F. Bretagnol

Long-term functional results after sphincter-saving resection for rectal cancer.

INTRODUCTION A number of patients suffer from gastrointestinal side effects following sphincter-saving resection of the rectum. The aim of this study was to assess frequency and risk factors of long-term gastrointestinal side effects after sphincter-saving resection for rectal cancer. PATIENTS AND METHODS Between 1980 and 1997, among 209 patients treated for rectal cancer by rectal resection and sphincter conservation, 145 who were alive without recurrence or colostomy, responded to a questionnaire. There were 85 males and 60 females with a mean age of 64 Years; the follow-up was 5.4 Years. The functional result was considered good if the number of stools per 24h was three or less with normal continence and poor if the number of stools was four or more or if fecal incontinence was present. Influence of age, gender, anastomotic height, type of sutured colon, colonic pouch, defunctioning stoma, leakage, stenosis, radiotherapy, history of irritable bowel syndrome and follow-up were analyzed. RESULTS The mean anastomotic height was 5 cm from the anal margin. Functional results were good in 56% of patients and poor in 44%. Univariate analysis showed three variables to be significantly associated with the functional results: anastomotic height (P=0.001), radiotherapy (P=0.03) and follow-up > 24 Months (P=0.009). Multivariate analysis showed that only anastomotic height independently influenced functional results. They were good in 76%, 53% and 35% of patients for anastomoses located above 6 cm, between 6 and 3 cm, and below 3 cm from the anal margin, respectively. CONCLUSION After sphincter-saving resection for rectal cancer, about half of patients have poor long-term functional results, the latter being related only to the anastomotic height. This suggests the need to preserve a small part of the rectum when oncologically feasible.

Determinants of outcome following laparoscopic peritoneal lavage for perforated diverticulitis

Laparoscopic peritoneal lavage has been proposed for generalized peritonitis from perforated diverticulitis to avoid a stoma. Reports of its feasibility and safety are promising. This study aimed to establish determinants of failure to enable improved selection of patients for this approach.

Appendicite épiploïque primitive : une étiologie d’abdomen aigu révélée par la tomodensitométrie

Resume Les appendicites epiploiques primitives sont des etiologies sous-estimees d’abdomen aigu douloureux. Nous rapportons 2 observations ou le diagnostic a pu etre affirme par la tomodensitometrie helicoidale. Il s’agit d’une veritable entite clinique dont la semiologie tomodensitometrique est caracteristique. L’evolution de cette pathologie est le plus souvent favorable, autorisant un traitement medical premier de cette affection.

Chirurgie du cancer du rectum

Surgical resection is the only curative procedure for carcinoma of the rectum. Healds development of total mesorectal excision has made it the standard approach for mobile, non-fixed tumors; it permits optimal local control with less than 10% local recurrence at five years and minimizes nerve damage and genito-urinary complications. Although initial short-term results of laparoscopic approaches are very promising, the final role of laparoscopy has not yet been established. Neo-adjuvant radiotherapy should be proposed for locally advanced (T3, T4, and/or N+) tumors of the low and mid-rectum. Radiochemotherapy coupled with intersphincteric dissection offers hope for sphicter-sparing extirpation of even the lowest of rectal cancers. Local resection through a trans-anal approach may be considered for small (<3 cm.), mobile, well-differentiated tumors lying within 8 cm. of the anal verge if rectal echo-endoscopy shows an in-situ tumor or a T1 lesion with no evidence of lymphadenopathy. Future strategies may enlarge the indications for local resection if and when radiochemotherapy can achieve a complete local response (tumor sterilization).

Quelle est la place du traitement local

Actuellement, le traitement chirurgical standard est la résection antérieure rectale avec exérèse complète du mésorectum (TME) et anastomose colorectale ou coloanale pour les tumeurs du moyen et haut rectum ou l’amputation abdominopérinéale (AAP) avec colostomie terminale définitive pour les tumeurs bas situées [1]. Une technique rigoureuse avec TME permet à 5 ans un taux de récidives globales de 5 %. Dans l’étude multicentrique hollandaise, le taux de récidives locales était de 0,7 % après exérèse radicale des tumeurs T1-T2 N0 [2].