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Invited Critique |

Laparoscopic Colorectal Resection for Bowel Endometriosis—Invited Critique

Susan Galandiuk, MD
Arch Surg. 2009;144(3):239. doi:10.1001/archsurg.2008.579.
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Minelli et al report a large series of 357 patients undergoing laparoscopic colorectal resection for endometriosis during a 5-year period with a median follow-up of 19.6 months. One should consider that colonic involvement of endometriosis occurs in roughly 10% of patients and does not require surgery in all of these patients.

There are several additional points to be made:

  • Notwithstanding specialty turf and related issues, if one does a lot of something and does it well, one gets very good results and helps patients, no matter what the field or area of interest. This applies to turf issues between and among all specialists.

  • Despite “salami slicing” and serial publication of slowly growing clinical series that add a few cases at a time to each serial publication, there is merit to publication of substantial increases in clinical series, with longer-term follow-up and other valuable clinical data that give us information about the utility of different surgical techniques. In this example, changing to the nerve-sparing technique led to an improved clinical outcome.

  • Endometriosis in this report seems to behave like cancer, in the sense that, if one has a failed first operation, one is more likely to have a recurrence, in this case presumably owing to the difficulty of finding disease amid surgical adhesions. Surgeons with such patients should decide whether it might not be in their patients' best interests to refer them for a proper operation as the first procedure.

  • Old-fashioned things are good! Although laparoscopy is newer, common sense and tried-and-true surgical workhorses, such as the omentum, continue to protect and help the patient and the surgeon, even if the method of access is different.

  • Symptoms due to endometriosis affecting the bowel are like long-standing Crohn disease intestinal strictures: they have a fibrotic component and are less likely to benefit from medical therapy and more likely to require and respond to surgical treatment.

  • Similar to several other disorders, only at operation can you get a true idea of the full extent of the endometriosis.

  • With the authors' excellent clinical outcome, notably in terms of urinary incontinence, fertility, and surgical morbidity, one can only argue that patients with endometriosis who do not respond to medical therapy be sent to surgeons with such expertise as these authors. I applaud the authors for their attention to detail, careful patient selection, and continuing follow-up of their patients in an effort to improve clinical outcomes.

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