Conservative vs radical bowel surgery for endometriosis: A systematic analysis of complications

Abstract

Background Endometriosis of the bowel can be associated with significant morbidity. Surgery to remove it carries risks. Options include conservative shaving or discoid resection and more radical segmental bowel resection. Aims To determine if more conservative shaving or discoid bowel resection is associated with fewer risks than more radical segmental resection. Material and Methods This study is a systematic review. We considered eligible any cohort, observational or randomised controlled trial (RCT) study of at least ten women per arm comparing conservative vs radical bowel surgery for endometriosis. We divided complications into two groups, major and minor. One additional article was added due to its significance in answering our study question as well as the high quality of the study design as an RCT. Results There were 3041 studies screened. Eleven studies were included (n = 1648). For major complications, the risk ratio for shaving and disc excision vs segmental resection is 0.31 (95% CI 0.21–0.46), while the risk difference is −0.25 (95% CI −0.41 to 0.10). For minor complications, the risk ratio is 0.63 (95% CI 0.36–1.09), while the risk difference is −0.03 (95% CI −0.12 to 0.05). Conclusions Conservative shaving or discoid excision surgery is associated with reduced complications. Previous studies demonstrated a trend toward this finding, but suffered from relatively low participant numbers, increasing the risk of type one statistical error. Our results allow surgeons to make informed choices about potential complications when deciding how to approach bowel endometriosis. The results also allow patients to have more information about the risks. However, outcomes in the studies analysed are heterogenous and are from low‐quality evidence.

Deep infiltrative endometriosis of the sigmoid colon: an uncommon lesion of the colon seen on colonoscopy

“…Surgical approaches to bowel endometriosis include shave excision, disc excision and segmental bowel resection, depending on the extent of bowel involvement, clinical condition and evidence of malignant change. Shave and disc excision have a notably lower risk for major complications in comparison to segmental resection, with one study reporting a risk ratio of 0.31 (95% CI 0.21–0.46) 9 . In our case, localized surgical disc excision enabled adequate removal of this lesion without the greater risks associated with an anterior resection.…”

Conservative surgery versus colorectal resection for endometrial deposits: a systematic review and meta-analysis of surgical and long-term outcomes

“…When long term function is assessed, there is no difference in reported outcomes between conservative surgery and formal resection. This is the most up-to-date meta-analysis [33][34][35] on conservative versus colorectal resection for rectal endometriosis and the rst one to compare both the two main groups and also the subgroups (S vs SR, DE vs SR) in terms of group comparability (previous surgeries, endometriosis staging and Enzian C grading), surgical outcomes and long-term outcomes. While shaving is associated with fewer postoperative complications and the shortest operative time, discoid excision is comparable to colorectal resection in terms of complications.…”

Treatment preferences for medication or surgery in patients with deep endometriosis and bowel involvement – a discrete choice experiment

“…Supporters of radical surgery have an approach almost similar to oncological surgical approaches 22,23 and aim to reduce pain, prevent recurrence and perhaps even cure women with DE. The potential price they have to pay for this approach is theoretically more severe complications and the risk of LARS 24 . Surgeons who believe in a more cautious approach aim to reduce pain symptoms and accept possible recurrence/incomplete removal of endometriosis, but try to reduce severe complications and prevent possible permanent bowel symptoms (LARS) 25‐27 …”

“…The potential price they have to pay for this approach is theoretically more severe complications and the risk of LARS. 24 Surgeons who believe in a more cautious approach aim to reduce pain symptoms and accept possible recurrence/incomplete removal of endometriosis, but try to reduce severe complications and prevent possible permanent bowel symptoms (LARS). [25][26][27]…”