Endometriosis Center, Clinique Tivoli-Ducos, Bordeaux, France.
Department of Gynecology and Obstetrics, Aarhus University Hospital, Aarhus, Denmark.
Hum Reprod. 2020 Jul 1;35(7):1601-1611. doi: 10.1093/humrep/deaa131.
What are the risk factors and prevalence of bowel fistula following surgical management of deep endometriosis infiltrating the rectosigmoid and how can it be managed?
In patients managed for deep endometriosis of the rectosigmoid, risk of fistula is increased by bowel opening during both segmental colorectal resection and disc excision and rectovaginal fistula repair is more challenging than for bowel leakage.
Bowel fistula is known to be a severe complication of colorectal endometriosis surgery; however, there is little available data on its prevalence in large series or on specific management.
STUDY DESIGN, SIZE, DURATION: A retrospective study employing data prospectively recorded in the North-West Inter Regional Female Cohort for Patients with Endometriosis (CIRENDO) from June 2009 to May 2019, in three tertiary referral centres.
PARTICIPANTS/MATERIALS, SETTING, METHODS: One thousand one hundred and two patients presenting with deep endometriosis infiltrating the rectosigmoid, who were managed by shaving, disc excision or colorectal resection. The prevalence of bowel fistula was assessed, and factors related to the complication and its surgical management.
Of 1102 patients enrolled in the study, 52.5% had a past history of gynaecological surgery and 52.7% had unsuccessfully attempted to conceive for over 12 months. Digestive tract subocclusion/occlusion was recorded in 12.7%, hydronephrosis in 4.5% and baseline severe bladder dysfunction in 1.5%. An exclusive laparoscopic approach was carried out in 96.8% of patients. Rectal shaving was performed in 31.9%, disc excision in 23.1%, colorectal resection in 35.8% and combined disc excision and sigmoid colon resection in 2.9%. For various reasons, the nodule was not completely removed in 6.4%, while in 7.2% of cases complementary procedures on the ileum, caecum and right colon were required. Parametrium excision was performed in 7.8%, dissection and excision of sacral roots in 4%, and surgery for ureteral endometriosis in 11.9%. Diverting stoma was performed in 21.8%. Thirty-seven patients presented with bowel fistulae (3.4%) of whom 23 (62.2%) were found to have rectovaginal fistulae and 14 (37.8%) leakage. Logistic regression model showed rectal lumen opening to increase risk of fistula when compared with shaving, regardless of nodule size: adjusted odds ratio (95% CI) for disc excision, colorectal resection and association of disc excision + segmental resection was 6.8 (1.9-23.8), 4.8 (1.4-16.9) and 11 (2.1-58.6), respectively. Repair of 23 rectovaginal fistulae required 1, 2, 3 or 4 additional surgical procedures in 12 (52.2%), 8 (34.8%), 2 (8.7%) and 1 patient (4.3%), respectively. Repair of leakage in 14 patients required 1 procedure (stoma) in 12 cases (85.7%) and a second procedure (colorectal resection) in 2 cases (14.3%). All patients, excepted five women managed by delayed coloanal anastomosis, underwent a supplementary surgical procedure for stoma repair. The period of time required for diverting stoma following repair of rectovaginal fistulae was significantly longer than for repair of leakages (median values 10 and 5 months, respectively, P = 0.008).
LIMITATIONS, REASONS FOR CAUTION: The main limits relate to the heterogeneity of techniques used in removal of rectosigmoid nodules and repairing fistulae, the lack of accurate information about the level of nodules, the small number of centres and that a majority of patients were managed by one surgeon.
Deep endometriosis infiltrating the rectosigmoid can be managed laparoscopically with a relatively low risk of bowel fistula. When the type of bowel procedure can be chosen, performance of shaving instead of disc excision or colorectal resection is suggested considering the lower risk of bowel fistula. Rectovaginal fistula repair is more challenging than for bowel leakage and may require up to four additional surgical procedures.
STUDY FUNDING/COMPETING INTEREST(S): CIRENDO is financed by the G4 Group (The University Hospitals of Rouen, Lille, Amiens and Caen) and the ROUENDOMETRIOSE Association. No financial support was received for this study. H.R. reports personal fees from ETHICON, Plasma Surgical, Olympus and Nordic Pharma outside the submitted work. The other authors declare no conflict of interests related to this topic.
在直肠乙状结肠深部子宫内膜异位症的手术治疗中，肠瘘的风险因素和患病率是多少？如何处理？
在接受直肠乙状结肠深部子宫内膜异位症治疗的患者中，肠切开术和盘切除术期间的肠开口会增加瘘管的风险，而阴道直肠瘘的修复比肠漏更具挑战性。
肠瘘是结直肠子宫内膜异位症手术的严重并发症；然而，关于大型系列或特定管理中其患病率的信息很少。
研究设计、大小和持续时间：这是一项回顾性研究，使用 2009 年 6 月至 2019 年 5 月期间在三个三级转诊中心的西北区域女性子宫内膜异位症患者队列（CIRENDO）前瞻性记录的数据。
参与者/材料、设置、方法：1102 名患有直肠乙状结肠深部子宫内膜异位症的患者，采用刮除术、盘切除术或结直肠切除术进行治疗。评估了肠瘘的患病率，并评估了与并发症及其手术管理相关的因素。
在研究中纳入的 1102 名患者中，52.5%有妇科手术史，52.7%尝试受孕超过 12 个月未成功。12.7%记录有消化道闭阻/梗阻，4.5%有肾积水，1.5%有基线严重膀胱功能障碍。96.8%的患者采用了纯粹的腹腔镜方法。31.9%行直肠刮除术，23.1%行盘切除术，35.8%行结直肠切除术，2.9%行盘切除术和乙状结肠切除术联合。由于各种原因，6.4%的病灶未能完全切除，7.2%的患者需要对回肠、盲肠和右结肠进行补充手术。7.8%的患者行子宫旁切除术，4%行骶神经根解剖和切除术，11.9%行输尿管子宫内膜异位症手术。21.8%的患者行转流性造口术。37 名患者出现肠瘘（3.4%），其中 23 名（62.2%）为阴道直肠瘘，14 名（37.8%）为漏。逻辑回归模型显示，与刮除术相比，直肠管腔开口增加了瘘管的风险，无论病灶大小如何：盘切除术、结直肠切除术和盘切除术+节段切除术的调整后的优势比（95%CI）分别为 6.8（1.9-23.8）、4.8（1.4-16.9）和 11（2.1-58.6）。23 例阴道直肠瘘的修复需要 1、2、3 或 4 次额外的手术，分别在 12 例（52.2%）、8 例（34.8%）、2 例（8.7%）和 1 例（4.3%）患者中进行。14 例漏的修复需要 1 例（造口术）在 12 例（85.7%），2 例（14.3%）需要第二次手术（结直肠切除术）。除 5 例女性患者接受延迟结肠直肠吻合术外，所有患者均接受了造口修复的补充手术。阴道直肠瘘修复后的转流性造口时间明显长于漏的修复（中位数分别为 10 个月和 5 个月，P=0.008）。
局限性、谨慎的原因：主要限制与直肠乙状结肠结节切除的技术多样性、缺乏关于结节水平的准确信息、中心数量较少以及大多数患者由一名外科医生治疗有关。
直肠乙状结肠深部子宫内膜异位症可以通过腹腔镜手术进行治疗，肠瘘的风险相对较低。当可以选择肠手术类型时，与盘切除术或结直肠切除术相比，建议选择刮除术，因为肠瘘的风险较低。阴道直肠瘘的修复比肠漏更具挑战性，可能需要多达 4 次额外的手术。
研究资金/利益冲突：CIRENDO 由鲁昂、里尔、亚眠和卡昂的大学附属医院和 ROUENDOMETRIOSE 协会资助。本研究未获得任何财务支持。HR 报告个人从 ETHICON、Plasma Surgical、Olympus 和 Nordic Pharma 获得与该主题相关的费用。其他作者声明与该主题没有利益冲突。
