GENERAL GYNECOLOGY Bowel dysfunction before and after surgery for endometriosis Horace Roman, MD, PhD; Vale ´rie Bridoux, MD, PhD; Jean Jacques Tuech, MD, PhD; Loic Marpeau, MD; Carla da Costa, MD; Guillaume Savoye, MD, PhD; Lucian Puscasiu, MD, PhD O ver the past 2 decades, more and more surgical teams worldwide have gained the experience to safely perform complex techniques required in efficient surgical treatment of rectal endometriosis. In early scientific reports, the authors proposed the surgical re- moval of deep fibrotic endometriosis with or without conservation of the rectum. 1-4 Many surgeons reported their own series, focusing on the surgical technique that had been predominantly or exclusively used, and using post- operative pain improvement as a strong argument in the support of their surgical strategy. 5-7 Rates for postoperative immediate complications vary throughout retro- spective studies with rates that are logi- cally higher than those related to surgical management for other gynecological benign diseases. The overall rate of post- operative complications following bowel resection averages 22.2%, with 11% major complications. 8 Postoperative com- plications following procedures with rectal conservation, ie, shaving and full- thickness disc excision, appear less fre- quent (1.3%), even though they are often not completely avoidable. 9 More recently, a few surgeons have observed that, despite unquestionable improvement in pelvic pain, some patients still experience postoperative unpleasant digestive symptoms, either unchanged or even increased by rectal surgery. 10 Conse- quently, to assess the goals for their treat- ment of rectal endometriosis and the patients for which rectal surgery is worth- while, it is fundamental to understand the relationship between deep endometriosis infiltrating the rectum, digestive com- plaints, and surgical treatment. Are rectal nodules responsible for all digestive complaints? We have previously suggested that digestive complaints reported by women presenting with deep fibrotic endome- triosis of the rectum can be explained by 3 major consequences of disease devel- opment: anterior or lateral fixation of the rectum to adjacent anatomic struc- tures, rectal stenosis, and cyclic inflam- mation of the rectal wall. 11 Rectal fixation on uterosacral liga- ments, uterine cervix, or vaginal fornix may be responsible for abnormal irre- ducible angulations of the digestive tract (Figure 1), disturbing stool progression, and likely to result in defecation pain or constipation. 11 Rectal stenosis is the consequence of nodule protrusion into the rectum (Figure 2) and may be revealed as an intraluminal indentation From the Department of Gynecology and Obstetrics (Drs Roman and Marpeau), Research Group EA 4308 “Spermatogenesis and Male Gamete Quality” (Dr Roman), Department of Digestive Surgery (Drs Bridoux and Tuech), Digestive Tract Research Group EA3234/IFRMP23 (Drs Bridoux, Tuech, and Savoye), Department of Radiology (Dr da Costa), and Department of Gastroenterology (Dr Savoye), Rouen University Hospital, Rouen, France, and Department of Gynaecology and Obstetrics, University Hospital, Targu Mures, Romania (Dr Puscasiu). Received Jan. 9, 2013; revised March 25, 2013; accepted April 4, 2013. The authors report no conflict of interest. Presented at the 21st annual meeting of the European Society of Gynecologic Endoscopy, Paris, France, Sept. 11-14, 2012. Reprints: Horace Roman, MD, PhD, Clinique Gynécologique et Obstétricale, Centre Hospitalier Universitaire Charles Nicolle, 1 Rue de Germont, 76031 Rouen, France. [email protected]. 0002-9378/$36.00 ª 2013 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2013.04.015 The relationship between deep fibrotic endometriosis of the rectum and digestive symptoms as well as the impact of surgical treatment on digestive complaints appears increasingly complex. With the exception of cases in which the disease leads to rectal stenosis, it seems likely that certain digestive symptoms are a result of cyclic inflammatory phenomena leading to irritation of the digestive tract and not necessarily the result of actual involvement of the rectum by the disease itself because they frequently occur in women free of rectal nodules. Functional or inflammatory bowel diseases and rectal hypersensitivity may be associated with pelvic endometriosis and consequently joe- pardize the hypothetical causal relationship between the presence of a rectal nodule and digestive complaints. Women treated surgically for rectal endometriosis may continue to experience postoperative digestive complaints, such as constipation. Despite successful surgery free of intra- and postoperative complications and significant improvement in well-being and pelvic pain, several unpleasant digestive symptoms may be incompletely cured by the surgery. Furthermore, de novo postoperative digestive complaints may occur after rectal surgery. Retrospective data suggest that performing colorectal resection is related to less favorable digestive functional outcomes than the use of conservative procedures such as shaving or full-thickness disc excision. These hypotheses need to be confirmed by prospective randomized trials comparing rectal radical and conservative approaches. Bearing in mind the complex relationship between rectal nodules, digestive symptoms and rectal surgery, particular care must be taken in the preoperative assessment of digestive function and in choosing the most suitable surgical procedure. Key words: colorectal resection, constipation, deep endometriosis, digestive symptoms, rectal endometriosis, shaving 524 American Journal of Obstetrics & Gynecology DECEMBER 2013 Clinical Opinion www. AJOG.org
Transcript
Clinical Opinion www.AJOG.org
GENERAL GYNECOLOGY
Bowel dysfunction before and after surgery for endometriosisHorace Roman, MD, PhD; Valerie Bridoux, MD, PhD; Jean Jacques Tuech, MD, PhD; Loic Marpeau, MD;Carla da Costa, MD; Guillaume Savoye, MD, PhD; Lucian Puscasiu, MD, PhD
The relationship between deep fibrotic endometriosis of the rectum and digestivesymptoms as well as the impact of surgical treatment on digestive complaints appearsincreasingly complex. With the exception of cases in which the disease leads to rectalstenosis, it seems likely that certain digestive symptoms are a result of cyclic inflammatoryphenomena leading to irritation of the digestive tract and not necessarily the result ofactual involvement of the rectum by the disease itself because they frequently occur inwomen free of rectal nodules. Functional or inflammatory bowel diseases and rectalhypersensitivity may be associated with pelvic endometriosis and consequently joe-pardize the hypothetical causal relationship between the presence of a rectal nodule anddigestive complaints. Women treated surgically for rectal endometriosis may continue toexperience postoperative digestive complaints, such as constipation. Despite successfulsurgery free of intra- and postoperative complications and significant improvement inwell-being and pelvic pain, several unpleasant digestive symptoms may be incompletelycured by the surgery. Furthermore, de novo postoperative digestive complaints may occurafter rectal surgery. Retrospective data suggest that performing colorectal resection isrelated to less favorable digestive functional outcomes than the use of conservativeprocedures such as shaving or full-thickness disc excision. These hypotheses need to beconfirmed by prospective randomized trials comparing rectal radical and conservativeapproaches. Bearing in mind the complex relationship between rectal nodules, digestivesymptoms and rectal surgery, particular care must be taken in the preoperativeassessment of digestive function and in choosing the most suitable surgical procedure.
O more surgical teams worldwidehave gained the experience to safelyperform complex techniques requiredin efficient surgical treatment of rectalendometriosis. In early scientific reports,the authors proposed the surgical re-moval of deep fibrotic endometriosis
From the Department of Gynecology and Obstetrics4308 “Spermatogenesis and Male Gamete Quality(Drs Bridoux and Tuech), Digestive Tract Researchand Savoye), Department of Radiology (Dr da CosSavoye), RouenUniversity Hospital, Rouen, France,University Hospital, Targu Mures, Romania (Dr Pus
Received Jan. 9, 2013; revised March 25, 2013; a
The authors report no conflict of interest.
Presented at the 21st annual meeting of the EuropFrance, Sept. 11-14, 2012.
Reprints: Horace Roman, MD, PhD, Clinique GynéUniversitaire Charles Nicolle, 1 Rue de Germont, 76
0002-9378/$36.00 � ª 2013 Mosby, Inc. All rights reser
524 American Journal of Obstetrics & Gynecology
with or without conservation of therectum.1-4 Many surgeons reported theirown series, focusing on the surgicaltechnique that had been predominantlyor exclusively used, and using post-operative pain improvement as a strongargument in the support of their surgicalstrategy.5-7
(Drs Roman andMarpeau), Research Group EA” (Dr Roman), Department of Digestive SurgeryGroup EA3234/IFRMP23 (Drs Bridoux, Tuech,ta), and Department of Gastroenterology (DrandDepartment ofGynaecology andObstetrics,casiu).
ccepted April 4, 2013.
ean Society of Gynecologic Endoscopy, Paris,
cologique et Obstétricale, Centre Hospitalier031 Rouen, France. [email protected].
Rates for postoperative immediatecomplications vary throughout retro-spective studies with rates that are logi-cally higher than those related to surgicalmanagement for other gynecologicalbenign diseases. The overall rate of post-operative complications following bowelresection averages 22.2%, with 11%major complications.8 Postoperative com-plications following procedures withrectal conservation, ie, shaving and full-thickness disc excision, appear less fre-quent (1.3%), even though they areoften not completely avoidable.9
More recently, a few surgeons haveobserved that, despite unquestionableimprovement in pelvic pain, some patientsstill experience postoperative unpleasantdigestive symptoms, either unchanged oreven increased by rectal surgery.10 Conse-quently, to assess the goals for their treat-ment of rectal endometriosis and thepatients for which rectal surgery is worth-while, it is fundamental to understand therelationship between deep endometriosisinfiltrating the rectum, digestive com-plaints, and surgical treatment.
Are rectal nodules responsible for alldigestive complaints?We have previously suggested thatdigestive complaints reported by womenpresenting with deep fibrotic endome-triosis of the rectum can be explained by3 major consequences of disease devel-opment: anterior or lateral fixation ofthe rectum to adjacent anatomic struc-tures, rectal stenosis, and cyclic inflam-mation of the rectal wall.11
Rectal fixation on uterosacral liga-ments, uterine cervix, or vaginal fornixmay be responsible for abnormal irre-ducible angulations of the digestive tract(Figure 1), disturbing stool progression,and likely to result in defecation painor constipation.11 Rectal stenosis is theconsequence of nodule protrusion intothe rectum (Figure 2) and may berevealed as an intraluminal indentation
Deep endometriosis infiltrating the rectum and pushing internal rectal layers inside the rectal lumen.
A, Macroscopic view. B, Microscopic view.Roman. Bowel dysfunction, endometriosis, and surgery. Am J Obstet Gynecol 2013.
www.AJOG.org General Gynecology Clinical Opinion
on barium enema or computed tomog-raphyebased virtual colonoscopy (CTC;Figure 3).12 In low andmidrectal noduleslocated up to 8-10 cm from the anus,stenosis may be clinically confirmedthrough examination by an intrarectalfinger, whereas for nodules located abovethis limit, CTC examination providesmore complete information.
The thresholds used to define steno-sis in imaging examination can varythrough different series, and their cor-relation with clinical symptoms or sur-gical indications is yet to be established.However, the greater the rectal infiltra-tion, the more frequent the rectal ste-nosis. A decrease in rectal diameterhas been shown from CTC examina-tion in up to 79% of patients whosenodules involved more than 20 mmof the rectum.13 With regard to clinicalimpact, women presenting with rectalendometriosis responsible for rectalstenosis had an increased prevalenceof constipation, defecation pain, appe-tite disorders, a longer time necessaryto defecate, and an increased stoolconsistency.14
Stenosis responsible for subocclusivesymptoms is more likely to occur atthe rectosigmoid junction than at therectal ampulla at which the diameter isnaturally larger. Rectal stenosis appearsto seldom lead to complete occlusion(1.2% in our series, unpublished data)(Figure 4), which may occur duringperiods15 or during the flare-up phase ofmedical treatment using a gonadotropin-releasing hormone (GnRH) analog.16
The inflammatory nature of endome-triosis deposits located in close proximityto the terminal large bowel and localprostaglandin release may explain cyclicalteration of bowel function.17 Inflam-mation acts as an irritant factor, leadingto an increase in the daily number ofbowel movements (usually described asdiarrhea and smooth or liquid stools),in defecation pain, and in a feeling ofincomplete emptying of the rectumduring menstruation.
In a recent study, we compared diges-tive symptoms in 3 groups of womenwith distinct localizations of pelvic endo-metriosis, respectively, superficial endo-metriosis of the Douglas pouch, deep
endometriosis sparing the rectum, andrectal endometriosis.14 Although womenpresenting with rectal endometriosiswere more likely to present cyclic defe-cation pain (67.9%), cyclic constipation(54.7%), and a significantly longer stoolevacuation time, these complaints were
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also frequent in the other 2 groups.Because certain digestive complaints alsooccur in women free of any rectalinvolvement, the results suggest that, inwomen affected by rectal endometriosis,these complaints may be unrelated torectal infiltration by the disease.
Computed tomography-based virtual colonoscopy (CTC) revealing rectal stenosis because of deep
endometriosis infiltrating the anterior rectal wall. A, Two-dimensional sagittal view of the insufflated
rectum showing an important reduction in rectal diameter. B, Three-dimensional virtual endoluminal
view showing narrowing of the lumen corresponding to rectal stenosis. C, Three-dimensional
transparent rendering mode double-contrast enema-like view displaying colorectal anatomy and
exact location of the stenosis. D, Deep endometriosis nodule responsible for rectal stenosis.Roman. Bowel dysfunction, endometriosis, and surgery. Am J Obstet Gynecol 2013.
Clinical Opinion General Gynecology www.AJOG.org
The inflammatory mechanism of cyclicdigestive function in women with rectalendometriosis has recently been con-firmed in a study in which anorectalmanometry was performed in womenpresenting deep endometriotic nodules,which were mainly infiltrating the middlerectum.18 The most frequent complaintswere of dyschesia and constipation (40%),feeling incomplete evacuation (36%), andstool fragmentation (52%). Anorectalmanometry performed during the inter-menstrual phase revealed the absence ofabnormal bowelmotility, rectal functionaldisorders, or nerve plexus dysfunction.The major alteration was an increase inresting pressure for the internal analsphincter in 80% of women, which wasmost likely the consequence of chronicinflammation, resulting in pain and
526 American Journal of Obstetrics & Gynecology
muscle spasm, similar to that observed inother inflammatory diseases.19
The findings suggest that cyclic in-flammation is a critical factor in digestivecomplaints and offer an explanationfor the cyclic character of symptoms.Furthermore, they offer an explanation asto why colorectal resection does not sys-tematically result in the relief of preop-erative constipation.For some women, the relationship
between pelvic endometriosis and diges-tive complaints may be even more com-plex because of the hidden confoundingeffect of rectal hypersensitivity. Recentdata demonstrated that digestive symp-toms consistent with irritable bowelsyndrome could be identified in 65% ofwomen with minimal or mild endome-triosis and in 50% of women with
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moderate and severe endometriosis,whereas they are absent in asymptomaticwomen undergoing laparoscopic sterili-zation.20 Rectal barostat examinationrevealed low rectal sensory threshold andlow rectal compliance in women affectedby endometriosis, suggesting an increasein rectal sensitivity in women withendometriosis, independent of stage ofdisease.
Women with endometriosis are atincreased risk of developing inflamma-tory bowel diseases such as Crohn’sdisease or ulcerative colitis, more than20 years after the diagnosis of endo-metriosis,21 which may jeopardize thehypothetical causal relationship betweenpresence of a rectal nodule and diges-tive complaints. Women with irritablebowel syndrome may present cyclicvariation of pain intensity22; further-more, in postmenopausal women theuse of hormone replacement therapyseems to be associated with a high inci-dence of irritable bowel syndrome.23 Asignificant improvement in scores ofbowel symptoms and quality of lifewas observed following GnRH analogadministration, thus demonstrating thatworsening of bowel symptoms duringmenses is mandatorily related to notonly pelvic endometriosis but also toirritable bowel syndrome.22
In conclusion, rectal nodules arenot found to be responsible for all di-gestive complaints, and therefore, thepresence of such complaints in womenaffected by rectal endometriosis can-not provide the basis of a strong argu-ment in favor of mandatory colorectalresection.
Does rectal nodule removal relieve alldigestive complaints?There is increasing evidence that womentreated surgically for rectal endometriosismay continue to experience postoperativedigestive complaints. Despite successfulsurgery free of intra- and postoperativecomplications and significant improve-ment in well-being and pelvic pain,several unpleasant digestive symptomsmay be incompletely cured by surgery.
In women undergoing colorectalendometriosis, the rate of women re-porting diarrhea halved.24 Conversely,
Magnetic resonance imaging revealing severe rectal stenosis caused by deep endometriosis infil-
trating the rectum in a patient presenting with rectal occlusion. A, Sagittal T2-weighted view. B, Axial
T2-weighted view.
Roman. Bowel dysfunction, endometriosis, and surgery. Am J Obstet Gynecol 2013.
www.AJOG.org General Gynecology Clinical Opinion
the rate of women presenting con-stipation only insignificantly decreased,whereas that of those reporting tenes-mus postoperatively increased.
In another retrospective study in-cluding a series of women exclusivelymanaged by colorectal resection,6 despitepostoperative improvement in qualityof life and gynecological and digestivesymptoms, postoperative intensity ofconstipation only slightly decreased,whereas defecation pain and tenesmuswere the same or increased in, respec-tively, 45%, 22%, and 59% of thesewomen. A randomized controlled trialcomparing colorectal resection by openand laparoscopic route provided detailedpostoperative data showing that thispostoperative improvement in digestivecomplaints does not apply to all patientsor all symptoms,25 and the overall im-provement in constipation was lessmarked than for dyschesia and diarrhea.
We recently reported preliminaryresults of a detailed evaluation of post-operative digestive symptoms using gas-trointestinal standardized questionnairesin 75 patients treated for rectal endo-metriosis whose postoperative follow-upexceeded 12 months.26 Colorectal resec-tion was performed in 35% of cases andconservative rectal surgery (shaving orfull-thickness disc excision) in 65%.
For the diagnosis of constipation,the Knowles-Eccersley-Scott-SymptomQuestionnaire (KESS) was used (range,0e39, with overall values superior to 10in patients with constipation),27 whereasthe quality of life was evaluated using theGastrointestinal Quality of Life Index(GIQLI) self-administered question-naire (range, 0e144, and overall valuesinferior to 100 for patients sufferingfrom gastrointestinal diseases).28 Meanvalues of the KESS constipation scoreand GIQLI were, respectively, 11 � 7(range, 0e29) and 104 � 24 (range,44e140), supporting evidence that rectalsurgery does not provide mandatory re-lief of digestive symptoms, even thoughpoor digestive outcomes are generallyoutweighed by relief of dyspareunia,pelvic pain, and an improvement inquality of sexual intercourse.
Several authors have suggested thatperforming a nerve-sparing technique
avoids postoperative digestive complica-tions related to rectal denervation. Landiet al29 reported their experience con-cerning nerve-sparing colorectal resectionof rectal endometriosis, reporting thatpreservation of hypogastric plexus andsplanhnic nerves may avoid unfavorablefunctional outcomes related to bladdervoiding, rectal voiding, and vaginallubrification. Patients having benefitedfrom a nerve-sparing technique presentedpostoperative abnormal bowelmovementin 20% vs 49% in controls. Althoughintraoperative identification of nervesappears to decrease unfavorable rectalfunctional outcomes following colorectalresection, it is likely that it cannotcompletely prevent rectal denervationand that rectal dysfunction is related tonot only rectal denervation but is alsomultifactorial.
Is rectal surgery responsible forpostoperative de novo digestivecomplaints?Our team recently reported a series of5 women presenting postoperative denovo severe unpleasant constipationfollowing colorectal resection for rectalendometriosis.10 These patients weretaken from a sample of 25 patients
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followed up over and above 24 months,so their digestive functional complaintstherefore are likely to be definitive. Fullinvestigations were carried out to under-stand the mechanism for postoperativeconstipation and revealed 4 differentetiologies: rectal neurological sequela,stenosis of the colorectal anastomosis,colorectal intussuseption through theanastomosis, and unmasked transitconstipation.
In our practice, prior to November2007, rectal endometriosis nodules weresystematically removed using colorectalsegmental resection followed by colorectalanastomosis and systematic resection ofposterior vaginal fornix. Colorectal re-sections were performed at all times byexperienced general surgeons, havingperformed several hundred proceduresfor various indications such as rectalcancer, inflammatory bowel diseases, andcolorectal endometriosis.
November 2007 marked a change inour surgical preference and generalconvictions concerning the disease, inresponse to then-published data andexchanges with other surgical teams.30-32
From this date onward, we have consid-ered that although with nodule excisionthe removal of rectal implants might
be microscopically incomplete,33,34 athorough relief of symptoms couldbe obtained by a conservative surgicalprocedure associated with prolongedpostoperative amenorrhea. Moreover,we felt that colorectal segmental resec-tion was an overly complex procedurefollowed in some cases by unpleasantfunctional digestive symptoms in youngpatients.35,36 Thus, we have adopteda conservative surgical approach andattempt conservation of the rectum byeither shaving or disc excision wheneverpossible and independently of the depthand length of rectal involvement.26
The surgical procedure that we use inrectal shaving is similar to that performedby other surgical teams and as firstdescribed by Donnez et al.37 Both para-rectal spaces are opened below the laterallimits of the rectal nodule, and the noduleis then dissected away from the rectalwall, using the PlasmaJet (Plasma Surgi-cal Limited, Abingdon,Oxfordshire, UK)or the Ultracision Harmonic Scalpel(Ethicon Endosurgery, Cincinnati, OH).A dissection is made into the thicknessof the rectal wall to remove all abnormalfibrous lesions involving the rectal layers,using a high-magnification endoscopicview. Partial or full-thickness rectalwall defects are closed laparoscopicallyin 1 or 2 layers using resorbable sutures.The procedure may be completed by afull-thickness disc excision removing theshaved area using transanal staplers.38
This conservative approach can also betermed symptom-guided,11 distinguish-ing it from an oncological-like ap-proach based on mandatory colorectalresection.7,39 Since adoption of this ap-proach, the rate of colorectal resectionperformed by the authors has decreasedfrom 67% to 20%. These circumstancesallowed comparison of outcomes be-tween colorectal resection and conser-vative rectal surgery revealing thatwomen managed by colorectal resectionwere more likely to experience unfavor-able postoperative outcomes, such asrectal dysfunction.26,40,41
Further analysis specifically com-pared the 2 surgical approaches, radicalvs conservative during 2 periods oftime.26 Using gastrointestinal standard-ized questionnaires, we found statistically
528 American Journal of Obstetrics & Gynecology
significant differences invariably in favorof the conservative approach group,owing to a lower risk of postoperativeconstipation and improvement in well-being. Statistically significant differencesconcerned the mean values of the KESSand GIQLI scores, unsuccessful evac-uatory attempts, feeling incompleteevacuation, abdominal pain, time takento evacuate, and difficulty to evacuatealong with painful evacuation effort andhard stool consistency. Despite thestudy’s retrospective design, our resultssuggest that attempting rectal conserva-tion in rectal endometriosis is associatedwith more favorable functional digestiveoutcomes.Several circumstances may induce
postoperative bowel dysfunction follow-ing colorectal resection. First, perform-ing colorectal resection by laparoscopyrequires the section of both the meso-rectum and the mesocolon to allow forcolorectal segment to be removed fromthe abdomen. This procedure may leadto denervation of the colon locatedimmediately above the anastomosis42
because despite attempts to limit thelength of the colorectal specimen re-moved, the length of mesocolon sec-tioned is rigorously long, and there is arisk of denervation.Second, the use of a transanal stapler
to carry out colorectal anastomosis maylead to progressive stenosis of the cir-cular staple lines. This appears to bemore frequent, up to 19%, in womenmanaged for rectal endometriosis43 thanin those treated for other diseases andmay be due to pelvic chronic inflam-mation associated with severe endome-triosis. Stenosis leads to the recurrenceof dyschesia and constipation, eitherimmediately or after the closure of thestomia.Third, removal of rectal reservoir
reduces rectal storage capacity and maybe responsible for transitory or long-term increases in daily bowel move-ments. It also leads to a decrease in theability to attenuate the transmission ofhigh intracolonic pressure toward theanal sphincter. In women undergoingproctectomy, the occurrence of con-tractile motor activity within the colicreservoir can lead to fecal incontinence,
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despite a protective rise in anal pres-sure, which remains lower than pres-sure recorded in the colon.44,45 The riskof postoperative fecal incontinence isdifficult to evaluate in a series of youngwomen managed for rectal endometri-osis because of its long-term nature,especially when further traumatic vagi-nal deliveries weaken anal sphinctertonicity.
To compare functional digestive out-comes following both radical and con-servative rectal surgery, a randomizedcontrolled trial (Functional Outcomesof Surgical Management of DeepEndometriosis Infiltrating the Rectum[ENDORE]) has been launched, in-cluding women with deep endometrioticnodules for which rectal involvementexceeds 20 mm.46 We expect to observea statistically significant improvementin the digestive functional outcomesfollowing conservative rectal manage-ment when assessed 24 months aftersurgery. To date, after 20 months, 88% ofpatients required have been enrolled anda full report is planned for 2015.
Meanwhile, patients undergoing sur-gery for rectal endometriosis should beinformed as to the degree of risk ofpostoperative complications and out-comes associated with the different typesof procedures, on the consequences ofpossible complications, and on alter-native therapeutic options to enableinformed choice. In addition, patientsshould be informed of the level ofexpertise of the available surgeons and onthe need for referral to a center of excel-lence should an adequately experiencedmultidisciplinary surgical team not beavailable because the risk of complica-tions appears to vary in relation to thelevel of expertise of the surgical team.47
ConclusionDespite a myriad of retrospective studiesconcluding that rectal surgery, andparticularly colorectal resection, is justi-fied, safe, and efficient in the treatmentof rectal endometriosis, the debatearound the recommended type of sur-gery is far from closed. Arguments suchas improvement in dyspareunia, pelvicpain, and quality of life fail to convince,and the relief of gynecological symptoms
may not be directly achieved by tailoringthe rectum. The complex nature ofthe relationship between rectal nodules,digestive symptoms, and rectal surgeryrequires particular care to be taken inthe preoperative assessment of digestivefunction and in selecting the most suit-able surgical procedure. -
ACKNOWLEDGMENTS
H.R. and L.P. wrote the first draft of the report.G.S. and L.P. revised the manuscript. H.R. andJ.J.T. performed the surgical procedures.C.d.C. performed the computed tomographyebased virtual colonoscopy. All authors contrib-uted to the writing of the final manuscript andapproved it to be published.
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