Surgical outcomes after colorectal surgery for endometriosis: Systematic Review and Meta-Analysis

International audienceObjective: To assess the impact of type of surgery for colorectal endometriosis -rectal shaving, discoid or colorectal segmental resection- on complications and surgical outcomes.Data sources: We performed a systematic review of all English and French language full-text articles addressing surgical management of colorectal endometriosis and compared the postoperative complications according to surgical technique by meta-analysis. The PubMed, Clinical Trials.gov Cochrane Library and Web of Science databases were searched for relevant studies published before March 27, 2020. The search strategy used the following MeSH terms: ("bowel endometriosis" or "colorectal endometriosis") AND ("surgery for endometriosis" or "conservative management" or "radical management" or "colorectal resection" or "shaving" or "full thickness resection" or "disc excision") AND ("treatment", "outcomes", "long term results" and "complications").Methods of study selection: Two authors conducted the literature search and independently screened abstracts for inclusion, with resolution of any difference by three other authors. Studies were included when data on surgical management (shaving, disc excision and/ or segmental resection) were provided and when postoperative outcomes were detailed with at least the number of complications. The risk of bias was assessed according to the Cochrane recommendations.Tabulation, integration, and results: Of the168 full-text articles assessed for eligibility, 60 were included in the qualitative synthesis. Seventeen of these were included in the meta-analysis on rectovaginal fistula, 10 on anastomotic leakage, five on anastomotic stenosis, and nine on voiding dysfunction <30 days. The mean complication rate according to shaving, discoid excision and segmental resection were 2.2%, 9.7% and 9.9%, respectively. Rectal shaving was less associated with rectovaginal fistula than discoid excision (OR=0.19; 95% CI [0.10-0.36], p<0.00001, I2=33%) and segmental colorectal resection (OR=0.26, 95% IC [0.15-0.44], p<0.00001, I2=0%). No difference was found in the occurrence of rectovaginal fistula between discoid excision and segmental colorectal resection (OR=1.07, 95%CI [0.70-1.63], p=0.76, I2=0%). Rectal shaving was less associated with leakage than disc excision (OR=0.22, 95% IC [0.06-0.73], p=0.01, I2=86%). No difference was found in the occurrence of leakage between rectal shaving and segmental colorectal resection (OR=0.32, 95% IC [0.10-1.01], p=0.05, I2=71%) or between disc excision and segmental colorectal resection (OR=0.32, 95% IC [0.30-1.58], p=0.38, I2=0%). Disc excision was less associated with anastomotic stenosis than segmental resection (OR=0.15, 95% IC [0.05-0.48], p=0.001, I2=59%). Disc excision was associated with more voiding dysfunction <30 days than rectal shaving (OR=12.9, 95% IC [1.40-119.34], p=0.02, I2=0%). No difference was found in the occurrence of voiding dysfunction <30 days between segmental resection and rectal shaving (OR=3.05, 95% IC [0.55-16.87], p=0.20, I2=0%) or between segmental colorectal and discoid resection (OR=0.99, 95% IC [0.54-1.85], p=0.99, I2=71%).Conclusion: Colorectal surgery for endometriosis exposes patients to a risk of severe complications such as rectovaginal fistula, anastomotic leakage, anastomotic stenosis and voiding dysfunction. Rectal shaving appears to be less associated with postoperative complications than disc excision and segmental colorectal resection. However, this technique is not suitable in all patients with large bowel infiltration. Compared to segmental colorectal resection, disc excision has several advantages including shorter operating time, shorter hospital stay and lower risk of postoperative bowel stenosis

Voiding Dysfunction after Colorectal Surgery for Endometriosis: A Systematic Review and Meta-analysis

International audienceObjective: Surgical management of deep endometriosis is associated with a high incidence of lower urinary tract dysfunction. The aim of the current systematic review and meta-analysis was to assess the rates of voiding dysfunction according to colorectal shaving, discoid excision, and segmental resection for deep endometriosis.Data sources: We performed a systematic review using bibliographic citations from PubMed, Clinical Trials.gov, Embase, Cochrane Library, and Web of Science databases. Medical Subject Headings terms for colorectal endometriosis and voiding dysfunction were combined and restricted to the French and English languages. The final search was performed on August 28, 2019. The outcome measured was the occurrence of postoperative voiding dysfunction.Methods of study selection: Study Quality Assessment Tools were used to assess the quality of included studies. Studies rated as good and fair were included. Two reviewers independently assessed the quality of each included study, discrepancies were discussed; if consensus was not reached, a third reviewer was consulted.Tabulation, integration and results: Out of 201 relevant published reports, 51 studies were ultimately reviewed systematically and 13 were included in the meta-analysis. Rectal shaving was statistically less associated with postoperative voiding dysfunction than segmental colorectal resection (Odds ratio [OR] 0.34; 95% confidence intervals [CI], 0.18-0.63; I2 = 0%; p 1 month than segmental colorectal resection (OR 0.3; 95% CI, 0.14-0.66; I2 = 0%; p = .003). This outcome was no longer significant when comparing discoid excision and segmental colorectal resection (OR 0.72; 95% CI, 0.4-1.31; I2 = 63%; p = .28).Conclusion: Colorectal surgery for endometriosis has a significant impact on urinary function regardless of the technique. However, rectal shaving causes less postoperative voiding dysfunction than discoid excision or segmental resection

Prevesical peritoneum interposition to prevent risk of rectovaginal fistula after en bloc colorectal resection with hysterectomy for endometriosis: Results of a pilot study

International audienceObjective: To evaluate the risk of rectovaginal fistula after en bloc hysterectomy and colorectal resection (H-CR) for endometriosis using prevesical peritoneum interposition.Study design: A retrospective study conducted at Tenon University Hospital, expert center in endometriosis, from June 2016 to June 2018. Patients undergoing H-CR with prevesical peritoneum interposition without protective defunctioning stoma were included.Results: Of the 160 patients who underwent surgery with colorectal resection for endometriosis during the study period, 27 had H-CR (15 with segmental and 12 with discoïd colorectal resection) and were included. The median age (range) was 45 years (41-47.5). Eight patients (13 %) were nulliparous. All procedures were performed by laparoscopy. Parametrial resection was performed in 14 cases (52 %). Associated bowel procedures were ileocecal resection (n = 5) and appendectomy (n = 2). Median follow-up (range) was 14.6 months (10.5-20.2). Nine (33.3 %) patients experienced intra- or postoperative complications including one grade I, four grade II, two grade IIIA and two grade IIIB complications (Clavien-Dindo classification). Seven patients (26 %) experienced postoperative voiding dysfunction. One suspicion of rectovaginal fistula associated with pelvic abscess was diagnosed 4 weeks after surgery but not confirmed during a second operation.Conclusion: Despite the small sample size, the present pilot study supports the practice of prevesical peritoneum interposition to limit the risk of rectovaginal fistula in patients who undergo H-CR for deep endometriosis