Maternal Mental Health During and Before the COVID-19 Pandemic: A Comparative Analysis in the Kingdom of Bahrain.

Introduction The coronavirus disease 2019 (COVID-19) pandemic created a crisis in health care systems worldwide. The maternity services were restricted due to the pandemic regulations. The psychological burden on the pregnant women was to various extents. Individuals and organizations implemented support schemes to understand and support their mental health. In our study, the psychological impact of pregnant women who contracted COVID-19 during pregnancy was compared with pregnancy of the same population before the pandemic as it could be a précised and helpful method to counsel pregnant women effectually. Study design This retrospective study included 111 women and was conducted at Bahrain Defense Force Hospital from January 2021 until December 2021. The researchers distributed a Hospital Anxiety and Depression Scale (HADS) questionnaire to women who delivered babies during the pandemic. The researchers then analyzed these scores and compared them with the scores of a control group of women who completed their pregnancies before the pandemic. The data were analyzed using SPSS Version 25.0 (IBM Corp., Armonk, NY). P-values of less than 0.05 were considered statistically significant. Results The HADS questionnaire results demonstrated that women's anxiety and depression during their pregnancy during the COVID-19 pandemic were significantly higher than that during their pregnancy before the pandemic, with a mean score of 14.97 (95% CI: 14.5 to 15.4) and 9.4 (95% CI: 8.8 to 9.9), respectively, and a p-value of <0.001. Additionally, during the COVID-19 pandemic, 100% of participants were "abnormal" in the anxiety category, and 86.5% were "abnormal" in the depression category, whereas before the pandemic, 0.9% of the studied population were abnormal, 3.6% were borderline abnormal, and 95.5% were normal in the depression category. The comparison of these scores highlighted that the pandemic had a significant negative psychological effect on the mothers during pregnancy, thus increasing their anxiety and depression. The correlated personal, social, and clinical factors were fear of delivery, fear of disease transmission, loss of family support, social isolation, uncertainty of life, and economic crises. Depression scores were significantly correlated to factors such as fear of disease transmission to the baby (p=0.027), fear of delivery (p=0.008), and loss of family support (p=0.001). Contributing factors and anxiety scores yielded significant correlations with fear of delivery (rs =0.258), fear of transmission (rs=0.198), and uncertainty of disease life (rs=0.247). As for depression, it was significantly correlated to one factor: loss of family support (rs=-0.335). Conclusion The mental health, in terms of anxiety and depression, of pregnant women was significantly affected during the COVID-19 pandemic.

COVID-19 vaccinations in pregnancy: Save mother and baby from COVID-19 pandemic.

OBJECTIVE: The current study investigated the immune response of maternal coronavirus disease 2019 (COVID-19) vaccination and vertical transmission of anti-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spike (S) and nucleocapsid (N) proteins. STUDY DESIGN: This retrospective study included pregnant women in Bahrain Defense Force Hospital from March 2021 to September 2021 who were vaccinated with Sinopharm or Pfizer/BioNTech. Testing of anti-N and -S levels from paired samples of maternal and umbilical cord blood was performed at the time of delivery. The immune response to vaccination, association with maternal and fetal factors, and vertical transmission of antibodies were studied. RESULTS: The current study included 79 pregnant women. The median gestational age for those vaccinated with Sinopharm was 28 weeks and those vaccinated with Pfizer was 31 weeks, with 100% of the vaccinated population generating antibodies and showing vertical transmission. The anti-N and -S titers and interval frequencies varied in both vaccinations. The anti-N and -S and transfer ratio statistically correlated with maternal age, gestational age at delivery, latency period, and birth weight of the neonates differently in both vaccines. In addition, the peak level of antibodies and transfer ratios varied. CONCLUSION: Although variations are exhibited in both types of vaccination, the vaccinated pregnant population generated a significant level of anti-N and -S and showed vertical transmission.

Maternal Obesity: An Obstetric Risk.

OBJECTIVE: To analyze the obstetric risks and to evaluate the effects of maternal obesity during pregnancy and postpartum period. METHOD: This is a retrospective study of pregnant women with a BMI of more the 30 conducted at Bahrain Defence Force Hospital, West Riffa, Bahrain, from September 2019 to August 2020. Data includes demographic characteristics, and course of pregnancy from gestational age 24 weeks, through intrapartum to the postpartum period. Adverse maternal effects and delivery complications were the primary study outcomes. The BMI was calculated at the time of the booking visit. Comparative analysis was done to calculate the odds of each outcome taking a non-obese group (BMI less than 30) as a reference.  Results: The total number of pregnant women studied was 2972, out of which 1657 had BMI ≥30. In our study, women with high BMI were older (p<0.0001). High BMI was associated with high parity and higher miscarriage history. High BMI increased the risk of developing hypertension (OR 2.5; 95%CI 1.1-5.3). This analysis also found that high BMI was associated with increased risk of antepartum hemorrhage (OR 2.4; 95%CI 1-5.4), postpartum complications (OR1.6; 95%CI 1.1-2.2), and a hospital stay of more than five days (OR 1.6; 95%CI 1.3-2). High BMI patients were less likely to have Intrauterine growth restriction (OR 0.6; 95%CI 0.3-0.9). High BMI patients did not have an increased risk of gestational diabetes mellitus, induction of labor, or caesarean birth. CONCLUSION: Higher BMI pregnant women are associated with higher incidences of hypertension. The high BMI group also had a significant relationship with antepartum hemorrhage and postpartum length of stay.

Maternal COVID-19 Disease and COVID-19 Immunization.

Aim This study aimed to evaluate the immune response and vertical transmission of anti-severe acute respiratory syndrome (SARS) antibodies in vaccinated, expectant mothers infected with coronavirus disease 2019 (COVID-19) and to study the sequelae. Study design This was a retrospective study of pregnant women conducted at Bahrain Defense Force Hospital from March 2021 to September 2021. The study population was divided into two groups: group 1 was vaccinated with Sinopharm or Pfizer/BioNTech during pregnancy and never infected with COVID-19. Group 2 was unvaccinated and had been infected with COVID-19. Immune responses such as anti-nucleocapsid (anti-N) and anti-spike (anti-S) from paired samples of maternal and umbilical cord blood were measured with Elecsys immunoassay (Roche Holding AG: Basel, Switzerland) at the time of delivery. Obstetric complications such as preterm labor, preeclampsia, and stillbirth were assessed. Analysis was performed using SPSS version 26.0 (IBM Corp: Armonk, NY) and Minitab version 18 (Minitab, LLC: State College, PA). A p-value of less than 0.05 was considered statistically significant. Results The study included 90 vaccinated and 90 COVID-19-recovered pregnant women. Matched samples were available for 80 vaccinated and 74 COVID-19-recovered women. Group 1 had significantly higher levels of anti-S for both the mother and the cord blood and a significantly higher transfer ratio of anti-S. Group 2 had higher levels of anti-N. In group 1, the paired sample titer of anti-S had a weak negative correlation with maternal age whereas, in group 2, the mother's anti-N had a weak positive correlation with age. Antibodies of COVID-19-recovered mothers and cord blood had a moderate negative correlation with gestational age, except for the mother's anti-N. In group 1, the transfer ratio of anti-N and anti-S had a statistically significant association with gestational age. Preterm delivery had a high prevalence of anti-transfer ratios of <1, and delivery at >37 weeks had a high prevalence of ≥1. In group 2, 90% of preterm deliveries had transfer ratios of anti-S <1. The latency period of the COVID-19 group had a statistically significant association with the antibody transfer ratio. An interval of less than 100 days had a high prevalence in the ratio of <1. An interval of more than 100 days had a high prevalence in the ratio of ≥1. There was no significant latency period in group 1. Group 1 had a 75% prevalence of an anti-S transfer ratio ≥1 with a birth weight of >3500 g; group 2 had no significance in birth weight. We did not find significance in the sequelae of morbidities in either group. Conclusion The production of the antibody N in the COVID-19-infected and antibody S in the vaccinated pregnant women as well as the vertical transmission of antibodies was efficacious. Significant variation was found regarding maternal age in both groups. The transfer ratio of the antibodies in the vaccinated and COVID-19-recovered women was significantly higher in terms of babies of the vaccinated and the infected population. The transfer ratios were distinct according to the latency period and birth weight of the infants.

Impacts and effects of COVID-19 infection in pregnancy.

OBJECTIVES: To explore the trimester wise significance of the primary outcome in pregnant women during coronavirus disease-19 (COVID-19) pandemic. METHODS: Retrospective observational study of pregnant women who were infected with COVID-19 from April 2020 until March 2021 at Bahrain Defense Force Hospital, Riffa, Bahrain. The study focused on the effects in relation to gestational age (GA), association with variables, severity, and treatment. A p-value of ≤0.05 was considered significant. RESULTS: During the study period, 74 COVID-19 cases were identified from the recorded 2944 pregnant women. The mean GA at diagnosis was 33.5±12.2 weeks, and the mean GA at birth was 38.4±1.8 weeks. Analysis of the obstetric complications revealed fetal growth restriction (FGR) had a p-value of <0.001. According to the trimester wise analysis, between the gestational period at diagnosis and the outcome of pregnancy, significant p-value of <0.01 was found in miscarriage. There were no significant associations found in GA at diagnosis and delivery, complications in relation to maternal age and body mass index, and no maternal morbidities or mortalities. CONCLUSION: In our study, FGR and miscarriage were the identified complications. However, the maternal and neonatal end result of COVID-19 was satisfactory.

Excision of deep endometriosis nodules of the parametrium and sacral roots in 10 steps.

OBJECTIVE: To present 10 consecutive, standardized, and reproducible surgical steps allowing complete excision of deep endometriosis nodules infiltrating the parametrium and sacral roots. DESIGN: Surgical video presenting the 10 surgical steps. Local institutional review board approval was not required for this video article, because the video describes a technique and the patient cannot be identified whatsoever. SETTING: Endometriosis Center. PATIENTS: Patients undergoing excision of deep endometriosis nodules of the parametrium and sacral roots. INTERVENTION: The excision of deep endometriosis infiltrating the parametrium down to the sacral roots may be performed following 10 steps: complete ureterolysis and removal of ureteral stenosis; opening of the pararectal space in contact with the rectum in a sagittal plane; dissection caudally toward the rectovaginal space, section of the rectovaginal nodule in two separate blocks infiltrating the rectum and vagina, respectively, all the way down to the levator ani muscles; dissection of the presacral space and identification of the superior hypogastric plexus and hypogastric nerve; transverse incision of the peritoneum at the level of the promotorium, extended laterally above the origin of the hypogastric vessels; anterograde dissection of the hypogastric artery and identification of the hypogastric vein; anterograde dissection of the hypogastric vein and opening of Okabayashi space, followed by identification and, when required, ligation of hypogastric vein tributaries; dissection is extended behind the venous network with identification of the pyriform muscles and sacral roots S2, S3, and S4; anterograde dissection of the nerve network and inferior hypogastric plexus, up to the posterior limits of the deep endometriosis nodule; and excision of the deep endometriosis nodule from the posterior limit to the inferior limit in contact with the sacral roots, which should be released or shaved, then to the lateral limit in contact with the pyriform muscle and lateral pelvic wall. Additional steps may be required to remove adjacent infiltration of the vagina, rectum, bladder, or ureters. The movie does not reflect a similar approach in cases of isolated nodules of the sciatic nerves involving a specific lateral dissection plane between the external iliac vessels and the iliopsoas muscle. MAIN OUTCOME MEASURES: Description of 10 successive surgical steps. RESULTS: The 10-step procedure already has been employed in 70 women with deep endometriosis of the parametria involving sacral roots, in whom sensory or motor complaints were not completely relieved by continuous amenorrhea provided by contraceptive pill intake or gonadotropin-releasing hormone analogs. Baseline complaints included somatic pain (85.7%), severe bladder dysfunction (10%), or hydronephrosis (24.3%). Main localizations concerned sacral roots (95.7%), sciatic nerves (7.1%), mid/low rectum (87.1%), and bladder (21.4%). Operative time was 224 ± 94 minutes. Among postoperative complications, we recorded rectovaginal fistulae (14.3%), urinary tract fistulae (4.3%), and bladder dysfunction at 3 weeks (22.9%) and 12 months (5.7%) after the surgery. CONCLUSIONS: Laparoscopic excision of deep endometriosis nodules of the parametria involving the sacral roots is a challenging procedure, requiring good anatomic and surgical skills. Teaching such a complex procedure is a delicate task. By following 10 sequential steps, the surgeon may reduce the risk of hemorrhage originating from the hypogastric venous network, preserve as much as possible autonomic nerves and organ function, and successfully excise deep endometriosis nodules. However, transection of the internal iliac artery and vein should not be systematic, as it may adversely affect the vascular supply of the pelvis. Transection of small pelvic splanchnic nerves should be performed only if they actually are included in fibrous nodules, as it may be followed by sexual, bladder, and rectal dysfunction or perineal sensory effects. Although the 10 steps attempt to standardize the surgical approach in a challenging localization of deep endometriosis, they are not mandatory and their use should be individualized.

Multiple Nodule Removal by Disc Excision and Segmental Resection in Multifocal Colorectal Endometriosis.

STUDY OBJECTIVE: To report postoperative outcomes after dual digestive resection for deep endometriosis infiltrating the rectum and the colon. DESIGN: A retrospective study using data prospectively recorded in the CIRENDO database (Canadian Task Force classification II-2). SETTING: A university tertiary referral center. PATIENTS: Twenty-one patients managed for multiple colorectal deep endometriosis infiltrating nodules. INTERVENTIONS: Concomitant disc excision and segmental resection of both the rectum and sigmoid colon. MEASUREMENTS AND MAIN RESULTS: The assessment of postoperative outcomes was performed. Rectal nodules were managed by disc excision and segmental resection in 20 patients and 1 patient, respectively. Sigmoid colon nodules were removed by short segmental resection and disc excision in 15 and 6 patients, respectively. The rectal nodule diameter was between 1 and 3 cm and over 3 cm in 33% and 67% of patients, respectively. Associated vaginal infiltration requiring vaginal excision was recorded in 76.2% of patients. The mean diameter of the rectal disc removed averaged 4.6 cm, and the mean height of the rectal suture was 5.8 cm. The length of the sigmoid colon specimen and the height of the anastomosis were 7.3 cm and 18.5 cm, respectively. The mean operative time was 290 minutes, and the mean postoperative follow-up averaged 30 months. Clavien-Dindo 3 complications occurred in 28% of patients, including 4 with rectal fistulae (19%). The pregnancy rate was 67% among patients with pregnancy intention. CONCLUSION: Our data suggest that combining disc excision and segmental resection to remove multiple deep endometriosis nodules infiltrating the rectum and the sigmoid colon can preserve the healthy bowel located between 2 consecutive nodules. However, the rate of postoperative complications is high, particularly in patients with large low rectal nodules.

Surgical Outcomes of Urinary Tract Deep Infiltrating Endometriosis.

OBJECTIVE: To report the outcomes of surgical management of urinary tract endometriosis. DESIGN: Retrospective study based on prospectively recorded data (NCT02294825) (Canadian Task Force classification II-3). SETTING: University tertiary referral center. PATIENTS: Eighty-one women treated for urinary tract endometriosis between July 2009 and December 2015 were included, including 39 with bladder endometriosis, 31 with ureteral endometriosis, and 11 with both ureteral and bladder endometriosis. Owing to bilateral ureteral localization in 8 women, 50 different ureteral procedures were recorded. INTERVENTION: Procedures performed included resection of bladder endometriosis nodules, advanced ureterolysis, ureteral resection followed by end-to-end anastomosis, and ureteroneocystostomy. MEASUREMENTS AND MAIN RESULTS: The main outcome measure was the outcome of the surgical management of urinary tract endometriosis. Fifty women presented with deep infiltrating endometriosis (DIE) of the bladder and underwent either full-thickness excision of the nodule (70%) or excision of the bladder wall without opening of the bladder (30%). Ureteral lesions were treated by ureterolysis in 78% of the patients and by primary segmental resection in 22%. No patient required nephrectomy. Histological analysis revealed intrinsic ureteral endometriosis in 54.5% of cases. Clavien-Dindo grade III complications were present in 16% of the patients who underwent surgery for ureteral nodules and in 8% of those who underwent surgery for bladder endometriosis. Overall delayed postoperative outcomes were favorable regarding urinary symptoms and fertility. Patients were followed up for a minimum of 12 months and a maximum of 7 years postoperatively, with no recorded recurrences. CONCLUSION: Surgical outcomes of urinary tract endometriosis are generally satisfactory; however, the risk of postoperative complications should be taken into consideration. Therefore, all such procedures should be managed by an experienced multidisciplinary team.

Abdominal wall endometriosis following cesarean section: a study of the growth rate of parietal endometriosis implants.

BACKGROUND: The study aimed to estimate the growth rate of abdominal wall endometriosis (AWE) following cesarean section (CS), in order to potentially identify a growth model of endometriosis in vivo. METHODS: This monocentric, retrospective study included 23 patients presenting 26 nodules of post-CS AWE treated by surgical excision. Nodule surface and volume, time-lapse between surgery and AWE as well as the contraception used were noted. A comparison between nodules' features was performed depending on hormonal vs. non-hormonal contraception. RESULTS: The time-lapse between CS and AWE surgery had a mean value of 48 months. The mean surface of an AWE nodule was of 3.83 cm2, and the mean volume was of 5.32 cm3. Comparison between the main surface and volume in patients receiving hormonal vs. non-hormonal contraception was statistically non-significant. No statistically significant correlation between AWE dimension and time was revealed. In patients presenting more than one lesion, nodules appeared to grow following variable patterns. CONCLUSIONS: AWE natural history was characterized by inter- and intra-individual variability, independently of the method of contraception used.

Functional outcomes after disc excision in deep endometriosis of the rectum using transanal staplers: a series of 111 consecutive patients.

OBJECTIVE: To assess the postoperative outcomes of patients with rectal endometriosis managed by disc excision using transanal staplers. DESIGN: Prospective study using data recorded in the CIRENDO database (NCT02294825). SETTING: University tertiary referral center. PATIENT(S): A total of 111 consecutive patients managed between June 2009 and June 2016. INTERVENTION(S): We performed rectal disc excision using two different transanal staplers: [1] the Contour Transtar stapler (the Rouen technique); and [2] the end to end anastomosis circular transanal stapler. MAIN OUTCOMES MEASURE(S): Pre- and postoperative digestive function was assessed using standardized gastrointestinal questionnaires: the Gastrointestinal Quality of Life Index and the Knowles-Eccersley-Scott Symptom Questionnaire. RESULT(S): The two staplers were used in 42 (37.8%) and 69 patients (62.2%), respectively. The largest diameter of specimens achieved was significantly higher using the Rouen technique (mean ± SD, 59 ± 11 mm vs. 36 ± 7 mm), which was used to remove nodules located lower in the rectum (5.5 ± 1.3 cm vs. 9.7 ± 2.5 cm) infiltrating more frequently the adjacent posterior vaginal wall (83.3% vs. 49.3%). Associated nodules involving sigmoid colon were managed by distinct procedures, either disc excision (2.7%) or segmental resection of sigmoid colon (9.9%). Postoperative values for the Gastrointestinal Quality of Life Index increased 1 and 3 years after the surgery, but improvement in constipation was not significant. The probability of pregnancy at 1 year after the arrest of medical treatment was 73.3% (95% confidence interval 54.9%-88.9%), with a majority of spontaneous conceptions. CONCLUSION(S): Disc excision using transanal staplers is a valuable alternative to colorectal resection in selected patients presenting with rectal endometriosis, allowing for good preservation of rectal function.

Does preoperative antimüllerian hormone level influence postoperative pregnancy rate in women undergoing surgery for severe endometriosis?

OBJECTIVE: To compare postoperative pregnancy rates as they relate to presurgery antimüllerian hormone (AMH) level in patients with stage 3 and 4 endometriosis. DESIGN: Retrospective comparative study using data prospectively recorded in the North-West Inter-Regional Female Cohort for Patients with Endometriosis (CIRENDO) database. SETTING: University tertiary referral center. PATIENT(S): One hundred eighty patients with stage 3 and 4 endometriosis and pregnancy intention, managed from June 2010 to March 2015, were divided into two groups according to their preoperative AMH levels: group A (AMH ≥2 ng/mL) and group B (AMH <2 ng/mL). INTERVENTION(S): Surgical procedure involved ovarian endometrioma ablation by plasma energy along with resection of various localizations of the disease. Postoperative conception was either spontaneous or used assisted reproductive technology, depending on patient characteristics. MAIN OUTCOME MEASURE(S): Patient characteristics, preoperative symptoms, infertility history, intraoperative findings, and probability of pregnancy were recorded and compared between the two groups. RESULT(S): Among 180 women enrolled in the study, 134 (74.4%) were assigned to group A and 46 (25.6%) to group B. The women's ages were, respectively, 30 ± 3.8 and 32 ± 4.6 years. Pregnancy was achieved by 134 (74.4%) patients, and conception was spontaneous in 74 of them (55.2%). Pregnancy rates in groups A and B were, respectively, 74.6% (100 women) and 73.9% (34 women), while spontaneous conception represented 54% (54 women) and 58.8% (20 women). The probability of pregnancy at 12, 24, and 36 months after surgery in groups A and B was comparable, respectively, 65% (95% confidence interval [CI], 55%-75%), 77% (95% CI, 86%-68%), and 83% (95% CI, 90%-75%) versus 50% (95% CI, 69%-34%), 77% (95% CI, 90%-61%), and 83% (95% CI, 94%-68%). Supplementary analysis in women with normal (≥2 ng/mL), low (1-1.99 ng/mL), and very low (<1 ng/mL) AMH level showed an inverse relationship between AMH level, age, and antecedents of miscarriage; however, postoperative pregnancy rates were comparable among the three groups at 12 and 24 months, respectively, 59.5% (95% CI, 49.3%-70%) and 77.4% (95% CI, 68%-85.4%); 57.1% (95% CI, 34%-83%) and 78.6% (95% CI, 55.2%-94.8%); and 46.7% (95% CI, 25.6%-73.7%) and 73.3% (95% CI, 50.4%-91.7%). CONCLUSION(S): The probability of postoperative pregnancy was comparable between women with low and normal AMH level who were managed for stage 3 and 4 endometriosis and who were a mean age of 30 years. However, the small sample size might have been unable to detect differences in pregnancy and live-birth rates between the two groups. As the majority of pregnancies were spontaneous, our results suggest that surgical management may be offered to young patients with severe endometriosis and reduced ovarian reserve with good fertility outcomes.

Nerve Sparing and Surgery for Deep Infiltrating Endometriosis: Pessimism of the Intellect or Optimism of the Will.

Nerve-sparing surgery is an emerging technique for surgery-related dysfunction. Within the past 15 years, an essential progress in recognition and understanding of the anatomy of the pelvic autonomous nervous system has been made. Surgical preservation of vegetative nerves has become well known in many cancer centers. The technique has led to improvement of the quality of life following oncologic radical procedures. Positive results have led to the adoption of such techniques in the surgical treatment of deep infiltrating endometriosis in an aim to prevent urinary, rectal, and sexual dysfunction. Even though nerve-sparing excision of endometriosis is feasible and offers good outcomes in terms of bladder morbidity; digestive and sexual functions seem to be more complex to assess. Moreover, functional impairment in deep infiltrating endometriosis may preexist prior to surgery and function may not be restored despite nerve preservation. In cases where endometriosis lesions are deeply embedded in the parametrium, nerve-sparing techniques may only be feasible in those with a unilateral involvement. The nerve-sparing surgical approach is therefore a safer radical surgery in the hands of experienced surgeons that has to be tailored to the unique nature of deep infiltrating endometriosis and balanced between the natural aggressiveness of such a debilitating disease and postoperative morbidity. Good knowledge of pelvic nerve anatomy and function allows understanding of related symptoms to reduce morbidity, whenever this goal is still achievable.

Long-term functional outcomes following colorectal resection versus shaving for rectal endometriosis.

BACKGROUND: Two surgical approaches usually are used in the surgical management of deep infiltrating endometriosis of the rectum: the radical approach that mainly is based on colorectal resection and the conservative or symptom-guided approach that prioritizes conservation of the rectum. There are no data available that compare long-term functional digestive outcomes of 1 approach to the other. OBJECTIVE: The purpose of this study was to compare long-term digestive outcomes in women who were treated by either rectal shaving or colorectal resection for deep endometriosis infiltrating the rectum. STUDY DESIGN: A retrospective comparative study was performed. All women who were treated with surgery for deep endometriosis infiltrating the rectum by either shaving or colorectal resection at the University Hospital of Rouen from January 2005 to January 2010 were enrolled. Follow-up evaluation was carried out for a minimum of 5 years. Postoperative evaluation of digestive symptoms was performed by 4 standardized gastrointestinal questionnaires: the Gastrointestinal Quality of Life Index, the Knowles-Eccersley-Scott-Symptom score for constipation, the Wexner score for anal continence, and the Bristol Stool Score. Symptoms that were related to endometriosis, fertility, and disease recurrence were obtained from a specific questionnaire. RESULTS: A total of 77 women were included. Three women were lost to follow up (3.9%), and 3 were treated by disc excision (3.9%). The mean follow-up time was 80±19 months. Forty-six women underwent conservative rectal shaving, and 25 women underwent colorectal resection. Patient characteristics and the severity of the disease were comparable in both groups. Patients who were treated by rectal shaving had significantly better Gastrointestinal Quality of Life Index values, lower Knowles-Eccersley-Scott-Symptom scores for postoperative constipation, and better anal continence. No statistically significant differences were revealed for postoperative pelvic pain. Rectal recurrence occurred in 8.7% of patients who were treated by conservative surgery: 4.3% underwent secondary colorectal resection and 4.3% were treated secondarily by rectal shaving. Consequently, avoiding a recurrence for merely 1 patient would have required 11 patients to undergo colorectal resection instead of shaving. CONCLUSION: Our data suggest that, in patients who are treated for rectal endometriosis, colorectal resection does not improve long-term postoperative functional outcomes when compared with rectal shaving.

Continuous Amenorrhea May Be Insufficient to Stop the Progression of Colorectal Endometriosis.

We present the case of a patient in whom consecutive imaging assessment and surgery demonstrated the obvious progression of colorectal endometriosis under continuous medical therapy. A 26-year-old nullipara presented with secondary dysmenorrhea, deep dyspareunia, diarrhea, and constipation during menstruation. Magnetic resonance imaging (MRI) assessment revealed 2 right ovarian endometriomas, but no deep endometriosis lesion. Intraoperatively, we found a 2-cm length of thickened and congestive area of sigmoid colon, along with small superficial lesions arising in the small bowel and appendix. We performed ablation of ovarian endometriomas and appendectomy, and decided to not resect the bowel. Postoperative computed tomography-based virtual colonoscopy (CTC) revealed a slight abnormality of the sigmoid colon. Endorectal ultrasound identified a normal rectum and sigmoid colon. Despite long-term continuous medical treatment, the patient presented 4 years later with impaired digestion consisting in constipation alternating with diarrhea, bloating, dyschesia, and pelvic pain. MRI and CTC revealed an abnormal sigmoid colon from 42 to 50 cm above the anus, with digestive tract diameter reduced from 10 mm down to the virtual lumen, along with an overall rigid appearance. Laparoscopy revealed the extent of endometriosis lesions in the sigmoid colon and multiple implantations in the small bowel. We performed sigmoid and small bowel resection. This case demonstrates the obvious progression of deep rectal endometriosis despite 4 years of continuous hormonal therapy.

Laparoscopic management of diaphragmatic endometriosis by three different approaches.

OBJECTIVE: To report our three surgical approaches in the management of diaphragmatic endometriosis. DESIGN: Video article presenting laparoscopic surgical techniques, with and without robotic assistance. SETTING: University hospital. PATIENT(S): Nulliparas with deep endometriosis associated with multiple endometriosis lesions of the diaphragm. INTERVENTION(S): Laparoscopic approach in women who present with small black-pigmented diaphragmatic lesions, with or without infiltration of the diaphragm, which are ablated using plasma energy. Robotic-assisted laparoscopic route in larger deep infiltrating implants, which are resected. To avoid phrenic nerve injury, robotic-assisted thoracoscopy is preferred in large lesions involving the central tendon of the diaphragm. MAIN OUTCOME MEASURE(S): The steps of each technique are emphasized. Surgical technique reports in anonymous patients are exempted from ethical approval by the Institutional Review Board. RESULT(S): Seven patients have been managed by these procedures from July 2015 to March 2016. Patients' functional outcomes were uneventful, with no phrenic nerve palsy or residual chest and right shoulder pain. CONCLUSION(S): By combining resection and ablation techniques, the laparoscopy and thoracoscopy route, conventional and robotic-assisted minimally invasive approach, we offer a surgical strategy that is as conservative as possible, with an aim to limit postoperative adhesions between the liver and the diaphragm, and avoid diaphragmatic paralysis.