REVUE DE PRESSE / PRESS REVIEW
Treatment of complex anal fistulas with the collagen fistula plug
Christoforidis D, Etzioni DA, Goldberg SM, Madoff RD, Mellgren A (2008)
Dis Colon Rectum [Epub ahead of print]
Purpose: Anal fistulas that involve a significant amount of sphincter may be difficult to treat without compro- mising continence function. In this study, we evaluated our experience with the Surgisis (R) anal fistula plug, which was recently reported to be successful in more than 80 percent of patients with complex fistulas.
Methods: We retrospectively collected patient and fistula characteristics, procedure details, and follow-up information for all patients treated with the anal fistula plug at our institution from January 2006 through April 2007. The outcome was considered successful if the external opening was closed and if the patient had no drainage at the last follow-up. Using multivariate statistics, we analyzed the relationship between anal fistula plug success and several key variables.
Results: From January 2006 through April 2007, 47 patients with 49 complex anal fistulas underwent 64 anal fistula plug procedures. The median follow-up time for patients who were considered healed was 6.5 (range, 3-11) months. The success rate was 31 percent per procedure and 43 percent per patient. An increased amount of external sphincter involvement was associated with a higher failure rate (P< 0.05).
Conclusions: In our early experience with the anal fistula plug, 43 percent of patients with complex anal fistulas were successfully treated. Patients with less external sphincter involvement were more likely to heal.
Commentaire :L’obturation des trajets fistuleux par un bouchon de collage`ne repre´sente une alternative the´rapeutique plus se´duisante que la colle (le bouchon a une texture plus cohe´rente et un de´litement moindre) et plus simple que les autres alternatives chirurgicales d’e´pargne sphincte´rienne (lambeaux). Dans l’attente des re´sultats des essais randomise´s et controˆle´s, les re´sultats des travaux re´trospectifs ont fait l’objet de plusieurs publications re´centes. Celle-ci n’e´chappe pas aux critiques formule´es avec les pre´ce´dents travaux : collection bicen- trique d’une se´rie de cas, crite`res de fermeture du trajet assez sommaires, suivi franchement court pour une pathologie dont les re´cidives tardives sont une des caracte´ristiques de son histoire naturelle. Deux points me´ritent ne´anmoins une attention dans ce travail parce qu’ils sont rapporte´s par d’autres e´tudes e´valuant colles
ou bouchons : le taux de succe`s du geste chirurgical est nettement moins e´leve´ que celui des travaux initiaux (31 %) ; la me´thode semble plus efficace lorsque les fistules sont basses que lorsque les fistules sont hautes...
Cotation :
L. Siproudhis
Sacral nerve stimulation for fecal incontinence:
external anal sphincter defect versus intact anal sphincter
Chan MK, Tjandra JJ (2008)
Dis Colon Rectum [Epub ahead of print]
Purpose: This prospective study was designed to assess the effectiveness of sacral nerve stimulation for fecal incontinence in patients with external anal sphincter defect and to evaluate its efficacy regarding presence and size of sphincter defect.
Methods:Fifty-three consecutive patients who under- went sacral nerve stimulation for fecal incontinence were divided into two groups: external anal sphincter defect group (N = 21) versus intact sphincter group (N = 32).
Follow-up was performed at 3, 6, and 12 months with anorectal physiology, Wexner’s score, bowel diary, and quality of life questionnaires.
Results: The external anal sphincter defect group (defect < 90 degrees: defect 90-120 degrees = 11:10) and intact sphincter group were comparable with regard to age (mean, 63 versus 63.6) and sex. Incidence of internal anal sphincter defect and pudendal neuropathy was similar. All 53 patients benefited from sacral nerve stimulation. Weekly incontinent episodes decreased from 13.8 to 5 (P< 0.0001) for patients with external anal sphincter defects and from 6.7 to 2 (P= 0.001) for patients with intact sphincter at 12-month follow-up.
Quality of life scores improved in both groups (P < 0.0125). There was no significant difference in improvement in functional outcomes after sacral nerve stimulation between patients with or without external anal sphincter defects. Clinical benefit of sacral nerve stimulation was similar among patients with external anal sphincter defects, irrespective of its size. Presence of pudendal neuropathy did not affect outcome of neuro- stimulation.
Conclusions:Sacral nerve stimulation for fecal incon- tinence is as effective in patients with external anal sphincter defects as those with intact sphincter and the result is similar for defect size up to 120 degrees of circumference.
DOI 10.1007/s11725-008-0097-5
Commentaire :Attention, lecteur presse´ : ne tient pas compte des conclusions de ce travail parce qu’il abuse de ta cre´dulite´ ! Il est, en effet, toujours difficile d’e´mettre des conclusions utiles a` la pratique clinique au terme de la lecture d’un tel article : a` cela plusieurs raisons dont cette e´quipe de Melbourne est si coutumie`re. Pre´sente´e comme un travail prospectif, la pe´riode d’analyse du travail se te´lescope avec un autre travail controˆle´, randomise´, mene´ durant la meˆme pe´riode sur un nombre plus important de malades (pas de mention de´clarative au comite´ d’e´thique, analyse de sous-groupe probable).
Le nombre de malades de l’e´tude et les hypothe`ses d’e´quivalence non calcule´es laissent pre´sager un manque de puissance certain du travail. Finalement, l’e´tude qui permettrait de dire s’il faut ou non proposer en premie`re intention la neuromodulation aux malades incontinents en rapport avec des le´sions sphincte´riennes (la vraie question clinique) devrait eˆtre un essai controˆle´ rando- mise´ chez les malades ayant une incontinence par de´fect sphincte´rien et a` qui on proposerait soit une re´paration sphincte´rienne directe, soit une neuromodulation des racines sacre´es.
Cotation :
L. Siproudhis
Evaluation of rectal sensory and motor function by means of the electronic barostat
after stapled hemorrhoidopexy
De Nardi P, Corsetti M, Passaretti S, et al. (2008) Dis Colon Rectum [Epub ahead of print]
Purpose:Stapled hemorrhoidopexy is designed to replace the hemorrhoids into the anal canal by excising the redundant rectal mucosa above the anorectal ring, thus resulting in an intrarectal suture. Few studies have evaluated rectal function after this procedure. This prospective study was designed to use the electronic barostat to assess whether rectal motor and sensory functions change after stapled hemorrhoidopexy.
Methods: Ten patients (4 women, mean age, 46 9 years) with third-degree and fourth-degree hemor- rhoids who underwent stapled hemorrhoidopexy were studied. One week before and six months after surgery, they underwent three different rectal distensions (pres- sure-controlled stepwise, volume-controlled stepwise, and ramp) controlled by an electronic barostat.
Results:Rectal distensibility was significantly lower after surgery during pressure stepwise (P= 0.01), during volume stepwise (P = 0.006), and during ramp distension (P = 0.001). Volume thresholds for desire to defecate, urgency, and discomfort were significantly lower after surgery during all three distensions (P< 0.05). Volume threshold for first perception also was significantly lower after surgery during volume ramp distension (P= 0.01).
Conclusions:Rectal distensibility and volume thresholds for sensations decrease after stapled hemorrhoidopexy.
These impairments persist for at least six months after surgery.
Commentaire :Les techniques chirurgicales de re´sec- tion a` la pince me´canique exposent en the´orie a` des modifications des parame`tres physiologiques de la paroi du bas rectum. Des e´tudes manome´triques ont pu ainsi montrer que la compliance rectale e´tait modifie´e apre`s re´section rectale transanale et pouvait expliquer les impe´riosite´s et la polyche´sie de´crites chez certains malades. Cette e´tude physiologique mene´e sur une petite se´rie de cas montre que les volumes de perception rectale sont diminue´s durablement (six mois) apre`s une inter- vention d’he´morroı¨dopexie. La me´thode d’analyse par technique de barostat souligne, en outre, qu’il existe tre`s clairement une diminution de la compliance rectale dans les volumes ou les pressions de distension les plus e´leve´s.
Il semble s’agir effectivement d’une diminution des capacite´s du re´servoir rectal plus qu’une modification isole´e de la sensibilite´ rectale. Les auteurs sugge`rent dans leur conclusion le lien existant entre cette modification physiologique et la survenue possible de troubles de la continence apre`s ce geste. Il faut aujourd’hui souhaiter que le devenir a` tre`s long terme des malades ope´re´s par anopexie ne re´ve`le pas un sur-risque de manifestations d’incontinence par impe´riosite´.
Cotation :
L. Siproudhis
Efficacy of probiotics in irritable Bowel syndrome:
a meta-analysis of randomized, controlled trials Nikfar S, Rahimi R, Rahimi F, et al. (2008)
Dis Colon Rectum [Epub ahead of print]
Purpose: This study was designed to evaluate whether probiotics improve symptoms in patients with irritable bowel syndrome.
Methods:PubMed, Embase, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials were searched for studies that investigated the efficacy of probiotics in the management of irritable bowel syn- drome. Clinical improvement was the key outcome of interest. Data were searched within the time period of 1966 through September 2007.
Results: Eight randomized, placebo-controlled, clinical trials met our criteria and were included in the analysis.
Pooling of eight trials for the outcome of clinical improvement yielded a significant relative risk of 1.22 (95 percent confidence interval, 1.07-1.4;P= 0.0042).
Conclusions: Probiotics may improve symptoms of irritable bowel syndrome and can be used as supplement to standard therapy.
Commentaire :Une me´ta-analyse tre`s attendue des biocolopathes est, en de´finitive, bien de´cevante dans ses conclusions. L’effet probiotique existe et il est statistiquement significatif par rapport aux effets observe´s sous placebo. En revanche, la pertinence clinique du be´ne´fice attendu est moindre. Si on suspecte que la zone grise des travaux non publie´s soit vaste dans ce domaine, on peut craindre que l’avenir de ces classes the´rapeutiques soit compromis dans le champ du traitement du syndrome de l’intestin irritable.
Cotation :
L. Siproudhis
Development of abdominal pain and IBS following gynaecological surgery:
a prospective controlled study
Sperber AD, Morris CB, Greemberg L, et al. (2008) Gastroenterology 134: 75-84
Background and aims: Irritable bowel syndrome (IBS) develops after bacterial enteritis that causes injury to the bowel mucosa. It’s unclear whether abdominal pain or IBS results from gynecological surgery that could injure abdominopelvic nerves. The aim of this prospective, controlled study was to assess the incidence of pain or IBS in women undergoing elective gynecological surgery compared to non-surgical controls and to identify factors associated with their development.
Methods: One hundred thirty-two women without GI symptoms undergoing elective gynecological surgery for non-painful conditions were compared with 123 non- surgery controls without GI symptoms. Sociodemographic, psychosocial, and surgery-related variables were potential predictor variables of pain at 3 and/or 12 months.
Results: Three surgical patients (2.7 %), but no controls, developed IBS at 12 months. Significantly more surgical patients had abdominal pain at 3 or 12 months (15.3 versus 3.6 %,P = 0.003). No sociodemographic or surgery-related variables predicted pain development, but it was predicted by psychosocial factors including anticipation of difficult recovery from surgery (P= 0.01), perception of severity/constancy of illness (P= 0.04), and reduced sense of coherence (P= 0.01).
Conclusions:Among women undergoing gynecologi- cal for non-pain indications the development of IBS was not significantly greater than controls. However, abdo- minal pain did develop in 17 % of women in the surgical group, suggesting that surgery facilitated its develop- ment. Notably, only psychosocial variables predicted pain development, implying that pain development associated with central registration and amplification of the afferent signal (via cognitive and emotional input) must be considered along with the peripheral injury itself. These findings contribute to understanding the pathophysiology of functional GI pain.
Commentaire :Chez des femmes, une chirurgie gyne´- cologique, quels qu’en soient le type et l’indication, n’est pas un facteur favorisant du SII mais favorise l’appa- rition de douleurs abdominales. Des e´tudes ante´rieures, beaucoup moins bien mene´es, sugge´raient une telle relation mais les crite`res diagnostiques e´taient moins stricts. Cependant, comme le signalent les auteurs, une erreur lie´e a` un effectif insuffisant de patient est possible.
L’apparition de douleurs abdominales postope´ratoires, souvent intenses (> 4 sur une EVA chez pre`s de la moitie´
des patientes), e´tait uniquement explique´e par des facteurs psychosociaux. Le type d’abord, la pre´sence de complications ou l’indication chirurgicale n’e´taient pas des facteurs pre´dictifs de survenue d’une douleur.
A` l’inverse d’autres e´tudes re´centes, le score de catas- trophisme a` l’inclusion n’e´tait pas un facteur pre´dictif significatif. Cette e´tude e´tait re´alise´e en Israe¨l dans une population d’origine ethnique varie´e (environ 50 % de natif israe´lien, 30 % de l’Europe de l’Est, 15 % de l’Asie ou de l’Afrique et 5 % de l’Europe de l’Ouest), mais ce facteur n’e´tait e´galement pas pre´dictif de la survenue d’une douleur. Parmi les trois facteurs identifie´s (l’anticipation d’une convalescence difficile, la perception de la se´ve´rite´
de la maladie mesure´e par le questionnaire IMIQ et une re´duction du sens de cohe´rence), les auteurs sugge`rent dans leur discussion qu’une prise en charge psychologique pre´ope´ratoire adapte´e pourrait avoir permis une pre´ven- tion efficace de ce syndrome douloureux... mais dont la prise en charge et le retentissement ne sont malheureu- sement pas de´taille´s dans l’article. Ces donne´es me´ritent cependant d’eˆtre confirme´es et d’autres e´tudes de ce type devraient eˆtre re´alise´es pour les autres chirurgies abdominales.
Cotation :
B. Coffin
A placebo-controlled trial of prucalopride for severe chronic constipation
Camilleri M, Kerstens R, Rykx A, Vandeplassche L (2008) N Engl J Med 29(358): 2344-54
Background:In this 12-week trial, we aimed to determine the efficacy of prucalopride, a selective, high-affinity 5-hydroxytryptamine 4-receptor agonist, in patients with severe chronic constipation.
Methods: In our multicenter, randomized, placebo- controlled, parallel-group, phase 3 trial, patients with severe chronic constipation (2 spontaneous, complete bowel movements per week) received placebo or 2 or 4 mg of prucalopride, once daily, for 12 weeks. The primary efficacy end point was the proportion of patients having three or more spontaneous, complete bowel movements per week, averaged over 12 weeks. Secondary efficacy end points were derived from daily diaries and
validated questionnaires completed by patients. Adverse events, clinical laboratory values, and cardiovascular effects were monitored.
Results: Efficacy was analyzed in 620 patients. The proportion of patients with three or more spontaneous, complete bowel movements per week was 30.9 % of those receiving 2 mg of prucalopride and 28.4 % of those receiving 4 mg of prucalopride, as compared with 12.0 % in the placebo group (P < 0.001 for both comparisons).
Over 12 weeks, 47.3 % of patients receiving 2 mg of prucalopride and 46.6 % of those receiving 4 mg of prucalopride had an increase in the number of sponta- neous, complete bowel movements of one or more per week, on average, as compared with 25.8 % in the placebo group (P< 0.001 for both comparisons). All other secondary efficacy end points, including patients’
satisfaction with their bowel function and treatment and their perception of the severity of their constipation symptoms, were significantly improved with the use of 2 or 4 mg of prucalopride as compared with placebo, at week 12. The most frequent treatment-related adverse events were headache and abdominal pain. There were no significant cardiovascular effects of treatment.
Conclusions: Over 12 weeks, prucalopride signifi- cantly improved bowel function and reduced the severity of symptoms in patients with severe chronic constipa- tion. Larger and longer trials are required to further assess the risks and benefits of the use of prucalopride for chronic constipation.
Commentaire :Il s’agit d’une e´tude de phase III multicentrique en double insu randomise´e contre placebo avec deux doses de prucalopride 2 et 4 mg, en administra- tion orale une fois par jour avant le petit-de´jeuner. Le prucalopride qui a un effet moteur colique est un agoniste 5HT4 se´lectif et de haute affinite´ par rapport au te´gase´rod. Il n’aurait pas d’effet sur les canaux hERG ou sur le re´cepteur 5HT1B. Les mole´cules ayant un tropisme pour ces effecteurs ont, en effet, e´te´ responsables d’effets secondaires cardio- vasculaires et a` l’origine de l’arreˆt de la commercialisation du te´gase´rod aux E´tats-Unis. Cette e´tude a e´te´ re´alise´e chez 620 patients (87,9 % de femmes) recrute´s dans 38 centres aux E´tats-Unis d’avril 1998 a` mai 1999 ayant une constipation chronique se´ve`re (deux selles ou moins de deux selles e´mises de fac¸on spontane´e par semaine, pendant six mois avec des selles dures, une sensation d’e´vacuation incomple`te et des efforts de pousse´e pour au moins 25 % des selles). Le crite`re de jugement principal e´tait la proportion de malades re´pondeurs (trois selles spontane´es ou plus par semaine). Il e´tait de 30,9 % a` 2 mg, 28,4 % a` 4 mg et 12 % avec le placebo (p < 0,001). Il existait e´galement un be´ne´fice the´rapeutique sur certains crite`res secondaires comme l’augmentation de plus d’une selle par semaine a` 12 semaines (47,3 % a` la dose de 2 mg, 46,6 % a` 4 mg et 25,8 % avec le placebo [p < 0,001]). La satisfaction des patients sur leur transit, la perception de la se´ve´rite´ des symptoˆmes de
constipation et un index de qualite´ de vie e´taient e´galement ame´liore´s. Il n’y a pas eu plus d’effets secondaires en dehors d’une incidence plus importante de la diarrhe´e sous prucalopride par rapport au placebo. Ces donne´es montrant une ame´lioration notable du transit avec un traitement par prucalopride (efficacite´ identique pour 4 et 2 mg) par rapport au placebo sont inte´ressantes. Il est surprenant que ces donne´es ne soient publie´es que dix ans apre`s la fin des inclusions : elles me´ritent d’eˆtre confirme´es par d’autres e´tudes e´valuant, notamment l’efficacite´ du prucalopride chez l’homme.
Cotation :
J.-M. Sabate
Randomized clinical trial of early versus delayed temporary stoma closure after proctectomy Alves A, Panis Y, Lelong B, et al. (2008)
Br J Surg 95: 693-8
Background: Temporary faecal diversion is recommen- ded with a low colorectal, coloanal or ileoanal anasto- mosis (LA). This randomized study evaluated early (EC;
8 days) versus late (LC; 2 months) closure of the temporary stoma.
Methods: Patients undergoing rectal resection with LA were eligible to participate. If there was no radio- logical sign of anastomotic leakage after 7 days, patients were randomized to EC or LC. The primary endpoints were postoperative morbidity and mortality 90 days after the initial resection.
Results:Some 186 patients were analysed. There were no deaths within 90 days and overall morbidity rates were similar in the EC and LC groups (31 versus 38 percent respectively; P = 0.254). Overall surgical complication (both 15 percent; P = 1.000) and reopera- tion (both 8 percent; P = 1.000) rates were similar, but wound complications were more frequent after EC (19 versus 5 percent;P= 0.007). Small bowel obstruction (3 versus 16 percent;P = 0.002) and medical complica- tions (5 versus 15 percent;P= 0.021) were more common with LC. Median (range) hospital stay was reduced by EC (16 [6-59] versus 18 [9-262] days;P= 0.013).
Conclusions: Early stoma closure is feasible in selected patients, with reduced hospital stay, bowel obstruction and medical complications, but a higher wound complication rate.
Commentaire :Il s’agit de la premie`re e´tude rando- mise´e de´montrant la faisabilite´ de la fermeture pre´coce de l’ile´ostomie (j8) sans augmentation de la mortalite´ et de la morbidite´ par rapport a` la fermeture classique a`
deux mois et avec un be´ne´fice en termes de dure´e d’hospitalisation. Toutefois, cette strate´gie n’est possible que chez un groupe de patients se´lectionne´s (pre`s d’un
tiers des patients ont e´te´ exclus avant la randomisation), c’est-a`-dire n’ayant aucune complication postope´ratoire imme´diate. La fermeture pre´coce de l’ile´ostomie permet d’e´viter la morbidite´ observe´e chez 30 % des patients au cours des deux mois, mais surtout pourrait permettre de de´buter rapidement une chimiothe´rapie adjuvante dans le cas des cancers du rectum.
Cotation :
A. Alves
First-line chemotherapy versus bowel tumor resection plus chemotherapy for patients with unresectable synchronous colorectal hepatic metastases
Galizia G, Lieto E, Orditura M, et al. (2008) Arch Surg 143: 352-8
Hypothesis: Bowel resection followed by chemotherapy is a better management strategy than immediate chemo- therapy in asymptomatic patients with colorectal cancer and unresectable liver-only metastases at presentation.
Design:Retrospective study.
Setting:University hospital.
Patients: Sixty-five consecutive symptom-free colo- rectal cancer patients with unresectable synchronous metastases confined to the liver undergoing bowel tumor resection plus systemic chemotherapy (42 patients [resection group]) or chemotherapy first (23 patients [chemotherapy group]).
Main outcome measures: Long-term survival and identification of prognostic indicators of outcome.
Results:In the resection group, the mean and median overall survival times were shown to be significantly better than those in the chemotherapy group (P= 0.03).
Performance status, basal serum levels of lactic dehy- drogenase and alkaline phosphatase, percentage of liver involvement, potentially curative resection of the bowel tumor, and type of treatment (resection versus chemo- therapy) were demonstrated to be the only variables significantly correlated with long-term survival. On multivariate analysis, performance status, extent of liver involvement, and type of treatment were shown to be the only covariates independently associated with survival rate. The rate of liver metastasis downstaging with subsequent curative hepatic resection was clearly associated with good performance status, limited liver involvement, and resection of the bowel tumor.
Conclusions: Achieving complete cure in asympto- matic colorectal cancer patients with unresectable synchronous liver-only metastases appears to be mostly the result of shrinkage and resection of hepatic metastases. In patients with good performance status and limited liver involvement, bowel tumor resection appears to be the best treatment option for this purpose.
Commentaire :Il s’agit d’une e´tude re´trospective comparant chez des patients atteints d’un cancer colorectal asymptomatique avec des me´tastases he´pati- ques synchrones (MH) non re´se´cables, la chirurgie digestive premie`re (n = 42) a` la chimiothe´rapie premie`re (n = 23). Les deux groupes e´taient comparables en termes d’aˆge, de sex-ratio, de localisation tumorale primitive de marqueurs tumoraux et du degre´ d’envahissement he´patique des MH. Aucun patient du groupe chirurgie n’est de´ce´de´ en postope´ratoire imme´diat et la morbidite´
globale e´tait de 21 %. Pre`s d’un tiers des patients du groupe chimiothe´rapie ont eu des complications lie´es a` la tumeur primitive laisse´e en place (perforation, he´morra- gie, occlusion...). La re´section premie`re permettait d’observer une augmentation significative de la survie globale (me´diane 15 versus 12 mois, p = 0,03, ainsi que de la survie actuarielle a` un et quatre ans (72 versus 61 % et 15 versus 0 %, p = 0,03). La re´section curative des MH a pu eˆtre obtenue chez 12 % des patients du groupe chirurgie et 4 % des patients du groupe chimiothe´rapie.
En analyse multivarie´e, les trois facteurs inde´pendants de survie e´taient le statut OMS du patient, le faible envahissement du foie et la chirurgie premie`re. En re´sume´, les auteurs recommandent de re´se´quer la tumeur primitive colorectale lorsque le patient est en bon e´tat ge´ne´ral et que l’envahissement he´patique des MH est infe´rieur a` 50 %.
Cotation :
A. Alves
Risk factors for opportunistic infections in patients with inflammatory bowel disease Toruner M, Loftus EV Jr., Harmsen WS, et al. (2008) Gastroenterology 134: 929-36
Background and aims: We sought to identify and quantify the clinical factors that were associated with opportunistic infections in inflammatory bowel disease patients.
Methods:We identified 100 consecutive IBD patients with opportunistic infections. For each case, 2 matched IBD patients who did not have a history of opportunistic infection were selected as controls. Conditional logistic regression was used to assess associations between putative risk factors and opportunistic infections, pre- sented as odds ratios (OR) and 95 % confidence intervals (CI).
Results:In univariate analysis, use of corticosteroids (OR: 3.4; 95 %CI: 1.8-6.2), azathioprine/6-mercaptopu- rine (OR: 3.1; 95 %CI: 1.7-5.5), and infliximab (OR: 4.4;
95 %CI: 1.2-17.1) were associated individually with significantly increased odds for opportunistic infection.
Multivariate analysis indicated that use of any one of these drugs yielded an OR of 2.9 (95 %CI: 1.5-5.3),
whereas use of 2 or 3 of these drugs yielded an OR of 14.5 (95 %CI: 4.9-43) for opportunistic infection. The relative risk of opportunistic infection was greatest in IBD patients seen at older than 50 years of age (OR: 3.0;
95 %CI: 1.2-7.2, relative to those 24 years or younger). No patient died from opportunistic infection.
Conclusions: Immunosuppressive medications, espe- cially when used in combination, and older age are associated with increased risk of opportunistic infec- tions. The absolute risk of opportunistic infection in IBD patients remains to be determined, as does any potential benefit of any preventive strategy.
Commentaire :Il s’agit ici d’un article majeur pour la prise en charge pratique des patients atteints de maladies inflammatoires chroniques intestinales. Il montre une de´multiplication impressionnante du risque d’infection opportuniste chez les patients traite´s par l’association d’au moins deux me´dicaments (immunosuppresseurs, corticoı¨des ou anti-TNF). Cette situation fre´quente doit donc eˆtre syste´matiquement rediscute´e chez nos patients.
Les strate´gies classiques par traitements gradue´s (de´rive´s salicyle´s, puis corticoı¨des, puis immunosuppresseurs et enfin anti-TNF) n’ont pas de´montre´ leur efficacite´ a`
enrayer l’e´volutivite´ naturelle des MICI. Aussi, des strate´gies d’utilisation plus pre´coce des anti-TNF ou des immunosuppresseurs sont a` l’e´tude. Ces futures strate´gies devront donc inte´grer les risques infectieux lie´s aux associations de traitements.
Cotation :
X. Treton
Associations with tight junction genes PARD3 and MAGI2 in Dutch patients point to a common barrier defect for coeliac disease
and ulcerative colitis
Wapenaar MC, Monsuur AJ, van Bodegraven AA, et al.
(2008) Gut 57: 438-40
Background: Coeliac disease (gluten-sensitive entero- pathy; GSE) and inflammatory bowel disease (IBD) are common gastrointestinal disorders. Both display enhan- ced intestinal permeability, initiated by gluten exposure (GSE) or bacterial interactions (IBD). Previous studies showed the association of both diseases with variants in MYO9B, presumably involved in epithelial permeability.
Aim:It was hypothesised that genetic variants in tight junction genes might affect epithelial barrier function, thus contributing to a shared pathogenesis of GSE and IBD.
Methods:This hypothesis was tested with a compre- hensive genetic association analysis of 41 genes from the tight junction pathway, represented by 197 tag single nucleotide polymorphism (SNP) markers.
Results: Two genes, PARD3 (two SNPs) and MAGI2 (two SNPs), showed weak association with GSE in a Dutch cohort. Replication in a British GSE cohort yielded significance for one SNP in PARD3 and suggestive associations for two additional SNPs, one each in PARD3 and MAGI2. Joint analysis of the British and Dutch data further substantiated the association for both PARD3 (rs10763976,P = 6.410(–5); OR: 1.23; 95 %CI:
1.11-1.37) and MAGI2(rs6962966, P = 7.610(–4); OR:
1.19; 95 %CI: 1.08-1.32). Association was also observed in Dutch ulcerative colitis patients withMAGI2(rs6962966, P = 0.0036; OR: 1.26; 95 %CI: 1.08-1.47), and suggestive association withPARD3 (rs4379776,P= 0.068).
Conclusions: These results suggest that coeliac disease and ulcerative colitis may share a common aetiology through tight junction-mediated barrier defects, although the observations need further replication.
Commentaire :Cette e´tude ge´ne´tique, conduite sur des populations de patients hollandais et anglais, identifie des polymorphismes sur deux ge`nes implique´s dans la cohe´sion de l’e´pithe´lium digestif et la perme´abi- lite´ intestinale, au cours de la maladie cœliaque et de la RCH. Elle pre´sente l’avantage, pour la RCH, a` la fois de pre´ciser le roˆle e´mergeant d’une barrie`re digestive de´fectueuse, vis-a`-vis de la flore intestinale, et d’identifier des ge`nes de susceptibilite´ potentiellement importants. Il paraıˆt cependant ne´cessaire d’e´tendre cette e´tude a` la maladie de Crohn ainsi qu’a` des populations d’autres pays pour en valider l’inte´reˆt.
Cotation :
X. Treton
Mechanical bowel preparation for elective
colorectal surgery: a multicentre randomized trial Contant CME, Hop WCJ, van’t Sant HP, et al. (2007) Lancet 370: 2112-17
Summary:Background Mechanical bowel preparation is a common practice before elective colorectal surgery. We aimed to compare the rate of anastomotic leakage after elective colorectal resections and primary anastomoses between patients who did or did not have mechanical bowel preparation.
Methods: We did a multicentre randomized non- inferiority study at 13 hospitals. We randomly assigned 1,431 patients who were going to have elective colorectal surgery to either receive mechanical bowel preparation or not. Patients who did not have mechanical bowel preparation had a normal meal on the day before the operation. Those who did were given a fluid diet, and mechanical bowel preparation with either polyethylene glycol or sodium phosphate. The primary endpoint was anastomotic leakage, and the study was designed to test the hypothesis that patients who are given mechanical
bowel preparation before colorectal surgery do not have a lower risk of anastomotic leakage than those who are not. The median follow-up was 24 days (IQR: 17-34). We analysed patients who were treated as per protocol. This study is registered with ClinicalTrials.gov, number NCT00288496. Findings 77 patients were excluded: 46 who did not have a bowel resection; 21 because of missing outcome data; and 10 who withdrew, cancelled, or were excluded for other reasons. The rate of anastomotic leakage did not differ between both groups:
32/670 (4.8 %) patients who had mechanical bowel preparation and 37/684 (5.4 %) in those who did not (difference 0.6 %; 95 %CI: 1.7-2.9; P = 0.69). Patients who had mechanical bowel preparation had fewer abscesses after anastomotic leakage than those who did not (2/670 [0.3 %] versus 17/684 [2.5 %], P = 0.001).
Other septic complications, fascia dehiscence, and mortality did not differ between groups.
Interpretation: We advise that mechanical bowel preparation before elective colorectal surgery can safely be abandoned.
Commentaire :Il est rare qu’une revue aussi presti- gieuse que leLancetse lance dans un de´bat aussi trivial que celui de la pre´paration colique avant chirurgie colorectale. Finalement, le de´bat n’est peut-eˆtre pas aussi trivial que c¸a... Cette e´tude, une des plus importantes de la litte´rature en nombre de patients inclus, montre, comme les pre´ce´dentes, que la pre´paration colique avant chirurgie colorectale ne sert... a` rien. Quand est-ce que les chirurgiens franc¸ais seront enfin de´finitivement convaincus de l’inutilite´ (voire du caracte`re ne´faste) de cette pratique obsole`te ?
Cotation :
Y. Panis
Morbidity, quality of life, and body image of laparoscopic-assisted versus open ileocolic resection for Crohn ’ s disease: a comparative study Eshuis EJ, Polle SW, Frederik Slors JF, et al. (2008) Dis Colon Rectum 50: 858-67
Purpose: Several studies have compared conventional open ileocolic resection with a laparoscopic-assisted approach. However, long-term outcome after laparos- copic-assisted ileocolic resection remains to be determi- ned. This study was designed to compare long-term
results of surgical recurrence, quality of life, body image, and cosmesis in patients who underwent laparoscopic- assisted or open ileocolic resection for Crohn’s disease.
Methods: Seventy-eight consecutive patients who underwent ileocolic resection during the period 1995 to 1998 were analyzed; 48 underwent a conventional open approach in the Academic Medical Centre (Amsterdam, The Netherlands) and 30 underwent a laparoscopic- assisted approach in the Leiden University Medical Centre (Leiden, The Netherlands). Primary outcome parameters were reoperation and readmission rate.
Secondary outcome parameters were quality of life, body image, and cosmesis.
Results: The two groups were comparable for characteristics of sex, age, and immunosuppressive therapy. Seventy-one patients had a complete follow-up of median: 8.5 years. Resection for recurrent Crohn’s disease was performed in 6 of 27 (22 percent) and 10 of 44 (23 percent) patients in the laparoscopic and open groups, respectively. Reoperations for incisional hernia were only performed after conventional open ileocolic resection (3/44 = 6.8 percent). Quality of life and body image were comparable, but cosmesis scores were significantly higher in the laparoscopic group.
Conclusions: Despite small numbers, we found that surgical recurrence and quality of life after laparoscopic- assisted and open ileocolic resection were comparable.
Incisional hernias occurred only after open ileocolic resection, and laparoscopic-assisted ileocolic resection resulted in a significantly better cosmesis.
Commentaire :S’il y a maintenant beaucoup d’e´tudes (et meˆme deux me´ta-analyses) vantant les me´rites de la laparoscopie dans la re´section ile´ocolique pour maladie de Crohn, il n’existait jusqu’a` ce jour qu’une seule e´tude sur le devenir a` long terme, notamment en termes de re´cidive de la maladie. Cette e´tude hollandaise comparative (versus la laparotomie), avec un suivi me´dian de pre`s de neuf ans, montre clairement que le taux de re´cidive chirurgicale est e´quivalent apre`s laparoscopie et laparotomie. Ce n’est pas une surprise, mais cela valide de´finitivement l’approche laparoscopique dans cette indication. De plus, les e´ven- trations n’e´taient observe´es que dans le groupe laparotomie.
Si la qualite´ de vie globale e´tait e´quivalente dans les deux groupes, il y avait un be´ne´fice « cosme´tique » significatif a`
l’approche laparoscopique. Ce dernier re´sultat pourrait paraıˆtre insignifiant, mais est en fait important chez des patients souvent jeunes.
Cotation :
Y. Panis
