REVUE DE PRESSE / PRESS REVIEW
Thirty-year analysis of a colonoscopic surveillance program for neoplasia in ulcerative colitis
Rutter MD, Saunders BP, Wilkinson KH, et al. (2006) Gastroenterology 130: 1030-8
Background and aims:The value of colonoscopic sur- veillance for neoplasia in long-standing extensive ulce- rative colitis remains controversial. This study reports on prospectively collected data from a surveillance program over a 30-year period.
Methods:Data were obtained from the prospective surveillance database, medical records, colonoscopy, and histology reports. The primary end point was defined as death, colectomy, withdrawal from surveillance, or census date (January 1, 2001). Follow-up information was obtained for patients who left the program.
Results:Six hundred patients underwent 2627 colo- noscopies during 5932 patient-years of follow-up. The cecal intubation rate was 98.7%, with no significant complications. Seventy-four patients (12.3%) developed neoplasia, including 30 colorectal cancers (CRCs). There was no difference in median age at onset of colitis for those with or without CRC (P= 0.8, Mann-Whitney).
The cumulative incidence of CRC by colitis duration was 2.5% at 20 years, 7.6% at 30 years, and 10.8% at 40 years.
The 5-year survival rate was 73.3%. Sixteen of 30 cancers were interval cancers. CRC incidence decreased over time (r =–0.40,P= 0.04; linear regression).
Conclusions: Colonoscopic surveillance is safe and allows the vast majority of patients to retain their colon.
Although two thirds of patients with potentially life- threatening neoplasia benefited from surveillance, the program was not wholly effective in cancer prevention.
The cancer incidence, however, was considerably lower than in the majority of other studies, and was constant for up to 40 years of colitis duration, suggesting there is no need to intensify surveillance over time.
Commentaire :Le de´pistage pre´coce des le´sions ne´o- plasiques et pre´ne´oplasiques est le principal enjeu de la surveillance de la RCH. Cet article re´sume 30 ans d’expe´rience de l’e´quipe du Saint-Mark’s Hospital, pionnie`re en la matie`re. Il confirme l’inte´reˆt de la coloscopie (de´tection pre´coce de dysplasie et/ou de cancer chez 85 patients/600) mais aussi ses insuffisances (16 cancers sur 30 de´veloppe´s dans l’intervalle entre deux examens de surveillance). Les auteurs concluent logi- quement sur les possibilite´s d’ame´lioration des pro- grammes de de´pistage par une meilleure se´lection des
patients et par l’apport des nouvelles techniques de chromoendoscopie.
Cotation :
P. Bulois Service d’he´patogastroente´rologie, Hoˆpital Huriez, CHU, 1, place de Verdun, F-59037 Lille Cedex, France Correspondance : E-mail : [email protected]
Does chromoendoscopy with structure enhancement improve the colonoscopic adenoma detection rate?
Lapalus MG, Helbert T, Napoleon B, et al., Socie´te´ franc¸aise d’endoscopie digestive (2006) Endoscopy 38: 444-8
Background and aims:Colonoscopy is still considered the standard investigation for the detection of colorectal adenomas, but the miss rate, especially for small and flat lesions, remains unacceptably high. Chromoscopy has been shown to increase the yield for lesion detection in inflammatory bowel disease. The aim of this randomized prospective study was to determine whether a combination of chromoscopy and structure enhancement could increase the adenoma detection rate in high-risk patients.
Patients and methods:All patients included in the trial had a personal history of colorectal adenomas and/or a family history of colorectal cancer (but excluding genetic syndromes). They were randomized to one of two tandem colonoscopy groups, with the first pass consisting of conventional colonoscopy for both groups, followed by either chromoscopy and structure enhancement (the
‘‘study’’ group) or a second conventional colonoscopy (the control group) for the second-pass colonoscopy. All detected lesions was examined histopathologically after endoscopic resection or biopsy. The principal outcome parameter was the adenoma detection rate; the number, histopathology, and location of lesions was also recorded.
Results:A total of 292 patients were included in the study (146 patients in each group). The patients’ demographic characteristics, the indications for colonoscopy, and the quality of bowel preparation were similar in the two groups.
There was a significant difference between the two groups with respect to the median duration of the examination (18.9 minutes in the control group vs. 27.1 minutes for the study group, P< 0.001). Although more hyperplastic lesions were detected throughout the colon in the study DOI 10.1007/s11725-006-0004-x
group (P= 0.033), there was no difference between the two groups in either the proportion of patients with at least one adenoma or in the total number of adenomas detected.
Chromoscopy and structure enhancement diagnosed signi- ficantly more diminutive adenomas (< 5 mm) in the right colon, compared with controls (P = 0.039).
Conclusions:On the basis of our results we cannot generally recommend the systematic use of chromoscopy and structure enhancement in a high-risk patient population, although the detection of small adenomas in the proximal colon was improved.
Commentaire :Les progre`s techniques des dernie`res ge´ne´rations d’endoscopes sont spectaculaires mais leurs indications respectives restent a` pre´ciser. Ce travail issu de la SFED visait a` e´valuer de manie`re prospective l’inte´reˆt de la chromoendoscopie associe´e au rehaussement de structure au cours des coloscopies de de´pistage. Les re´sultats sont de´cevants, avec un taux de de´tection comparable mais un temps d’exploration allonge´. Cela ne remet pas en cause l’utilite´ de la chromoendoscopie dans la caracte´risation des tumeurs coliques mais limite son inte´reˆt dans leur de´pistage.
Cotation :
P. Bulois Service d’he´patogastroente´rologie, Hoˆpital Huriez, CHU, 1, place de Verdun, F-59037 Lille Cedex, France Correspondance : E-mail : [email protected]
Elevated anal squamous cell carcinoma risk associated with benign inflammatory anal lesions Nordenvall C, Nyren O, Ye W Gut (2006) 55: 703-707
Background: The association between benign anal lesions and anal cancer is still unclear. Few data from large cohort studies are available.
Methods:We conducted a register based retrospective cohort study including 45,186 patients hospitalised for inflammatory anal lesions (anal fissures, fistulas, and perianal abscesses) as well as 79,808 haemorrhoid patients, from 1965 to 2002. Multiple record linkages identified all incident anal (squamous cell carcinoma only) and colorectal cancers through to 2002. Relative risk was estimated by standardised incidence ratio (SIR), the ratio of observed number of cases divided by that expected in the age, sex, and calendar year-matched general Swedish population.
Results:There was a distinct incidence peak in the first three years of follow up among patients with inflammatory lesions. SIR then levelled off at around 3 and remained at this level throughout follow up (SIR during years 3-37 of follow up was 3.3 [95% confidence interval 1.8-5.7]). A similar initial incidence peak was observed among haemorrhoid patients but was confined to the first year; SIR was 2.8 in the second year, and then it decreased further and was close to unity in
the following years (SIR during years 3-37 was 1.3 [95%
confidence interval 0.7-2.1]). Among inflammatory lesion and haemorrhoid patients, a significantly increased risk of colorectal cancer was observed only in the first year after hospitalisation.
Conclusions:Inflammatory benign anal lesions are associated with a significantly increased long term risk of anal cancer. In contrast, haemorrhoids appear not to be a risk factor for this malignancy.
Commentaire :Le carcinome e´pidermoı¨de de l’anus reste une tumeur rare si l’on excepte la population a`
risque des homosexuels masculins infecte´s par les virus VIH et HPV. L’association d’un cancer anal a` une suppuration pe´rine´ale e´voluant depuis plusieurs anne´es est connue, la litte´rature est riche de plusieurs cas cliniques de ce type. Si ce travail conclut a` un risque accru de cancer chez les malades atteints de suppurations et de fissures anales, il convient de rester circonspect tant ce type d’e´tude peut facilement eˆtre biaise´. Les donne´es de la litte´rature concernant ce risque sont par ailleurs divergentes.
Cotation :
A. Se´ne´joux Service de coloproctologie, Hoˆpital Le´opold-Bellan, 19-21, rue Vercinge´torix, F-75014 Paris, France Correspondance : E-mail : agnes.senejoux@wanadoofr
Red hot chili pepper and hemorrhoids:
the explosion of a myth: results of a prospective, randomized, placebo-controlled, crossover trial Altomare DF, Rinaldi M, La Torre F, et al. (2006) Dis Colon Rectum 49: 1018-23
Purpose:Spicy foods are appreciated by a large part of the world population but have been blamed for causing hemorrhoids or exacerbating their symptoms, although no epidemiologic studies have been performed support- ing this hypothesis. In this double-blind, randomized, placebo-controlled, crossover trial, we have studied the effects of a single dose of red hot chili pepper on the hemorrhoidal symptoms.
Methods:Fifty patients with second-degree and third- degree symptomatic hemorrhoids were randomly assigned to take a capsule containing red hot chili powder or placebo during lunch, scoring five hemorrhoidal symptoms (bleeding, swelling, pain, itching, and burning) on a visual analog scale. After one week, crossover treatment was administered according to the same methodology. Other treatments and foods potentially related with anorectal symptoms were discontinued during the study periods.
Results:Patients assigned low scores to their hemor- rhoidal symptoms before the study and the scores remained unchanged during the 48 hours after both
placebo and chili pepper treatment, the latter showing no statistically significant effects.
Conclusions:There is no scientific evidence that a spicy meal based on red hot chili pepper may worsen hemorrhoidal symptoms and, therefore, there is no reason to prevent these patients from occasionally enjoying a spicy dish if they so wish.
Commentaire :Il fallait oser ! En matie`re de facteurs de risque de la maladie he´morroı¨daire les donne´es concernant la consommation d’e´pices divergent. Les auteurs ont voulu e´tayer les croyances populaires par un travail scientifique en allant jusqu’a` interviewer un professeur de cuisine pour doser leurs ge´lules de piment. Mais peut-on eˆtre certain que le contenu de ces ge´lules e´tait vraiment comparable a` un repas richement e´pice´ ?N’y a-t-il que le piment en cause ? Ou bienexiste-t-ildes facteurs interme´diaires ?
Cotation :
A. Se´ne´joux Service de coloproctologie, Hoˆpital Le´opold-Bellan, 19-21, rue Vercinge´torix, F-75014 Paris, France Correspondance : E-mail : agnes.senejoux@wanadoofr
Electrical stimulation and pelvic floor muscle training with biofeedback inpatients with fecal incontinence: a cohort study of 281 patients Terra MP, Dobben AC, Berghmans B, et al. (2006) Dis Colon Rectum 49: 1149-59
Purpose:Pelvic floor rehabilitation is an appealing treatment for patients with fecal incontinence but reported results vary. This study was designed to assess the outcome of pelvic floor rehabilitation in a large series of consecutive patients with fecal incontinence caused by different etiologies.
Methods:A total of 281 patients (252 females) were included. Data about medical history, anal manometry, rectal capacity measurement, and endoanal sonography were collected. Subgroups of patients were defined by anal sphincter complex integrity, and nature and possible underlying causes of fecal incontinence. Subsequently patients were referred for pelvic floor rehabilitation, comprising nine sessions of electric stimulation and pelvic floor muscle training with biofeedback. Pelvic floor rehabilitation outcome was documented with Vaizey score, anal manometry, and rectal capacity measurement findings.
Results:Vaizey score improved from baseline in 143 of 239 patients (60 percent), remained unchanged in 56 patients (23 percent), and deteriorated in 40 patients (17 percent).
Mean Vaizey score reduced with 3.2 points (P< 0.001).
A Vaizey score reduction of50 percent was observed in 32 patients (13 percent). Mean squeeze pressure (+5.1 mm Hg; P= 0.04) and maximal tolerated volume (+11 ml;P= 0.01) improved from baseline. Resting pressure
(P= 0.22), sensory threshold (P= 0.52), and urge sensation (P= 0.06) remained unchanged. Subgroup analyses did not show substantial differences in effects of pelvic floor rehabilitation between subgroups.
Conclusions:Pelvic floor rehabilitation leads overall to a modest improvement in severity of fecal inconti- nence, squeeze pressure, and maximal tolerated volume.
Only in a few patients, a substantial improvement of the baseline Vaizey score was observed. Further studies are needed to identify patients who most likely will benefit from pelvic floor rehabilitation.
Commentaire :Cette e´tude de cohorte prospective multicentrique ne´erlandaise est d’une remarquable qua- lite´ dans l’e´valuation qu’elle a su mener de la prise en charge re´e´ducative de l’incontinence fe´cale. Remarquable dans sa me´thodologie parce qu’elle est multicentrique (16 centres) ; qu’elle implique un nombre important de malades, que la qualite´ des informations recueillies est excellente et standardise´e, que les proce´dures de re´e´duca- tion sont optimales, multiples (e´lectrostimulation, bio- feedback sensitif et moteur, conseils) et e´galement standardise´es, que les indicateurs physiologiques d’effi- cacite´ sont multiples et pertinents (pressions de repos, activite´ EMG, sensibilite´ rectale). Cette e´tude est surtout remarquable parce qu’elle souligne la faible pertinence de ce mode de prise en charge the´rapeutique : une ame´liora- tion (de quelque niveau que ce soit) est rapporte´e, dans cet essai ouvert, dans pre`s de 60 % des cas mais un be´ne´fice franc (diminution de moitie´ du score d’incontinence ou plus) n’est observe´ que dans 13 % des cas. Ce travail enfonce un coin supple´mentaire dans l’effondrement de l’e´difice de la prise en charge re´e´ducative de l’incontinence fe´cale. Il rejoint les conclusions e´galement ne´gatives de la re´cente me´ta-analyse des essais controˆle´s actuellement publie´s[1].
Cotation :
[1] Norton C, Cody J, Hosker G (2006) Biofeedback and/or sphincter exercises for the treatment of faecal incontinence in adults.
Cochrane Database Syst Rev 3: CD002111
L. Siproudhis Fe´de´ration he´patodigestive, Hoˆpital Pontchaillou, F-35033 Rennes Cedex, France Correspondance : E-mail : [email protected]
Systematic review: the efficacy of treatments for irritable bowel syndrome – a European perspective Tack J, Fried M, Houghton LA, et al. (2006)
Aliment Pharmacol Ther 24: 183-205
Background: Irritable bowel syndrome (IBS) is a common, chronic disorder, characterized by abdominal pain/discomfort, bloating and altered bowel habit.
Aim: To conduct a systematic evidence-based review of pharmacological therapies currently used, or in clinical development, for the treatment of IBS in Europe.
The safety and tolerability of these therapies are the subject of an accompanying review.
Methods:A literature search was completed for randomized controlled studies which included adult patients with IBS and an active or placebo control, assessed IBS symptoms, and were published in English between January 1980 and June 2005. The level of evidence for efficacy was graded according to the quality of the trial design and the study outcome.
Results:There is some evidence for improvement of individual IBS symptoms with antidiarrhoeals (diarrhoea), antispasmodics (abdominal pain/discomfort), bulking agents (constipation), tricyclic antidepressants (abdominal pain/discomfort) and behavioural therapy. In contrast, there is strong evidence for the improvement of global IBS symptoms with two new serotonergic agents: the 5-HT4 selective agonist tegaserod (IBS with constipation) and the 5-HT3 antagonist alosetron (IBS with diarrhoea). Further data are required for the 5-HT3 antagonist, cilansetron, and the mixed 5-HT3 antagonist/5-HT4 agonist renzapride before their utility in IBS can be appraised.
Conclusions:There is limited evidence for the efficacy, safety and tolerability of therapies currently available in Europe for the treatment of IBS. Overall, there is an absence of pharmacological agents licensed specifically for the treatment of IBS subtypes, and new agents are awaited in Europe that will allow changes in clinical practice to focus on and improve global IBS symptoms.
Commentaire : Syndrome de l’intestin irritable : les me´dicaments disponibles en Europe ne sont pas efficaces et les me´dicaments efficaces ne sont pas disponiblesest un titre qui pourrait re´sumer de fac¸on peut-eˆtre un peu lapidaire deux articles parus dans Alimentary Pharmacology and Therapeuticsde juillet 2006. Le premier article est une revue syste´matique selon un point de vue europe´en, de l’efficacite´
des traitements du syndrome de l’intestin irritable (SII). Cet article de 23 pages (147 re´fe´rences) est suivi d’une revue (cf.infra) consacre´e a` la tole´rance des traitements pharma- cologiques du SII (30 pages, 118 re´fe´rences). Les auteurs indiquent que l’e´criture de ces deux revues syste´matiques ont be´ne´ficie´ de l’aide de NOVARTIS. Les auteurs ont recherche´ les essais randomise´s controˆle´s, publie´s en anglais.
Ils ont grade´la qualite´de ces essais et pour chaque traitement, ils ont utilise´une classification en deux niveaux de preuve : le niveau I est obtenu avec des essais de bonne qualite´ (10 sur une e´chelle de 14 points), atteignant la significativite´
statistique pour le crite`re principal, un nombre de patients suffisant et un sche´ma d’e´tude ade´quat. Le niveau II est de´fini comme provenant d’essais de qualite´ faible (1 a` 5) ou interme´diaire (6 a` 10) qui ont e´choue´ a` atteindre la significativite´ statistique pour le crite`re principal et/ou avaient des biais ou des e´chantillons de patients insuffisants.
Une me´ta-analyse n’a pas e´te´ faite en raison des variations
tre`s importantes entre les essais. Les antispasmodiques comprennent les anticholinergiques et les de´rive´s de la papave´rine. Les essais sont de qualite´ me´diocre avec de petits nombres de patients et n’ont pas utilise´les crite`res de Rome du fait de leur anciennete´. Il est possible que la douleur abdominale soit ame´liore´e chez certains patients mais il n’y a pas d’effets sur les symptoˆmes globaux du SII (niveau II). Les laxatifs de lest ont un effet favorable sur la constipation (niveau II). Les laxatifs stimulants ou les laxatifs osmotiques n’ont pas fait l’objet d’essais controˆle´s chez les patients avec SII. Le lope´ramide n’a pas d’effet sur la symptomatologie globale du SII et n’ame´liore pas l’inconfort ou la douleur abdominale. Il est efficace sur la diarrhe´e de certains patients (niveau II). La dompe´ridone et le me´toclopramide n’ont pas d’efficacite´de´montre´e dans le SII. Les antide´presseurs ne sont pas efficaces pour soulager la symptomatologie globale du SII mais ont certains effets be´ne´fiques sur la douleur (niveau II) pour ce qui concerne les tricycliques. Les inhibiteurs de recapture de la se´rotonine n’ont pas d’efficacite´ prouve´e dans les essais controˆle´s re´alise´s (deux essais re´cents de bonne qualite´ avec la paroxe´tine). L’efficacite´ du te´gase´rod a e´te´
de´montre´e par plusieurs essais randomise´s de bonne qualite´
chez des femmes souffrant de SII avec constipation et par une me´ta-analyse (niveau I) L’alose´tron est un traitement efficace chez les femmes souffrant de SII avec diarrhe´e (niveau I).
L’ondanse´tron n’est pas efficace (niveau II). On manque de donne´es publie´es sur le cilanse´tron.
Cette the´rapie comportementale n’est pas efficace chez les patients avec SII mais peut ame´liorer certains symptoˆmes notamment d’ordre psychologique (niveau II).
Cotation :
M.-A. Bigard Service d’he´patogastroente´rologie, CHU de Nancy-Brabois, F-54511 Vandœuvre-Le`s-Nancy, France Correspondance : E-mail : [email protected]
Systematic review: the safety and tolerability of pharmacological agents for treatment of irritable bowel syndrome – a European perspective Heading R, Bardhan K, Hollerbach S, et al. (2006) Aliment Pharmacol Ther 24: 207-36
Aim:To use an evidence-based approach to evaluate the safety and tolerability of the treatments available for irritable bowel syndrome (IBS), or in clinical development, in Europe. A separate review appraises the evidence for the efficacy of these therapies
Methods:A literature search (for 1980 to 2005) was completed for all relevant clinical trial data and other articles which included safety information on the use of pharmacological IBS therapies. Clinical trials were scored according to the level of safety information, and adverse event incidence reported when possible.
Results:The tolerability of many of the agents used to treat IBS in Europe is poorly understood. However, serotonergic agents, such as tegaserod and alosetron, which are currently unavailable in Europe, have undergone rigorous assessment in IBS and their benefits have been established. Following initial marketing of alosetron for use in patients with IBS with diarrhoea, concerns about severe constipation and ischaemic colitis resulted in restriction of its use to women with severe IBS symptoms. This highlights the importance of post-marketing surveillance and post- marketing studies in refining the therapeutic indication of new IBS therapies, which will help to identify appropriate recipients for the drug and establish the impact of adverse reactions in clinical practice.
Conclusions:There is a significant lack of data on the safety and tolerability of the therapies currently used routinely to treat IBS in Europe. The newer agents have undergone rigorous assessment, such that their benefits and risks in treating IBS are established. Defining their place among the spectrum of available therapies remains challenging when the benefits and risks of the older treatments are so poorly characterized.
Commentaire :Il existe clairement un manque de donne´es aussi bien pour les atropiniques que pour les de´rive´s de la papave´rine. Les atropiniques entraıˆnent une se´cheresse de bouche, des nause´es et une constipation. Les papave´riniques sont bien tole´re´s mais il s’agit plutoˆt des donne´es de l’expe´rience accumule´e pendant de nombreu- ses anne´es de commercialisation. Les laxatifs de lest entraıˆnent exce`s de gaz, ballonnements et me´te´orisme mais pas d’effets secondaires pre´occupants. Il n’y a pas de donne´es pour les autres cate´gories de laxatifs dans le SII.
Le lope´ramide entraıˆne essentiellement une constipation.
Il n’y a pas de donne´es pour le me´toclopramide dans le SII. La dompe´ridone a entraıˆne´ plus d’effets secondaires que le placebo dans un essai dans les SII (notamment douleur mammaire et galactorrhe´e). Les effets secondai- res des antide´presseurs ont e´te´ tre`s peu e´value´s dans les essais au cours du SII. Les tricycliques peuvent entraıˆner une constipation. Le te´gase´rod apparaıˆt bien tole´re´ avec essentiellement survenue de diarrhe´e, d’intensite´ le´ge`re et de caracte`re transitoire. La tole´rance des antagonistes 5-HT3 n’est pas bonne avec survenue de constipations se´ve`res et de colites ische´miques. L’alose´tron commercia- lise´ en 2000 aux E´tat-Unis a e´te´ retire´ apre`s neuf mois de commercialisation en raison de la survenue de 70 cas de complications se´ve`res (49 colites ische´miques, 21 consti- pations se´ve`res avec 44 ne´cessite´s d’hospitalisation, dix interventions chirurgicales et trois de´ce`s). La survenue d’une colite ische´mique au cours d’un traitement par alose´tron est estime´e a` 1 pour 750 a` 1000 patients traite´s.
L’alose´tron a e´te´ re´introduit aux E´tat-Unisen juin 2000 avec un acce`s restreint pour les patientes pre´sentant un SII avec diarrhe´e invalidante, durant depuis plus de six mois et apre`s e´chec des traitements conventionnels.
L’alose´tron n’a pas e´te´ enregistre´ en Europe. Le cilanse´-
tron semble pre´senter les meˆmes inconve´nients et sa demande d’enregistrement en Europe n’a pas e´te´ accepte´e.
Ces revues tre`s comple`tes de la litte´rature sur l’efficacite´ et la tole´rance des traitements du SII mon- trent : 1/que les me´dicaments disponibles en Europe et largement utilise´s dans le SII n’ont pas d’efficacite´
de´montre´e sur les symptoˆmes de ce syndrome par des essais controˆle´s randomise´s de bonne qualite´. Ces traite- ments comportent essentiellement les antispasmodiques, les re´gulateurs du transit et les antide´presseurs. 2/Les nouveaux traitements agissant sur un des re´cepteurs a` la se´rotonine sont efficaces sur les symptoˆmes du SII. Les anti-5HT3 (alose´tron, cilanse´tron) sont efficaces sur les formes avec diarrhe´e chez la femme mais entraıˆnent des complications graves inadmissibles dans le cadre d’une maladie parfaitement be´nigne quoiqu’invalidante dans certains cas. Le tegase´rod, agoniste 5-HT4 est efficace dans les formes avec constipation chez la femme mais la diffe´rence d’efficacite´ avec le placebo n’atteint pas 10 %, ce qui fait que la mole´cule n’a pas e´te´ enregistre´e par l’Agence Europe´enne du Me´dicament et n’est donc pas disponible dans la communaute´ europe´enne.
Cotation :
M.-A. Bigard Service d’he´patogastroente´rologie, CHU de Nancy-Brabois, F-54511 Vandœuvre-Le`s-Nancy, France Correspondance : E-mail : [email protected]
Does a negative screening colonoscopy ever need to be repeated?
Brenner H, Chang-Claude J, Seiler CM, Sturmer T (2006) Hoffmeister Gut 55: 1145-50
Background and aims:Screening colonoscopy is thought to be a powerful and cost-effective tool to reduce colorectal cancer incidence and mortality. Whether and when colonoscopy with negative findings has to be repeated is not well defined. The aim of this study was to assess the long term risk of clinically manifest colorectal cancer among subjects with negative findings at colonoscopy.
Patients:Three hundred (and) eighty cases and 485 controls participating in a population based case- control study in Germany.
Methods:Detailed history and results of previous colonoscopies were obtained by interview and from medical records. Adjusted relative risks of colorectal cancer among subjects with a previous negative colonos- copy compared with those without previous colonoscopy were estimated according to time since colonoscopy.
Results:Subjects with previous negative colonoscopy had a 74% lower risk of colorectal cancer than those without previous colonoscopy (adjusted odds ratio (aOR) = 0.26 (95% confidence interval, 0.16 to 0.40)). This low risk was
seen even if the colonoscopy had been done up to 20 or more years previously. Particularly low risks were seen for sigma cancer (aOR = 0.13 (0.04 to 0.43)) and for rectal cancer (aOR = 0.19 (0.09 to 0.39)), and after a negative screening colonoscopy at ages 55 to 64 (aOR = 0.17 (0.08 to 0.39)) and older (aOR = 0.21 (0.10 to 0.41)).
Conclusions:Subjects with negative findings at colonos- copy are at very low risk of colorectal cancer and might not need to undergo repeat colonoscopy for 20 years or more, if at all. The possibility of extending screening intervals to 20 years or more might reduce complications and increase the feasibility and cost-effectiveness of colonoscopy based screening programmes.
Commentaire :La recherche de sang dans les selles par test Hemoccult II pratique´e tous les deux ans reste l’unique me´thode valide´e pour le de´pistage de masse du cancer colorectal (CCR) car cette me´thode est la seule qui a de´montre´ la possibilite´ de re´duction de la mortalite´ par CCR a` l’e´chelon d’une population, ce qu’aucune autre strate´gie de pre´vention n’a re´alise´. Cependant, ce de´pistage de masse n’est pas encore organise´ a` l’e´chelon d’un pays entier et en France, seule une partie des de´partements a organise´ ce de´pistage avec des taux de succe`s variables. Il est donc fre´quent pour les gastroente´rologues de voir arriver dans leurs cabinets des sujets bien portants, sans facteur de risque particulier ni familial, ni personnel, mais de´sireux de be´ne´ficier d’une coloscopie de de´pistage. La demande est ge´ne´ralement motive´e par une connaissance de la fre´quence du CCR (risque de 3,5 % a` l’aˆge de 74 ans) et de la possibilite´ d’une pre´vention par exe´re`se des ade´no- mes. Il est difficile de refuser cet examen mais il n’y a pas de de´termination de l’aˆge optimal de re´alisation (55-60 ans habituellement, un examen trop pre´coce entraıˆnant un fort pourcentage d’examens ne´gatifs pour le de´pistage des ade´nomes). Il n’y a pas non plus de recommandation sur la ne´cessite´ ou non de refaire la coloscopie si l’examen initial est ne´gatif et si oui dans quel de´lai. Tre`s souvent, les sujets se voient recommander un examen tous les cinq ans, ce qui paraıˆt excessif dans une population a` risque moyen en raison des dangers de la coloscopie et du couˆt de cette exploration. Le but de l’e´tude re´alise´e a` Heidelberg e´tait donc de de´terminer le risque a` long terme d’avoir un cancer re´ve´le´ par des signes cliniques chez des sujets ayant eu une coloscopie ne´gative dans leurs ante´ce´dents. Il s’agissait d’une e´tude cas te´moin avec 380 cas et 485 te´moins. Les cas avaient donc eu un CCR, a` l’exclusion de sujets atteints de MICI, les controˆles e´taient apparie´s pour l’aˆge, le sexe et le lieu de re´sidence. L’histoire me´dicale de´taille´e et les re´sultats des coloscopies pre´ce´dentes e´taient obtenus par des interviews et par la revue des dossiers me´dicaux. Les risques relatifs de CCR parmi les patients avec coloscopie pre´ce´dente ne´gative e´taient compare´s a` celui des sujets sans coloscopie dans les ante´ce´dents. Au total, les sujets ayant eu une coloscopie ne´gative avaient une diminution du risque de CCR de 74 % (OR = 0,26 IC 95% : 0,16-0,40). Ce faible risque existait meˆme si la coloscopie avait e´te´ re´alise´e
20 ans ou plus auparavant. Un risque particulie`rement faible e´tait note´ pour le cancer du sigmoı¨de (OR = 0,13) et pour le cancer rectal (OR = 0,19) ainsi que lorsque la coloscopie avait eu lieu entre les aˆges de 55 et 64 ans (OR = 0,17) ou plus de 64 ans (OR = 0,21). Cette e´tude porte cependant sur un nombre limite´de patients et l’existence de facteurs confondants est possible. La moindre re´duction de cancers du coˆlon droit pourrait s’expliquer par des coloscopies incomple`tes ou par une biologie tumorale diffe´rente entre CCR du coˆlon droit et du coˆlon gauche.
Enfin, on peut toujours questionner une coloscopie
« normale » quand on sait que pre`s de 20 % des ade´nomes, quelquefois de gros volume, e´chappent a` la coloscopie ! Quoi qu’il en soit, il s’agit de donne´es rassurantes. Si une coloscopie est normale vers l’aˆge de 55-60 ans, il ne semble pas utile de proposer un nouvel examen a` un sujet sans facteurs de risque particuliers. Il reste a` de´montrer que le de´pistage par coloscopie « une fois dans la vie » est une me´thode applicable et efficace a` l’e´chelon d’une population ce qui est une autre affaire quand on sait que la coloscopie virtuelle peut venir bouleverser toutes nos strate´gies.
Cotation :
M.-A. Bigard Service d’he´patogastroente´rologie, CHU de Nancy-Brabois, F-54511 Vandœuvre-Le`s-Nancy, France Correspondance : E-mail : [email protected]
Decrease in mortality in Lynch syndrome families because of surveillance
de Jong AE, Hendriks YM, Kleibeuker JH, et al. (2006) Gastroenterology 130: 665-71
Background and aims:Lynch syndrome family members have a high risk of developing colorectal (CRC), endometrial (EC), and other cancers. A large-scale surveillance program was introduced in The Netherlands in the late 1980s. The aims of the study were to evaluate the effectiveness of this program by assessing mortality because of CRC and EC before and after 1990 and to compare mortality because of all cancers (except CRC/
EC) with mortality in the general population.
Methods:Family members with at least 50% proba- bility of being a carrier were selected for the study. The standardized mortality ratio (SMR) because of cancer and the absolute excess risk of death (AER) were calculated.
Results:In the total cohort (N= 2788), 445 subjects had died because of cancer. The 3 most frequent causes of cancer-related deaths were CRC (50.3%), EC (6.7%), and brain tumors (6.7%). A significant decrease (70%) in SMR for CRC over time was observed (P < 0.001); the SMR for EC showed no decreasing trend over time. A significantly increased SMR was found for cancer of the
small bowel (SMR = 18.3), brain (SMR = 9.1), kidney/
ureter (SMR = 5.9), ovarium (SMR = 2.3), pancreas (SMR = 2.2), and stomach (SMR = 2.1). The AER was significantly increased for brain tumors only.
Conclusions:Since the introduction of surveillance, the mortality because of CRC has decreased. Except for brain tumors, we did not find a significantly increased AER for tumors other than CRC/EC.
Commentaire :La surveillance spe´cifique des patients a` haut risque de cancer en raison d’un syndrome de Lynch a permis de diminuer la mortalite´ par cancer colorectal, rapporte une e´tude ne´erlandaise publie´e dansGastroen- terology. Depuis la fin des anne´es 1980, un programme de surveillance des familles HNPCC a e´te´ mis en place aux Pays-Bas. L’objectif principal de cette e´tude e´tait d’e´valuer l’efficacite´ de ce programme en analysant l’e´volution du taux de mortalite´ par cancer colorectal avant et apre`s 1990.
L’analyse a porte´ sur les donne´es de 2 788 patients dont 733 e´taient de´ce´de´s. La cause de de´ce`s e´tait connue dans 89 % des cas et e´tait un cancer dans 61 % des cas. Les cinq causes les plus fre´quentes de de´ce`s par cancer e´taient : cancer colorectal : 50,3 %, cancer de l’endome`tre : 6,7 %, tumeur ce´re´brale : 6,7 %, cancer bronchopulmonaire : 4,5 % et cancer de l’estomac 4,1 %. La comparaison des taux standardise´s de mortalite´ (SMR) entre les pe´riodes 1960–
1974, 1975-1989 et 1990–2004 a montre´ une diminution significative du risque de de´ce`s par cancer colorec- tal : SMR passe´ de 32,3 pour la pe´riode 1960–1975 a` 10,1 pour la pe´riode 1990–2004 (p < 0,001). Il existait e´gale- ment une diminution du risque de de´ce`s par cancer de l’endome`tre mais qui n’e´taient pas significative : SMR passe´ de 23,4 pour la pe´riode 1960–1975 a` 14,1 pour la pe´riode 1990–2004. Pour le cancer colorectal, la re´duction du risque e´tait significativement plus importante chez les patients ayant re´alise´ les coloscopies de surveillance que chez les patients ne l’ayant pas fait. Le risque de de´ce`s par cancer colorectal e´tait statistiquement plus e´leve´ chez les patients porteurs d’une mutation d’hMLH1 ou hMSH2 par rapport aux patients porteurs de la mutation d’hMSH6.
Ces donne´es sugge`rent l’efficacite´ et l’inte´reˆt du pro- gramme de surveillance endoscopique chez des patients a`
haut risque de de´velopper un cancer colorectal, meˆme si la diminution observe´e de mortalite´ par cancer colorectal ne peut pas eˆtre formellement attribue´e dans sa totalite´ au programme de de´pistage. La diminution non significative du risque de de´ce`s par cancer de l’endome`tre peut eˆtre explique´e soit par l’inefficacite´ des proce´dures de sur- veillance, soit par le fait qu’il s’agit d’une tumeur plus rarement mortelle.
Cotation :
E. Mitry Service d’he´patogastroente´rologie, Hoˆpital Ambroise-Pare´, 9, avenue Charles-de-Gaulle, F-92104 Boulogne-Billancourt cedex, France Correspondance : E-mail : [email protected]
The outcome after restorative proctocolectomy with or without defunctioning ileostomy Remzi FH, Fazio VW, Gorgun E, et al. (2006) Dis Colon Rectum 49: 470-477
Purpose:Controversy exists regarding the safety for omission of diverting ileostomy in restorative proctoco- lectomy because of fears of increased septic complica- tions. This study was designed to evaluate the outcomes of restorative proctocolectomy in a consecutive series of patients by comparing postoperative complications, functional results, and quality of life in patients with and without diverting ileostomy.
Methods:Data regarding demographics, length of stay, surgical characteristics, and complications were reviewed and recorded according to the presence (N = 1,725) or absence (N= 277) of a diverting ileostomy at the time of pelvic pouch surgery. Criteria for omission of ileostomy included: stapled anastomosis, tension-free anastomosis, intact tissue rings, good hemostasis, absence of airleaks, malnutrition, toxicity, anemia, and prolonged consumption of steroids. Functional outcome and quality of life indicators were prospectively recorded and compared.
Results:Patients in the ileostomy group had greater body surface area and older mean age at time of surgery, were taking greater doses of steroids preoperatively, and required more blood transfusions at the time of surgery compared with the one-stage (P< 0.05). There were no differences between the two groups in septic complications (P> 0.05). Early postoperative ileus was more common in the one-stage group (P< 0.001). There were no differences between the groups in quality of life and functional outcomes.
Conclusions:For carefully selected patients undergo- ing restorative proctocolectomy with ileal pouch-anal anastomosis, omission of diverting ileostomy is a safe procedure that does not lead to an increase in septic complications or mortality. Quality of life and functional results are similar to those who undergo ileal pouch-anal anastomosis with diversion, provided that certain selec- tion factors are considered.
Commentaire :La place de l’ile´ostomie de protection lors de la re´alisation d’une anastomose ile´o-anale est un sujet controverse´. Mais le risque re´el ou suppose´
d’augmentation des complications septiques pelviennes postope´ratoires, avec a` terme la crainte de mauvais re´sultat fonctionnel voire de perte du re´servoir font que la plupart du temps est re´alise´e une ile´ostomie temporaire de protection. Cette e´tude de la Cleveland Clinic, certes non controˆle´e, mais avec des effectifs importants, sugge`re en fait qu’il est probablement pre´fe´rable de ne pas faire d’ile´ostomie... mais seulement chez des patients bien se´lectionne´s (anastomose me´ca- nique, sans tension, avec une he´mostase correcte, et sur
un terrain non de´nutri, non ane´mie´, et sans cortico- the´rapie). Dans cette situation, le re´sultat ope´ratoire et a`
long terme est e´quivalent a` celui des patients avec ile´ostomie.
Cotation :
Y. Panis Service de chirurgie colorectale, Hoˆpital Beaujon, 100, boulevard du Ge´ne´ral-Leclerc, F-92110 Clichy, France Correspondance : E-mail : [email protected]
Population-based study of prognostic factors in stage II colonic cancer
Morris M, Platell C, de Boer B, et al. (2006) Br J Surg 93: 866-871
Background:Adjuvant chemotherapy in stage II colorec- tal cancer may be considered for patients whose tumours have poor prognostic features. The aim of this study was to evaluate the prognostic significance of commonly reported clinical and pathological features of stage II colonic cancer.
Methods:A population-based observational study of all patients with stage II colonic cancer diagnosed in the state of Western Australia from 1993 to 2003 was performed. A total of 1306 patients treated by surgery alone were identified, with a median follow-up of 59 (range 0-145) months.
Results:Multivariable analysis revealed that the only independent prognostic factors for disease-specific sur- vival were stage T4 (hazard ratio (HR) 1.75 (95 per cent confidence interval (c.i.) 1.32 to 2.32); P< 0.001) and vascular invasion (HR 1.63 (95 per cent c.i. 1.15 to 2.30);
P < 0.001). In younger patients (aged 75 years or less), who are more likely to be considered for chemotherapy, these two features showed independent prognostic significance but with higher HR values (1.96 for stage T4 and 2.73 for vascular invasion). Stage T4 and/or the presence of vascular invasion identified a ‘poor’ pro- gnostic group, comprising 26.6 per cent of younger patients and with a 5-year survival rate of 71.2 per cent.
The remaining ‘good’ prognostic group had a survival rate of 84.3 per cent at 5 years’ follow-up.
Conclusion: This study highlights the importance of accurate pathological assessment of tumour stage and vascular invasion for the prognostic stratification of patients with stage II colonic cancer. The results provide clarification of guidelines for the management of stage II disease in relation to recommendations for chemotherapy.
Commentaire :S’l est admis par beaucoup qu’une chimiothe´rapie adjuvante est probablement ne´cessaire dans les cancers du coˆlon de stade II se pre´sentant sous
une forme occlusive ou perfore´e, il n’existe pas de consensus clair pour les crite`res anatomopathologiques.
Cette e´tude de population, sans eˆtre tre`s originale permet de confirmer l’importance de deux crite`res de´ja` sugge´re´s dans d’autres e´tudes : l’existence d’une tumeur T4, et celle d’un envahissement vasculaire. En revanche, dans cette e´tude portant sur un grand nombre de patient, l’existence d’une perforation n’e´tait pas un facteur pronostic inde´pendant ! Toujours est-il que cette e´tude, apre`s d’autres, justifie de proposer de plus en plus facilement une chimiothe´rapie adjuvante, notamment chez les sujets de moins de 75 ans, en cas de cancer colique de stade II pre´sentant un ou plusieurs crite`res possi- blement de mauvais pronostic.
Cotation :
Y. Panis Service de chirurgie colorectale, Hoˆpital Beaujon, 100, boulevard du Ge´ne´ral-Leclerc, F-92110 Clichy, France Correspondance : E-mail : [email protected]
Population-based study of risk factors for postoperative death after anterior resection of the rectum
Matthiessen P, Hallbook O, Rutegard J, et al. (2006) Br J Surg 93: 498-503
Background:The aim of this population-based study was to analyse risk factors for death within 30 days after anterior resection of the rectum.
Methods: Between 1987 and 1995 a total of 6833 patients underwent elective anterior resection of the rectum in Sweden. One hundred and forty of these patients died within 30 days or during the initial hospital stay. These patients were compared with a randomly chosen cohort of 423 patients who underwent the same operation during the same interval, and were alive after 30 days and discharged from hospital. The association between death and 12 putative risk factors was studied.
Results: The mortality rate after elective anterior resection was 2.1 per cent (140 of 6833). The incidence of clinical anastomotic leakage was 42.1 per cent (59 of 140) among those who died and 10.9 per cent (46 of 423) in the cohort group. Multivariate regression analysis identified clinical leakage, increased age, male sex, Dukes’ ‘D’ stage and intraoperative adverse events as independent risk factors for death within 30 days.
Conclusion: Clinical anastomotic leakage was a major cause of postoperative death after anterior resection.
Commentaire :Cette e´tude re´trospective a mis en e´vidence cinq facteurs inde´pendants de mortalite´ apre`s re´section ante´rieure du rectum pour cancer:
– la de´sunion anastomotique clinique ;
– l’aˆge avance´, le sexe masculin ; – le stade D de Dukes ;
– les complications intraope´ratoires.
Toutefois, le facteur le plus important reste la survenue d’une de´sunion anastomotique clinique (odds-ratio : 5,4). Malgre´ une meilleure connaissance actuelle des facteurs de risque de de´sunion anastomo- tique (sexe masculin, obe´site´, absence de drainage pelvien et d’ile´ostomie de protection), cette e´tude soule`ve le proble`me du diagnostic trop tardif de la de´sunion anastomotique. En effet pre`s d’un tiers des de´sunions anastomotiques a e´te´ diagnostique´ a`
l’autopsie...
Cotation :
A. Alve`s Service de chirurgie colorectale, Hoˆpital Beaujon, 100, boulevard du Ge´ne´ral-Leclerc, F-92110 Clichy Correspondance : E-mail : [email protected]
Systematic review of postoperative complications in patients with inflammatory bowel disease treated with immunomodulators
Subramanian V, Pollok RC, Kang JY, et al. (2006) Br J Surg 93: 793-9
Background:This systematic review examined the use of immunomodulators and the risk of postoperative complications after abdominal surgery in patients with inflammatory bowel disease.
Methods:Electronic databases (PubMed, Embase, Ingenta, Zetoc and Ovid) were searched and the reference lists in all articles identified were hand-searched for further relevant papers. Studies were included if they evaluated postoperative complications and defined exposure to individual immunomodulators.
Results:All 11 studies that met the inclusion criteria were observational studies; two were reported only in abstract form. Five studies reported risks associated with azathio- prine, five reported risks associated with cyclosporin and three reported risks associated with infliximab. None showed an increased risk of either total or infectious complications associated with immunomodulator use.
However, subgroup analysis in one study, published as an abstract, suggested increased rates of anastomotic compli- cations and reoperation associated with azathioprine.
Conclusion:Available evidence does not suggest an increased rate of postoperative complications associated with immunomodulator use.
Commentaire :Parmi les 11 e´tudes retenues, aucune n’a montre´ une augmentation de la morbidite´, y compris des complications infectieuses, chez les patients ope´re´s pour une maladie inflammatoire chronique de l’intestin et sous im- munosuppresseurs. Cependant, ces e´tudes e´taient re´trospec- tives et les groupes e´taient de faibles effectifs. Une large e´tude controˆle´e semble ne´cessaire afin de valider ces re´sultats.
Cotation :
A. Alve`s Service de chirurgie colorectale, Hoˆpital Beaujon, 100, boulevard du Ge´ne´ral-Leclerc, F-92110 Clichy, France Correspondance : E-mail : [email protected]
