{"paper_id":"e8582e76-fa7e-4ed6-9116-0be883a0323e","body_text":"Archives of the Balkan Medical Union\nCopyright © 2019 Balkan Medical Union\nvol. 54, no. 4, pp. 735-738\nDecember 2019\nRÉSUMÉ\nApproche laparoscopique de l’endométriose colorec-\ntale à infiltration profonde\nL’endométriose à infiltration profonde est une maladie \ndébilitante qui affecte généralement les jeunes femmes \net a un impact important sur la qualité de la vie. Du \nfait qu’il s’agit toujours d’une affection bénigne affec-\ntant généralement les patients en âge de procréer, une \nintervention chirurgicale radicale et agressive peut être \nconsidérée comme une mutilation excessive par cer-\ntains cas. En conséquence, l’attention a été concentrée \nsur le traitement de ces patients de manière moins in-\nvasive, des procédures comme le rasage rectal ou l’exci-\nsion locale de l’épaisseur totale étant proposées. Dans \nl’entre-temps, une fois que les techniques mini-inva-\nsives ont évolué, la chirurgie coelioscopique a été large-\nment proposée au cours de la dernière décennie pour \ntraiter cette pathologie. Le présent document est une \nrevue de la littérature des plus grandes études ayant \nétudié et comparé les résultats après une approche mi-\nni-invasive de l’endométriose colorectale à infiltration \nprofonde.\nMots-clés: résection colorectale, rasage, résection, \nrésection de l’épaisseur complète, endométriose.\nABSTRACT\nDeep infiltrating endometriosis is a debilitating dis-\nease which usually affects young women and signifi-\ncantly impacts on the quality of life. Due to the fact \nthat it remains a benign condition which usually af-\nfects patients at the reproductive age, an aggressive, \nradical surgical procedure might be considered as a too \nmutilating one by certain cases. In consequence, at-\ntention was focused on treating these patients in a less \ninvasive manner, procedures like rectal shaving or full \nthickness local excision being proposed. In the mean-\ntime, once the minimally invasive techniques evolved, \nlaparoscopic surgery has been widely proposed in the \nlast decade in order to treat this pathology. The cur-\nrent paper is a literature review of the largest studies \nwhich investigated and compared the outcomes after \nminimally invasive approach for deep infiltrating colo-\nrectal endometriosis.\nKeywords: colorectal resection, shaving, full thick-\nness resection, endometriosis.\nMINIREVIEW\n  LAPAROSCOPIC MANAGEMENT OF DEEP INFILTRATING \nCOLORECTAL ENDOMETRIOSIS\nNicolae BACALBASA1,2 , Irina BALESCU3, Mihaela VILCU1,2, Iulian BREZEAN1,2\n1 „Carol Davila“ University of Medicine and Pharmacy, Bucharest, Romania\n2 „Ion Cantacuzino“ Clinical Hospital, Bucharest, Romania\n3 Ponderas Academic Hospital, Bucharest, Romania\nReceived 26 Aug 2019, Accepted 16 Oct 2019\nhttps:/ /doi.org/10.31688/ABMU.2019.54.4. 18\n Address for correspondence:   Nicolae BACALBASA\n„Carol Davila“ University of Medicine and Pharmacy, Bucharest, Romania\nEmail: nicolae_bacalbasa@yahoo.ro, Phone +40 723 540 426\n\nLaparoscopic management of deep infi ltrating colorectal endometriosis – BACALBASA et al\n736 / vol. 54, no. 4\nINTRODUCTION\nDefined by the presence of nodules invading the \nperitoneal surface on a depth of at least 5 mm, deep \ninfiltrating endometriosis is a debilitating disease \nwhich might affect various pelvic viscera such as the \nurinary bladder, small bowel, large bowel, rectum or \neven other extra- pelvic structures such as the dia-\nphragmatic muscle. In such cases most often the real \nextent of the disease remains hardly to be evaluated \nduring the preoperative workup, the most appropri-\nate information being obtained Intraoperatively, after \na close inspection of all the pelvic and abdominal \nstructures. In these conditions a minimally invasive \nsurgical approach remains the option of choice; this \ntherapeutic strategy is also sustained by the fact that \nendometriosis is in fact a benign disease which usu-\nally affects young women, the wide inspection of the \nwhole abdomen and pelvic structure in a laparoscopic \nmanner being beneficial. When it comes to the deep \ninfiltrating rectal nodules of endometriosis, the op-\ntion of choice depends on the extent of the lesions \nwhich is best evaluated during the laparoscopic ex-\nploration\n1,2.\nTherapeutic strategies in patients with deep \ninfiltrating colorectal endometriosis\nAccording to the extent of the disease, patients \nwith colorectal endometriosis can be submitted to \ndifferent surgical procedures such as rectal shaving, \nfull thickness rectal resection or even colorectal resec-\ntions. Although nowadays the majority of patients are \nsubmitted to colorectal resections, it is widely demon-\nstrated that this approach might be associated with \nthe apparition of the postoperative anterior rectal \nresection syndrome as well as with other debilitating \nsymptoms and a poor quality of life. Conversely, pa-\ntients submitted to local excision have a higher risk of \ndeveloping local recurrences; however, it is estimated \nthat up to 60% of cases might be initially treated in a \nconservative manner\n3. According to Roman’s paper, \nwhat happens now in the field of deep infiltrating en-\ndometriosis is similar to the evolution of the concept \nof radical surgery for breast cancer patients: although \ninitially it has been considered that the only option of \nchoice in such cases remained Halstead’s procedure, \nin time it has been demonstrated that similar onco-\nlogical outcomes could be provided if less invasive \nresections were performed such as Patey, Madden or \neven local resection and lymph node dissection\n3.\nAs for the management of patients with deep \ninfiltrating endometriosis inducing luminal nar-\nrowing, although most authors consider that the \nonly option of choice is represented by colorectal \nresections, other authors consider that deep shaving \nalone or in association with disc excision might  \nprovide better functional and organic benefits\n3-5. \nHowever, the option should be chosen after discuss-\ning with the patient and her family about the future \npotential risks of local complication and recurrence \nof the disease.\nStudies demonstrating the role of laparoscopic \ncolorectal resections in deep infiltrating endo-\nmetriosis\nColorectal resection for deep infiltrating en-\ndometriosis has been considered for a long period \nof time as the election surgical procedure for deep \ninfiltrating endometriosis. The procedure has been \ninvestigated from both the short-term and long-term \noutcomes and proved to offer a good local control \nof the disease. When it comes to the surgical ap-\nproach, the place of the open procedures has been \ntaken recently by the minimally invasive ones; in this \nway a faster recovery has been provided for these pa-\ntients. One of the largest studies conducted on the \ntheme of the short- term outcomes after the two \ntypes of surgical procedures was published in 2016 \nin the International Journal of Surgery\n6. The study \nincluded 101686 women submitted to colorectal re-\nsections, 268 of them being performed for colorec-\ntal endometriosis between 2005 and 2014. The au-\nthors underlined the fact that the number of cases \nsubmitted to colorectal resections for endometriosis \nincreased over time, most often these procedures be-\ning performed by the general surgeons. The authors \nreported a median hospital in stay of 4 days, 14.2% of \ncases suffered no complication, 10 cases being read-\nmitted within the first 30 days. When it came to the \ntype of approach, there was no statistical difference \nbetween the number of open versus laparoscopic ap-\nproach; however, patients submitted to a laparoscopic \napproach benefited from a shorter operative time and \na shorter hospital in stay. Therefore, at that moment \nthe authors demonstrated the increasing trend for \ncolorectal resections when compared to conservative \nprocedures in order to treat deep infiltrating endo-\nmetriosis\n6.\nAnother important issue is the one regarding \nthe necessity of stoma creation in patients presenting \ninfiltrating nodules with intestinal obstruction. Most \noften these patients are young and they can hardly \naccept the idea of an ostomy especially due to the fact \nthat they suffer from a benign condition. In order \nto avoid ostomy creation in young patients with be-\nnign pathology certain authors opined for endoscopic \nstenting followed by interval laparoscopic resection \nand anastomosis\n7.\n\nArchives of the Balkan Medical Union\nDecember 2019 / 737\nStudies sustaining the role of the laparoscop-\nic conservative approach in deep infiltrating \nendometriosis\nAs for the conservative approach in endometrio-\nsis, there are two options of choice which consist of \nrectal shaving (consisting of resection of the endome-\ntrial nodule alone, the continuity of the rectal wall \nbeing entirely preserved) or of full thickness resec-\ntion (in which the nodule is resected in block with \nthe rectal wall, the resulting defect being therefore \nsutured)\n8-10. However, due to the fact that usually \neach surgical team prefers one type of surgery ver-\nsus the other, there is scarce data originating from \ncomparative studies regarding the two conservative \nmethods\n3,10,11. The first study which was conducted \non this issue and which realized a comparison be-\ntween the two methods was published in 2016 in the \nAmerican Journal of Obstetrics and Gynecology\n12. \nThe study included 46 women submitted to conserva-\ntive rectal shaving and 25 women submitted to colo-\nrectal resections in the Department of Obstetrics and \nGynecology at Rouen University Hospital (France). \nThe preoperative investigations demonstrated that \nthere was no significant difference in terms of me-\ndian diameter of the rectal nodules or associated \nvisceral resections; however, patients submitted to \ncolorectal resections presented a significantly higher \nlevel of rectal wall invasion, in this group for cases \npresenting lesions invading the mucosa (while in the \nother group no patient presented such lesions); anoth-\ner interesting observation was the one that patients \nsubmitted to colorectal resections were rather submit-\nted to surgery before November 2007 – the moment \nwhen the new protocol regarding the rectal shaving \nwas introduced. When it comes to cases in which \nrectal and vaginal resections were performed divert-\ning ostomies were also associated in order to decrease \nthe risk of recto-vaginal leaks. When it comes to the \npostoperative outcomes, the number of cases which \npresented postoperative rectal bleeding or stoma re-\nlated complications was significantly higher among \npatients who underwent colorectal resections when \ncompared to those in whom rectal shaving had been \nperformed. As for the long-term outcomes, patients \nsubmitted to conservative surgery – reported a signifi-\ncantly better quality of life including a lower need for \nlaxative use, a lower number of unsuccessful rectal \nevacuation, a lower degree of postoperative pain and \na lower level of painful evacuation effort. As for the \nevolution of the disease, four cases among those sub-\nmitted to rectal shaving developed recurrent disease \nat the site of the previous shaving, two of them being \ntreated by re-shaving and the other two being treated \nby colorectal resection; however, none of the patients \nsubmitted to colorectal resection did experience any \nrecurrent disease\n12.\nOne of the most recent studies which com-\npared these three techniques (shaving versus dis-\ncoid resection versus colorectal resections) was con-\nducted by Gutierrez et al and was published in the \nEuropean Journal of Obstetrics & Gynecology and \nReproductive Biology in 2019\n13. The study included \n143 patients submitted to surgery for endometriosis \nwith bowel involvement: 76 cases were submitted to \nsegmental resections, 20 patients were submitted to \ndiscoid resections while the remaining 47 cases were \nsubmitted to rectal shaving. The authors underlined \nthe fact that a significant difference was seen between \nthe two groups when it comes to the history of pre-\nvious surgery, the length of surgery, the dimensions \nand the location of the nodules as well as to the rate \nof intraoperative complications. Therefore, patients \nsubmitted to conservative procedures had a lower \nrate of preoperative history of previous surgeries,  \nbenefited from a shorter length of the surgical pro-\ncedures and were diagnosed with a lower diameter \nof the nodules; however, the rate of postoperative \ncomplications was higher among cases submitted to \nconservative procedures. In the meantime, the rate \nof recurrence was higher among patients submitted \nto conservative approach, underlining the fact that \nthese procedures should be rather reserved for pre-\nmenopausal women\n13.\nTherapeutic strategies in patients present-\ning diffuse infiltration of the colorectal area \nthrough multiple endometrial nodules\nWhen it comes to patients presenting multiple \nendometrial nodules, certain authors proposed per-\nforming a radical resection involving all the nodules \nleading to extended colorectal surgical procedures\n14-16. \nHowever, this option should be carefully chosen es-\npecially due to the fact that endometriosis remains a \nbenign condition and the age of the affected patients \nis usually low. Therefore, in such conditions a more \nconservative approach could be beneficial\n17-19. This \nmight consist of multiple local excisions and sutures; \nin such cases the most important prognostic factor is \nrepresented by the length of the free of sutures seg-\nment, which should be of at least 50 mm (due to the \nfact that closer than 50 mm sutures are rather con-\nsidered as being ischemic)\n3. One case which comes to \ndemonstrate the efficacy of local excision in patients \npresenting multiple endometrial nodules invading the \ncolorectal area has been included in the ENDORE \nclinical trial. In this case the patient had been diag-\nnosed with three nodules involving the rectum (with \na maximal length of 4 cm), the sigmoid colon (with a \nmaximum length of 3 cm) and the transverse colon \n\nLaparoscopic management of deep infi ltrating colorectal endometriosis – BACALBASA et al\n738 / vol. 54, no. 4\n(and measuring 2 cm in length). According to the \ntraditional model, the patient would had been sub-\nmitted to a total colectomy with the preservation of \nthe last 3-4 cm of the rectum; however, the authors \ndecided to perform three separate full thickness re-\nsections and reported a favorable postoperative out-\ncome at the four- year follow-up\n20.\nCONCLUSIONS\nIn patients presenting deep infiltrating colo-\nrectal endometriosis multiple therapeutic strategies \nhave been proposed so far, with promising results. \nHowever, the option of choice should be tailored in \neach case according to patient’s history, extent of the \ndisease and wish. According to the latest studies, a \nsignificant number of cases might benefit from less \nextended procedures.\nAcknowledgements\nThis work was supported by the project entitled \n„Multidisciplinary Consortium for Supporting the \nResearch Skills in Diagnosing, Treating and Identifying \nPredictive Factors of Malignant Gynecologic Disorders“, \nproject number PN-III-P1-1.2-PCCDI2017-0833.\nCompliance with Ethics Requirements:\n„The authors declare no conflict of interest regarding \nthis article“\n„The authors declare that all the procedures and ex-\nperiments of this study respect the ethical standards in the \nHelsinki Declaration of 1975, as revised in 2008(5), as \nwell as the national law.“\nREFERENCES\n1. Koninckx PR, Martin D. Treatment of deeply infiltrating \nendometriosis. Curr Opin Obstet Gynecol  1994; 6(3): 231-241.\n2. Roman H, Vassilieff M, Gourcerol G, et al. 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Spinu DA, Marcu RD, Socea B, et al. Ureteral JJ stents: which \none is better? Rev Chim (Bucharest)  2018;69(8):2061-2063.\n17. Bodean O, Bratu OG, Bohiltea R, et al. The efficacy of syn-\nthetic oral progestin pills in patients with severe endome-\ntriosis. Rev Chim (Bucharest)  2018;69(6):1411-1415.\n18. Diaconu CC, Arsene D, Balaceanu A, Bartos D. A rare \ntumor revealed by abdominal trauma: case presenta-\ntion. Romanian Journal of Morphology and Embryology  \n2014;55(3):973-976.\n19. Tiglis M, Neagu TP, Elfara M, et al. Nefopam and its role \nin modulating acute and chronic pain. Rev Chim (Bucharest)  \n2018;69(10):2877-2880.\n20. Roman H, Tuech JJ, Slim K, Canis M. Functional outcomes \nof surgical management of deep endometriosis infiltrat-\ning the rectum (ENDORE). NCT01291576. Available at \nhttp:/ /clinicaltrials.gov/ct2/show/NCT01291576?term¼ \nNCT01291576&rank¼1; 2011. (Accessed August 9, 2019)","source_license":"CC0","license_restricted":false}