Journal of Gynecology Obstetrics and Human Reproduction
Original ArticleA 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
Introduction
Surgical management of deep infiltrating endometriosis of the rectum and sigmoid colon (DIERS) has become a topic of increasing interest in gynecological surgery, leading to much debate. Over the last 20 years, there has been a steady rise in the number of scientific articles published, and many surgical teams worldwide have reported their experience. Five years ago, Meuleman et al. reported a large review of the literature, pooling 49 original studies, which enrolled 3894 patients with colorectal endometriosis [1]. Among them, 71% were managed by colorectal resection, 10% by full thickness disc excision, and 17% benefited from various techniques of shaving. However, a comparison of clinical outcomes between different surgical techniques was not possible. Despite the indubitable merits of this review, it is obvious that it does not provide an overview of the management of colorectal endometriosis worldwide, but only a focus on those teams, which reported their series before 2010.
Nevertheless, the review by Meuleman et al. confirmed two surgical philosophies or approaches commonly used in the management of colorectal endometriosis: a radical approach mainly based on colorectal segmental resection [2], [3], [4], [5], [6], [7] and the conservative or symptom-guided approach prioritising conservation of the rectum [8], [9], [10], [11]. The latter may be performed without opening the rectum (shaving or partial thickness excision) or by removing the nodule along with surrounding rectal wall (full thickness or disc excision) [10], [12], [13]. Due to the paucity of comparative studies in the literature [13], [14], [15], [16], it should be emphasized that present available data are provided by retrospective series reported by surgeons who generally perform only one technique. In series with patients managed by only one surgical procedure, it may be unclear whether only patients having benefited from this procedure were included, or whether surgeons routinely performed only this procedure [17]. Consequently, recommendations concerning the surgical management of DIERS are based on meagre evidence and tend to reflect a surgeon's personal convictions and experience [18]. For these reasons, there is a lack of accurate information on the actual percentage of patients who had one or other technique, as well as postoperative complications related to each strategy.
According to national medical databases such as PMSI (Programme de Médicalisation des Systèmes d’Information), identification of surgical procedures performed on the digestive tract for DIERS is a serious concern. Although patients undergoing segmental resection may be specifically identified using appropriate codes, such as HJFA004, no specific codes exist for full thickness disc excision or deep shaving (partial thickness excision). For these reasons, estimation of the real number of patients managed for DIERS requires a future study pooling all the series provided by all the surgeons having managed this disease during a given period of time. Such was the concern of the surgical teams, which decided to found FRIENDS (French coloRectal Infiltrating ENDometriosis Study) in January 2016, in order to foster shared experiences and improve DIERS management.
The aim of our study was to provide a snapshot of real-life practice in France in 2015 particularly regarding surgical route, procedures performed, and main immediate postoperative complications.
Section snippets
Methods
The present study pooled a series of patients managed for DIERS in 56 public and private healthcare facilities in France, from January 1st to December 31st 2015. Infiltration of the large bowel wall was defined as involvement of muscular, submucosal or mucosal layers (patients presenting with only superficial involvement of bowel serosa were excluded). So as to involve the largest number of healthcare facilities in France, the first author (H.R.) invited all heads of department of gynecology
Results
All the heads of departments replied to the invitation to participate to the survey. All the surgeons invited to join the group accepted the invitation and reported their personal series of patients managed in 2015. Thus, surgeons from 56 healthcare facilities joined the FRIENDS group: 33 university hospitals, 4 general hospitals and 19 private hospitals (Fig. 1). They were located in 13 different regions in France (Fig. 2). They reported data concerning 1135 patients managed for DIERS from
Discussion
We report the results of a large survey including 56 healthcare facilities and 141 gynecologic and general surgeons involved in the management of patients with DIERS in France in 2015. Such a study is particularly rare in the literature and allows a precise overview of the surgical management of DIERS in the general population and an accurate estimation of the total number of procedures performed during a 1 year period of time in France.
Nevertheless, our study presents several weaknesses. It is
Conclusion
Our study depicts the actual management of DIERS in France in 2015. The study reveals a surprisingly high number of facilities involved in the multidisciplinary management of DIERS and emphasizes the fact that DIERS is definitely a frequent disease. Our study also reveals the lack of standardized management of DIERS in France, as surgical procedures significantly differ from one center to another. The FRIENDS group may be the tool of choice to carry out further clinical trials in the field of
FRIENDS study group
List of gynecologist and colorectal surgeons who managed the patients enrolled in the study: CHU de Rouen: Pr Horace Roman, Dr Basma Darwish, Dr Julie Ness, Dr Gauthier Dietrich, Dr Benoit Resch, Pr Jean-Jacques Tuech, Dr Emmanuel Huet, Dr Rachid Chati, Dr Julien Coget, Dr Valérie Bridoux; CHU Lille: Dr Chrystèle Rubod, Pr Pierre Collinet, Pr Guillaume Piessen, Dr Thibaut Crombé, Dr Williams Tessier; CHU Toulouse: Pr Pierre Laguevaque; CHU Tenon: Pr Emile Daraï, Pr Marcos Ballester; Hôpital
Disclosure of interest
Horace Roman reports personal fees for participating in master classes where presented his experience in the use of PlasmaJet.
Acknowledgments
We thank Miss Amelie Breant, for her valuable management of the database.
The authors are grateful to Nikki Sabourin-Gibbs, Rouen university hospital, for her help in editing the manuscript.
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