLaparoscopia\nCirurgia\n colorretal\nr e s u m o\nObjetivo: Demonstrar a padronizac¸ã o da cirurgia de endometriose profunda com acometi-\nmento\n intestinal.\nMétodos:\n Estudo prospectivo que avaliou 74 mulheres submetidas à cirurgia padronizada\npara\n endometriose profunda intestinal. Divididas em dois grupos, segundo os achados da\nultrassonografia\n anorretal tridimensional, o Grupo I com lesões acometendo a gordura perir-\nretal\n e o Grupo II com lesões acometendo, pelo menos, a camada muscular própria do\nreto.\nResultados:\n Não houve diferenc¸a  estatisticamente significativa  entre os grupos em relac¸ã o ao\ntamanho\n do foco e à distância da lesão ao músculo puborretal (p > 0,05). O tipo de cirurgia\nrealizada foi laparoscopia sem achados da lesão em um paciente (1,35%), ressecc¸ã o em\ndisco\n em 13 pacientes (17,56%), Shaving em 45 pacientes (60,81%) e retossigmoidectomia\nem\n 15 pacientes (20,27%). As complicac¸ ões encontradas foram sangramento pelo dreno\ncom\n tratamento conservador em 3 pacientes (4,05%), fístula em 2 pacientes submetidas ao\nmétodo\n de shaving (2,70%), 3 pacientes (4,05%) com Síndrome da Ressecc¸ã o Anterior do Reto\n(LARS),\n com melhora ao tratamento conservador. Lesões em outros órgãos também foram\nobservadas\n durante a videolaparoscopia.\nConclusão:\n A padronizac¸ã o cirúrgica é importante para orientar o cirurgião geral/colorretal\nna\n abordagem eficaz  na endometriose intestinal.\n©\n 2019 Publicado por Elsevier Editora Ltda. em nome de Sociedade Brasileira de\nColoproctologia. Este ´e um artigo Open Access sob uma licenc¸a  CC BY -NC-ND (http://\ncreativecommons.org/licenses/by-nc-nd/4.0/).\nIntroduction\nEndometriosis\n is a benign gynecological condition character-\nized by the formation of ectopic endometrial tissue1 with a\nconsequent chronic inflammatory  reaction; it affects 4%–17%\nof women of reproductive age. Studies report that between\n15% and 30% of women with endometriosis present deep infil-\ntrative disease,2 whose management can often be difficult  and\nchallenging.\nDeep\n endometriosis is defined  as endometriotic implants\nthat\n penetrate >5 mm beneath the peritoneal surface.3 These\nimplants are commonly found in the uterosacral liga-\nments, rectovaginal septum, or intestinal wall; they are\noften responsible for the patient’s symptoms, which include\ndyspareunia, dysmenorrhea, pain during defecation, or rec-\ntal bleeding during menstruation.4 Rectal or rectosigmoid\njunction involvement indicates a severe form of deep infil-\ntrating endometriosis that affects 5.3%–12%  of women with\nendometriosis.4\nSurgery may be the only appropriate treatment.5 Complete\nresection of all symptomatic lesions has been shown to be a\ndefinitive  treatment of deep endometriosis.6,7 Treatment aims\nto improve the quality of life of the patient and reduce the\nrates of recurrence of the disease, as well as improve fertility,\na situation usually confused with the persistence of injuries\nafter incomplete surgical procedures.8–10\nObjective\nTo present the standardization of the surgical procedure for\ndeep endometriosis with intestinal involvement performed by\na colorectal surgery team.\nPatients and methods\nThis was a prospective, observational, cross-sectional study\nevaluating\n 180 female patients with pelvic endometriosis and\nsuspected intestinal involvement who were referred from\nthe gynecology outpatient clinic to the Department of Colo-\nproctology from April 2010 to August 2012. Of these, 74\npatients participated in all stages and were included in the\nstudy, as their medical records were complete and included\nsurgery details, bleeding data, and complete description of\nthe materials. The evaluation consisted of a thorough phys-\nical examination (rectal and vaginal examination). Initially,\nall patients underwent three-dimensional anorectal ultra-\nsound (3D-US, performed by a single examiner [DMRL]) and\ncolonoscopy to evaluate the intestinal mucosa and exclude\nconcomitant diseases. In 3D-US, the images of the endometri-\notic foci are characterized as heterogeneous hypoechoic areas\nwith a larger diameter outside the rectal wall, i.e., infiltrat-\ning the intestinal wall layers from the inside out: perirectal,\nserosa, muscularis, submucosa, and mucosa (Fig. 1). This is\nillustrated in Fig. 1, which depicts an endometriotic lesion\naffecting all rectal wall layers (axial section, two groups).\nGroup\n I (GI) consisted of 38 women with a mean age of 33.85\nyears, ranging from 21 to 47 years, with lesions affecting the\nperirectal fat. Of these, 13 had undergone prior surgery for\nendometriosis. Group II (GII) consisted of 36 women, with a\nmean age of 34.67 years, ranging from 26 to 48 years, whose\nimages suggested endometriotic foci affecting at least the\nmuscularis layer of the rectum. Of these, 17 had undergone\nprior surgery for endometriosis.\nAfter this initial stage, in which 3D-US was used to assess\nthe localization of the endometriosis focus in relation to the\n\n\nj coloproctol (rio j). 2 0 1 9; 3 9(3) :191–196  193\nfoco\nlower rectum\nrectal muscularis\nmucosa\nFig. 1 –  Endometriotic lesion affecting all rectal wall layers\n(axial section).\nFig. 2 –  Patient positioned at the surgical table with the leg\nin abduction and Trendelenburg position.\nstratum of the affected rectum, its distance from the puborec-\ntalis, and adjacent structures affected, patients were referred\nto a videolaparoscopic surgical procedure (VLP), which was\nperformed by a multidisciplinary team. The first  surgical stage\nwas performed by two gynecologists (NC and DG) and the\nsecond surgical stage, by two colorectal surgeons (UES and\nGK). Intestinal preparation was performed in all women 24 h\nbefore the surgery with phospho-soda solution. All patients\nwere operated under general anesthesia, with preoperative\nprophylactic antibiotic treatment and antithrombotic prophy-\nlaxis with low molecular weight heparin.\nFor all patients, the colorectal surgical strategy was based\non the results presented by 3D-US and intraoperative surgical\nfindings  in accordance with the following protocol:\n1. Correct positioning of the patient in the surgical procedure,\nwith\n legs in abduction and in the Trendelenburg position\n(Fig. 2): the positioning of the patient during surgery is\nextremely important, since it allows improving the field  for\nvisualization of the structures at each surgical stage and\ndecreases trauma to the abdominal organs.\n2. Placement of the fourth trochar and complete surgi-\ncal materials (Fig. 3): one 5.0 mm trochar positioned\nin the left iliac fossa and another one in the right\nFig. 3 –  Trochar position.\nparaumbilical region; one 10.0 mm trochar in the right iliac\nfossa and another one in the umbilical scar. The fourth\ntrochar\n is\n important, as it allows a more advanced dissec-\ntion\n of the characteristic blocks observed in endometriosis.\n3. Inventory of abdominal cavity through an assessment\nof the peritoneal organs in endometriosis11; the small\nand large intestines were assessed, as well as the other\nintraperitoneal organs. Through this method, it is possi-\nble\n to evaluate all the organs, including the possibility of\nfinding  obstructive lesions not previously seen on imaging\ntests.\n4. Routine use of the uterine and rectal manipulator: It acts\nas another trochar for presentation of the surgical field,\nmainly for visualizing the pelvic block. The rectal manip-\nulator\n is used to guide the surgeon during release of the\nblock, preventing rectal puncture or laceration, as well as\ndecreasing the trauma in the organs involved during the\nprocedure.\n5. Isolation and ligation of the ureter: in cases of block in the\novarian fossa, it is important that it is completely released\nand\n resected using the ureter as a guide, thus preventing\naccidents.\n6. Special care in the manipulation of gynecological organs,\nincluding presence of a gynecologist in the intraopera-\ntive period: these patients are women of childbearing age\nwho often still have reproductive desire. The gynecologi-\ncal organs must be manipulated so as to avoid trauma and\nconsequent infertility.\n\n\n194 j coloproctol (rio j). 2 0 1 9; 3 9(3) :191–196\n7. Preservation of the superior rectal artery: this is important,\nconsidering that the vast majority of the lesions are located\nin the middle rectum and, depending on the treatment cho-\nsen and the degree of infiltration,  it is necessary to resect\nthis segment.12 Low anterior recession syndrome (LARS)\nwas\n described in 2012 and consists of the following symp-\ntoms: fecal urgency, episodes of incontinence, increased\nevacuation frequency, bloating, and fecal fragmentation.13\nThis syndrome greatly harms the patients’ quality of life,\nespecially considering the young population affected. This\ntechnique aims to reduce the onset of this syndrome.\n8. Proper handling of the stapler for resecting the various\ntypes of rectosigmoid infiltration:  endometriosis lesions\nare usually are anterior and there is no need to resect the\ntotal circumference of the rectum. Proper handling of the\ncircular stapler allows simple or even double resection of\nthe anterior wall of the rectum only.\n9. Possibility of vaginal access for intraoperatory palpation,\nmanipulation, opening, and removal of surgical pieces\n(NOTES14): it decreases the number of abdominal incisions,\nfor better patient recovery, and reduces surgical trauma.\nBefore\n surgery, all women gave their informed consent to\na planned procedure, including bowel resection, colostomy, or\nileostomy and possible laparotomy conversion, if necessary.\nThe project was approved by the Medical Ethics Committee\nof Hospital Gênesis/CEDIMED under protocol No. 07 and all\npatients signed the informed consent term.\nStatistical analyses were performed using GraphPad Prism\n5.0.\n Data evaluations included descriptive statistical methods\n(mean and standard error). Student’s t-test (non-paired) was\napplied to the numerical values assessed between the groups:\nage, size of the endometriotic focus, and distance from this\nfocus to the puborectalis muscle. Differences were considered\nsignificant  at p <\n 0.05.\nResults\nThe mean age of the patients was 33.85 (21–48)  years. All nod-\nules were located in the anterior quadrant of the rectum. No\nstatistically significant  difference was observed between the\ngroups regarding the size of the focus (Fig. 4) or in relation to\nthe distance of the lesion to the puborectalis muscle (Fig. 5;\n4\n3\n2\nGroup I\nFoci size (cm)\n Group II\n1\n0\ncm\nFig. 4 –  Foci size on GI and GII (p > 0.05).\nDistance from the foci to the\nsphincter apparatus (cm)\n7.5\n6.0\n2.5\n0.0\nGroup I Group II\ncm\nFig.\n 5 –  Distance from lesion to the puborectalis muscle in\nGI\n and GII (p > 0.05).\nStudent’s t-test; p > 0.05). The mean time of surgery by the\ncolorectal surgery team was 100 min.\nIn GI, the mean endometrial foci size was 1.97 cm, with a\nstandard deviation of 0.70 and a standard error of 0.11. The\nmean distance of the lesion to the puborectalis muscle was\n4.45 cm, with a standard deviation of 0.98 and a standard error\nof 0.15. The images from GII were characterized by the pres-\nence\n of heterogeneous irregular hypoechogenic masses with\ninvasion of at least the muscular layer of the rectum. The\nmean GII foci size was 2.34 cm, with a standard deviation of\n0.82 and a standard error of 0.13. The mean distance from the\nlesion to the puborectalis muscle was 4.31 cm, with a standard\ndeviation of 0.82 and a standard error of 0.13.\nThe colorectal surgical procedures performed were shav-\ning, disk resection, or rectosigmoidectomy. The surgeon made\ntheir decision based on the diameter and depth affected by\nthe foci evidenced in 3D-US.\nIn addition to the gynecological organs involved and the\nrectum, during videolaparoscopy lesions were found in the\nappendix\n (n\n =\n 15), bladder (n = 10), sigmoid (n = 4), mesentery\n(n\n = 4), ileum (n = 5), cecum (n = 3), ureter (n = 4), and diaphragm\n(n = 1).\nIn three patients, due to ureter/bladder involvement, it was\nnecessary to call a third surgical team (urological surgery).\nThe colorectal surgical procedures were decided by the sur-\ngeon, based on videolaparoscopic findings  and correlated with\nthe\n 3D-US findings.  Laparoscopy presented no lesion findings\nin one patient (1.35%); disk resection was performed in 13\npatients (17.56%); shaving, in 45 patients (60.81%); and rec-\ntosigmoidectomy, in 15 patients (20.27%).\nThe use of a Penrose drain was chosen in 15% of the\npatients when considering both groups, with an average with-\ndrawal time of five  days. No cases required conversion to\nlaparotomy or ostomy.\nThe following complications were observed: bleeding from\nthe drain in three patients (4.05%; 3/74), treated conserva-\ntively; and fistula  in two patients submitted to the shaving\nmethod (2.70%; 2/74), treated through videolaparoscopy with\ncavity lavage with simple raffia,  drainage, and antibiotic ther-\napy.\n Three patients (4.05%; 3/74) presented LARS syndrome,\nwith\n improvement with clinical treatment and associated\n\n\nj coloproctol (rio j). 2 0 1 9; 3 9(3) :191–196  195\nbiofeedback. The mean length of hospital stay was two days\n(1–5  days).\nDiscussion\nIntestinal endometriosis is an increasingly frequent reality\nin clinical coloproctology practice. It predominantly affects\nyoung women,\n and has very peculiar characteristics, making\nits treatment challenging; it requires new knowledge for diag-\nnosis and surgery, and is one of the few diseases that improves\nfrom a certain age onwards. The main goal of treatment is to\nmaintain quality of life and reproductive desire.\nDeep infiltrative  endometriosis of the rectum is charac-\nterized by affecting at least the muscle layer of the rectal\nwall.15 It is a chronic disease that compromises the quality\nof life of\n women\n by causing progressive pelvic pain, dyspare-\nunia,\n and digestive symptoms such as diarrhea, constipation,\ntenesmus, dyschezia, and painful defecation, among other\nsymptoms.16 The rectum and the rectosigmoid junction are\nthe preferred locations of all intestinal endometriosis sites,\ncomprising 70%–93%\n of patients.17\nPatients’ digestive complaints can be explained by three\nmain consequences of rectal endometriotic nodules: cyclic\nmicrohemorrhages with rectal wall inflammation,  fixation  of\nthe rectum to the cervix, or rectal stenosis.18 However, most\ncases are\n asymptomatic from the gastrointestinal standpoint.\nTherefore, an intestinal assessment should be performed on\nall patients with deep pelvic disease.\nAnorectal\n ultrasonography is a technique with good sensi-\ntivity and specificity  for the visualization of rectal infiltration\nin patients with deep pelvic endometriosis. It should be used\nto define  the best surgical approach.19\nThe treatment\n of intestinal endometriosis is not\nyet precisely established. Some groups of general sur-\ngeons/coloproctologists are on a learning curve regarding the\nbest conduct in each case. For a long time, the management\nwas similar to the surgical treatment of rectal cancer or even\ndiverticular disease. Redwine et al.20 reported the vaginal\nremoval of a rectovaginal nodule and Abrão et al.21 reported\na case of vaginal removal of the rectosigmoid segment, with\nstapled anastomosis. However, after many reports of immedi-\nate or late functional complications, the surgical approach to\nintestinal endometriosis is tending toward more economical\nresections. The objective of this new approach is to improve\nthe\n quality of life of patients regarding pain, fertility, and\ndecrease of LARS syndrome.12,13\nIn cases of deep infiltrative  endometriosis, surgery should\nbe recommended, as it presents a significant  improvement in\nall parameters of pelvic pain and quality of life.22 Laparoscopy\nwas shown to be a viable approach in this type of proce-\ndure, and the complication rates are related to the surgeon’s\nexperience.23\nSeveral surgical approaches are generally adopted in the\ntreatment of deep endometriosis of the rectum: nodule exci-\nsion without opening the lumen of the rectum (shaving),\nremoval\n of the nodule along with the surrounding rectal wall\n(disc excision), or colorectal resection of the affected segment\n(classic rectosigmoidectomy). However, there is no consensus\nin the literature about the indications for each procedure.24\nThis study presented similar results in terms of surgi-\ncal time and complications in the immediate trans- and\npost-operative period.25–29 The standardization of intesti-\nnal endometriosis surgery aims to guide and train gen-\neral/colorectal surgeons on the main surgical stages.\nConclusion\nThe correct understanding of endometriosis affecting young\nwomen and their quality of life is critical for surgeons who\naiming to treat this challenging\n condition. Surgical standard-\nization\n is important to guide the general/colorectal surgeon in\nthe effective approach in intestinal endometriosis, aiming to\nreduce risks and improve the quality of life of these patients.\nConflicts  of interest\nThe authors declare no conflicts  of interest.\nr e f e r e n c e s\n1. Clement MD. Diseases of the peritoneum (including\nendometriosis).\n In: Kurman RJ, editor. Blaustein’s pathology of\nthe\n female genital tract. Springer-Verlag; 2002. p. 729–89.\n2. Roseau G, Dumontier I, Palazzo L, Chapron C, Dousset B,\nChaussade\n S, et al. Rectosigmoid endometriosis: endoscopic\nultrasound\n features and clinical implications. Endoscopy.\n2000;32:525–30.\n3. Darwish B, Roman H. Surgical treatment of deep infiltrating\nrectal\n endometriosis: in favor of less aggressive surgery. Am J\nObstet\n Gynecol. 2016;215:195–200.\n4.\n Daraï E, Cohen J, Ballester M. Colorectal endometriosis and\nfertility.\n Eur J Obstet Gynecol Reprod Biol. 2017;209:86–94.\n5. Roman H, Kouteich K, Gromez A, Hochain P, Resch B, Marpeau\nL.\n Endorectal ultrasound accuracy in the diagnosis of rectal\nendometriosis\n infiltration  depth. Fertil Steril. 2008;90:1008–13.\n6. Ford J, English J, Miles WA, Giannopoulo T. Pain, quality of life\nand\n complications following the radical resection of\nrectovaginal\n endometriosis. BJOG. 2004;111:353–6.\n7. Chopin N, Vieira M, Borghese B, Foulot H, Dousset B, Coste J,\net\n al. Operative management of deeply infiltrating\nendometriosis:\n results on pelvic pain symptoms according to\na\n surgical classification.  J Minim Invasive Gynecol.\n2005;12:106–12.\n8. Remorgida V, Ragni N, Ferrero S, Anserini P, T orelli P, Fulcheri\nE.\n How complete is full thickness resection of bowel\nendometriotic\n lesions? A prospective surgical and histological\nstudy.\n Hum Reprod. 2005;20:2317–20.\n9. Vignali M, Bianchi S, Candiani M, Spadaccini G, Oggioni G,\nBusacca\n M. Surgical treatment of deep endometriosis and risk\nof\n recurrence. J Minim Invasive Gynecol. 2005;12:508–13.\n10. Dubernard\n G, Piketty M, Rouzier R, Houry S, Bazot M, Darai E.\nQuality\n of life after laparoscopic colorectal resection for\nendometriosis.\n Hum Reprod. 2006;21:1243–7.\n11. Sagae EU, Lopasso F, Abrão MS, Cavalli N, Rodrigues JJG.\nEndometriose\n do trato gastrintestinal –  correlac¸ ões clínicas e\nlaparoscópicas.\n Rev Bras Coloproctol. 2007;27:423–31.\n12. Lima DMR, Bortolli JP , Kurachi G, Sagae UE. Importance of\nsuperior\n rectal artery preservation in videolaparoscopic\nrectosigmoidectomy\n for benign disease. Adv Res\nGastroenterol\n Hepatol. 2017;4.\n13.\n Bryant CL, Lunniss PJ, Knowles CH, Thaha MA, Chan CL.\nAnterior\n resection syndrome. Lancet Oncol. 2012;13:e403–8.\n\n\n196 j coloproctol (rio j). 2 0 1 9; 3 9(3) :191–196\n14. Redwine DB, Koning M, Sharpe DR. Laparoscopic assisted\ntransvaginal\n segmental resection of the rectosigmoid colon\nfor\n endometriosis. Fertil Steril. 1996;65:193–7.\n15. Chapron C, Fauconnier UMA, Vieira M, Barakat H, Dousset B,\nPansini\n V, et al. Distribuic¸ã o anatômica da endometriose\nprofundamente\n infiltrante:  implicac¸ ões cirúrgicas e\nproposic¸ã o\n para uma classificac¸ã o . Hum Reprod.\n2003;18:157–61.\n16. Roman H, Vassilieff M, Gourcerol\n G, SavoyeAnne G, Loïc ML,\nMichot MF , et al. Surgical management of deep infiltrating\nendometriosis\n of the rectum: pleading for a symptom-guided\napproach.\n Hum Reprod. 2011;26:274–81.\n17. Bailey HR, Ott MT , Hartendorp P. Aggressive surgical\nmanagement\n for advanced colorectal endometriosis. Dis\nColon\n Rectum. 1994;37:747–53.\n18. Roman H, Vassilieff M, Gourcerol G, Savoye G, Leroi AM,\nMarpeau\n L, et al. Surgical management of deep infiltrating\nendometriosis\n of the rectum: pleading for a symptom-guided\napproach.\n Hum Reprod. 2011;26:274–81.\n19. Abbas B, de Parades V, Gadonneix P, Etienney I, Salet-Lizée D,\nVillet\n R, et al. Endorectal ultrasonography in predicting rectal\nwall\n infiltration  in patients with deep pelvic endometriosis: a\nmodern\n tool for an ancient disease. Dis Colon Rectum.\n2006;49:869–75.\n20. Redwine DB, Koning M, Sharpe DR. Laparoscopically assisted\ntransvaginal\n segmental resection of the rectosigmoid colon\nfor endometriosis. Fertil Steril. 1996;65:193–7.\n21. Abrão MS, Sagae EU, Gonzales M, Podgaec S, Dias JÁ Jr.\nTreatment\n of rectosigmoidectomy endometrioses by\nlaparoscopically\n assisted vaginal rectosigmoidectomy. Int J\nGynaecol\n Obstet. 2005;91:27–31.\n22. Riiskjær  M, Kesmodel US, Lars AM, Ljungmann K,\nSeyer-Hansen\n M. Pelvic pain and quality of life before and\nafter laparoscopic bowel resection for rectosigmoid\nendometriosis:\n a prospective, observational study. Dis Colon\nRectum.\n 2018;61:221–9.\n23. Tarjanne S, Heikinheimo O, Mentula M, Härkki P.\nComplications\n and long-term follow-up on colorectal\nresections\n in the treatment of deep infiltrating  endometriosis\nextending\n to bowel wall. Acta Obstet Gynecol Scand.\n2015;94:72–9.\n24. Donnez O, Roman H. Choosing the right surgical technique\nfor deep endometriosis: shaving, disc excision or bowel\nresection?\n Fertil Steril. 2017;108:0015–282.\n25. Roman H, Milles M, Vassilieff M, Resch B, T uech JJ, Huet E,\net\n al. Long-term functional outcomes following colorectal\nresection\n versus shaving for rectal endometriosis. Am J\nObstet\n Gynecol. 2016;215, 762.e1–9.\n26. Roman H, Moatassim-Drissa S, Marty N, Milles M, Vallée A,\nDesnyder\n E, et al. Rectal shaving for deep endometriosis\ninfiltrating  the rectum: a 5year continuous retrospective\nseries.\n Fertil Steril. 2016;106:1438–45.\n27. Roman H, FRIENDS group (French Colorectal Infiltrating\nEndometriosis\n Study group). A national snapshot of the\nsurgical\n management of deep infiltrating  endometriosis of\nthe\n rectum and colon in France in 2015: a multicenter series\nof\n 1135 cases. J Gynecol Obstet Hum Reprod. 2017;46:159–65.\n28. Roman H, Darwish B,\n Bridoux V, Chati R, Kermiche S, Coget J,\net al. Functional outcomes after disc excision in deep\nendometriosis\n of the rectum using transanal staplers: a series\nof\n 111 consecutive patients. Fertil Steril. 2017;107:977–86.\n29. Thiels CA, Shenoy CC, Ubl DS, Habermann EB, Kelley SR,\nMathis\n KL. Rates, trends, and short-term outcomes of\ncolorectal\n resections for endometriosis: an ACS-NSQIP review.\nInt\n J Surg. 2016;31:5–9.","source_license":"CC0","license_restricted":false}