Surgical management of deep infiltrating endometriosis with bowel involvement: a narrative review

Deep infiltrating endometriosis (DIE) involving the bowel represents a complex and challenging subset of this condition, affecting approximately 5–12% of women with endometriosis and often leading to significant pain, bowel symptoms, and impaired quality of life (1,2). The rectosigmoid colon is the most frequently affected site, reported in approximately 70–90% of cases across different series, while less commonly involved segments include the appendix (3–18%), the terminal ileum (2–16%), and the cecum/ileocecal region (up to 14%) (3,4). Management of these lesions is challenging and often requires surgical intervention, as medical therapy with hormonal inhibitors, though capable of alleviating some symptoms, is frequently associated with adverse effects such as headache, weight gain, or loss of libido, leading to treatment discontinuation in more than 55% of patients (5,6). Moreover, current evidence does not fully clarify whether medical therapy can halt or prevent disease progression, highlighting the central role of surgery, particularly in severe cases, where it is associated with substantial improvements in pain and overall quality of life (4). Over recent decades, a range of surgical techniques has been developed to manage bowel DIE, from conservative approaches such as shaving, to more radical procedures including discoid excision and segmental bowel resection (7-9). These techniques differ in invasiveness, complexity, and associated risks, creating a clinical dilemma between achieving complete disease eradication and preserving bowel function (9). Surgical complications such as anastomotic leakage, fistulas, and postoperative bowel or urinary dysfunction further influence the choice of approach (9,10). Despite advances in surgical methods and perioperative care, recurrence after bowel surgery remains a major challenge, with rates varying widely according to disease extent and surgical technique (1,2). Functional outcomes—including bowel, urinary, and sexual function—also significantly impact postoperative quality of life and must be considered during surgical planning (6,10). The advent of minimally invasive techniques, especially robot-assisted surgery, offers promising opportunities for enhanced precision and potentially improved functional preservation (3). Given the heterogeneous nature of available evidence and the complexity of bowel-involved DIE, a comprehensive synthesis of outcomes associated with different surgical techniques is essential to inform clinical decision-making. Previous reviews often focus on single surgical approaches, specific outcomes, or conventional laparoscopic methods, without integrating functional results or emerging technologies. As a result, clinicians currently lack clear, evidence-based guidance to balance disease eradication, complication risk, and functional preservation when selecting the optimal surgical strategy. This narrative review addresses these gaps by directly comparing all major surgical techniques for bowel-involved DIE—shaving, discoid excision, and segmental resection—while evaluating functional outcomes, recurrence, and the impact of emerging technologies such as robot-assisted surgery. By integrating these elements, the review provides a more comprehensive, patient-centered synthesis of current evidence and practical guidance for individualized surgical decision-making in this complex and heterogeneous field. We present this article in accordance with the Narrative Review reporting checklist (available at https://ales.amegroups.com/article/view/10.21037/ales-2025-1-54/rc).

The search strategy is summarized in Table 1. A literature review was performed between 14th May and 1st July 2025 using the PubMed database to identify relevant articles on treatment in DIE with intestinal involvement. Keyword searches included: “intestinal deep infiltration endometriosis”, “intestinal endometriosis”, “colorectal deep endometriosis”, “colorectal endometriosis”, “surgery deep infiltration endometriosis” and “intestinal surgery deep endometriosis”. Only English articles were included. After the identification of relevant articles, the abstracts were read to select eligible articles for full-text revision. References of identified articles were searched for additional relevant articles. Case reports, editorial letters, and non-English articles were excluded. Table 1 | Items | Specification | |---|---| | Date of search | 14th May and 1st July 2025 | | Database searched | PubMed | | Search terms used | “Intestinal deep infiltration endometriosis”, “intestinal endometriosis”, “colorectal deep endometriosis”, “colorectal endometriosis”, “surgery deep infiltration endometriosis” and “intestinal surgery deep endometriosis” | | Timeframe | January 1, 2010 to January 1, 2025 | | Inclusion and exclusion criteria | Inclusion criteria: original articles, systematic reviews, and meta-analysis | | Exclusion criteria: case reports, editorial letters, and non-English articles were excluded | | | Selection process | Participating authors identified relevant articles based on content, clinical relevance, and date of publication |

A total of 136 articles were retrieved from PubMed using the aforementioned keywords. After filtering relevance and excluding duplicates, 17 articles were chosen for full-text analysis. Articles characteristics are specified in Table 2. Table 2 | Author | Year | N (patients) | Age (years) | Type of surgery | Follow-up (months) | Type of studies included | |---|---|---|---|---|---|---| | Ianieri et al. (1) | 2018 | 2,696 | Not reported | Shaving, discoid resection and segmental bowel resections | 1–138 | Systematic review and meta-analysis of observational studies | | Bendifallah et al. (2) | 2020 | 1,366 | Not reported | Shaving, discoid resection and segmental bowel resections | Not fully reported (>12) | Systematic review and meta-analysis of observational studies | | Ong et al. (3) | 2024 | 536 | Not reported | Shaving, discoid resection and segmental bowel resections | Not reported | Systematic review of observational studies | | Bendifallah et al. (4) | 2021 | 2,737 | Not reported | Shaving, discoid resection and segmental bowel resections | Not reported | Systematic review and meta-analysis of observational studies | | Dunselman et al. (6) | 2014 | N/A | N/A | N/A | N/A | Consensus-based clinical practice guideline | | Balla et al. (7) | 2018 | 3,079 | 34 | Segmental bowel resection | Not reported | Systematic review of observational studies | | Vesale et al. (8) | 2020 | 1,349 | Not reported | Shaving, discoid resection and segmental bowel resections | Not reported | Systematic review and meta-analysis of observational studies | | Popoutchi et al. (9) | 2021 | 1,187 | 30–38 | Shaving, discoid resection and segmental bowel resections | 1–43 | Systematic review of randomized controlled trials and observational studies | | De Cicco et al. (10) | 2011 | 1,107 | Not reported | Segmental bowel resection | Not reported | Systematic review of observational studies | | Darici et al. (11) | 2022 | 976 | Not reported | Segmental bowel resection | Not reported | Systematic review of observational studies | | Roman et al. (12) | 2018 | 60 | 27–36 | Shaving, discoid resection and segmental bowel resections | 24 | Randomized clinical trial | | Roman et al. (13) | 2021 | 51 | 24–49 | Segmental bowel resection | Not reported | Observational study | | Roman et al. (14) | 2017 | 1,135 | Not reported | Shaving, discoid resection and segmental bowel resections | Not reported | Multicenter observational study | | Quintairos et al. (15) | 2022 | 1,145 | Not reported | Shaving, discoid resection and segmental bowel resections | Not reported | Systematic review and meta-analysis of observational studies | | O'Brien et al. (16) | 2023 | 2,861 | Not reported | Shaving, discoid resection and segmental bowel resections | Not reported | Systematic review and meta-analysis of observational studies | | Meuleman et al. (17) | 2012 | 500 | Not reported | Segmental bowel resection | 16–40 | Systematic review of observational studies | | Arcoverde et al. (18) | 2019 | 5,621 | Not reported | Not reported | Not reported | Systematic review and meta-analysis of observational studies | N/A, not available. The surgical management of DIE is primarily categorized into three techniques: shaving, discoid excision, and segmental bowel resection. Each technique exhibits distinct profiles regarding short- and long-term outcomes, functional impact and recurrence and quality of life. While standardized criteria for selecting the surgical approach are lacking in the literature, conservative techniques are generally favored for small, minimally infiltrative lesions, whereas segmental intestinal resections are indicated for larger or more aggressive lesions. Ultimately, the choice of procedure rests on the operating surgeon’s judgment, considering both lesion characteristics and patient-specific factors (11,12). Accurate preoperative assessment is crucial. Imaging modalities such as pelvic magnetic resonance imaging (MRI) and rectal endoscopic ultrasound provide valuable guidance in selecting the most appropriate surgical approach, demonstrating high sensitivity for detecting muscular layer invasion of the intestinal wall. MRI is particularly effective for evaluating the extent of rectosigmoid involvement and identifying lesions with a wall thickness greater than 6 mm, which correlates with muscular infiltration. Rectal endoscopic ultrasound complements MRI, especially for lower lesions or when MRI findings are equivocal, allowing precise mapping of lesion depth and aiding in the choice between conservative techniques (shaving or discoid resection) and segmental bowel resection (19-21). Shaving Shaving involves the superficial removal of endometriotic lesions from the bowel surface, preserving bowel integrity without full-thickness excision, as shown in Figure 1. It is typically reserved for small (<3 cm), superficial, or partial-thickness lesions without significant bowel lumen stenosis. As a conservative surgical technique, shaving is a viable option for treating multiple segments of the intestine, including the small bowel. In multifocal disease, multiple shaving procedures can be performed provided that affected nodules are separated by at least 5 cm of healthy intestine, allowing maximal bowel preservation and minimizing postoperative dysfunction. Overall, this approach enables less invasive surgery, with lower complication rates and a faster recovery (13-15,22). Short-term outcomes Shaving demonstrates the most favorable perioperative safety profile among the three techniques. Complication rates range from 5% to 15%, primarily minor and manageable without invasive interventions (1,4,9). Operative times are shorter, and intraoperative blood loss is minimized. Patients usually experience less postoperative pain, facilitating early mobilization and hospital discharge within 1 to 3 days (4,9). Postoperative bowel function tends to be preserved with low incidence of early constipation, diarrhea, or tenesmus (15). Long-term outcomes and recurrence While shaving limits surgical morbidity, it carries a higher risk of disease recurrence, reported in 15% to 30% of cases (1,2). This is mainly attributed to the potential for incomplete excision of deeply infiltrating lesions. Patients may require secondary and more aggressive procedures for symptom recurrence or lesion progression. Functional outcomes and quality of life Conservative bowel surgery using shaving for DIE provides significant improvements in quality of life and gastrointestinal function, while preserving bowel and autonomic nerve integrity. This approach results in lower rates of postoperative voiding dysfunction and fecal incontinence compared with more radical resections (8,15,23,24). However, shaving may carry a higher risk of disease recurrence, which can affect long-term quality of life (18). Overall, shaving offers an effective balance between symptom control, functional preservation, and patient-reported outcomes. Discoid excision Discoid excision entails full-thickness excision of a localized nodule of endometriosis from the bowel wall, as shown in Figure 2. This technique is best suited for deep isolated nodules smaller than 3 cm without extensive circumferential involvement or stenosis. Short-term outcomes Discoid excision has intermediate perioperative morbidity, with complication rates between 10% and 20%. Common complications include localized anastomotic leakage, stenosis at the resection site, and occasional bowel obstruction (7,11). Hospitalization averages 3 to 5 days, with most patients returning to daily activities within weeks (4). Long-term outcomes and recurrence Recurrence rates after discoid excision range from 10% to 25%, indicating improved disease control compared to shaving (2,7). However, the risk of fibrosis or stenosis at the surgical site remains a concern as it may imply reintervention. Functional outcomes and quality of life Discoid excision balances disease clearance with functional preservation. Patients generally maintain good bowel and urinary function, experiencing fewer functional deficits than those undergoing segmental resection (8,11). Quality of life gains are notable, reflecting effective symptom control with acceptable morbidity (18). Segmental bowel resection Segmental bowel resection entails en bloc removal of the diseased bowel segment. It is indicated for extensive, multifocal, large (>3 cm) nodules or significant bowel stenosis, as shown in Figure 3. Short-term outcomes Segmental resection carries the highest perioperative risk. Complication rates vary widely but may reach up to 40%, including serious adverse events such as anastomotic leakage (4–7%), rectovaginal fistulas (2–5%), pelvic abscesses (7–12%), and postoperative ileus (10–15%) (2,4,8). Surgery involves longer operative times, increased blood loss and extended hospital stays, commonly 5 to 10 days (4,8). Postoperative pain is more severe, and recovery is prolonged. Long-term outcomes and recurrence This technique offers the lowest recurrence rates, often reported between 5% and 15%, due to radical disease excision. Recurrence of intestinal endometriosis after segmental bowel resection can occur despite complete surgical excision, and is influenced by several factors. Incomplete removal of microscopic disease at resection margins is a primary contributor, while lesion characteristics such as size, depth, and multifocality can make total excision challenging. Additionally, the estrogen-dependent nature of endometriosis means that lack of postoperative hormonal suppression can promote regrowth of residual tissue. Adequate postoperative follow-up is crucial to detect and manage recurrence early. Overall, meticulous surgical planning, precise technique, appropriate hormonal therapy, and regular monitoring are key to minimizing recurrence risk and optimizing long-term patient outcomes (1,2,4). Functional outcomes and quality of life Despite superior disease control, segmental resection is linked to increased risks of long-term functional complications. Resection involving the rectum may result in low anterior resection syndrome (LARS), presenting with urgency, frequent bowel movements, and fecal incontinence, which can significantly impact postoperative quality of life. (8,10). Voiding and sexual dysfunction also occur frequently, likely due to autonomic nerve injury during extensive dissection (8). Nonetheless, patients generally report substantial pain relief and improvements in global quality of life following surgery (16-18). Short- and long-term morbidity is summarized in Tables 3,4, respectively. Table 3 | Complication | Shaving | Discoid excision | Segmental resection | |---|---|---|---| | Intraoperative bleeding/hematoma (%) | 1–5 | 3–8 | 5–15 | | Pelvic abscess (%) | <2 | 3–6 | 7–12 | | Anastomotic leak (%) | <1 (rare) | 1–2 | 4–7 | | Rectovaginal fistula (%) | <1 | <1 | 2–5 | | Postoperative ileus (%) | 2–4 | 5–10 | 10–15 | | Voiding dysfunction/urinary retention (%) | <1 | 2–5 | 10–20 | | Average hospital stay (days) | 1–3 | 3–5 | 5–10 | | Overall morbidity (any complication) (%) | 5–15 | 10–20 | 20–40 | Table 4 | Complication | Shaving | Discoid excision | Segmental resection | |---|---|---|---| | Disease recurrence/symptom relapse (%) | 15–30 | 10–25 | 5–15 | | Chronic constipation (%) | 5–10 | 5–10 | 10–20 | | Fecal incontinence/urgency (%) | <2 | 2–5 | 5–12 | | Anastomotic stricture (%) | 6 months) (%) | <1 | 3–7 | 10–25 | | Sexual dysfunction/dyspareunia (%) | 5–10 | 8–15 | 10–20 | | Bowel function impairment (overall) (%) | 10–20 | 15–25 | 25–40 | | Overall long-term morbidity (%) | 15–25 | 20–30 | 30–45 |

Our narrative review of surgical strategies for bowel-involved DIE underscores the challenge of achieving complete disease removal while minimizing perioperative short- and long-term morbidity. The three main surgical techniques—shaving, discoid excision, and segmental bowel resection—each present distinct advantages and limitations that must be carefully weighed against patient-specific factors, disease extent, and surgical expertise. In line with these considerations, recent very long-term data provide important insights into the durability of these approaches. A 15-year follow-up study of women undergoing surgery for colorectal endometriosis has shown generally favorable functional and patient-reported outcomes, with stable continence scores, low rates of severe bowel dysfunction, and high levels of long-term satisfaction (25). Although a modest but statistically significant decline in gastrointestinal quality of life was observed over time, clinically relevant impairment remained uncommon. Reoperation and recurrence rates were low, and fertility outcomes were largely favorable, supporting the long-term effectiveness of surgical management when performed in specialized centers. These findings emphasize the importance of individualized surgical planning and reinforce the need to balance disease eradication with preservation of long-term functional outcomes. Balancing radicality and functional preservation The data clearly illustrate a trade-off between surgical radicality and postoperative morbidity. Shaving, the least invasive technique, offers superior short-term safety with reduced complication rates, shorter hospital stays, and quicker recovery. This technique preserves bowel integrity and pelvic autonomic nerves, translating into better early functional outcomes and quality of life while improving bowel symptoms including constipation, urgency and frequency (1,4,7-9). However, the higher recurrence rates associated with shaving underscore its limitation in completely eradicating deeply infiltrating lesions. For patients prioritizing preservation of function or with limited disease, shaving may represent an optimal first-line approach, but it requires close postoperative surveillance and the possibility of additional interventions if symptoms recur. Discoid excision provides a balanced middle ground by allowing full-thickness removal of localized lesions with acceptable morbidity and improved long-term disease control. While it may carry higher short-term complication risks than shaving, these usually remain substantially lower than those associated with segmental resection (7,8). The risk of postoperative stenosis or fibrosis at the resection site, though uncommon, necessitates careful patient selection and surgical technique refinement. Importantly, discoid excision preserves much of the bowel and pelvic nerve function, which may mitigate severe long-term dysfunction seen with more radical surgery (8,9). Segmental bowel resection provides the most disease clearance, reflected in low recurrence rates and effective relief of obstructive symptoms. Nevertheless, it carries substantially higher perioperative morbidity, including serious complications such as anastomotic leakage and fistula formation (2-4), as well as long-term bowel dysfunction—manifesting as LARS, fecal incontinence, and urinary or sexual dysfunction—which significantly impacts quality of life (15,16). It is essential to recognize that in certain clinical scenarios—such as extensive, multifocal, or obstructive disease—radical surgery is clearly indicated (20). These decisions are inherently complex, requiring careful assessment of disease burden, patient priorities, and multidisciplinary input. Surgical planning must balance the benefits of complete disease clearance against the substantial functional risks, acknowledging that there is no universal solution and that each case demands individualized consideration. Recent evidence from an updated systematic review and meta-analysis underscores the functional implications of surgical radicality in bowelinvolved DIE (26). In an analysis of 22 studies comparing colorectal procedures, conservative approaches—namely rectal shaving and discoid excision—were associated with significantly lower rates of postoperative voiding dysfunction compared with segmental resection. Rectal shaving, in particular, demonstrated a markedly reduced likelihood of both early and persistent voiding dysfunction relative to more radical resection, and conservative procedures overall showed a protective effect against urinary morbidity. These findings reinforce the concept that less invasive techniques may better preserve pelvic autonomic nerve function and lower urinary tract outcomes, which are critical aspects of postoperative quality of life. However, the decision to pursue conservative versus radical surgery must still account for disease extent and individual patient priorities, as radical approaches may be required to achieve complete disease clearance in more advanced or obstructive cases. Role of surgical expertise and multidisciplinary care Outcomes across all techniques are closely tied to surgeon experience and the availability of multidisciplinary teams. Given the complexity of pelvic anatomy and DIE pathology, involvement of colorectal surgeons alongside gynecologic surgeons improves surgical precision and reduces complications (4,8). Multidisciplinary evaluation allows for accurate mapping of disease extent, identification of potential urinary or bowel involvement, and selection of the most appropriate surgical approach, whether conservative or segmental. Moreover, such coordination is associated with lower rates of voiding dysfunction, fecal incontinence, and other procedure-related complications, ultimately contributing to improved quality of life and patient satisfaction. The importance of nerve-sparing techniques cannot be overstated, particularly in segmental resections, to preserve autonomic function and minimize voiding and sexual dysfunction (8). Optimizing preoperative assessment, including imaging and multidisciplinary planning, is essential to select the most appropriate surgical approach and anticipate intraoperative challenges. The implementation of Enhanced Recovery After Surgery (ERAS) protocols is increasingly recognized as a key factor in optimizing outcomes specifically for these patients. ERAS programs focus on preoperative counseling, optimized anesthesia, early mobilization and early enteral nutrition, which collectively reduce postoperative pain, shorten hospital stay and accelerate functional recovery. Evidence suggests that adherence to ERAS protocols in this patient population minimizes surgical stress, lowers complication rates, and enhances overall patient satisfaction, contributing to improved postoperative quality of life (4). Emerging role of robotic surgery and technological advances Although this review focused primarily on conventional laparoscopic and open techniques, robot-assisted surgery and intraoperative neuromonitoring have emerged as promising approaches for bowel-involved DIE. Robotic platforms provide enhanced dexterity, three-dimensional visualization, and improved ergonomics, potentially facilitating precise dissection in complex anatomical planes (3). Early observational reports suggest possible reductions in intraoperative complications and improved preservation of autonomic nerves. However, the supporting evidence remains limited and largely non-randomized, and critical factors such as the surgical learning curve, procedural costs, availability, and external validity have not been adequately addressed (3). Similarly, adjunctive technologies, including fluorescence imaging for nerve identification and pelvic intraoperative neuromonitoring, may enhance nerve-sparing outcomes and reduce morbidity (4,27). While systematic evaluation in intestinal endometriosis is lacking, evidence from malignant rectal surgery indicates potential benefits. Nevertheless, the translation of these findings to benign bowel DIE must be interpreted with caution.

and future directions The heterogeneity of study designs, patient populations, and outcome measures represents a major limitation of the current evidence base and restricts the ability to draw definitive conclusions. The majority of available data are derived from observational studies and meta-analyses of non-randomized studies with variable follow-up periods. Consequently, comparative conclusions between surgical techniques are commonly derived from low- to moderate-quality evidence, which may limit the reliability of the available findings. Furthermore, as this review is primarily narrative in nature and largely based on systematic reviews of observational studies, which often share overlapping primary sources, there is a potential risk of duplicated evidence and overestimation on the robustness of the reported findings. There is a clear need for well-designed, adequately powered randomized controlled trials directly comparing surgical techniques, with standardized definitions and reporting of complications, recurrence rates, and patient-reported outcomes. Furthermore, long-term functional outcomes and quality of life measures remain insufficiently investigated and should be prioritized in future research to improve clinical decision-making and patient counseling. The systematic integration of validated bowel, urinary and sexual function questionnaires into clinical studies and routine practice would enhance the assessment of postoperative morbidity and overall patient well-being. Given the limited case volumes and the high technical complexity of intestinal endometriosis surgery, centralization of care in tertiary referral centers with specialized multidisciplinary teams may represent an important strategy to improve outcomes. Such centralization facilitates the development of surgical expertise, standardized perioperative management, unified data collection, and robust outcome reporting, thereby strengthening the quality of future evidence.

The surgical management of bowel-involved DIE remains highly complex and requires a patient-centered, individualized approach. No single surgical technique is universally applicable, and treatment selection should be guided by lesion characteristics, symptom severity, and patient preferences regarding functional outcomes and recurrence risk. However, most current recommendations are primarily based on observational studies and meta-analyses of non-randomized data, with a limited contribution from high-quality randomized controlled trials, resulting in a low overall level of evidence and restricting the strength of comparative conclusions. Shaving, discoid excision, and segmental bowel resection each present distinct advantages and limitations, underscoring the importance of careful patient selection and shared decision-making. Advanced surgical technologies may enhance precision and functional preservation, but their clinical value requires further validation. Optimal outcomes depend on multidisciplinary collaboration, surgical expertise, and systematic assessment of patient-reported outcomes. Future research should prioritize well-designed randomized controlled trials, standardized outcome measures, and long-term follow-up to strengthen the evidence base and support informed, evidence-based management of this challenging condition. Acknowledgments None. Footnote Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://ales.amegroups.com/article/view/10.21037/ales-2025-1-54/rc Peer Review File: Available at https://ales.amegroups.com/article/view/10.21037/ales-2025-1-54/prf Funding: None. Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://ales.amegroups.com/article/view/10.21037/ales-2025-1-54/coif). The authors have no conflicts of interest to declare. Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

- Ianieri MM, Mautone D, Ceccaroni M. Recurrence in Deep Infiltrating Endometriosis: A Systematic Review of the Literature. J Minim Invasive Gynecol 2018;25:786-93. [Crossref] [PubMed] - Bendifallah S, Vesale E, Daraï E, et al. Recurrence after Surgery for Colorectal Endometriosis: A Systematic Review and Meta-analysis. J Minim Invasive Gynecol 2020;27:441-451.e2. [Crossref] [PubMed] - Ong HI, Shulman N, Nugraha P, et al. Role of robot-assisted laparoscopy in deep infiltrating endometriosis with bowel involvement: a systematic review and application of the IDEAL framework. Int J Colorectal Dis 2024;39:98. [Crossref] [PubMed] - Bendifallah S, Puchar A, Vesale E, et al. Surgical Outcomes after Colorectal Surgery for Endometriosis: A Systematic Review and Meta-analysis. J Minim Invasive Gynecol 2021;28:453-66. [Crossref] [PubMed] - Westhoff CL, Heartwell S, Edwards S, et al. Oral contraceptive discontinuation: do side effects matter? Am J Obstet Gynecol 2007;196:412.e1-6; discussion 412.e6-7. [Crossref] [PubMed] - Dunselman GA, Vermeulen N, Becker C, et al. ESHRE guideline: management of women with endometriosis. Hum Reprod 2014;29:400-12. [Crossref] [PubMed] - Balla A, Quaresima S, Subiela JD, et al. Outcomes after rectosigmoid resection for endometriosis: a systematic literature review. Int J Colorectal Dis 2018;33:835-47. [Crossref] [PubMed] - Vesale E, Roman H, Moawad G, et al. Voiding Dysfunction after Colorectal Surgery for Endometriosis: A Systematic Review and Meta-analysis. J Minim Invasive Gynecol 2020;27:1490-1502.e3. [Crossref] [PubMed] - Popoutchi P, Marques OW Junior, Averbach P, et al. Surgical techniques for the treatment of rectal endometriosis: a systematic review of randomized controlled trials and observational studies. Arq Gastroenterol 2021;58:548-59. [Crossref] [PubMed] - De Cicco C, Corona R, Schonman R, et al. Bowel resection for deep endometriosis: a systematic review. BJOG 2011;118:285-91. [Crossref] [PubMed] - Darici E, Salama M, Bokor A, et al. Different segmental resection techniques and postoperative complications in patients with colorectal endometriosis: A systematic review. Acta Obstet Gynecol Scand 2022;101:705-18. [Crossref] [PubMed] - Roman H, Bubenheim M, Huet E, et al. Conservative surgery versus colorectal resection in deep endometriosis infiltrating the rectum: a randomized trial. Hum Reprod 2018;33:47-57. [Crossref] [PubMed] - Roman H, Merlot B, Forestier D, et al. Nonvisualized palpable bowel endometriotic satellites. Hum Reprod 2021;36:656-65. [Crossref] [PubMed] - Roman HFRIENDS group. (French coloRectal Infiltrating ENDometriosis Study group). A national snapshot of the surgical management of deep infiltrating endometriosis of the rectum and colon in France in 2015: A multicenter series of 1135 cases. J Gynecol Obstet Hum Reprod 2017;46:159-65. - Quintairos RA, Brito LGO, Farah D, et al. Conservative versus Radical Surgery for Women with Deep Infiltrating Endometriosis: Systematic Review and Meta-analysis of Bowel Function. J Minim Invasive Gynecol 2022;29:1231-40. [Crossref] [PubMed] - O’Brien L, Morarasu S, Morarasu BC, et al. Conservative surgery versus colorectal resection for endometriosis with rectal involvement: a systematic review and meta-analysis of surgical and long-term outcomes. Int J Colorectal Dis 2023;38:55. - Meuleman C, Tomassetti C, D’Hooghe TM. Clinical outcome after laparoscopic radical excision of endometriosis and laparoscopic segmental bowel resection. Curr Opin Obstet Gynecol 2012;24:245-52. [Crossref] [PubMed] - Arcoverde FVL, Andres MP, Borrelli GM, et al. Surgery for Endometriosis Improves Major Domains of Quality of Life: A Systematic Review and Meta-Analysis. J Minim Invasive Gynecol 2019;26:266-78. [Crossref] [PubMed] - Sloss S, Mooney S, Ellett L, et al. Preoperative Imaging in Patients with Deep Infiltrating Endometriosis: An Important Aid in Predicting Depth of Infiltration in Rectosigmoid Disease. J Minim Invasive Gynecol 2022;29:633-40. [Crossref] [PubMed] - Trippia CH, Zomer MT, Terazaki CR, et al. Relevance of Imaging Examinations in the Surgical Planning of Patients with Bowel Endometriosis. Clin Med Insights Reprod Health 2016;10:1-8. [Crossref] [PubMed] - Vlek SL, Zwart EAH, Schreurs AMF, et al. Deep endometriosis muscular infiltration of the bowel wall: correlation between MRI and histopathology. Clin Radiol 2023;78:661-5. [Crossref] [PubMed] - Chou D, Perera S, Condous G, et al. Shaving for Bowel Endometriosis. J Minim Invasive Gynecol 2020;27:268-9. [Crossref] [PubMed] - Seracchioli R, Ferrini G, Montanari G, et al. Does laparoscopic shaving for deep infiltrating endometriosis alter intestinal function? A prospective study. Aust N Z J Obstet Gynaecol 2015;55:357-62. - Mabrouk M, Ferrini G, Montanari G, et al. Does colorectal endometriosis alter intestinal functions? A prospective manometric and questionnaire-based study. Fertil Steril 2012;97:652-6. - Crestani A, Merlot B, Belingar F, et al. Very long-term outcomes after surgery for colorectal endometriosis: a 15-year follow-up study. Fertil Steril 2026;125:725-7. [Crossref] [PubMed] - Madar A, Crestani A, Eraud P, et al. Voiding dysfunction after surgery for colorectal deep infiltrating endometriosis: an updated systematic review and meta-analysis. Updates Surg 2025;77:739-48. [Crossref] [PubMed] - Kneist W, Ghadimi M, Runkel N, et al. Pelvic Intraoperative Neuromonitoring Prevents Dysfunction in Patients With Rectal Cancer: Results From a Multicenter, Randomized, Controlled Clinical Trial of a NEUROmonitoring System (NEUROS). Ann Surg 2023;277:e737-44. [Crossref] [PubMed] Cite this article as: Besa A, Bravo R, Pena R, Tavares S, Valverde S, Otero A, Pera M. Surgical management of deep infiltrating endometriosis with bowel involvement: a narrative review. Ann Laparosc Endosc Surg 2026;11:28.