{"paper_id":"f9860329-8fe8-41d6-9090-520c632ca828","body_text":"J Surg, an open access journal\nISSN: 2575-9760\n1 V olume 09; Issue 11\nResearch Article\nGastrointestinal Outcomes Following Segmental \nColorectal Resection for Treating Deep Infiltrating \nEndometriosis: A Retrospective Study \nAli Mohtashami1*, Kanika Chaudhri1,2, Cameron Law1,3,4, Shing Wong3,4, \nSurya Krishnan1,3,4, Shahrir Kabir1,5, Alan Lam1,5 \n1Royal North Shore Hospital, Sydney, Australia\n2The George Institute for Global Health, New South Wales, Australia\n3Prince of Wales Public Hospital, Sydney, Australia\n4Prince of Wales Private Hospital, Sydney, Australia\n5The Mater Hospital, Sydney, Australia\nJournal of Surgery\nMohtashami A, et al. J Surg 9: 11114\nwww.doi.org/10.29011/2575-9760.11114\nwww.gavinpublishers.com\n*Corresponding author: Ali Mohtashami, Department of Colorectal, The Royal North Shore Hospital, Level 8, Reserve Rd, St \nLeonards NSW 2065, Australia \nCitation: Mohtashami A, Law C, Chaudhri K, Wong S, Krishnan S, et al. (2024) Gastrointestinal Outcomes Following Segmental \nColorectal Resection for Treating Deep Infiltrating Endometriosis: A Retrospective Study Protocol. J Surg 9: 11114 DOI: 10.29011/2575-\n9760.11114\nReceived Date: 14 August 2024; Accepted Date: 19 August 2024; Published Date: 21 August 2024\nAbstract\nIntroduction: Often, symptoms of bowel endometriosis are mistaken, with incorrect diagnoses such as irritable bowel syndrome \nbeing made, with endometriosis going untreated for many years. Surgical treatment involves the resection of endometriosis lesions. \nA low anterior resection can leave patients with a broad spectrum of symptoms, leading to erratic bowel habits that reduce their \nquality of life. This protocol aims to assess whether colorectal segmental resection for deep infiltrating bowel endometriosis improves \ngastrointestinal functional outcomes for women undergoing surgery for pelvic endometriosis. \nMethods and Analysis: A multicentre retrospective study from 2011 to 2021 will be conducted. It will include women who underwent \npelvic surgery for endometriosis requiring colonic or rectal resection. Operative and post-operative patient data will be obtained. The \nClavien Dindo grading of surgical complications between all patients will be assessed. The low anterior resection syndrome score data \nwill be summarised using their median, range, and percentage of total and compared using the Mann-Whitney U-test. \nEthics and dissemination: The study will be conducted in compliance with the conditions of ethics committee approval. Results are \nintended to be published in peer-reviewed scientific journals and, where appropriate, presented at national and international surgical \nmeetings.\nRegistration details: Ethics approval reference number: 2022/ETH00809 (PID00910)\n\nCitation: Mohtashami A, Law C, Chaudhri K, Wong S, Krishnan S, et al. (2024) Gastrointestinal Outcomes Following Segmental \nColorectal Resection for Treating Deep Infiltrating Endometriosis: A Retrospective Study Protocol. J Surg 9: 11114 DOI: 10.29011/2575-\n9760.11114\n2\nV olume 09; Issue 11\nJ Surg, an open access journal\nISSN: 2575-9760\nKeywords: Colorectal resection; Endometriosis; Gastrointestinal \noutcome\nStrengths and Limitations\n•\t A multicentre retrospective cohort study of previously collected \ndata from 2011-2021 of patients undergoing laparoscopic or \nopen surgery for deep infiltrating endometriosis and having a \nsubsequent segmental colorectal resection is quicker, cheaper, \nand more accessible than prospective cohort studies.\n•\t The sample size is limited to the number of participants that \nmeet the inclusion criteria.\n•\t Due to this study’s retrospective and multicentre nature, it will \nbe prone to recall or misclassification bias.\nBackground\nEndometriosis is a heterogeneous disease that has extensive \nvariation in anatomical and clinical presentations, and it affects up \nto 15% of women in their reproductive years. Deep endometriosis \ncan affect surrounding pelvic structures, including the bowel and \nrectosigmoid [1]. Rates of bowel endometriosis vary, with reports \nranging from 3 to 37%. Of the bowel involved, the rectum, or \nrectosigmoid junction, will be affected in up to 90% of cases [2]. \nThe main reason for operative management of endometriosis is pain \n(ref); often, symptoms of bowel endometriosis are mistaken, with \nincorrect diagnoses such as IBS being made, with endometriosis \ngoing untreated for many years. These symptoms include \npelvic pain, constipation, diarrhea, tenesmus, cramping, and \nbloating. Endoscopic evaluation is typically standard. Colorectal \ninvolvement occurs at the time of laparoscopic surgery. However, \nthere are no widely accepted guidelines to direct the workup or \nintra-operative colonic management (shaving, disc resection, \nsegmental resection with anastomosis), and it is often surgeon-\ndependent with a gross assessment of nodules on laparoscope and \nassisted by pre-operative ultrasound scans with varying accuracy \n[3]. Young and otherwise fit females are sometimes subject to the \nmorbidity of colonic resections, which, when undertaken, increase \nthe likelihood of complications, prolong the operation, and may \nnot lead to better functional outcomes. Leaks occur in up to 8% of \npatients who undergo an anterior resection, depending on the study \nand cohort [4,5]. Conflicting data exists regarding leak rates of \nresections undertaken for endometriosis, although there is a relative \nlack of data surrounding this, possibly because of the difficulty in \nstandardizing surgical techniques for this disease [6,7]. Although \nstudies have investigated the functional outcomes of disc resection \n[8,9], A low anterior resection can leave patients with a broad \nspectrum of symptoms leading to erratic bowel habits that reduce \ntheir quality of life [10,11]. These symptoms may not be any better \nthan the symptoms of bowel endometriosis. These symptoms \nare likely less prevalent with more conservative measures, \nsuch as shaving of endometrial deposits or a disc resection [8]. \nUnfortunately, complete excision of pelvic disease may not be \npossible. In a systematic review of women who underwent bowel \nresection for colorectal endometriosis, six studies reported up to \n20% of specimens had margins positive for endometriosis [7]. \nThe rates of recurrence of endometriosis should, therefore, also \nbe considered in the decision-making process, as this leads to a \nrecurrence in their pre-operative symptoms. Current literature \nsuggests this is up to 50% in 5 years for some patients [12,13].\nData on patients’ gastrointestinal functional outcomes following \nsegmental resection is limited and conflicts with low-volume \nquality studies. This study will assess whether colorectal segmental \nresection for deep infiltrating bowel endometriosis improved \ngastrointestinal functional outcomes for women undergoing \nsurgery for pelvic endometriosis. It will identify overall rates \nof complications among patients undergoing colonic or rectal \nresection.\nMethods and Analysis\nStudy Objectives \nPrimary Outcome Measures: The primary outcome of this \nstudy is to assess whether segmental colorectal resection leads to \nimprovement in gastrointestinal function. This will be measured \nby the patient’s gastrointestinal symptoms, using the low anterior \nresection syndrome questionnaire, which was recorded by the \nphysician at follow-up. \nSecondary Outcome Measures: The secondary outcome is to \nidentify overall complication rates, compare the literature for \ncolorectal resections, and review if resection led to improvements in \npelvic pain.  Rates of complications will be measured by including \nmorbidity as determined by the Clavien Dindo grading system, \nlength of hospital stay, unplanned readmission rates, unplanned \nreturn to the intensive care unit, and non-surgical complications \n(such as a urinary tract infection). In addition, the same data will \nbe used to compare the different types of colorectal resections and \nsee if superiority between the resections exists. Lastly, patient \nnotes will be hand-searched to identify pre and post-surgical pain \nscores. \nStudy Design\nA multicentre retrospective cohort study of previously collected \ndata from 2011-2021 of patients undergoing laparoscopic or \nopen surgery for deep infiltrating endometriosis and having a \nsubsequent segmental colorectal resection in co-located hospitals \nwithin urban New South Wales, Australia. All study sites perform \nthe same procedure and with the same surgeons. Patients with deep \ninfiltrating bowel endometriosis who have undergone segmental \n\nCitation: Mohtashami A, Law C, Chaudhri K, Wong S, Krishnan S, et al. (2024) Gastrointestinal Outcomes Following Segmental \nColorectal Resection for Treating Deep Infiltrating Endometriosis: A Retrospective Study Protocol. J Surg 9: 11114 DOI: 10.29011/2575-\n9760.11114\n3\nV olume 09; Issue 11\nJ Surg, an open access journal\nISSN: 2575-9760\ncolorectal resection will be retrospectively identified from a \ndatabase. Patients not undergoing resection will be excluded from \nthe study.\nInclusion Criteria\nWomen who underwent pelvic surgery for endometriosis requiring \ncolonic or rectal resection in the 10-year study period. Both \nlaparoscopic and open resections will be included. \nExclusion Criteria\nThose patients who either had no bowel involvement, diseased \nshave from their colon or rectum, or were undergoing disc resection \nwill be excluded from the study.\nStatistical Methods\nCategorical variables will be presented as counts and percentages \nand analyzed using Fisher’s exact or Chi-square tests. Continuous \nvariables will be expressed as the mean and standard deviation \nfor normally distributed data and analyzed using T-tests. The \nLow Anterior Resection Syndrome (LARS) score data will be \nsummarised using their median, range, and percentage of total and \ncompared using the Mann-Whitney U-test.\nData Management\nData Collection \nOver the past 10 years, data has been collected through surgeon \nconsultation notes, pre-and post-operative follow-up appointments, \nand in-hospital assessments. This information has been transcribed \ninto an electronic database.\nExisting data in the database will be collected from various sources, \nsuch as electronic medical records via Powerchart, corresponding \nletters, and pathology systems. The database contains the following \ninformation; \n1) Patient characteristics include age, sex, smoking status, the \nAmerican Society of Anesthesiologist grade of the patient, \ncomorbidities, operative details, use of adjuvant therapy, and \ntype and stage of disease. \n2) Post-operative data includes length of stay, unplanned return \nto theatre, unplanned intensive care unit admission, unplanned \nre-intubation, and unplanned readmission to the hospital. \n3) Specific surgical complications recorded include anastomotic \nleak, haemorrhage, intra-abdominal abscess, and wound \ninfection. \n4) Non-surgical complications include respiratory, cardiac, and \nthromboembolic.\nData Storage\nData is routinely collected on all patients who undergo \nendometriosis surgery by the surgeons at our institution. Patients \nsign consent to allow this information to be stored and used for \nclinical research in a de-identified way. The data in the database \nis controlled by a single researcher and is stored securely in a \npassword-protected manner. Identifiable data is only stored using \na code; therefore, patient data is anonymous. The data resides \non a password-protected computer within a locked room within \nthe surgical department offices, which require key card swipe \naccess. Privacy will be maintained by ensuring only the principal \ninvestigators can access this. All data sheets and databases will \nbe retained for at least five years post-study completion and then \nappropriately destroyed.\nEthics and Dissemination\nThe study will comply with all protocol stipulations, the conditions \nof ethics committee approval, the NHMRC National Statement \non Ethical Conduct in Human Research (2007), and the Note for \nGuidance on Good Clinical Practice (CPMP/ICH-135/95). Ethics \napproval has been granted by the Research Ethics Governance \nInformation System (REGIS), REGIS reference number 2022/\nETH00809 (PID00910). Results are intended to be published in \npeer-reviewed scientific journals and, where appropriate, presented \nat national and international surgical meetings.\nDiscussion and Limitations\nThis study can guide future studies by generating hypotheses to \nbe studied further by more extensive, more expensive prospective \nstudies. The results from this study will be presented to the \nscientific and clinical communities. We would expect results \nfrom the study to be presented at national and international levels \nand to be published in a scientific journal with open access. We \nintend that results will be used to inform consensus guidelines on \noptimum treatment pathways following Gastrointestinal outcomes \nfollowing segmental colorectal resection for treating deep \ninfiltrating endometriosis. We acknowledge that there is a risk of \nselection bias.\nPatients and Public Involvement \nSince all data will be retrieved from medical records and \nanaesthesia charts without any impact on future treatment for \nthe involved patients, we did not involve patients or the public in \ndesigning this study or writing the protocol.\nFunding: The authors have not declared a specific grant for this \nresearch from any funding agency in the public, commercial or \nnot-for-profit sectors.\n\nCitation: Mohtashami A, Law C, Chaudhri K, Wong S, Krishnan S, et al. (2024) Gastrointestinal Outcomes Following Segmental \nColorectal Resection for Treating Deep Infiltrating Endometriosis: A Retrospective Study Protocol. J Surg 9: 11114 DOI: 10.29011/2575-\n9760.11114\n4\nV olume 09; Issue 11\nJ Surg, an open access journal\nISSN: 2575-9760\nReferences\n1. Jacques D, et al. (1995) “Surgery: Rectovaginal septum, endometriosis \nor adenomyosis: Laparoscopic management in a series of 231 \npatients.” Human Reproduction 10.3 :630-635.\n2. Wolthuis AM, et al. (2014) “Bowel endometriosis: colorectal surgeon’s \nperspective in a multidisciplinary surgical team.” World Journal of \nGastroenterology: WJG 20.42 15616: 15616-15623\n3. Ros C, et al. (2017)  “Bowel preparation improves the accuracy \nof transvaginal ultrasound in the diagnosis of rectosigmoid deep \ninfiltrating endometriosis: a prospective study.” Journal of Minimally \nInvasive Gynecology 24.7 :1145-1151\n4. Pakkastie TE, Luukkonen PE and Järvinen HJ. (1994) “Anastomotic \nleakage after anterior resection of the rectum.” The European Journal \nof Surgery= Acta Chirurgica 160.5: 293-297.\n5. Tan WS, et al. (2009)  “Meta-analysis of defunctioning stomas in low \nanterior resection for rectal cancer.” Journal of British Surgery 96.5 \n462-472.\n6. Meuleman C, Tomassetti C and Hooghe TMD. (2012) “Clinical outcome \nafter laparoscopic radical excision of endometriosis and laparoscopic \nsegmental bowel resection.” Current Opinion in Obstetrics and \nGynecology 24.4 : 245-252.\n7. Meuleman C, et al. (2011) “Surgical treatment of deeply infiltrating \nendometriosis with colorectal involvement.” Human Reproduction \nUpdate 17.3 : 311-326.\n8.  Ada NG, et al. (2016) “Medium to long‐term gastrointestinal outcomes \nfollowing disc resection of the rectum for treatment of endometriosis \nusing a validated scoring questionnaire.” Australian and New Zealand \nJournal of Obstetrics and Gynaecology 56.4 : 408-413. \n9.  Julian CYIP, et al. (2020) “Rectal disc resection improves stool \nfrequency in patients with deep infiltrating endometriosis: a \nprospective study.” Australian and New Zealand Journal of Obstetrics \nand Gynaecology 60.3 : 454-458.\n10. Bryant CLC, et al. (2012)  “Anterior resection syndrome.” The Lancet \noncology 13.9 : e403-e408.\n11. Juul T , et al. (2014) “Low anterior resection syndrome and quality \nof life: an international multicenter study.” Diseases of the Colon & \nRectum 57.5 : 585-591.\n12. Bendifallah S, et al.(2020) “Recurrence after surgery for colorectal \nendometriosis: a systematic review and meta-analysis.” Journal of \nMinimally Invasive Gynecology 27.2 : 441-451.\n13. Emmertsen KJ, and Laurberg S. (2012) “Low anterior resection \nsyndrome score: development and validation of a symptom-based \nscoring system for bowel dysfunction after low anterior resection for \nrectal cancer.” Annals of surgery 255.5 : 922-928.","source_license":"CC0","license_restricted":false}