Segmental bowel resection for deep infiltrating endometriosis

Riiskjær et al. report the functional outcome of segmental bowel resection for rectosigmoid endometriosis during the laparoscopic treatment of deep infiltrating disease. This large, prospective study, employing validated outcome measures, is a welcome addition to the literature. We note that some patients who underwent discoid resection of bowel endometriosis were included. Segmental resection and disc resection entail different degrees of dissection, perhaps resulting in variable neurological effects. Injury to the inferior hypogastric plexi and their visceral branches is thought to mediate the functional problems associated with excisional surgery for endometriosis. It remains difficult to determine the impact of bowel resection alone on autonomic function, as the removal of other disease will influence outcome. The authors describe attempts to preserve autonomic nerves during surgery and ‘nerve sparing’ techniques have been reported (Landi et al. Hum Reprod. 2006;21:774–81). Sexual function improved after surgery, driven primarily by a reduction in dyspareunia. Statistically significant improvements in sexual satisfaction, intimacy, desire, and coital frequency were also noted. The reduction in dyspareunia and associated distress represents a change in SVQ responses from ‘quite a bit’ to ‘a little’ and these improvements are likely to be clinically meaningful. At baseline and 1 year postoperatively, almost half of the study population described major symptoms stratified by the LARS questionnaire. Defaecation frequency increased after surgery, although the median scores for other bowel symptoms were unchanged. These data imply that segmental bowel resection should not be undertaken in the expectation that functional bowel symptoms will improve. The impact of surgery on painful defaecation was not reported, although we note plans for future publication. Median ICIQ-FLUTS scores were similar before and after surgery, although the authors did report a reduction in postoperative bladder pain. The pathophysiological explanation for this is unclear. If the effect is real, it could be related to the surgical treatment of bladder lesions or to a reduction in central sensitisation following surgical treatment of disease elsewhere. Measures of central tendency such as the median describe the average characteristics of a population. Although they are informative summary statistics, they can conceal information about the risk of new-onset symptoms. The inclusion of these data might have complemented the analysis. The need for intermittent catheterisation after this type of surgery is common, although voiding usually returns in the long-term (Minelli et al. Arch Surg 2009;144:234–9). Catheter dependence was not reported but would have been an interesting addition. In summary, this large, prospective series demonstrates that in their hands, sexual function after surgery improves, and the median effect of surgery on bladder function is likely neutral. Although bowel frequency increased, patients were no more likely to experience faecal urgency or anal incontinence after surgery than before. Although local excision of bowel endometriosis is preferred to segmental resection where feasible (Fanfani et al. Fertil Steril 2010;94:444–9), these data provide further evidence that segmental resection can be undertaken with a low risk of functional consequences. However, it must be appreciated that the extent of dissection outside the proximity of the bowel is likely to have influenced the results. Full disclosure of interests available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.