Associated ICE location may correlate to rectal endometriosis severity

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An associated ileocecal location is a marker of severity in 25% cases of women undergoing complete resection for low rectal endometriosis (LRE), according to the results of a retrospective cohort study. However, the report in BJOG found that for complete surgical resection, “combining resection of ileocecal endometriosis (ICE) and LRE did not appear to increase postoperative rates of complications, morbidity or recurrence, nor did it seem to impair long‐term clinical outcomes,” the French authors wrote.

Methods
All surgeries were performed between January 1995 and December 2015 at Cochin Hospital in Paris. The study population was a series of nonpregnant women younger than age 42, with pain refractory to medical treatment, severe endometriosis, and colorectal involvement.

Rectal infiltration of at least the external muscularis layer was confirmed by pathological findings in all 375 cases, for which 74.4% had no lesion of the ileocecal region, 18.1% had histologically proven ileocecal endometriosis (ICE) and 7.5% had isolated appendiceal endometriosis (A-positive).

The main outcomes and measures were mean number and type of deep infiltrating endometriosis (DIE) lesions, existence of an associated endometrioma, and mean total American Society for Reproductive Medicine (ASRM) score.

Findings
The frequency of ICE was 25.6%. Women with it had a significantly higher adjusted number of DIE lesions (odds ratio [OR] = 1.43; 95% confidence interval [CI]: 1.02 to 3.03; P = 0.048), higher prevalence of endometriomas (OR = 1.91; 95% CI: 1.04 to 3.51; P = 0.044), more associated DIE sigmoid lesions (OR = 2.12; 95% CI: 1.07 to 3.91; P = 0.025), and a higher mean total ASRM score (OR = 2.07; 95% CI: 1.12 to 4.14; P = 0.025).

But women with ICE resected during the surgical procedure for LRE did not have more adverse postop clinical outcomes than ICE‐negative patients.

Mean follow-up was 93 months. At the last recorded patient visit, 84% of women achieved complete relief of symptoms and 8% had very satisfactory functional results. “Bowel function was slightly impaired during the first year, due to increased stool frequency and clustering, and 90% of the women received anti-diarrhoeal and bulking medications for a median duration of 7.8 months,” the authors wrote. However, no women in the series developed a recurrence of intestinal or urological endometriosis.

Five-year follow-up data were available for 269 women, of whom 11% still complained that they needed to push for voiding. The overall endometriosis recurrence rate was 7.4% among these 269 women: 4.8% for recurrent endometrioma and 2.6% for recurrent DIE. This recurrence rate was similar in all three groups: 7.6% in ICE-negative women, 7.8% in ICE-positive women and 5.0% in A-positive women.

Conclusions
The finding that additional ileocecal resection in ICE-positive women was not linked to either greater postop morbidity or a higher rate of anastomotic leakage secondary to ileocecal resection might be partially due to the combination of mechanical bowel preparation and the protocol for defunctioning ileostomy. Study results also support that surgical mobilization of the ileocaecal junction is necessary to avoid missing the diagnosis of additional ICE.

“Although clinically silent in most patients, the presence of ICE in women with LRE is a marker of disease severity that should prompt clinicians to look for ICE on preoperative imaging and during surgery,” the authors wrote.