The Problem of Anastomotic Stricture After Rectosigmoid Resection in Deep Infiltrating Endometriosis

摘要

Background: Deep infiltrating endometriosis (DIE) of the large bowel is infiltration of the large-bowel wall by endometrial-like implants and is associated with fibrosis and muscular hyperplasia. Deep endometriosis affects ~20% of patients with endometriosis. Objective: The aim of this research was to assess the importance of anastomotic stricture (AS) after large-bowel resection for DIE of the colon. Materials and Methods: This was a retrospective analysis of prospectively collected data. A consecutive series of 113 colonic resections for DIE were performed to address pain and/or infertility. There were low and very-low resections (n=82) with mechanical end-to-end anastomosis associated with or without partial colpectomy, segmental sigmoid resections with side-to-end anastomosis (?=27), and ileocecal resections with latero-lateral anastomosis (ft=4). Pneumatic balloon dilatation was performed in cases of AS (ft=22 in 13 patients). Patients were asked preoperatively and at 4, 8, 12, and 24 months postoperatively, about symptoms of constipation, small-caliber stools, and abdominal bloating. Patients presenting with those symptoms underwent double-contrast barium enema. When the smallest diameter of the suture was <12mm in the anteroposterior or profile positions, diagnostic and therapeutic rectosigmoidoscopy was performed. Pneumatic dilatation was performed in patients with AS, until they were symptom-free. Mean operating time, age, body mass index, follow-up, length of the large-bowel resection, and largest diameter of the lesion on the colon were compared between a group with confirmed symptomatic AS and a group without AS or without suspicion of AS. Statistical analysis was performed with a two-tailed Student's t-test. Results: Thirteen patients (12%) had AS and underwent dilatation. The mean diameter of AS was 8.6+1 mm and the final diameter after dilatation was 14.3±3.lmm. The mean distance between AS and anal verge was 8±2cm. The mean delay of occurrence of symptoms of AS was 7.8 ±1.2 weeks. The total number of dilatations was 22.38% of patients with confirmed AS who underwent a second dilatation. AS occurred only after low or very low rectal resections associated with colpectomy and mechanical end-to-end anastomosis. All patients with AS (n= 13) were symptom-free after one or several dilatations. No difference was found between the AS group and the group without AS or without suspicion of AS. Conclusions: AS seems to be a frequent complication after low or very low rectal resections associated with posterior colpectomy and mechanical end-to-end anastomosis. AS may require several dilatations. It occurs mainly after low or very low rectal resections. Long-term good results can be achieved with endoscopic balloon dilatation. Surgeons should be aware of this potential complication and inform patients clearly before performing operations. Further comparative studies based on this specific complication are necessary before drawing definitive conclusions about prevention and the most adequate treatments. (J GYNECOL SURG 32:35)