Casas Sara Gortázar de Las, Spagnolo Emanuela, Saverio Salomone Di, Álvarez-Gallego Mario, Carrasco Ana López, López María Carbonell, Cobos Sergio Torres, Campo Constantino Fondevila, Gutiérrez Alicia Hernández, Miguelañez Isabel Pascual
Department of General Surgery, La Paz University Hospital, Madrid, Spain.
Department of Obstetrics and Gynecology, La Paz University Hospital, Madrid, Spain.
Ann Coloproctol. 2023 Jun;39(3):216-222. doi: 10.3393/ac.2021.00829.0118. Epub 2022 Mar 7.
The surgical management of deep infiltrative endometriosis (DE) involving the rectum remains a challenge. The objective of this study was to assess the outcomes from a single tertiary center over a decade with an emphasis on the role of a protective loop ileostomy (PI).
A retrospective review of outcomes for 168 patients managed between 2008 and 2018 is presented including 57 rectal shaves, 23 discoid excisions, and 88 segmental rectal resections.
The nodule size (mean±standard deviation) in the segmental resection group was 32.7±11.2 mm, 23.4±10.5 mm for discoid excision, and 18.8±6.0 mm for rectal shaves. A PI was performed in 19 elective cases (11.3%) usually for an ultra-low anastomosis <5 cm from the anal verge. All Clavien-Dindo grade III/IV complications occurred after segmental resections and included 5 anastomotic leaks, 6 rectovaginal fistulas, 2 ureteric fistulas, and 1 ureteric stenosis. Of 26 stomas (15.5%), there were 19 PIs, 3 secondary ileostomies (after complications), and 4 end colostomies. The median time to PI closure was 5.8 months (range, 0.4-16.7 months) in uncomplicated disease compared with 9.2 months (range, 4.7-18.4 months) when initial postoperative complications were recorded (P=0.019). Only 1 patient with a recurrent rectovaginal fistula had a permanent colostomy.
In patients with DE and rectal involvement a PI is selectively used for low anastomoses and complex pelvic reconstructions. Protective stomas and those used in the definitive management of a major postoperative complication can usually be reversed.
涉及直肠的深部浸润性子宫内膜异位症（DE）的手术管理仍然是一项挑战。本研究的目的是评估一个单一三级中心在十年间的治疗结果，重点是保护性回肠造口术（PI）的作用。
对2008年至2018年间接受治疗的168例患者的结果进行回顾性分析，包括57例直肠剃除术、23例盘状切除术和88例直肠节段切除术。
节段切除组的结节大小（均值±标准差）为32.7±11.2mm，盘状切除组为23.4±10.5mm，直肠剃除组为18.8±6.0mm。19例择期手术（11.3%）进行了PI，通常用于距肛缘<5cm的超低位吻合。所有Clavien-Dindo III/IV级并发症均发生在节段切除术后，包括5例吻合口漏、6例直肠阴道瘘、2例输尿管瘘和1例输尿管狭窄。在26个造口（15.5%）中，有19个PI、3个二次回肠造口术（并发症后）和4个结肠造口术。在无并发症的疾病中，PI关闭的中位时间为5.8个月（范围0.4-16.7个月），而记录有术后初始并发症时为9.2个月（范围4.7-18.4个月）（P=0.019）。只有1例复发性直肠阴道瘘患者进行了永久性结肠造口术。
在患有DE并累及直肠的患者中，PI选择性用于低位吻合和复杂的盆腔重建。保护性造口以及用于术后主要并发症确定性管理的造口通常可以还纳。
