Evaluation of peri-operative management in women with deep endometriosis candidates for bowel surgery: a survey from the Italian Society of Gynecologic Endoscopy

Study objective: There is great consensus that the implementation of ERAS approach is beneficial for surgical patients, but there is paucity of data concerning its application in women with deep endometriosis (DE) who are candidates for bowel surgery. The present survey was aimed at gathering detailed information on perioperative management of DE patients undergoing sigmoid/rectal (discoid or segmental) resection within SEGI group. Design: Baseline survey. Setting: National survey conducted within the main Italian cooperative group in minimally invasive gynecologic surgery (SEGI). Patients: The study did not involve patients. Interventions: A 63-item questionnaire, covering ERAS items for gynecologic/elective colorectal surgery, was sent to SEGI centres. Only questionnaires from centres reporting to perform ≥10 sigmoid/rectal resections per year were considered for the present analysis. Measurements and main results: Thirty-three/38 (86.8%) questionnaires were analysed. The rates of concordance with the ERAS guidelines were 40.4%, 64.4%, and 62.6%, respectively, for pre-operative, intra-operative, and post-operative items. The proportion of overall agreement was 56.6%. Pre-operative diet, fasting and bowel preparation, correction of anaemia, avoidance of peritoneal drains, post-operative feeding and early mobilization were the most controversial. Comparative analysis revealed that the referred rates of complete disease removal and conversion to open surgery were significantly different depending on case volume (p=0.044 and p=0.003, respectively) and gynecologist's/surgeon's experience (p=0.042 and p=0.022, respectively), with higher chances of obtaining a complete laparoscopic/robotic excision of endometriosis in centres reporting ≥30 DE surgeries performed per year and/or ≥90% of bowel resections performed by a gynecologist/general surgeon specifically dedicated to DE management. In contrast, the rates of concordance with the ERAS guidelines were not significantly different according to case volume (p=0.081) and gynecologist's/surgeon's experience (p=0.294). Conclusion: This is the first study conducted on a national scale for DE. The present survey reveals a sub-optimal compliance to the ERAS recommendations, and underline the need for improving the quality of peri-operative care in DE patients undergoing sigmoid/rectal resection. The present study is a first step to build a consistent structured reporting platform for the SEGI units and facilitate a wide implementation and standardization of ERAS protocol for DE patients in Italy.