DOI 10.1007/s11725-015-0585-3
REVUE DE PRESSE / PRESS REVIEW
Disease‑Free Survival after Complete Mesocolic Excision Compared with Conventional Colon Cancer Surgery: a Retrospective,
Population‑Based Study
Bertelsen CA, Neuenschwander AU, Jansen JE, et al (2015) Lancet Oncol 16:161–8
Background: Application of the principles of total meso
rectal excision to colon cancer by undertaking complete mesocolic excision (CME) has been proposed to improve oncological outcomes. We aimed to investigate whether implementation of CME improved diseasefree survival compared with conventional colon resection.
Methods: Data for all patients who underwent elective resec
tion for Union for International Cancer Control (UICC) stage I–III colon adenocarcinomas in the Capital Region of Denmark between June 1, 2008, and Dec 31, 2011, were retrieved for this populationbased study. The CME group consisted of patients who underwent CME surgery in a centre validated to perform such surgery; the control group consisted of patients under
going conventional colon resection in three other hospitals.
Data were collected from the Danish Colorectal Cancer Group (DCCG) database and medical charts. Patients were excluded if they had stage IV disease, metachronous colorectal cancer, rectal cancer (≤ 15 cm from anal verge) in the absence of syn
chronous colon adenocarcinoma, tumour of the appendix, or R2 resections. Survival data were collected on Nov 13, 2014, from the DCCG database, which is continuously updated by the National Central Office of Civil Registration.
Findings: The CME group consisted of 364 patients and the nonCME group consisted of 1,031 patients. For all patients, 4year diseasefree survival was 85.8% (95% CI: [81.4–
90.1]) after CME and 75.9% (72.2–79.7) after nonCME sur
gery (logrank P = 0.0010). 4year diseasefree survival for patients with UICC stage I disease in the CME group was 100% compared with 89.8% (83.1–96.6) in the nonCME group (logrank P = 0.046). For patients with UICC stage II disease, 4year diseasefree survival was 91.9% (95% CI:
[87.2–96.6]) in the CME group compared with 77.9% (71.6–
84.1) in the nonCME group (logrank P = 0.0033), and for patients with UICC stage III disease, it was 73.5% (63.6–
83.5) in the CME group compared with 67.5% (61.8–73.2) in the nonCME group (logrank P = 0.13). Multivariable Cox regression showed that CME surgery was a significant,
independent predictive factor for higher diseasefree survival for all patients (hazard ratio: 0.59, 95% CI: [0.42–0.83]), and also for patients with UICC stage II (0.44, 0.23–0.86) and stage III disease (0.64, 0.42–1.00). After propensity score matching, diseasefree survival was significantly higher after CME, irrespective of UICC stage, with 4year diseasefree survival of 85.8% (95% CI: [81.4–90.1]) after CME and 73.4% (66.2–80.6) after nonCME (logrank P = 0.0014).
Interpretation: Our data indicate that CME surgery is associated with better diseasefree survival than is conven
tional colon cancer resection for patients with stage I–III colon adenocarcinoma. Implementation of CME surgery might improve outcomes for patients with colon cancer.
Commentaires : Voilà un papier dont la conclusion est pour le moins surprenante, en tout cas pour moi, mais qui mérite de s’y arrêter, et ce pour plusieurs raisons. Tout d’abord, il est publié dans une très bonne revue. Ensuite, il s’agit d’une étude de population comme savent si bien les faire les pays nordiques, et donc même s’il ne s’agit pas d’une étude randomisée, les résultats sont souvent pertinents. Donc en quoi ce bénéfice démontré dans cette étude de « l’exérèse totale du mésocôlon » lors des colec‑
tomies pour cancer est‑il aussi « surprenant » ? D’abord, car depuis l’idée initiale de Hohenberger, d’Erlangen, dont le concept est de faire dans le côlon, ce que Heald a fait dans le rectum avec l’exérèse totale du mésorectum, aucune étude n’a jamais clairement démontré son bénéfice, hormis par Erlangen, et ce uniquement dans les cancers du côlon droit mais pas à gauche. Car, en effet, dans les cancers du côlon gauche, on ne voit pas trop ce qui pourrait changer par rapport à un curage à l’origine des vaisseaux. Ensuite, car Hohenberger n’a jamais voulu faire d’étude randomisée, ce qui est fort dommage. Enfin, car la technique d’« exérèse totale du mésocôlon » est en fait très proche de la technique actuelle de curage ganglionnaire (il rajoute simplement une dissection un peu plus étendue et monobloc peut‑être). Ainsi est‑ce un réel progrès, et il faudrait encore faire mieux, ou alors est‑ce qu’en fait cette publication démontre simplement qu’un bon curage ganglionnaire est nécessaire (ce que tout le monde pense évidemment) et qu’il ne faut pas traiter un cancer du côlon droit comme un Crohn iléocæcal, enfonçant ainsi simplement une porte déjà ouverte ? Affaire à suivre…
Cotation : ☺☺
Y. Panis
A Randomized Trial of Laparoscopic versus Open Surgery for Rectal Cancer Bonjer HJ, Deijen CL, Abis GA, et al (2015) N Engl J Med 372:1324–32
Background: Laparoscopic resection of colorectal can
cer is widely used. However, robust evidence to conclude that laparoscopic surgery and open surgery have similar outcomes in rectal cancer is lacking. A trial was designed to compare 3year rates of cancer recurrence in the pelvic or perineal area (locoregional recurrence) and survival after laparoscopic and open resection of rectal cancer.
Methods: In this international trial conducted in 30 hos
pitals, we randomly assigned patients with a solitary adeno
carcinoma of the rectum within 15 cm of the anal verge, not invading adjacent tissues, and without distant metastases to undergo either laparoscopic or open surgery in a 2:1 ratio.
The primary end point was locoregional recurrence 3 years after the index surgery. Secondary end points included dis
easefree and overall survival.
Results: A total of 1,044 patients were included (699 in the laparoscopicsurgery group and 345 in the opensurgery group). At 3 years, the locoregional recurrence rate was 5.0%
in the two groups (difference, 0 percentage points; 90% con
fidence interval [CI]: −2.6 to 2.6). Disease‑free survival rates were 74.8% in the laparoscopicsurgery group and 70.8% in the opensurgery group (difference, 4.0 percentage points;
95% CI: −1.9 to 9.9). Overall survival rates were 86.7% in the laparoscopicsurgery group and 83.6% in the opensurgery group (difference, 3.1 percentage points; 95% CI: −1.6 to 7.8).
Conclusions: Laparoscopic surgery in patients with rectal cancer was associated with rates of locoregional recurrence and diseasefree and overall survival similar to those for open surgery. (Funded by Ethicon EndoSurgery Europe and oth
ers; COLOR II ClinicalTrials.gov number, NCT00297791.) Commentaires : Pour ceux qui auraient été en hiberna‑
tion depuis dix ans, finalement vous n’avez rien raté. Voici le papier qui valide définitivement l’approche laparosco‑
pique dans le traitement chirurgical du cancer du rectum.
Et hop, la messe est dite et puis c’est tout. En plus, l’Europe fait la nique aux Américains en publiant cet essai COLOR II dans le New England ! Rien à dire donc de nouveau. Uni‑
quement la confirmation de l’équivalence à long terme sur un point de vue oncologique, par rapport à la laparotomie, mais c’est déjà beaucoup. Pour les plus jeunes, il va falloir s’y mettre ; mais attention, sélectionnez au début les cas faciles : haut rectum, puis très bas rectum, puis en dernier les grosses tumeurs chez l’homme du moyen rectum : les pires… Mais c’est aussi le cas en laparotomie !
Cotation : ☺☺
Y. Panis
Long‑Term Follow‑up after Surgery for Simple and Complex Cryptoglandular Fistulas:
Fecal Incontinence and Impact on Quality of Life Visscher AP, Schuur D, Roos R, et al (2015)
Dis Colon Rectum 58:533–9
Surgical management of cryptoglandular fistulas is a chal
lenge because the consequences of anal surgery potentially include fecal incontinence and impaired quality of life.
Objective: To assess factors associated with fecal inconti
nence after surgery for simple and complex crypto glandular fistulas and to determine the impact of incontinence on quality of life.
Design: The design is retrospective and crosssectional.
Settings: This study was conducted at an academic ter
tiary center and at a private center specializing in procto
logic surgery.
Patients: All patients who underwent preoperative endo
anal ultrasound for cryptoglandular fistula between 2002 and 2012.
Main outcome measures: A questionnaire was sent out in October 2013 to evaluate incontinence (Wexner score) and its impact on quality of life (FIQL). Variables tested for association were patient demographics, fistula type, number of incised abscesses (0,1,>1), number of fistulo
tomies (0,1,>1) and number of sphinctersparing proce
dures (0,1,>1).
Results: Of the 141 patients participating, 116 (82%;
76 men, 40 women) returned all the questionnaires. Median followup from the first perianal fistula surgery was 7.8 years (range: 2.1–18.1 years). Thirtynine patients (34%) experi
enced incontinence. Surgical fistulotomy, multiple abscess drainages and a high transsphincteric or suprasphincteric fistula tract were associated with incontinence. As compared to simple fistula (Wexner score, 1.2 [SD: 2.1]), incontinence was worse after surgery for complex fistula (Wexner score, 4.7 [SD: 6.2], P = 0.001), as were quality of life elements, including lifestyle (P = 0.030), depression (P = 0.077) and embarrassment (P < 0.001).
Limitations: Mainly retrospective design without a stand
ardized treatment protocol.
Conclusion: Surgical fistulotomy is the strongest risk factor for fecal incontinence. The severity of incontinence increases with the complexity of the fistula, negatively influencing quality of life. Special attention should be paid to these patients so as to mitigate symptoms later in life.
A shift to sphinctersparing procedures appears warranted.
Commentaires : Encore une étude rétrospective d’éva‑
luation à long terme des résultats après prise en charge d’une fistule anale. Les mérites de cet article par rap‑
port aux publications analogues ? Un peu l’effectif de 141 patients, un peu plus le recul moyen de près de huit ans
qui offre un suivi qu’on peut décemment qualifier de long terme, un peu plus encore de s’être spécifiquement intéressé aux troubles de la continence et à la qualité de vie, éva‑
lués grâce à des questionnaires standardisés, et un peu plus encore (et encore) l’évaluation préopératoire systématique par échographie endoanale qui permet d’offrir une classi‑
fication anatomique fiable des fistules. Qu’en ressort‑il ? Qu’un tiers des patients répondant à l’enquête avaient des troubles de la continence, ce qui positionne cette étude dans la tranche haute de ce qui a déjà été rapporté. Et que les fac‑
teurs pronostiques défavorables « habituels », très intuitifs et par ailleurs déjà montrés empiriquement dans d’autres études, sont effectivement confirmés comme péjoratifs. Un énième rappel, sans doute jamais inutile, que les patients sont potentiellement tous à risque mais certains plus que d’autres, qu’ils doivent être prévenus et qu’il faut systéma‑
tiquement évoquer la possibilité de techniques d’épargne en cas de patient à haut risque.
Cotation : ☺☺
J.D. Zeitoun
Systematic Review and Meta‑Analysis of Surgical Interventions for High Cryptoglandular Perianal Fistula
Göttgens KW, Smeets RR, Stassen LP, et al (2015) Int J Colorectal Dis 30:583–93 [Epub 2014 Dec 10]
Purpose: Perianal fistulas, and specifically high perianal fistulas, remain a surgical treatment challenge. Many tech
niques have, and still are, being developed to improve out
come after surgery. A systematic review and metaanalysis was performed for surgical treatments for high crypto
glandular perianal fistulas.
Methods: Medline (Pubmed, Ovid), Embase and The Cochrane Library databases were searched for relevant ran
domized controlled trials on surgical treatments for high cryptoglandular perianal fistulas. Two independent review
ers selected articles for inclusion based on title, abstract and outcomes described. The main outcome measurement was the recurrence/healing rate. Secondary outcomes were con
tinence status, quality of life and complications.
Results: The number of randomized trials available was low. Fourteen studies could be included in the review.
A metaanalysis could only be performed for the mucosa advancement flap versus the fistula plug, and did not show a result in favour of either technique in recurrence or complica
tion rate. The mucosa advancement flap was the most inves
tigated technique, but did not show an advantage over any other technique. Other techniques identified in randomized studies were seton treatment, medicated seton treatment,
fibrin glue, autologous stem cells, island flap anoplasty, rec
tal wall advancement flap, ligation of intersphincteric fistula tract, sphincter reconstruction, sphincterpreserving seton and techniques combined with antibiotics. None of these techniques seem superior to each other.
Conclusions: The best surgical treatment for high crypto
glandular perianal fistulas could not be identified. More randomized controlled trials are needed to find the best treatment. The mucosa advancement flap is the most inves
tigated technique available.
Commentaires : Cette équipe a eu le mérite d’essayer de conduire une revue systématique et méta‑analyse des diffé‑
rents essais randomisés et contrôlés évaluant les traitements chirurgicaux des fistules anales ; l’idée étant de dégager une hiérarchie des traitements actuellement disponibles et d’orienter le choix thérapeutique. Malheureusement, les auteurs ont probablement manqué leur cible dans la mesure où la littérature incluse dans leur travail est quantitativement (et qualitativement) trop faible pour permettre à cet article d’être conclusif. On retiendra tout de même que le lambeau d’avancement est la technique chirurgicale ayant fait l’objet de la plus forte attention sans toutefois qu’elle ait démontré de manière convaincante une supériorité sur les techniques concurrentes. La décision thérapeutique dans les fistules anales devrait donc continuer — et pour un moment — à dépendre de l’expertise et du choix de l’opérateur.
Cotation : ☺
J.D. Zeitoun
Magnetic Anal Sphincter Augmentation in Patients with Severe Fecal Incontinence Pakravan F, Helmes C (2015)
Dis Colon Rectum 58:109–14
Background: Fecal incontinence s a common, distressing condition with limited surgical options.
Objective: This study examines the results of mag
netic sphincter augmentation in patients with severe fecal incontinence.
Design: This was a singlecenter, prospective, non
randomized investigation.
Setting: This study was conducted in a private colorectal practice.
Patients: The cohort included all of the patients implanted with magnetic sphincter augmentation between January 2012 and October 2013.
Intervention: Magnetic sphincter augmentation was studied.
Main outcome measures: Adverse events, symptom severity, quality of life, bowel diary, and manometry data were collected.
Results: Eighteen patients (15 women), with mean age of 69 years (range: 31–91 years), were implanted with magnetic sphincter augmentation. Followup ranged from 353 to 738 days. Previous treatment consisted of periph
eral nerve evaluation test in 10 patients (56%), 2 patients (11%) with previous permanent sacral nerve stimulation, and 1 patient (6%) with previous implantation of an artificial bowel sphincter. Implantation was successful in 17 (94%) of 18 patients. Five patients (29%) had postoperative pain, and 5 patients (29%) had temporary swelling and erythema in both gluteal regions after the implantation. No devices were explanted during the followup. Cleveland Clinic Inconti
nence Score decreased from a mean of 17.5 (range: 14.0–
20.0) to 7.3 (range: 0–12.0), and Fecal Incontinence Quality of Life scores improved in all of the domains. Bowel diary results showed that 76% of the patients with implants experi
enced a ≥ 50% reduction in the number of fecal incontinence episodes per week. Manometry at 6 months after implanta
tion showed increased mean resting and squeeze pressures.
Limitations: This study does not allow for comparison between surgical treatments and involves a limited number of patients.
Conclusions: Magnetic sphincter augmentation shows con
sistent results for the treatment of severe fecal incontinence in this patient group. The surgical procedure is straightforward as compared with other implantable devices. The safety pro
file is acceptable. Magnetic sphincter augmentation is a prom
ising new treatment with the potential to become a firstline surgical therapy for patients with severe fecal incontinence.
Commentaires : Le sphincter magnétique est une tech‑
nique chirurgicale de traitement de l’incontinence fécale en plein développement. Nous avons la chance d’avoir une équipe française de pointe qui en a déjà une expérience de la technique et qui coordonne actuellement une étude clinique.
Cet article a toutes les caractéristiques (et les faiblesses) des études préliminaires évaluant un nouveau traitement : faible nombre de malades inclus, absence de groupe témoin, patients hétérogènes (voir les traitements antérieurs qu’ils avaient reçus), durée de suivi limitée et… résultats trop beaux. En pratique, il faut tout de même saluer le mérite de ce travail et les promesses soulevées par le sphincter magnétique pour améliorer la vie des patients incontinents qui — comme le rappelle souvent un autre contributeur de cette revue de presse — sont nombreux et démunis. La route est encore longue pour définir l’efficacité exacte, le profil de complications, le coût optimal et les indications thérapeu‑
tiques de cette technique, mais le chemin a été engagé et il y a fort à parier qu’il sera fructueux. Nous ne manquerons pas ici de rapporter les autres études cliniques qui accroî‑
tront nos connaissances sur cette option riche d’espoirs.
Cotation : ☺
J.D. Zeitoun
Obstetric Anal Sphincter Injury
and Anal Incontinence Following Vaginal Birth:
a Systematic Review and Meta‑analysis LaCross A, Groff M, Smaldone A (2015) J Midwifery Womens Health 60:37–47
Introduction: The aim of this study was to systemati
cally review current evidence for the relationship between obstetric anal sphincter injury (ie, episiotomy and third or fourthdegree perineal lacerations) and anal incontinence in parous women.
Methods: Pubmed, Ovid (Medline), Cochrane Trials, and Cumulative Index to Nursing and Allied Health Literature were searched. Studies eligible for review assessed the rela
tionship between episiotomy and/or third or fourthdegree perineal laceration and anal incontinence. Two reviewers independently searched for studies for review and used the MetaAnalysis of Observational Studies in Epidemiol
ogy guidelines. Quality of individual studies was appraised using the Downs and Black criteria. Pooled effect sizes were estimated for the relationships between episiotomy and third or fourthdegree perineal laceration with anal incontinence using random effects metaanalysis models.
Heterogeneity of each model was assessed using Cochran Q and I(2) statistics.
Results: Of 578 articles, 19 studies (7 prospective cohort studies, 6 retrospective studies, one casecontrol study, and 5 populationbased crosssectional studies) met inclusion/
exclusion criteria for the systematic review. Of the 19 studies, 3 examined episiotomy, 7 examined third or fourthdegree perineal laceration, and 9 studies examined both risk fac
tors for anal incontinence. Eight studies (N = 2,929 women) examining the relationship between episiotomy and anal incontinence and 12 studies (N = 2,288 women) examin
ing the relationship between third or fourthdegree perineal laceration and anal incontinence met criteria for inclusion in the metaanalyses. Pooled odds ratios (ORs) demonstrated a significant association between perineal trauma (episiot
omy [OR: 1.74; 95% confidence interval [CI]: [1.28–2.38];
Q = 8.9; P <0.26; I(2) = 21.4] and third or fourthdegree perineal laceration (OR: 2.66; 95% CI: [1.77–3.98];
Q = 27.9; P =0.002; I(2) = 64.1) and anal incontinence.
Discussion: Both episiotomy and third or fourthdegree perineal laceration are significantly associated with anal incontinence after vaginal birth. The evidence provided in this systematic review and metaanalysis highlights the importance of reducing perineal trauma during vagi
nal births in order to ameliorate anal incontinence in parous women.
Commentaires : Effort louable que cette analyse sys‑
tématique de la littérature qui tâche de quantifier le risque de troubles de la continence fécale induit par une
délivrance difficile et les facteurs de risque qui y sont associés. Le nombre de cas analysés est important à la fois dans le champ des déchirures périnéales et dans l’ana‑
lyse de l’effet induit par l’épisiotomie. Sans surprise, les déchirures de degré 3 et plus multiplient par près de trois le risque d’incontinence secondaire. De façon plus origi‑
nale, l’épisiotomie représente également un facteur asso‑
cié significatif avec un odds ratio de 1,75. Cette donnée controversée reste néanmoins scientifiquement assez ténue du fait de l’hétérogénéité des études citées, de l’absence d’analyse distinguant les épisiotomies médianes et médio‑
latérales. Cependant, l’effet est plus qu’une tendance (cf. figure ci‑après), et elle doit inciter le praticien à une certaine circonspection dans l’examen des cicatrices péri‑
néales de la délivrance.
Cotation : ☺☺
L. Siproudhis
Figure Forest Plots for Pooled Analysis of Episiotomy (top) and Perineal Laceration (bottom)
Does Childbirth Play a Role in the Etiology of Rectocele?
Guzmán Rojas R, Quintero C, Shek KL, Dietz HP (2015) Int Urogynecol J 26:737–41 [Epub 2015 Mar 10]
Introduction and hypothesis: Rectoceles are common among parous women and they are believed to be due to dis
ruption or distension of the rectovaginal septum as a result of childbirth. However, the etiology of rectocele is likely to be more complex since posterior compartment prolapse does occur in nulliparous women. This study was designed to determine the role of childbearing as an etiological factor in true radiological rectocele.
Methods: This was a secondary analysis of the data from 657 primiparous women recruited as part of a previously reported study and another ongoing prospective study.
Women were invited for antenatal and postnatal appoint
ments comprising an interview, clinical examination and translabial ultrasonography. The presence and depth of any rectocele were determined on maximum Valsalva maneuver, as was descent of the rectal ampulla. Potential demographic and obstetric factors as predictors of rectocele development were evaluated using either multiple regression or logistic regression analysis as appropriate.
Results: A true rectocele was identified in 4% of women antenatally and in 16% after childbirth (P < 0.001). Mean rectocele depth was 13.5 mm (10–23.2 mm). The mean antepartum position of the rectal ampulla on Valsalva maneuver was 4.39 mm above and it was 1.64 mm below the symphysis pubis postpartum (P < 0.0001). De novo appearance of true rectocele was significantly associated with a history of previous < 20 weeks pregnancy and fetal birth weight. Body mass index and length of the second stage were associated with rectocele depth increase.
Conclusions: Childbirth seems to play a distinct role in the pathogenesis of rectocele. Both maternal and fetal fac
tors seem to contribute.
Commentaires : Voici une étude attendue par des clini‑
ciens constatant souvent le développement d’une rectocèle symptomatique dans le prolongement anatomique d’une cicatrice d’épisiotomie. Cette étude conforte l’incidence accrue des rectocèles anatomiques chez les primipares, mais elle apporte aussi des données supplémentaires qui concernent non seulement les conditions de la délivrance mais aussi les critères fœtomaternels (poids du bébé, IMC maternel) comme facteurs associés au développement de la rectocèle. Il reste néanmoins que les conditions d’analyse sont influencées par une évaluation à très court terme (cinq mois), des conditions d’examen assez artificielles et peu valides (échographie), qu’elles concernent des rectocèles dans l’ensemble de petite taille et peu symptomatiques.
Enfin, les odds ratio sont très réduits, ce qui limite encore la pertinence clinique de telles assertions. Une histoire à suivre à long terme.
Cotation : ☺
L. Siproudhis
ANMS–ESNM Position Paper and Consensus Guidelines on Biofeedback Therapy
for Anorectal Disorders
Rao SS, Benninga MA, Bharucha AE, et al (2015) Neurogastroenterol Motil 27:594–609 [Epub 2015 Apr 1]
Background: Anorectal disorders such as dyssynergic defecation, fecal incontinence, levator ani syndrome, and solitary rectal ulcer syndrome are common, and affect both the adult and pediatric populations. Although they are treated with several treatment approaches, over the last two decades, biofeedback therapy using visual and verbal feed
back techniques has emerged as an useful option. Because it is safe, it is commonly recommended. However, the clinical efficacy of biofeedback therapy in adults and children is not clearly known, and there is a lack of critical appraisal of the techniques used and the outcomes of biofeedback therapy for these disorders.
Purpose: The American Neurogastroenterology and Motility Society and the European Society of Neurogastro
enterology and Motility convened a task force to examine the indications, study performance characteristics, meth
odologies used, and the efficacy of biofeedback therapy, and to provide evidencebased recommendations. Based on the strength of evidence, biofeedback therapy is recom
mended for the shortterm and longterm treatment of con
stipation with dyssynergic defecation (Level I, Grade A), and for the treatment of fecal incontinence (Level II, Grade B). Biofeedback therapy may be useful in the shortterm treatment of Levator Ani Syndrome with dyssynergic def
ecation (Level II, Grade B), and solitary rectal ulcer syn
drome with dyssynergic defecation (Level III, Grade C), but the evidence is fair. Evidence does not support the use of biofeedback for the treatment of childhood constipation (Level 1, Grade D).
Commentaires : Voici la riposte américaine aux méta‑ana‑
lyses « européennes » récentes de la Cochrane (Woodward S, Norton C, Chiarelli P. (2014) Biofeedback for treatment of chronic idiopathic constipation in adults. Cochrane Data
base Syst Rev 3:CD008486). Il s’agit d’un travail d’analyse systématique de la littérature et de recommandation sur la place de la rééducation dans la prise en charge des troubles fonctionnels anorectaux. Il apparaît, dans ce travail, que le niveau de preuve et de recommandation est supérieur pour
proposer une rééducation instrumentale chez les malades qui souffrent d’une constipation d’évacuation par rapport à celui qui recommande son utilisation dans le traitement de l’incontinence. Cette donnée va un peu à l’encontre des pratiques de soins actuelles qui tendent à privilégier cette stratégie dans le traitement des troubles de la continence alors que le bénéfice thérapeutique est quantitativement limité par rapport à des méthodes plus simples comme la régulation du transit.
Cotation : ☺☺☺
L. Siproudhis
A Systematic Review of Sacral Nerve Stimulation for Low Anterior Resection Syndrome
Ramage L, Qiu S, Kontovounisios C, et al (2015) Colorectal Dis [Epub ahead of print]
Aim: The efficacy of sacral nerve stimulation (SNS) in low anterior resection syndrome (LARS) is largely undocu
mented. A review of the literature was carried out to study this question.
Method: Pubmed, Medline and Cochrane databases were searched for relevant articles up to August 2014. Studies were included if they evaluated the use of SNS following rectal resection and assessed at least one of the follow
ing end points: bowel function, quality of life and ano
neorectal physiology. No restrictions on language or study size were made.
Results: Seven papers were identified including one case report and six prospective case series. These included 43 patients with a median followup of 15 months. After peripheral nerve evaluation (PNE) definitive implantation was carried out in 34 (79.1%) patients. Overall, 32 (94.1%) of the 34 patients experienced improvement of symptoms which, based on intention to treat, was 32/43 (74.4%).
Conclusion: The review suggests that SNS for faecal incontinence in LARS has success rates comparable to its use for other forms of faecal incontinence.
Commentaires : Y croyez‑vous ? Les patients qui souffrent d’un syndrome de la résection rectale pourraient bénéfi‑
cier de cette approche thérapeutique près de trois fois sur quatre. Cependant, cette analyse de la littérature repose sur le regroupement de collections de cas souvent très réduits dans les publications prises séparément. Ces conclusions sont assez en décalage avec les expériences individuelles de plusieurs centres français, ce qui laisse penser que la
« zone grise » des données non publiées est probablement importante. Cela doit conduire à réaliser un registre de l’ensemble des malades testés dans cette indication ou à analyser les résultats des malades ayant un LARS parmi
l’ensemble des malades neuromodulés (registre national en place, données rétrospectives du registre Nemo).
Cotation : ☺
L. Siproudhis
Long‑Term Impact of Full‑Thickness Rectal Prolapse Treatment on Fecal Incontinence Wallenhorst T, Bouguen G, Brochard C, et al (2015) Surgery [Epub ahead of print]
Background: Fecal incontinence is frequently associated with rectal prolapse, but little is known about recovery after treatment of the prolapse.
Objective: We therefore aimed to investigate the long
term outcome of fecal incontinence in a cohort of patients suffering from fullthickness rectal prolapse.
Design: A database of 145 patients diagnosed with fullthickness rectal prolapse was compiled prospectively over a 7year period (2003–2010).
Main outcome measures: Patients were referred to a single institution and assessed by standardized ques
tionnaires, anorectal manometry, endosonography, and evacuation proctography. Fecal incontinence was evalu
ated according to the Cleveland Clinic Score; continence improvement was defined by ≥ 50% improvement of the Cleveland Clinic Score.
Results: Among the population studied (134 women, 11 men; median followup, 38.9 months [range: 21.2–67.2]), 103 patients (71%) underwent operation for their prolapse and 42 (29%) did not. According to the Cleveland Clinic Score, 139 patients (96%) suffered from fecal incontinence before treatment and 64 (46%) reported improvement at the end of the followup. Pretreatment history of incontinence symptoms for > 2 years (hazard ratio [HR]: 1.99; 95% CI:
[1.14–3.46]; P =0.015) and ventral rectopexy (HR: 1.86;
95% CI: [1.026–3.326]; P =0.04) were associated with con
tinence improvement. Patients who underwent an operative procedure other than ventral rectopexy had similar outcome as compared with nonoperated patients. Conversely, chronic pelvic pain precluded fecal incontinence improvement (HR:
0.32; 95% CI: [0.135–0.668]; P =0.0017).
Limitations: Followup, returned questionnaires, and the heterogeneous reasons put forth for declining surgery may introduce some methodologic bias.
Conclusion: Fecal incontinence in patients suffering from rectal prolapse is improved when ventral rectopexy is per
formed compared with other operative or medical therapies.
Commentaires : La rectopexie est actuellement le traite‑
ment de référence du prolapsus du rectum. Ses résultats sont bons si l’on considère le critère « récidive » qui est le
plus pertinent au premier abord. Avec un taux de récidives de moins de 10 % dans la plupart des études, le résultat est donc très bon. L’impact sur la fonction anorectale est plus difficile à apprécier. Les Rennais se sont mis en tête d’évaluer la chirurgie du prolapsus du rectum sous l’angle du bénéfice fonctionnel… Et grâce à leur structure dédiée très efficace et incontournable dans la région bretonne, les résultats sont d’autant plus crédibles. Le message de leur dernière publication est assez clair et conforte ce que beaucoup pensent : la rectopexie restitue une anatomie rectale qui améliore la continence… Encore un bon point pour la rectopexie !
Cotation : ☺☺
G. Meurette
Sacral Nerve Stimulation for Faecal Incontinence and Constipation: a European Consensus
Statement
Maeda Y, O’Connell PR, Lehur PA, et al (2015) Colorectal Dis 17:O74–O87
Aim: In Europe during the last decade sacral nerve stim
ulation (SNS) or sacral neuromodulation (SNM) has been used to treat faecal incontinence (FI) and constipation.
Despite this, there is little consensus on baseline investiga
tions, patient selection and operative technique. A modified Delphi process was conducted to seek consensus on the cur
rent practice of SNS/SNM for FI and constipation.
Method: A systematic literature search of SNS for FI and constipation was conducted using Pubmed. A set of questions derived from the search and expert opinion were answered online on two occasions by an international panel of specialists from Europe. A 1day facetoface meeting of the experts finalized the discussion.
Results: Three hundred and ninetythree articles were identified from the literature search, of which 147 ful
filled the inclusion criteria. Twentytwo specialists in FI and constipation from Europe participated. Agreement was achieved on 43 (86%) of 50 domains including the setup of service, patient selection, baseline investigations, operative technique and programming of the device. The median of agreement was 95% (35–100%).
Conclusion: Consensus was achieved on the majority of domains of SNS/SNM for FI and constipation. This should serve as a benchmark for safe and quality practice of SNS/
SNM in Europe.
Commentaires : La neuromodulation sacrée est un trai‑
tement désormais validé pour l’incontinence anale. Ses indications dans d’autres domaines des pathologies diges‑
tives sont également en évaluation (notamment dans la
constipation). Cette approche thérapeutique prend défini‑
tivement une place croissante dans la prise en charge des affections pelvipérinéales. Néanmoins, on manque encore aujourd’hui de paramètres objectifs pour standardiser les indications, la procédure elle‑même, le réglage du dispositif ainsi que la surveillance des patients. Il était donc oppor‑
tun d’effectuer une conférence d’experts sur le sujet. Vingt et un experts européens ont donc établi une conférence de consensus qui sert aujourd’hui de référence pour ceux qui pratiquent ou souhaitent débuter la neuromodulation sacrée. La méthodologie suit la procédure DELPHI et le consensus est obtenu dans la majorité des situations…, ce qui est bon signe !
Cotation : ☺☺☺
G. Meurette
Overtreatment of Young Adults with Colon
Cancer. More Intense Treatments with Unmatched Survival Gains
Kneuertz PJ, Chang GJ, Yuan Hu C, et al (2015) JAMA Surg doi: 10.1001/jamasurg.2014.3572 [Epub ahead of print]
Importance: Colon cancer is increasing among adults younger than 50 years. However, the prognosis of young
onset colon cancer remains poorly defined given significant agerelated demographic, disease, and treatment differences.
Objective: To define stagespecific treatments and prog
nosis of colon cancer diagnosed in young adults (ages:
18–49 years) vs older adults (ages: 65–75 years) outside of the clinical trial setting while accounting for realworld agerelated variations in patient, tumor, and treatment factors.
Design, setting, and participants: A nationwide cohort study was conducted among US hospitals accredited by the American College of Surgeons Commission on Cancer. Participants were 13,102 patients diagnosed as hav
ing youngonset colon adenocarcinoma aged 18 to 49 years and 37,007 patients diagnosed as having lateronset colon adenocarcinoma aged 65 to 75 years treated between Janu
ary 1, 2003, and December 31, 2005, and reported to the National Cancer Data Base.
Exposures: Patients who underwent surgical resection and postoperative systemic chemotherapy of curative intent.
Main outcomes and measures: The primary end point was stagespecific relative survival, an objective measure of survival among patients with cancer, adjusting for base
line mortality rates and independent of the data on cause of death. The secondary end point was stagespecific likeli
hood of receiving postoperative systemic chemotherapy.
Results: Most youngonset colon cancer was initially seen at advanced stages (61.8% had stage III or IV). After adjusting for patientrelated and tumorrelated factors, young patients were more likely to receive systemic chem
otherapy, particularly multiagent regimens, at all stages relative to those with lateronset disease. These odds ratios were 2.88 (95% CI: [2.21–3.77]) for stage I, 3.93 (95% CI:
[3.58–4.31]) for stage II, 2.42 (95% CI: [2.18–2.68]) for stage III, and 2.74 (95% CI: [2.44–3.07]) for stage IV. The significantly more intense treatments received by younger patients were unmatched by any survival gain, which was nil for stage II (relative risk: 0.90; 95% CI: [0.69–
1.17]) and marginal for stage III (relative risk: 0.89; 95%
CI: [0.81–0.97]) and stage IV (relative risk: 0.84; 95% CI:
[0.79–0.90]).
Conclusions and relevance: Young adults with colon cancer received significantly more postoperative systemic chemotherapy at all stages, but they experienced only mini
mal gain in adjusted survival compared with their older counterparts who received less treatment. This mismatch suggests that attention should be given to longterm cancer survivorship in young adults with colon cancer because they likely face survivorship needs that are distinct from those of their older counterparts.
Commentaires : Très belle étude sur la prise en charge des cancers colorectaux aux États‑Unis. On entend souvent en RCP qu’il faut traiter plus intensément un patient parce qu’il est jeune… Les conclusions de cette étude avec plus de 50 000 patients sont assez édifiantes : des patients opérés d’un cancer de stades I ou II à bas risque reçoivent une chimiothérapie adjuvante (non indiquée…) dans 19 % des cas ! Pour les patients jeunes (moins de 50 ans), ce taux grimpe à 37 %. Cette surprescription de chimiothérapie ne s’accompagne d’aucun bénéfice sur la survie de ces patients jeunes. Voici donc des données à connaître pour les présenter en RCP…
Cotation : ☺☺☺
J. Lefevre
