COMMENTARY

Colorectal Endometriosis: Medical or Surgical Therapy?

Peter Kovacs, MD, PhD

Disclosures

June 20, 2018

Endometriosis

Endometriosis (stroma plus glands in extrauterine locations) is a common, benign gynecologic problem. Endometriosis responds to steroids and undergoes cyclic changes during the menstrual cycle. The associated symptoms are partly due to bleeding from endometrial lesions and partly due to inflammation, scarring, and pressure on nerve endings.[1]

There is no cure for endometriosis, but treatment of its symptoms is often required. Medical or surgical options are available. Medical treatment induces a hypoestrogenic state or decidualization of the lesions. Surgery involves resection, excision, or ablation of endometriosis.

Endometriosis most often is found along the Fallopian tubes, on the ovaries, or in the cul-de-sac. However, it may infiltrate the bladder, ureters, or bowel, and rarely, it can be found in distant locations.

Surgical Versus Medical Treatment of Colorectal Endometriosis

A recent parallel cohort study[2] compared the efficacy of surgical versus medical treatment for colorectal endometriosis.

Women 18-50 years of age with deep infiltrating intestinal endometriosis were invited to participate. Those with bowel occlusion, more than 60% bowel stenosis, or subocclusive symptoms were excluded. Patients were counseled about options for medical (continuous monophasic contraceptive pill use or progestin) and surgical (laparoscopy or laparotomy with disc excision or segmental resection) management.

Postintervention follow-up was performed every 6 months, and bowel symptoms, sexual functioning, psychological status, pain, and quality of life were assessed using questionnaires.

Of the 87 women who were enrolled, 50 chose medical treatment and 37 opted for surgery. In the surgery group, 92% underwent segmental resection. Median follow-up was 40-45 months.

In the medical therapy group, 74% of those who took hormones (76% used progestin and 24% took a contraceptive pill) had side effects, which included weight gain, decreased libido, bloating, headache, vaginal dryness, and mood changes. In the surgery group, 6 of 37 surgeries were accompanied by major complications: anastomosis dehiscence, intra-abdominal bleeding, fistula, and colostomy occlusion.

At 12 months, 78% of the medical therapy group and 76% of those undergoing surgery were satisfied or very satisfied with their choice of treatment (odds ratio [OR], 1.14; 95% confidence interval [CI], 0.42-3.12). Corresponding figures at final follow-up were 72% among the medical group and 65% among the surgery group (OR, 1.39; 95% CI, 0.56-3.48).

Baseline bowel symptoms (diarrhea, cramping) were worse in the surgery group. All bowel symptoms significantly improved in both groups, except for diarrhea in the surgery group. Menstrual symptoms and pain improved in both groups, although these improvements were more pronounced in the medical therapy group. Psychological symptoms similarly improved in both groups.

Overall, after 3 years of follow-up, more than two thirds of women who chose medical therapy for deep infiltrating endometriosis were satisfied with their treatment.

Viewpoint

Symptomatic endometriosis requires treatment (surgical or medical) because it has a significant negative impact on quality of life. The participants in this study were referred for surgery owing to endometriosis infiltrating the bowels, but a thorough discussion about the pros and cons of medical versus surgical treatment took place before a decision was made. Medical treatment induces temporary relief and may be associated with systemic side effects, whereas surgery, which may be associated with postoperative complications, offers a longer disease-free period, but recurrence in the bowel wall cannot be ruled out.

Most participants in this study who chose medical therapy had some side effects, but only three (6%) withdrew from the study owing to severe side effects. Of the surgical group, 16% had major surgical complications.

Clinical improvement and satisfaction were similar with both approaches after 3 years of follow-up. Some women who underwent surgery used contraceptive pills postoperatively, so the added benefit of medical therapy cannot be excluded in their cases.

This study demonstrates that the patient has to be involved in the decision-making, and a shared decision can be achieved once the patient is fully informed about the risks and benefits of surgery versus medical therapy.

For severe bowel stenosis, especially when occlusive symptoms are present, surgery is the only alternative. In these cases, rectosigmoid shaving or disc excision are preferred over segmental resection.[3] In less severe cases, medical treatment should be considered as first-line management before a more invasive approach is selected.[4]

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