REVUE DE PRESSE / PRESS REVIEW
Impact of hospital volume on postoperative morbidity and mortality following a colectomy for ulcerative colitis
Kaplan GG, McCarthy EP, Ayanian JZ, et al. (2008) Gastroenterology 134: 680-7
Background and aims: Postoperative morbidity and mortality following a colectomy for ulcerative colitis (UC) has been primarily reported from tertiary care referral centers that perform a high volume of operations; however, the postoperative outcomes among nonselected hospitals are not known. We set out to evaluate postoperative morbidity and mortality using a nationally representative database and to determine the factors that influenced outcomes.
Methods: We analyzed the 1995-2005 Nationwide Inpatient Sample to identify 7,108 discharges for UC patients who underwent a total abdominal colectomy.
The effects of hospital volume on postoperative morbi- dity and mortality were evaluated in logistic regression models adjusting for demographic and clinical factors.
Results:Postoperative mortality and morbidity rates were 2.3 and 30.8%, respectively. Most operations were performed in low-volume hospitals that had an increased risk of death (adjusted odds ratio [aOR], 2.42; 95%
confidence interval [CI]: 1.26-4.63). In-hospital mortality was increased in patients who were admitted emergently (aOR, 5.40; 95% CI: 3.48-8.40), aged: 60-80 years (aOR, 8.70; 95% CI: 3.30-22.92), and those with Medicaid (aOR, 4.29; 95% CI: 2.13-8.66). Emergently admitted UC patients whose surgery was performed six days after their admission had significantly increased likelihood of in-hospital death (aOR, 2.12; 95% CI: 1.13-3.97).
Conclusions: Postoperative mortality was lowest in hospitals that performed the highest volume of opera- tions. Increasing the proportion of total colectomies performed in high-volume hospitals may improve clinical outcomes for patients with UC.
Commentaire :Depuis quelques anne´es, la mode en chirurgie digestive est d’e´valuer les re´sultats postope´ra- toires en termes de morbidite´ et de mortalite´, en fonction de l’importance de l’activite´ du centre ou` a e´te´ traite´ le patient (« hospital volume » pour les anglo-saxons).
Ainsi, par exemple, de nombreux papiers ont clairement sugge´re´ qu’un chirurgien colorectal qui ope´rait dans un centre a` grand volume (plus de 30 proctectomies/an) avait, et ce de manie`re significative, de meilleurs re´sultats en terme de mortalite´ ope´ratoire, que de morbidite´, mais aussi en terme de conservation sphincte´rienne qu’un
chirurgien travaillant dans un centre faisant moins de cinq cas/an. Il manquait un papier sur la chirurgie des MICI, et tout particulie`rement de la RCH. C’est chose faite avec cette e´tude de population ame´ricaine portant sur plus de 7 000 colectomies pour RCH. Les re´sultats sont sans appel et vont dans le meˆme sens que pour le cancer du rectum : les centres a` « gros volume », c’est-a`-dire plus de 11 colectomies/an pour RCH (ce qui finalement n’est de´ja` pas e´norme), font beaucoup mieux en termes de mortalite´ ope´ratoire, avec une diffe´rence significative, puisque celle-ci passe de 0,7 % dans les « gros centres » a` 4 % dans les petits centres (p < 0,0001). E´tant donne´
la particularite´ de la prise en charge des patients avec RCH, avec la ne´cessite´ aussi e´videmment d’un centre de gastroente´rologie spe´cialise´e dans le domaine, on ne peut que plaider, comme les auteurs, pour un regroupement de cette activite´ tre`s spe´cifique, dans les centres a` « gros volume ». Mais en France, le de´bat n’est pas simple...
Cotation :
Y. Panis
Incidentally detected Meckel diverticulum:
to resect or not to resect?
Zani A, Eaton S, Rees CM, Pierro A (2008) Ann Surg 247: 276-81
Background: Management of incidentally detected Meckel diverticulum (MD) remains controversial. Our aims were to establish: (1) the prevalence of MD; (2) the morbidity and (3) mortality due to MD.
Methods: Systematic review: A total of 244 papers meeting defined criteria were included; there were no prospective or randomized studies. MD prevalence and mortality from autopsy studies, postoperative complica- tions, and outcome of incidentally detected MD were extracted. Population-based data: Data were obtained from national databases on MD as cause of death, and on number of MD resections per year.
Results:The prevalence of MD is 1.2% and historical mortality of MD was 0.01%. The current mortality from MD is 0.001%. The number of MD resections per year per 100,000 populations decreased significantly after the pediatric age range (P< 0.001). Resection of incidentally detected MD has a significantly higher postoperative complication rate than leaving it in situ (P< 0.0001). The long-term outcome of patients with incidentally detected MD left in situ showed no complications. Seven-hundred fifty-eight patients would require incidentally detected MD resection to prevent 1 death from MD.
DOI 10.1007/s11725-008-0092-x
Conclusions: MD is present in 1.2% of the population, it is a very rare cause of mortality, and it is primarily a disease of the young. Leaving an incidentally detected MD in situ reduces the risk of postoperative complications without increasing late complications.
A large number of MD resections would need to be performed to prevent 1 death from MD. The above evidence does not support the resection of incidentally detected MD.
Commentaire :Faut-il ou non, chez l’adulte, enlever syste´matiquement un diverticule de Meckel de´couvert, par hasard lors d’une autre intervention. Vaste de´bat, comme dirait De Gaulle. Cette question, qui a beaucoup agite´ les esprits dans le landerneau chirurgical, me´ritait une e´tude sur une grande e´chelle pour avoir (enfin !) une re´ponse claire. Les auteurs ont donc fait une analyse syste´matique de la litte´rature sur le sujet (portant sur 244 publications) mais aussi une analyse de population a`
partir d’une base de donne´es nationale. Les re´sultats montrent que non seulement le diverticule de Meckel est peu fre´quent (pre´valence de 1,2 %), mais encore qu’il tue rarement (mortalite´ de 0,001 % actuellement !) et qu’enlever un meckel de´couvert par hasard a surtout l’e´norme avantage d’augmenter tre`s significativement la morbidite´ postope´ratoire ! A` l’inverse, le suivi a` long terme de diverticules de Meckel laisse´s en place ne montre... rien du tout, puisque ces derniers restent asymptomatiques. Il est donc urgent devant un diverti- cule de Meckel asymptomatique de l’adulte de ne rien faire du tout...
Cotation :
Y. Panis
Complete clinical response after preoperative chemoradiation in rectal cancer: is a ‘‘wait and see’’ policy justified?
Glynne-Jones R, Wallace M, Livingstone JI,
Meyrick-Thomas J (2008) Dis Colon Rectum 51: 10-9
Purpose: A proportion of patients, who receive pre- operative chemoradiation for locally advanced (T3, T4, NX) rectal cancer achieve a complete clinical response and a pathologic complete response in the region of 15 to 30 percent. Support is growing in the United Kingdom for the concept of ‘‘waiting to see’’ and not proceeding to radical surgery when a complete clinical response is observed. The purpose of this review was to use a literature search to assess how often complete clinical response is achieved after neoadjuvant chemoradiation, the concordance of this finding with pathologic complete response, and to determine whether it is feasible to observe patients who achieve complete clinical response rather than proceed to surgery.
Results:In total, 218 Phase I/II or retrospective studies and 28 Phase III trials of preoperative radiotherapy or chemoradiation were identified: 96 percent of trials documented the pathologic complete response, but only 38 trials presented data on the achievement of a complete clinical response/partial clinical response. Only five studies were found in which patients with clinically staged T2/T3 tumors were treated with radiotherapy/
chemoradiation and did not routinely proceed to surgery and also reported on the long-term outcome of a ‘‘wait and see’’ policy.
Discussion: It remains uncertain whether the degree of response to chemoradiation in terms of complete clinical response or pathologic complete response is a useful clinical end point. Studies that include T3 rectal cancer are associated with high local recurrence rates after nonsurgical treatment. Few studies report long- term outcome after achievement of a complete clinical response.
Conclusions: The end point of complete clinical response is inconsistently defined and seems insuf- ficiently robust with only partial concordance with pathologic complete response. The rationale of a ‘‘wait and see’’ policy when complete clinical response status is achieved relies on retrospective observations, which are currently insufficient to support this policy except in patients who are recognized to be unfit for or refuse radical surgery.
Commentaire :Voici un article qui donne une bonne orientation au de´bat tre`s actuel de la place de la radiochimiothe´rapie comme traitement exclusif du cancer du bas rectum. Il est vrai que la litte´rature nous donne matie`re a` confusion, entre des se´ries qui e´valuent les effets secondaires du traitement adjuvant, incitant plutoˆt a` limiter les indications de radiochimiothe´rapie aux tumeurs pour lesquelles le seul traitement chirurgical ne saurait eˆtre optimal et d’autres travaux qui s’inter- rogent sur la validite´ de la radiochimiothe´rapie comme traitement exclusif de cancers du bas rectum, plaidant a` l’inverse pour un traitement plus agressif encore (en particulier la chimiothe´rapie) afin d’e´viter ou de limiter la chirurgie. Cette revue ne constitue pas une me´ta- analyse, mais un registre des articles publie´s et soule`ve tre`s clairement deux proble`mes : la de´finition de la re´ponse clinique comple`te au traitement, qui reste tre`s variable selon les e´tudes... En te´moigne le faible nombre d’e´tudes le rapportant (38/218 = 17 %) ! Et par ailleurs, la corre´lation entre re´ponse clinique et re´ponse pathologique comple`te qui n’exce`de pas 50 % !
Autrement dit, la seule fac¸on de savoir si le traitement est efficace est d’ope´rer les patients... D’autant plus que la tumeur est e´volue´e (T3).
Cotation :
G. Meurette
Absence of lymph nodes in the resected specimen after radical surgery for distal rectal cancer and neoadjuvant chemoradiation therapy:
What does it mean?
Habr-Gama A, Perez RO, Poscurshim I, et al. (2008) Dis Colon Rectum 51: 277-83
Purpose: The number of retrieved lymph nodes during radical surgery has been considered of great importance to ensure adequate staging and radical resection.
However, this finding may not be applicable after neoadjuvant therapy in which, not only is there a decrease in lymph nodes recovered, but also a subgroup of patients with absence of lymph nodes in the resected specimen.
Methods:Patients with absence of lymph nodes were compared with patients with ypN0 disease and patients with ypN+ disease.
Results: Thirty-two patients (11 percent) had absence of lymph nodes, 171 patients (61 percent) had ypN0 disease, and 78 patients (28 percent) had ypN+ disease. Patients with absence of lymph nodes had significantly lower ypT status (ypT0-1, 40 vs. 13 percent;P< 0.001) and decreased risk of perineural invasion (6 vs. 21 percent; P = 0.04) compared with ypN0 patients. Five-year disease-free survival (74 percent) was similar to patients with ypN0 (59 percent; P = 0.2), and both were significantly better than patients with ypN+ disease (30 percent;P< 0.001).
Conclusions:Absence of lymph nodes retrieved from the resected specimen is associated with favorable pathologic features (ypT and perineural invasion status) and good disease-free survival rates. In this setting, absence of retrieved lymph nodes may reflect improved response to neoadjuvant chemoradiation therapy rather than inappropriate or suboptimal oncologic radicality.
Commentaires :Les auteurs ont e´value´ les re´sultats et l’impact de l’absence de ganglions sur une pie`ce de proctectomie pour cancer du rectum apre`s radiochimio- the´rapie ne´oadjuvante. S’il est e´tabli pour les cancers du coˆlon que 12 ganglions doivent eˆtre analyse´s sur la pie`ce ope´ratoire afin de de´finir le statut ganglionnaire et ne pas sous-estimer un stade III, indication d’une chimio- the´rapie, ce nombre est plus flou pour les pie`ces de proctectomie. Plusieurs travaux ont, en effet, sugge´re´ que le nombre de ganglions pourrait eˆtre diminue´ par la radiochimiothe´rapie ne´oadjuvante. Dans cette e´tude, 11 % des patients n’avaient pas de ganglions pre´sents sur la pie`ce de proctectomie (Nx), 61 % des patients e´taient N0 et 28 N+. Le statut Nx des patients e´tait significativement associe´ a` un stade tumoral pre´the´ra- peutique moins e´volue´, a` un stade tumoral de´finitif de meilleur pronostic et a` un risque diminue´ d’invasion lymphovasculaire et pe´rinerveux. En termes de re´cidive et de survie a` cinq ans, il n’existait pas de diffe´rence
significative entre les patients Nx et N0 (19 vs 29 % et 91 vs 91 %, respectivement). En revanche, par rapport aux patients N+, les patients Nx avaient de manie`re significative une diminution du taux de re´cidive (58 vs 19 %, p = 0,001) et une ame´lioration de la survie (66 vs 91 %, p < 0,001). Les auteurs sugge`rent que le statut Nx, apre`s radiochimiothe´rapie ne´oadjuvante suivie d’une proctectomie, illustrerait une tre`s bonne re´ponse de la tumeur a` la radiochimiothe´rapie et ne serait pas associe´
a` un risque e´leve´ de re´cidive.
Cotation :
A. Alves
Results of systematic second-look surgery in patients at high risk of developing colorectal peritoneal carcinomatosis
Elias D, Goe´re´ D, Di Pietrantonio D, et al. (2008) Ann Surg 247: 445-50
Objective: The aim of this prospective study was to analyze the impact of second-look surgery in an attempt to treat peritoneal carcinomatosis (PC) at an early stage in a series of patients at high risk of developing PC from colorectal cancer.
Background: The prognosis of colorectal PC has recently been improved with hyperthermic intraperito- neal chemotherapy (HIPEC) after complete cytoreduc- tive surgery (CCRS), and could be further improved if PC could be treated at an early stage. But, currently, the diagnosis of early PC is not accessible to imaging.
Patients and methods:From 1999 to 2006, 29 patients without any sign of recurrence on imaging studies underwent second-look surgery 13 months after resection of the primary tumor. Patients were selected according to primary tumor-associated criteria: resected minimal synchronous macroscopic PC (N = 16), synchronous ovarian metastases (N = 4), perforated primary tumor (N = 9).
Results: PC was found and treated with CCRS plus HIPEC in 16 of 29 (55%) cases, corresponding to 10 of 16 patients with initial PC, 3 of 4 patients with synchronous ovarian metastases and 3 of 9 patients with a perforated primary tumor. There was no postoperative mortality, and morbidity (grade III/IV) occurred in 14% of cases.
After a median follow-up of 27 months (range: 6-96), 8 of 16 patients treated with CCRS and HIPEC are free of disease, 4 relapsed in the peritoneum, and 4 developed isolated visceral metastases.
Conclusion: Performing second-look surgery at one year in selected patients at high risk of developing PC allowed the early detection and treatment of PC in 55%
of cases. Our preliminary results have encouraged us to pursue this strategy and to evaluate it in a prospective multicenter trial.
Commentaires :La chimiohyperthermie intrape´rito- ne´ale (CHIP) associe´e a` une exe´re`se comple`te des nodules de carcinose pe´ritone´ale permet d’observer actuellement une survie globale a` cinq ans comprise entre 40 et 48 %. Ces re´sultats ont e´te´ obtenus en cas de de´couverte pre´coce de la carcinose pe´ritone´ale. Les auteurs ont donc e´value´ la place et l’impact d’un « second-look chirurgical » chez des patients ope´re´s d’un cancer colorectal a` haut risque de de´velopper une carcinose pe´ritone´ale (carcinose pe´ritone´ale limite´e et re´se´que´e lors de la premie`re intervention n = 16 ; me´tastases ovariennes associe´es et re´se´que´es n = 4 ; cancer colorectal perfore´ et re´se´que´, n = 9). Aucun des 26 patients inclus dans cette e´tude n’avait de signes objectifs de re´cidive lors du « second-look chirurgical » re´alise´ a` un an. Il a e´te´
de´couvert chez 16 patients (55 %) une carcinose pe´ritone´ale conduisant alors a` une re´section chirurgicale associe´e a` une CHIP. Six autres patients ont eu une CHIP en raison de la pre´sence d’une carcinose lors de la premie`re laparotomie.
Aucun patient n’est de´ce´de´. La morbidite´ globale e´tait de 38 % et la dure´e d’hospitalisation de 16 jours. Avec un suivi me´dian de 27 mois, 17 patients e´taient en vie sans re´cidive, sept patients avaient une re´cidive de leur carcinose pe´ritone´ale et cinq patients avaient des me´tastases visce´ra- les. Les auteurs sugge`rent que ce « second-look chirurgical », un an apre`s une re´section d’un cancer colorectal a` haut risque de de´velopper une carcinose pe´ritone´ale, a permis non seulement de de´tecter, chez 55 % des patients, une re´cidive de la carcinose pe´ritone´ale, mais e´galement de proposer un traitement agressif associant une nouvelle re´section et une CHIP.
Cotation :
A. Alves
Sacral nerve stimulation is more effective than optimal medical therapy for severe fecal incontinence: a randomized, controlled study Tjandra JJ, Chan MK, Yeh CH, Murray-Green C (2008) Dis Colon Rectum (in press)
Purpose: This randomized study was designed to compare the effect of sacral neuromodulation with optimal medical therapy in patients with severe fecal incontinence.
Methods: Patients (aged: 39-86 years) with severe fecal incontinence were randomized to have sacral nerve stimulation (SNS group; N = 60) or best supportive therapy (control;N= 60), which consisted of pelvic floor exercises, bulking agent, and dietary manipulation. Full assessment included endoanal ultrasound, anorectal physiology, two-week bowel diary, and fecal inconti- nence quality of life index. The follow-up duration was 12 months.
Results: The sacral nerve stimulation group was similar to the control group with regard to gender
(F:M = 11:1 vs. 14:1) and age (mean: 63.9 vs. 63 years). The incidence of a defect of 120 degrees of the external anal sphincter and pudendal neuropathy was similar between the groups. Trial screening improved inconti- nent episodes by more than 50 percent in 54 patients (90 percent). Full-stage sacral nerve stimulation was performed in 53 of these 54 ‘‘successful’’ patients. There were no septic complications. With sacral nerve stimula- tion, mean incontinent episodes per week decreased from 9.5 to 3.1 (P < 0.0001) and mean incontinent days per week from 3.3 to 1 (P < 0.0001). Perfect continence was accomplished in 25 patients (47.2 percent). In the sacral nerve stimulation group, there was a significant (P< 0.0001) improvement in fecal incontinence quality of life index in all four domains. By contrast, there was no significant improvement in fecal continence and the fecal incontinence quality of life scores in the control group.
Conclusions: Sacral neuromodulation significantly improved the outcome in patients with severe fecal incontinence compared with the control group under- going optimal medical therapy.
Commentaire :Cet ultime papier de Joe Tjandra est aussi posthume. Il illustre une fois encore l’enthousiasme de´bordant de ce chirurgien pour la prise en charge the´rapeutique des malades souffrant d’incontinence. Si l’objectif de son travail e´tait de de´montrer « la quantite´
de be´ne´fice » des modes de prise en charge, il prouve que rien ne vaut la neuromodulation des racines sacre´es parce que la tole´rance, la proportion de malades implante´s et surtout le niveau de satisfaction ne souffrent d’aucune comparaison par rapport aux autres modes de prise en charge conservateurs ou mini-invasifs (y compris les biosilicones). La qualite´ des re´sultats laisse perplexe tant elle est quasi parfaite pour les malades en termes de diminution du score symptomatique ou d’ame´lioration de la qualite´ de vie. Ce travail finalement invite a` un e´largissement des indications de la neuromodulation et a` proposer cette alternative assez toˆt apre`s le de´but de la prise en charge (avant les gestes de re´paration sphincte´rienne ?).
Cotation :
L. Siproudhis
SECCA(R) Procedure for the treatment of fecal incontinence: results of five-year follow-up Takahashi-Monroy T, Morales M, Garcia-Osogobio S, et al.
(2008) Dis Colon Rectum 51: 355-9
Purpose: This study evaluated the long-term (5-year) durability of radiofrequency energy delivery for fecal incontinence.
Methods:This was an extension of the follow-up from our original prospective study in which patients who
suffered from fecal incontinence were treated with the SECCA(R) system for radiofrequency energy delivery to the anal canal muscle. The Cleveland Clinic Florida Fecal Incontinence Scale (0-20), fecal incontinence-related quality of life score, and Medical Outcomes Study Short-Form 36 were administered to five years. Diffe- rences between baseline and follow-up were analyzed by using paired t-test.
Results:A total of 19 patients were treated and followed for five years, including 18 females (aged: 57.1 (range: 44-77) years). The mean duration for fecal incontinence was 7.1 (range: 1-21) years. At five-year follow-up, the mean fecal incontinence score had improved from 14.37 to 8.26 (P < 0.00025) with 16 patients (84.2 percent) demonstrating > 50 percent improvement. All fecal incontinence-related quality of life scores improved, including lifestyle (2.43 to 3.15; P< 0.00075), coping (1.73 to 2.6; P < 0.00083), depression (2.24 to 3.15;
P < 0.0002), and embarrassment (1.56 to 2.51;
P< 0.0003). The social function component of the Short- Form 36 improved from 38.3 to 60 (P < 0.05). There was a trend toward improvement in the mental component summary of the Short-Form 36 from 38.1 to 48.14. There were no long-term complications.
Conclusions:Significant and sustained improvements in fecal incontinence symptoms and quality of life are seen at five years after treatment with the SECCA(R) system. This treatment should be considered for patients suffering from fecal incontinence not amenable to surgery and who have failed conservative management.
Commentaire :La radiofre´quence est une alternative the´rapeutique conceptuellement se´duisante dans la prise en charge des malades souffrant de troubles de la continence en rapport avec une hypotonie de repos du canal anal ou des le´sions du sphincter anal interne parce que dans ce cadre, les options the´rapeutiques sont peu nombreuses.
La re´alisation d’escarres de coagulation multiples sous- muqueux a` la partie haute du canal anal peut ainsi induire une meilleure re´sistance aux passages des selles chez les malades incontinents. Les essais sont peu nombreux dans le domaine, et la premie`re e´quipe ayant publie´ un tout petit essai ouvert sur le sujet apporte dans ce travail re´cent quelques e´le´ments statistiques montrant une efficacite´ de la me´thode par l’ame´lioration de la qualite´ de vie dans plusieurs de ses dimensions ainsi que par une diminution significative du score d’incontinence chez 19 malades. Le lecteur reste ne´anmoins assez dubitatif par la me´diocre pertinence clinique de la diminution des scores, le faible effectif de ce travail multicentrique et l’intervalle temporel long entre la premie`re et la dernie`re publication de cette e´quipe. Ceci n’augure pas de perspective enthousiasmante pour ce type de prise en charge the´rapeutique...
Cotation :
L. Siproudhis
Stapled transanal rectal resection in solitary rectal ulcer associated with prolapse
of the rectum: a prospective study
Boccasanta P, Venturi M, Calabro G, et al. (2008) Dis Colon Rectum 51: 348-54
Purpose: At present, none of the conventional surgical treatments of solitary rectal ulcer associated with internal rectal prolapse seems to be satisfactory because of the high incidence of recurrence. The stapled transanal rectal resection has been demonstrated to successfully cure patients with internal rectal prolapse associated with rectocele, or prolapsed hemorrhoids.
This prospective study was designed to evaluate the short-term and long-term results of stapled transanal rectal resection in patients affected by solitary rectal ulcer associated with internal rectal prolapse and nonresponders to biofeedback therapy.
Methods:Fourteen patients were selected on the basis of validated constipation and continence scorings, clinical examination, anorectal manometry, defecography, and colonoscopy and were submitted to biofeedback therapy.
Ten nonresponders were operated on and followed up with incidence of failure, defined as no improvement of symptoms and/or recurrence of rectal ulceration, as the primary outcome measure. Operative time, hospital stay, postoperative pain, time to return to normal activity, overall patient satisfaction index, and presence of residual rectal prolapse also were evaluated.
Results: At a mean follow-up of 27.2 (range: 24-34) months, symptoms significantly improved, with 80 percent of excellent/good results and none of the ten operated patients showed a recurrence of rectal ulcer. Operative time, hospital stay, and time to return to normal activity were similar to those reported after stapled transanal rectal resection for obstructed defecation, whereas postoperative pain was slightly higher. One patient complained of perineal abscess, requiring surgery.
Discussion: The stapled transanal rectal resection is safe and effective in the cure of solitary rectal ulcer associated with internal rectal prolapse, with minimal complications and no recurrences after two years.
Randomized trials with sufficient number of patients are necessary to compare the efficacy of stapled transanal rectal resection with the traditional surgical treatments of this rare condition.
Commentaire :Voici une inte´ressante alternative the´rapeutique a` proposer a` des patients pour lesquels nous sommes trop souvent de´munis ou de´c¸us par les approches classiques. La qualite´ de vie des malades souffrant d’un syndrome de l’ulce`re solitaire du rectum est alte´re´e et peu modifie´e par le type de prise en charge the´rapeutique qu’il s’agisse des techniques chirurgicales les plus classiques ou les approches conservatrices
(laxatifs, re´e´ducation)1. Dans l’expe´rience rapporte´e par Boccasanta et al., huit malades sur dix traite´s par re´section rectale transanale ont un re´sultat fonctionnel bon ou excellent deux ans apre`s le geste : les scores de constipation et d’incontinence s’ame´liorent de fac¸on importante et les symptoˆmes re´siduels sont e´tonnamment rares (te´nesme et saignement une fois sur dix). La principale question concerne la reproductibilite´ de cette e´tude italienne ayant traite´ dix patients. Un beau projet d’e´tude ouverte multicentrique que la SNFCP devrait promouvoir !
Cotation :
L. Siproudhis
Length of follow-up after fistulotomy and fistulectomy associated with endorectal advancement flap repair for fistula in ano Ortiz H, Marzo M, de Miguel M, et al. (2008) Br J Surg 95(4): 484-7
Background: The length of follow-up required after surgical repair of cryptoglandular fistula in ano has not been established. This prospective study determined the follow-up time needed to establish that an anal fistula has been cured after elective fistulotomy or fistulectomy associated with endorectal advancement flap (ERAF) repair.
Methods: Between January 2001 and June 2004, consecutive patients with anal fistula of cryptoglandular aetiology were included provided that they lived within the catchment area of the hospital and agreed to participate in a follow-up programme, which comprised scheduled visits every month until complete wound healing and annually thereafter.
Results: Some 206 of 219 eligible patients were evaluable; fistulotomy was performed in 115 and ERAF repair in 91. Median follow-up was 42 (range: 24-65) months. Eighteen patients had recurrence of the fistula during follow-up, with a median time to relapse of 5.0 (range: 1.0-11.7) months. There were no recurrences after 1 year.
Conclusion: Recurrence of fistula in ano of crypto- glandular origin treated by means of fistulotomy or ERAF repair occurs within the first year of operation.
Commentaire :Combien de temps faut-il suivre une fistule anale ope´re´e avant de conside´rer celle-ci comme gue´rie ? Il n’y avait pas de re´ponse claire a` cette question dans la litte´rature, les re´ponses e´tant tre`s variables et les e´tudes le plus souvent re´trospectives. Ce travail prospectif, mene´ sur une cohorte de 206 malades traite´s par
traitement conventionnel ou lambeau d’avancement et suivis pendant 42 mois, conclut qu’au-dela` d’un an, le risque est nul. Dans cette se´rie, la re´cidive (8,7 % des cas) survient le plus souvent dans les six premiers mois, c’est- a`-dire pre´cocement. La re´cidive e´tait plus fre´quente pour les fistules hautes que pour les fistules basses et les patients traite´s par lambeau d’avancement re´cidivaient dans 18 % des cas (ce qui peut de´ja` paraıˆtre comme d’excellents re´sultats pour cette technique !) versus 1,7 % pour ceux ayant be´ne´ficie´ d’une fistulotomie. De quoi rassurer les patients allant bien sans attendre des anne´es... ?
Cotation :
A. Sene´joux
Topical sucralfate decreases pain after hemorrhoidectomy and improves healing:
a randomized, blinded, controlled study Gupta PJ, Heda PS, Kalaskar S, Tamaskar VP (2008) Dis Colon Rectum 51(2): 231-4
Purpose: Oral and topical sucralfate is regularly used in ulcers of gastrointestinal tract, vaginal and perianal excoriations, and radiation burns. This study was designed to determine whether there was any advantage of topical application of sucralfate in reducing post- operative pain and promoting wound healing after open hemorrhoidectomy in patients with Grades III or IV hemorrhoids.
Methods: A total of 116 patients were randomly assigned to receive sucralfate cream (sucralfate group) or placebo cream (control group) applied to the surgical site. Weekly pain score was evaluated by using Visual Analog Scale. The amount of analgesic tablets consumed in each week also was assessed. At the end of four weeks, two independent surgeons assessed the wound healing.
Results: There was no significant difference in age, gender distribution, and number of excised hemorrhoid piles between the two groups. Patients in the topical sucralfate group experienced significantly less pain at Day 7 (Visual Analog Scalestandard error of the mean, 3.70.3 vs. 6.10.7;P< 0.002) and at Day 14 (1.60.2 vs. 3.1 0.6; P < 0.01). Likewise patients who received sucralfate cream used less analgesic tablets compared with the placebo group. In the sucralfate group, the overall wound healing ranked significantly better than in controls (P< 0.02).
Conclusions: Topical sucralfate significantly reduces pain at Days 7 and 14 after hemorrhoidectomy and promotes faster wound healing compared with that of a placebo.
1Meurette G, Siproudhis L, Regenet N, Frampas E, Proux M, Lehur PA Poor symptomatic relief and quality of life in patients treated for ‘‘solitary rectal ulcer syndrome without external rectal prolapse’’ Int J Colorectal Dis. 2008; 23: 521-526.
Commentaire :Ce travail est le premier a` montrer que le sucralfate en topique permet de diminuer la douleur postope´ratoire apre`s he´morroı¨dectomie et d’ame´liorer la cicatrisation. Les me´canismes d’action de ce produit initialement utilise´ comme anti-ulce´reux sont hypothe´ti- ques. Sur les le´sions ulce´reuses, il joue un roˆle de barrie`re me´canique graˆce a` des liaisons e´lectrostatiques avec les prote´ines de l’ulce`re. Le sucralfate a des proprie´te´s anti- bacte´riennes et angioge´niques (sa structure est semblable a` celle de l’he´parine). Certains travaux ont de´montre´ que
ce produit stimule la cicatrisation en se liant au facteur de croissance des fibroblastes et en inhibant sa de´gradation.
Une voie inte´ressante donc pour ame´liorer la prise en charge postope´ratoire des he´morroı¨dectomise´s, mais soulignons qu’en France, ce produit n’a pas d’AMM dans cette indication et que la forme topique utilise´e dans ce travail n’est pas disponible (l’excipient utilise´ e´tait la vaseline).
Cotation :
A. Sene´joux
