Irradiation du petit bassin et fonction ano-rectale.

peer reviewedLe traitement adjuvant des cancers du rectum a pour buts de stériliser la maladie résiduelle infra-clinique et d’améliorer le contrôle local. Depuis plus de 20 ans, des milliers de malades ont été inclus dans des études randomisées, visant d’abord à mettre en évidence un gain de survie et une réduction des récidives loco-régionales, en relation avec la radiothérapie pré- ou postopératoire, combinée ou non à la chimiothérapie. Les conséquences en termes de qualité de vie de ces traitements ont pourtant été peu étudiées, et la tolérance fonctionnelle du néo-rectum et de l’appareil sphinctérien à la radiothérapie restent mal connues [1]. Les difficultés liées à l’étude des effets de l’irradiation sur les tissus normaux, ainsi que la variabilité inter-individuelle de la réponse à la radiothérapie, s’ajoutent et rendent le sujet plus complexe encore. Les radiothérapeutes adaptent leur technique afin de réduire autant que possible la dose administrée aux tissus normaux avoisinant la tumeur. Dans le cas de l’irradiation du petit bassin, c’est l’intestin grêle qui a longtemps été considéré comme la structure à risque de complications, alors que l’atteinte du sphincter anal était rarement mentionnée [2]. Malgré les répercussions importantes de la dysfonction ano-rectale sur la qualité de vie des malades, l’atteinte du sphincter anal par la radiothérapie est restée un aspect négligé du traitement adjuvant des cancers du petit bassin [3]. Cet article a pour but, à travers une revue de la littérature, de mettre en évidence les effets qualitatifs et quantitatifs de la radiothérapie sur la fonction du sphincter anal, ainsi que de proposer une modification de la technique actuelle d’irradiation des cancers du bas rectum

Bleeding Meckel's diverticulum diagnosis: an unusual indication for computed tomography

Despite the wide use of modern investigation techniques, the diagnosis of complications related to Meckel's diverticulum (MD) remains difficult. Arteriography is commonly indicated for acute bleeding, and radionuclide scans may help in identifying the site of intestinal hemorrhage. In contrast, computed tomography (CT) is usually considered little use in the diagnosis of bleeding MD. We present the case of a young patient with massive gastrointestinal hemorrhage, in whom the diagnosis of MD bleeding was preoperatively made with contrast-enhanced CT after two negatives arteriographie

Practice parameters for the treatment of colonic diverticular disease: Italian Society of Colon and Rectal Surgery (SICCR) guidelines

The mission of the Italian Society of Colorectal Surgery (SICCR) is to optimize patient care. Providing evidence-based practice guidelines is therefore of key importance. About the present report it concernes the SICCR practice guidelines for the diagnosis and treatment of diverticular disease of the colon. The guidelines are not intended to define the sole standard of care but to provide evidence-based recommendations regarding the available therapeutic options

Long-term quality of life after endoscopic dilation of strictured colorectal or colocolonic anastomoses

Background: Endoscopic balloon dilation is the first-line treatment for benign colorectal anastomotic strictures. We aimed to objectively assess its long-term results. Methods: Gastrointestinal symptoms and health-related quality of life (HRQoL) were assessed at long-term after balloon dilation of anastomotic strictures in 31 consecutive patients (excluding those with inflammatory bowel disease) as well as and controls, using the validated Gastrointestinal Quality of Life Index (GIQLI). Most colectomies had been performed for benign diseases, with anastomoses located at the colorectal junction. Results: Completed surveys were collected from 81 subjects, including 27 study patients (response rate 87%), 27 surgical controls matched for age, gender, and indication of colectomy, and 27 healthy subjects. At a mean of 3.9±2.3 years after the first endoscopic balloon-dilation, study patients self-reported significantly more gastrointestinal symptoms than controls; these included frequent and urgent bowel movements, bloating, food restriction (p≤0.001, all comparisons), diarrhea, excessive passage of gas through the anus (p<0.01, all comparisons), constipation, and abdominal pain (p<0.05, all comparisons). Health-related quality of life was significantly impaired in study patients versus surgical controls and healthy subjects (GIQLI scores, 104±20, 119±24, and 121±16, respectively; p=0.005). Impaired HRQoL subdimensions included gastrointestinal symptoms (p<0.001), stress by treatment (p<0.05), and emotional status (p=0.08). HRQoL was independent of the delay between stricture dilation and the survey. Follow-up endoscopy (performed in 21/27 [78%] study patients, including the 7 patients with the lowest HRQoL, and 19 [70%] surgical controls) disclosed anastomoses larger than 13 mm in all cases. Conclusions: Health-related quality of life is significantly impaired at long-term after standard balloon-dilation of benign anastomotic colorectal strictures as a result of gastrointestinal symptoms and stress by treatment. This impairment might be related to the fact that an anastomotic diameter ≥13 mm, although commonly used to define successful endoscopic treatment, is insufficient to provide long-term symptom relief in some patients, or to other, yet to be identified, factor

Laparoscopic versus open resection for appendix carcinoid

Background: Since an increasing number of appendectomies are performed via laparoscopy, it is crucial to determine the impact of this approach on appendix carcinoid (AC) outcome. The goal of this study was to compare results of laparoscopic (LAP) versus open (OP) appendectomy for AC according to intend to treat approach. Methods: A retrospective review (1991-2003) identified 39 patients (median age, 36 years; range, 12-83) treated by laparoscopy (LAP) or laparotomy (OP) for AC in a single institution. Follow-up was complete for all patients (median, 67 months; range, 4-132). Results: Most cases had associated acute appendicitis (64%). Median carcinoid size was 1.1 cm (range, 0.3-5) and 0.4 cm (range, 0.2-3) in the LAP and OP groups, respectively. LAP and OP were performed in 21 (54%) and 18 (46%) patients, respectively. Surgical margins were positive in two patients in the LAP group and one patient in the OP group (p = 0.6). Right colectomies were performed for AC >2 cm in five patients after LAP and in four patients after OP (p = 0.9). Actuarial 5-year survival rates were 100 and 94% in the LAP and OP groups, respectively (p = 0.2). Two patients died in the OP group, one due to metastatic carcinoid and the other due to metachronous colorectal cancer. Synchronous or metachronous colorectal carcinomas developed in six patients (15%). Conclusion: Laparoscopic appendectomy is a safe procedure for AC, with carcinologic and long-term results similar to those of conventional appendectomy. Thus, pre- or per-operative suspicion of AC is not a contraindication to LAP. Prognosis of AC appears more dependent on carcinoid malignant potential or associated tumors. Risk for developing colorectal adenocarcinoma is high in AC patients and warrants follow-up of all patients with colonoscopic screenin

Results from percutaneous drainage of Hinchey stage II diverticulitis guided by computed tomography scan

Background: Percutaneous abscess drainage guided by computed tomography scan is considered the initial step in the management of patients presenting with Hinchey II diverticulitis. The rationale behind this approach is to manage the septic complication conservatively and to follow this later using elective sigmoidectomy with primary anastomosis. Methods: The clinical outcomes for Hinchey II patients who underwent percutaneous abscess drainage in our institution were reviewed. Drainage was considered a failure when signs of continuing sepsis developed, abscess or fistula recurred within 4 weeks of drainage, and emergency surgical resection with or without a colostomy had to be performed. Results: A total of 34 patients (17 men and 17 women; median age, 71 years; range, 34-90 years) were considered for analysis. The median abscess size was 6 cm (range, 3-18 cm), and the median duration of drainage was 8 days (range, 1-18 days). Drainage was considered successful for 23 patients (67%). The causes of failure for the remaining 11 patients included continuing sepsis (n = 5), abscess recurrence (n = 5), and fistula formation (n = 1). Ten patients who failed percutaneous abscess drainage underwent an emergency Hartmann procedure, with a median delay of 14 days (range, 1-65 days) between drainage and surgery. Three patients in this group (33%) died in the immediate postoperative period. Among the 23 patients successfully drained, 12 underwent elective sigmoid resection with a primary anastomosis. The median delay between drainage and surgery was 101 days (range, 40-420 days). In this group, there were no anastomotic leaks and no mortality. Conclusion: Drainage of Hinchey II diverticulitis guided by computed scan was successful in two-thirds of the cases, and 35% of the patients eventually underwent a safe elective sigmoid resection with primary anastomosis. By contrast, failure of percutaneous abscess drainage to control sepsis is associated with a high mortality rate when an emergency resection is performed. The current results demonstrate that percutaneous abscess drainage is an effective initial therapeutic approach for patients with Hinchey II diverticulitis, and that emergency surgery should be avoided whenever possibl

Risk factors for mortality-morbidity after emergency-urgent colorectal surgery

Background: The aim of this study was to assess the risk factors associated with mortality and morbidity following emergency or urgent colorectal surgery. Materials and methods: All data regarding the 462 patients who underwent emergency colonic resection in our institution between November 2002 and December 2007 were prospectively entered into a computerized database. Results: The median age of patients was 73 (range 17-98)years. The most common indications for surgery were: 171 adenocarcinomas (37%), 129 complicated diverticulitis (28%), and 35 colonic ischemia (7.5%). Overall mortality and morbidity rates were 14% and 36%, respectively. In multivariate analysis, the only parameter significantly associated with postoperative mortality was blood loss >500cm3 (odds ratio (OR) = 3.33, 95% confidence interval (CI) 1.63-6.82, p = 0.001). There were three parameters which correlated with postoperative morbidity: ASA score ≥3 (OR = 2.9, 95% CI 1.9-4.5, p < 0.001), colonic ischemia (OR = 3.4, 95% CI 1.4-7.7, p = 0.006), and stoma creation (OR = 2.2, 95% CI 1.4-3.4, p = 0.0003). Conclusions: The main risk factors for postoperative morbidity and mortality following emergency colorectal surgery are related to: (1) patients' ASA score, (2) colonic ischemia, and (3) perioperative bleeding. These variables should be considered in the elaboration of future scoring systems to predict outcome of emergency colorectal surger

Oxaliplatin combined with irinotecan and 5-fluorouracil/leucovorin (OCFL) in metastatic colorectal cancer: a phase I-II study

Background:: A phase I-II multicenter trial was conducted to define the maximal tolerated dose and describe the activity of an OCFL combination using oxaliplatin (OHP), irinotecan (CPT-11) and 5-fluorouracil (FU)/leucovorin (LV) in metastatic colorectal cancer (CRC). Patients and methods:: CRC patients not pretreated with palliative chemotherapy, with performance status ≤1 and adequate haematological, kidney and liver function, were eligible. Treatment consisted in weekly 24-h infusion 5-FU (2300 mg/m2)/LV (30 mg) and alternating OHP (70-85 mg/m2, days 1 and 15) and CPT-11 (80-140 mg/m2, days 8 and 22) repeated every 5 weeks. OHP and CPT-11 were escalated in cohorts of three to six patients. Results:: Thirty patients received a median of five cycles. Dose-limiting toxicity occurred at dose level 3, and the recommended dose was OHP 70 mg/m2, CPT-11 100 mg/m2, LV 30 mg and 5-FU 2300 mg/m2/24 h. Grade ≥3 toxicities were diarrhea 23%, neutropenia 20%, fatigue 7%, and neurologic 7%. Two febrile neutropenia episodes (one fatal) were recorded. Among 28 patients with measurable disease (90%), we observed two complete and 20 partial responses; overall RR was 78% (95% CI, 59% to 92%). Median time to progression and overall survival were 9.5 and 25.4 months, respectively. Seven patients underwent liver metastases resection. Conclusion:: OCFL is an overall well tolerated regimen with very high efficacy, which makes it most suitable for tumour control before surgery of metastatic diseas

Predicting survival after pulmonary metastasectomy for colorectal cancer: previous liver metastases matter

BACKGROUND: Few patients with lung metastases from colorectal cancer (CRC) are candidates for surgical therapy with a curative intent, and it is currently impossible to identify those who may benefit the most from thoracotomy. The aim of this study was to determine the impact of various parameters on survival after pulmonary metastasectomy for CRC. METHODS: We performed a retrospective analysis of 40 consecutive patients (median age 63.5 [range 33-82] years) who underwent resection of pulmonary metastases from CRC in our institution from 1996 to 2009. RESULTS: Median follow-up was 33 (range 4-139) months. Twenty-four (60%) patients did not have previous liver metastases before undergoing lung surgery. Median disease-free interval between primary colorectal tumor and development of lung metastases was 32.5 months. 3- and 5-year overall survival after thoracotomy was 70.1% and 43.4%, respectively. In multivariate analysis, the following parameters were correlated with tumor recurrence after thoracotomy; a history of previous liver metastases (HR = 3.8, 95%CI 1.4-9.8); and lung surgery other than wedge resection (HR = 3.0, 95%CI 1.1-7.8). Prior resection of liver metastases was also correlated with an increased risk of death (HR = 5.1, 95% CI 1.1-24.8, p = 0.04). Median survival after thoracotomy was 87 (range 34-139) months in the group of patients without liver metastases versus 40 (range 28-51) months in patients who had undergone prior hepatectomy (p = 0.09). CONCLUSION: The main parameter associated with poor outcome after lung resection of CRC metastases is a history of liver metastases

Surgical options for localized and advanced gastrointestinal stromal tumors

The development of imitinab has led to a revolution in the management of gastrointestinal stromal tumors (GIST), but surgical resection remains the cornerstone of treatment for patients with localized disease. The principles to surgical treatment of GIST include careful handling of tissues to prevent tumor rupture and resection to negative margins without the need for wide excision. Minimally invasive techniques have proven equally efficacious provided appropriate oncologic resections are performed. J. Surg. Oncol. 2011; 104:882–887. © 2011 Wiley Periodicals, Inc.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/88036/1/21892_ftp.pd