Surgeons should not resist rectal resection in endometriosis

Rectal resection for deeply infiltrating endometriosis can be performed with limited morbidity, say the authors of an Australian study.

Reporting their surgical experience over a 9-year period, they found that 82.4% of patients were asymptomatic or had symptom improvement following surgery, while complications occurred in only 14%.

The authors hope their results will help support a resolution of the current dichotomy in treatment, whereby some physicians favor surgery while others do not recommend resection at all, primarily due to concerns about morbidity.

"It is likely that a more pragmatic approach will be adopted with selective resection of lesions taking into consideration the patient's preferences, desires for fertility, and the characteristics of the lesion," say Michael Solomon (University of Sydney, Australia) and colleagues.

The study included 91 patients with deeply infiltrative endometriosis who had 92 rectal resections. Of these, 66 were disc resections and 26 were segmental resections and, overall, 88% were performed laparoscopically. On average, the women were 35 years old and had experienced symptoms for 8.2 years.

The authors, reporting in Diseases of the Colon and Rectum, found that all but three of the 79 patients who were followed up for a median of 27.4 months experienced symptomatic improvement. Recurrent endometriosis occurred in 8.8% of patients, with only one (1.3%) patient requiring further bowel resection for deeply infiltrative endometriosis.

Nine patients experienced major complications including intraoperative blood loss requiring transfusion, postoperative anastomotic bleed, and ureteric injury. A further four patients experienced minor complications. However, there were no cases of rectovaginal fistulae or anastomotic leaks, which are often attributed as a major concern by reluctant surgeons.

To prevent complications, Solomon et al recommend the use of an interposition omental flap to separate the rectum and vagina whenever there is a vaginal defect near the anastomosis, as well as a selective approach to performing ileostomy. They also suggest that the use of oral contraceptives may have helped reduce the risk for recurrence.

The team concludes that their results support the use of rectal resection for endometriosis and highlight the benefits of a multidisciplinary approach: "We attribute our results to the long-term collaboration between endogynecology and colorectal surgery and would emphasize the importance of an experienced team in achieving the best operative and functional outcomes."

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