Long-term evaluation of quality of life and gastrointestinal well-being after segmental colo-rectal resection for deep infiltrating endometriosis (ENDO-RESECT QoL)

Purposes The primary objective is to assess the long-term quality of life (QoL) and gastrointestinal well-being in patients with endometriosis (DIE) who underwent segmental resection (SR), through specific questionnaires focused on endometriosis and specific gastrointestinal evaluation. The secondary objectives are represented by the evaluation of peri-operative and post-operative outcomes of the procedure.

This observational cohort study ENDO-RESECT (ClinicalTrials.gov ID: NCT03824054) reports all clinical data about women who underwent SR for DIE between October 2005 and November 2017. In the part of the study dedicated to the QoL assessment, the questionnaires adopted were the Endometriosis Health Profile (EHP30), the Psychological General Well-Being Index and the Hospital Anxiety and Depression Scale, the Gastrointestinal Well-being questionnaire and the Bristol Stool chart. Major post-surgical morbidity and obstetric outcomes were also collected.

50 women (18% stage III and 82% stage IV rAFS) were considered for enrollment. EHP-30 interpretation demonstrated a significant improvement in all continuous variables, except for fertility concerns. The overall gastrointestinal QoL and most of the specific symptoms improved after surgery. Frequent bowel movements appeared in the 13% of the series not resulting in an impairment of general and gastrointestinal QoL. Constipation remained unchanged. Patients with depressive mood managed with laparoscopy, benefited the most from SR; moreover, patients with multinodular bowel localizations experienced a greater reduction in abdominal pain. Median FU after SR was 42.5 months (range 12–157 months). Only three (6%) cases of late major grade III complications were documented. The pregnancy rate was 50%.

Improvement of general QoL and most of gastrointestinal symptoms was documented after SR. Similar content being viewed by others

Koninckx PR, Meuleman C, Demeyere S et al (1991) Suggestive evidence that pelvic endometriosis is a progressive disease, whereas deeply infiltrating endometriosis is associated with pelvic pain. Fertil Steril 55:759–765 Ek Malin, Roth Bodil, Ekström Per, Valentin Lil, Bengtsson Mariette, Ohlsson Bodil (2015) Gastrointestinal symptoms among endometriosis patients—a case-cohort study. BMC Women’s Health 15:59. https://doi.org/10.1186/s12905-015-0213-2 Donnez J, Nisolle M, Casanas-Roux F et al (1995) Rectovaginal septum, endometriosis or adenomyosis: laparoscopic management in a series of 231 patients. Hum Reprod 10:630–635 Koninckx PR, Martin D (1994) Treatment of deeply infiltrating endometriosis. Curr Opin Obstet Gynecol 6:231–241 Vitale SG, La Rosa VL, Rapisarda AMC, Lagana’ AS (2017) Impact of endometriosis on quality of life and psychological well-being. J Psychosom Obstet Gynaecol 38(4):317–319. https://doi.org/10.1080/0167482x.2016.1244185 Cosentino F, Turco LC, Ferrandina G et al (2017) Endometrial stromal sarcoma arising from endometriosis Incidence, management and treatment of primary extrauterine localization. J Endometr Pelvic Pain Disord. https://doi.org/10.5301/jeppd.5000287 Duffy JM, Arambage K, Correa FJ et al (2014) Laparoscopic surgery for endometriosis. Cochrane Database Syst Rev 4:CD011031 Cosentino F, Vizzielli G, Turco LC et al (2018) Near-infrared imaging with indocyanine green for detection of endometriosis lesions (Gre-Endo Trial): a pilot study. J Minim Invasive Gynecol 25(7):1249–1254. https://doi.org/10.1016/j.jmig.2018.02.023 Abrao MS, Petraglia F, Falcone T, Keckstein J, Osuga Y, Chapron C (2015) Deep endometriosis infiltrating the recto-sigmoid: critical factors to consider before management. Hum Reprod Update 21:329–339 Bassi MA, Podgaec S, Dias JA, D’Amico Filho N, Petta CA, Abrao MS (2011) Quality of life after segmental resection of the rectosigmoid by laparoscopy in patients with deep infiltrating endometriosis with bowel involvement. J Minim Invasive Gynecol 18(6):730–733. https://doi.org/10.1016/j.jmig.2011.07.014 Meuleman C, Tomassetti C, Wolthuis A et al (2014) Clinical outcome after radical excision of moderate-severe endometriosis with or without bowel resection and reanastomosis: a prospective cohort study. Ann Surg 259(3):522–531. https://doi.org/10.1097/SLA.0b013e31828dfc5c Roman H, Milles M, Vassilieff M et al (2016) Long-term functional outcomes following colorectal resection versus shaving for rectal endometriosis. Am J Obstet Gynecol 215(762):e1–e9 Daraï E, Bazot M, Rouzier R, Houry S, Dubernard G (2007) Outcome of laparoscopic colorectal resection for endometriosis. Curr Opin Obstet Gynecol 19(4):308–313 Roman H, Vassilieff M, Tuech JJ et al (2013) Postoperative digestive function after radical versus conservative surgical philosophy for deep endometriosis infiltrating the rectum. Fertil Steril 99(6):1695–1704. https://doi.org/10.1016/j.fertnstert.2013.01.131 Kent A, Shakir F, Rockall T et al (2016) Laparoscopic surgery for severe rectovaginal endometriosis compromising the bowel: a prospective cohort study. J Minim Invasive Gynecol 23(4):526–534. https://doi.org/10.1016/j.jmig.2015.12.006 Roman H, Bubenheim M, Huet E, Bridoux V, Zacharopoulou C, Daraï E, Collinet P, Tuech J-J (2018) Conservative surgery versus colorectal resection in deep endometriosis infiltrating the rectum: a randomized trial. Hum Reprod 33(1):47–57 Guerriero S, Ajossa S, Pascual MA, Rodriguez I, Piras A, Perniciano M, Saba L, Paoletti AM, Mais V, Alcazar JL (2019) Ultrasonographic ‘soft’ markers for the detection of rectosigmoid endometriosis. Ultrasound Obstet Gynecol. https://doi.org/10.1002/uog.20289 Bourdel N, Alves J, Pickering G, Ramilo I, Roman H, Canis M (2015) Systematic review of endometriosis pain assessment: how to choose a scale? Hum Reprod Update 21(1):136–152. https://doi.org/10.1093/humupd/dmu046 Jones G, Kennedy S, Barnard A et al (2001) Development of an endometriosis quality-of-life instrument: the Endometriosis Health Profile-30. Obstet Gynecol 98:258–264 Grossi E, Mosconi P, Groth N, Niero M, Apolone G (2002) Questionario Psychological General Well-Being Index. Versione Italiana. Istituto di ricerche farmacologiche “Mario Negri”-Milano, Maggio Moorey S, Greer S, Watson M et al (1991) The factor structure and factor stability of the hospital anxiety and depression scale in patients with cancer. Br J Psychiatry 158:255–259 Revicki DA, Wood M, Wiklund I, Crawley J (1998) Reliability and validity of the Gastrointestinal Symptom Rating Scale in patients with gastroesophageal reflux disease. Qual Life Res 7(1):75–83 Heaton KW, Lewis SJ (1997) Stool form scale as a useful guide to intestinal transit time. Scand J Gastroenterol 32(9):920–924 Jones G, Jenkinson C, Kennedy S (2004) Evaluating the sensitivity to change of the Endometriosis Health Profile Questionnaire. The EHP-30. Qual Life Res 13:705–713 Jones G, Jenkinson C, Taylor N, Mills A, Kennedy S (2006) Measuring quality of life in women with endometriosis: tests of data quality, score reliability, response rate and scaling assumptions of the Endometriosis Health Profile Questionnaire. Hum Reprod 21:2686–2693 Kulich KR, Calabrese C, Pacini F, Vigneri S, Carlsson J, Wiklund IK (2004) Psychometric validation of the italian translation of the gastrointestinal symptom-rating scale and quality of life in reflux and dyspepsia questionnaire in patients with gastro-oesophageal reflux disease. Clin Drug Investig 24(4):205–215 Kulich KR, Madisch A, Pacini F, Piqué JM et al (2008) Reliability and validity of the Gastrointestinal Symptom Rating Scale (GSRS) and Quality of Life in Reflux and Dyspepsia (QOLRAD) questionnaire in dyspepsia: a six-country study. Health Qual Life Outcomes 6:12 Tack J, Talley NJ (2013) Functional dyspepsia—symptoms, definitions and validity of the Rome III criteria. Nat Rev Gastroenterol Hepatol 10(3):134–141. https://doi.org/10.1038/nrgastro.2013.14 Montesani C, Pronio A, Santella S et al (2004) Rectal cancer surgery with sphincter preservation: functional results related to the level of anastomosis. Clinical and instrumental study. Hepatogastroenterology 51(57):718–721 American Fertility Society (1985) Revised American Fertility Society classification of endometriosis. Fertil Steril 43(3):351–352 Katayama H, Kurokawa Y, Nakamura K et al (2016) Extended Clavien–Dindo classification of surgical complications: Japan Clinical Oncology Group postoperative complications Criteria. Surg Today 46(6):668–685. https://doi.org/10.1007/s00595-015-1236-x Vlahos N, Vlachos A, Triantafyllidou O, Vitoratos N, Creatsas G (2013) Continuous versus cyclic use of oral contraceptives after surgery for symptomatic endometriosis: a prospective cohort study. Fertil Steril 100(5):1337–1342. https://doi.org/10.1016/j.fertnstert.2013.07.008 Dubernard G, Piketty M, Rouzier R, Houry S, Bazot M, Darai E (2006) Quality of life after laparoscopic colorectal resection for endometriosis. Hum Reprod 21:1243–1247 Roman H, Loisel C, Resch B (2010) Delayed functional outcomes associated with surgical management of deep rectovaginal endometriosis with rectal involvement: giving patients an informed choice. Hum Reprod 25(4):890–899. https://doi.org/10.1093/humrep/dep407 Meuleman C, Tomassetti C, D’Hoore A et al (2011) Surgical treatment of deeply infiltrating endometriosis with colorectal involvement. Hum Reprod Update 17:311–326 Vitale SG, La Rosa VL, Vitagliano A et al (2018) Sexual function and quality of life in patients affected by deep infiltrating endometriosis: current evidence and future perspectives. J Endometr Pelvic Pain Disord 9(4):270–274 Laganà AS, La Rosa VL, Rapisarda AMC et al (2017) Anxiety and depression in patients with endometriosis: impact and management challenges. Int J Womens Health 9:323–330 Vitale SG, La Rosa VL, Rapisarda AMC, Laganà AS (2017) Endometriosis and infertility: the impact on quality of life and mental health. J Endometr Pelvic Pain Disord 9(2):112–115 Luscombe GM, Markham R, Judio M, Grigoriu A, Fraser IS (2009) Abdominal bloating: an under-recognized endometriosis symptom. J Obstet Gynaecol Can 31(12):1159–1171 Agrawal A, Whorwell PJ (2008) Review article: abdominal bloating and distension in functional gastrointestinal disorders-epidemiology and exploration of possible mechanisms. Aliment Pharmacol Ther 27(1):2–10 Roman H, Bubenheim M, Huet E, Bridoux V, Zacharopoulou C, Collinet P, Daraï E, Tuech J-J (2019) Baseline severe constipation negatively impacts functional outcomes of surgery for deep endometriosis infiltrating the rectum: results of the ENDORE randomized trial. Gynecol Obstet Hum Reprod 48:625–629 Fond G, Loundou A, Hamdani N et al (2014) Anxiety and depression comorbidities in irritable bowel syndrome (IBS): a systematic review and meta-analysis. Eur Arch Psychiatry Clin Neurosci 264(8):651–660. https://doi.org/10.1007/s00406-014-0502-z Rangan V, Mitsuhashi S, Singh P et al (2018) Risk factors for fecal urgency among individuals with and without diarrhea, based on data from the National Health and Nutrition Examination Survey. Clin Gastroenterol Hepatol 16(9):1450–1458e2. https://doi.org/10.1016/j.cgh.2018.02.020 Singh P, Takazawa E, Rangan V et al (2019) Fecal urgency is common in constipated patients and is associated with anxiety. Neurogastroenterol Motil 31(4):e13545. https://doi.org/10.1111/nmo.13545 Duepree HJ, Senagore AJ, Delaney CP, Marcello PW, Brady KM, Falcone T (2002) Laparoscopic resection of deep pelvic endometriosis with rectosigmoid involvement. J Am Coll Surg 195:754–758 De Cicco C, Corona R, Schonman R, Mailova K, Ussia A, Koninckx PR (2011) Bowel resection for deep endometriosis: a systematic review. BJOG 118:285–291 ten Broek RP, Issa Y, van Santbrink EJ et al (2013) Burden of adhesions in abdominal and pelvic surgery: systematic review and met-analysis. BMJ 3(347):f5588. https://doi.org/10.1136/bmj.f5588 Roman H, Moatassim-Drissa S, Marty N et al (2016) Rectal shaving for deep endometriosis infiltrating the rectum: a 5-year continuous retrospective series. Fertil Steril 106(6):1438–1445e2. https://doi.org/10.1016/j.fertnstert.2016.07.1097 Dousset B, Leconte M, Borghese B et al (2010) Complete surgery for low rectal endometriosis. Long-term results of a 100-case prospective study. Ann Surg 251(5):887–895. https://doi.org/10.1097/sla.0b013e3181d9722d Bertocchi E, Barugola G, Benini M et al (2019) Colorectal anastomotic stenosis: lesson learned after 1643 colorectal resections for deep infiltrating endometriosis. J Minim Invasive Gynecol 26(1):100–104. https://doi.org/10.1016/j.jmig.2018.03.033

The authors thank Dr. Franziska Michaela Lohmeyer (Fondazione Policlinico Universitario A. Gemelli IRCCS-Direzione Scientifica IRCCS) and Dr Richard Renston M.D. for their important contribution in revising the form and the English language of this article. Funding This study did not receive any fund. Author information Authors and Affiliations Corresponding author Ethics declarations Conflict of interest The authors declare that they have no conflict of interest. Ethical approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee (No. PROT. APROV. IST CICOG-31-10-18\100) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors. Informed consent Informed consent was obtained from all individual participants included in the study. Additional information Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Electronic supplementary material Below is the link to the electronic supplementary material. Supplementary figure 1 (download TIFF ) Mean GSRS score for specific symptoms (reflux, diarrhea syndrome, constipation syndrome, abdominal pain, indigestion syndrome) in relation to single vs multiple nodules at referred pre-surgical status and at last FU after surgery. p value calculated by t-test for 2 means. a Single nodule and b multiple nodules (TIFF 82 kb) Supplementary figure 2 (download TIFF ) Mean GSRS score for specific symptoms (reflux, diarrhea syndrome, constipation syndrome, abdominal pain, indigestion syndrome) in relation to the state of anxiety at referred pre-surgical status and at last FU after surgery. p value calculated by t-test for 2 means. a Non anxious patients and b anxious patients (TIFF 81 kb) Supplementary figure 3 (download TIFF ) Mean GSRS score for specific symptoms (reflux, diarrhea syndrome, constipation syndrome, abdominal pain, indigestion syndrome) in relation to the state of depression at referred pre-surgical status and at last FU after surgery. p value calculated by t-test for 2 means. a Non depressed patients and b depressed patients (TIFF 81 kb) Supplementary figure 4 (download TIFF ) Mean GSRS score for specific symptoms (reflux, diarrhea syndrome, constipation syndrome, abdominal pain, indigestion syndrome) in patients underwent different surgical approach at referred pre-surgical status and at last FU after surgery. p value calculated by t-test for 2 means. a Laparoscopy and b laparotomy (TIFF 81 kb) Rights and permissions About this article Cite this article Turco, L.C., Scaldaferri, F., Chiantera, V. et al. Long-term evaluation of quality of life and gastrointestinal well-being after segmental colo-rectal resection for deep infiltrating endometriosis (ENDO-RESECT QoL). Arch Gynecol Obstet 301, 217–228 (2020). https://doi.org/10.1007/s00404-019-05382-8 Received: Accepted: Published: Version of record: Issue date: DOI: https://doi.org/10.1007/s00404-019-05382-8