Double Disk Excision of Large Deep Endometriosis Nodules Infiltrating the Low and Mid Rectum: A Pilot Study of 20 Cases

Abstract

To report the technique of double disk excision of deep endometriosis nodules infiltrating the mid or low rectum and surgical outcomes. Design: A retrospective case series using data prospectively recorded in the North-West Inter Regional Female Cohort for Patients with Endometriosis database. Setting: University tertiary referral center. Patients: Twenty women managed for large deep endometriosis nodules infiltrating the mid or low rectum. Interventions: Double disk excision using transanal end-to-end anastomosis circular stapler. Measurements and Main Results: Twenty women managed by double disk excision from May 2016 to September 2019 were included in the study. The mean time of intervention was 149 § 74 minutes. The cumulated mean diameter of the excised rectal disks was 53.4 § 19.1 mm, whereas in 85% of the women, it was ≥50 mm. The mean distance between the lowest margin of the disk and the anal verge was 66 mm. Vaginal infiltration was removed in 15 patients (75%), and in 6 patients (30%) it exceeded 30 mm in diameter. Owing to the presence of sigmoid colon nodules, 2 patients (10%) underwent concomitant segmental sigmoid resection of 4 cm and 6 cm in length, respectively. Transitory stoma was performed in 8 patients (40%) owing to concomitant vaginal excision >3 cm in size. After a follow-up varying from 3 months to 42 months, no digestive fistula was recorded. The rate of Clavien-Dindo 3 complications was 15%. Conclusion: Double disk excision is suitable for excising large deep endometriosis nodules infiltrating the mid or low rectum and is associated with a low severe complication rate with good functional outcomes in women. Further studies are required to assess the improvement of functional outcomes in deep endometriosis nodules infiltrating the mid or low rectum in comparison with colorectal resection.

Surgery for deep infiltrating rectal endometriosis—Selecting the right approach

“…Therefore, a diverting stoma has been used selectively by several teams in the context of preventing a rectovaginal fistula 16 . Several randomized trials have demonstrated the protective role of a preventive stoma in low rectal cancer surgery 17–20 . In patients with no concomitant vaginal excision but this is mainly with regards to anastomotic leakage rather than rectovaginal fistula formation and cannot be extrapolated without proper evidence.…”

Surgical treatment of colorectal endometriosis: an updated review

“…An alternate approach for excision of larger endometriotic nodules is the double disc excision technique, in which two circular EEA staplers are fired successively. In a pilot study by Namazov et al [29], this technique was used to excise low-and mid-rectal nodules with a mean diameter of 53.4 AE 19.1 mm and mean distance of 66 mm from the anal verge.…”

Colorectal Endometriosis: Ample data without definitive recommendations.

“…For lesions larger than 3 cm shaving is still a reasonable option, however, it is also appropriate to perform a disc excision utilising either a trans-anal stapler or a hand-sewn repair. Evidence also suggests that for nodules larger than 5 cm a double disc excision is a safe and feasible option for surgeons familiar with this technique ( Namazov et al, 2020 ). When multiple nodules larger than 3 cm are infiltrating the bowel a segmental resection is preferred over multiple different disc excisions, however, this recommendation should not supersede clinical judgment.…”