DOI 10.1007/s11725-015-0571-9
REVUE DE PRESSE / PRESS REVIEW
The Results of Seton Drainage Combined with Anti‑TNFα Therapy for Anal Fistula in Crohn’s Disease
Haennig A, Staumont G, Lepage B, et al (2015)
Colorectal Dis doi: 10.1111/codi.12851 [Epub ahead of print]
Aim: Combined infliximab and sphincter‑sparing surgery can be effective in perianal fistula associated with Crohn’s disease (CD). The study aimed to assess the efficacy of local surgery combined with infliximab on sustained fistula clo‑
sure and to identify predictive factors for response after this combined treatment.
Method: Between 2000 and 2010, 81 patients with fistu‑
lising perianal Crohn’s disease were included in this obser‑
vational study. Drainage with a loose seton was followed by infliximab therapy. The primary end points were the rate of complete fistula closure and time required for this to occur.
Results: The fistula was complex in 71 (88%) of the 81 patients. Local proctologic surgery was carried out in 77 (95%) including seton drainage in 62 (80.5%) of these.
This was continued for a median duration of 3.8 months and the patient then received infliximab therapy. The median follow‑up after treatment was 64 months (2–263).
Initial complete closure of the fistula occurred in 71 (88%) cases at a median interval of 12.4 months (1–147) from the start of treatment. Recurrence was observed in 29 (41%) patients at a median interval of 38.5 months (2–48) from the start of treatment. They were treated again with com‑
bined treatment with successful closure in 19 (65.5%) patients. The total rate of closure of the fistula was 75.3%.
Female gender, anal stenosis, recto‑vaginal and complex fistula formation were factors independently associated with failure of combined treatment.
Conclusion: Seton drainage for several months combined with Infliximab therapy is effective in closing the fistula in 75% of patients with complex perianal fistula formation associated with Crohn’s disease.
Commentaire : Voici une étude, certes rétrospective, qui confirme qu’il faut savoir associer traitement médical et chirurgie pour traiter les fistules anales au cours de la maladie de Crohn. Dans les essais sur les biothérapies (ACCENT II et analyse en sous‑groupe de CHARM), approximativement la moitié des patients ferment leurs
fistules sous traitement d’entretien. Ce travail tend à mon‑
trer qu’on peut faire mieux et obtenir trois quarts de ferme‑
ture en combinant traitement médical et chirurgie. Certes, la chirurgie la plus fréquemment réalisée est un drainage par séton, étape souvent indispensable à la mise en route du traitement, mais il peut également s’agir d’interventions de « réparation » (encollage, lambeau d’avancement ou plus rarement fistulotomie). L’étude souligne que le drainage par séton est le plus souvent long, quatre mois en moyenne, et que les fistules rectovaginales, complexes ou associées à une sténose anale gardent un pronostic péjoratif.
Cotation : ☺☺
A. Senéjoux
Medical Student Recognition of Benign Anorectal Conditions: the Effect of Attending the Outpatient Colorectal Clinic
Spanos CP, Tsapas A, Abatzis‑Papadopoulos M, et al (2014) BMC Surg 19:14–95
Background: Benign anorectal conditions are fairly common. Physicians of various specialties usually see patients with these conditions before being referred to colo‑
rectal specialists, frequently with an incorrect diagnosis.
We sought to evaluate the effect of attending an outpatient colorectal clinic by medical students on the diagnostic accu‑
racy of these conditions.
Methods: Over a 1‑year period, medical students were randomized into a group that attended the clinic, and one that did not. Both groups were shown images of six common benign anorectal conditions. The overall diagnostic accuracy as well as the diagnostic accuracy for each one of these con‑
ditions was prospectively evaluated for both groups.
Results: Nineteen students attended clinic and 17 did not.
Overall diagnostic accuracy was 80.6% for students attend‑
ing clinic and 43.1% for non‑attending students (P < 0.05).
In the attending group, diagnostic accuracy was signifi‑
cantly greater for prolapsed internal hemorrhoids (73.6 versus 35.2%, P < 0.05), thrombosed external hemorrhoid, (73.6 versus 17.6%, P < 0.05) fissure (100 versus 47%, P < 0.05), and anal tags (68.4 versus 11.7%, P < 0.05%).
Conclusion: Exposure to these conditions during surgical clerkships in medical school may help future specialists pro‑
vide better care for patients with benign anorectal disorders.
Commentaires : Une idée originale que de comparer l’efficacité de l’enseignement de la proctologie usuelle avec de simples photos avec l’enseignement en situation, au che‑
vet du patient ! Les résultats sont sans équivoque : rien ne vaut le stage pratique pour faire le bon diagnostic ! Deux fois plus d’étudiants ont « tout bon » après un stage alors que pour l’enseignement uniquement virtuel, les erreurs concernent près de 60 % des diagnostics…
Cotation : ☺☺☺
A. Senéjoux
Changes in Medical Treatment and Surgery Rates in Inflammatory Bowel Disease:
a Nationwide Cohort Study 1979–2011 Rungoe C, Langholz E, Andersson M, et al (2014) Gut 63:1607–16
Introduction: Treatment possibilities have changed in inflammatory bowel disease (IBD). We assessed changes in medical treatment and surgery over time and impact of medications on risk of surgery in a population‑based cohort.
Methods: 48,967 individuals were diagnosed with IBD (Crohn’s disease (CD), 13,185; ulcerative colitis (UC), 35,782) during 1979–2011. Cumulative probability of receiving 5‑aminosalicylic acids (5‑ASA), topical, oral corticosteroids, thiopurines, and tumour necrosis factor‑α (TNF‑α) blockers, and of first minor or major surgery according to period of diagnosis, was estimated. Medication use and risk of surgery was examined by Cox regression.
Results: 5‑year cumulative probability of first major surgery decreased from 44.7% in cohort (1979–1986) to 19.6% in cohort (2003–2011) (P < 0.001) for CD, and from 11.7% in cohort (1979–1986) to 7.5% in cohort (2003–
2011) (P < 0.001) for UC. Minor surgery risk decreased significantly in CD. From cohort (1995–2002) to cohort (2003–2011), a significant increase in use of thiopurines and TNF‑α blockers was observed, paralleled by a significant decrease in use of 5‑ASA and corticosteroids. Comparing use of azathioprine (or oral corticosteroids) to never‑use, no convincing surgery‑sparing effect was found. Comparing use in 3+ months of a given drug with use < 3 months, only 3+ months use of oral corticosteroids reduced the risk of surgery in patients with disease duration of > 1 year.
Conclusions: Parallel to an increasing use of thiopurines and TNF‑α blockers in IBD over time, a persistent signifi‑
cant decrease in surgery rates was observed along with a
significant decrease in use of 5‑ASA and corticosteroids.
However, no convincing surgery‑sparing effect of newer medications was found.
Commentaires : Il est difficile de mesurer l’impact des
« nouveaux » traitements sur l’histoire naturelle des MICI.
Une façon est de regarder si le risque de recourir à une chirurgie majeure (de résection) diminue depuis l’introduc‑
tion des anti‑TNF. Cette vaste étude en population, ayant suivi près de 49 000 patients avec MICI entre 1979 et 2011, présente des résultats encourageants, avec une baisse signi‑
ficative du recours à un traitement chirurgical majeur, dans les périodes les plus récentes (après 2003). En parallèle, l’exposition aux corticoïdes et aux salicylés diminue égale‑
ment au profit des thiopurines et des anti‑TNF. Cependant, attention à ne pas surinterpréter les résultats de cette étude qui présente des concordances d’observations, mais dont on ne peut déduire une réelle causalité, en raison du caractère rétrospectif et des multiples biais de ce type d’étude. Il peut s’agir, certes, d’un effet des anti‑TNF, mais également d’un recours plus rapide aux traitements, d’une meilleure éduca‑
tion/observance, etc., etc., mais c’est tout de même encou‑
rageant, les progrès sont réels.
Cotation : ☺☺☺
X. Treton
A Step Toward NOTES Total Mesorectal Excision for Rectal Cancer.
Endoscopic Transanal Proctectomy Tuech JJ, Karoui M, Lelong B, et al (2015) Ann Surg 261:228–33
Background: Previous publications have suggested that endoscopic transanal proctectomy (ETAP) is a promising technique and may be an alternative to conventional low anterior resection for rectal cancer. The aim of this study was to evaluate the technical feasibility of ETAP, with a par‑
ticular focus on postoperative and oncological results and on functional outcomes.
Methods: This study was a multicenter prospective study of unselected consecutive patients with low rectal cancer requiring proctectomy and coloanal anastomosis. All patients underwent a standardized procedure. The study endpoints were the safety and adequacy of the oncological resection criteria. All patients were evaluated with the Wexner Fecal Incontinence Questionnaire after stoma closure.
Results: Fifty‑six consecutive patients (41 men) under‑
went ETAP between February 2010 and June 2012. The median age was 65 years (39–83), and the median body mass index was 27 (20–42). No intraoperative complications were
encountered. There was no postoperative mortality, and the morbidity rate was 26%. The mesorectum was complete in 47 cases (84%) and nearly complete in 9 cases (16%). The median number of lymph nodes retrieved was 12 (range, 7–29) per patient. The median radial and distal margins were 8 mm (0–20) and 10 mm (3–40), respectively. R0 resection was achieved in 53 patients (94.6%). The median Wexner score was 4 (3–12). Thirteen (28%) patients reported stool fragmentation and difficult evacuation.
Conclusions: ETAP is a feasible alternative surgical option to conventional laparoscopy for rectal resection and may represent a promising step toward rectal natural orifice transluminal endoscopic surgery.
Commentaires : Deux études sur le même sujet « hot » dans le même numéro d’Annals of Surgery : la possibilité ou non de pouvoir sans risque réaliser des proctectomies pour cancer « par en bas ». L’une de Lacy de Barcelone, promoteur de la technique… et une française. Prenons la française ! Étude tricentrique, une des toutes premières sur le sujet, avant sûrement plein d’autres… Elle démontre sans discussion la faisabilité de la technique. Attendons main‑
tenant l’étude randomisée française qui doit commencer bientôt sous l’égide du GRECCAR. Car faisable ne suffit pas. Faut‑il encore que cela soit mieux que la technique laparoscopique classique « par en haut ». À suivre…
Cotation : ☺☺☺
Y. Panis
Long‑term Oncologic Outcomes of Robotic Low Anterior Resection for Rectal Cancer:
a Comparative Study with Laparoscopic Surgery Park EJ, Cho MS, Baek SJ, et al (2015)
Ann Surg 261:129–37
Objective: The aim of this study is to evaluate long‑term oncologic outcomes of robotic surgery for rectal cancer compared with laparoscopic surgery at a single institution.
Background: Robotic surgery is regarded as a new modality to surpass the technical limitations of conven‑
tional surgery. Short‑term outcomes of robotic surgery for rectal cancer were acceptable in previous reports. How‑
ever, evidence of long‑term feasibility and oncologic safety is required.
Methods: Between April 2006 and August 2011, 217 patients who underwent minimally invasive surgery for rectal cancer with stage I–III disease were enrolled pro‑
spectively (robot, N = 133; laparoscopy, N = 84). Median follow‑up period was 58 months (range, 4–80 months). Peri‑
operative clinicopathologic outcomes, morbidities, 5‑year survival rates, prognostic factors, and cost were evaluated.
Results: Perioperative clinicopathologic outcomes dem‑
onstrated no significant differences except for the conversion rate and length of hospital stay. The 5‑year overall survival rate was 92.8% in robotic, and 93.5% in laparoscopic surgical procedures (P = 0.829). The 5‑year disease‑free sur‑
vival rate was 81.9% and 78.7%, respectively (P = 0.547).
Local recurrence was similar: 2.3% and 1.2% (P = 0.649).
According to the univariate analysis, this type of surgical approach was not a prognostic factor for long‑term survival.
The patient’s mean payment for robotic surgery was approx‑
imately 2.34 times higher than laparoscopic surgery.
Conclusions: No significant differences were found in the 5‑year overall, disease‑free survival and local recurrence rates between robotic and laparoscopic surgical procedures.
We concluded that robotic surgery for rectal cancer failed to offer any oncologic or clinical benefits as compared with laparoscopy despite an increased cost.
Commentaires : Finalement, plutôt que de méchamment critiquer le robot en chirurgie colorectale, et se faire accu‑
ser ensuite de ne pas connaître bien le sujet, voire d’être jaloux, autant faire parler les promoteurs de la technique.
C’est encore plus simple… S’il existe un expert mondial sur le sujet, c’est bien le Dr Park. Lisez donc simplement la conclusion de son dernier article ci‑dessus que je laisse en anglais pour ne pas dénaturer ses propos : « Robotic sur‑
gery failed to offer any oncologic or clinical benefits… » La messe serait‑elle dite ?
Cotation : ☺☺☺
Y. Panis
Comparative Efficacy of Pharmacologic Interventions in Preventing Relapse of Crohn’s Disease After Surgery:
a Systematic Review and Network Meta‑analysis Singh S, Garg SK, Pardi DS, et al (2015)
Gastroenterology 148:64–76
Background & aims: There are several drugs that might decrease the risk of relapse of Crohn’s disease (CD) after sur‑
gery, but it is unclear whether one is superior to others. We estimated the comparative efficacy of different pharmacologic interventions for postoperative prophylaxis of CD, through a network meta‑analysis of randomized controlled trials.
Methods: We conducted a systematic search of the lit‑
erature through March 2014. We identified randomized controlled trials that compared the abilities of mesalamine, antibiotics, budesonide, immunomodulators, anti‑tumor necrosis factor α (anti‑TNF) (started within 3 months of surgery), and/or placebo or no intervention to prevent clini‑
cal and/or endoscopic relapse of CD in adults after surgical
resection. We used Bayesian network meta‑analysis to com‑
bine direct and indirect evidence and estimate the relative effects of treatment.
Results: We identified 21 trials comprising 2006 par‑
ticipants comparing 7 treatment strategies. In a network meta‑analysis, compared with placebo, mesalamine (relative risk [RR], 0.60; 95% credible interval [CrI], 0.37–0.88), antibiotics (RR, 0.26; 95% CrI, 0.08–0.61), immunomodulator monotherapy (RR, 0.36; 95% CrI, 0.17–
0.63), immunomodulator with antibiotics (RR, 0.11; 95%
CrI, 0.02–0.51), and anti‑TNF monotherapy (RR, 0.04; 95%
CrI, 0.00–0.14), but not budesonide (RR, 0.93; 95% CrI, 0.40–1.84), reduced the risk of clinical relapse. Likewise, compared with placebo, antibiotics (RR, 0.41; 95% CrI, 0.15–0.92), immunomodulator monotherapy (RR, 0.33;
95% CrI, 0.13–0.68), immunomodulator with antibiotics (RR, 0.16; 95% CrI, 0.04–0.48), and anti‑TNF monotherapy (RR, 0.01; 95% CrI, 0.00–0.05), but neither mesalamine (RR, 0.67; 95% CrI, 0.39–1.08) nor budesonide (RR, 0.86;
95% CrI, 0.61–1.22), reduced the risk of endoscopic relapse.
Anti‑TNF monotherapy was the most effective pharmaco‑
logic intervention for postoperative prophylaxis, with large effect sizes relative to all other strategies (clinical relapse:
RR, 0.02–0.20; endoscopic relapse: RR, 0.005–0.04).
Conclusions: Based on Bayesian network meta‑analysis combining direct and indirect treatment comparisons, anti‑TNF monotherapy appears to be the most effective strategy for postoperative prophylaxis for CD.
Commentaires : La maladie de Crohn iléale en raison de ses complications (sténoses ou perforations) expose les patients à une résection chirurgicale avec un risque de 30 % à cinq ans et 50 % à dix ans. Après résection, la maladie récidive en endoscopie puis cliniquement dans une propor‑
tion non négligeable (environ la moitié des patients à cinq ans). De nombreux médicaments (5ASA, budésonide, anti‑
biotiques, immunosuppresseurs et anti‑TNF) permettent de diminuer le risque de récidive, mais leur efficacité n’a pas été comparée. Par une méthode statistique, la méta‑
analyse en réseau, les auteurs comparent entre eux l’effet des différents traitements étudiés en préventif de la récidive postopératoire, uniquement à partir des essais contrôlés randomisés. Dans toutes les études, les traitements ont été introduits dans les trois mois postopératoires. À partir de 21 essais (soit 2006 patients), il est démontré que les anti‑
biotiques, les immunosuppresseurs et les anti‑TNF réduisent le risque de récidive endoscopique et clinique à un an avec un effet supérieur des anti‑TNF en monothérapie par rapport à toutes les molécules et que les dérivés salicylés ne réduisent que le risque de récidive clinique. Il manque cependant dans cette étude de données sur le long terme et sur les coûts.
Cotation : ☺☺
M. Simon
Epidemiology, Pathophysiology,
and Classification of Fecal Incontinence:
State of the Science Summary for the National Institute of Diabetes and Digestive
and Kidney Diseases (NIDDK) Workshop Bharucha AE, Dunivan G, Goode PS, et al (2015) Am J Gastroenterol 110:127–36.
doi: 10.1038/ajg.2014.396. Epub 2014 Dec 23
In August 2013, the National Institutes of Health sponsored a conference to address major gaps in our understanding of the epidemiology, pathophysiology, and management of fecal incontinence (FI) and to identify topics for future clinical research. This article is the first of a two‑part sum‑
mary of those proceedings. FI is a common symptom, with a prevalence that ranges from 7 to 15% in community‑
dwelling men and women, but it is often underreported, as providers seldom screen for FI and patients do not volun‑
teer the symptom, even though the symptoms can have a devastating impact on the quality of life. Rough estimates suggest that FI is associated with a substantial economic burden, particularly in patients who require surgical ther‑
apy. Bowel disturbances, particularly diarrhea, the symp‑
tom of rectal urgency, and burden of chronic illness are the strongest independent risk factors for FI in the community.
Smoking, obesity, and inappropriate cholecystectomy are emerging, potentially modifiable risk factors. Other risk factors for FI include advanced age, female gender, disease burden (comorbidity count, diabetes), anal sphincter trauma (obstetrical injury, prior surgery), and decreased physical activity. Neurological disorders, inflammatory bowel dis‑
ease, and pelvic floor anatomical disturbances (rectal pro‑
lapse) are also associated with FI. The pathophysiological mechanisms responsible for FI include diarrhea, anal and pelvic floor weakness, reduced rectal compliance, and reduced or increased rectal sensation; many patients have multifaceted anorectal dysfunctions. The type (urge, pas‑
sive or combined), etiology (anorectal disturbance, bowel symptoms, or both), and severity of FI provide the basis for classifying FI; these domains can be integrated to com‑
prehensively characterize the symptom. Several validated scales for classifying symptom severity and its impact on the quality of life are available. Symptom severity scales should incorporate the frequency, volume, consistency, and nature (urge or passive) of stool leakage. Despite the basic understanding of FI, there are still major knowledge gaps in disease epidemiology and pathogenesis, necessitating future clinical research in FI. Am J Gastroenterol advance online publication, 23 December 2014; doi:10.1038/ajg.2014.396.
Commentaire : L’incontinence anale est un problème de santé publique. Nous sommes beaucoup investis dans cette prise en charge à être convaincus que l’enjeu des années
à venir sera de faire admettre cette réalité à nos tutelles…
C’est peut‑être en train d’aboutir (ou en tout cas sur la bonne voie) à en croire cet article à l’initiative du Natio‑
nal Institute of Health qui recense les progrès récents dans la compréhension des mécanismes physiopathologiques et dresse la liste des scores validés reconnus pour chiffrer ce handicap. C’est surtout un plaidoyer pour initier des pro‑
jets de recherche dans le domaine de l’épidémiologie et le traitement de cette affection si longtemps restée tabou…
C’est un signe important fait à notre communauté scienti‑
fique. Nous avons eu raison de nous intéresser à l’inconti‑
nence anale, elle prendra (enfin) une place méritée dans nos thématiques de recherche institutionnelle. On peut espérer des moyens…
Cotation : ☺☺☺
G. Meurette
Sacral Neuromodulation for Faecal Incontinence:
is the Outcome Compromised in Patients with High‑grade Internal Rectal Prolapse?
Prapasrivorakul S, Gosselink M, Gorissen KJ, et al (2015) Int J Colorectal Dis 30:229–34.
doi: 10.1007/s00384‑014‑2078‑5. Epub 2014 Nov 30 Background: High‑grade internal rectal prolapse appears to be one of the contributing factors in the multifactorial ori‑
gin of faecal incontinence. Whether it affects the outcome of sacral neuromodulation is unknown. We compared the func‑
tional results of sacral neuromodulation for faecal inconti‑
nence in patients with and without a high‑grade internal rectal prolapse.
Method: One hundred six consecutive patients suffer‑
ing from faecal incontinence, who were eligible for sacral neuromodulation between 2009 and 2012, were identified from a prospective database. All patients underwent pre‑
operative defaecating proctography, anorectal manometry
and ultrasound. Symptoms were assessed preoperatively and at 12 months after operation using a standardized ques‑
tionnaire incorporating the Faecal Incontinence Severity Index (FISI range = 0–61) and the Gastrointestinal Quality of Life Index (GIQLI). Success was defined as a decrease in the FISI score of 50% or more.
Results: High‑grade internal rectal prolapse (HIRP) was found in 36 patients (34%). The patient characteristics were similar in both groups. Temporary test stimulation was successful in 60 patients without HIRP (86%) and in 25 patients with HIRP (69%) (P = 0.03). A permanent pulse generator was then implanted on these patients. After 1‑year follow‑up, the median FISI was reduced in patients with‑
out HIRP from 37 to 23 (P < 0.01). No significant change in FISI score was observed in patients with a HIRP (FISI, 38 to 34; P = 0.16). Quality of life (GIQLI) was only improved in patients without HIRP. A successful outcome per protocol was achieved in 31 patients without HIRP (52%) versus 4 patients with HIRP (16%) (P < 0.01).
Conclusion: The presence of a high‑grade internal rectal prolapse has a detrimental effect on sacral neuromodulation for faecal incontinence.
Commentaire : Devant un tableau d’incontinence anale avec procidence interne du rectum, faut‑il corriger le trouble de la statique pelvienne ou bien proposer un test de neuro‑
modulation sacrée en première intention? Voilà une bonne question. Cet article ne répond pas directement, mais il nous met en garde : lorsqu’il existe une procidence rectale, la neuromodulation sacrée fonctionne moins bien, le test est moins souvent positif, et parmi ceux qui sont implantés, le résultat sur le contrôle de la continence est moins bon. Voilà une information intéressante qui nous inciterait à proposer la correction d’une procidence rectale (lorsqu’elle existe) avant d’entreprendre une neuromodulation pour augmenter son efficacité. Ce qui sous‑entend aussi de la rechercher de façon systématique.
Cotation : ☺☺☺
G. Meurette
