Low anterior resection syndrome in patients undergoing bowel segmental resection for rectosigmoid endometriosis: A retrospective long-term follow-up study

Aim The aim of this work was to evaluate the prevalence of low anterior resection syndrome (LARS) and its long-term evolution following colorectal segmental resection for deep infiltrating endometriosis (DIE) and identify any associated risk factors.

A retrospective observational study was conducted on 124 patients who underwent bowel segmental resection for DIE between 2008 and 2023 at a single tertiary centre. Postoperative rectal function was assessed using the LARS score, and logistic regression analysis was performed to identify independent risk factors for minor/major LARS.

LARS was observed in 5.6% of patients, with 1.6% presenting minor LARS and 4.0% major LARS. Logistic regression identified parametrial resection (odds ratio = 6.2, p = 0.04) as an independent risk factor for minor/major LARS. LARS severity remained stable in all cases over a mean follow-up of 6.9 ± 3.7 years.

As for previously reported studies, our data highlight a relatively low prevalence of LARS following bowel DIE surgery with stable severity over time. Identifying parametrial resection as an independent risk factor underlines the critical need to recognize this specific aspect of endometriosis surgery, ensuring that it is thoroughly addressed during surgical planning and integrated into patient counselling for proper outcomes and expectations. Prospective studies are needed to confirm these findings, explore additional risk factors and better understand the factors influencing long-term outcomes in this patient population. CONFLICT OF INTEREST STATEMENT The authors declare no conflicts of interest. DATA AVAILABILITY STATEMENT The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

- 1Keane C, Wells C, O'Grady G, Bissett IP. Defining low anterior resection syndrome: a systematic review of the literature. Colorectal Dis. 2017; 19(8): 713–722. https://doi.org/10.1111/codi.13767 - 2Xu LL, Cheng TC, Xiang NJ, Chen P, Jiang ZW, Liu XX. Risk factors for severe low anterior resection syndrome in patients with rectal cancer undergoing sphincter-preserving resection: a systematic review and meta-analysis. Oncol Lett. 2024; 27(1): 30. https://doi.org/10.3892/ol.2023.14163 - 3Nguyen TH, Chokshi RV. Low anterior resection syndrome. Curr Gastroenterol Rep. 2020; 22(10): 48. https://doi.org/10.1007/s11894-020-00785-z - 4Zhang R, Luo W, Qiu Y, Chen F, Luo D, Yang Y, et al. Clinical management of low anterior resection syndrome: review of the current diagnosis and treatment. Cancers (Basel). 2023; 15(20):5011. https://doi.org/10.3390/cancers15205011 - 5Emile SH, Garoufalia Z, Barsom S, Horesh N, Gefen R, Zhou P, et al. Systematic review and meta-analysis of randomized clinical trials on the treatment of low anterior resection syndrome. Surgery. 2023; 173(6): 1352–1358. https://doi.org/10.1016/j.surg.2023.02.010 - 6Giudice LC, Kao LC. Endometriosis. Lancet. 2004; 364(9447): 1789–1799. https://doi.org/10.1016/s0140-6736(04)17403-5 - 7Sampson JA. Peritoneal endometriosis due to premenstrual dissemination of endometrial tissue into the peritoneal cavity. Am J Obstet Gynecol. 1927; 14: 422–469. - 8Berkley KJ, Rapkin AJ, Papka RE. The pains of endometriosis. Science. 2005; 308(5728): 1587–1589. https://doi.org/10.1126/science.1111445 - 9de Ziegler D, Borghese B, Chapron C. Endometriosis and infertility: pathophysiology and management. Lancet. 2010; 376(9742): 730–738. https://doi.org/10.1016/s0140-6736(10)60490-4 - 10Chapron C, Chopin N, Borghese B, Foulot H, Dousset B, Vacher-Lavenu MC, et al. Deeply infiltrating endometriosis: Pathogenetic implications of the anatomical distribution. Hum Reprod. 2006; 21(7): 1839–1845. https://doi.org/10.1093/humrep/del079 - 11Scioscia M, Bruni F, Ceccaroni M, Steinkasserer M, Stepniewska A, Minelli L. Distribution of endometriotic lesions in endometriosis stage IV supports the menstrual reflux theory and requires specific preoperative assessment and therapy. Acta Obstet Gynecol Scand. 2011; 90(2): 136–139. https://doi.org/10.1111/j.1600-0412.2010.01008.x - 12Donnez O, Roman H. Choosing the right surgical technique for deep endometriosis: shaving, disc excision, or bowel resection? Fertil Steril. 2017; 108(6): 931–942. https://doi.org/10.1016/j.fertnstert.2017.09.006 - 13Becker CM, Bokor A, Heikinheimo O, Horne A, Jansen F, Kiesel L, et al. ESHRE guideline: endometriosis. Hum Reprod Open. 2022; 2022(2):hoac009. doi:10.1093/hropen/hoac009 - 14Farella M, Tuech JJ, Bridoux V, Coget J, Chati R, Resch B, et al. Surgical management by disk excision or rectal resection of low rectal endometriosis and risk of low anterior resection syndrome: a retrospective comparative study. J Minim Invasive Gynecol. 2021; 28(12): 2013–2024. https://doi.org/10.1016/j.jmig.2021.05.007 - 15Bokor A, Hudelist G, Dobó N, Dauser B, Farella M, Brubel R, et al. Low anterior resection syndrome following different surgical approaches for low rectal endometriosis: a retrospective multicenter study. Acta Obstet Gynecol Scand. 2021; 100(5): 860–867. https://doi.org/10.1111/aogs.14046 - 16Hudelist G, Aas-Eng MK, Birsan T, Berger F, Sevelda U, Kirchner L, et al. Pain and fertility outcomes of nerve-sparing, full-thickness disk or segmental bowel resection for deep infiltrating endometriosis-a prospective cohort study. Acta Obstet Gynecol Scand. 2018; 97(12): 1438–1446. https://doi.org/10.1111/aogs.13436 - 17O'Brien L, Morarasu S, Morarasu BC, Neary PC, Musina AM, Velenciuc N, et al. Conservative surgery versus colorectal resection for endometriosis with rectal involvement: a systematic review and meta-analysis of surgical and long-term outcomes. Int J Colorectal Dis. 2023; 38(1): 55. https://doi.org/10.1007/s00384-023-04352-6 - 18Abrão MS, Andres MP, Barbosa RN, Bassi MA, Kho RM. Optimizing perioperative outcomes with selective bowel resection following an algorithm based on preoperative imaging for bowel endometriosis. J Minim Invasive Gynecol. 2020; 27(4): 883–891. https://doi.org/10.1016/j.jmig.2019.06.010 - 19Malzoni M, Di Giovanni A, Exacoustos C, Lannino G, Capece R, Perone C, et al. Feasibility and safety of laparoscopic-assisted bowel segmental resection for deep infiltrating endometriosis: a retrospective cohort study with description of technique. J Minim Invasive Gynecol. 2016; 23(4): 512–525. https://doi.org/10.1016/j.jmig.2015.09.024 - 20Minelli L, Fanfani F, Fagotti A, Ruffo G, Ceccaroni M, Mereu L, et al. Laparoscopic colorectal resection for bowel endometriosis: feasibility, complications, and clinical outcome. Arch Surg. 2009; 144(3): 234–239. https://doi.org/10.1001/archsurg.2008.555 - 21Emmertsen KJ, Laurberg S. Low anterior resection syndrome score: development and validation of a symptom-based scoring system for bowel dysfunction after low anterior resection for rectal cancer. Ann Surg. 2012; 255(5): 922–928. https://doi.org/10.1097/SLA.0b013e31824f1c21 - 22Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004; 240(2): 205–213. https://doi.org/10.1097/01.sla.0000133083.54934.ae - 23Hudelist G, Pashkunova D, Darici E, Rath A, Mitrowitz J, Dauser B, et al. Pain, gastrointestinal function and fertility outcomes of modified nerve-vessel sparing segmental and full thickness discoid resection for deep colorectal endometriosis – a prospective cohort study. Acta Obstet Gynecol Scand. 2023; 102(10): 1347–1358. https://doi.org/10.1111/aogs.14676 - 24Scheepers WFW, Maas JWM, van de Kar MMA. Bowel function and quality of life following surgery for deep endometriosis. J Psychosom Obstet Gynaecol. 2022; 43(3): 334–339. https://doi.org/10.1080/0167482x.2021.1952570 - 25Barra F, Ferrero S, Zorzi C, Evangelisti G, Perrone U, Valente I, et al. ‘From the tip to the deep of the iceberg’: parametrial involvement in endometriosis. Best Pract Res Clin Obstet Gynaecol. 2024; 94:102493. https://doi.org/10.1016/j.bpobgyn.2024.102493 - 26Ceccaroni M, Clarizia R, Roviglione G, Ruffo G. Neuro-anatomy of the posterior parametrium and surgical considerations for a nerve-sparing approach in radical pelvic surgery. Surg Endosc. 2013; 27(11): 4386–4394. https://doi.org/10.1007/s00464-013-3043-z - 27Ng A, Yang P, Wong S, Vancaillie T, Krishnan S. Medium to long-term gastrointestinal outcomes following disc resection of the rectum for treatment of endometriosis using a validated scoring questionnaire. Aust N Z J Obstet Gynaecol. 2016; 56(4): 408–413. https://doi.org/10.1111/ajo.12476 - 28Klapczynski C, Derbal S, Braund S, Coget J, Forestier D, Seyer-Hansen M, et al. Evaluation of functional outcomes after disc excision of deep endometriosis involving low and mid rectum using standardized questionnaires: a series of 80 patients. Colorectal Dis. 2021; 23(4): 944–954. https://doi.org/10.1111/codi.15485 - 29Pieniowski EHA, Palmer GJ, Juul T, Lagergren P, Johar A, Emmertsen KJ, et al. Low anterior resection syndrome and quality of life after sphincter-sparing rectal cancer surgery: a long-term longitudinal follow-up. Dis Colon Rectum. 2019; 62(1): 14–20. https://doi.org/10.1097/dcr.0000000000001228 - 30Sturiale A, Martellucci J, Zurli L, Vaccaro C, Brusciano L, Limongelli P, et al. Long-term functional follow-up after anterior rectal resection for cancer. Int J Colorectal Dis. 2017; 32(1): 83–88. https://doi.org/10.1007/s00384-016-2659-6 - 31Chen TY, Wiltink LM, Nout RA, Meershoek-Klein Kranenbarg E, Laurberg S, Marijnen CA, et al. Bowel function 14 years after preoperative short-course radiotherapy and total mesorectal excision for rectal cancer: report of a multicenter randomized trial. Clin Colorectal Cancer. 2015; 14(2): 106–114. https://doi.org/10.1016/j.clcc.2014.12.007 Citing Literature Article Metrics Total unique accesses to an article’s full text in HTML or PDF/ePDF format.More metric information Scite metrics Explore this article's citation statements on scite.ai Share QR Code Generating QR code QR code copied to clipboard! Something went wrong while generating your QR code. Please try again in a moment. If the issue persists, refresh the page or contact support. Export citation Unable to load citation data. Please try again in a moment. 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