Postoperative complications after deep bowel endometriosis surgery: is the surgical technique the only one to blame?
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Postoperative complications after deep bowel endometriosis surgery: is the surgical technique the only one to blame? Rogério Serafim Parra1 · Marley Ribeiro Feitosa1 · Omar Féres1 Received: 8 July 2020 / Accepted: 6 November 2020 © Springer-Verlag GmbH Germany, part of Springer Nature 2020
To the editor, Gornes et al. [1] recently published a retrospective study with 164 patients to evaluate the postoperative complications (POC) after rectal shaving (RS), disc resection (DR), and segmental resection (SR) for deep infiltrating endometriosis (DIE) with bowel involvement. They observed an increased risk of overall POC and rectovaginal fistula (RVF) after SR. Despite the relevant information, some issues need further discussion. First, in the group of patients submitted to SR, heterogeneous surgical procedures (different surgeons with distinct abdominal access techniques) and two colorectal anastomosis techniques (manual vs. stapled) were included. For instance, open surgery can be associated with higher POC rates when compared to minimally invasive procedures and double stapling is the safest technique for low colorectal anastomoses [2]. The inclusion of patients with manual anastomosis may have interfered with POC rates. Therefore, it is not known whether the high rates of RVF and stoma were a consequence of the resection or the type of anastomosis (manual vs. stapled). Second, more than half of the patients had undergone RS, which contradicts the authors who stated that the high levels of POC may have been explained by the recruitment of patients with more severe disease. Third, the authors excluded nine patients operated due to endometriosis recurrence, which is usually technically difficult and may be associated with higher POC rates [3]. Finally, the presence * Rogério Serafim Parra [email protected] Marley Ribeiro Feitosa [email protected] Omar Féres [email protected] 1
of a colorectal surgeon at the beginning of the surgery is crucial. Despite the knowledge that the choice of the surgical technique depends on the preoperative assessment, in some situations, surgical procedures may change and conservative surgery (for example, RS or DR) can become a major operation (SR or multiple resections). In conclusion, the POC rates observed by the authors were probably not exclusively related to the surgical technique but also to the severity of the disease. In addition, the identification of the high-risk sub-group may have been biased by the lack of homogeneity of the patients and of the surgical techniques. Despite our comments, the data presented in the article strongly suggest that the team is experienced in DIE surgery with a high volume of cases per year. In addition, the importance of the knowledge of risk factors for POC after bowel surgery for endometriosis has been appropriately highlighted. Acknowledgements All authors report no conflict of interest and there has been no financial support for this work that could have influenced its outcome. Author contributions RSP wr
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