A national snapshot of the surgical management of deep infiltrating endometriosis of the rectum and colon in France in 2015: A multicenter series of 1135 cases.

OBJECTIVE: To perform a survey on the characteristics of the surgical management of patients with deep infiltrating endometriosis of the rectum and the sigmoid colon (DIERS) in France in 2015.
METHOD: Case-series study enrolling patients with DIERS involving muscularis, submucosa or mucosa, operated on from January 1st to December 31st 2015, in 56 healthcare facilities in France. Surgeons filled in questionnaires concerning the number of patients, deep endometriosis localizations, surgical route and techniques used on digestive tract, associated surgical procedures and major complications. Data were pooled in a single database.
RESULTS: A total of 1135 patients from 56 healthcare facilities were enrolled in the series (33 university hospitals, 4 general hospitals and 19 private hospitals). Deep endometriosis infiltrated only the rectum in 56.8% of cases, the rectum and the sigmoid colon in 36.3% and only the sigmoid colon in 6.9%. Associated localizations involved the cecum in 6.6% of cases, small bowel in 4.7%, bladder in 9%, and were responsible for stenosis of the ureters in 13.4% and for hydronephrosis in 6.8%. Surgery was performed using conventional laparoscopy in 82.2% of cases, robotic-assisted laparoscopy in 9.7% and open surgery in 8.1%. Rectal shaving was carried out in 48.1% of cases, disc excision in 7.3%, colorectal segmental resection in 40.4% and sigmoid colon segmental resection in 6.4% (2 different procedures could be associated in the same patient). Ureter resection was carried out in only 4% of cases, representing 29.6% of cases with stenosis of the ureters. Bladder resection was carried out in 6.9%. Vaginal resection and hysterectomy were performed in 33 and 14.7% of cases respectively, while temporary stoma was used in 19.1%. Anastomotic leakage occurred in 0.8% of cases, pelvic abscess in 3.4%, rectovaginal fistula in 2.7%, ureter fistula in 0.7%, while 8.6% of patients either required catheterization after recovery or had a post-voiding bladder volume superior to 100mL. According to the surgical procedure used, the risk of rectovaginal fistula was 1.3, 3.6 and 3.9% after shaving, disc excision and segmental resection respectively. Intensive care was required in 1.1% and blood transfusion in 2.2%. One patient died (0.1%) after rectal shaving.
CONCLUSIONS: Our 2015 survey of a large number of patients managed for DIERS in France confirms that DIERS is far from being a rare disease. Even in the setting of complex procedures requiring multidisciplinary teams, a laparoscopic approach can achieve successful surgical treatment in 9 out of 10 patients with an acceptable risk of major postoperative complications.