Follow-up of bowel endometriosis resections performed using the double circular stapler technique: A decade's experience

Abstract

Study objective: To report individual early and long-term functional outcomes of 43 women who underwent double circular stapler technique (DCST) for colorectal deep endometriosis (DE).

Methods: This multidisciplinary observational study was a retrospective case series report exploiting a long-established database of clinical information from a single private institution. The cohort consists of consecutive patients from January/2010 through July/2021 who underwent minimally invasive surgical treatment of DE. Inclusion criteria: all women whose bowel DE was managed by DCST. The assessment of bowel function was based on Obstructed Defecation Syndrome score, Gastrointestinal Symptom Rating Scale and Bowel Function in the Community Tool. Outcomes also included intra and postoperative complications, lower urinary tract symptoms, endometriosis-related menstrual and nonmenstrual pain (numeric rating scale), and conception. The analysis of the results was guided by a semi-qualitative reasoning based on individual changes.

Results: The follow-up ranged from 1.4 to 123.8 months (median 38.2). All women presented with DE (mostly rASRM stage 4) and underwent large resections. No procedure was converted to open surgery nor required blood transfusion or ostomies. There was no anastomotic leakage. The risk of rectovaginal bowel fistula was 2.3% (CI 95%: <0.1-7.0) - one case. No patient had long-term urinary retention after surgery. At the most recent follow-up on dysuria, dyschezia, dysmenorrhea, dyspareunia and cyclic low back pain, 88 to 100% of women had favorable responses (improvements ≥ 3 points in symptomatic women or asymptomatic women who remained pain-free). One patient reported important worsening of her intestinal function, requiring continuous use of laxatives. Considering the 20 women with pregnancy intent, 14 (70%) conceived after surgery.

Discussion / conclusion: Preliminary results were encouraging in the past. The current assessment including long-term follow-up supports DCST for colorectal DE as a feasible, useful, and safe strategy for avoiding segmental colorectal resection when appropriately indicated and properly performed.

Fig 1. Current surgical approach to bowel endometriosis resection adopted by the Crispi Institute for Minimally Invasive Surgery – a private institution located in Rio de Janeiro, RJ, Brazil.

Although the linear stapler resection has been shown as a safe alternative to segmental colorectal resection for endometriotic nodules on the anterior rectal wall when less than one-third of the circumference is affected [63], it was not used in this series.

Fig 2. Main steps of double circular stapler technique for colorectal deep endometriosis.

(1) The circular stapler 1 passes the lesion; (2) Opening the circular stapler; (3) Suture stitch limiting the area to be resected; (4) Suture to anchor the lesion; (5) Sutures forcing the lesion into the stapler; (6) Circular stapler closing; (7) Removing the circular stapler 1; (8) The circular stapler 2 passes the residual lesion; (9) Opening the circular stapler; (10) Suture stitch limiting the area to be resected; (11) Suture to anchor the lesion; (12) Sutures forcing the remaining lesion into the stapler; (13) Circular stapler closing; (14) Removing the circular stapler 2.

Fig 3. Study flow diagram-Double circular stapler technique (DCST).

All surgeries were performed by the Crispi Institute for Minimally Invasive Surgery team (Rio de Janeiro, Brazil).