Surgical Treatment Experience of Intestinal Endometriosis

Study Design: Retrospective descriptive cohort. Population: Patients who underwent endometriosis resection with colorectal intervention between January 2019 and December 2023. A total of 36 patients met the inclusion criteria at San José Hospital, Bogotá, Colombia.

To describe the demographic and clinical characteristics, surgical procedures, and intra- and postoperative complications. Main Results: Ten patients (27.7%) presented gastrointestinal symptoms that were not associated with lesion size. Six patients (16.6%) had positive findings on physical examination, whereas abnormal imaging results were documented in 25 patients (69.4%). Lesions were most frequently located in the rectum (91.6%), followed by the sigmoid colon, appendix, and cecum. More than half of the lesions (52%) measured less than 3 cm. The intraoperative complication rate was 13.9%, and postoperative complications occurred in 16.7% of cases.

The management of intestinal endometriosis requires a multidisciplinary approach involving expert gynecological endoscopists in collaboration with colorectal surgeons to minimize complications. Our findings highlight the importance of individualized surgical strategies, with a focus on fertility preservation whenever possible.

Endometriosis, Intestinal diseases, Therapeutics

Endometriosis is a chronic inflammatory condition that affects approximately 10% of women of reproductive age and 35–50% of patients with pelvic pain or infertility.1 It can be classified into two categories: genital and extragenital.2 Among the extragenital presentations, the most frequent form is intestinal endometriosis. Reported rates indicate that 3.8–37% of patients with known endometriosis also present with this condition. It may manifest as deeply infiltrative lesions of the muscularis or mucosa, or as superficial disease affecting the serosal or subserosal bowel layers. Due to variability in definitions and diagnostic criteria, estimates of incidence differ significantly.1 The most common initial symptoms include dysmenorrhea, deep dyspareunia, chronic pelvic pain, and dyschezia. Other manifestations may include catamenial diarrhea, constipation, bloating, pain while sitting, and radiation of pain to the perineum.1 Transvaginal ultrasound, as described by Hudelist et al, has demonstrated a specificity of 92–100% and a sensitivity of 71–98%. However, its limitations include the possibility of missing lesions located in the sigmoid colon. In such cases, computed tomography–based virtual colonoscopy may help predict the severity of bowel involvement by generating three-dimensional models.3 Magnetic resonance imaging (MRI) also offers advantages, particularly in evaluating deep infiltrating endometriosis and its relationship with subperitoneal structures.4 Regardless of the modality, standardized reporting is essential, including lesion size, location, depth of infiltration, presence of luminal stenosis, and number of nodules. Such detailed descriptions are critical for adequate surgical planning. Currently, several surgical options are available, including rectal shaving, discoid excision, and segmental resection. The choice of technique depends on patient-related factors—such as age, fertility preservation, and lesion location—as well as surgical expertise. A systematic review by Bendifallah et al reported mean complication rates of 2.2% for shaving, 9.7% for discoid excision, and 9.9% for segmental resection, with an overall mean complication rate of 5.7%. Regarding anastomotic leakage, rectal shaving was associated with lower rates compared to discoid excision, while no significant difference was found between shaving and segmental resection.5 Considering the variability of surgical techniques and the demonstrated impact of hospital and surgeon case volume on morbidity, especially in colorectal endometriosis,6 the objective of this study was to describe the types of surgical procedures performed by the colorectal surgery service at San José Hospital, Bogotá, between January 2019 and December 2023. We also aimed to analyze the sociodemographic, clinical, and preoperative imaging characteristics of patients, correlating these with intraoperative findings and postoperative outcomes (Table 1). Table 1. | Variable | n (%) | |---|---| | Age (years) | 36 (SD 5.4) | | Parity | 25 (69.4) | | Nulliparous | 11 (30.6) | | Multiparous | 22 (61.1) | | Symptoms | 18 (50.0) | | Pelvic pain | 17 (47.2) | | Dyspareunia | 15 (41.7) | | Dysmenorrhea | 4 (11.1) | | Abnormal uterine bleeding | 15 (41.7) | | Constipation | 4 (11.1) | | Dyzchezia | 5 (13.9) | | Clinical examination findings | 6 (16.7) | | Rectovaginal nodule palpation | 2 (33.3) | | Myofascial tenderness – Trigger Points | 4 (66.7) | | Pharmacological treatment | | | None | 19 (52.8) | | Yes | 17 (47.2) | | Oral progestins | 15 (88.2) | | GNRH analogues | 2 (11.8) | | Radiological findings | | | Positive imaging findings | 25 (69.4) | | MRI | 14 (56.0) | | Endometriosis—mapping ultrasound | 11 (44.0) |

We conducted a retrospective descriptive cohort study of patients who underwent endometriosis resection with colorectal intervention at a university hospital between January 2019 and December 2023, Intestinal resections were performed by the colorectal surgery ang gynecology team using a standardized minimally invasive approach, primarily laparoscopic or A minority of procedures required conversion to open surgery. Inclusion criteria were patients older than 18 years who underwent intestinal endometriosis resection during the study period. Exclusion criteria were incomplete medical records (missing ultrasound, surgical, or pathology descriptions) and cases in which intestinal lesion resection was not feasible due to intraoperative findings. Surgeries were conducted within a multidisciplinary surgical model, where the gynecologic endometriosis specialist led the deep pelvic dissection and the colorectal surgeon performed the intestinal resections and anastomoses. In the same way the gynecologic endometriosis specialist was attended to excision of deep infiltrating endometriosis, cystectomy for endometriomas, hysterectomy, unilateral or bilateral oophorectomy and ureterolysis and pelvic space dissection. A consecutive nonprobabilistic sampling strategy was applied, yielding a final cohort of 36 patients. Clinical records were reviewed to assess reported symptoms and available imaging studies at admission. Surgical descriptions and pathology reports were analyzed, and postoperative complications (POCs) were identified through follow-up visits recorded by the endoscopic gynecology service until the first postoperative control (Table 2). Table 2. | Variable | n (%) | |---|---| | Surgical time (minutes) | 240 (IQR 180–240) | | Procedures performed by colorectal surgery | | | Discoid resection | 10 (27.8) | | Shaving | 11 (30.6) | | Segmental resection | 7 (19.4) | | Appendectomy | 4 (11.1) | | Combined procedures | 8 (22.2) | | Shaving + segmental resection | 5 (62.5) | | Shaving + discoid resection | 2 (25.0) | | Discoid + segmental resection | 1 (12.5) | | Localization of endometriosis lesions | | | Rectum | 33 (91.7) | | Sigmoid colon | 11 (30.6) | | Appendix | 3 (8.3) | | Ileum | 1 (2.8) | | Cecum | 1 (2.8) | | Lesion diameter | | | ≥3 cm | 17 (47.2) | | <3 cm | 19 (52.8) | | Number of lesions | | | Single | 25 (69.4) | | Two | 7 (19.4) | | Three | 4 (11.1) | | Fertility-preserving surgery (in nulliparous women) | | | Yes | 20 (80.0) | | No | 5 (20.0) | | Intraoperative complications | | | None | 31 (86.1) | | Intestinal injury | 3 (8.3) | | Urinary injury | 2 (5.6) | | Postoperative complications | | | Surgical site infection | 2 (6.6) | | Urinary tract infection | 1 (3.8) | | Fistula | 1 (2.8) | | Hospital stay (days) | 3 (IQR 2–5) | | Postoperative follow-up (days) | 18 (IQR 14–19) | Data collection was performed using a structured form designed in Google Drive spreadsheets, with validation rules applied to ensure a single response per variable. Patients’ identities were anonymized using consecutive numerical codes. Descriptive analyses were conducted: qualitative variables were expressed as absolute and relative frequencies, and quantitative variables were summarized using measures of central tendency (mean or median) and dispersion (standard deviation [SD] or interquartile range [IQR]), depending on distribution. Data normality was assessed using the Shapiro–Wilk test. Statistical analysis was performed with Stata 18 software. The study was conducted in compliance with Resolution 8430 of 1993, which establishes scientific, technical, and administrative standards for health research in Colombia, adhering to the ethical principles outlined in Articles 5 and 6. According to Article 11, this research was classified as risk-free. Confidentiality of personal and identifying data was ensured, in compliance with Law 1581 of 2012 on personal data protection. The study was approved by the Bioethics Committee of San José Hospital, Bogotá Surgery Society. It is a quaternary-care referral center that treats highly complex cases and therefore maintains a broad range of advanced medical and surgical specialties. PillCam was not utilized because capsule endoscopy is not recommended for the evaluation of bowel endometriosis, which predominantly affects the serosa and muscularis, not the mucosa. Thus, no comparison was made.

A total of 157 patients underwent intestinal endometriosis resection by minimally invasive approach, primarily laparoscopic surgery by the colorectal surgery service and gynecology endoscopy group during the study period. Of these, 36 patients met the inclusion criteria and were included in the analysis (Table 3). Table 3. | Anatomic Site | Shaving n (%) | Discoid n (%) | Segmental n (%) | Combined n (%) | |---|---|---|---|---| | Rectum | 10 (30.3) | 10 (30.3) | 6 (18.2) | 7 (21.2) | | Sigmoid colon | 3 (27.3) | 1 (9.1) | 4 (36.4) | 3 (27.3) | | Cecum | 0 | 0 | 0 | 1 (100) | | Ileum | 0 | 0 | 0 | 1 (100) | The mean patient age was 36 years (SD 5.4; range 23–47). Most patients (66.7%, n = 24) had no reported comorbidities, while 27.8% (n = 10) presented with conditions such as migraine or gastritis; diabetes mellitus and hypertension were reported in one patient each (2.8%). Regarding reproductive history, 69.4% (n = 25) were nulliparous, and 30.6% (n = 11) had previous deliveries. Pharmacological treatment was recorded in 47.2% (n = 17), predominantly oral progestins (88.2%, n = 15), with the remainder receiving GnRH analogues (11.8%, n = 2) (Table 4). Table 4. | Type of Surgery | Lesion Diameter, cm (Median, IQR) | |---|---| | Shaving | 1.5 (1–2) | | Discoid resection | 2 (1–2) | | Segmental resection | 3 (3–3.5) | | Shaving + discoid resection | 2.5 (1–4) | | Shaving + segmental resection | 3 (3–8) | | Discoid + segmental resection | 3 (3–3) | The most frequent symptoms were pain (61.1%, n = 22), dyspareunia (50%, n = 18), dysmenorrhea (47.2%, n = 17), and abnormal uterine bleeding (41.7%, n = 15). Positive findings on physical examination were documented in 16.7% (n = 6), including rectovaginal nodule palpation (33.3%, n = 2) and myofascial tenderness or trigger points. Imaging abnormalities were observed in 69.4% (n = 25), most commonly on MRI (56%, n = 14), with the remainder identified by endometriosis-mapping ultrasound. With regard to surgical management, 66.7% (n = 24) underwent fertility-preserving procedures in conjunction with colorectal surgery, while 33.3% (n = 12) underwent surgery without fertility preservation. The procedures performed included shaving (30.6%, n = 11), discoid resection (27.8%, n = 10), segmental resection (19.4%, n = 7), appendectomy (11.1%, n = 4), and combined techniques (22.2%, n = 8). Lesions were most frequently located in the rectum (91.7%, n = 33), followed by the sigmoid colon (30.6%, n = 11), appendix (8.3%, n = 3), ileum (2.8%, n = 1), and cecum (2.8%, n = 1). Beyond gastrointestinal involvement, no additional anatomical manifestations of endometriosis were detected, including thoracic/pulmonary, cerebral, external genital, or cervical disease. Lesion diameter was <3 cm in 52.8% (n = 19) and ≥3 cm in 47.2% (n = 17). Multiple lesions were identified in 30.5% (n = 11). Among patients with a single lesion, shaving (27.8%, n = 10) and discoid resection (22.2%, n = 8) were the most frequent approaches. In those with ≥2 lesions, shaving plus segmental resection was performed in 3 patients, and segmental resection alone in 2 patients. By anatomic site, rectal involvement was managed with shaving (30.3%, n = 10), discoid resection (30.3%, n = 10), segmental resection (18.2%, n = 6), or combined procedures (21.2%, n = 7). In the sigmoid colon, segmental resection (36.4%, n = 4) and shaving (27.3%, n = 3) were most frequent. Involvement of the cecum and ileum was primarily managed with shaving plus segmental resection. Median lesion diameter by procedure type was 1.5 cm (IQR 1–2) for shaving, 2 cm (IQR 1–2) for discoid resection, and 3 cm (IQR 3–3.5) for segmental resection. Patients with lesions ≥3 cm most frequently reported dyspareunia (52.9%, n = 9), abnormal uterine bleeding (58.8%, n = 10), pain (58.8%, n = 10), and dysmenorrhea (52.9%, n = 9). All pathology reports confirmed benign disease. Intraoperative complications occurred in 13.9% (n = 5), including intestinal injury (8.3%, n = 3) and urinary tract injury (5.6%, n = 2). POCs were also reported in 13.9% (n = 5), consisting of surgical site infection (5.6%, n = 2), urinary tract infection (2.8%, n = 1), and fistula (2.8%, n = 1). The mean operative time was 240 minutes (range 180–300), and the median hospital stay was 3 days (range 1–10). Median postoperative follow-up was 18 days (IQR 14–19).

This study highlights key aspects of surgical intervention and multidisciplinary management of intestinal endometriosis at a high-complexity referral center. Optimal care requires teams composed of specialists with not only advanced training but also extensive clinical experience and a detailed understanding of pelvic anatomy to ensure successful surgical outcomes.7,8 The gynecology team played a central role in deep pelvic dissection, Excision of gynecologic endometriotic implants (ovaries, uterosacral ligaments, bladder, rectovaginal septum), preserving reproductive structures when applicable, preoperative evaluation and indication for surgery. Preoperative planning plays a fundamental role in reducing morbidity. Imaging studies are critical in this process. In our cohort, imaging sensitivity was 69.4%, which is lower than the sensitivity reported in the literature—up to 88% for MRI and 98% for ultrasound. Notably, most patients underwent MRI rather than endometriosis-mapping ultrasound, resulting in higher costs for the healthcare system. It is important to emphasize that endometriosis-mapping ultrasound is not yet included in Colombia’s mandatory health plan, despite its proven diagnostic value.9 Colonoscopy was performed in patients with intestinal symptoms, rectal bleeding, or suspected significant stenosis, complementing MRI findings. Fertility-preserving surgery was performed in 66.7% of patients, consistent with current literature that underscores the importance of reproductive preservation in women of childbearing age affected by this condition. Vercellini et al emphasized that, given its heterogeneous presentation and extensive anatomical involvement, endometriosis can compromise fertility, making conservative approaches a priority, especially in nulliparous women.10 Nonetheless, 33.3% of patients in our series underwent nonfertility-preserving procedures. This reflects not only patient reproductive choices but also a risk–benefit assessment by endoscopic gynecologists and colorectal surgeons. Roman et al support the view that surgical decisions should be individualized, taking into account disease extent, symptoms, reproductive desire, and correlation with imaging findings.8,11,12 Management of patients with multiple endometriotic lesions of varying sizes (52.8% <3 cm vs 47.2% ≥3 cm) further illustrates the technical complexity of these procedures. The high frequency of rectal involvement (91.7%) suggests both a predilection of endometriosis for this site and a possible selection bias toward patients with more severe symptoms referred to tertiary centers.13 Patients with intestinal endometriosis exhibited variable symptom patterns depending on lesion diameter. Among those with lesions <3 cm, the most frequent symptoms were pelvic pain (63.2%), dyspareunia (42.1%), and infertility (42.1%). In patients with lesions ≥3 cm, the most prevalent symptoms were abnormal uterine bleeding (58.8%), pelvic pain (58.8%), and dyspareunia (52.9%). Overall, larger lesions (≥3 cm) were more commonly associated with abnormal uterine bleeding, whereas smaller lesions (<3 cm) showed a slightly higher frequency of infertility complaints.13 Intraoperative and POCs rates (13.9% each) were consistent with previously reported data.5,14 While acceptable given the complexity of the procedures, these outcomes underscore the need for meticulous preoperative planning and careful postoperative management. Every complication should be carefully evaluated to guide improvements in surgical strategies. Overall, this study reinforces the need for multidisciplinary management by expert gynecological endoscopists working in close collaboration with colorectal surgeons. This approach minimizes surgical morbidity while maximizing the likelihood of fertility preservation when clinically feasible.15 Long-term outcomes such as recurrence rates and functional outcomes (e.g., bowel function, fertility) are not addressed.

This study underscores the importance of an individualized approach to the surgical management of intestinal endometriosis, with an emphasis on fertility preservation whenever clinically feasible. Our findings are consistent with the existing literature, supporting the role of multidisciplinary teams in optimizing outcomes. The multidisciplinary approach enabled coordinated preoperative planning (gynecology, colorectal surgery, radiology), risk stratification, selection of surgical approach, intraoperative decision-making, management of complications. Future research should focus on the long-term effects of different surgical techniques, particularly their impact on quality of life, symptom control, and reproductive outcomes. In addition, the development of more detailed clinical guidelines is recommended to guide surgical decision-making and help manage patient expectations regarding fertility and symptom relief. Footnotes Conflict of interests: none. Disclosure: none. Funding sources: none. This work received Institutional Review Board approval: bioethics committee of the San Jose Hospital, Bogotá, Colombia. Contributor Information Henry Octavio Rodríguez, Gynecological Endoscopic Surgery, Obstetrics and Gynecology Department, Fundación Universitaria de Ciencias de la Salud, Bogotá, Colombia. (Drs. Rodríguez, Andrade Rodriguez, and Gomez). Javier Alejandro Garcia Salazar, Obstetrics and Gynecology, Fundación Universitaria de Ciencias de la Salud, Bogotá, Colombia. (Dr. Garcia Salazar). Diana Carolina Andrade Rodriguez, Gynecological Endoscopic Surgery, Obstetrics and Gynecology Department, Fundación Universitaria de Ciencias de la Salud, Bogotá, Colombia. (Drs. Rodríguez, Andrade Rodriguez, and Gomez). Milena Gomez, Gynecological Endoscopic Surgery, Obstetrics and Gynecology Department, Fundación Universitaria de Ciencias de la Salud, Bogotá, Colombia. (Drs. Rodríguez, Andrade Rodriguez, and Gomez). María Camila Restrepo, Research Vice Rectory, Fundación Universitaria de Ciencias de la Salud, Bogotá, Colombia. (Dr. Restrepo).

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