International Journal of Colorectal Disease

, Volume 33, Issue 7, pp 835–847 | Cite as

Outcomes after rectosigmoid resection for endometriosis: a systematic literature review

  • Andrea BallaEmail author
  • Silvia Quaresima
  • José D. Subiela
  • Mostafa Shalaby
  • Giuseppe Petrella
  • Pierpaolo Sileri



“Endometriosis” is defined such as the presence of endometrial glands and stroma outside the uterine cavity. This ectopic condition may develop as deeply infiltrating endometriosis (DIE) when a solid mass is located deeper than 5 mm underneath the peritoneum including the intestinal wall. The ideal surgical treatment is still under search, and treatment may range from simple shaving to rectal resection. The aim of the present systematic review is to report and analyze the postoperative outcomes after rectosigmoid resection for endometriosis.


We performed a systematic review according to Meta-analysis of Observational Studies in Epidemiology guidelines. The search was carried out in the PubMed database, using the keywords: “rectal resection” AND “endometriosis” and “rectosigmoid resection” AND “endometriosis.” The search revealed 380 papers of which 78 were fully analyzed.


Thirty-eight articles published between 1998 and 2017 were included. Three thousand seventy-nine patients (mean age 34.28 ± 2.46) were included. Laparoscopic approach was the most employed (90.3%) followed by the open one (7.9%) and the robotic one (1.7%). Overall operative time was 238.47 ± 66.82. Conversion rate was 2.7%. In more than 80% of cases, associated procedures were performed. Intraoperative complications were observed in 1% of cases. The overall postoperative complications rate was 18.5% (571 patients), and the most frequent complication was recto-vaginal fistula (74 patients, 2.4%). Postoperative mortality rate was 0.03% and mean hospital stay was 8.88 ± 3.71 days.


Despite the large and extremely various number of associated procedures, rectosigmoid resection is a feasible and safe technique to treat endometriosis.


Endometriosis Deeply infiltrating endometriosis (DIE) Rectal resection Rectosigmoid resection Postoperative outcomes 


Compliance with ethical standards

Conflict of interest

Andrea Balla, Silvia Quaresima, José D. Subiela, Mostafa Shalaby, Giuseppe Petrella, and Pierpaolo Sileri have no conflicts of interest or financial ties to disclose.


  1. 1.
    Vercellini P, Viganò P, Somigliana E, Fedele L (2014) Endometriosis: pathogenesis and treatment. Nat Rev Endocrinol 10(5):261–275. CrossRefPubMedGoogle Scholar
  2. 2.
    Kamergorodsky G, Lemos N, Rodrigues FC, Asanuma FY, D'Amora P, Schor E, Girão MJ (2015 Aug) Evaluation of pre- and post-operative symptoms in patients submitted to linear stapler nodulectomy due to anterior rectal wall endometriosis. Surg Endosc 29(8):2389–2393. CrossRefPubMedGoogle Scholar
  3. 3.
    Riiskjær M, Forman A, Kesmodel US, Andersen LM, Ljungmann K, Seyer-Hansen M (2017) Diagnostic value of serial measurement of C-reactive protein in the detection of a surgical complication after laparoscopic bowel resection for endometriosis. Gynecol Obstet Investig 82(4):410–416. CrossRefGoogle Scholar
  4. 4.
    Roman H, Abo C, Huet E, Bridoux V, Auber M, Oden S, Marpeau L, Tuech JJ (2015) Full-thickness disc excision in deep endometriotic nodules of the rectum: a prospective cohort. Dis Colon rectum Oct 58(10):957–966.
  5. 5.
    Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, Moher D, Becker BJ, Sipe TA, Thacker SB (2000) Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA 283(15):2008–2012CrossRefPubMedGoogle Scholar
  6. 6.
    Lo CK, Mertz D, Loeb M (2014) Newcastle-Ottawa Scale: comparing reviewers’ to authors’ assessments. BMC Med Res Methodol 14:45. CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Hozo SP, Djulbegovic B, Hozo I (2005) Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol 5:13CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Urbach DR, Reedijk M, Richard CS, Lie KI, Ross TM (1998) Bowel resection for intestinal endometriosis. Dis Colon Rectum Sep 41(9):1158–1164Google Scholar
  9. 9.
    Darai E, Thomassin I, Barranger E, Detchev R, Cortez A, Houry S, Bazot M (2005) Feasibility and clinical outcome of laparoscopic colorectal resection for endometriosis. Am J Obstet Gynecol Feb 192(2):394–400CrossRefGoogle Scholar
  10. 10.
    Campagnacci R, Perretta S, Guerrieri M, Paganini AM, De Sanctis A, Ciavattini A, Lezoche E. (2005). Laparoscopic colorectal resection for endometriosis. Surg Endosc 19(5):662–664Google Scholar
  11. 11.
    Abrao MS, Sagae UE, Gonzales M, Podgaec S, Dias JA Jr. (2005). Treatment of rectosigmoid endometriosis by laparoscopically assisted vaginal rectosigmoidectomy. Int J Gynaecol Obstet;91(1):27–31Google Scholar
  12. 12.
    Dubernard G, Piketty M, Rouzier R, Houry S, Bazot M, Darai E (2006) Quality of life after laparoscopic colorectal resection for endometriosis. Hum Reprod 21(5):1243–1247CrossRefPubMedGoogle Scholar
  13. 13.
    Ribeiro PA, Rodrigues FC, Kehdi IP, Rossini L, Abdalla HS, Donadio N, Aoki T (2006) Laparoscopic resection of intestinal endometriosis: a 5-year experience. J Minim Invasive Gynecol 13(5):442–446CrossRefPubMedGoogle Scholar
  14. 14.
    Seracchioli R, Poggioli G, Pierangeli F, Manuzzi L, Gualerzi B, Savelli L, Remorgida V, Mabrouk M, Venturoli S (2007) Surgical outcome and long-term follow up after laparoscopic rectosigmoid resection in women with deep infiltrating endometriosis. BJOG 114(7):889–895CrossRefPubMedGoogle Scholar
  15. 15.
    Zanetti-Dällenbach R, Bartley J, Müller C, Schneider A, Köhler C (2008) Combined vaginal-laparoscopic-abdominal approach for the surgical treatment of rectovaginal endometriosis with bowel resection: a comparison of this new technique with various established approaches by laparoscopy and laparotomy, 22. Surg Endosc (4):995–1001Google Scholar
  16. 16.
    Ghezzi F, Cromi A, Ciravolo G, Rampinelli F, Braga M, Boni L (2008) A new laparoscopic-transvaginal technique for rectosigmoid resection in patients with endometriosis. Fertil Steril Nov 90(5):1964–1968. CrossRefGoogle Scholar
  17. 17.
    Minelli L, Fanfani F, Fagotti A, Ruffo G, Ceccaroni M, Mereu L, Landi S, Pomini P, Scambia G (2009) Laparoscopic colorectal resection for bowel endometriosis: feasibility, complications, and clinical outcome. Arch Surg 144(3):234–239; discussion 239. CrossRefPubMedGoogle Scholar
  18. 18.
    De Nardi P, Osman N, Ferrari S, Carlucci M, Persico P, Staudacher C (2009) Laparoscopic treatment of deep pelvic endometriosis with rectal involvement. Dis Colon Rectum 52(3):419–424.
  19. 19.
    Bracale U, Azioni G, Rosati M, Barone M, Pignata G (2009) Deep pelvic endometriosis (Adamyan IV stage): multidisciplinary laparoscopic treatments. Acta Chir Iugosl 56(1):41–46CrossRefPubMedGoogle Scholar
  20. 20.
    Kim JS, Hur H, Min BS, Kim H, Sohn SK, Cho CH, Kim NK (2009) Intestinal endometriosis mimicking carcinoma of rectum and sigmoid colon: a report of five cases. Yonsei Med J 50(5):732–735. CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Kössi J, Setälä M, Enholm B, Luostarinen M (2010) The early outcome of laparoscopic sigmoid and rectal resection for endometriosis. Colorectal Dis 12(3):232–235. CrossRefPubMedGoogle Scholar
  22. 22.
    Dousset B, Leconte M, Borghese B, Millischer AE, Roseau G, Arkwright S, Chapron C (2010) Complete surgery for low rectal endometriosis: long-term results of a 100-case prospective study. Ann Surg May 251(5):887–895. CrossRefGoogle Scholar
  23. 23.
    Daraï E, Dubernard G, Coutant C, Frey C, Rouzier R, Ballester M (2010) Randomized trial of laparoscopically assisted versus open colorectal resection for endometriosis: morbidity, symptoms, quality of life, and fertility. Ann Surg 251(6):1018–1023. CrossRefPubMedGoogle Scholar
  24. 24.
    Roman H, Rozsnayi F, Puscasiu L, Resch B, Belhiba H, Lefebure B, Scotte M, Michot F, Marpeau L, Tuech JJ. (2010). Complications associated with two laparoscopic procedures used in the management of rectal endometriosis. JSLS. Apr-Jun;14(2):169–77. doi:
  25. 25.
    Moawad NS, Guido R, Ramanathan R, Mansuria S, Lee T (2011) Comparison of laparoscopic anterior discoid resection and laparoscopic low anterior resection of deep infiltrating rectosigmoid endometriosis. JSLS 15(3):331–338. CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Lim PC, Kang E, do Park H (2011) Robot-assisted total intracorporeal low anterior resection with primary anastomosis and radical dissection for treatment of stage IV endometriosis with bowel involvement: morbidity and its outcome. J Robot Surg 5(4):273–278. CrossRefPubMedGoogle Scholar
  27. 27.
    Ruffo G, Sartori A, Crippa S, Partelli S, Barugola G, Manzoni A, Steinasserer M, Minelli L, Falconi M (2012) Laparoscopic rectal resection for severe endometriosis of the mid and low rectum: technique and operative results. Surg Endosc 26(4):1035–1040. CrossRefPubMedGoogle Scholar
  28. 28.
    Ceccaroni M, Clarizia R, Bruni F, D'Urso E, Gagliardi ML, Roviglione G, Minelli L, Ruffo G (2012) Nerve-sparing laparoscopic eradication of deep endometriosis with segmental rectal and parametrial resection: the Negrar method. A single-center, prospective, clinical trial. Surg Endosc 26(7):2029–2045. CrossRefPubMedGoogle Scholar
  29. 29.
    Vitobello D, Fattizzi N, Santoro G, Rosati R, Baldazzi G, Bulletti C, Palmara V (2013) Robotic surgery and standard laparoscopy: a surgical hybrid technique for use in colorectal endometriosis. J Obstet Gynaecol Res 39(1):217–222. CrossRefPubMedGoogle Scholar
  30. 30.
    Kössi J, Setälä M, Mäkinen J, Härkki P, Luostarinen M (2013) Quality of life and sexual function 1 year after laparoscopic rectosigmoid resection for endometriosis. Colorectal Dis 15(1):102–108. CrossRefPubMedGoogle Scholar
  31. 31.
    Neme RM, Schraibman V, Okazaki S, Maccapani G, Chen WJ, Domit CD, Kaufmann OG, Advincula AP (2013) Deep infiltrating colorectal endometriosis treated with robotic-assisted rectosigmoidectomy. JSLS 17(2):227–234. CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Cassini D, Cerullo G, Miccini M, Manoochehri F, Ercoli A, Baldazzi G (2014) Robotic hybrid technique in rectal surgery for deep pelvic endometriosis. Surg Innov 21(1):52–58. CrossRefPubMedGoogle Scholar
  33. 33.
    Fleisch MC, Hepp P, Kaleta T, Schulte A, Esch J, Rein D, Fehm T, Beyer I (2014) Feasibility and first long-term results after laparoscopic rectal segment resection and vaginal specimen retrieval for deep infiltrating endometriosis. Arch Gynecol Obstet 289(6):1241–1247. CrossRefPubMedGoogle Scholar
  34. 34.
    Mangler M, Herbstleb J, Mechsner S, Bartley J, Schneider A, Köhler C (2014) Long-term follow-up and recurrence rate after mesorectum-sparing bowel resection among women with rectovaginal endometriosis. Int J Gynaecol Obstet 125(3):266–269. CrossRefPubMedGoogle Scholar
  35. 35.
    English J, Sajid MS, Lo J, Hudelist G, Baig MK, Miles WA (2014) Limited segmental rectal resection in the treatment of deeply infiltrating rectal endometriosis: 10 years’ experience from a tertiary referral unit. Gastroenterol Rep (Oxf) 2(4):288–294. CrossRefGoogle Scholar
  36. 36.
    Akladios C, Messori P, Faller E, Puga M, Afors K, Leroy J, Wattiez A (2015) Is ileostomy always necessary following rectal resection for deep infiltrating endometriosis? J Minim Invasive Gynecol 22(1):103–109. CrossRefPubMedGoogle Scholar
  37. 37.
    Tarjanne S, Heikinheimo O, Mentula M, Härkki P (2015) Complications and long-term follow-up on colorectal resections in the treatment of deep infiltrating endometriosis extending to bowel wall. Acta Obstet Gynecol Scand 94(1):72–79. CrossRefPubMedGoogle Scholar
  38. 38.
    Rausei S, Sambucci D, Spampatti S, Cassinotti E, Dionigi G, David G, Ghezzi F, Uccella S, Boni L (2015) Laparoscopic treatment of deep infiltrating endometriosis: results of the combined laparoscopic gynecologic and colorectal surgery. Surg Endosc 29(10):2904–2909. CrossRefPubMedGoogle Scholar
  39. 39.
    Milone M, Vignali A, Milone F, Pignata G, Elmore U, Musella M, De Placido G, Mollo A, Fernandez LM, Coretti G, Bracale U, Rosati R. (2015). Colorectal resection in deep pelvic endometriosis: Surgical technique and post-operative complications. World J Gastroenterol;21(47):13345–13351. doi:
  40. 40.
    Malzoni M, Di Giovanni A, Exacoustos C, Lannino G, Capece R, Perone C, Rasile M, Iuzzolino D (2016) Feasibility and safety of laparoscopic-assisted bowel segmental resection for deep infiltrating endometriosis: a retrospective cohort study with description of technique. J Minim Invasive Gynecol 23(4):512–525. CrossRefPubMedGoogle Scholar
  41. 41.
    Roman H, Hennetier C, Darwish B, Badescu A, Csanyi M, Aziz M, Tuech JJ, Abo C (2016) Bowel occult microscopic endometriosis in resection margins in deep colorectal endometriosis specimens has no impact on short-term postoperative outcomes. Fertil Steril 105(2):423–9.e7. CrossRefPubMedGoogle Scholar
  42. 42.
    Riiskjaer M, Greisen S, Glavind-Kristensen M, Kesmodel US, Forman A, Seyer-Hansen M (2016) Pelvic organ function before and after laparoscopic bowel resection for rectosigmoid endometriosis: a prospective, observational study. BJOG 123(8):1360–1367. CrossRefPubMedGoogle Scholar
  43. 43.
    Roman H, Milles M, Vassilieff M, Resch B, Tuech JJ, Huet E, Darwish B, Abo C. (2016). Long-term functional outcomes following colorectal resection versus shaving for rectal endometriosis. Am J Obstet Gynecol;215(6):762.e1–762762.e9. doi:
  44. 44.
    Vlek SL, Lier MCI, Koedam TWA, Melgers I, Dekker JJML, Bonjer JH, Mijatovic V, Tuynman JB (2017) Transanal minimally invasive rectal resection for deep endometriosis: a promising technique. Colorectal Dis 19(6):576–581. CrossRefPubMedGoogle Scholar
  45. 45.
    Renner SP, Kessler H, Topal N, Proske K, Adler W, Burghaus S, Haupt W, Beckmann MW, Lermann J (2017) Major and minor complications after anterior rectal resection for deeply infiltrating endometriosis. Arch Gynecol Obstet 295(5):1277–1285. CrossRefPubMedGoogle Scholar
  46. 46.
    Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group (2010) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg 8(5):336–341. CrossRefPubMedGoogle Scholar
  47. 47.
    Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, de Santibañes E, Pekolj J, Slankamenac K, Bassi C, Graf R, Vonlanthen R, Padbury R, Cameron JL, Makuuchi M (2009) The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 250(2):187–196CrossRefPubMedGoogle Scholar
  48. 48.
    Kalogera E, Nitschmann CC, Dowdy SC, Cliby WA, Langstraat CL. (2017). A prospective algorithm to reduce anastomotic leaks after rectosigmoid resection for gynecologic malignancies. Gynecol Oncol 2017;144(2):343–347. doi:
  49. 49.
    Abo C, Moatassim S, Marty N, Saint Ghislain M, Huet E, Bridoux V, Tuech JJ, Roman H (2018) Postoperative complications after bowel endometriosis surgery by shaving, disc excision, or segmental resection: a three-arm comparative analysis of 364 consecutive cases. Fertil Steril 2018 109(1):172–178.e1. CrossRefGoogle Scholar
  50. 50.
    Afors K, Centini G, Fernandes R, Murtada R, Zupi E, Akladios C, Wattiez A (2016) Segmental and Discoid Resection are Preferential to Bowel Shaving for Medium-Term Symptomatic Relief in Patients With Bowel Endometriosis. J Minim Invasive Gynecol 2016 23(7):1123–1129. CrossRefGoogle Scholar
  51. 51.
    Roman H, Bubenheim M, Huet E, Bridoux V, Zacharopoulou C, Daraï E, Collinet P, Tuech JJ (2018) Conservative surgery versus colorectal resection in deep endometriosis infiltrating the rectum: a randomized trial. Hum Reprod 33(1):47–57. CrossRefPubMedGoogle Scholar
  52. 52.
    Rex JC Jr, Khubchandani IT (1992) Rectovaginal fistula: complication of low anterior resection. Dis Colon Rectum 35(4):354–356Google Scholar
  53. 53.
    Kosugi C, Saito N, Kimata Y, Ono M, Sugito M, Ito M, Sato K, Koda K, Miyazaki M (2005) Rectovaginal fistulas after rectal cancer surgery: incidence and operative repair by gluteal-fold flap repair. Surgery 137(3):329–336CrossRefPubMedGoogle Scholar
  54. 54.
    Antonsen HK, Kronborg O (1987) Early complications after low anterior resection for rectal cancer using the EEA stapling device. A prospective trial Dis Colon rectum 30(8):579–583Google Scholar
  55. 55.
    Arbman G (1993) Rectovaginal fistulas and the double-stapling technique. Dis Colon Rectum 36(3):310–311Google Scholar
  56. 56.
    Baran JJ, Goldstein SD, Resnik AM (1992) The double-staple technique in colorectal anastomosis: a critical review. Am Surg 58(4):270–272PubMedGoogle Scholar
  57. 57.
    Fleshner PR, Schoetz DJ Jr, Roberts PL, Murray JJ, Coller JA, Veidenheimer MC (1992) Anastomotic-vaginal fistula after colorectal surgery. Dis Colon Rectum 35(10):938–943Google Scholar
  58. 58.
    Nakagoe T, Sawai T, Tuji T, Nanashima A, Yamaguchi H, Yasutake T, Ayabe H (1999) Avoidance of rectovaginal fistula as a complication after low anterior resection for rectal cancerusing a double-stapling technique. J Surg Oncol 71(3):196–197CrossRefPubMedGoogle Scholar
  59. 59.
    Sugarbaker PH (1996) Rectovaginal fistula following low circular stapled anastomosis in women with rectal cancer. J Surg Oncol 61(2):155–158CrossRefPubMedGoogle Scholar
  60. 60.
    Tsutsumi N, Yoshida Y, Maehara Y, Kohnoe S (2007) Rectovaginal fistula following double-stapling anastomosis in low anterior resection for rectal cancer. Hepatogastroenterology 54(78):1682–1683PubMedGoogle Scholar
  61. 61.
    Watanabe J, Ota M, Kawaguchi D, Shima H, Kaida S, Osada S, Kamimukai N, Kamiya N, Ishibe A, Watanabe K, Matsuyama R, Akiyama H, Ichikawa Y, Oba M, Endo I (2015) Incidence and risk factors for rectovaginal fistula after low anterior resection for rectal cancer. Int J Colorectal Dis 30(12):1659–1666. CrossRefPubMedGoogle Scholar
  62. 62.
    Paun BC, Cassie S, MacLean AR, Dixon E, Buie WD (2010) Postoperative complications following surgery for rectal cancer. Ann Surg 251(5):807–818. CrossRefPubMedGoogle Scholar
  63. 63.
    Fujita F, Torashima Y, Kuroki T, Eguchi S (2014) Risk factors and predictive factors for anastomotic leakage after resection for colorectal cancer: reappraisal of the literature. Surg Today 44(9):1595–1602. CrossRefPubMedGoogle Scholar
  64. 64.
    Hayden DM, Mora Pinzon MC, Francescatti AB, Saclarides TJ (2014) Patient factors may predict anastomotic complications after rectal cancer surgery: anastomotic complications in rectal cancer. Ann Med Surg (Lond) 4(1):11–16. CrossRefGoogle Scholar
  65. 65.
    Paganini AM, Balla A, Quaresima S, D'Ambrosio G, Bruzzone P, Lezoche E (2015) Tricks to decrease the suture line dehiscence rate during endoluminal loco-regional resection (ELRR) by transanal endoscopic microsurgery (TEM). Surg Endosc 29(5):1045–1050. CrossRefPubMedGoogle Scholar
  66. 66.
    Kobayashi M, Mohri Y, Ohi M, Inoue Y, Araki T, Okita Y, Kusunoki M (2014) Risk factors for anastomotic leakage and favorable antimicrobial treatment as empirical therapy for intra-abdominal infection in patients undergoing colorectal surgery. Surg Today 44(3):487–493. CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of General Surgery and Surgical Specialties “Paride Stefanini”, SapienzaUniversity of RomeRomeItaly
  2. 2.Department of Urology, Fundació Puigvert, Carrer de Cartegena 340Universidad Autónoma de BarcelonaBarcelonaSpain
  3. 3.Department of General SurgeryUniversity of Rome “Tor Vergata”RomeItaly

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