"The Sword in the Stone": radical excision of deep infiltrating endometriosis with bowel shaving-a single-centre experience on 703 consecutive patients

Background Laparoscopic segmental bowel resection, disc excision and rectal shaving are described as surgical options for the treatment of bowel endometriosis, but the gold standard has not yet established. The aim of the study is to investigate the efficacy of the laparoscopic bowel shaving technique in terms of pain symptomatology and to analyse early and late postoperative complications.

Retrospective cohort study of a series of 703 consecutive patients treated between January 2014 and December 2019 in a tertiary care referral centre. All patients underwent laparoscopic bowel shaving with concomitant radical excision of DIE.

Bilateral posterolateral parametrectomy and ureterolysis were performed, respectively, in 314 (44.7%) and 318 cases (45.2%). A radical hysterectomy was performed in 107 cases (82.9%). Postoperative complications were infrequent: 17 patients required a reoperation (2.4%) and in this subgroup we registered 2 rectovaginal fistulas (0.3%), 4 patients received blood transfusion (0.6%), 12 patients (1.7%) experienced postoperative fever, 6 patients experienced impaired bladder voiding (0.9%) after 6 months. Median follow-up was 14 months. The study reported good clinical and surgical results, with a regression of symptoms (p < 0.0001) and an overall rate of recurrence of 6.5%. Clinical and instrumental criteria of bowel endometriosis relapse were exclusively detected in 5 patients (0.8%). Eleven patients (1.7%) with relapsed endometriosis were reoperated.

Bowel shaving is a feasible and valuable surgical procedure. It is only the last step of a complex surgery which is aimed to minimize the residual quote of infiltrating nodule and requires a multidisciplinary team to achieve optimal treatment preoperatively, intraoperatively and postoperatively. Similar content being viewed by others Change history 09 October 2021 This article was updated to correct the author listing, where given and family names were reversed. 12 October 2021 A Correction to this paper has been published: https://doi.org/10.1007/s00464-021-08762-x

Giudice LC, Kao LC (2004) Endometriosis. The Lancet 364(9447):1789–1799. https://doi.org/10.1016/S0140-6736(04)17403-5 Nisolle M, Donnez J (1997) Peritoneal endometriosis, ovarian endometriosis, and adenomyotic nodules of the rectovaginal septum are three different entities. Fertil Steril 68(4):585–596. https://doi.org/10.1016/S0015-0282(97)00191-X Chapron C, Chopin N, Borghese B et al (2006) Deeply infiltrating endometriosis: pathogenetic implications of the anatomical distribution. Hum Reprod 21(7):1839–1845. https://doi.org/10.1093/humrep/del079 Remorgida V, Ferrero S, Fulcheri E, Ragni N, Martin DC (2007) Bowel endometriosis: presentation, diagnosis, and treatment. Obstet Gynecol Surv 62(7):461–470. https://doi.org/10.1097/01.ogx.0000268688.55653.5c Vercellini P, Buggio L, Berlanda N, Barbara G, Somigliana E, Bosari S (2016) Estrogen-progestins and progestins for the management of endometriosis. Fertil Steril 106(7):1552-1571.e2. https://doi.org/10.1016/j.fertnstert.2016.10.022 Leone Roberti Maggiore U, Ferrero S, Candiani M, Somigliana E, Viganò P, Vercellini P (2017) Bladder endometriosis: a systematic review of pathogenesis, diagnosis, treatment, impact on fertility, and risk of malignant transformation. Eur Urol 71(5):790–807. https://doi.org/10.1016/j.eururo.2016.12.015 Donnez J, Squifflet J (2010) Complications, pregnancy and recurrence in a prospective series of 500 patients operated on by the shaving technique for deep rectovaginal endometriotic nodules. Hum Reprod 25(8):1949–1958. https://doi.org/10.1093/humrep/deq135 Roman H, Bubenheim M, Huet E et al (2018) Conservative surgery versus colorectal resection in deep endometriosis infiltrating the rectum: a randomized trial. Hum Reprod 33(1):47–57. https://doi.org/10.1093/humrep/dex336 American Society for Reproductive (1997) Revised American Society for Reproductive Medicine classification of endometriosis: 1996. Fertil Steril 67(5):817–821. https://doi.org/10.1016/S0015-0282(97)81391-X Wewers ME, Lowe NK (1990) A critical review of visual analogue scales in the measurement of clinical phenomena. Res Nurs Health 13(4):227–236. https://doi.org/10.1002/nur.4770130405 Ceccaroni M, Clarizia R, Bruni F et al (2012) Nerve-sparing laparoscopic eradication of deep endometriosis with segmental rectal and parametrial resection: the Negrar method. A single-center, prospective, clinical trial. Surg Endosc 26(7):2029–2045. https://doi.org/10.1007/s00464-012-2153-3 Ceccaroni M, Clarizia R, Roviglione G, Ruffo G (2013) Neuro-anatomy of the posterior parametrium and surgical considerations for a nerve-sparing approach in radical pelvic surgery. Surg Endosc 27(11):4386–4394. https://doi.org/10.1007/s00464-013-3043-z Ceccaroni M, Clarizia R, Roviglione G (2020) Nerve-sparing surgery for deep infiltrating endometriosis: laparoscopic eradication of deep infiltrating endometriosis with rectal and parametrial resection according to the Negrar method. J Minim Invasive Gynecol 27(2):263–264. https://doi.org/10.1016/j.jmig.2019.09.002 Nisolle M, Brichant G, Tebache L (2019) Choosing the right technique for deep endometriosis. Best Pract Res Clin Obstet Gynaecol 59:56–65. https://doi.org/10.1016/j.bpobgyn.2019.01.010 Dindo D, Demartines N, Clavien P-A (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213. https://doi.org/10.1097/01.sla.0000133083.54934.ae Ferrero S, Barra F, Leone Roberti Maggiore U (2018) Current and emerging therapeutics for the management of endometriosis. Drugs 78(10):995–1012. https://doi.org/10.1007/s40265-018-0928-0 Anaf V (2000) Relationship between endometriotic foci and nerves in rectovaginal endometriotic nodules. Hum Reprod 15(8):1744–1750. https://doi.org/10.1093/humrep/15.8.1744 Chapron C, Santulli P, de Ziegler D et al (2012) Ovarian endometrioma: severe pelvic pain is associated with deeply infiltrating endometriosis. Hum Reprod 27(3):702–711. https://doi.org/10.1093/humrep/der462 Ferrero S, Marcello C (2020) Clinical management of bowel endometriosis. Springer, Cham Vercellini P, Giudice LC, Evers JLH, Abrao MS (2015) Reducing low-value care in endometriosis between limited evidence and unresolved issues: a proposal. Hum Reprod 30(9):1996–2004. https://doi.org/10.1093/humrep/dev157 Ceccaroni M, Pontrelli G, Scioscia M, Ruffo G, Bruni F, Minelli L (2010) Nerve-sparing laparoscopic radical excision of deep endometriosis with rectal and parametrial resection. J Minim Invasive Gynecol 17(1):14–15. https://doi.org/10.1016/j.jmig.2009.03.018 Abrao MS, Petraglia F, Falcone T, Keckstein J, Osuga Y, Chapron C (2015) Deep endometriosis infiltrating the recto-sigmoid: critical factors to consider before management. Hum Reprod Update 21(3):329–339. https://doi.org/10.1093/humupd/dmv003 Nezhat C, Li A, Falik R et al (2018) Bowel endometriosis: diagnosis and management. Am J Obstet Gynecol 218(6):549–562. https://doi.org/10.1016/j.ajog.2017.09.023 Kho RM, Andres MP, Borrelli GM, Neto JS, Zanluchi A, Abrão MS (2018) Surgical treatment of different types of endometriosis: comparison of major society guidelines and preferred clinical algorithms. Best Pract Res Clin Obstet Gynaecol 51:102–110. https://doi.org/10.1016/j.bpobgyn.2018.01.020 Donnez O, Roman H (2017) Choosing the right surgical technique for deep endometriosis: shaving, disc excision, or bowel resection? Fertil Steril 108(6):931–942. https://doi.org/10.1016/j.fertnstert.2017.09.006 Roman H, Darwish B, Bridoux V et al (2017) Functional outcomes after disc excision in deep endometriosis of the rectum using transanal staplers: a series of 111 consecutive patients. Fertil Steril 107(4):977-986.e2. https://doi.org/10.1016/j.fertnstert.2016.12.030 Bazot M, Daraï E (2017) Diagnosis of deep endometriosis: clinical examination, ultrasonography, magnetic resonance imaging, and other techniques. Fertil Steril 108(6):886–894. https://doi.org/10.1016/j.fertnstert.2017.10.026 Nisenblat V, Bossuyt PM, Farquhar C, Johnson N, Hull ML (2016) Imaging modalities for the non-invasive diagnosis of endometriosis. Cochrane Gynaecology and Fertility Group, ed. Cochrane Database Syst Rev. https://doi.org/10.1002/14651858.CD009591.pub2 Hudelist G, English J, Thomas AE, Tinelli A, Singer CF, Keckstein J (2011) Diagnostic accuracy of transvaginal ultrasound for non-invasive diagnosis of bowel endometriosis: systematic review and meta-analysis: transvaginal ultrasound in the diagnosis of bowel endometriosis. Ultrasound Obstet Gynecol 37(3):257–263. https://doi.org/10.1002/uog.8858 Piketty M, Chopin N, Dousset B et al (2008) Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod 24(3):602–607. https://doi.org/10.1093/humrep/den405 Guerriero S, Condous G, van den Bosch T et al (2016) Systematic approach to sonographic evaluation of the pelvis in women with suspected endometriosis, including terms, definitions and measurements: a consensus opinion from the International Deep Endometriosis Analysis (IDEA) group. Ultrasound Obstet Gynecol 48(3):318–332. https://doi.org/10.1002/uog.15955 Indrielle-Kelly T, Frühauf F, Fanta M et al (2020) Diagnostic accuracy of ultrasound and MRI in the mapping of deep pelvic endometriosis using the international deep endometriosis analysis (IDEA) consensus. Biomed Res Int 2020:1–11. https://doi.org/10.1155/2020/3583989 Ribeiro HSAA, Ribeiro PA, Rossini L, Rodrigues FC, Donadio N, Aoki T (2008) Double-contrast barium enema and transrectal endoscopic ultrasonography in the diagnosis of intestinal deeply infiltrating endometriosis. J Minim Invasive Gynecol 15(3):315–320. https://doi.org/10.1016/j.jmig.2008.02.001 Bergamini V, Ghezzi F, Scarperi S, Raffaelli R, Cromi A, Franchi M (2010) Preoperative assessment of intestinal endometriosis: a comparison of Transvaginal Sonography with Water-Contrast in the Rectum, Transrectal Sonography, and Barium Enema. Abdom Imaging 35(6):732–736. https://doi.org/10.1007/s00261-010-9610-z Faccioli N, Foti G, Manfredi R et al (2010) Evaluation of colonic involvement in endometriosis: double-contrast barium enema vs. magnetic resonance imaging. Abdom Imaging 35(4):414–421. https://doi.org/10.1007/s00261-009-9544-5 Jiang J, Liu Y, Wang K, Wu X, Tang Y (2017) Rectal water contrast transvaginal ultrasound versus double-contrast barium enema in the diagnosis of bowel endometriosis. BMJ Open 7(9):e017216. https://doi.org/10.1136/bmjopen-2017-017216 Vigano P, Candiani M, Monno A, Giacomini E, Vercellini P, Somigliana E (2018) Time to redefine endometriosis including its pro-fibrotic nature. Hum Reprod 33(3):347–352. https://doi.org/10.1093/humrep/dex354 De Cicco C, Corona R, Schonman R, Mailova K, Ussia A, Koninckx P (2011) Bowel resection for deep endometriosis: a systematic review: systematic review of bowel resection for deep endometriosis. BJOG Int J Obstet Gynaecol 118(3):285–291. https://doi.org/10.1111/j.1471-0528.2010.02744.x Meuleman C, Tomassetti C, D’Hoore A et al (2011) Surgical treatment of deeply infiltrating endometriosis with colorectal involvement. Hum Reprod Update 17(3):311–326. https://doi.org/10.1093/humupd/dmq057 Ferrero S, Stabilini C, Barra F, Clarizia R, Roviglione G, Ceccaroni M (2020) Bowel resection for intestinal endometriosis. Best Pract Res Clin Obstet Gynaecol. https://doi.org/10.1016/j.bpobgyn.2020.05.008 Roman H, Moatassim-Drissa S, Marty N et al (2016) Rectal shaving for deep endometriosis infiltrating the rectum: a 5-year continuous retrospective series. Fertil Steril 106(6):1438-1445.e2. https://doi.org/10.1016/j.fertnstert.2016.07.1097 Slack A, Child T, Lindsey I et al (2007) Urological and colorectal complications following surgery for rectovaginal endometriosis. BJOG Int J Obstet Gynaecol 114(10):1278–1282. https://doi.org/10.1111/j.1471-0528.2007.01477.x Roman H, Vassilieff M, Gourcerol G et al (2011) Surgical management of deep infiltrating endometriosis of the rectum: pleading for a symptom-guided approach. Hum Reprod 26(2):274–281. https://doi.org/10.1093/humrep/deq332 Roman H, Bourdel N (2009) Contre la résection segmentaire systématique dans les endométrioses colorectales. Ne remplaçons pas les douleurs par des symptômes digestifs désagréables! Gynécol Obstét Fertil 37(4):358–362. https://doi.org/10.1016/j.gyobfe.2009.03.002 Matsuzaki S, Houlle C, Botchorishvili R, Pouly J-L, Mage G, Canis M (2009) Excision of the posterior vaginal fornix is necessary to ensure complete resection of rectovaginal endometriotic nodules of more than 2 cm in size. Fertil Steril 91(4):1314–1315. https://doi.org/10.1016/j.fertnstert.2008.01.101 Vassilieff M, Suaud O, Collet-Savoye C et al (2011) Coloscanner à l’air avec coloscopie virtuelle : arguments dans le choix du traitement chirurgical des endométrioses colorectales. Gynecol Obstet Fertil 39(6):339–345. https://doi.org/10.1016/j.gyobfe.2011.04.004 Ceccaroni M, Bounous VE, Clarizia R, Mautone D, Mabrouk M (2019) Recurrent endometriosis: a battle against an unknown enemy. Eur J Contracept Reprod Health Care 24(6):464–474. https://doi.org/10.1080/13625187.2019.1662391 Roman H, Tuech J-J, Huet E et al (2019) Excision versus colorectal resection in deep endometriosis infiltrating the rectum: 5-year follow-up of patients enrolled in a randomized controlled trial. Hum Reprod 34(12):2362–2371. https://doi.org/10.1093/humrep/dez217 Roman H, Milles M, Vassilieff M et al (2016) Long-term functional outcomes following colorectal resection versus shaving for rectal endometriosis. Am J Obstet Gynecol 215(6):762.e1-762.e9. https://doi.org/10.1016/j.ajog.2016.06.055 Roman H, Chanavaz-Lacheray I, Ballester M et al (2018) High postoperative fertility rate following surgical management of colorectal endometriosis. Hum Reprod. https://doi.org/10.1093/humrep/dey146 Stepniewska A, Pomini P, Bruni F et al (2009) Laparoscopic treatment of bowel endometriosis in infertile women. Hum Reprod 24(7):1619–1625. https://doi.org/10.1093/humrep/dep083 Wolthuis AM (2014) Bowel endometriosis: colorectal surgeon’s perspective in a multidisciplinary surgical team. WJG 20(42):15616. https://doi.org/10.3748/wjg.v20.i42.15616 Vercellini P, Viganò P, Frattaruolo MP, Borghi A, Somigliana E (2018) Bowel surgery as a fertility-enhancing procedure in patients with colorectal endometriosis: methodological, pathogenic and ethical issues. Hum Reprod 33(7):1205–1211. https://doi.org/10.1093/humrep/dey104 Author information Authors and Affiliations Corresponding author Ethics declarations Disclosures Drs. Ceccaroni, Clarizia, Mussi, Stepniewska, De Mitri, Ceccarello, Ruffo, Bruni, Rettore and Surico have no conflicts of interest or financial ties to disclose. Additional information Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Bowel shaving is effective as the last step of a complex surgery, especially in the context of a “frozen pelvis” where the real extension of infiltration might be over-rated and halo fibrosis is represented around the infiltrating endometriotic nodule. Rights and permissions About this article Cite this article Ceccaroni, M., Clarizia, R., Mussi, E.A. et al. “The Sword in the Stone”: radical excision of deep infiltrating endometriosis with bowel shaving—a single-centre experience on 703 consecutive patients. Surg Endosc 36, 3418–3431 (2022). https://doi.org/10.1007/s00464-021-08663-z Received: Accepted: Published: Version of record: Issue date: DOI: https://doi.org/10.1007/s00464-021-08663-z