Combined approach of full thickness disc excision of deep endometriosis nodules infiltrating the rectum

Horace Roman, MD, PhD, Emmanuel Huet, MD, PD, Valerie Bridoux, MD, PhD, Jean-Jacques Tuech, MD, PhD. Rouen University Hospital, France

Objective: To report a personal case series of patients presenting with deep endometriosis of the rectum managed by combined laparoscopic-transanal/transvaginal full thickness disc excision of the rectum.

Methods: Patients managed using this procedure from June 2009 to September 2014 at Rouen University Hospital, France, were prospectively included in the series. The technique began by laparoscopic deep shaving of the rectum, followed by transanal full thickness disc excision of the shaved rectal area, using either EEA circular or Contour Transtar staplers. In patients with large resection of the vagina, the disc excision of the rectum could be carried out transvaginally. Prospective recording of pre-, intra- and postoperative data was performed, and digestive function was assessed using KESS and GIQLI questionnaires.

Results: Fifty patients having benefited from disc excision were included during 57 months, representing 16.8% of 298 patients managed for colorectal endometriosis. Mean (SD) follow up was 20 months (18). 88% of patients enrolled in the series were nullipara and 34% were known to be infertile. 76% reported preoperative defecation pain, 52% cyclic diarrhea and 54%cyclic constipation. Mean (SD) age, AFSr, KESS and GIQLI scores were respectively 29 (3.7) years, 56 (31), 13.1 (6.3) and 86 (23). The largest nodule diameter measured >=3 cm in 73% of cases and <=2 cm in 27%. Operative time was 260 (98) min. Disc excision was performed transanally using the Contour transtar stapler in 18 cases (36%), using the EEA circular stapler in 30 cases (60%) and directly transvaginally in 2 cases (4%). Associated procedures were performed, such as resection of sigmoid colon (6%), disc excision of sigmoid colon (10%), small bowel resection (2%), cecum resection (2%), excision of the vagina (62%), bladder resection (4%), ureter resection (4%) and ovarian endometriosis cyst ablation using plasma energy (38%). Discontinuous stoma was carried out in 58%. The mean (SD) diameter of discs removed was 45 mm (16), with a range from 25 to 90 mm. Two rectovaginal fistulae occurred (4%) and were repaired after 3 months with favorable outcomes. Transitory bladder atony was recorded in 14%. Two complications related to colostoma required secondary surgical procedures (4%). Assessment of digestive function was performed preoperatively (n=50), at 1 year (n=25) and at 3 years postoperatively (n=10). This showed a significant improvement in KESS score (P=0.003) and GIQLI score (P<0.001), and a major decrease in the rate of patients with defecation pain (P<0.001), constipation (P<0.001) and diarrhea (P<0.001). Among patients with pregnancy intention, the rate of pregnancy was 80%, and that of “take home baby” 60%, with a rate of spontaneous conception as high as 63%.

Conclusion: Full thickness disc excision of rectal nodules represents a valuable alternative to colorectal resection in young patients with deep endometriosis infiltrating the rectum. Postoperative unfavorable events and mid term functional outcomes are encouraging, while the pregnancy rate appears among the highest reported in the literature.

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