Bowel dysfunction in patients with motor complete spinal cord injury: clinical, neurological, and pathophysiological associations

BACKGROUND: Abnormal bowel function is a key problem in patients with spinal cord injury (SCI). Previous works provided only partial information on colonic transit time (CTT) or anal dysfunction but did not identified a comprehensive neurogenic bowel pattern. AIM: To evaluate clinical, neurological, and pathophysiological counterparts of neurogenic bowel in patients with motor complete SCI. METHODS: Fifty-four patients (56% men, mean age 35 yr) with chronic motor complete SCI (mean evolution time 6 yr) were evaluated: 41% with injuries above T7 (> T7) and 59% with injuries below T7 (< T7); patients were also classified according to the presence or not of sacral spinal reflexes. Clinical assessment, total and segmental CTT quantification, anorectal function evaluation by manometry, intrarectal balloon distension, and surface electromyography were performed. RESULTS: Three different neuropathophysiological patterns were observed: Pattern A, present in > T7 injuries, characterized by very frequent constipation (86%) with significant defecatory difficulty and not very severe incontinence (Mean Wexner score 4.5); it was related to moderate delay in CTT (mainly in the left colon and recto-sigma), incapacity to increase the intra-abdominal pressure, and the absence of anal relaxation during the defecatory maneuvre; Pattern B, present in < T7 injuries with preserved sacral reflexes, characterized by not so frequent constipation (50%) but very significant defecatory difficulty and not very severe incontinence (Wexner 4.8); the pathophysiological counterpart was a moderate delay in CTT, capacity to increase intra-abdominal pressure, increased anal resistance during the defecatory maneuver, and presence of external anal sphincter (EAS) contraction when intra-abdominal pressure increased and during rectal distension; Pattern C, present in < T7 injuries without sacral reflexes, characterized by not very frequent constipation (56%) with less defecatory difficulty and greater severity of incontinence (Wexner 7.2); this was associated with severe delay in CTT (mainly in the left colon), capacity to increase intra-abdominal pressure, absence of anal resistance during the defecatory maneuver, and absence of EAS contraction when intra-abdominal pressure increased and during rectal distension. CONCLUSION: In patients with motor complete SCI, we were able to define three different neuropathophysiological patterns that are associated with bowel function abnormalities and clinical complaints; this might be of help when designing therapeutic strategies.     

Short-term effects of magnetic sacral dermatome stimulation for idiopathic slow transit constipation: Sham-controlled, cross-over pilot study

Background and Aim: An increase in recto‐sigmoid colon activity through electrical stimulation of the sacral dermatomes has previously been reported. It has not been evaluated whether or not sacral dermatome stimulation has beneficial effects on constipation symptoms and anorectal function in constipated patients. Our aim was to evaluate short‐term effects of magnetic stimulation of the sacral dermatomes on constipation symptoms and anorectal function in patients with idiopathic slow transit constipation. Method: Fourteen patients with idiopathic slow transit constipation were enrolled. Constipation symptoms, stool form and anorectal function were assessed before treatment, and at 3 and 6 weeks of treatment. Six‐week treatment consisted of either a 3‐week period of sham treatment or a 3‐week period of magnetic stimulation of the S2‐S3 dermatomes, which was performed in a randomized cross‐over design. Results: During the stimulation period, the frequency score of spontaneous bowel movements decreased in eight of the 14 patients (2.9 [2–3]vs 1.4 [0–2]), whose threshold volumes for urge to defecate and maximum tolerable volumes were significantly greater than those of the non‐responders, and significantly decreased at the end of treatment. The degree of straining on defecation also significantly decreased in the responders. Responders had shorter right colonic transit time and longer left colonic transit time compared to the non‐responders. Sham treatment did not affect constipation symptoms, stool form and rectal sensation. Conclusion: Sacral dermatome stimulation may offer potential for therapeutic benefit for a subset of patients with idiopathic slow transit constipation, particularly constipated patients with rectal hyposensation or hindgut dysfunction.     

Challenging problems presenting as constipation

Patients who seek medical care for constipation present challenges which may involve communication problems, difficulties in diagnosis, lack of optimal therapy, uncorrectable underlying disorders, or psychiatric issues which complicated management. This review describes some of these challenges, and presents management approaches that may increase the likelihood of satisfactory treatment outcomes. Situations which are reviewed include the diagnostic evaluation of the new patient with constipation; syndromes of uncertain pathophysiology including irritable bowel syndrome, slow transit constipation, and pelvic floor dysfunction; constipation associated with neurologic disorders including spinal cord injury, Parkinson's disease, and multiple sclerosis; and psychiatric issues which complicate the management of constipation, including recognition of associated psychiatric diseases, unusual attitudes toward bowel function, eating disorders, and referral for psychiatric care.     

Sacral Nerve Stimulation in Patients with Severe Constipation

Purpose Constipation is frequently a multifactorial disease. This study was designed to evaluate the potential effects of sacral nerve stimulation for patients suffering from severe chronic constipation. Methods Nineteen patients suffering from pathologic colonic transit time or rectal outlet obstruction were included. Only patients with severe rectal outlet obstruction who needed digital manipulation for defecation or patients suffering from pathologic colonic transit constipation with less than two bowel movements per week were regarded as candidates. A temporary stimulation lead was implanted into the sacral foramen that showed the best muscular response. After an evaluation period, the stimulation electrode was removed. An improvement in constipation (more than 2 bowel movements per week or defecation without digital manipulation, respectively) during the test stimulation, as well as a recurrence of prestimulation constipation symptoms during the following surveillance period of three weeks were prerequisites for implanting the permanent sacral nerve stimulating system. Results All of the patients showed a positive motor response to acute needle stimulation. After the evaluation period, eight patients (42 percent) reported an improvement of constipation, and permanent systems were implanted successfully. During the median follow-up of 11 (range, 2–20) months, a significant improvement in the Wexner constipation score was observed compared with the preoperative baseline level (baseline: median: 23, range, 18–27; 12 months after implantation: median, 8, range, 4–13). After successful sacral nerve stimulation, patients also showed a significant improvement in their quality of life. Conclusions Patients suffering from severe constipation are a new challenge for sacral nerve stimulation but further research on pelvic floor function is needed. Supported by the man power of the Ludwig Boltzmann Institute for Surgical Oncology–Cluster of Translational Oncology.     

Gastrointestinal complications in stroke survivors.

The objective of this study was to highlight the gastrointestinal problems that occur in stroke survivors, which may also reduce their quality of life. Stroke patients admitted over an 18-month period were evaluated for common gastrointestinal symptoms as well as type and site of stroke. Symptoms evaluated included vomiting, dysphagia, constipation, masticatory difficulties and sialorrhea among others. Similar symptoms were sought for among controls. There were 54 experimental and 46 control subjects consisting of 25 (46.3%) men and 29 (53.7%) women and 32 (69.6%) men and 14 (30.4%) women respectively. The dominant gastrointestinal symptom was constipation 14 (25.9%), followed by masticatory difficulty 11 (20.4%). Other significant gastrointestinal (GI) symptoms and signs were incomplete bowel evacuation, fecal incontinence, sialorrhea, and dysphagia. There was no significant difference in GI symptoms in either sex, site or type of stroke, except that constipation and incomplete evacuation were commoner in ischaemic stroke. It is advocated that feeding and bowel care should be instituted among stroke patients.     

Chronic Gastrointestinal Problems in Spinal Cord Injury Patients: A Prospective Analysis

Detailed interviews of 127 consecutive patients seen by our spinal cord injury service were performed in order to determine the prevalence and characteristics of chronic gastrointestinal problems in spinal cord injury (SCI) patients. Chronic gastrointestinal problems were defined as recurring symptoms that were significant enough to alter lifestyle or require chronic treatment. Thirty-four (27%) of the patients had a significant chronic gastrointestinal problem. The limited manner through which SCI patients can manifest symptoms resulted in complaints which were characteristically quite vague. The most common problems that impaired quality of life were poorly localized abdominal pain (14%) and difficulty with bowel evacuation (20%). Hemorrhoids (74%), abdominal distention (43%), and autonomic hyperreflexia arising from the gastrointestinal tract (43%) were also very common, but had a lesser impact on lifestyle. Twenty-three percent of our population required at least one admission to the hospital for a gastrointestinal complaint following their injury. The prevalence of chronic gastrointestinal symptoms increased with time after injury, suggesting that these problems are acquired, and may therefore be avoided by the adoption of certain chronic care routines. Chronic gastrointestinal problems in SCI patients merit more study because they are: 1) very different from those in the general population, 2) responsible for a disproportionately great amount of morbidity in these patients, 3) potentially preventable.     

Microchip implants on the anterior sacral roots in patients with spinal trauma: Does it improve bowel function?

PURPOSE: This study evaluated the effect of anterior sacral roots stimulator implants on bowel function of patients with spinal cord trauma. METHOD: Eight patients with spinal cord injury and constipation had anterior sacral roots stimulator implants inserted for concomitant bladder dysfunction. Questionnaires on bowel function and anorectal manometry tests were given before and after insertion of the implants. RESULTS: Six patients achieved improvement in bowel function. Four of these patients could defecate spontaneously following stimulation. Two patients had no improvement in bowel function. Anorectal manometry studies showed a negative rectoanal pressure difference at the time of stimulation. All patients were unable to defecate during stimulation. Positive rectoanal pressure difference was recorded in the six patients who had improved bowel function. This may be attributable to the slower relaxation of the smooth rectal muscle compared with the easily fatigable striated external anal sphincter. CONCLUSION: Anterior sacral roots stimulator implants can improve bowel function in patients with spinal cord trauma.     

Neuromodulation for constipation: sacral and transcutaneous stimulation

Constipation is a frequently occurring digestive ailment that is usually treated conservatively. Neuromodulation is altering function of an organ by altering neural activity. This paper reviews methods of neuromodulation used to treat constipation. This includes direct stimulation of sacral nerves and stimulation across the skin. Direct stimulation of sacral nerves is the most well developed method and is presented in detail. It is generally accepted that the mechanism of action is modulation rather than stimulation so it is called sacral neuromodulation (SNM). SNM involves percutaneous placement of an electrode in the third sacral foramen and implanting a stimulating device under the skin in the buttocks. SNM is founded on the physiological principle that activity in one neural pathway modulates pre-existing activity in another through synaptic interaction. The mechanism of action in constipation may be neuromodulation of the extrinsic neural control of the large bowel or modulation of reflexes inhibiting large bowel function. Limited evidence is available to assess the outcome of SNM in constipation. Results in the medium term seem promising for selected patients with idiopathic slow and normal transit constipation not responding to optimal conservative treatment. Adverse events include electrode migration and infection. The availability of a testing phase provides a predictor of treatment outcome. In addition, transcutaneous stimulation using sticky pad electrodes over the lumbosacral region or acupuncture points has been reported to improve constipation symptoms. In general, the level of evidence is low and further studies are needed.     

Dermatoglyphic (fingerprint) evidence for a congenital syndrome of early onset constipation and abdominal pain

Chronic idiopathic constipation and abdominal pain are the most common gastrointestinal symptoms but their cause is rarely determined; therefore, they usually are called functional. To determine if congenital factors play a role in these disorders, we examined dermatoglyphic (fingerprint) patterns, a congenital marker, in 155 consecutive patients with gastrointestinal complaints. Sixty-four percent of patients with constipation and abdominal pain before age 10 yr had one or more digital arches, compared with 10% of patients without constipation and abdominal pain (p less than 0.001). Seventy percent of constipated patients with arches had the onset of symptoms before age 10 yr compared with 23% of constipated patients without arches (p less than 0.001) and 14% of patients with symptoms other than constipation (p less than 0.001). Compared with an age- and sex-matched sample of patients without arches, patients with arches had a higher prevalence of constipation and abdominal pain before age 10 (p = 0.003), were more likely (p less than 0.001) to have chronic intestinal pseudoobstruction (an organic disorder), and were less likely (p = 0.013) to have irritable bowel syndrome (a functional disorder). Identification of a congenital marker, digital arches, associated with early onset constipation and abdominal pain may help to differentiate a congenital organic syndrome from functional disorders such as the irritable bowel syndrome.     

Efficacy and Tolerability of Prucalopride in Patients with Constipation due to Spinal Cord Injury

Background: Chronic constipation (CC) often occurs after spinal cord injury (SCI). Prucalopride is a novel, highly selective, specific serotonin 4 receptor agonist with enterokinetic properties. We evaluate the tolerability and pilot efficacy of prucalopride in the treatment of CC due to SCI. Methods: Double-blind, placebo-controlled, pilot, phase II, dose-escalation study. After 4 weeks' run in, patients received prucalopride 1 mg ( n = 8) or placebo ( n = 4); 11 new patients were randomized to prucalopride 2 mg ( n = 8) or placebo ( n = 3) once daily for 4 weeks. Patients recorded bowel function (diary) and assessed constipation severity and treatment efficacy (visual analogue scale (VAS) 0-100 mm). Colonic transit times were determined. Results: Compared with run in, mean changes in constipation severity (VAS) increased with placebo, but decreased with prucalopride 1 and 2 mg. The VAS score for treatment efficacy showed a clear dose response (medians 4, 52 and 73 for placebo, 1 and 2 mg, respectively). Diary data showed an improvement in average weekly frequency of all bowel movements over 4 weeks within the 2 mg group (median 0.6; 95% CI 0.2; 1.2). There was a significant reduction in median colonic transit time with 2 mg ( n = 4; -38.5 h (95% CI-80; -5)). Four patients (2 mg) reported moderate/severe abdominal pain, and two of these discontinued treatment. There were no clinically relevant effects on any of the safety parameters. Conclusion: This pilot study indicates that prucalopride can play an important role in the management of patients with CC due to SCI.     

Functional chest pain: esophageal or overlapping functional disorder

BACKGROUND: Whether patients with functional chest pain have an esophageal or overlapping functional disorder of the gut is unclear. We investigated the prevalence of functional gastrointestinal disorders in patients with functional chest pain. METHODS: One hundred patients with functional chest pain and normal cardiac, endoscopic, and manometric studies were evaluated for esophageal hypersensitivity with a balloon distension test. Subsequently, a modified Rome II functional bowel disorder questionnaire was mailed to these subjects. Prevalence of irritable bowel syndrome (IBS) and other functional disorder were determined using the Rome II criteria. In addition, we assessed the prevalence of chest pain in 81 patients with functional constipation. RESULTS: There were 69 responders (54 women); 2 were excluded. Fifty-five patients (82%) fulfilled criteria for other functional disorders besides chest pain. Although there was an overlap, IBS (27%) and abdominal bloating (22%) were most common; dyspepsia (7%), dysphagia (7%), nonspecific bowel disorder (7%), constipation (4%), abdominal pain (3%), and diarrhea (1%) were less common. Among responders, 52 (78%) had esophageal hypersensitivity and 15 (22%) had normosensitivity, with similar prevalence of functional disorders. Thirty-two (39%) of the subjects with functional constipation reported chest pain occasionally, and 5 (6%) frequently. CONCLUSIONS: Approximately 80% of patients with functional chest pain exhibit features of other functional disorders including IBS suggesting an overlap. This association is independent of esophageal hypersensitivity. Recognition of this overlap may facilitate better management of these patients.     

生物反馈训练治疗盆底肌痉挛综合症的临床疗效观察

目的探讨生物反馈训练治疗盆底肌痉挛综合症的临床疗效,并对便秘患者进行主观生存质量评价和客观肛门直肠测压检测。 方法将新疆医科大学第一附属医院便秘诊疗门诊收治的诊断明确的盆底肌痉挛综合症患者按患者意愿分为生物反馈训练治疗组和骶神经刺激治疗组,每组患者40例,对两组患者至少随访3个月,并使用生存质量自评表PAC-QOL中文版对入组病人进行生理、社会心理、担忧及满意度四方面进行主观评价和肛门直肠测压的客观评价。 结果主观方面,与骶神经刺激治疗组相比,生物反馈训练治疗可明显改善便秘患者生理、社会心理、担忧及满意度,提高患者生活质量;客观方面,生物反馈训练治疗更能增加直肠感觉阈值,降低肛管静息压和肛管最大收缩压,改善排便困难症状。 结论生物反馈训练治疗可明显改善盆底肌痉挛综合症患者的便秘症状,提高便秘患者的生活质量。     

Perception, assessment, treatment, and management of pain in the elderly

Twenty to 50% of community elderly suffer from pain. Up to 80% of the institutionalized elderly report at least one pain problem. Multiple pain etiologies that occur in elderly patients may be the occurrence of multiple chronic diseases: osteoarthritis, RA, cancer, DJD, bone/joint disorders, osteoporosis, surgical pain, trauma, neuropathic pain, and nociceptive pain. The incidence of unrelieved pain inhibits respiration, decreases mobility, and decreases their functional status, which may lead to iatrogenic events, which include pneumonia, constipation and deep vein thrombosis. Prolonged inpatient stays and extended care facilities or nursing homes may decrease the elderly patient's expectations of quality of life and initiate social isolation. There exists some roadblocks or barriers to the detection of pain in the elderly client. These include social, emotional, cognitive, and subjective issues with the patient.     

Nutritional care of the patient with constipation

Chronic constipation is defined as a symptom-based disorder based on the presence for at least 3 months in the last year of unsatisfactory defecation characterized by infrequent stools, difficult stool passage, or both. On the other hand, the presence of clinically important abdominal discomfort or pain associated with constipation defines irritable bowel syndrome (IBS) with constipation. Intake of dietary fibre and bulking agents (psyllium) may be effective in alleviating chronic constipation in patients without slow colonic transit or disordered constipation. On the other hand, fibre may improve stool consistency in patients with IBS with constipation, but it is considered to be not effective in improving abdominal pain, distension or bloating. Probiotics may be effective in relieving constipation; however, the effect of lactic acid bacteria ingestion may be dependent on the bacterial strain used and the population being studied. Lactulose, which is a substrate for lactic acid bacteria (prebiotic), is effective to treat patients with chronic constipation.     

Effect of ear mushroom (Auricularia) on functional constipation]

BACKGROUND/AIMS: Constipation is one of the most prevalent gastrointestinal complaints. High fiber intake is recommended as an initial therapy for constipation. Ear mushroom is known to have higher fiber contents about 50% than other mushroom. The aim of this study was to evaluate the effect of fiber supplements using ear mushrooms on the improvement of functional constipation. METHODS: We conducted a double blind study with 3 groups (placebo, ear mushrooms alone, and ear mushrooms with additives including cascara sagrada, etc.), which were randomly assigned out of 34 patients with functional constipation, defined by modified Rome II criteria. Number of bowel movement, straining, sense of incomplete evacuation, stool consistency, satisfactory relief, abdominal pain/discomfort and colon transit time were evaluated and analyzed before, during and after the treatment. RESULTS: Both ear mushrooms alone and ear mushrooms with additives significantly improved number of bowel movement, straining, sense of incomplete evacuation, stool consistency and satisfactory relief in patients with functional chronic constipation (p<0.05). Although the use of ear mushrooms with additives was found to be more effective on the improvement of constipation than ear mushrooms alone, it may induce abdominal discomfort or pain. CONCLUSIONS: In patients with functional constipation, fiber supplements using ear mushrooms significantly improved constipation related symptoms without serious side effect.     

Subtypes of constipation: sorting out the confusion

In patients with chronic constipation, identifying subtypes based on underlying physiology guides subsequent therapeutic choices. Chronic constipation subtypes include slow-transit constipation, pelvic floor dyssynergia, functional constipation, and irritable bowel syndrome with constipation. Chronic constipation subtypes are defined by the result of colonic transit, pelvic floor function, and the presence or absence of significant abdominal pain. Although a variety of tests are available, the most straightforward approach uses the 5-day colonic marker test of transit and anorectal manometry with balloon expulsion testing to evaluate for pelvic floor dysfunction. Patients with normal physiologic tests have either irritable bowel syndrome with constipation or normal-transit constipation. Significant overlap exists between subtypes and a clear distinction is not always possible, with up to a 50% overlap between patients with slow-transit constipation and irritable bowel syndrome, approximately 10% of patients evaluated exhibiting both slow transit and pelvic floor dyssynergia, and 50% of patients with pelvic floor dyssynergia also found to have slow transit. Symptom severity assessment provides the rationale for pursuing further testing and directing the aggressiveness of treatment as patients with greater symptom severity have reduced quality of life and poor physical functioning scores. Few constipation-specific validated measures exist for measuring symptom severity in chronic constipation. In clinical practice severity may be defined as mild symptoms having minimal impact upon daily activities or moderate to severe symptoms that increasingly interfere with daily life.     

Efficacy and tolerability of prucalopride in patients with constipation due to spinal cord injury

BACKGROUND: Chronic constipation (CC) often occurs after spinal cord injury (SCI). Prucalopride is a novel, highly selective, specific serotonin4 receptor agonist with enterokinetic properties. We evaluate the tolerability and pilot efficacy of prucalopride in the treatment of CC due to SCL. METHODS: Double-blind, placebo-controlled, pilot, phase 11, dose-escalation study. After 4 weeks' run in, patients received prucalopride 1 mg (n = 8) or placebo (n = 4); 11 new patients were randomized to prucalopride 2 mg (n = 8) or placebo (n = 3) once daily for 4 weeks. Patients recorded bowel function (diary) and assessed constipation severity and treatment efficacy (visual analogue scale (VAS) 0-100 mm). Colonic transit times were determined. RESULTS: Compared with run in. mean changes in constipation severity (VAS) increased with placebo, but decreased with prucalopride 1 and 2 mg. The VAS score for treatment efficacy showed a clear dose response (medians 4, 52 and 73 for placebo, 1 and 2 mg, respectively). Diary data showed an improvement in average weekly frequency of all bowel movements over 4 weeks within the 2 mg group (median 0.6; 95% CI 0.2; 1.2). There was a significant reduction in median colonic transit time with 2 mg (n = 4; -38.5 h (95% CI -80; -5)). Four patients (2 mg) reported moderate/severe abdominal pain, and two of these discontinued treatment. There were no clinically relevant effects on any of the safety parameters. CONCLUSION: This pilot study indicates that prucalopride can play an important role in the management of patients with CC due to SCI.     

Current gut-directed therapies for irritable bowel syndrome

Opinion statement Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder that can present with a wide array of symptoms that make treatment difficult. Current therapies are directed at relieving symptoms of abdominal pain or discomfort, bloating, constipation, and diarrhea. Pharmacologic agents used to treat IBS-associated pain include myorelaxants, peppermint oil, and peripherally acting opiates. Dicyclomine and hyoscyamine, the two myorelaxants available in the United States, have not been proven effective in reducing abdominal pain in patients with IBS. The efficacy of peppermint oil is debated, but methodological problems with existing studies preclude definitive judgment. Loperamide is ineffective for relief of abdominal pain. For IBS patients with excessive abdominal bloating, a small number of studies suggest that bacterial eradication with gut-directed antibiotics and bacterial reconstitution with nonpathogenic probiotics may reduce flatulence. For constipation-predominant (C-IBS) symptoms, current treatment options include fiber supplementation, polyethylene glycol, and tegaserod. Soluble fibers (ispaghula, calcium polycarbophil, psyllium) are more effective than insoluble fibers (wheat bran, corn fiber) in alleviating global symptoms and relieving constipation, although fiber in general has marginal benefit in treatment of overall IBS symptoms. Polyethylene glycol increases bowel frequency in chronic constipation, but its overall efficacy against IBS is unclear. Tegaserod, a 5-HT₄ agonist, demonstrates superiority over placebo in improving bowel frequency and stool consistency and alleviating abdominal pain and bloating in women with C-IBS. Overall global symptoms are modestly improved with tegaserod when compared with placebo. Additional agents under investigation for C-IBS include the ClC₂ chloride channel opener lubiprostone, μ-opioid receptor antagonist alvimopan, and 5-HT₄ agonist renzapride. For diarrhea-predominant (D-IBS) symptoms, available therapies include loperamide, alosetron, and clonidine. Alosetron, a 5-HT₃ antagonist, is superior to placebo for reducing bowel frequency, improving stool consistency, and relieving abdominal pain in women with D-IBS. However, alosetron is available under a restricted license because of concerns for ischemic colitis and severe constipation necessitating colectomy. Clonidine may be helpful in alleviating global symptoms for D-IBS patients.     

Multidisciplinary laparoscopic treatment for bowel endometriosis

Endometriosis is a handicapping disease affecting young females in the reproductive period. It mainly occurs in the pelvis and affects the bowel in 3–37%. Endometriosis can cause menstrual and non-menstrual pelvic pain and infertility. Colorectal involvement results in alterations of bowel habit such as constipation, diarrhoea, tenesmus, and rarely rectal bleeding. A precise diagnosis about the presence, location and extent is necessary. Based on clinical examination, the diagnosis of bowel endometriosis can be made by transvaginal ultrasound, barium enema examination and magnetic resonance imaging. Multidisciplinary laparoscopic treatment has become the standard of care and depending on size of the lesion and site of involvement full-thickness disc excision or bowel resection is performed by an experienced colorectal surgeon. Anastomotic complications occur around 1%. Long-term outcome after bowel resection for severe endometriosis is good with a pregnancy rate of 50%.