Laparoscopic segmental colorectal resection for endometriosis: limits and complications

Surg Endosc (2007) 21: 1572–1577 DOI: 10.1007/s00464-006-9160-1 Ó Springer Science+Business Media, LLC 2007

Laparoscopic segmental colorectal resection for endometriosis: limits and complications E. Darai,1 G. Ackerman,1 M. Bazot,2 R. Rouzier,1 G. Dubernard1 1 2

Service de gyne´cologie, Obste´trique et me´decine de la reproduction, Hoˆpital Tenon, 4 rue de la chine, 75020, Paris, France Service de Radiologie, Hoˆpital Tenon, 4 rue de la Chine, 75020, Paris, France

Received: 30 September 2006/Accepted: 7 October 2006/Online publication: 7 March 2007

Abstract Background: Deep pelvic endometriosis with colorectal involvement is a complex disorder often requiring segmental bowel resection. This study investigated the limits and complications of laparoscopic segmental colorectal resection. Methods: Laparoscopic segmental colorectal resection was performed for 71 women with bowel endometriosis. Intra- and postoperative complications were evaluated, together with symptom outcomes, by means of questionnaires completed before and after surgery. Surgical procedures and complications were compared between the first part of the study (40 cases, previously published) and the second part (31 cases). Results: Of the 71 women, 64 (90%) underwent laparoscopic segmental colorectal resection, with 7 requiring laparoconversion. Major complications occurred in nine cases (12.6%), six with rectovaginal fistulae and three with pelvic abscesses. The mean operating time decreased significantly during the study (p < 0.05). The mean followup period after colorectal resection was 24.4 ± 2.2 months. No differences in the rates of laparoconversion or complications were observed between the two periods, whereas major associated surgical procedures were more frequent during the second period. Dysmenorrhea (p < 0.0001), dyspareunia (p = 0.0001), pain at defecation (p = 0.0004), bowel movement pain or cramping (p < 0.0001), lower back pain (p < 0.0001), and asthenia (p < 0.0001) were improved after the operation, with no difference between the study periods. Conclusion: This large series confirms the feasibility and efficacy of laparoscopic segmental colorectal resection. However, women must be informed of the risk for potentially severe complications. Key words: Bowel endometriosis — Colorectal endometriosis — Colorectal resection — Deep pelvic endometriosis — Endometriosis — Laparoscopy Correspondence to: E. Darai

Endometriosis is a gynecologic disorder defined by the presence of the endometrial gland and stroma outside the uterus [1]. Deep infiltrating pelvic endometriosis with bowel involvement is one of the most invasive forms and can cause infertility, chronic pelvic pain, pain at defecation, and altered quality of life [2–4]. Bowel endometriosis is estimated to occur in 5.3% to 12% of women with endometriosis [5, 6]. In specialized centers, its prevalence can reach 35% among women with deep pelvic endometriosis [7]. The rectum and rectosigmoid junction together account for 70% to 93% of all intestinal endometriotic sites [8, 9]. Since the first case of laparoscopic sigmoid resection for endometriosis published by Redwine and Sharpe [10], a few small studies have confirmed the feasibility of laparoscopic colorectal resection for endometriosis, albeit with a wide range of complications [11–15]. Nezhat et al. [11] noted no intra- or postoperative complications, whereas Possover et al. [13] observed dehiscence of the bowel anastomosis in 5.8% of cases and Daraı¨ et al. [15] reported rectovaginal fistulae in 7.5% of cases. This apparent discrepancy may be related partly to the inclusion of women undergoing segmental full, deep partial, or superficial rectal resections, which carry a risk of various complications [16, 17]. Recently, Remorgida et al. [18] demonstrated that segmental colorectal resection is the best surgical option in this setting, because of the risk for persistent lesions in almost 50% of women who undergo full-thickness disc or superficial rectal resection. This study aimed to determine the feasibility and intra- and postoperative complications of laparoscopic segmental colorectal resection for endometriosis.

Patients and methods Patients Between March 2001 and July 2005, 81 women with colorectal endometriosis were referred to the gynecology department of Tenon Hos-

1573 pital, Paris. Before surgery, all the women underwent both magnetic resonance imaging (MRI) and rectal endoscopic sonography (RES). To avoid a possible bias linked to the type of surgery, only women with muscularis involvement detected by MRI, RES, or both underwent segmental colorectal resection and were included in this study. Women undergoing superficial rectal resection (n = 6), those requiring a first laparotomy, and those treated exclusively by the vaginal route (n = 4) were excluded from the study. Among these latter four women, three had previously undergone laparotomy, respectively, for a uterine myoma 9 cm in diameter (n = 1), for ureteral involvement of endometriosis requiring a reimplantation into the bladder (n = 1), and for adnexal abscesses (n = 1). The last woman underwent hysterectomy and rectal resection exclusively by the vaginal approach. Consequently, the study population was composed of 71 women. The mean age of the study population was 33.2 ± 0.8 years, and 75% of the women were nulliparous. The mean body mass index (BMI) was 22.6 ± 0.5 kg/m2. The mean gestity and parity were, respectively, 0.5 ± 0.1 pregnancies and 0.3 ± 0.1 children. Of the 71 women, 40 (56.4%) had previously undergone surgery for endometriosis. All the patients received GnRh analogs for 3 months before surgery.

Operative technique All the women completed questionnaires on gynecologic symptoms (dysmenorrhea, nonmenstrual pelvic pain, dyspareunia), gastrointestinal disorders (pain at bowel movement, intestinal cramping, pain at defecation, cyclic rectal bleeding), and nonspecific disorders (lower back pain, asthenia). The symptom questionnaires used before and after colorectal resection were the same as those used in our previous study [15]. For quantitative evaluation before and after surgery, the women completed an interview-based questionnaire on symptoms using a 10-point analog rating scale with choices ranging from 0 (absent) to 10 (unbearable). For semiqualitative evaluation before and after surgery, the women completed a questionnaire designed to show whether symptoms had appeared, disappeared, worsened, or remained stable. The laparoscopic procedure was performed with the patient in the modified dorsolithotomy position under endotracheal general anesthesia. Prophylactic anticoagulant therapy (low-molecular-weight heparin) was given the evening before the operation, and prophylactic antibiotic therapy (cefazolin 2 g administered intravenously [IV]) was given at the beginning of the operation. All the procedures were performed by one of the authors (E.D.). After induction of pneumoperitoneum and insertion of the videolaparoscope through the umbilicus, three suprapubic trocars were introduced: a 5- or 12-mm trocar in the right iliac fossa, a 15-mm trocar in the median suprapubic area, and a 5-mm trocar in the left iliac fossa. After exploration of the pelvic cavity to evaluate the extent of endometriotic lesions, and after adhesiolysis and/or ovarian cystectomy if required, the colorectum was examined to verify the presence of deep infiltrating endometriosis with bowel involvement. Then the sigmoid and rectum were released using bipolar forceps and scissors. All endometriotic lesions, including those affecting the uterosacral ligaments, torus uterinus, peritoneum of the pouch of Douglas, and colorectum, were mobilized before the colorectum was sectioned with an endoscopic stapler. After the median suprapubic or left iliac trocar was withdrawn, the incision was enlarged to 3 or 4 cm to allow the colorectum to be exteriorized and resected before creation of a purse for the anvil. The colon was replaced in the pelvic cavity before closure of the abdominal incision. An end-to-end or lateroterminal colorectal anastomosis then was created using a rectally introduced stapler. A drain was inserted behind the colorectal anastomosis before closure of the trocar incisions. A Foley catheter was left in place for 48 h. The operating time was calculated from insertion of the Veress needle to skin suture. Postoperative fever was defined as a body temperature of at least 38°C on two consecutive occasions at least 6 h apart, excluding the first 24 h. The incidences of intra- and postoperative complications and blood transfusions were recorded, as well as the length of the postoperative hospital stay. Blood loss was estimated from the difference in the hemoglobin level before and 24 h after the procedure. The women were seen again 6 to 8 weeks after surgery. The immediate and short-term postoperative outcomes were gathered from

the hospital and outpatient medical records. The length of the resected colorectum was measured on the specimen. To evaluate changes in the surgical procedures and morbidity as the study progressed, we compared the characteristics of the first 40 colorectal resections (data previously published) [15] with the subsequent 31 consecutive colorectal resections. Parametric and nonparametric continuous variables were compared using StudentÕs t-test and the Mann-Whitney test, and categorical variables were compared using the chi-square test or FisherÕs exact test, as appropriate. Correlations were identified with analysis of variance (ANOVA) and SpearmanÕs test. All p values less than 0.05 were considered statistically significant.

Results Surgical findings Of the 71 women, 64 (90%) underwent segmental colorectal resection by laparoscopy. The remaining seven women (10%) required conversion to open surgery because of dissection difficulties. Initial laparoscopic inspection showed severe adhesions in four of these women. One of the women had previously undergone three laparotomic procedures, including two cystectomies for endometrioma and one for myomectomy, and another had a history of colostomy for rectal perforation related to surgical treatment of deep pelvic infiltrating endometriosis. Two laparoconversions were required, in the one case for ureteral involvement by endometriosis (requiring segmental ureterectomy with reimplantation into the bladder) and in the other case for incomplete circular stapled anastomosis at the end of the laparoscopic procedure. The last conversion was required for hemorrhage. During surgery, 62 (87.3%) of the 71 women were found to have complete obliteration of the pouch of Douglas. In addition to segmental colorectal resection, 23 women (32.4%) underwent ovarian cystectomy with complete removal of the cystic wall, and 6 women (8.3%) underwent salpingo-oophorectomy (bilateral in 4 cases and unilateral in 2 cases). Salpingectomy for hematosalpinx was performed bilaterally in three cases and unilaterally in two cases. Torus resection was performed in 67 cases (94.4%). Uterosacral ligament resection was performed unilaterally in 9 cases (12.7%) and bilaterally in 53 (74.6%) cases. Of the 71 women, 62 (87.3%) had one rectosigmoid endometriotic nodule, and the remaining 9 (12.7%) had multiple rectosigmoid lesions. Extensive ureterolysis was required in 50 cases (70.4%), performed bilaterally in 24 cases and unilaterally in 26 cases. Partial vaginal resection was necessary for 21 women (19.7%), hysterectomy for 7 women (9.8%), and appendectomy for 2 women (2.8%). Other major procedures included nephrectomy (1 case), bladder resection (1 case), ureteral resection with laparoscopic reimplantation into the bladder (1 case), and multiple bowel resection (4 cases). Protective colostomy was performed for five women (6.9%). Intra- and postoperative complications The mean operating time was 6.1 h (range, 3–13 h). The woman with the longest operating time had a history of colorectal resection by both the vaginal and laparotomic

1574 Table 1. Qualitative evaluation of gynecologic, digestive, and general symptoms after colorectal resection for endometriosis Symptom (n)

Disappeared n (%)

Decreased n (%)

Same n (%)

Increased n (%)

Dysmenorrhea (61) Dyspareunia (57) Pain on defecation (31) Bowel movement pain or cramping (51) Lower back pain(40) Asthenia (45)

30 29 8 22 22 10

26 21 17 17 11 25

5 5 4 7 6 5

0 2 2 5 1 5

(49) (51) (26) (43) (55) (23)

(43) (37) (55) (33) (27) (55)

(8) (9) (13) (14) (15) (11)

(3) (6) (10) (3) (11)

Table 2. Quantitative evaluation of gynecologic, digestive, and general symptoms before and after laparoscopic colorectal resection for endometriosis

Symptom

Mean preoperative intensity score

Mean postoperative intensity score

p Value

Dysmenorrhea Dyspareunia Pain at defecation Bowel movement pain or cramping Lower back pain Asthenia

7.5 5.6 3.4 4.5 4.5 4.8

1.8 1.8 1.7 1.9 1.4 2.2