Medical treatment or surgery for colorectal endometriosis? : results of a shared decision-making approach
Articolo
Data di Pubblicazione:
2018
Citazione:
Medical treatment or surgery for colorectal endometriosis? : results of a shared decision-making approach / P. Vercellini, M.P. Frattaruolo, R. Rosati, D. Dridi, A. Roberto, P. Mosconi, O. De Giorgi, F.M. Cribiù, E. Somigliana. - In: HUMAN REPRODUCTION. - ISSN 0268-1161. - 33:2(2018), pp. 202-211. [10.1093/humrep/dex364]
Abstract:
STUDY QUESTION:
What is the degree of patient satisfaction in women with symptomatic colorectal endometriosis who choose medical or surgical treatment after a shared decision-making (SDM) process?
SUMMARY ANSWER:
The degree of satisfaction with treatment was high both in women who chose medical treatment with a low-dose oral contraceptive (OCP) or a progestin, and in those who chose to undergo surgical resection of bowel endometriosis.
WHAT IS KNOWN ALREADY:
Hormonal therapies and surgery for colorectal endometriosis have been investigated in non-comparative studies with inconsistent results.
STUDY DESIGN, SIZE, DURATION:
Parallel cohort study conducted on 87 women referring to our centre with an indication to surgery for colorectal endometriosis. A standardised SDM process was adopted, allowing women to choose their preferred treatment. Median follow-up was 40 [18-60] months in the medical therapy group and 45 [30-67] in the surgery group.
PARTICIPANTS/MATERIALS, SETTING, METHODS:
Patients with endometriosis infiltrating the proximal rectum, the rectosigmoid junction, and the sigmoid, not causing severe sub-occlusive symptoms were enroled. A total of 50 patients chose treatment with an OCP (n = 12) or a progestin (n = 38), whereas 37 women confirmed their previous indication to surgery. Patient satisfaction was graded according to a 5-category scale. Variations in bowel and pain symptoms were measured by means of a 0-10 numeric rating scale. Constipation was assessed with the Knowles-Eccersley-Scott Symptom Questionnaire (KESS), health-related quality of life with the Short Form-12 questionnaire (SF-12), psychological status with the Hospital Anxiety and Depression scale (HADS) and sexual functioning with the Female Sexual Function Index (FSFI).
MAIN RESULTS AND THE ROLE OF CHANCE:
Six women in the medical therapy group requested surgery because of drug inefficacy (n = 3) or intolerance (n = 3). Seven major complications were observed in the surgery group (19%). At 12-month follow-up, 39 (78%) women in the medical therapy group were satisfied with their treatment, compared with 28 (76%) in the surgery group (adjusted odds ratio (OR), 1.37; 95% confidence interval (CI), 0.45-4.15; intention-to-treat analysis). Corresponding figures at final follow-up assessment were 72% in the former group and 65% in the latter one (adjusted OR, 1.74; 95% CI, 0.62-4.85). The 60-month cumulative proportion of dissatisfaction-free participants was 71% in the medical therapy group compared with 61% in the surgery group (P = 0.61); the Hazard incidence rate ratio was 1.21 (95% CI, 0.57-2.62). Intestinal complaints were ameliorated by both treatments. Significant between-group differences in favour of medical treatment were observed at 12-month follow-up in diarrhoea, dysmenorrhoea, non-menstrual pelvic pain and SF-12 physical component scores. The total HADS score improved significantly in both groups, whereas the total FSFI score improved only in women who chose medical therapy.
LIMITATIONS REASONS FOR CAUTION:
As treatments were not randomly assigned, selection bias and confounding are likely. The small sample size exposes to the risk of type II errors.
WIDER IMPLICATIONS OF THE FINDINGS:
When adequately informed and empowered through a SDM process, most patients with non-occlusive colorectal endometriosis who had already received a surgical indication, preferred medical therapy. The possibility of choosing the preferred treatment may allow maximisation of the potential effect of the interventions.
STUDY FUNDING/COMPETING INTEREST(S):
This study was financed by Italian fiscal contribution '5 × 1000'-Ministero dell'Istruzione, dell'Università e della Ricerca-devolved to Fondazione Istituto di Ricovero e Cura a Carattere Scientifi
Tipologia IRIS:
01 - Articolo su periodico
Keywords:
colorectal endometriosis; constipation; endometriosis; medical treatment; surgery
Elenco autori:
P. Vercellini, M.P. Frattaruolo, R. Riccardo, D. Dhouha, R. Anna, M. Paola, D.G. Olga, C. Fulvia Milena, E. Somigliana
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