Delayed functional outcomes associated with surgical management of deep rectovaginal endometriosis with rectal involvement: giving patients an informed choice.

BACKGROUND: The aim of this study was to compare delayed functional digestive and urinary outcomes following two different surgical procedures used in the management of rectal endometriosis. METHODS: Women who had undergone surgical management of rectal endometriosis with at least 1 year of post-operative follow-up were included in a retrospective study. Post-operative symptoms were evaluated using specific questionnaires which focused on pelvic pain and functional outcomes. RESULTS: There were 41 women who underwent surgical treatment of symptomatic rectal endometriosis. Post-operative follow-up was completed over 26 +/- 13 months (range 12-53). Colorectal segmental resection was performed in 25 women (61%) and nodule excision in 16 (39%). An increase in the number of daily stools > or =3 was observed in 13 (52%) and 3 (19%) patients managed, respectively, by segmental resection and nodule excision (P = 0.02). Severe constipation (<1 stool/5 days) was recorded in three women having undergone segmental resection. The probabilities of being free of dysmenorrhea, dyspareunia and non-cyclic pain at 24 months in women managed by segmental resection and nodule excision were, respectively, 80% (95% CI: 55-92%), 65% (95% CI: 42-81%), 43% (95% CI: 23-62%) and 62% (95% CI: 34-81%), 81% (95% CI: 52-94), 69% (95% CI: 40-86%). When pain recurrences occurred, a significantly lower post-operative score for pain was observed in both groups. No significant difference in pain improvement was found between surgical procedures. CONCLUSION: Colorectal segmental resection appears to be associated with several unpleasant functional symptoms when compared with nodule excision. Information about functional outcomes should be provided to patients managed for rectal endometriosis, and should be considered when deciding on the most appropriate treatment of this disease.

Nonoperable patients with superficial esophageal cancer treated by photodynamic therapy after chemoradiotherapy have more severe complications than patients treated in primary intent.

INTRODUCTION: Photodynamic therapy (PDT) is a therapeutic option in patients with a superficial esophageal cancer. Recently, PDT was shown to be effective as a salvage therapy for a local recurrence after chemoradiotherapy (CRT). AIM: To compare retrospectively the results and the complications rate of PDT between consecutive patients treated in primary intent for a superficial esophageal cancer versus patients treated by PDT for a local recurrence after CRT. METHODS: Between 1999 and 2007 in a single center, 40 consecutive patients were treated by PDT for a superficial esophageal cancer, 25 (group 1) in primary intent and 15 (group 2) for a local recurrence after CRT. Two days after intravenous (IV) Photofrin (2 mg/kg), the phototherapy was performed with a dye laser. The treatment response and severe complications, defined as perforation and stricture requiring endoscopic dilation, were compared between the two groups. RESULTS: The patient and tumor characteristics were not different between the two groups. In group 1, 19 out of 25 patients (76%) were successfully treated versus 8 out of 15 patients (53%) in group 2 (P= 0.17). Severe complications occurred more frequently in patients with a prior CRT (8%vs 46.7%, P= 0.008) and included two perforations and five strictures requiring endoscopic dilation, while only two strictures occurred in group 1. A prior CRT was an independent risk factor of severe complications (odds ratio [OR] 8.05; 95% confidence interval [CI]1.22-43.0). CONCLUSIONS: Severe complications were significantly more frequent in patients treated after a prior CRT. PDT as a salvage therapy in patients with a local recurrence after CRT for esophageal cancer tended to be less efficient than in first-line treatment.

Is painful rectovaginal endometriosis an intermediate stage of rectal endometriosis?

OBJECTIVE: To compare the history of pain complaints of women presenting rectovaginal and rectal endometriosis to show that rectovaginal locations may progress to a rectal involvement of the disease. DESIGN: Retrospective comparative study. SETTING: Department of Gynecology and Obstetrics, University Hospital Rouen, France. PATIENT(S): Thirty-two patients with rectovaginal endometriosis and 16 patients with rectal involvement. INTERVENTION(S): Standardized questionnaires recording the clinical history of painful deep endometriosis up to diagnosis. MAIN OUTCOME MEASURE(S): Length of time from onset of pain to diagnosis, types of pain, disability related to the pain, and number of physicians consulted before the diagnosis was made. RESULT(S): Women with rectal endometriosis had an earlier onset of dysmenorrhoea. The age of dysmenorrhoea and the length of time between the onset of the first pain to the first time that the endometriosis was suspected were significantly increased in women with rectal endometriosis. Pain during defecation was more frequent in patients with rectal endometriosis. Women consulted an average of three physicians before the endometriosis diagnosis was suggested. A nongynecologist physician made the diagnosis of rectovaginal and rectal endometriosis in respectively 26% and 31% of cases. CONCLUSION(S): Rectal endometriosis is associated with an earlier onset and a longer history of painful symptoms until the diagnosis was made when compared with rectovaginal endometriosis locations. These observations support the hypothesis that rectovaginal location may be an intermediate stage of rectal endometriosis.

Endorectal ultrasound accuracy in the diagnosis of rectal endometriosis infiltration depth.

OBJECTIVE: To evaluate the accuracy of endorectal ultrasound examination to ascertain the deepest rectal layer involved in rectal endometriosis. DESIGN: Retrospective study. SETTING: Department of obstetrics and gynecology at a university hospital in France. PATIENT(S): Women presenting with rectal endometriosis who had undergone rectal resection during a 22-month period. INTERVENTION(S): Endorectal ultrasonography. MAIN OUTCOME MEASURE(S): The predicted rectal infiltration depth by using endorectal examination was compared with histological findings. The level of agreement was evaluated by using the coefficients of concordance kappa and weighted kappa. RESULT(S): Sixteen women were included in the study. Rectal resection was segmental in 14 cases and was limited in 2 cases. The agreement between 2 examinations was considered good in 9 cases (56%). Endorectal ultrasound overestimated the depth of infiltration in 5 cases and underestimated it in 2 cases. The coefficients of concordance kappa (95% confidence interval) and weighted kappa (95% confidence interval) were, respectively, 0.17 (0-0.34) and 0.22 (0.04-0.4), corresponding to poor concordance between the endorectal ultrasonography and histological examination. CONCLUSION(S): Accuracy in the prediction of rectal-layer involvement in endorectal ultrasonography appears to be limited. This information should not be considered sufficient when selecting the type of rectal-resection procedure.

[Assessment of the quality and psychological impact of information delivered using official consent forms in digestive endoscopy]. / Evaluation de la qualité et de l'impact de l'information transmise par les fiches d'endoscopie digestive élaborées par les sociétés savantes.

AIM: To test the impact of information brochures and informed consent forms in patients undergoing digestive endoscopy procedures. METHOD: All patients undergoing digestive endoscopy procedures during a two-month period were given information about the procedure to be performed by delivery of an information form produced by the French Endoscopy and Gastroenterology Societies. The patients were then asked to sign an inform consent form. A questionnaire about the informed consent form and the consent experience was given to all patients after the endoscopic procedure. RESULTS: The questionnaire was completed by 108 consecutive patients. The informed consent form was completely read by 96.3% and understood by 95%. Sixteen percent asked for complementary information, all about complications. Twenty percent were distressed by the explanations. Receiving written information was surprising for 22.2% of the patients, and distressing for 18.5% mainly when endoscopy was planned without general anesthesia (P=0.01 versus general anesthesia). Obtaining informed consent was qualified as a normal procedure for 47.2%, but distressing for 19.4%. It was considered by 41.1% as a way for doctors to be discharged from their obligations. CONCLUSION: The informed consent forms written by scientific societies are easy to understand. One third of the patients were distressed or surprised to be given oral or written information. To sign a written consent form before an endoscopy procedure is considered to be a means of discharging practitioners from their responsibilities for 30% of the patients.

Acute esophageal necrosis: a 1-year prospective study.

BACKGROUND: A prospective 1-year study was conducted to assess the frequency, clinical spectrum, histologic description, and follow-up of acute esophageal necrosis unrelated to ingestion of caustic or corrosive agents. METHODS: The diagnosis of acute esophageal necrosis was based on a diffusely black esophagus at endoscopy and typical histologic features of diffuse mucosal and submucosal necrosis. Ingestion of caustic and corrosive agents was excluded in all patients. Medical history, associated diseases, and clinical symptoms were recorded for each patient. Nutritional status was evaluated based on clinical and biochemical parameters. Treatment included short-term parenteral nutrition and intravenous administration of a pump proton inhibitor. A second endoscopy was performed when possible at 2 weeks after presentation to assess regression of acute esophageal necrosis. RESULTS: Among 3900 patients who underwent EGD, 8 (0.2%) with acute esophageal necrosis were identified. Nutritional status was poor for 6 patients. Complete resolution of acute esophageal necrosis without further recurrence was observed in 4. No esophageal strictures appeared during follow-up. Four patients died, but no death was directly related to acute esophageal necrosis. CONCLUSION: Acute esophageal necrosis is not as infrequent an endoscopic finding as has been reported. Acute esophageal necrosis appears to be associated with poor general health status and is not a purely local phenomenon.