Rectal endometriosis: Results of radical excision and review of published work

Background: The aim of this paper is to review the results of surgical excision of rectal endometriosis and review the published work on this challenging condition. Methods: All cases of endometriosis involving the rectum treated by a single colorectal surgeon were identified from a prospective database and the results reviewed. Results: Between 1995 and 2005, 213 rectal procedures were carried out on 203 patients together with an endogynaecologist. Eighteen cases involved dissection of endometriosis off the rectal wall, 58 involved full-thickness excision of the anterior rectal wall and 137 segmental excisions of the rectum were carried out. A loop ileostomy was required in 7 (5%) of the segmental resections. Seventy-five per cent of the cases were either laparoscopic or laparoscopically assisted. Infertility was significantly more common in the group requiring a segmental resection (P = 0.026) and a history of rectal pain during defecation more common in patients having dissection of endometriosis off the rectal wall (P = 0.031). There were no other significant differences between the different types of rectal surgery. The morbidity for all rectal procedures was 7% and there was one anastomotic leak in the segmental resection group. The actuarial rectal recurrence rate of endometriosis was 22.2% 95% confidence interval (CI) (2.5, 42.0) for dissection off the rectal wall and this was significantly different from the recurrence of 5.17% 95%CI (0.0, 10.9) for anterior rectal wall excision and 2.19% 95%CI (0.0, 4.6) for segmental rectal resection (P = 0.007). The overall rectal recurrence for all cases was 4.69% 95%CI (1.8, 7.5). Conclusion: Endometriosis of the rectum can be successfully treated with low morbidity and low recurrence rates by excising the disease as completely as possible using full-thickness excision of the anterior rectal wall or segmental resection of the rectum.