Effect of Retaining the Uterus During Anterior Resection for Rectosigmoid Bowel Endometriosis

Introduction

Endometriosis is defined as the presence of endometrial tissue outside the uterus and is a significant health problem affecting 10%–15% of women of reproductive age. The condition often causes symptoms such as dysmenorrhea, pelvic pain, dyspareunia, and infertility, ¹ and has negative impacts on a patient's social and economic life, as well as her mental and psychologic health.^2,3

The bowel is the most common site of extragenital endometriosis, affecting 3%–37% of cases of deep infiltrating endometriosis.^4,5 Symptoms include diarrhea, constipation, perimenstrual changes in bowel habits, rectal bleeding, dyschezia, tenesmus, abdominal distention, small-caliber stools, and colicky abdominal pain. ⁶

Bowel endometriosis is most commonly found on the rectosigmoid junction and rectum (65.7%), and sigmoid colon (17.4%), followed by the appendix (6.4%), cecum and ileocecal junction (4.1%), and small bowel (4.7%). ⁷ Endometriosis limited to the serosa should be classified as peritoneal disease, and the bowel is considered to be involved when endometriosis reaches at least the subserous fat tissue. ⁶

Treatment options include a radical approach based on colorectal segmental resection, and the conservative approach prioritizing conservation of the rectum either without opening the rectum (shaving) or by removing the nodule along with the surrounding rectal wall (disc excision). ⁸ Choice of surgical approach depends on the location of the lesion, depth of infiltration, number of nodules, and presence or absence of stricture.^9,10

The aims of the current study were: (1) to investigate the effects of anterior resection for rectosigmoid endometriosis on symptoms of endometriosis and surgical morbidity; (2) to compare outcomes between women who underwent hysterectomy at the time of their anterior resection with those who had their uteri conserved; and (3) to identify any risk factors for surgical complications.

Materials and Methods

This was a retrospective cohort study conducted at a university-affiliated, tertiary-referral medical center. A list of women who underwent anterior resection for endometriosis within a 5-year period between January 1, 2013, and December 31, 2017, was provided by health information services.

Women with suspected bowel endometriosis were seen by both gynecologic and colorectal teams preoperatively for counseling and consenting, and the surgeries were scheduled as combined cases. At discharge from the hospital, 2 follow-up appointments were made for the patients to be seen by the 2 teams 3 months postsurgery.

The following data were collected: patient characteristics, including age, body mass index (BMI), parity, history of previous laparoscopy or laparotomy, and symptoms; surgical management, including types of gynecologic and colorectal procedures; intraoperative and postoperative complications; and gynecologic and colorectal follow-up findings.

Data were analyzed using SPSS, version 23 (IBM Corp., Armonk, NY, USA). Categorical variables were summarized by frequency and percentage, and continuous variables were summarized by mean and standard deviation (SD) or median and interquartile range for nonnormally distributed variables. Patient characteristics, surgical management, and postoperative details were compared between women who elected to have hysterectomies and those who did not. Patient characteristics and surgical management were compared between those women with postoperative complications and women without such complications. Pearson's χ ² test or Fisher's exact test when more than 20% of the expected values were <5 were used for categorical variables, and continuous variables were examined using a Student's t-test or a Mann–Whitney-U test if the variables were not normally distributed.

The study was judged to meet the requirements of the National Health and Medical Research Council's National Statement on Ethical Conduct in Human Research, and ethics approval was obtained from the Institutional Human Research Ethics Committee (Reference number HREC/17/QRBW/602).

Results

During the study timeperiod, 33 women underwent anterior resection. Their ages ranged from 26 to 50 (mean: 36.4 years), and their BMIs ranged from 17.7 to 35.5 (mean: 27.5) (Table 1). Sixteen women (48.5%) were nulliparous, and parity ranged from 0 to 6 (mean: 1).

Seventeen women (51.5%) underwent hysterectomies and 16 women wished to retain their fertility and, therefore, did not undergo hysterectomies. There were 4 cases (12.1%) of concurrent ileostomy and 4 cases of appendectomy. There were 32 laparoscopic cases (97.0%), 3 of which were converted to laparotomies, and 1 case (3.0%) was intended to be a laparotomy. The average length of bowel removed was 159.3mm (SD: 65.5). There were no intraoperative complications.

The length of stay ranged from 4 to 32 days (mean: 8 days). Postoperative complications occurred in 12 (36.4%) women. There were 3 (9.1%) cases of voiding dysfunction requiring temporary self-catheterization; 2 (6.1%) cases of anastomotic leaks; 2 cases of ileus managed conservatively; 2 readmissions for conservative management of gastrointestinal symptoms; and 1 case (3%) each of pancreatitis, abdominal-wall seroma, and anterior resection syndrome. The 2 women with anastomotic leaks had the longest stays of 32 and 22 days.

All women reported either complete resolution of their symptoms or reduced pain symptoms at the follow-up appointments. Eight women (24.2%) reported altered bowel habits, for which 2 women underwent colonoscopy with normal findings. All women with altered bowel habits were managed conservatively.

Women who elected to have hysterectomies tended to be older (hysterectomy: age 39.8 [SD: 5.6 years] versus no hysterectomy: 32.8 [SD: 4.2 years]) and to have children (hysterectomy: 76.5 % versus no hysterectomy: 25.0 %; Table 1). All women who had hysterectomies had anterior resections without ileostomy, compared to 75.0 % of women who did not have a hysterectomies (p = 0.044). The lengths of bowel resections was similar between groups: 157.4 mm (SD: 74.3) for the no-hysterectomy group, compared to 161.2 mm (SD: 58.4) for the hysterectomy group. There were no significant differences in the percentage of postoperative complications between the 2 groups.

Fourteen women with postoperative complications were compared to 19 women who did not experience postoperative complications. There were no significant differences in patient characteristics, preoperative symptoms, types of surgical management, or lengths of bowel resection between the 2 groups. (Table 2)

Discussion

Anterior resection for bowel endometriosis was effective, as the patients in the current study reported either complete resolution of their symptoms or reduced endometriosis-related pain symptoms at their follow-up appointments. This is consistent with a 2016 study reporting significant decreases in visual analogue scale (VAS) scores for dysmenorrhea, dyspareunia, and dyschezia after segmental resection, ¹¹ and a systematic review published in 2011 stating that pain relief after bowel resection for deep endometriosis was consistent with 71.4%–93.6% of women being pain-free after 1 year of follow up. ¹²

Concerns regarding bowel resection over conservative approaches, including shaving and disc excision, involve the potential for surgical complications. In the current study, 24.2% of women had altered bowel habits and 6.1% of cases were complicated with anastomotic leaks associated with extended lengths of hospital stays. Other surgical complications reported in the literature include fistulae (0%–14%); hemorrhages (1%–11%); and infections, including abscesses (1%–3%).^12,13 Yet, the conservative approach could be associated with higher risks of recurrences and subsequent needs for further surgery. Recurrences after surgery have been reported to be 27.6%, 13.3%, and 6.6% after shaving, disc excision, and segmental resection respectively. ¹¹

The current authors compared women who underwent hysterectomy with those who did not, and there were no significant differences in the percentage of postoperative complications between the 2 groups. Although this is encouraging for women who wish to conserve their fertility, this finding was limited to the follow up period of 3 months. When 83 women who underwent surgery for rectovaginal endometriosis with retention of their uteri and at least 1 ovary were followed up at 36 months, the cumulative rates of pain recurrence, clinical or sonographic recurrence, and new treatment (surgical and/or gonadotropin-releasing hormone agonist treatment) were relatively high at 28%, 34% and 27%, respectively. ¹⁴

When characteristics of women with and without postoperative complications were compared, no significant differences were identified in any of the parameters, including lengths of bowel resections. With respect to histologic patterns and clinical outcomes for segmental bowel resections for colorectal endometriosis, no statistically significant differences in anatomical and pain recurrences, pain symptoms, and quality-of-life improvements were found among patients with or without positive margins, satellite lesions, and different degrees of vertical infiltrations. ¹⁵

The current study identified 1 case of postoperative pancreatitis, which was managed conservatively with intravenous fluid, diet modification, and analgesia. The 2 most common causes of acute pancreatitis are gallstones and alcohol abuse, and the other etiologies include hypertriglyceridemia, medications, trauma, infections, and iatrogenesis. ¹⁶ Colectomy requiring significant retroperitoneal dissection, particularly at the splenic flexure, might result in pancreatic manipulation and trauma.^17,18

The current study demonstrated that, despite the modest number of bowel segmental resections for endometriosis performed at this institution, the majority of the cases were completed laparoscopically with relatively low complication rates. However, the sample size was small in this retrospective chart review and, as such, the p-values for comparisons should be interpreted with caution.

Conclusions

Future studies involving long-term follow-u3p and fertility outcomes for patients who retain their uteri would be beneficial. The incidence of surgical morbidity involved with the bowel poses a therapeutic dilemma. Having a sound rationale behind the management plan for each patient and careful preoperative counseling are essential.