DOI 10.1007/s11725-010-0223-z
Revue De pResse / press review
Safety and efficacy of laparoscopic ventral mesh rectopexy for complex rectocele
Wong M, Meurette G, Abet E, et al. (2010) Colorectal Dis June (in press)
Abstract: Aim Complex rectocoele possesses at least one of the following characteristics: a concurrent enterocoele, size greater than 3 cm or internal rectal prolapse. Laparoscopic ventral mesh rectopexy, previously described for external rectal prolapse, was evaluated for symptomatic complex rectocoele.
Method: From January 2004 to December 2008, 84 (50.9%) patients (mean age 64 ± 5 years) underwent laparoscopic ventral mesh rectopexy for symptomatic complex rectocele, confirmed preoperatively on dynamic defaecography, with 26 (31%) patients having a concurrent cystocoele. The operative technique was standardised and those with cysto- coele underwent bladder mesh suspension during the same procedure. Prospectively collected data were analysed for pre-operative symptoms, operative and functional results (constipation, faecal incontinence, dyspareunia and satis- faction score).
Results: The conversion rate was 3.6%, and periopera- tive morbidity 4.8% with no mortality. At a median follow up of 29 (4–59) months, there was a significant decrease in vaginal discomfort (86 to 20%) and obstructed defaecation symptoms (83 to 46%), P < 0.001. There was no significant change in faecal incontinence (20 to 16%), no worsening of preoperative symptoms or new complaints of constipation, dyspareunia or faecal incontinence. Overall, 88% of patients reported an improvement in overall well-being.
Conclusion: Laparoscopic ventral mesh rectopexy is a safe and effective method for treating symptomatic complex rectocoele.
Commentaires : L’approche laparoscopique des recto- cèles est cohérente en cas de troubles de la statique pel- vienne intriquée au prix d’une morbidité faible. Ce geste corrige efficacement le trouble anatomique, mais la correc- tion de la fonction est imparfaite : près de la moitié des malades dyschésiques le restent après le geste, et les trou- bles de la continence sont inchangés. Ces données sont à mettre en perspective avec celles de l’étude toulousaine décrite ensuite. Cependant, la force du travail de l’équipe
nantaise est de conforter le concept d’approche laparosco- pique des troubles de la statique pelvienne, en termes de morbidité et d’efficacité anatomique à l’heure où les inter- positions prothétiques de la chirurgie vaginale livrent des résultats à court et moyen termes assez décevants.
Table 1. Comparison of symptoms before and after laparoscopic ventral mesh rectopexy
symptom patients with symptoms before surgery (%)
patients with symptoms after surgery (%)
p
Obstructed defaecation
83 46 < 0.001
vaginal discomfort
86 20 < 0.001
Faecal incontinence
20 16 > 0.05
De novo constipation
– 0 –
De novo dyspareunia
– 0 –
Cotation
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L. Siproudhis
The effect of abdominal ventral rectopexy
on faecal incontinence and constipation in patients with internal intra-anal rectal intussusception Portier G, Kirzin S, Cabarrot P, et al. (2010)
Colorectal Dis May 22 (in press)
Introduction: Optimal treatment of anal incontinence in a patient with a normal anal sphincter is controversial, as is the role of intra-anal rectal intussusception in anal incon- tinence. We evaluated the results of abdominal ventral rec- topexy on anal continence in such patients.
Method: Forty consecutive patients with incontinence and intra-anal rectal intussusception without a sphincter defect were treated by abdominal ventral mesh rectopexy without sigmoidectomy. The Cleveland Clinic Incontinence score (CCIs), patient satisfaction, constipation before and after surgery and recurrence were recorded.
© Springer-Verlag France 2010
Results: The mean CCI scores were 13.2 (=/–4.25) pre- operatively and 3 (± 3.44) postoperatively (P < 0.0001).
Patient assessment was reported as “cured” in 26 (65%),
“improved” in 13 (32.5%), and “unchanged” in one patient.
Constipation was induced in two patients; and was cured in 13 of 20 (65%) patients who were constipated before sur- gery. One case of recurrent prolapse occurred after a mean follow-up of 38 months.
Conclusion: Intra-anal rectal intussusception may be associated with anal incontinence. For these patients, abdominal ventral mesh rectopexy appears to be adequate treatment.
Commentaires : Ce travail publié par l’équipe de Tou- louse est innovant dans le champ pathogénique et thérapeu- tique de l’incontinence fécale. Sur le plan des concepts, il considère que la procidence interne du rectum est un facteur étiologique des troubles de la continence lorsque celle-ci s’invagine dans le canal anal chez les malades n’ayant pas de lésion sphinctérienne. Il conduit donc, à rechercher cette anomalie dans le bilan étiologique d’une incontinence fécale. Sur le plan thérapeutique, parce que l’approche thérapeutique par rectopexie induit une amélioration fran- che, durable et cliniquement pertinente des troubles de la continence (Table 1). Si ce travail est confirmé par d’autres équipes, cette donnée pourrait être de nature à modifier les paradigmes de prises en charge des troubles de la conti- nence fécale.
Table 1. Functional results after ventral rectopexy preoperative postoperative CCis (± se) 13.3 (4.25) 3 (3.44)
Urgency 27 8
Constipation
Yes 20 7
No 20 18
Cotation
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L. Siproudhis
Assessing the safety, effectiveness,
and quality of life after the STARR procedure for obstructed defecation:
results of the German STARR registry
Schwandner O, Fürst A, German STARR Registry Study Group (2010)
Arch Surg 5:505–13
Background: Internal rectal prolapse and rectocele are fre- quent clinical findings in patients with obstructed defeca- tion syndrome (ODS). However, there is still no evidence
whether stapled transanal rectal resection (STARR) provides a safe and effective surgical option. Therefore, the German STARR registry was initiated to assess safety, effectiveness, and quality of life.
Methods: The German STARR registry was designed as an interventional, prospective, multicenter audit. Primary outcomes include safety (morbidity and adverse events), effectiveness (ODS, symptom severity, and incontinence scores), and quality of life (PAC-QoL and EQ-5D) docu- mented at baseline and at 6 and 12 months. Statistical evalua- tion was performed by an independent research organization of clinical epidemiology.
Results: Complete data of 379 patients (78% females, mean age 57.8 years) were entered into the registry database.
Mean operative time was 40 minutes, mean hospitalization was 5.5 days. A total of 103 complications and adverse events were reported in 80 patients (21.1%) including sta- ple line complications (minor bleeding, infection, or partial dehiscence; 7.1%), major bleeding (2.9%), and postsurgi- cal stenosis (2.1%). Comparisons of ODS and symptom severity scores (SSS) demonstrated a significant reduction in ODS score between baseline (mean 11.14) and 6 months (mean 6.43), which was maintained at 12 months (mean 6.45), and SSS at preoperative and at 6- and 12-month follow-up (13.02 vs 7.34 vs 6.59; paired t test, P < 0.001).
Significant reduction in ODS symptoms was matched by an improvement in quality of life as judged by symptom-spe- cific PAC-QoL and generic ED-5Q (utility and visual analog scale) scores and was not associated with an impairment of incontinence score following STARR (P > 0.05). However, 11 patients (2.9%) showed de novo incontinence, and new- onset symptoms of fecal urgency were observed in 25.3%
of patients.
Conclusion: These data indicate that STARR is a safe and effective procedure. However, conclusions are limited due to the selection and reporting bias of a registry. The problem of fecal urgency needs cautious reassessment.
Commentaires : Qui poursuivrait le développement d’une technique de chirurgie fonctionnelle anorectale qui induit des troubles de la continence et des impériosités fécales dans 3 et 25 % des cas respectivement ? Bien que supportée par des subventions de l’industrie, l’expérience allemande de la résection rectale transanale agrafée pour le traitement de la procidence interne et de la rectocèle a deux atouts : son caractère multicentrique (registre, reproductibilité et diffusion de la technique) et l’importance numérique du registre (n = 379, suivi à 6 et 12 mois). Il est peut-être pru- dent d’attendre des données complémentaires d’innocuité à plus long terme avant de promouvoir le développement de la technique.
Cotation
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L. Siproudhis
Chronic posterior tibial nerve transcutaneous electrical nerve stimulation (TENS)
to treat fecal incontinence
Eléouet M, Siproudhis L, Guillou N, et al. (2010) Int J Colorectal Dis June (in press)
Aim: Transcutaneous electrical nerve stimulation (TENS) is a possible alternative to sacral nerve stimulation because the neurophysiologic targets might be similar but the former method is non-invasive and cheaper. The aim of the study was to assess both symptom and quality of life (QoL) improvements in patients suffering from severe FI.
Methods: Thirty-two patients (M/F, 30/2; age, 61 ± 13 years) were enrolled in a pilot trial because they suffered from a severe and stable FI (Cleveland Score 14.5 ± 2.8 [11–20]) for a long duration (95 ± 91 months). TENS was deliv- ered 20 minutes bis in die at home (Schwa Medico, P3).
Assessment was realized at 1, 3, and 6 months with both semi-directive and self-administered questionnaires. Main endpoint was the quantified success rate after 1 month of follow-up.
Results: Mean subjective improvement was 26 ± 30%:
20 (63%) patients reported some degree of improvement and 10 (32%) at least a 25% improvement in fecal incontinence.
The Cleveland Score significantly decreased at 1 (11 ± 4;
P < 0.001), 3 (11 ± 5; P < 0.001), and 6 (10 ± 5; P < 0.001) months. All subscales of QoL were significantly improved after a 3-month period of stimulation. However, constipa- tion score and number of pads did not change. There was no adverse event.
Conclusion: TENS provides slight improvement in FI.
This justifies both neurophysiology assessment and ran- domized controlled studies before further diffusion of the technique.
Commentaires : La stimulation tibiale postérieure est une approche non invasive du traitement de l’inconti- nence fécale. Comme pour toute étude ouverte évaluant un bénéfice dans le champ de la prise en charge d’un trou- ble fonctionnel, la proportion de malades améliorés est importante. La méthode ne profite pas à tous les malades de cette étude prospective monocentrique (Fig. 1). Comme dans toute étude évaluant le bénéfice d’une approche thé- rapeutique non chirurgicale de l’incontinence fécale, la pertinence clinique d’efficacité est modeste (gain moyen de trois points de score), mais il se maintient dans le temps (un an).
Cotation
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L. Siproudhis
Transcutaneous electrical posterior tibial nerve stimulation for faecal incontinence:
effects on symptoms and quality of life Vitton V, Damon H, Roman S, Mion F (2010) Int J Colorectal Dis 25:1017–20
Purpose: Faecal incontinence is a disabling symptom which may be particularly difficult to treat. Recent studies showed that transcutaneous electrical posterior tibial nerve stimula- tion may improve faecal continence. In this study, we aimed to evaluate the effectiveness of this technique and tried to individualize predictive factors of success.
Methods: Twenty-four patients suffering from faecal incontinence were treated 20 minutes per day by applying transcutaneous electrical posterior tibial nerve stimulation for 3 months. A clinical evaluation was performed at the end of treatment, with Wexner’s score and analogical scales for symptoms. After 3 months, if the treatment was successful, patients were proposed to continue on the treatment. Pre- dictive factors such as age, symptom duration, proctologic history, obstetrical history, anorectal manometric data and quality-of-life score were also analysed.
Results: At 3 months, 13 patients (54%) reported a sig- nificant symptomatic improvement with a significant modi- fication in the Wexner’s score (14 vs 12, P < 0.025). At a median follow-up of 15 months, there were still 11 patients whose condition was improved.
Conclusion: This study shows encouraging mid-term results, and even if further randomized studies are neces- sary, transcutaneous electrical posterior tibial nerve stimu- lation may be a new and easy-to-use therapeutic option to treat faecal incontinence
Commentaires : Un travail lyonnais en miroir de l’expé- rience rennaise avec des résultats comparables, mais des conclusions peut-être sensiblement plus optimistes. Nous
attendons donc, avec impatience les données de l’étude contrôlée randomisée contre placebo multicentrique pilotée par Rouen dans le cadre d’une offre PHRC (essai TENSIA).
Cotation
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L. Siproudhis
Patterns of recurrence in patients with acute diverticulitis
Eglinton T, Nguyen T, Raniga S, et al. (2010) Br J Surg 6:952–7
Background: The natural history of acute diverticulitis remains unclear, with the role of prophylactic surgery following con- servatively managed diverticulitis increasingly controversial.
This study investigated recurrence rates, patterns and compli- cations after conservatively managed diverticulitis.
Methods: This was a retrospective chart review of all patients admitted with diverticulitis between June 1997 and June 2002. Demographic data, management, recurrence rates, complications and subsequent surgery were recorded.
Results: Some 502 patients were identified, 337 with uncomplicated and 165 with complicated diverticulitis. Median follow-up was 101 (range 60–124) months. Of 320 patients with uncomplicated diverticulitis managed conservatively, 60 (18.8%) had one episode of recurrence, whereas 15 (4.7%) had two or more episodes. After an initial attack of uncom- plicated diverticulitis, only 5.0% developed complicated dis- ease. Complicated disease recurred in 24%, compared with a recurrence rate of 23.4% in those with uncomplicated diver- ticulitis (P = 0.622). When recurrence occurred, it usually did so within 12 months of the initial episode.
Conclusion: Acute diverticulitis has a low recurrence rate and rarely progresses to complications. Any recurrence is usually early, in a pattern more consistent with failure of the index episode to settle. Subsequent elective surgery to prevent recurrence and the development of complications should be used sparingly.
Commentaires : Une belle étude de cohorte sur le devenir de 502 patients ayant eu une poussée de sigmoïdite diverti- culaire qui confirme la tendance à la non-intervention avec un recul de plus de cinq ans. Deux tiers des patients avaient une sigmoïdite non compliquée. Après un traitement médi- cal, le taux de récidive était de 24 % avec une seule poussée pour 19 % et plusieurs poussées pour 5 % des patients. La récidive pouvait être traitée médicalement chez 95 % des patients avec un taux de stomie inférieur à 1 % pour ceux ayant été opérés. Les poussées compliquées (abcès, perfo- ration) avaient le même taux de récidive : 24 % après trai- tement médical. Ces récidives nécessitaient un traitement chirurgical dans 12 % des cas.
Malgré les biais inhérents à une étude rétrospective, ces résultats poussent au traitement médical pour les poussées non compliquées, mais probablement pour les poussées compliquées ayant bien répondu au traitement médical.
Une étude randomisée prospective serait nécessaire pour confirmer cet attentisme après sigmoïdite compliquée.
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J.-H. Lefevre
Complete surgery for low rectal endometriosis:
long-term results of a 100-case prospective study Dousset B, Leconte M, Borghese B, et al. (2010) Ann Surg 5:887–95
Objective: We conducted a prospective study to assess the long-term results of complete surgery for low rectal endometriosis (LRE), paying particular attention to surgi- cal complications, functional results, and disease recurrence after a follow-up of at least 5 years.
Summary background data: Deep infiltrating endome- triosis (DIE) may infiltrate the midlow rectum and lead to severe pelvic pain. Complete resection of LRE is reluctantly considered by young women of childbearing age.
Methods: From 1995 to 2003, 100 women with severe pelvic pain and previous incomplete surgery (N = 82) under- went complete open surgery for LRE after thorough preop- erative imaging work-up. This included total or subtotal rectal excision with combined resection of all extrarectal endometriotic lesions. Univariate analysis of predictive fac- tors for transient neurogenic bladder and surgical complica- tions was performed. Mean follow-up was 78 ± 15 months.
Results: All patients underwent rectal resection with straight coloanal (N = 16) or low colorectal anastomosis (N = 84). A concomitant extrarectal procedure was required in all instances, including gynecologic procedures (N = 100), additional intestinal (N = 45), and urologic (N = 23) resec- tions. A fertility-preserving procedure was possible in 92%
of the patients. Mean numbers of DIE and endometriotic lesions were 3.9 ± 1.4 and 5.5 ± 1.6 per patient, respectively.
There were no deaths and the surgical morbidity rate was 16%. Sixteen patients developed a transient peripheral neu- rogenic bladder, which was more frequently observed after colonanal anastomosis (P < 0.001) or concomitant hyster- ectomy (P < 0.01) and in patients with more than 4 DIE lesions (P < 0.05). At last follow-up, 94 patients had com- plete (N = 83) or very satisfactory (N = 11) relief of symp- toms. Urine voiding and fecal continence was satisfactory in all cases. There was no recurrence of colorectal and/
or urologic endometriosis and the overall DIE recurrence rate was 2%.
Conclusions: Complete surgery for LRE provides excel- lent long-term functional results in 94% of the patients, pro- vided all extraintestinal endometriotic lesions are resected during the same surgical procedure. In that setting, the over- all 5-year recurrence rate is very low.
Commentaires : L’endométriose digestive est assez rare touchant 10 % des femmes avec une endométriose. La locali- sation rectosigmoïdienne est la plus fréquente (65 %). Cette étude rapporte les résultats d’une prise en charge chirur- gicale agressive avec une résection « carcinologique » de l’intégralité des nodules d’endométriose par laparotomie.
Cent femmes ont été opérées entre 1995 et 2003. L’endomé- triose était avancée avec 1,6 lésion digestive par patiente et des gestes associés à la résection rectale fréquente (34 sig- moïdectomies, 64 colpectomies, 7 urétérectomies, 9 cystec- tomies partielles…). La morbidité est faible avec 6 % de fis- tules digestives ou rectovaginales. Seize pour cent des fem- mes avaient besoin d’autosondage urinaire temporaire pour vessie neurologique avec une fonction urinaire normale au long cours. La fonction digestive était très satisfaisante chez ces jeunes patientes ayant toutes eu une anastomose directe sans confection d’un réservoir (1,8 selle par jour à cinq ans, aucune incontinence, 2 % de prise médicamenteuse, 9 % de fractionnement). Concernant, l’efficacité de cette chirurgie, elle est excellente avec un taux de récidive d’endométriose digestive de 2 % et un score de satisfaction sur la dispa- rition des symptômes digestifs et gynécologiques de 94 %.
Il faut attendre maintenant les résultats de la laparoscopie dans cette indication.
Cotation
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J.-H. Lefevre
Comparative study of the house advancement Flap, Rhomboid Flap, and Y-V Anoplasty in treatment of anal stenosis:
A prospective randomized study
Farid M, Youssef M, El Nakeeb A, et al. (2010) Dis Colon Rectum 53:790–7
Purpose: Anal stenosis represents a technical challenge for surgical management. We compared the effects of house flap, rhomboid flap, and Y-V anoplasty procedures in a ran- domized study in patients with anal stenosis.
Methods: Consecutive patients treated for anal stenosis at our institution were evaluated for inclusion. Participants were randomly allocated to receive house flap, rhomboid flap, or Y-V anoplasty. Follow-up visits were after 1 week, 1 month, 6 months, and 1 year. Study variables included cal- iber of the anal canal (measured with a conical calibrator), clinical improvement, patient satisfaction (visual analog
scale), incontinence (Pescatori incontinence scale), and quality of life (GI Quality of Life Inventory).
Results: Sixty patients with anal stenosis were randomized and completed the study. Operative time was 62 ± 10 min- utes for house flap, 44 ± 13 minutes for rhomboid flap, and 35 ± 9 minutes for Y-V anoplasty (P = 0.042). At 1 year, anal caliber was 23.9 ± 2.33 mm for house flap, 18.1 ± 2.05 mm for rhomboid flap, and 16.4 ± 2.05 mm for Y-V anoplasty (P = 0.04), with a highly significant increase for the house flap (P = 0.001). The groups differed significantly regarding clinical improvement at 1 month (95% for house flap, 80%
for rhomboid flap, and 65% for Y-V anoplasty, P = 0.01) and differences persisted at 1 year. Significant differences were seen among groups at 1 year in GI Quality of Life Inventory scores (P = 0.03), with significant improvement only for the house flap (P = 0.01).
Conclusion: Anal stenosis can be effectively managed with the house flap procedure, with the sole disadvantage of longer operative time. Although all 3 procedures are simple and easy to perform, the house flap appears to pro- duce the greatest clinical improvement, patient satisfac- tion, and improvement in quality of life, with the fewest complications.
Commentaires : La sténose anale est une pathologie rare, mais invalidante. Elle est avant tout d’origine iatro- gène, compliquant la chirurgie hémorroïdaire. Si le trai- tement conservateur associant laxatifs et dilatations ana- les est le plus souvent suffisant pour les sténoses légères à modérées, les sténoses sévères nécessitent habituellement un traitement chirurgical. Plusieurs techniques de plastie visant à augmenter le calibre du canal anal sont proposées dans cette indication. La procédure idéale doit être efficace, simple à réaliser et avoir un faible taux de complications, en particulier de nécrose du greffon. La littérature concernant ces techniques est généralement de faible niveau de preuve.
Ce travail est le seul existant comparant de façon scienti- fique les trois techniques principales. Il montre que si les trois méthodes sont efficaces, la technique de « house flap plasty » donne les meilleurs résultats même si elle est un peu plus longue à réaliser.
Cotation
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A. Senéjoux
Burnout and medical errors among American surgeons
Shanafelt TD, Balch CM, Bechamps G, et al. (2010) Ann Surg 251:995–1000
Objective: To evaluate the relationship between burnout and perceived major medical errors among American surgeons.
Background: Despite efforts to improve patient safety, medical errors by physicians remain a common cause of morbidity and mortality.
Methods: Members of the American College of Surgeons were sent an anonymous, cross-sectional survey in June 2008. The survey included self-assessment of major medi- cal errors, a validated depression screening tool, and stand- ardized assessments of burnout and quality of life (QOL).
Results: Of 7,905 participating surgeons, 700 (8.9%) reported concern they had made a major medical error in the last 3 months. Over 70% of surgeons attributed the error to individual rather than system level factors. Reporting an error during the last 3 months had a large, statistically signif- icant adverse relationship with mental QOL, all 3 domains of burnout (emotional exhaustion, depersonalization, and personal accomplishment) and symptoms of depression.
Each one point increase in depersonalization (scale range, 0–33) was associated with an 11% increase in the likeli- hood of reporting an error while each one point increase in emotional exhaustion (scale range, 0–54) was associated with a 5% increase. Burnout and depression remained inde- pendent predictors of reporting a recent major medical error on multivariate analysis that controlled for other personal and professional factors. The frequency of overnight call, practice setting, method of compensation, and number of hours worked were not associated with errors on multivari- ate analysis.
Conclusions: Major medical errors reported by surgeons are strongly related to a surgeon’s degree of burnout and their mental QOL. Studies are needed to determine how to reduce surgeon distress and how to support surgeons when medical errors occur.
Commentaires : L’erreur médicale peut avoir des consé- quences graves pour le malade. Ce travail ambitieux a consisté à interroger près de 25 000 chirurgiens américains membres de l’American College of Surgeons. Le taux de réponse de 32 % était bon. Les chirurgiens reconnaissaient à 7,8 % avoir au moins fait une erreur médicale dans les trois mois précédents. Le risque était plus important chez les chirurgiens travaillant le plus : ceux ayant fait une erreur travaillaient en moyenne près de 5 heures de plus par semaine que les autres ; ceux consacrant plus de 50 % de leur temps de travail aux soins faisaient deux fois plus d’erreurs que les autres… L’épuisement professionnel ou burnout et la qualité de vie mentale seraient donc bien source d’erreurs médicales. Prenons donc soins de nos patients… mais aussi de nous…
Cotation
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A. Senéjoux
Long-term outcome of endoscopic dilatation in patients with Crohn’s disease is not affected by disease activity or medical therapy
Van Assche G, Thienpont C, D’Hoore A, et al. (2010) Gut 3:320–4 [Epub 2009 Oct 19]
Background: Endoscopic dilatation of Crohn’s disease- related strictures is an alternative to surgical resection in selected patients. The influence of disease activity and con- comitant medical therapy on long-term outcomes is largely unknown.
Aim and methods: To study the long-term safety and effi- cacy of stricture dilatation in a single centre cohort.
Results: Between 1995 and 2006, 237 dilatations where performed in 138 patients (mean age 50.6 ± 13.4, 56%
female) for a clinically obstructive stricture (< 5 cm, 84%
anastomotic). Immediate success of a first dilatation was 97% with a 5% serious complication rate. After a median follow-up of 5.8 years (IQR 3.0–8.4), recurrent obstruc- tive symptoms led to a new dilatation in 46% or surgery in 24%. Neither elevated levels of C-reactive protein nor endoscopic disease activity predicted the need for new intervention. None of the concomitant therapies influenced the outcome.
Conclusion: This largest series ever reported confirms that long term efficacy of endoscopic dilatation of Crohn’s disease outweighs the complication risk. Neither active dis- ease at the time of dilatation nor medical therapy afterwards predicts recurrent dilatation or surgery.
Commentaires : Cette étude par l’équipe de Louvain est la plus importante série rétrospective de dilatation endos- copique de sténoses intestinales sur maladie de Crohn. Avec un suivi prolongé par rapport aux études antérieures, il est montré que 76 % des patients n’ont pas eu besoin d’être opérés et que plus de la moitié n’ont pas nécessité de nou- velle dilatation endoscopique. Ces résultats sont impor- tants, car ils concernent des patients ayant une maladie sévère, puisque la sténose survient sur une anastomose chez 84 % des patients et sous immunosuppresseurs chez 2/3 des patients. Le taux acceptable de complications (principale- ment la perforation) fait de la dilatation un traitement alter- natif à la chirurgie, permettant de préserver l’intestin grêle.
Cette étude ne permet malheureusement pas de déterminer de facteurs prédictifs de réponses à long terme, comme le caractère inflammatoire, l’usage d’immunosuppresseur ou l’absence de tabagisme.
Cotation
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M. Simon
Mucosal healing predicts sustained clinical remission in patients with early-stage Crohn’s disease
Baert F, Moortgat L, Van Assche G, et al. (2010) Gastroenterology 2:463–8; quiz e10-1. Epub 2009 Oct 8 Background and aims: Few prospective data are available to support the clinical relevance of mucosal healing in patients with Crohn’s disease. This study examined whether com- plete healing, determined by endoscopy, predicts a better outcome in Crohn’s disease.
Methods: One-hundred thirty-three newly diagnosed and treatment-naïve Crohn’s disease patients were given either a combination of immunosuppressive therapy (aza- thioprine) and 3 infusions of infliximab or treatment with conventional corticosteroids. Patients given azathioprine were given repeated doses of infliximab for relapses, patients given corticosteroids were given azathioprine in cases of corticosteroid dependency and infliximab only if azathioprine failed. A representative subset of 49 patients from the initially randomized cohort underwent ileocolon- oscopy after 2 years of therapy. Correlation analysis was performed between different clinical parameters including endoscopic activity (Simple Endoscopic Score) and clini- cal outcome 2 years after this endoscopic examination.
Data were available from 46 patients 3 and 4 years after therapy began.
Results: Complete mucosal healing, defined as a Sim- ple Endoscopic Score of 0 after 2 years of therapy, was the only factor that predicted sustained, steroid-free remission 3 and 4 years after therapy was initiated; it was observed in 17 of 24 patients (70.8%) vs 6 of 22 patients with
lesions detected by endoscopy (27.3%, Simple Endoscopic Score > 0) (P = 0.036; odds ratio = 4.352; 95% confidence interval, 1.10–17.220). Fifteen of 17 patients with mucosal healing at year 2 maintained in remission without further infliximab infusions during years 3 and 4 (P = 0.032; odds ratio = 4.883; 95% confidence interval, 1.144–20.844).
Conclusions: Complete mucosal healing in patients with early-stage Crohn’s disease is associated with sig- nificantly higher steroid-free remission rates 4 years after therapy began.
Commentaires : L’utilisation des anti-TNF dans la mala- die de Crohn a permis d’élargir nos ambitions thérapeuti- ques avec la possibilité de cicatriser les lésions muqueu- ses. Cependant, le bénéfice clinique de cette cicatrisation a peu été évalué. Cette étude prospective analyse la valeur prédictive de la cicatrisation sur l’évolution clinique de la maladie. Les 49 patients issus de l’étude Step-up versus Top Down chez qui une endoscopie avait été réalisée à deux ans de traitement ont été suivis deux années supplémentaires, et il est démontré que la proportion de rémission sans corticoï- des au cours du suivi est significativement supérieure chez les patients ayant une cicatrisation muqueuse (70 versus 27 %), ainsi que la rémission sans anti-TNF (62,5 vs 18 %).
Seule la cicatrisation muqueuse influence la rémission cli- nique au cours du suivi de deux ans, ce qui n’est ni le cas de la combinaison précoce d’immunosuppresseurs, ni du CDAI, ni de la CRP. Si la cicatrisation muqueuse influence favorablement l’évolution de la maladie, elle devient donc un objectif thérapeutique majeur.
Cotation
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M. Simon
