Endometriosis Center, Clinique Tivoli-Ducos (Drs. Roman, Merlot, Noailles, Magne, and Forestier), Bordeaux; Department of Gynecology and Obstetrics, Aarhus University Hospital, Aarhus, Denmark (Dr. Roman).
Department of Digestive Surgery, Rouen University Hospital (Drs. Bridoux and Tuech).
J Minim Invasive Gynecol. 2022 Jan;29(1):56-64.e1. doi: 10.1016/j.jmig.2021.06.013. Epub 2021 Jun 25.
To assess whether a liberal policy of preventive stoma (LPS) reduces the rate of rectovaginal fistulas in women with excision of deep endometriosis requiring concomitant vaginal and rectal sutures in comparison with a more restrictive policy of preventive stoma (RPS) and to assess the risk factors for rectovaginal fistula.
Retrospective before-and-after comparative study.
Two referral centers, one with an LPS and the other with an RPS.
A total of 363 patients with deep endometriosis infiltrating the rectum and the vagina.
Rectal disc excision or colorectal resection concomitantly with vaginal excision.
Two hundred forty-one and 122 women received surgery at the LPS and RPS centers, respectively. The rate of preventive stomas was 71.4% at the LPS center (n = 172) and 30.3% at the RPS center (N = 37). Rectovaginal fistula was recorded in 31 cases (8.5%): nineteen women were managed at the LPS center, and 12 women underwent surgery at the RPS center. It occurred in, respectively, 9.4%, 10.8%, 10.1%, and 7% of the women managed without and with a stoma at the RPS center and of those managed without and with a stoma at the LPS center (p = .72). The height of the rectal stapled line was significantly lower in the women undergoing a stoma, particularly in those managed at the RPS center (5.4 ± 1.8 cm). Performing rectal sutures within 8 cm from the anal verge increased the risk of rectovaginal fistula more than 3-fold, independently of stoma creation, surgical procedure carried out on the rectum, size of vaginal infiltration, or associated excision of deep endometriosis involving the pelvic nerves (odds ratio 3.4; 95% confidence interval, 1.3-9.1).
No statistically significant differences were found in terms of the risk of rectovaginal fistula between women with rectovaginal endometriosis managed by either an LPS or an RPS; however, these findings need to be confirmed by a randomized trial.
评估在需要同时行阴道和直肠缝合的深部子宫内膜异位症切除术中，采用预防性造口的宽松政策（LPS）与采用预防性造口的严格政策（RPS）相比，是否可以降低直肠阴道瘘的发生率，并评估直肠阴道瘘的危险因素。
回顾性前后比较研究。
两个转诊中心，一个采用 LPS，另一个采用 RPS。
共 363 例直肠和阴道深部子宫内膜异位症浸润患者。
直肠盘状切除术或结直肠切除术同时行阴道切除术。
241 例和 122 例女性分别在 LPS 和 RPS 中心接受手术。在 LPS 中心，预防性造口率为 71.4%（n=172），在 RPS 中心为 30.3%（N=37）。记录到 31 例直肠阴道瘘（8.5%）：19 例女性在 LPS 中心接受治疗，12 例女性在 RPS 中心接受手术。在 RPS 中心未行造口术和行造口术的女性中分别有 9.4%、10.8%、10.1%和 7%发生直肠阴道瘘（p=0.72）。在接受造口术的女性中，直肠吻合钉线的高度明显较低，尤其是在 RPS 中心接受治疗的女性中（5.4±1.8cm）。在距肛门边缘 8cm 内进行直肠缝合会使直肠阴道瘘的风险增加 3 倍以上，这与造口术的建立、对直肠进行的手术、阴道浸润的大小或累及盆腔神经的深部子宫内膜异位症的相关切除无关（比值比 3.4；95%置信区间，1.3-9.1）。
在采用 LPS 或 RPS 治疗直肠阴道内异症的女性中，直肠阴道瘘的风险无统计学差异；然而，这些发现需要通过随机试验来证实。
