Colorectal Resection in Endometriosis Patients: Correlation Between Histopathological Findings and Postoperative Outcome.

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Peter Tschann, Nikola Vitlarow, Martin Hufschmidt, Daniel Lechner, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-115333/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 23 Jan, 2021 Read the published version in European Journal of Medical Research → Version 1 posted 7 You are reading this latest preprint version Abstract Introduction Endometriosis is associated with a high number of chronic pelvic pain and reduced quality of life. Colorectal resections in case of bowel involvement of endometriosis is associated with an unneglectable morbidity in young and healthy patients. There is no linear correlation established between the degree of symptoms and stage of endometriosis. The aim of this study was to correlate the histological findings to preoperative pain scores in colorectal resected patients with endometriosis. Methods 25 Patients who underwent colorectal resection for endometriosis between 2014 and 2019 were included in this retrospective study. Pain level was assessed preoperatively and postoperatively via phone call in May 2020. Histopathology was correlated to preoperative symptoms and postoperative outcome. Results Average follow-up time was 38.68 months (±19.92). Preoperative VAS-score was 8.32 (±1.70). We observed a significant reduction of pain level in all patients after surgery ( p ≤ 0.005). Pain levels were equal regarding the presence of satellite spots and various degrees of infiltration depth. The resection margins were clear in all patients. Postoperative complications occurred in 6 cases (24%), anastomotic leakage was observed in 3 patients (12%). Average VAS-score at time of follow-up was 1.70 (±2.54). Conclusion Our data demonstrate that adequate colorectal resection leads to reduction of pain and an increase of quality of life irrespective of histopathological findings. An experienced team is necessary in order to improve intraoperative outcome and to reduce postoperative morbidity in case of complication. Health Economics & Outcomes Research Endometriosis bowel involvement colorectal resection histopathology pain level Figures Figure 1 Figure 1 Introduction Endometriosis is a chronic gynaecological disease, defined as the presence of endometrial glands and stroma outside the uterine cavity, predominantly in the pelvic compartment, rarely at the diaphragm, pleura or pericardium [1–3]. It is an estrogen-dependent chronic inflammatory condition which is associated with pelvic pain and infertility, and affects women in their reproductive period [1, 3]. Endometriosis is not a rare condition: It affects 6-10% of women in the reproductive period, 50-60% of women and teenage girls with chronic pelvic pain, and about 50% of women with infertility [3–5]. The economic burden is high because of health care costs and a decrease in productivity of afflicted patients[6]. Affected women lose about 10 hours of work weekly [1, 7]. The pathogenesis is still under debate. The most robust evidence is based on the “retrograde menstruation phenomenon” [1, 3, 8]. Endometrial fragments are driven through the fallopian tubes, possibly by uterine contractions which effect a pressure gradient in the tube. Once the endometrial cells reach the peritoneum they can implant grow and invade other structures [1]. Possible risk factors for this process are early age at menarche, long duration of menstrual flows, as well as molecular and cellular alterations [1, 9]. Endometriosis lesions can be divided into superficial peritoneal implants, ovarian cysts and deep nodules or plaques, which can individually involve or infiltrate the parametria, Douglas pouch, rectum, bladder, sigmoid colon or cecum. The rectum and sigmoid colon are the most frequent involved structures, accounting about 90% of intestinal endometriosis cases [2]. Clinical symptoms are depending on the location and extension of endometriosis disease. Rectal or sigmoid endometriosis are often associated with severe progressive symptoms, such as abdominal and pelvic pain, diarrhoea, constipation, haematochezia and rarely bowel obstruction symptoms [10]. However most of the patients’ quality of life is restricted by pain, infertility and repeated operations or long-term medical therapy [11]. Colorectal segmental resection or local bowel wall excision are the usually recommended procedures in case of bowel involvement. Especially transmural infiltration requires a segmental bowel resection, and these procedures are associated with unneglectable morbidity. Anastomotic leakage remains one of the most threatening complications after colorectal surgery with an incidence up to 20% [12–14]. This is a life threating complication, even for healthy and young endometriosis patients. The aim of this study was to evaluate the histopathology of vertical bowel involvement and the outcome after colorectal resection of patients with deep infiltrating endometriosis. Particularly we wanted to investigate the relationship between histopathological findings and preoperative symptoms. Materials And Methods Study population 388 patients underwent surgery because of endometriosis at the Academic Teaching Hospital in Feldkirch between January 2014 and December 2019. All patients had a typical previous history for endometriosis and were transferred to the certified endometriosis centre of the hospital. Inclusion criteria were colorectal resection for endometriosis. Patients who only underwent diagnostic laparoscopy or bowel wall excisions were excluded. The study was presented to the Ethics Committee of the Province of Vorarlberg (EK-0.04-289). Surgical procedure: 25 patients underwent a colorectal resection in case of deep infiltrating endometriosis between January 2014 and December 2019. The indication for bowel resection was posed by the gynaecologist, the bowel resection was performed by two specialised colorectal surgeons. All procedures were performed laparoscopically in conventional multiport technique using a Pfannenstil incision or in reduced port technique using an umbilical OCTO™-port for specimen retrieval. The intraoperative resection margins were defined clinically by each surgeon. Complications and surgical outcome were recorded routinely. Severity of complications were graded according the Clavien - Dindo classification for surgical complications [15]. Histological evaluation: Histopathology and preoperative symptoms were correlated to postoperative outcome. The histopathological examination was performed by our pathologist. The specimen was immediately fixed with 4% formaldehyde. After fixation, a macroscopic description followed by paraffin preparation for microscopical evaluation was done. Vertical involvement and satellite spots were recorded as well as the involvement of the resection margins (Figure 1). Preoperative evaluation: Before every procedure, all patients underwent detailed history of symptoms. Preoperative scoring of pain symptoms was performed using a 10-point visual analog scale (VAS) (0=no pain; 10=severe pain). In any case of bowel symptoms (pain on defecation, constipation, diarrhoea, bloating, rectal bleeding, tenesmus) a colonoscopy was performed preoperatively. Magnet resonance imaging was not done routinely. Outcome and follow-up: All patients who underwent laparoscopic bowel resection were evaluated by a phone call in May 2020. All data of the interview by call were registered in an electronic format (Microsoft Excel©). Scoring of pain symptoms was performed using the VAS-scale. Patients’ satisfaction and condition were recorded as well as reinterventions because of endometriosis if they were not performed in our hospital. Continuous data are represented as mean (±SD) and were assessed by the Mann-Whitney-U-test. Data were collected using Microsoft Excel© and analysed with online-based tools. Significance was set at a p value of <0.05. Results 25 patients with an average age of 34.16 (±5.45) and a mean BMI of 21.76 (±2.60) underwent laparoscopic bowel resection for deep infiltrating endometriosis. Only 2 patients (12.0%) were scored ASA II, all the others (88.0%) were ASA I. Comorbidities were not observed in our cohort. Patients’ characteristics, preoperative assessments, symptoms, VAS and need for pain drugs preoperatively are shown in Table 1. Preoperative colonoscopy was done in 14 cases (56.0%), MRI was performed in 19 patients (76.0%) with endometriosis symptoms. Diagnostic laparoscopy was done in 7 (28.0%) patients before colorectal resection as a two-step approach. The leading symptom for patient’s presentation to hospital was dysmenorrhoea in 22 (88.0%) cases. Dyspareunia was recorded in 8 (32.0%) and unfulfilled desire for children in 9 (36.0%) patients. Bowel specific symptoms are shown in table 2. The average VAS preoperatively was 8.32 (±1.70). 22 (88.0%) patients needed pain killers during menstruation. 13 (52.0%) patients had a history of previous therapeutic laparoscopy for endometriosis, in 1 (4.0%) patient a hysterectomy was performed before surgery because of adenomyosis uteri reason. Perioperative results are shown in Table 2. The average operation time was 200 min (±49). A rectal resection was performed in 14 cases (56%), in 3 patients (12%) rectal resection combined with hysterectomy and in 1 case simultaneous rectal resection with ileocecal resection was performed. Sigmoid resection was done in 6 cases (24.0%). In 1 patient (4.0%) only ileocecal resection was performed. In cases of left-sided colonic resection, the average anastomosis height was 9.12 (±4.46). In 23 patients (92%) a simultaneous gynaecological resection was necessary because of additional endometriosis spots. A protective stoma was done in 4 cases (16.0%). We observed no intraoperative complications and we had no conversions to laparotomy. The average hospital stay was 7.37 days (±2.65). Overall, we observed 6 complications (24.0%). In 3 cases (12.0%) anastomotic leakage was diagnosed; anastomotic bleeding was observed in 2 cases (8.0%) and in 1 patient (4.0%) infected haematoma required surgery. Endoscopic clipping was performed in 2 cases of anastomotic bleeding, 2 cases required endo VAC therapy, re-laparoscopy was done in case of infected haematoma. A Hartmann’s procedure was necessary in 1 patient. Pathological findings are shown in Table 3. Histopathological assessment showed a mucosal infiltration in 2 patients (8.0%). Submucosal involvement was recorded in 6 cases (24.0%), muscularis propria in 17 patients (68.0%). All patients had endometriosis infiltration in subserosa or serosa. Satellite spots were observed in 6 cases (24.0%). In 23 patients (92.0%) additional endometriosis locations were resected during the same operation. In all patient’s resection margins were clear. Follow up data are shown in Table 4. During the study period repeated surgery was not necessary because of endometriosis. The average follow-up time was 38.68 months (±19.92). The mean VAS-score at time of follow-up was 1.70 (±2.54). 6 patients (24.0%) reported about mild dysmenorrhoea, intestinal symptoms (constipation and diarrhoea) were rare and only recorded in 2 cases (8.0%). In 1 patient (4.0%) a bladder emptying disorder and in 3 patients (12.0%) a minor LARS (=low anterior resection syndrome) was observed. After surgery 5 patients (20.0%) got pregnant, 2 patients (8.0%) gave birth. Relationship between vertical bowel infiltration and/or additional satellite spots to pre- and postoperative VAS-score at time of follow-up are shown in table 5. Preoperatively we observed no difference in pain levels of patients with satellite spots (VAS: 8.66) or without (VAS: 8.21). Moreover, pain level in mucosal infiltration (VAS: 9.00) was similar to patients with submucosal (VAS: 8.50) or muscularis propria infiltration (VAS: 8.17) ( p = 0.93). Pre- and postoperative VAS-scores did not differ significantly regarding the development of any complication (table 8). In the group with complications, the average VAS-score preoperatively was 8.66 (±1.50), 8.21 (±1.78) in patients without complications ( p = 0.68). Postoperative VAS was 1.33 (±2.16) in case of complication and 1.83 (±2.70) in patients without ( p = 0.74). Pain scores preoperatively and at time of follow up are shown in Table 6. At the time of the follow-up we observed a significant improvement in pain (VAS: 8.32 vs. 1.70) and in gastrointestinal symptoms ( p = 0.00001). In case of satellite spots preoperative VAS was 8.66 (±1.03), postoperative we found a significant decrease to 1,50 (±1.97) ( p = 0.005). Also, in patients without satellite spots the outcome was significant (8.21 [±1.87] preoperative vs. 1,77 [±2.75] postoperative; p = 0.00001). Mucosal infiltration showed a preoperative VAS-score up to 9.00 (±1.41), postoperative we could show a significant reduction to 0.00 (±0.00) ( p = 0.005). We observed similar in patients with submucosal involvement (8.50 vs. 1.66; p = 0.05) and in case of muscularis propria infiltration (8.17 vs. 1.93; p = 0.00001). Patients’ satisfaction after surgery was enhanced. We observed no recurrent disease during time of the follow-up. Discussion Colorectal resection in case of bowel involvement of endometriosis is associated with a considerable morbidity in young and healthy patients. Endometriosis is associated with a high number of chronic pelvic pain and reduced quality of life. Bowel involvement causes several intestinal symptoms. Postoperative outcome is related to the removal of involved bowel[16]. In case of deep infiltrating endometriosis with infiltration of several bowel layers a disc excision or shaving may lead to persistence of bowel symptoms. Several studies demonstrated that laparoscopic bowel resection for deep infiltrating endometriosis is associated with an significant improvement in quality of life and pain scores [17–19]. Fedele et al. showed that the risk for recurrence requiring further treatment was significantly higher in patients who did not undergo colorectal resection for endometriosis [20]. Our study reports the result of bowel resection in deep infiltrating endometriosis in correlation to histopathological findings and postoperative outcome. We could show that there is no difference regarding preoperative pain level in correlation to vertical infiltration depth and the presence of satellite spots. Overall postoperative pain level was satisfying and significantly better than preoperative regardless of vertical infiltration or the presence of satellite spots. Moreover, we observed no recurrence and no reoperation for endometriosis at the time of the follow-up. In most of the cases the indication for surgery is pain. 88% of our patients need analgesics before surgery. Preoperative the average VAS-score was 8.32. Postoperative, the symptoms decreased significantly to an average VAS of 1.70 ( p =<0.00001). It is widely accepted that preoperative assessment should include physical examination, transvaginal ultrasound and a pelvic MRI. Neither sonography or pelvic MRI have a 100% effectivity in prediction or confirmation of endometriosis but they are useful tools in preoperative diagnosis with a high sensitivity and specificity [21]. Routine colonoscopy is not recommended in case of suspected deep infiltrating bowel endometriosis [22, 23]. We would recommend endoscopy especially in case of rectal bleeding to rule out chronic inflammatory bowel diseases and malignancies. Routine diagnostic laparoscopy is obsolete because of repeated admission, persistence of symptoms and the same effectivity as preoperative transvaginal ultrasound or pelvic MRI [24]. Furthermore, a two-step approach should be indicated restrictively because of a low information content especially for rectal- or rectovaginal endometriosis. To open the rectovaginal space only for diagnostic reason implicates the growth of fibrosis, which makes a second procedure more difficult. The histological examination showed the presence of satellite spots in 24% of the cases. We could show that preoperative pain levels are similar in patients with satellite spots or without (table 6). Our data are in accordance to literature: Three studies showed a presence of satellite spots in up to 64% of the cases, also pain level were similar in patients with and without satellite spots [2, 17, 25]. We observed similar pain levels in patients with mucosal or submucosal infiltration. It is well known that deep infiltrating endometriosis with bowel involvement is associated with a high degree of dysmenorrhoea combined with gastrointestinal symptoms and reduced quality of life. The resection margins of the resected specimen were clear in all cases, we had no need for recurrence surgery due to endometriosis in the follow-up time. A negative resection margin does not have an impact on postoperative symptoms and outcome in previous literature [2, 26]. Theoretically, the persistence of endometriosis spots may be responsible for a recurrence disease. It depends on surgeons’ experience and interdisciplinary team work to avoid positive margins, even if there is no correlation between positive margin and persistence of symptoms. We could show a significant improvement of postoperative pain level in all cases. This underlines the importance colorectal resections in case of deep infiltrating endometriosis. Furthermore, 7 of 9 patients with unfulfilled desire of children got pregnant, 2 patients gave birth. This is beside pain reduction an important effect of adequate surgery in an interdisciplinary team. Surgeons must consider that colorectal surgery is associated with a high morbidity in case of complication. We observed complications in 6 cases (24%), in 3 patients (12%) an anastomotic leakage occurred. A correlation between histopathological presence of satellite spots or vertical bowel infiltration and postoperative pain level did not exist. Postoperative pain level was not higher in case of leakage compared to patients without problems (table 8). Especially anastomotic leakage increases morbidity and mortality, length of stay and costs [27]. Only in one case a Hartmann’s procedure was necessary, in two cases an Endo-VAC therapy was possible to preserve the anastomosis. In these two cases a protective loop ileostomy had been performed in primary procedure. The risk for anastomotic leakage differs in literature between 7-30% [28–30]. To reduce the anastomotic leakage rate, we introduced intraoperative flexible endoscopy for air leak testing immediately after stapling of the anastomosis during the study period. It offers three benefits: Vision of perfusion, the integrity of stapler lines and an air leak test with the possibility to precise the localization of an air leak. In case of negative air leak test (with flexible endoscopy) a protective ileostomy is not indicated necessarily, independent of the height of the anastomosis. In case of positive air leakage intraoperative endoscopy, facilitates the detection of the insufficiency and offers the possibility of immediate closure by additional suturing. If the test is negative after additional suturing, a diverting ileostomy can be avoided. In case of continuous air leak, re-anastomosis should be considered. However, patients’ intra- and postoperative outcome strongly depends on the interdisciplinary cooperation between general surgeon and gynaecologist. Colorectal surgery is associated with a high morbidity. Colorectal resections because of endometriosis are challenging due to chronic inflammation. That is why an experienced team of gynaecologist and colorectal surgeon is needed in order to define the extent of adequate surgery and for safe and precise performance. Our study showed that the complete resection of the main lesion, leads to a good outcome according to postoperative pain levels and patients’ satisfaction. Weak points of the study are the low number of patients and that it was performed retrospectively. Conclusion Deep infiltrating endometriosis is associated with a high number of preoperative pain and reduction of quality of life. Adequate colorectal resection leads to significant pain reduction. A histological association between satellite spots or vertical bowel infiltration to preoperative pain levels were not significant in our study. An experienced interdisciplinary team seems necessary to avoid intraoperative problems and to reduce morbidity regarding postoperative complications. Declarations Acknowledgements: The authors like to thank Simone Minikus for English corrections. Funding: No funding was received for this study. Competing interests: The authors declare that they have no competing interests. Author contributions: PT, NV, MH, DL, PG, BA and IK designed the study. PT wrote the manuscript and prepared the tables. DL did the statistical analysis. Histological evaluation was done by NV, FO. All authors contributed toward data acquisition, data interpretation, and critical revision of the content of the manuscript and approved the final version of the manuscript. Ethics approval: The study was presented to the Ethics Committee of the Province of Vorarlberg (EK-0.04-289) and does not require any referral or vote by the Ethics Committee of the Province of Vorarlberg. Availability of data and material: The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request. Consent of publication: Not applicable. References Vercellini P, Viganò P, Somigliana E et al. (2014) Endometriosis: pathogenesis and treatment. 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J Gastrointest Surg 17: 1698–1707. https://doi.org/10.1007/s11605-013-2227-0 Tables Table 1: Patients’ characteristics, preoperative assessments, symptoms, VAS and need for pain drugs preoperatively: *MRI=magnet resonance tomography n = 25 Age 34.16 (±5.45) BMI 21.76 (±2.60) ASA Classification: I 22 (88.0%) II 3 (12.0%) III 0 (0.0%) Comorbidities 0 (0.0%) Preoperative assessment: Colonoscopy 14 (56.0%) MRI* 19 (76.0%) Preoperative diagnostic laparoscopy 7 (28.0%) Preoperative symptoms: tenesmus 2 (8.0%) abdominal distension 5 (20.0%) constipation 2 (8.0%) diarrhoea 3 (12.0%) haematochezia 5 (20.0%) pain on defecation 6 (24.0%) dyspareunia 8 (32.0%) dysmenorrhoea 22 (88.0%) dysuria 1 (4.0%) unfulfilled desire for children 9 (36.0%) neuropathic pain 1 (4.0%) chronic pelvic pain 4 (16.0%) Average VAS preoperative 8.32 (±1.70) Need for pain drugs during menstruation 22 (88.0%) Table 2: Perioperative Results: *from anal verge in case of rectal- or sigmoid resection n = 25 Previous therapeutic laparoscopy for endometriosis 13 (52.0%) Previous abdominal surgery 14 (56.0%) Previous hysterectomy 1 (4.0%) Operation time (min) 200 (±49) Operation procedure rectal resection 14 (56.0%) sigmoid resection 6 (24.0%) ileocaecal resection 1 (4.0%) rectal-resection+hysterectomy 3 (12.0%) rectal-resection+ileocaecal resection 1 (4.0%) height of anastomosis* 9.12 (±4.46) Simultaneous gynaecological operation 23 (92%) Duration of hospital stay (d) 7.37 (±2.65) Conversion to laparotomy 0 (0.0%) Intraoperative Complications 0 (0.0%) Need for ileostomy 4 (16.0%) Postoperative complications 6 (24.0%) anastomotic leakage 3 (12.0%) anastomotic bleeding 2 (8.0%) infected haematoma 1 (4%) Dindo-Clavien Classification IIIa 3 (12.0%) IIIb 3 (12.0%) Complication management Hartmann procedure 1 (4.0%) re-laparoscopy 1 (4.0%) endoscopic clipping 2 (8.0%) endo-VAC therapy 2 (8.0%) Re-performing surgery 2 (8.0%) Table 3: Pathological findings: n = 25 Vertical infiltration mucosa 2 (8.0%) submucosa 6 (24.0%) muscularis propria 17 (68.0%) subserosa 25 (100.0%) serosa 25 (100.0%) Satellite spots 6 (24.0%) Additional locations 23 (92.0%) peritoneum 6 (24.0%) vagina 3 (12.0%) sacrouterine ligament 7 (28.0%) bladder peritoneum 9 (36.0%) fallopian tube 3 (12.0%) ovary 8 (32%) parametries 2 (8.0%) Clear resection margins 25 (100.0%) Table 4: Follow-up: *LARS=low anterior resection syndrome n = 25 Follow-up time (months) 38.68 (±19.92) Re-Operation rate for endometriosis 0 (0.0%) Average VAS-score follow up 1.70 (±2.54) Postoperative symptoms tenesmus 0 (0.0%) Abdominal distension 0 (0.0%) rectal bleeding 0 (0.0%) constipation 1 (4.0%) diarrhoea 1 (4.0%) nausea and vomiting 0 (0.0%) pain on defecation 0 (0.0%) dyspareunia 0 (0.0%) dysmenorrhoea 6 (24.0%) dysuria 0 (0.0%) chronic pelvic pain 0 (0.0%) bladder emptying disorder 1 (4.0%) minor LARS* 3 (12.0%) Gravida 5 (20.0%) Para 2 (8.0%) Recurrence of endometriosis 0 (0.00%) Table 5: Pre- and postoperative VAS score: Correlation between patients with or without satellite spots and vertical bowel infiltration Satellite + (n = 6) Satellite - (n = 19) p Value VAS-score preoperative 8.66 (±1.03) 8.21 (±1.87) 0.97 VAS-score follow-up 1.50 (±1.97) 1.77 (±2.75) 0.94 Mucosa (n = 2) Submucosa (n = 6) Muscularis propria (n = 17) p Value VAS-score preoperative 9.00 (±1.41) 8.50 (±1.04) 8.17 (±1,94) 0.93 VAS-score follow-up 0.00 (±0,00) 1.66 (±2,42) 1.93 (±2.74) 0.73 Table 6: Semiquantitative data on pain levels before and at time of follow-up: VAS-score preoperative VAS-score follow-up p Value All patients (n = 25) 8.32 (±1.70) 1.70 (±2.54) 0.00001 Satellite + (n = 6) 8.66 (±1.03) 1.50 (±1.97) 0.005 Satellite - (n = 20) 8.21 (±1.87) 1.77 (±2.75) 0.00001 Mucosa (n = 2) 9.00 (±1.41) 0.00 (±0.00) 0.005 Submucosa (n = 6) 8.50 (±1.04) 1.66 (±2.42) 0.005 Muscularis propria (n = 17) 8.17 (±1.94) 1.93 (±2.74) 0.00001 Cite Share Download PDF Status: Published Journal Publication published 23 Jan, 2021 Read the published version in European Journal of Medical Research → Version 1 posted Review # 1 received at journal 15 Dec, 2020 Reviewers invited by journal 23 Nov, 2020 Reviewer # 1 agreed at journal 23 Nov, 2020 Editor assigned by journal 20 Nov, 2020 Submission checks completed at journal 20 Nov, 2020 Editor invited by journal 20 Nov, 2020 First submitted to journal 19 Nov, 2020 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-115333","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research","associatedPublications":[],"authors":[{"id":5289721,"identity":"88641bba-096f-4ce5-b7e6-c82fb08dd074","order_by":0,"name":"Peter Tschann","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9ElEQVRIiWNgGAWjYFADCRBRYWFgwHyAkFJmEGEA1XJGwsCALYGBAb8uZC2MbURoMWfvP/i4guGPPf/s5mePC+dJGJuzMTB+/oBHi2XPYWbDMwwGiTPuHDM3nrlNwsyyjYFZAp8tBjeS2SQbGAwSDCQSzKR5t0nYGNxvYMCv5f5j9p9ALfYGEunfpHnnALUcY2D+gd8WZjZGoBbGDRI5QFsaJMyAWtjw2mLZk2ws2WBgnDjjRk6ZNM8xCWODY4xtFmfwaDFnP/jwY0OFnD3/jPRt0jw1NoYbjjEfvlGBz2FIJAwAHYoPGOCVHQWjYBSMglEAAgCXEkVLierjbwAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0003-3950-0347","institution":"LKH Feldkirch: Landeskrankenhaus Feldkirch","correspondingAuthor":true,"prefix":"","firstName":"Peter","middleName":"","lastName":"Tschann","suffix":""},{"id":5289722,"identity":"51dc75f9-7734-4bca-ab7a-3801792b9f04","order_by":1,"name":"Nikola Vitlarow","email":"","orcid":"","institution":"Landeskrankenhaus Feldkirch","correspondingAuthor":false,"prefix":"","firstName":"Nikola","middleName":"","lastName":"Vitlarow","suffix":""},{"id":5289723,"identity":"28d7080e-1702-4f7b-b8d6-7e9a9db0a57f","order_by":2,"name":"Martin Hufschmidt","email":"","orcid":"","institution":"Landeskrankenhaus Feldkirch","correspondingAuthor":false,"prefix":"","firstName":"Martin","middleName":"","lastName":"Hufschmidt","suffix":""},{"id":5289724,"identity":"f5d1a70e-b5c6-43d0-9f6e-8ded2cf3678a","order_by":3,"name":"Daniel Lechner","email":"","orcid":"","institution":"Landeskrankenhaus Feldkirch","correspondingAuthor":false,"prefix":"","firstName":"Daniel","middleName":"","lastName":"Lechner","suffix":""},{"id":5289725,"identity":"fe7558be-90aa-47d5-b3d4-ab2eb5651d05","order_by":4,"name":"Paolo Girotti","email":"","orcid":"","institution":"LKH Feldkirch: Landeskrankenhaus Feldkirch","correspondingAuthor":false,"prefix":"","firstName":"Paolo","middleName":"","lastName":"Girotti","suffix":""},{"id":5289726,"identity":"0ac70e47-8f07-45b9-9e45-486097a7536d","order_by":5,"name":"Felix Offner","email":"","orcid":"","institution":"LKH Feldkirch: Landeskrankenhaus Feldkirch","correspondingAuthor":false,"prefix":"","firstName":"Felix","middleName":"","lastName":"Offner","suffix":""},{"id":5289727,"identity":"f6494bac-b473-4e8e-bec5-5166036d1c0c","order_by":6,"name":"Burghard Abendstein","email":"","orcid":"","institution":"LKH Feldkirch: Landeskrankenhaus Feldkirch","correspondingAuthor":false,"prefix":"","firstName":"Burghard","middleName":"","lastName":"Abendstein","suffix":""},{"id":5289728,"identity":"0ff09ebf-ab00-4575-b670-481adf9245c7","order_by":7,"name":"Ingmar Königsrainer","email":"","orcid":"","institution":"LKH Feldkirch: Landeskrankenhaus Feldkirch","correspondingAuthor":false,"prefix":"","firstName":"Ingmar","middleName":"","lastName":"Königsrainer","suffix":""}],"badges":[],"createdAt":"2020-11-24 20:29:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-115333/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-115333/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s40001-021-00484-z","type":"published","date":"2021-01-23T15:03:18+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":3926547,"identity":"60309c6d-31cd-4525-9cf7-ed3c852166e5","added_by":"auto","created_at":"2020-12-01 17:43:09","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":175975,"visible":true,"origin":"","legend":"Deep infiltrating endometriosis of the bowel after formalin fixation and paraffin preparation:\na)\tEndometriotic foci with the white, compact peritoneal tissue (arrow), muscularis propria (double arrow)\nb)\tMicroscopy - endometriotic foci infiltrating in the submucosa (star)\nc)\tMicroscopy - endometriotic foci in the muscularis propria.\nd)\tMicroscopy and Immunohistichemistry. CD10 (+) endometriotic Foci in the CD (-) Background of muscularis propria.\n","description":"","filename":"Figure1.JPG","url":"https://assets-eu.researchsquare.com/files/rs-115333/v1/57888d52630fdd27590e2ede.JPG"},{"id":3926543,"identity":"b66852ce-1eb6-4528-8701-4e51252b8825","added_by":"auto","created_at":"2020-12-01 17:43:03","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":175975,"visible":true,"origin":"","legend":"Deep infiltrating endometriosis of the bowel after formalin fixation and paraffin preparation:\na)\tEndometriotic foci with the white, compact peritoneal tissue (arrow), muscularis propria (double arrow)\nb)\tMicroscopy - endometriotic foci infiltrating in the submucosa (star)\nc)\tMicroscopy - endometriotic foci in the muscularis propria.\nd)\tMicroscopy and Immunohistichemistry. CD10 (+) endometriotic Foci in the CD (-) Background of muscularis propria.\n","description":"","filename":"Figure1.JPG","url":"https://assets-eu.researchsquare.com/files/rs-115333/v1/8928ff30a313175935b85946.JPG"},{"id":13620973,"identity":"f954aabe-1348-44cf-b2bd-314474d1a031","added_by":"auto","created_at":"2021-09-17 07:08:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":590489,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-115333/v1/9182a5d5-d01d-441e-845f-5db8c7f93729.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eColorectal Resection in Endometriosis Patients: Correlation Between Histopathological Findings and Postoperative Outcome.\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEndometriosis is a chronic gynaecological disease, defined as the presence of endometrial glands and stroma outside the uterine cavity, predominantly in the pelvic compartment, rarely at the diaphragm, pleura or pericardium [1\u0026ndash;3]. It is an estrogen-dependent chronic inflammatory condition which is associated with pelvic pain and infertility, and affects women in their reproductive period [1, 3]. Endometriosis is not a rare condition: It affects 6-10% of women in the reproductive period, 50-60% of women and teenage girls with chronic pelvic pain, and about 50% of women with infertility [3\u0026ndash;5]. The economic burden is high because of health care costs and a decrease in productivity of afflicted patients[6]. Affected women lose about 10 hours of work weekly [1, 7].\u003c/p\u003e\n\u003cp\u003eThe pathogenesis is still under debate. The most robust evidence is based on the \u0026ldquo;retrograde menstruation phenomenon\u0026rdquo; [1, 3, 8]. Endometrial fragments are driven through the fallopian tubes, possibly by uterine contractions which effect a pressure gradient in the tube. Once the endometrial cells reach the peritoneum they can implant grow and invade other structures [1]. Possible risk factors for this process are early age at menarche, long duration of menstrual flows, as well as molecular and cellular alterations [1, 9].\u003c/p\u003e\n\u003cp\u003eEndometriosis lesions can be divided into superficial peritoneal implants, ovarian cysts and deep nodules or plaques, which can individually involve or infiltrate the parametria, Douglas pouch, rectum, bladder, sigmoid colon or cecum. The rectum and sigmoid colon are the most frequent involved structures, accounting about 90% of intestinal endometriosis cases [2]. Clinical symptoms are depending on the location and extension of endometriosis disease. Rectal or sigmoid endometriosis are often associated with severe progressive symptoms, such as abdominal and pelvic pain, diarrhoea, constipation, haematochezia and rarely bowel obstruction symptoms [10]. However most of the patients\u0026rsquo; quality of life is restricted by pain, infertility and repeated operations or long-term medical therapy [11].\u003c/p\u003e\n\u003cp\u003eColorectal segmental resection or local bowel wall excision are the usually recommended procedures in case of bowel involvement. Especially transmural infiltration requires a segmental bowel resection, and these procedures are associated with unneglectable morbidity. Anastomotic leakage remains one of the most threatening complications after colorectal surgery with an incidence up to 20% [12\u0026ndash;14]. This is a life threating complication, even for healthy and young endometriosis patients.\u003c/p\u003e\n\u003cp\u003eThe aim of this study was to evaluate the histopathology of vertical bowel involvement and the outcome after colorectal resection of patients with deep infiltrating endometriosis. Particularly we wanted to investigate the relationship between histopathological findings and preoperative symptoms.\u003c/p\u003e"},{"header":"Materials And Methods","content":"\u003cp\u003eStudy population\u003c/p\u003e\n\u003cp\u003e388 patients underwent surgery because of endometriosis at the Academic Teaching Hospital in Feldkirch between January 2014 and December 2019. All patients had a typical previous history for endometriosis and were transferred to the certified endometriosis centre of the hospital. Inclusion criteria were colorectal resection for endometriosis. Patients who only underwent diagnostic laparoscopy or bowel wall excisions were excluded. The study was presented to the Ethics Committee of the Province of Vorarlberg (EK-0.04-289).\u003c/p\u003e\n\u003cp\u003eSurgical procedure:\u003c/p\u003e\n\u003cp\u003e25 patients underwent a colorectal resection in case of deep infiltrating endometriosis between January 2014 and December 2019. The indication for bowel resection was posed by the gynaecologist, the bowel resection was performed by two specialised colorectal surgeons. All procedures were performed laparoscopically in conventional multiport technique using a Pfannenstil incision or in reduced port technique using an umbilical OCTO\u0026trade;-port for specimen retrieval. The intraoperative resection margins were defined clinically by each surgeon. Complications and surgical outcome were recorded routinely. Severity of complications were graded according the Clavien - Dindo classification for surgical complications [15].\u003c/p\u003e\n\u003cp\u003eHistological evaluation:\u003c/p\u003e\n\u003cp\u003eHistopathology and preoperative symptoms were correlated to postoperative outcome. The histopathological examination was performed by our pathologist. The specimen was immediately fixed with 4% formaldehyde. After fixation, a macroscopic description followed by paraffin preparation for microscopical evaluation was done. Vertical involvement and satellite spots were recorded as well as the involvement of the resection margins (Figure 1).\u003c/p\u003e\n\u003cp\u003ePreoperative evaluation:\u003c/p\u003e\n\u003cp\u003eBefore every procedure, all patients underwent detailed history of symptoms. Preoperative scoring of pain symptoms was performed using a 10-point visual analog scale (VAS) (0=no pain; 10=severe pain). In any case of bowel symptoms (pain on defecation, constipation, diarrhoea, bloating, rectal bleeding, tenesmus) a colonoscopy was performed preoperatively. Magnet resonance imaging was not done routinely.\u003c/p\u003e\n\u003cp\u003eOutcome and follow-up:\u003c/p\u003e\n\u003cp\u003eAll patients who underwent laparoscopic bowel resection were evaluated by a phone call in May 2020. All data of the interview by call were registered in an electronic format (Microsoft Excel\u0026copy;). Scoring of pain symptoms was performed using the VAS-scale. Patients\u0026rsquo; satisfaction and condition were recorded as well as reinterventions because of endometriosis if they were not performed in our hospital.\u003c/p\u003e\n\u003cp\u003eContinuous data are represented as mean (\u0026plusmn;SD) and were assessed by the Mann-Whitney-U-test. Data were collected using Microsoft Excel\u0026copy; and analysed with online-based tools. Significance was set at a p value of \u0026lt;0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e25 patients with an average age of 34.16 (\u0026plusmn;5.45) and a mean BMI of 21.76 (\u0026plusmn;2.60) underwent laparoscopic bowel resection for deep infiltrating endometriosis. Only 2 patients (12.0%) were scored ASA II, all the others (88.0%) were ASA I. Comorbidities were not observed in our cohort.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePatients\u0026rsquo; characteristics, preoperative assessments, symptoms, VAS and need for pain drugs preoperatively are shown in Table 1.\u003c/p\u003e\n\u003cp\u003ePreoperative colonoscopy was done in 14 cases (56.0%), MRI was performed in 19 patients (76.0%) with endometriosis symptoms. Diagnostic laparoscopy was done in 7 (28.0%) patients before colorectal resection as a two-step approach. The leading symptom for patient\u0026rsquo;s presentation to hospital was dysmenorrhoea in 22 (88.0%) cases. Dyspareunia was recorded in 8 (32.0%) and unfulfilled desire for children in 9 (36.0%) patients. Bowel specific symptoms are shown in table 2. The average VAS preoperatively was 8.32 (\u0026plusmn;1.70). 22 (88.0%) patients needed pain killers during menstruation.\u003c/p\u003e\n\u003cp\u003e13 (52.0%) patients had a history of previous therapeutic laparoscopy for endometriosis, in 1 (4.0%) patient a hysterectomy was performed before surgery because of adenomyosis uteri reason.\u003c/p\u003e\n\u003cp\u003ePerioperative results are shown in Table 2.\u003c/p\u003e\n\u003cp\u003eThe average operation time was 200 min (\u0026plusmn;49). A rectal resection was performed in 14 cases (56%), in 3 patients (12%) rectal resection combined with hysterectomy and in 1 case simultaneous rectal resection with ileocecal resection was performed. Sigmoid resection was done in 6 cases (24.0%). In 1 patient (4.0%) only ileocecal resection was performed. In cases of left-sided colonic resection, the average anastomosis height was 9.12 (\u0026plusmn;4.46). In 23 patients (92%) a simultaneous gynaecological resection was necessary because of additional endometriosis spots. A protective stoma was done in 4 cases (16.0%). We observed no intraoperative complications and we had no conversions to laparotomy. The average hospital stay was 7.37 days (\u0026plusmn;2.65). Overall, we observed 6 complications (24.0%). In 3 cases (12.0%) anastomotic leakage was diagnosed; anastomotic bleeding was observed in 2 cases (8.0%) and in 1 patient (4.0%) infected haematoma required surgery. Endoscopic clipping was performed in 2 cases of anastomotic bleeding, 2 cases required endo VAC therapy, re-laparoscopy was done in case of infected haematoma. A Hartmann\u0026rsquo;s procedure was necessary in 1 patient.\u003c/p\u003e\n\u003cp\u003ePathological findings are shown in Table 3.\u003c/p\u003e\n\u003cp\u003eHistopathological assessment showed a mucosal infiltration in 2 patients (8.0%). Submucosal involvement was recorded in 6 cases (24.0%), muscularis propria in 17 patients (68.0%). All patients had endometriosis infiltration in subserosa or serosa. Satellite spots were observed in 6 cases (24.0%). In 23 patients (92.0%) additional endometriosis locations were resected during the same operation. In all patient\u0026rsquo;s resection margins were clear.\u003c/p\u003e\n\u003cp\u003eFollow up data are shown in Table 4.\u003c/p\u003e\n\u003cp\u003eDuring the study period repeated surgery was not necessary because of endometriosis. The average follow-up time was 38.68 months (\u0026plusmn;19.92). The mean VAS-score at time of follow-up was 1.70 (\u0026plusmn;2.54). 6 patients (24.0%) reported about mild dysmenorrhoea, intestinal symptoms (constipation and diarrhoea) were rare and only recorded in 2 cases (8.0%). In 1 patient (4.0%) a bladder emptying disorder and in 3 patients (12.0%) a minor LARS (=low anterior resection syndrome) was observed. After surgery 5 patients (20.0%) got pregnant, 2 patients (8.0%) gave birth.\u003c/p\u003e\n\u003cp\u003eRelationship between vertical bowel infiltration and/or additional satellite spots to pre- and postoperative VAS-score at time of follow-up are shown in table 5.\u003c/p\u003e\n\u003cp\u003ePreoperatively we observed no difference in pain levels of patients with satellite spots (VAS: 8.66) or without (VAS: 8.21). Moreover, pain level in mucosal infiltration (VAS: 9.00) was similar to patients with submucosal (VAS: 8.50) or muscularis propria infiltration (VAS: 8.17) (\u003cem\u003ep\u003c/em\u003e = 0.93).\u003c/p\u003e\n\u003cp\u003ePre- and postoperative VAS-scores did not differ significantly regarding the development of any complication (table 8). In the group with complications, the average VAS-score preoperatively was 8.66 (\u0026plusmn;1.50), 8.21 (\u0026plusmn;1.78) in patients without complications (\u003cem\u003ep\u003c/em\u003e = 0.68). Postoperative VAS was 1.33 (\u0026plusmn;2.16) in case of complication and 1.83 (\u0026plusmn;2.70) in patients without (\u003cem\u003ep\u003c/em\u003e = 0.74).\u003c/p\u003e\n\u003cp\u003ePain scores preoperatively and at time of follow up are shown in Table 6.\u003c/p\u003e\n\u003cp\u003eAt the time of the follow-up we observed a significant improvement in pain (VAS: 8.32 vs. 1.70) and in gastrointestinal symptoms (\u003cem\u003ep\u003c/em\u003e = 0.00001). In case of satellite spots preoperative VAS was 8.66 (\u0026plusmn;1.03), postoperative we found a significant decrease to 1,50 (\u0026plusmn;1.97) (\u003cem\u003ep\u003c/em\u003e = 0.005). Also, in patients without satellite spots the outcome was significant (8.21 [\u0026plusmn;1.87] preoperative vs. 1,77 [\u0026plusmn;2.75] postoperative; \u003cem\u003ep\u003c/em\u003e = 0.00001). Mucosal infiltration showed a preoperative VAS-score up to 9.00 (\u0026plusmn;1.41), postoperative we could show a significant reduction to 0.00 (\u0026plusmn;0.00) (\u003cem\u003ep \u003c/em\u003e= 0.005). We observed similar in patients with submucosal involvement (8.50 vs. 1.66; \u003cem\u003ep\u003c/em\u003e = 0.05) and in case of muscularis propria infiltration (8.17 vs. 1.93; \u003cem\u003ep\u003c/em\u003e = 0.00001). Patients\u0026rsquo; satisfaction after surgery was enhanced. We observed no recurrent disease during time of the follow-up.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eColorectal resection in case of bowel involvement of endometriosis is associated with a considerable morbidity in young and healthy patients. Endometriosis is associated with a high number of chronic pelvic pain and reduced quality of life. Bowel involvement causes several intestinal symptoms. Postoperative outcome is related to the removal of involved bowel[16]. In case of deep infiltrating endometriosis with infiltration of several bowel layers a disc excision or shaving may lead to persistence of bowel symptoms. Several studies demonstrated that laparoscopic bowel resection for deep infiltrating endometriosis is associated with an significant improvement in quality of life and pain scores [17\u0026ndash;19]. Fedele et al. showed that the risk for recurrence requiring further treatment was significantly higher in patients who did not undergo colorectal resection for endometriosis [20].\u003c/p\u003e\n\u003cp\u003eOur study reports the result of bowel resection in deep infiltrating endometriosis in correlation to histopathological findings and postoperative outcome. We could show that there is no difference regarding preoperative pain level in correlation to vertical infiltration depth and the presence of satellite spots. Overall postoperative pain level was satisfying and significantly better than preoperative regardless of vertical infiltration or the presence of satellite spots. Moreover, we observed no recurrence and no reoperation for endometriosis at the time of the follow-up.\u003c/p\u003e\n\u003cp\u003eIn most of the cases the indication for surgery is pain. 88% of our patients need analgesics before surgery. Preoperative the average VAS-score was 8.32. Postoperative, the symptoms decreased significantly to an average VAS of 1.70 (\u003cem\u003ep\u003c/em\u003e =\u0026lt;0.00001).\u003c/p\u003e\n\u003cp\u003eIt is widely accepted that preoperative assessment should include physical examination, transvaginal ultrasound and a pelvic MRI. Neither sonography or pelvic MRI have a 100% effectivity in prediction or confirmation of endometriosis but they are useful tools in preoperative diagnosis with a high sensitivity and specificity [21]. Routine colonoscopy is not recommended in case of suspected deep infiltrating bowel endometriosis [22, 23]. We would recommend endoscopy especially in case of rectal bleeding to rule out chronic inflammatory bowel diseases and malignancies. Routine diagnostic laparoscopy is obsolete because of repeated admission, persistence of symptoms and the same effectivity as preoperative transvaginal ultrasound or pelvic MRI [24]. Furthermore, a two-step approach should be indicated restrictively because of a low information content especially for rectal- or rectovaginal endometriosis. To open the rectovaginal space only for diagnostic reason implicates the growth of fibrosis, which makes a second procedure more difficult.\u003c/p\u003e\n\u003cp\u003eThe histological examination showed the presence of satellite spots in 24% of the cases. We could show that preoperative pain levels are similar in patients with satellite spots or without (table 6). Our data are in accordance to literature: Three studies showed a presence of satellite spots in up to 64% of the cases, also pain level were similar in patients with and without satellite spots [2, 17, 25]. We observed similar pain levels in patients with mucosal or submucosal infiltration. It is well known that deep infiltrating endometriosis with bowel involvement is associated with a high degree of dysmenorrhoea combined with gastrointestinal symptoms and reduced quality of life. The resection margins of the resected specimen were clear in all cases, we had no need for recurrence surgery due to endometriosis in the follow-up time. A negative resection margin does not have an impact on postoperative symptoms and outcome in previous literature [2, 26]. Theoretically, the persistence of endometriosis spots may be responsible for a recurrence disease. It depends on surgeons\u0026rsquo; experience and interdisciplinary team work to avoid positive margins, even if there is no correlation between positive margin and persistence of symptoms.\u003c/p\u003e\n\u003cp\u003eWe could show a significant improvement of postoperative pain level in all cases. This underlines the importance colorectal resections in case of deep infiltrating endometriosis. Furthermore, 7 of 9 patients with unfulfilled desire of children got pregnant, 2 patients gave birth. This is beside pain reduction an important effect of adequate surgery in an interdisciplinary team.\u003c/p\u003e\n\u003cp\u003eSurgeons must consider that colorectal surgery is associated with a high morbidity in case of complication. We observed complications in 6 cases (24%), in 3 patients (12%) an anastomotic leakage occurred. A correlation between histopathological presence of satellite spots or vertical bowel infiltration and postoperative pain level did not exist. Postoperative pain level was not higher in case of leakage compared to patients without problems (table 8).\u003c/p\u003e\n\u003cp\u003eEspecially anastomotic leakage increases morbidity and mortality, length of stay and costs [27]. Only in one case a Hartmann\u0026rsquo;s procedure was necessary, in two cases an Endo-VAC therapy was possible to preserve the anastomosis. In these two cases a protective loop ileostomy had been performed in primary procedure. The risk for anastomotic leakage differs in literature between 7-30% [28\u0026ndash;30]. To reduce the anastomotic leakage rate, we introduced intraoperative flexible endoscopy for air leak testing immediately after stapling of the anastomosis during the study period. It offers three benefits: Vision of perfusion, the integrity of stapler lines and an air leak test with the possibility to precise the localization of an air leak. In case of negative air leak test (with flexible endoscopy) a protective ileostomy is not indicated necessarily, independent of the height of the anastomosis. In case of positive air leakage intraoperative endoscopy, facilitates the detection of the insufficiency and offers the possibility of immediate closure by additional suturing. If the test is negative after additional suturing, a diverting ileostomy can be avoided. In case of continuous air leak, re-anastomosis should be considered.\u003c/p\u003e\n\u003cp\u003eHowever, patients\u0026rsquo; intra- and postoperative outcome strongly depends on the interdisciplinary cooperation between general surgeon and gynaecologist. Colorectal surgery is associated with a high morbidity. Colorectal resections because of endometriosis are challenging due to chronic inflammation. That is why an experienced team of gynaecologist and colorectal surgeon is needed in order to define the extent of adequate surgery and for safe and precise performance.\u003c/p\u003e\n\u003cp\u003eOur study showed that the complete resection of the main lesion, leads to a good outcome according to postoperative pain levels and patients\u0026rsquo; satisfaction. Weak points of the study are the low number of patients and that it was performed retrospectively.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eDeep infiltrating endometriosis is associated with a high number of preoperative pain and reduction of quality of life. Adequate colorectal resection leads to significant pain reduction. A histological association between satellite spots or vertical bowel infiltration to preoperative pain levels were not significant in our study. An experienced interdisciplinary team seems necessary to avoid intraoperative problems and to reduce morbidity regarding postoperative complications.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements: \u003c/strong\u003eThe authors like to thank Simone Minikus for English corrections.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding: \u003c/strong\u003eNo funding was received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions: \u003c/strong\u003ePT, NV, MH, DL, PG, BA and IK designed the study. PT wrote the manuscript and prepared the tables. DL did the statistical analysis. Histological evaluation was done by NV, FO. All authors contributed toward data acquisition, data interpretation, and critical revision of the content of the manuscript and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval:\u003c/strong\u003e The study was presented to the Ethics Committee of the Province of Vorarlberg (EK-0.04-289) and does not require any referral or vote by the Ethics Committee of the Province of Vorarlberg.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material: \u003c/strong\u003eThe datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent of publication:\u003c/strong\u003e Not applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eVercellini P, Vigan\u0026ograve; P, Somigliana E et al. (2014) Endometriosis: pathogenesis and treatment. Nat Rev Endocrinol 10:\u0026nbsp;261\u0026ndash;275. https://doi.org/10.1038/nrendo.2013.255\u003c/li\u003e\n\u003cli\u003eMabrouk M, Spagnolo E, Raimondo D et al. (2012) Segmental bowel resection for colorectal endometriosis: is there a correlation between histological pattern and clinical outcomes? Hum Reprod 27:\u0026nbsp;1314\u0026ndash;1319. https://doi.org/10.1093/humrep/des048\u003c/li\u003e\n\u003cli\u003eGiudice LC (2010) Clinical practice. Endometriosis. N Engl J Med 362:\u0026nbsp;2389\u0026ndash;2398. https://doi.org/10.1056/NEJMcp1000274\u003c/li\u003e\n\u003cli\u003eEskenazi B, Warner ML (1997) Epidemiology of endometriosis. Obstet Gynecol Clin North Am 24:\u0026nbsp;235\u0026ndash;258. https://doi.org/10.1016/s0889-8545(05)70302-8\u003c/li\u003e\n\u003cli\u003eGoldstein DP, deCholnoky C, Emans SJ et al. (1980) Laparoscopy in the diagnosis and management of pelvic pain in adolescents. J Reprod Med 24:\u0026nbsp;251\u0026ndash;256\u003c/li\u003e\n\u003cli\u003eSimoens S, Dunselman G, Dirksen C et al. (2012) The burden of endometriosis: costs and quality of life of women with endometriosis and treated in referral centres. Hum Reprod 27:\u0026nbsp;1292\u0026ndash;1299. https://doi.org/10.1093/humrep/des073\u003c/li\u003e\n\u003cli\u003eNnoaham KE, Hummelshoj L, Webster P et al. (2011) Impact of endometriosis on quality of life and work productivity: a multicenter study across ten countries. Fertil Steril 96:\u0026nbsp;366-373.e8. https://doi.org/10.1016/j.fertnstert.2011.05.090\u003c/li\u003e\n\u003cli\u003eBurney RO, Giudice LC (2012) Pathogenesis and pathophysiology of endometriosis. Fertil Steril 98:\u0026nbsp;511\u0026ndash;519. https://doi.org/10.1016/j.fertnstert.2012.06.029\u003c/li\u003e\n\u003cli\u003eMacer ML, Taylor HS (2012) Endometriosis and Infertility: A review of the pathogenesis and treatment of endometriosis-associated infertility. Obstet Gynecol Clin North Am 39:\u0026nbsp;535\u0026ndash;549. https://doi.org/10.1016/j.ogc.2012.10.002\u003c/li\u003e\n\u003cli\u003eFedele L, Bianchi S, Zanconato G et al. (2004) Long-term follow-up after conservative surgery for rectovaginal endometriosis. Am J Obstet Gynecol 190:\u0026nbsp;1020\u0026ndash;1024. https://doi.org/10.1016/j.ajog.2003.10.698\u003c/li\u003e\n\u003cli\u003eMoradi M, Parker M, Sneddon A et al. (2014) Impact of endometriosis on women's lives: a qualitative study. BMC Womens Health 14:\u0026nbsp;123. https://doi.org/10.1186/1472-6874-14-123\u003c/li\u003e\n\u003cli\u003eGessler B, Eriksson O, Angenete E (2017) Diagnosis, treatment, and consequences of anastomotic leakage in colorectal surgery. Int J Colorectal Dis 32:\u0026nbsp;549\u0026ndash;556. https://doi.org/10.1007/s00384-016-2744-x\u003c/li\u003e\n\u003cli\u003eHammond J, Lim S, Wan Y et al. (2014) The burden of gastrointestinal anastomotic leaks: an evaluation of clinical and economic outcomes. J Gastrointest Surg 18:\u0026nbsp;1176\u0026ndash;1185. https://doi.org/10.1007/s11605-014-2506-4\u003c/li\u003e\n\u003cli\u003eKryzauskas M, Poskus E, Dulskas A et al. (2020) The problem of colorectal anastomosis safety. Medicine (Baltimore) 99:\u0026nbsp;e18560. https://doi.org/10.1097/MD.0000000000018560\u003c/li\u003e\n\u003cli\u003eDindo 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:\u0026nbsp;205\u0026ndash;213. https://doi.org/10.1097/01.sla.0000133083.54934.ae\u003c/li\u003e\n\u003cli\u003eMinelli L, Fanfani F, Fagotti A et al. (2009) Laparoscopic colorectal resection for bowel endometriosis: feasibility, complications, and clinical outcome. Arch Surg 144:\u0026nbsp;234-9; discussion 239. https://doi.org/10.1001/archsurg.2008.555\u003c/li\u003e\n\u003cli\u003eKavallaris A, Chalvatzas N, Hornemann A et al. (2011) 94 months follow-up after laparoscopic assisted vaginal resection of septum rectovaginale and rectosigmoid in women with deep infiltrating endometriosis. Arch Gynecol Obstet 283:\u0026nbsp;1059\u0026ndash;1064. https://doi.org/10.1007/s00404-010-1499-9\u003c/li\u003e\n\u003cli\u003eCampagnacci R, Perretta S, Guerrieri M et al. (2005) Laparoscopic colorectal resection for endometriosis. Surg Endosc 19:\u0026nbsp;662\u0026ndash;664. https://doi.org/10.1007/s00464-004-8710-7\u003c/li\u003e\n\u003cli\u003eDubernard G, Piketty M, Rouzier R et al. (2006) Quality of life after laparoscopic colorectal resection for endometriosis. Hum Reprod 21:\u0026nbsp;1243\u0026ndash;1247. https://doi.org/10.1093/humrep/dei491\u003c/li\u003e\n\u003cli\u003eFedele L, Bianchi S, Zanconato G et al. (2004) Is rectovaginal endometriosis a progressive disease? Am J Obstet Gynecol 191:\u0026nbsp;1539\u0026ndash;1542. https://doi.org/10.1016/j.ajog.2004.06.104\u003c/li\u003e\n\u003cli\u003eKiesel L, Sourouni M (2019) Diagnosis of endometriosis in the 21st century. Climacteric 22:\u0026nbsp;296\u0026ndash;302. https://doi.org/10.1080/13697137.2019.1578743\u003c/li\u003e\n\u003cli\u003eTardieu A, Sire F, Gauthier T (2018) Performance des endoscopies diagnostiques (coloscopie, fertiloscopie, hyst\u0026eacute;roscopie, cystoscopie, c\u0026oelig;lioscopie) en cas d\u0026rsquo;endom\u0026eacute;triose, RPC Endom\u0026eacute;triose CNGOF-HAS (Diagnosis accuracy of endoscopy (laparoscopy, hysteroscopy, fertiloscopy, cystoscopy, colonoscopy) in case of endometriosis: CNGOF-HAS Endometriosis Guidelines). Gynecol Obstet Fertil Senol 46:\u0026nbsp;200\u0026ndash;208. https://doi.org/10.1016/j.gofs.2018.02.024\u003c/li\u003e\n\u003cli\u003eMilone M, Mollo A, Musella M et al. (2015) Role of colonoscopy in the diagnostic work-up of bowel endometriosis. World J Gastroenterol 21:\u0026nbsp;4997\u0026ndash;5001. https://doi.org/10.3748/wjg.v21.i16.4997\u003c/li\u003e\n\u003cli\u003eMenakaya UA, Rombauts L, Johnson NP (2016) Diagnostic laparoscopy in pre-surgical planning for higher stage endometriosis: Is it still relevant? Aust N Z J Obstet Gynaecol 56:\u0026nbsp;518\u0026ndash;522. https://doi.org/10.1111/ajo.12505\u003c/li\u003e\n\u003cli\u003eJinushi M, Arakawa A, Matsumoto T et al. (2011) Histopathologic analysis of intestinal endometriosis after laparoscopic low anterior resection. J Minim Invasive Gynecol 18:\u0026nbsp;48\u0026ndash;53. https://doi.org/10.1016/j.jmig.2010.08.696\u003c/li\u003e\n\u003cli\u003eRoman H, Hennetier C, Darwish B et al. (2016) Bowel occult microscopic endometriosis in resection margins in deep colorectal endometriosis specimens has no impact on short-term postoperative outcomes. Fertil Steril 105:\u0026nbsp;423-9.e7. https://doi.org/10.1016/j.fertnstert.2015.09.030\u003c/li\u003e\n\u003cli\u003eFalconi M, Pederzoli P (2001) The relevance of gastrointestinal fistulae in clinical practice: a review. Gut 49 Suppl 4:\u0026nbsp;iv2-10. https://doi.org/10.1136/gut.49.suppl_4.iv2\u003c/li\u003e\n\u003cli\u003eAly M, O'Brien JW, Clark F et al. (2019) Does intra-operative flexible endoscopy reduce anastomotic complications following left-sided colonic resections? A systematic review and meta-analysis. Colorectal Dis 21:\u0026nbsp;1354\u0026ndash;1363. https://doi.org/10.1111/codi.14740\u003c/li\u003e\n\u003cli\u003eHirst NA, Tiernan JP, Millner PA et al. (2014) Systematic review of methods to predict and detect anastomotic leakage in colorectal surgery. Colorectal Dis 16:\u0026nbsp;95\u0026ndash;109. https://doi.org/10.1111/codi.12411\u003c/li\u003e\n\u003cli\u003eShogan BD, Carlisle EM, Alverdy JC et al. (2013) Do we really know why colorectal anastomoses leak? J Gastrointest Surg 17:\u0026nbsp;1698\u0026ndash;1707. https://doi.org/10.1007/s11605-013-2227-0\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"1\" width=\"0\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"437\"\u003e\n\u003cp\u003eTable 1: Patients\u0026rsquo; characteristics, preoperative assessments, symptoms, VAS and need for pain drugs preoperatively:\u003c/p\u003e\n\u003cp\u003e*MRI=magnet resonance tomography\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"321\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"116\"\u003e\n\u003cp\u003en = 25\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"321\"\u003e\n\u003cp\u003eAge\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"116\"\u003e\n\u003cp\u003e34.16 (\u0026plusmn;5.45)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"321\"\u003e\n\u003cp\u003eBMI\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"116\"\u003e\n\u003cp\u003e21.76 (\u0026plusmn;2.60)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"321\"\u003e\n\u003cp\u003eASA Classification:\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"116\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"321\"\u003e\n\u003cp\u003eI\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"116\"\u003e\n\u003cp\u003e22 (88.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"321\"\u003e\n\u003cp\u003eII\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"116\"\u003e\n\u003cp\u003e3 (12.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"321\"\u003e\n\u003cp\u003eIII\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"116\"\u003e\n\u003cp\u003e0 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"321\"\u003e\n\u003cp\u003eComorbidities\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"116\"\u003e\n\u003cp\u003e0 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"321\"\u003e\n\u003cp\u003ePreoperative assessment:\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"116\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"321\"\u003e\n\u003cp\u003eColonoscopy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"116\"\u003e\n\u003cp\u003e14 (56.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"321\"\u003e\n\u003cp\u003eMRI*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"116\"\u003e\n\u003cp\u003e19 (76.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"321\"\u003e\n\u003cp\u003ePreoperative diagnostic laparoscopy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"116\"\u003e\n\u003cp\u003e7 (28.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"321\"\u003e\n\u003cp\u003ePreoperative symptoms:\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"116\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"321\"\u003e\n\u003cp\u003etenesmus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"116\"\u003e\n\u003cp\u003e2 (8.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"321\"\u003e\n\u003cp\u003eabdominal distension\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"116\"\u003e\n\u003cp\u003e5 (20.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"321\"\u003e\n\u003cp\u003econstipation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"116\"\u003e\n\u003cp\u003e2 (8.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"321\"\u003e\n\u003cp\u003ediarrhoea\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"116\"\u003e\n\u003cp\u003e3 (12.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"321\"\u003e\n\u003cp\u003ehaematochezia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"116\"\u003e\n\u003cp\u003e5 (20.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"321\"\u003e\n\u003cp\u003epain on defecation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"116\"\u003e\n\u003cp\u003e6 (24.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"321\"\u003e\n\u003cp\u003edyspareunia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"116\"\u003e\n\u003cp\u003e8 (32.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"321\"\u003e\n\u003cp\u003edysmenorrhoea\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"116\"\u003e\n\u003cp\u003e22 (88.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"321\"\u003e\n\u003cp\u003edysuria\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"116\"\u003e\n\u003cp\u003e1 (4.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"321\"\u003e\n\u003cp\u003eunfulfilled desire for children\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"116\"\u003e\n\u003cp\u003e9 (36.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"321\"\u003e\n\u003cp\u003eneuropathic pain\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"116\"\u003e\n\u003cp\u003e1 (4.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"321\"\u003e\n\u003cp\u003echronic pelvic pain\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"116\"\u003e\n\u003cp\u003e4 (16.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"321\"\u003e\n\u003cp\u003eAverage VAS preoperative\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"116\"\u003e\n\u003cp\u003e8.32 (\u0026plusmn;1.70)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"321\"\u003e\n\u003cp\u003eNeed for pain drugs during menstruation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"116\"\u003e\n\u003cp\u003e22 (88.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" width=\"0\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"437\"\u003e\n\u003cp\u003eTable 2: Perioperative Results:\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; *from anal verge in case of rectal- or sigmoid resection\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"351\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003en = 25\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"351\"\u003e\n\u003cp\u003ePrevious therapeutic laparoscopy for endometriosis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e13 (52.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"351\"\u003e\n\u003cp\u003ePrevious abdominal surgery\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e14 (56.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"351\"\u003e\n\u003cp\u003ePrevious hysterectomy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e1 (4.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"351\"\u003e\n\u003cp\u003eOperation time (min)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e200 (\u0026plusmn;49)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"351\"\u003e\n\u003cp\u003eOperation procedure\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"351\"\u003e\n\u003cp\u003erectal resection\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e14 (56.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"351\"\u003e\n\u003cp\u003esigmoid resection\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e6 (24.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"351\"\u003e\n\u003cp\u003eileocaecal resection\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e1 (4.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"351\"\u003e\n\u003cp\u003erectal-resection+hysterectomy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e3 (12.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"351\"\u003e\n\u003cp\u003erectal-resection+ileocaecal resection\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e1 (4.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"351\"\u003e\n\u003cp\u003eheight of anastomosis*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e9.12 (\u0026plusmn;4.46)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"351\"\u003e\n\u003cp\u003eSimultaneous gynaecological operation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e23 (92%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"351\"\u003e\n\u003cp\u003eDuration of hospital stay (d)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e7.37 (\u0026plusmn;2.65)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"351\"\u003e\n\u003cp\u003eConversion to laparotomy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e0 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"351\"\u003e\n\u003cp\u003eIntraoperative Complications\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e0 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"351\"\u003e\n\u003cp\u003eNeed for ileostomy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e4 (16.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"351\"\u003e\n\u003cp\u003ePostoperative complications\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e6 (24.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"351\"\u003e\n\u003cp\u003eanastomotic leakage\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e3 (12.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"351\"\u003e\n\u003cp\u003eanastomotic bleeding\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e2 (8.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"351\"\u003e\n\u003cp\u003einfected haematoma\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e1 (4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"351\"\u003e\n\u003cp\u003eDindo-Clavien Classification\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"351\"\u003e\n\u003cp\u003eIIIa\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e3 (12.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"351\"\u003e\n\u003cp\u003eIIIb\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e3 (12.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"351\"\u003e\n\u003cp\u003eComplication management\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"351\"\u003e\n\u003cp\u003eHartmann procedure\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e1 (4.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"351\"\u003e\n\u003cp\u003ere-laparoscopy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e1 (4.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"351\"\u003e\n\u003cp\u003eendoscopic clipping\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e2 (8.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"351\"\u003e\n\u003cp\u003eendo-VAC therapy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e2 (8.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"351\"\u003e\n\u003cp\u003eRe-performing surgery\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e2 (8.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" width=\"0\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"317\"\u003e\n\u003cp\u003eTable 3: Pathological findings:\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"317\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003en = 25\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"317\"\u003e\n\u003cp\u003eVertical infiltration\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"317\"\u003e\n\u003cp\u003emucosa\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e2 (8.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"317\"\u003e\n\u003cp\u003esubmucosa\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e6 (24.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"317\"\u003e\n\u003cp\u003emuscularis propria\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e17 (68.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"317\"\u003e\n\u003cp\u003esubserosa\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e25 (100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"317\"\u003e\n\u003cp\u003eserosa\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e25 (100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"317\"\u003e\n\u003cp\u003eSatellite spots\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e6 (24.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"317\"\u003e\n\u003cp\u003eAdditional locations\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e23 (92.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"317\"\u003e\n\u003cp\u003eperitoneum\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e6 (24.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"317\"\u003e\n\u003cp\u003evagina\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e3 (12.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"317\"\u003e\n\u003cp\u003esacrouterine ligament\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e7 (28.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"317\"\u003e\n\u003cp\u003ebladder peritoneum\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e9 (36.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"317\"\u003e\n\u003cp\u003efallopian tube\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e3 (12.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"317\"\u003e\n\u003cp\u003eovary\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e8 (32%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"317\"\u003e\n\u003cp\u003eparametries\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e2 (8.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"317\"\u003e\n\u003cp\u003eClear resection margins\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e25 (100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" width=\"0\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"437\"\u003e\n\u003cp\u003eTable 4: Follow-up:\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; *LARS=low anterior resection syndrome\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"308\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"129\"\u003e\n\u003cp\u003en = 25\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"308\"\u003e\n\u003cp\u003eFollow-up time (months)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"129\"\u003e\n\u003cp\u003e38.68 (\u0026plusmn;19.92)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"308\"\u003e\n\u003cp\u003eRe-Operation rate for endometriosis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"129\"\u003e\n\u003cp\u003e0 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"308\"\u003e\n\u003cp\u003eAverage VAS-score follow up\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"129\"\u003e\n\u003cp\u003e1.70 (\u0026plusmn;2.54)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"308\"\u003e\n\u003cp\u003ePostoperative symptoms\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"129\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"308\"\u003e\n\u003cp\u003etenesmus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"129\"\u003e\n\u003cp\u003e0 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"308\"\u003e\n\u003cp\u003eAbdominal distension\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"129\"\u003e\n\u003cp\u003e0 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"308\"\u003e\n\u003cp\u003erectal bleeding\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"129\"\u003e\n\u003cp\u003e0 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"308\"\u003e\n\u003cp\u003econstipation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"129\"\u003e\n\u003cp\u003e1 (4.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"308\"\u003e\n\u003cp\u003ediarrhoea\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"129\"\u003e\n\u003cp\u003e1 (4.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"308\"\u003e\n\u003cp\u003enausea and vomiting\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"129\"\u003e\n\u003cp\u003e0 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"308\"\u003e\n\u003cp\u003epain on defecation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"129\"\u003e\n\u003cp\u003e0 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"308\"\u003e\n\u003cp\u003edyspareunia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"129\"\u003e\n\u003cp\u003e0 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"308\"\u003e\n\u003cp\u003edysmenorrhoea\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"129\"\u003e\n\u003cp\u003e6 (24.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"308\"\u003e\n\u003cp\u003edysuria\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"129\"\u003e\n\u003cp\u003e0 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"308\"\u003e\n\u003cp\u003echronic pelvic pain\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"129\"\u003e\n\u003cp\u003e0 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"308\"\u003e\n\u003cp\u003ebladder emptying disorder\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"129\"\u003e\n\u003cp\u003e1 (4.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"308\"\u003e\n\u003cp\u003eminor LARS*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"129\"\u003e\n\u003cp\u003e3 (12.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"308\"\u003e\n\u003cp\u003eGravida\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"129\"\u003e\n\u003cp\u003e5 (20.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"308\"\u003e\n\u003cp\u003ePara\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"129\"\u003e\n\u003cp\u003e2 (8.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"308\"\u003e\n\u003cp\u003eRecurrence of endometriosis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"129\"\u003e\n\u003cp\u003e0 (0.00%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" width=\"0\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"4\" width=\"558\"\u003e\n\u003cp\u003eTable 5: Pre- and postoperative VAS score: Correlation between patients with or without satellite spots and vertical bowel infiltration\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"217\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"113\"\u003e\n\u003cp\u003eSatellite + (n = 6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003eSatellite - (n = 19)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u003cem\u003ep\u003c/em\u003e Value\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"217\"\u003e\n\u003cp\u003eVAS-score preoperative\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"113\"\u003e\n\u003cp\u003e8.66 (\u0026plusmn;1.03)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e8.21 (\u0026plusmn;1.87)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e0.97\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"217\"\u003e\n\u003cp\u003eVAS-score follow-up\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"113\"\u003e\n\u003cp\u003e1.50 (\u0026plusmn;1.97)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e1.77 (\u0026plusmn;2.75)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e0.94\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"217\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"113\"\u003e\n\u003cp\u003eMucosa\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; (n = 2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003eSubmucosa\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; (n = 6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003eMuscularis propria (n = 17)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u003cem\u003ep\u003c/em\u003e Value\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"217\"\u003e\n\u003cp\u003eVAS-score preoperative\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"113\"\u003e\n\u003cp\u003e9.00 (\u0026plusmn;1.41)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e8.50 (\u0026plusmn;1.04)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e8.17 (\u0026plusmn;1,94)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e0.93\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"217\"\u003e\n\u003cp\u003eVAS-score follow-up\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"113\"\u003e\n\u003cp\u003e0.00 (\u0026plusmn;0,00)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e1.66 (\u0026plusmn;2,42)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e1.93 (\u0026plusmn;2.74)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e0.73\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" width=\"0\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"3\" width=\"510\"\u003e\n\u003cp\u003eTable 6: Semiquantitative data on pain levels before and at time of follow-up:\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003eVAS-score preoperative\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"151\"\u003e\n\u003cp\u003eVAS-score follow-up\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u003cem\u003ep\u003c/em\u003e Value\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003eAll patients (n = 25)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e8.32 (\u0026plusmn;1.70)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"151\"\u003e\n\u003cp\u003e1.70 (\u0026plusmn;2.54)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e0.00001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003eSatellite + (n = 6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e8.66 (\u0026plusmn;1.03)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"151\"\u003e\n\u003cp\u003e1.50 (\u0026plusmn;1.97)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e0.005\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003eSatellite - (n = 20)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e8.21 (\u0026plusmn;1.87)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"151\"\u003e\n\u003cp\u003e1.77 (\u0026plusmn;2.75)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e0.00001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003eMucosa (n = 2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e9.00 (\u0026plusmn;1.41)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"151\"\u003e\n\u003cp\u003e0.00 (\u0026plusmn;0.00)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e0.005\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003eSubmucosa (n = 6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e8.50 (\u0026plusmn;1.04)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"151\"\u003e\n\u003cp\u003e1.66 (\u0026plusmn;2.42)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e0.005\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003eMuscularis propria (n = 17)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e8.17 (\u0026plusmn;1.94)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"151\"\u003e\n\u003cp\u003e1.93 (\u0026plusmn;2.74)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e0.00001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-medical-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejmr","sideBox":"Learn more about [European Journal of Medical Research](http://eurjmedres.biomedcentral.com)","snPcode":"40001","submissionUrl":"https://submission.nature.com/new-submission/40001/3","title":"European Journal of Medical Research","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Endometriosis, bowel involvement, colorectal resection, histopathology, pain level","lastPublishedDoi":"10.21203/rs.3.rs-115333/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-115333/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIntroduction\u003c/p\u003e\u003cp\u003eEndometriosis is associated with a high number of chronic pelvic pain and reduced quality of life. Colorectal resections in case of bowel involvement of endometriosis is associated with an unneglectable morbidity in young and healthy patients. There is no linear correlation established between the degree of symptoms and stage of endometriosis. The aim of this study was to correlate the histological findings to preoperative pain scores in colorectal resected patients with endometriosis. \u003c/p\u003e\u003cp\u003eMethods\u003c/p\u003e\u003cp\u003e25 Patients who underwent colorectal resection for endometriosis between 2014 and 2019 were included in this retrospective study. Pain level was assessed preoperatively and postoperatively via phone call in May 2020. Histopathology was correlated to preoperative symptoms and postoperative outcome. \u003c/p\u003e\u003cp\u003eResults\u003c/p\u003e\u003cp\u003eAverage follow-up time was 38.68 months (±19.92). Preoperative VAS-score was 8.32 (±1.70). We observed a significant reduction of pain level in all patients after surgery (\u003cem\u003ep ≤ \u003c/em\u003e0.005). Pain levels were equal regarding the presence of satellite spots and various degrees of infiltration depth. The resection margins were clear in all patients. Postoperative complications occurred in 6 cases (24%), anastomotic leakage was observed in 3 patients (12%). Average VAS-score at time of follow-up was 1.70 (±2.54). \u003c/p\u003e\u003cp\u003eConclusion\u003c/p\u003e\u003cp\u003eOur data demonstrate that adequate colorectal resection leads to reduction of pain and an increase of quality of life irrespective of histopathological findings. An experienced team is necessary in order to improve intraoperative outcome and to reduce postoperative morbidity in case of complication.\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Colorectal Resection in Endometriosis Patients: Correlation Between Histopathological Findings and Postoperative Outcome.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-12-01 17:43:01","doi":"10.21203/rs.3.rs-115333/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2020-12-16T00:00:00+00:00","index":1,"fulltext":"Recommendation: Reviewer's comments unavailable due to the journal's policy.\n"},{"type":"reviewersInvited","content":"","date":"2020-11-24T00:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-11-24T00:00:00+00:00","index":1,"fulltext":""},{"type":"editorAssigned","content":"","date":"2020-11-21T00:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-11-20T23:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-11-20T23:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"","date":"2020-11-20T00:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-medical-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejmr","sideBox":"Learn more about [European Journal of Medical Research](http://eurjmedres.biomedcentral.com)","snPcode":"40001","submissionUrl":"https://submission.nature.com/new-submission/40001/3","title":"European Journal of Medical Research","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"07cf10a4-aeb4-447e-b960-2a9e6f10b1f7","owner":[],"postedDate":"December 1st, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":1233063,"name":"Health Economics \u0026 Outcomes Research"}],"tags":[],"updatedAt":"2021-01-26T15:04:29+00:00","versionOfRecord":{"articleIdentity":"rs-115333","link":"https://doi.org/10.1186/s40001-021-00484-z","journal":{"identity":"european-journal-of-medical-research","isVorOnly":false,"title":"European Journal of Medical Research"},"publishedOn":"2021-01-23 15:03:18","publishedOnDateReadable":"January 23rd, 2021"},"versionCreatedAt":"2020-12-01 17:43:01","video":"","vorDoi":"10.1186/s40001-021-00484-z","vorDoiUrl":"https://doi.org/10.1186/s40001-021-00484-z","workflowStages":[]},"version":"v1","identity":"rs-115333","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-115333","identity":"rs-115333","version":["v1"]},"buildId":"B-jG_2CBjPDmsCi4Wdhf-","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}