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Arquillière J, Dubois A, Rullier E, Rouanet P, Denost Q, Celerier B, Pezet D, Passot G, Aboukassem A, Colombo PE, Mourregot A, Carrere S, Vaudoyer D, Gourgou S, Gauthier L, Cotte E. Learning curve for robotic-assisted total mesorectal excision: a multicentre, prospective study. Colorectal Dis 2023; 25:1863-1877. [PMID: 37525421 DOI: 10.1111/codi.16695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 05/19/2023] [Accepted: 06/26/2023] [Indexed: 08/02/2023]
Abstract
AIM Robotic-assisted surgery (RAS) is becoming increasingly important in colorectal surgery. Recognition of the short, safe learning curve (LC) could potentially improve implementation. We evaluated the extent and safety of the LC in robotic resection for rectal cancer. METHOD Consecutive rectal cancer resections (January 2018 to February 2021) were prospectively included from three French centres, involving nine surgeons. LC analyses only included surgeons who had performed more than 25 robotic rectal cancer surgeries. The primary endpoint was operating time LC and the secondary endpoint conversion rate LC. Interphase comparisons included demographic and intraoperative data, operating time, conversion rate, pathological specimen features and postoperative morbidity. RESULTS In 174 patients (69% men; mean age 62.6 years) the mean operating time was 334.5 ± 92.1 min. Operative procedures included low anterior resection (n = 143) and intersphincteric resection (n = 31). For operating time, there were two or three (centre-dependent) LC phases. After 12-21 cases (learning phase), there was a significant decrease in total operating time (all centres) and an increase in the number of harvested lymph nodes (two centres). For conversion rate, there were two or four LC phases. After 9-14 cases (learning phase), the conversion rate decreased significantly in two centres; in one centre, there was a nonsignificant decrease despite the treatment of significantly more obese patients and patients with previous abdominal surgery. There were no significant differences in interphase comparisons. CONCLUSION The LC for RAS in rectal cancer was achieved after 12-21 cases for the operating time and 9-14 cases for the conversion rate. RAS for rectal cancer was safe during this time, with no interphase differences in postoperative complications and circumferential resection margin.
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Affiliation(s)
- J Arquillière
- Department of Digestive and Oncological Surgery, Lyon University Hospital, Lyon-Sud Hospital, Pierre-Bénite, France
| | - A Dubois
- Department of Colorectal Surgery, CHU Estaing, Clermont-Ferrand, France
| | - E Rullier
- Department of Digestive Surgery, Colorectal Unit, Bordeaux University Hospital, Haut-Lévèque Hospital, Pessac, France
| | - P Rouanet
- Department of Colorectal Surgery, Institut Du Cancer De Montpellier, Montpellier, France
| | - Q Denost
- Bordeaux Colorectal Institute, Clinique Tivoli, Bordeaux, France
| | - B Celerier
- Department of Digestive Surgery, Colorectal Unit, Bordeaux University Hospital, Haut-Lévèque Hospital, Pessac, France
| | - D Pezet
- Department of Colorectal Surgery, CHU Estaing, Clermont-Ferrand, France
| | - G Passot
- Department of Digestive and Oncological Surgery, Lyon University Hospital, Lyon-Sud Hospital, Pierre-Bénite, France
- Lyon Center for Innovation in Cancer, CICLY EA 3738, Lyon 1 University, Lyon, France
| | - A Aboukassem
- Department of Colorectal Surgery, CHU Estaing, Clermont-Ferrand, France
| | - P E Colombo
- Department of Colorectal Surgery, Institut Du Cancer De Montpellier, Montpellier, France
| | - A Mourregot
- Department of Colorectal Surgery, Institut Du Cancer De Montpellier, Montpellier, France
| | - S Carrere
- Department of Colorectal Surgery, Institut Du Cancer De Montpellier, Montpellier, France
| | - D Vaudoyer
- Department of Digestive and Oncological Surgery, Lyon University Hospital, Lyon-Sud Hospital, Pierre-Bénite, France
- Lyon Center for Innovation in Cancer, CICLY EA 3738, Lyon 1 University, Lyon, France
| | - S Gourgou
- Biometrics Unit, Montpellier Cancer Institute (ICM), University of Montpellier, Montpellier, France
| | - L Gauthier
- Biometrics Unit, Montpellier Cancer Institute (ICM), University of Montpellier, Montpellier, France
| | - E Cotte
- Department of Digestive and Oncological Surgery, Lyon University Hospital, Lyon-Sud Hospital, Pierre-Bénite, France
- Lyon Center for Innovation in Cancer, CICLY EA 3738, Lyon 1 University, Lyon, France
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Martin M, Giraud N, Capdepont M, Sarrade C, Viaouet A, Smith D, Terrebonne E, Frulio N, Rullier A, Denost Q, Rullier E, Vendrely V. Morbidité chirurgicale sévère après une chimioradiothérapie néoadjuvante en technique conformationnelle tridimensionnelle comparée à la modulation d’intensité pour l’adénocarcinome rectal localement évolué. Cancer Radiother 2021. [DOI: 10.1016/j.canrad.2021.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Martin M, Giraud N, Capdepont M, Sarrade C, Viaouet A, Smith D, Terrebonne E, Frulio N, Rullier A, Denost Q, Rullier E, Vendrely V. PO-1244 Severe surgical morbidity after chemoradiotherapy conformational-3D versus IMRT for rectal cancer. Radiother Oncol 2021. [DOI: 10.1016/s0167-8140(21)07695-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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4
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Teste B, Rouanet P, Tuech JJ, Valverde A, Lelong B, Rivoire M, Faucheron JL, Jafari M, Portier G, Meunier B, Sielezneff I, Prudhomme M, Marchal F, Dubois A, Capdepont M, Denost Q, Rullier E. Early and late morbidity of local excision after chemoradiotherapy for rectal cancer. BJS Open 2021; 5:6294246. [PMID: 34097005 PMCID: PMC8183183 DOI: 10.1093/bjsopen/zrab043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 04/08/2021] [Indexed: 12/17/2022] Open
Abstract
Background Local excision (LE) after chemoradiotherapy is a new option in low rectal cancer, but morbidity has never been compared prospectively with total mesorectal excision (TME). Early and late morbidity were compared in patients treated either by LE or TME after neoadjuvant chemoradiotherapy for rectal cancer. Method This was a post-hoc analysis from a randomized trial. Patients with clinical T2/T3 low rectal cancer with good response to the chemoradiotherapy and having either LE, LE with eventual completion TME, or TME were considered. Early (1 month) and late (2 years) morbidities were compared between the three groups. Results There were no deaths following surgery in any of the three groups. Early surgical morbidity (20 per cent LE versus 36 per cent TME versus 43 per cent completion TME, P = 0.025) and late surgical morbidity (4 per cent versus 33 per cent versus 57 per cent, P < 0.001) were significantly lower in the LE group than in the TME or the completion TME group. of LE, was associated with the lowest rate of early (10 versus 18 versus 21 per cent, P = 0.217) and late medical morbidities (0 versus 7 versus 7 per cent, P = 0.154), although this did not represent a significant difference between the groups. The severity of overall morbidity was significantly lower at 2 years after LE compared with TME or completion TME (4 versus 28 versus 43 per cent grade 3–5, P < 0.001). Conclusion The rate of surgical complications after neoadjuvant chemoradiotherapy in the LE group was half that of TME group at 1 month and 10 times lower at 2 years. LE is a safe approach for organ preservation and should be considered as an alternative to watch-and-wait in complete clinical responders and to TME in subcomplete responders.
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Affiliation(s)
- B Teste
- Department of Colorectal Surgery, Magellan Centre, Haut-Leveque Hospital, University of Bordeaux, 33604 Pessac, France
| | - P Rouanet
- Département de Chirurgie Oncologique, ICM Val d'Aurelle, Montpellier, France
| | - J-J Tuech
- Service de Chirurgie Digestive, CHU Charles Nicolle, Rouen, France
| | - A Valverde
- Service de Chirurgie Digestive, Groupe Hospitalier Diaconesses Croix Saint-Simon, Paris, France
| | - B Lelong
- Département de Chirurgie Oncologique, Institut Paoli Calmette, Marseille, France
| | - M Rivoire
- Département de Chirurgie Oncologique, Centre Léon Bérard, Lyon, France
| | - J-L Faucheron
- Service de Chirurgie Digestive, Hôpital A. Michallon, La Tronche, France
| | - M Jafari
- Département de Chirurgie Oncologique, Centre Oscar Lambret, Lille, France
| | - G Portier
- Service de Chirurgie Digestive, Hôpital Purpan, Toulouse, France
| | - B Meunier
- Service de Chirurgie Viscérale, CHU Pontchaillou, Rennes, France
| | - I Sielezneff
- Service de Chirurgie Digestive, CHU Timone, Marseille, France
| | - M Prudhomme
- Département de Chirurgie Digestive et de Cancérologie Digestive, Hôpital Universitaire Carémeau, Nimes, France
| | - F Marchal
- Département de Chirurgie Oncologique, Institut de Cancérologie de Lorraine, Vandoeuvre les Nancy, France
| | - A Dubois
- Service de Chirurgie Générale et Digestive, Hôtel Dieu, Clermont-Ferrand, France
| | - M Capdepont
- Department of Colorectal Surgery, Magellan Centre, Haut-Leveque Hospital, University of Bordeaux, 33604 Pessac, France
| | - Q Denost
- Department of Colorectal Surgery, Magellan Centre, Haut-Leveque Hospital, University of Bordeaux, 33604 Pessac, France
| | - E Rullier
- Department of Colorectal Surgery, Magellan Centre, Haut-Leveque Hospital, University of Bordeaux, 33604 Pessac, France
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Rouanet P, Rivoire M, Gourgou S, Lelong B, Rullier E, Jafari M, Mineur L, Pocard M, Faucheron JL, Dravet F, Pezet D, Fabre JM, Bresler L, Balosso J, Lemanski C. Sphincter-saving surgery after neoadjuvant therapy for ultra-low rectal cancer where abdominoperineal resection was indicated: 10-year results of the GRECCAR 1 trial. Br J Surg 2021; 108:10-13. [PMID: 33640922 DOI: 10.1093/bjs/znaa010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 08/17/2020] [Accepted: 08/28/2020] [Indexed: 12/22/2022]
Abstract
This phase III trial included patients with ultra-low rectal adenocarcinoma that initially required abdominoperineal resection. The surgical decision was based on clinical tumour status after preoperative treatment. The overall sphincter-saving resection rate was 85 per cent, with 72 per cent rate of intersphincteric resection. Long-term results showed that changing the initial abdominoperineal resection indication into a sphincter-saving resection according to tumoral response is oncologically safe.
Saving the sphincter
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Affiliation(s)
- P Rouanet
- Department of Surgical Oncology, Institut Régional du Cancer de Montpellier-Val d'Aurelle, Montpellier, France
| | - M Rivoire
- Department of Surgical Oncology, Centre Léon Berard, Lyon, France
| | - S Gourgou
- Biometrics Unit, Montpellier Cancer Institute, Montpellier, France
| | - B Lelong
- Department of Surgical Oncology, Institut Paoli Calmettes, Marseille, France
| | - E Rullier
- Colorectal Department, Centre Hospitalier Universitaire Bordeaux, Bordeaux, France
| | - M Jafari
- Department of Surgical Oncology, Centre Oscar Lambret, Lille, France
| | - L Mineur
- Department of Radiation Oncology, Institut Sainte Catherine, Avignon, France
| | - M Pocard
- Department of Surgical Oncology, Gustave Roussy (Hôpital Lariboisière Assistance Publique-Hôpitaux de Paris), Paris, France
| | - J L Faucheron
- Colorectal Department, Centre Hospitalier Universitaire Grenoble, Grenoble, France
| | - F Dravet
- Department of Surgical Oncology, Centre René Gauducheau, Nantes, France
| | - D Pezet
- Colorectal Department, Centre Hospitalier Universitaire Clermont-Ferrand, Clermont-Ferrand, France
| | - J M Fabre
- Colorectal Department, Centre Hospitalier Universitaire Montpellier, Montpellier, France
| | - L Bresler
- Colorectal Department, Centre Hospitalier Universitaire Nancy, Nancy, France
| | - J Balosso
- Department of Radiotherapy, Centre Hospitalier Universitaire Grenoble, Grenoble, France
| | - C Lemanski
- Department of Radiotherapy, Institut Régional du Cancer de Montpellier-Val d'Aurelle, Montpellier, France
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6
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Celarier S, Monziols S, Célérier B, Assenat V, Carles P, Napolitano G, Laclau-Lacrouts M, Rullier E, Ouattara A, Denost Q. Low-pressure versus standard pressure laparoscopic colorectal surgery (PAROS trial): a phase III randomized controlled trial. Br J Surg 2021; 108:998-1005. [PMID: 33755088 DOI: 10.1093/bjs/znab069] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 01/26/2021] [Accepted: 01/29/2021] [Indexed: 12/19/2022]
Abstract
TRIAL DESIGN This is a phase III, double-blind, randomized, controlled trial. METHODS In this trial, patients with laparoscopic colectomy were assigned to either low pressure (LP: 7 mmHg) or standard pressure (SP: 12 mmHg) at a ratio of 1 : 1. The aim of this trial was to assess the impact of low-pressure pneumoperitoneum during laparoscopic colectomy on postoperative recovery. The primary endpoint was the duration of hospital stay. The main secondary endpoints were postoperative pain, consumption of analgesics and postoperative morbidity. RESULTS Some 138 patients were enrolled, of whom 11 were excluded and 127 were analysed: 62 with LP and 65 with SP. Duration of hospital stay (3 versus 4 days; P = 0.010), visual analog scale (0.5 versus 2.0; P = 0.008) and analgesic consumption (level II: 73 versus 88 per cent; P = 0.032; level III: 10 versus 23 per cent; P = 0.042) were lower with LP. Morbidity was not significantly different between the two groups (10 versus 17 per cent; P = 0.231). CONCLUSION Using low-pressure pneumoperitoneum in laparoscopic colonic resection improves postoperative recovery, shortening the duration of hospitalization and decreasing postoperative pain and analgesic consumption. This suggests that low pressure should become the standard of care for laparoscopic colectomy. TRIAL REGISTRATION NCT03813797.
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Affiliation(s)
- S Celarier
- CHU Bordeaux, Department of Digestive Surgery, Colorectal Unit, Haut-Lévêque Hospital, Pessac, France
| | - S Monziols
- CHU Bordeaux, Department of Anaesthesia and Critical Care, Magellan Medico-Surgical Centre, Bordeaux, France
| | - B Célérier
- CHU Bordeaux, Department of Digestive Surgery, Colorectal Unit, Haut-Lévêque Hospital, Pessac, France
| | - V Assenat
- CHU Bordeaux, Department of Digestive Surgery, Colorectal Unit, Haut-Lévêque Hospital, Pessac, France
| | - P Carles
- CHU Bordeaux, Department of Anaesthesia and Critical Care, Magellan Medico-Surgical Centre, Bordeaux, France
| | - G Napolitano
- CHU Bordeaux, Department of Anaesthesia and Critical Care, Magellan Medico-Surgical Centre, Bordeaux, France
| | - M Laclau-Lacrouts
- CHU Bordeaux, Department of Digestive Surgery, Colorectal Unit, Haut-Lévêque Hospital, Pessac, France
| | - E Rullier
- CHU Bordeaux, Department of Digestive Surgery, Colorectal Unit, Haut-Lévêque Hospital, Pessac, France
| | - A Ouattara
- CHU Bordeaux, Department of Anaesthesia and Critical Care, Magellan Medico-Surgical Centre, Bordeaux, France.,Université de Bordeaux, INSERM, U 1034, Biology of Cardiovascular Diseases, Pessac, France
| | - Q Denost
- CHU Bordeaux, Department of Digestive Surgery, Colorectal Unit, Haut-Lévêque Hospital, Pessac, France
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Denost Q, Rouanet P, Faucheron JL, Panis Y, Meunier B, Cotte E, Meurette G, Portier G, Sabbagh C, Loriau J, Benoist S, Piessen G, Sielezneff I, Lelong B, Mauvais F, Romain B, Barussaud ML, Capdepont M, Laurent C, Rullier E. Impact of early biochemical diagnosis of anastomotic leakage after rectal cancer surgery: long-term results from GRECCAR 5 trial. Br J Surg 2021; 108:605-608. [PMID: 33793764 DOI: 10.1093/bjs/znab003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 12/28/2020] [Indexed: 12/12/2022]
Abstract
Elevated C-reactive protein, should be used to prompt early detection of AL prior to the development of clinical symptoms. Early biochemical diagnosis and intervention of AL mitigates the negative impact of AL on oncological outcomes in patients with rectal cancer.
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Affiliation(s)
- Q Denost
- Département de Chirurgie Colorectal, Hôpital Haut-Lévèque, CHU Bordeaux, Pessac, France
| | - P Rouanet
- Département de Chirurgie Oncologique, ICM Val d'Aurelle, Montpellier, France
| | - J-L Faucheron
- Service de Chirurgie Digestive, Hôpital A. Michallon, La Tronche, France
| | - Y Panis
- Service de Chirurgie Digestive, Hôpital Beaujon, AP-HP, Clichy, France
| | - B Meunier
- Service de Chirurgie Viscérale, CHU Pontchaillou, Rennes, France
| | - E Cotte
- Service de Chirurgie Digestive, Hôpital Lyon Sud, CHU Lyon, Pierre-Bénite, France
| | - G Meurette
- Service de Chirurgie Digestive, Site Hôtel Dieu, Nantes, France
| | - G Portier
- Service de Chirurgie Digestive, Hôpital Purpan, Toulouse, France
| | - C Sabbagh
- Service de Chirurgie Digestive et Métabolique, CHU d'Amiens, Amiens, France
| | - J Loriau
- Service de Chirurgie Digestive et Obésité, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - S Benoist
- Service de Chirurgie Générale et Digestive, Hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France
| | - G Piessen
- Service de Chirurgie Digestive, Hôpital Claude Huriez, CHU Lille, Lille, France
| | - I Sielezneff
- Service de Chirurgie Digestive et Viscérale, CHU Timone, Marseille, France
| | - B Lelong
- Service de Chirurgie Digestive, Institut Paoli Calmette Institut Paoli Calmette, Marseille, France
| | - F Mauvais
- Service de Chirurgie Viscérale, CH de Beauvais, Beauvais, France
| | - B Romain
- Service de Chirurgie Générale et Digestive, Hôpital Universitaire de Hautepierre, Strasbourg, France
| | - M-L Barussaud
- Service de Chirurgie Digestive, CHU de Poitiers, Poitiers, France
| | - M Capdepont
- Département de Chirurgie Colorectal, Hôpital Haut-Lévèque, CHU Bordeaux, Pessac, France
| | - C Laurent
- Département de Chirurgie Colorectal, Hôpital Haut-Lévèque, CHU Bordeaux, Pessac, France
| | - E Rullier
- Département de Chirurgie Colorectal, Hôpital Haut-Lévèque, CHU Bordeaux, Pessac, France
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8
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Denost Q, Moreau JB, Vendrely V, Celerier B, Rullier A, Assenat V, Rullier E. Intersphincteric resection for low rectal cancer: the risk is functional rather than oncological. A 25-year experience from Bordeaux. Colorectal Dis 2020; 22:1603-1613. [PMID: 32649005 DOI: 10.1111/codi.15258] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 04/03/2020] [Indexed: 02/07/2023]
Abstract
AIM There are few data evaluating the long-term outcomes of intersphincteric resection (ISR), especially the impact of inclusion of more juxtapositioned and intra-anal tumours on oncological and functional outcomes. We compared the oncological and functional results of patients treated by total mesorectal excision and ISR for low rectal cancer over a 25-year period. METHOD This is a retrospective study from a single institution evaluating results of ISR over three periods: 1990-1998, 1999-2006 and 2007-2014. Patients treated by partial or total ISR, with or without neoadjuvant chemoradiotherapy, for low rectal cancer (≤ 6 cm from the anal verge) were included. We compared postoperative morbidity, quality of surgery and oncological and functional outcomes in the time periods studied. RESULTS Of 813 patients operated on for low rectal cancer, 303 had ISR. Tumour stage did not differ; however, the distance of the tumour from the anorectal junction decreased from 1 to 0 cm (P < 0.001) and the distal resection margin shortened from 25 to 10 mm (P < 0.001) from 1990 to 2014. The postoperative morbidity and quality of surgery did not change significantly over time. The 5-year local recurrence (4.3% vs 5.9% vs 3.5%; P = 0.741) and disease-free survival (72% vs 71% vs 75%; P = 0.918) did not differ between the three time periods. Functional results improved during the last period; however, overall 42% of patients experienced major bowel dysfunction. CONCLUSION Pushing the envelope of sphincter-saving resection in ultra-low rectal cancer reaching or invading the anal sphincter did not compromise oncological and functional outcomes. The main limitation of the ISR procedure appears to be functional rather than oncological, suggesting that bowel rehabilitation programmes should be developed.
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Affiliation(s)
- Q Denost
- Department of Colorectal Surgery, CHU Bordeaux, Haut-Leveque Hospital, University of Bordeaux, Pessac, France
| | - J-B Moreau
- Department of Colorectal Surgery, CHU Bordeaux, Haut-Leveque Hospital, University of Bordeaux, Pessac, France
| | - V Vendrely
- Department of Radiotherapy, CHU Bordeaux, Haut-Leveque Hospital, University of Bordeaux, Pessac, France
| | - B Celerier
- Department of Colorectal Surgery, CHU Bordeaux, Haut-Leveque Hospital, University of Bordeaux, Pessac, France
| | - A Rullier
- Department of Pathology, CHU Bordeaux, Pellegrin Hospital, University of Bordeaux, Bordeaux, France
| | - V Assenat
- Department of Colorectal Surgery, CHU Bordeaux, Haut-Leveque Hospital, University of Bordeaux, Pessac, France
| | - E Rullier
- Department of Colorectal Surgery, CHU Bordeaux, Haut-Leveque Hospital, University of Bordeaux, Pessac, France
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9
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François MO, Buscail E, Vendrely V, Célérier B, Assénat V, Moreau JB, Rullier E, Denost Q. Delayed coloanal anastomosis: an alternative option for restorative rectal cancer surgery after high-dose pelvic radiotherapy for prostate cancer. Colorectal Dis 2020; 22:1545-1552. [PMID: 32463973 DOI: 10.1111/codi.15144] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 03/27/2020] [Indexed: 02/08/2023]
Abstract
AIM Restorative total mesorectal excision (TME) for rectal cancer after high-dose pelvic radiotherapy for prostate cancer has been reported to provide an unacceptable rate of pelvic sepsis. In a previous publication we proposed that delayed coloanal anastomosis (DCAA) should be performed in this situation. The present study aimed to assess the feasibility and outcomes of this strategy. METHOD Between 2000 and 2018, 1094 men were operated on for rectal cancer in our institution. All men with T2/T3 mid and low rectal cancer with preoperative radiotherapy and restorative TME were considered for this study (n = 416). Patients with external-beam high-dose radiotherapy (EBHRT) for prostate cancer (70-78 Gy) were identified and compared with patients with conventional long-course chemoradiotherapy (CRT) followed by TME. We compared our already published historical cohort (2000-2012), including arm A (CRT + TME; n = 236) and arm B (EBHRT + TME; n = 12), with our early cohort (2013-2018), including arm C (CRT + TME; n = 158) and arm D (EBHRT + TME-DCAA; n = 10). The end-points were morbidity, pelvic sepsis, reoperation rate and quality of the specimen. RESULTS Overall morbidity was not significantly different between groups. Pelvic sepsis decreased from 50% (arm B) to 10% (arm D) with the use of DCAA (P = 0.074), and was similar between arms A, C and D. Quality of the specimen was not significantly different between the four groups. CONCLUSION Our results suggest that TME with DCAA in patients with previous EBHRT is feasible, with the same postoperative pelvic sepsis rate as conventional CRT.
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Affiliation(s)
- M-O François
- Department of Digestive Surgery, CHU de Bordeaux, Haut-Lévêque Hospital, Pessac, France
| | - E Buscail
- Department of Digestive Surgery, CHU de Bordeaux, Haut-Lévêque Hospital, Pessac, France
| | - V Vendrely
- Department of Radiotherapy, CHU de Bordeaux, Haut-Lévêque Hospital, Pessac, France
| | - B Célérier
- Department of Digestive Surgery, CHU de Bordeaux, Haut-Lévêque Hospital, Pessac, France
| | - V Assénat
- Department of Digestive Surgery, CHU de Bordeaux, Haut-Lévêque Hospital, Pessac, France
| | - J-B Moreau
- Department of Digestive Surgery, CHU de Bordeaux, Haut-Lévêque Hospital, Pessac, France
| | - E Rullier
- Department of Digestive Surgery, CHU de Bordeaux, Haut-Lévêque Hospital, Pessac, France
| | - Q Denost
- Department of Digestive Surgery, CHU de Bordeaux, Haut-Lévêque Hospital, Pessac, France
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Manceau G, Sabbagh C, Mege D, Lakkis Z, Bege T, Tuech JJ, Benoist S, Lefèvre JH, Karoui M, Bridoux V, Venara A, Beyer‐Berjot L, Codjia T, Dazza M, Gagnat G, Hamel S, Mallet L, Martre P, Philouze G, Roussel E, Tortajada P, Dumaine AS, Heyd B, Paquette B, Brunetti F, Esposito F, Lizzi V, Michot N, Denost Q, Rullier E, Tresallet C, Tetard O, Rivier P, Fayssal E, Collard M, Moszkowicz D, Lupinacci R, Peschaud F, Etienne JC, Loge L, Bege T, Corte H, D’Annunzio E, Humeau M, Issard J, Munoz N, Abba J, Jafar Y, Lacaze L, Sage PY, Susoko L, Trilling B, Arvieux C, Mauvais F, Ulloa‐Severino B, Pitel S, Vauchaussade de Chaumont A, Badic B, Blanc B, Bert M, Rat P, Ortega‐Deballon P, Chau A, Dejeante C, Piessen G, Grégoire E, Alfarai A, Cabau M, David A, Kadoche D, Dufour F, Goin G, Goudard Y, Pauleau G, Sockeel P, Villeon B, Pautrat K, Eveno C, Abdalla S, Couchard AC, Balbo G, Mabrut JY, Bellinger J, Bertrand M, Aumont A, Duchalais E, Messière AS, Tranchart A, Cazauran JB, Pichot‐Delahaye V, Dubuisson V, Maggiori L, Panis Y, Djawad‐Boumediene B, Fuks D, Kahn X, Huart E, Catheline JM, Lailler G, Baraket O, Baque P, Diaz de Cerio JM, Mariol P, Maes B, Fernoux P, Guillem P, Chatelain E, de Saint Roman C, Fixot K, Voron T, Parc Y. Colon sparing resection versus extended colectomy for left-sided obstructing colon cancer with caecal ischaemia or perforation: a nationwide study from the French Surgical Association. Colorectal Dis 2020; 22:1304-1313. [PMID: 32368856 DOI: 10.1111/codi.15111] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 04/02/2020] [Indexed: 02/08/2023]
Abstract
AIM It is not known whether patients with obstructive left colon cancer (OLCC) with caecal ischaemia or diastatic perforation (defined as a blowout of the caecal wall related to colonic overdistension) should undergo a (sub)total colectomy (STC) or an ileo-caecal resection with double-barrelled ileo-colostomy. We aimed to compare the results of these two strategies. METHOD From 2000 to 2015, 1220 patients with OLCC underwent surgery by clinicians who were members of the French Surgical Association. Of these cases, 201 (16%) were found to have caecal ischaemia or diastatic perforation intra-operatively: 174 patients (87%) underwent a STC (extended colectomy group) and 27 (13%) an ileo-caecal resection with double-end stoma (colon-sparing group). Outcomes were compared retrospectively. RESULTS In the extended colectomy group, 95 patients (55%) had primary anastomosis and 79 (45%) had a STC with an end ileostomy. In the colon-sparing group, 10 patients (37%) had simultaneous resection of their primary tumour with segmental colectomy and an anastomosis which was protected by a double-barrelled ileo-colostomy. The demographic data for the two groups were comparable. Median operative time was longer in the STC group (P = 0.0044). There was a decrease in postoperative mortality (7% vs 12%, P = 0.75) and overall morbidity (56% vs 67%, P = 0.37) including surgical (30% vs 40%, P = 0.29) and severe complications (17% vs 27%, P = 0.29) in the colon-sparing group, although these differences did not reach statistical significance. Cumulative morbidity included all surgical stages and the rate of permanent stoma was 66% and 37%, respectively, with no significant difference between the two groups. Overall survival and disease-free survival were similar between the two groups. CONCLUSION The colon-sparing strategy may represent a valid and safe alternative to STC in OLCC patients with caecal ischaemia or diastatic perforation.
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Affiliation(s)
- G Manceau
- Department of Digestive Surgery, Assistance Publique-Hôpitaux de Paris, Pitié Salpêtrière University Hospital, Sorbonne Université, Paris, France
| | - C Sabbagh
- Department of Digestive Surgery, Amiens University Hospital, Amiens, France
| | - D Mege
- Department of Digestive Surgery, Assistance Publique-Hôpitaux de Marseille, Timone University Hospital, Marseille, France
| | - Z Lakkis
- Department of Digestive Surgery, Besançon University Hospital, Besançon, France
| | - T Bege
- Department of Digestive Surgery, Assistance Publique Hôpitaux de Marseille, North University Hospital, Marseille, France
| | - J J Tuech
- Department of Digestive Surgery, Charles Nicolle University Hospital, Rouen, France
| | - S Benoist
- Department of Digestive Surgery, Assistance Publique-Hôpitaux de Paris, Bicêtre University Hospital, Université Paris-Sud, Le Kremlin Bicêtre, France
| | - J H Lefèvre
- Department of Digestive Surgery, Assistance Publique-Hôpitaux de Paris, Saint-Antoine University Hospital, Sorbonne Université, Paris, France
| | - M Karoui
- Department of Digestive Surgery, Assistance Publique-Hôpitaux de Paris, Pitié Salpêtrière University Hospital, Sorbonne Université, Paris, France
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11
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Denost Q, Solomon M, Tuech JJ, Ghouti L, Cotte E, Panis Y, Lelong B, Rouanet P, Faucheron JL, Jafari M, Lefevre JH, Rullier E, Heriot A, Austin K, Lee P, Brown W, Maillou-Martinaud H, Savel H, Quintard B, Broc G, Saillour-Glénisson F. International variation in managing locally advanced or recurrent rectal cancer: prospective benchmark analysis. Br J Surg 2020; 107:1846-1854. [PMID: 32786027 DOI: 10.1002/bjs.11854] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 06/03/2020] [Accepted: 06/04/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Tumour extension beyond the mesorectal plane (ymrT4) occurs in 5-10 per cent of patients with rectal cancer and 10 per cent of patients develop locally recurrent rectal cancer (LRRC) after primary surgery. There is global variation in healthcare delivery for these conditions. METHODS An international benchmark trial of the management of ymrT4 tumours and LRRC was undertaken in France and Australia between 2015 and 2017. Heterogeneity in management and operative decision-making were analysed by comparison of surgical resection rates, blinded intercountry reading of pelvic MRI, quality-of-life assessment and qualitative evaluations. RESULTS Among 154 patients (97 in France and 57 in Australia), 31·8 per cent had ymrT4 disease and 68·2 per cent LRRC. The surgical resection rates were 88 and 79 per cent in France and Australia respectively (P = 0·112). The concordance in operative planning was low (κ = 0·314); the rate of pelvic exenteration was lower in France than Australia both in clinical practice (36 of 78 versus 34 of 40; P < 0·001) and in theoretical conditions (10 of 25 versus 50 of 57; P = 0·002). The R0 resection rate was lower in France than Australia for LRRC (25 of 49 versus 18 of 21; P = 0·007) but not for ymrT4 tumours (21 of 26 versus 15 of 15; P = 0·139). Morbidity rates were similar. Patients who underwent non-exenterative procedures had higher scores on the mental functioning subscale at 12 months (P = 0·047), and a lower level of distress at 6 months (P = 0·049). Qualitative analysis highlighted five categories of psychosocial factors influencing treatment decisions: patient, strategy, specialist, organization and culture. CONCLUSION This international benchmark trial has highlighted the differences in worldwide treatment of locally advanced and LRRC. Standardized care should improve outcomes for these patients.
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Affiliation(s)
- Q Denost
- Department of Digestive Surgery, Colorectal Unit, Haut-leveque Hospital, Bordeaux University Hospital, Pessac, France
| | - M Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South, Wales
| | - J-J Tuech
- Department of Digestive Surgery, Charles Nicolle Hospital, Rouen University Hospital, Rouen, France
| | - L Ghouti
- Department of General and Digestive Surgery, Purpan Hospital, Toulouse University Hospital, Toulouse, France
| | - E Cotte
- Department of Digestive Surgery, Pierre-Bénite Hospital, Lyon University Hospital, Lyon, France
| | - Y Panis
- Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique - Hôpitaux de Paris, University Denis Diderot (Paris VII), Clichy, France
| | - B Lelong
- Department of Oncological Surgery, Paoli-Calmettes Institute, Marseille, France
| | - P Rouanet
- Department of Surgery, Montpellier Cancer Institute, University of Montpellier, Montpellier, France
| | - J-L Faucheron
- Colorectal Unit, Department of Surgery, Michallon Hospital, Grenoble University Hospital, Grenoble, France
| | - M Jafari
- Department of Oncological Surgery, Oscar Lambret Centre, Lille, France
| | - J H Lefevre
- Department of General and Digestive Surgery, Saint-Antoine Hospital, Sorbonne Université, Paris, France
| | - E Rullier
- Department of Digestive Surgery, Colorectal Unit, Haut-leveque Hospital, Bordeaux University Hospital, Pessac, France
| | - A Heriot
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - K Austin
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South, Wales
| | - P Lee
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South, Wales
| | - W Brown
- Surgical Outcome Research Centre, Royal Prince Alfred Hospital, University of Sydney, Sydney, New South, Wales
| | - H Maillou-Martinaud
- Department of Digestive Surgery, Colorectal Unit, Haut-leveque Hospital, Bordeaux University Hospital, Pessac, France
| | - H Savel
- Methodological Support Unit for Clinical and Epidemiological, Bordeaux, France
| | - B Quintard
- Bordeaux University Laboratoire de Psychologie EA 4136 'Handicap, Activité, Cognition, Santé', Institut National de la Santé et de la Recherche Médicale (INSERM), Unité Mixte de Recherche (U)1219 - Bordeaux Population Health.,INSERM, Bordeaux School of Public Health (INSPED), Centre INSERM U1219 - Bordeaux Population Health, Team EMOS, Bordeaux, France
| | - G Broc
- University Paul Valéry Montpellier 3, University of Montpellier, Epsylon EA 4556, Montpellier, France
| | - F Saillour-Glénisson
- Service d'Information Médicale, Public Health Centre, Centre Hospitalier Universitaire, Bordeaux, France.,University of Bordeaux, ISPED, Centre INSERM U1219 - Bordeaux Population Health, Bordeaux, France
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12
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Celarier S, Monziols S, Francois MO, Assenat V, Carles P, Capdepont M, Fleming C, Rullier E, Napolitano G, Denost Q. Randomized trial comparing low-pressure versus standard-pressure pneumoperitoneum in laparoscopic colectomy: PAROS trial. Trials 2020; 21:216. [PMID: 32087762 PMCID: PMC7036186 DOI: 10.1186/s13063-020-4140-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 02/04/2020] [Indexed: 01/07/2023] Open
Abstract
Background Laparoscopy, by its minimally invasive nature, has revolutionized digestive and particularly colorectal surgery by decreasing post-operative pain, morbidity, and length of hospital stay. In this trial, we aim to assess whether low pressure in laparoscopic colonic surgery (7 mm Hg instead of 12 mm Hg) could further reduce pain, analgesic consumption, and morbidity, resulting in a shorter hospital stay. Methods and analysis The PAROS trial is a phase III, double-blind, randomized controlled trial. We aim to recruit 138 patients undergoing laparoscopic colectomy. Participants will be randomly assigned to either a low-pressure group (7 mm Hg) or a standard-pressure group (12 mm Hg). The primary outcome will be a comparison of length of hospital stay between the two groups. Secondary outcomes will compare post-operative pain, consumption of analgesics, morbidity within 30 days, technical and oncological quality of the surgical procedure, time to passage of flatus and stool, and ambulation. All adverse events will be recorded. Analysis will be performed on an intention-to-treat basis. Trial registration This research received the approval from the Committee for the Protection of Persons and was the subject of information to the ANSM. This search is saved in the ID-RCB database under registration number 2018-A03028–47. This research is retrospectively registered January 23, 2019, at http://clinicaltrials.gov/ed under the name “LaPAroscopic Low pRessure cOlorectal Surgery (PAROS)”. This trial is ongoing.
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Affiliation(s)
- S Celarier
- Department of digestive Surgery, Colorectal Unit, Bordeaux University Hospital, 1 Avenue de Magellan, Pessac, 33600, France
| | - S Monziols
- Department of Anesthesia ans Critical Care, Bordeaux University Hospital, 1 Avenue de Magellan, Pessac, 33600, France
| | - M O Francois
- Department of digestive Surgery, Colorectal Unit, Bordeaux University Hospital, 1 Avenue de Magellan, Pessac, 33600, France
| | - V Assenat
- Department of digestive Surgery, Colorectal Unit, Bordeaux University Hospital, 1 Avenue de Magellan, Pessac, 33600, France
| | - P Carles
- Department of Anesthesia ans Critical Care, Bordeaux University Hospital, 1 Avenue de Magellan, Pessac, 33600, France
| | - M Capdepont
- Department of digestive Surgery, Colorectal Unit, Bordeaux University Hospital, 1 Avenue de Magellan, Pessac, 33600, France
| | - C Fleming
- Department of digestive Surgery, Colorectal Unit, Bordeaux University Hospital, 1 Avenue de Magellan, Pessac, 33600, France
| | - E Rullier
- Department of digestive Surgery, Colorectal Unit, Bordeaux University Hospital, 1 Avenue de Magellan, Pessac, 33600, France
| | - G Napolitano
- Department of Anesthesia ans Critical Care, Bordeaux University Hospital, 1 Avenue de Magellan, Pessac, 33600, France
| | - Q Denost
- Department of digestive Surgery, Colorectal Unit, Bordeaux University Hospital, 1 Avenue de Magellan, Pessac, 33600, France. .,Department of digestive Surgery, Bordeaux University Hospital, 1 Avenue de Magellan, Pessac, 33600, France.
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13
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Lakkis Z, Vernerey D, Mege D, Faucheron JL, Panis Y, Tuech JJ, Lefevre JH, Brouquet A, Dumont F, Borg C, Woronoff AS, Meurisse A, Heyd B, Rullier E. Morbidity and oncological outcomes of rectal cancer impaired by previous prostate malignancy. Br J Surg 2019; 106:1087-1098. [PMID: 31074509 DOI: 10.1002/bjs.11176] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 02/02/2019] [Accepted: 02/15/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Specific surgical and oncological outcomes in patients with rectal cancer surgery after a previous diagnosis of prostate cancer have not been well described. The aim of this study was to compare surgical outcomes in patients with rectal cancer with or without a history of prostate cancer. METHODS Patients who had surgery for rectal cancer with (PC group) or without (no-PC group) previous curative treatment for prostate cancer were enrolled between January 2001 and December 2015. Comparisons between the two groups were performed by multivariable Cox analysis, and after propensity score matching in a 3 : 1 ratio for demographic and tumour characteristics, and surgical and oncological outcomes. RESULTS A total of 944 patients with rectal cancer were enrolled, of whom 10·8 per cent had a history of prostate cancer. After matching, 83 patients who had received treatment for prostate cancer were compared with 249 who had not. The PC and no-PC groups were similar regarding patient characteristics. Extended total mesorectal excision, conversion to open surgery, transfusion and tumour perforation were more frequent in the PC group than in the no-PC group. Major surgical morbidity (28 versus 17·2 per cent; P = 0·036), anastomotic leakage (25 versus 13·7 per cent; P = 0·019) and permanent stoma (41 versus 12·4 per cent; P < 0·001) occurred more frequently in the PC group. Local recurrence was increased significantly in the PC group (17 versus 8·0 per cent; P = 0·019), and resulted in a significant decrease in disease-free and overall survival. CONCLUSION Prostate cancer treatment increases short- and long-term surgical morbidity in patients with rectal cancer, and impairs oncological outcomes.
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Affiliation(s)
- Z Lakkis
- Department of Digestive Surgery, University Hospital of Besançon, Besançon, France
| | - D Vernerey
- Methodological and Quality of Life Unit in Oncology, Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche 1098, University Hospital of Besançon, Besançon, France
| | - D Mege
- Department of Digestive and General Surgery, Timone Hospital, Marseille, France
| | - J-L Faucheron
- Colorectal Unit, Department of Surgery, Michallon University Hospital, Grenoble, France
| | - Y Panis
- Department of Colorectal Surgery, Beaujon Hospital, Clichy, France
| | - J-J Tuech
- Department of Digestive Surgery, Rouen University Hospital, Rouen, France
| | - J H Lefevre
- Department of General and Digestive Surgery, Saint-Antoine Hospital, Sorbonne Université, Paris, France
| | - A Brouquet
- Department of Digestive and Oncological Surgery, Bicêtre Hospital, Paris, France
| | - F Dumont
- General Surgical Oncology Department, Gustave Roussy, Villejuif, France
| | - C Borg
- Department of Medical Oncology, University Hospital of Besançon, Besançon, France
| | - A-S Woronoff
- Department of Doubs and Belfort Territory Cancer Registry, University Hospital of Besançon, Besançon, France
| | - A Meurisse
- Methodological and Quality of Life Unit in Oncology, Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche 1098, University Hospital of Besançon, Besançon, France
| | - B Heyd
- Department of Digestive Surgery, University Hospital of Besançon, Besançon, France
| | - E Rullier
- Department of Colorectal Surgery, Haut-Lévèque Hospital, Pessac, France
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14
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Read J, Tekkis P, Rullier E, Nicholls J, Mortensen N, Marks J, Steele RJC, Brown G. Session 3: Many ways to organ preserve the rectum but which is correct? Colorectal Dis 2018; 20 Suppl 1:82-87. [PMID: 29878680 DOI: 10.1111/codi.14085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
From the patient's perspective, cancer cure with full preservation of function is a crucial goal. There are many advances that have emerged which may make this possible in a greater proportion of patients without compromising oncological outcomes. Professor Tekkis reviews the options and evidence to date for 'organ preservation' and the expert panel discuss the implications for current and future patient care.
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Affiliation(s)
- J Read
- The Royal Marsden NHS Foundation Trust, London, UK
| | - P Tekkis
- The Royal Marsden NHS Foundation Trust, London, UK
| | - E Rullier
- Saint-Andre Hospital, University of Bordeaux, Bordeaux, France
| | | | | | - J Marks
- Lankenau Hospital, Wynnewood, Pennsylvania, USA
| | - R J C Steele
- Prevention, Early Detection and Treatment of Colorectal Cancer, University of Dundee, Dundee, UK
| | - G Brown
- The Royal Marsden NHS Foundation Trust, London, UK.,Imperial College London, London, UK
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15
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Borstlap WAA, van Oostendorp SE, Klaver CEL, Hahnloser D, Cunningham C, Rullier E, Bemelman WA, Tuynman JB, Tanis PJ. Organ preservation in rectal cancer: a synopsis of current guidelines. Colorectal Dis 2017; 20:201-210. [PMID: 29136328 DOI: 10.1111/codi.13960] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 08/14/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND The high morbidity associated with radical resection for rectal cancer is an incentive for surgeons to adopt strategies aimed at organ preservation, particularly for early disease. There are a number of different approaches to achieve this. In this study we have collated current national and international guidelines to produce a synopsis to support this changing practice. METHODS The databases PubMed, Embase, Trip database, national guideline clearinghouse, BMJ Best practice were interrogated. Guidelines published before 2010 were excluded. The AGREE-II tool was used for quality assessment. RESULTS 24 guidelines were drawn from 2278 potential publications. A consensus exists for local excision for "low risk" T1 rectal cancer but there is no agreement how to stratify the risk of treatment failure. There is a low level of agreement for rectal preservation for more advanced disease but when mentioned is recommended for unfit patients or in th context of a clinical trial. Guidelines are inconsistent with respect to surveillance in node negative disease and after, complete response to chemoradiotherapy CONCLUSION: According to current guidelines and consensus statements organ preservation for rectal cancer beyond low risk T1, is still considered experimental and only indicated in patients unsuitable for radical surgery.. Follow up strategies and cN0 staging deserve attention and highlight the need for high quality clinical trials. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- W A A Borstlap
- Department of Surgery, Academic Medical Center, University of Amsterdam, the Netherlands
| | | | - C E L Klaver
- Department of Surgery, Academic Medical Center, University of Amsterdam, the Netherlands
| | - D Hahnloser
- Department of Surgery, Lausanne University Hospital, Lausanne, Switzerland
| | - C Cunningham
- Department of Surgery, John Radcliffe Hospital, Oxford, UK
| | - E Rullier
- Department of Colorectal Surgery, Haut-Lévèque Hospital, Bordeaux, France
| | - W A Bemelman
- Department of Surgery, Academic Medical Center, University of Amsterdam, the Netherlands
| | - J B Tuynman
- Department of Surgery, VU Medical Center, Amsterdam, the Netherlands
| | - P J Tanis
- Department of Surgery, Academic Medical Center, University of Amsterdam, the Netherlands
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16
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Baird DLH, Denost Q, Simillis C, Pellino G, Rasheed S, Kontovounisios C, Tekkis PP, Rullier E. The effect of adjuvant chemotherapy on survival and recurrence after curative rectal cancer surgery in patients who are histologically node negative after neoadjuvant chemoradiotherapy. Colorectal Dis 2017; 19:980-986. [PMID: 28493401 DOI: 10.1111/codi.13714] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 03/20/2017] [Indexed: 02/08/2023]
Abstract
AIM The aim of this study was to evaluate whether adjuvant chemotherapy will affect recurrence rate or disease-free and overall survival in patients with rectal adenocarcinoma who were staged with MRI node-positive disease (mrN+) preoperatively. These patients underwent neoadjuvant chemoradiotherapy with curative rectal cancer surgery and their pathological staging was negative for nodal disease (ypN0). There is no consensus on the role of adjuvant chemotherapy in such patients. METHOD Patients who received neoadjuvant chemoradiotherapy and underwent curative rectal cancer surgery for rectal adenocarcinoma staged as [mrTxN+M0] on MRI staging and who on pathological staging were found to be [ypTxN0M0] were retrospectively identified from January 2008 December 2012 from two tertiary referral centres (Royal Marsden Hospital, London and Saint-Andre Hospital, Bordeaux). RESULTS One hundred and sixty-three patients were recruited and, after propensity matching at a ratio of 2:1, n = 80 patients were divided to receive adjuvant (n = 28) or no adjuvant treatment (n = 52). A comparison of adjuvant chemotherapy vs no adjuvant therapy showed that the mean overall survival was 2.67 vs 3.60 years (P = 0.42) and disease-free survival was 2.27 vs 3.32 years (P = 0.14). CONCLUSION This study found no significant difference in survival or disease recurrence between patients who received adjuvant chemotherapy and patients who did not. There is no clear evidence to support or dismiss the use of adjuvant chemotherapy for patients who were node positive on preoperative MRI and node negative on histopathological staging. Further multicentre prospective randomized trials are needed to identify the appropriate treatment regime for this group of patients.
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Affiliation(s)
- D L H Baird
- The Royal Marsden Hospital, London, UK.,Imperial College, London, UK
| | - Q Denost
- Saint-Andre Hospital, University of Bordeaux, Bordeaux, France
| | | | - G Pellino
- The Royal Marsden Hospital, London, UK
| | - S Rasheed
- The Royal Marsden Hospital, London, UK.,Imperial College, London, UK.,Chelsea and Westminster Hospital, London, UK
| | - C Kontovounisios
- The Royal Marsden Hospital, London, UK.,Imperial College, London, UK.,Chelsea and Westminster Hospital, London, UK
| | - P P Tekkis
- The Royal Marsden Hospital, London, UK.,Imperial College, London, UK.,Chelsea and Westminster Hospital, London, UK
| | - E Rullier
- Saint-Andre Hospital, University of Bordeaux, Bordeaux, France
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17
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Rouanet P, Rullier E, Lelong B, Maingon P, Tuech Jean J, Pezet D, Rivoire M, Meunier B, Nougaret S, Castan F, Lemanski C, Gourgou S, Ychou M. O-021 Tailored strategy for locally-advanced rectal carcinoma: preliminary results of a phase II multicenter trial (GRECCAR 4). Ann Oncol 2016. [DOI: 10.1093/annonc/mdw198.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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18
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Celerier B, Denost Q, Van Geluwe B, Pontallier A, Rullier E. The risk of definitive stoma formation at 10 years after low and ultralow anterior resection for rectal cancer. Colorectal Dis 2016; 18:59-66. [PMID: 26391723 DOI: 10.1111/codi.13124] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 05/15/2015] [Indexed: 12/11/2022]
Abstract
AIM The long-term risk of definitive stoma after sphincter-saving resection (SSR) for rectal cancer is underestimated and has never been reported for ultralow conservative surgery. We report the 10-year risk of definitive stoma after SSR for low rectal cancer. METHOD From 1994 to 2008, patients with low rectal cancer who were suitable for SSR were analysed retrospectively. Patients were divided into the following four groups: low colorectal anastomosis (LCRA); coloanal anastomosis (CAA); partial intersphincteric resection (pISR); and total intersphincteric resection (tISR). The end-point was the risk of a definitive stoma according to the type of anastomosis. RESULTS During the study period, 297 patients had SSR for low rectal cancer. The incidence of definitive stoma increased from 11% at 1 year to 22% at 10 years. The reasons were no closure of the loop ileostomy (4.7%), anastomotic morbidity (6.5%), anal incontinence (8%) and local recurrence (5.2%). The risk of definitive stoma was not influenced by type of surgery: 26% vs 18% vs 18% vs 19% (P = 0.578) for LCRA, CAA, pISR and tISR, respectively. Independent risk factors for definitive stoma were age > 65 years and surgical morbidity. CONCLUSION The risk of a definitive stoma after SSR increased two-fold between 1 and 10 years after surgery, from 11% to 22%. Ultralow conservative surgery (pISR and tISR) did not increase the risk of definitive stoma compared with conventional CAA or LCRA.
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Affiliation(s)
- B Celerier
- Department of Digestive Surgery, CHU Bordeaux, Saint André Hospital, Bordeaux, France.,Université Bordeaux Segalen, Bordeaux, France
| | - Q Denost
- Department of Digestive Surgery, CHU Bordeaux, Saint André Hospital, Bordeaux, France.,Université Bordeaux Segalen, Bordeaux, France
| | - B Van Geluwe
- Department of Digestive Surgery, CHU Bordeaux, Saint André Hospital, Bordeaux, France.,Université Bordeaux Segalen, Bordeaux, France
| | - A Pontallier
- Department of Digestive Surgery, CHU Bordeaux, Saint André Hospital, Bordeaux, France.,Université Bordeaux Segalen, Bordeaux, France
| | - E Rullier
- Department of Digestive Surgery, CHU Bordeaux, Saint André Hospital, Bordeaux, France.,Université Bordeaux Segalen, Bordeaux, France
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Denost Q, Faucheron J, Lefevre J, Panis Y, Cotte E, Rouanet P, Jafari M, Capdepont M, Rullier E, Pezet, Tuech, Benchimol, Massard, Prudhomme, Gainant, Regimbeau, Chenet, Pautrat, Paineau, Peluchon, Elias, Dumont, Evrard, Beaulieu, Mabrut, Vaudois, Rio, Gouthi, Mauvais, Bresler, Boissel, Tiret, Parc, Glehen, Rohr, Sastre, Paineau, Chenet, Fancois, Singier, Voirin, Risse, Quenet, Joyeux, Saint-Aubert, Khalil. French current management and oncological results of locally recurrent rectal cancer. Eur J Surg Oncol 2015; 41:1645-52. [DOI: 10.1016/j.ejso.2015.09.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 08/26/2015] [Accepted: 09/22/2015] [Indexed: 12/18/2022] Open
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Buscail E, Blondeau V, Adam JP, Pontallier A, Laurent C, Rullier E, Denost Q. Surgery for rectal cancer after high-dose radiotherapy for prostate cancer: is sphincter preservation relevant? Colorectal Dis 2015; 17:973-9. [PMID: 25824545 DOI: 10.1111/codi.12962] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 02/23/2015] [Indexed: 12/14/2022]
Abstract
AIM The feasibility and outcome of sphincter-saving resection for rectal cancer were assessed in patients previously treated by high-dose radiotherapy for prostate cancer. METHOD Between 2000 and 2012, 1066 patients underwent rectal excision for rectal cancer. Of these, 236 were treated by conventional radiotherapy (45 Gy) and sphincter-saving resection (Group A) and 12 were treated by external-beam radiotherapy (EBRT) for prostate cancer (70 Gy) and sphincter-saving resection (Group B) of whom five had a metachronous and seven a synchronous cancer. The end-points were surgical morbidity, pelvic sepsis, reoperation and definitive stoma. RESULTS Tumour characteristics were similar in both groups. Surgical morbidity (67% vs 25%, P = 0.004), anastomotic leakage (50% vs 10%, P = 0.001, and reoperation (50% vs 17%, P = 0.011) were significantly higher in Group B. Multivariate analyses showed that EBRT for prostate cancer was the only independent factor for anastomotic leakage (OR = 5.12; 95% CI 1.45-18.08; P = 0.011) and definitive stoma (OR = 10.56; 95% CI 3.02-39.92; P < 0.001). CONCLUSION High-dose radiotherapy for prostate cancer increases morbidity from rectal surgery and the risk of a permanent stoma. This suggests that a delayed coloanal anastomosis or a Hartmann procedure should be proposed as an alternative to low anterior resection in this population.
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Affiliation(s)
- E Buscail
- Department of Digestive Surgery and Université Bordeaux Segalen, CHU Bordeaux, Saint André Hospital, Bordeaux, France
| | - V Blondeau
- Department of Digestive Surgery and Université Bordeaux Segalen, CHU Bordeaux, Saint André Hospital, Bordeaux, France
| | - J-P Adam
- Department of Digestive Surgery and Université Bordeaux Segalen, CHU Bordeaux, Saint André Hospital, Bordeaux, France
| | - A Pontallier
- Department of Digestive Surgery and Université Bordeaux Segalen, CHU Bordeaux, Saint André Hospital, Bordeaux, France
| | - C Laurent
- Department of Digestive Surgery and Université Bordeaux Segalen, CHU Bordeaux, Saint André Hospital, Bordeaux, France
| | - E Rullier
- Department of Digestive Surgery and Université Bordeaux Segalen, CHU Bordeaux, Saint André Hospital, Bordeaux, France
| | - Q Denost
- Department of Digestive Surgery and Université Bordeaux Segalen, CHU Bordeaux, Saint André Hospital, Bordeaux, France
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21
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Messager M, Sabbagh C, Denost Q, Regimbeau JM, Laurent C, Rullier E, Sa Cunha A, Mariette C. Is there still a need for prophylactic intra-abdominal drainage in elective major gastro-intestinal surgery? J Visc Surg 2015; 152:305-13. [PMID: 26481067 DOI: 10.1016/j.jviscsurg.2015.09.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Prophylactic drainage of the abdominal cavity after gastro-intestinal surgery is widely used. The rationale is that intra-abdominal drainage enhances early detection of complications (gastro-intestinal leakage, hemorrhage, bile leak), prevents collection of fluid or pus, reduces morbidity and mortality, and decreases the duration of hospital stay. However, dogmatic attitudes favoring systematic drain placement should be questioned. The aim of this review was to evaluate the evidence supporting systematic use of prophylactic abdominal drainage following gastrectomy, pancreatectomy, liver resection, and rectal resection. Based on this review of the literature: (i) there was no evidence in favor of intra-peritoneal drainage following total or sub-total gastrectomy with respect to morbidity-mortality, nor was it helpful in the diagnosis or management of leakage, however the level of evidence is low, (ii) following pancreatic resection, data are conflicting but, overall, suggest that the absence of drainage is prejudicial, and support the notion that short-term drainage is better than long-term drainage, (iii) after liver resection without hepatico-intestinal anastomosis, high level evidence supports that there is no need for abdominal drainage, and (iv) following rectal resection, data are insufficient to establish recommendations. However, results from the French multicenter randomized controlled trial GRECCAR5 (NCT01269567) should provide new evidence this coming year. Accumulating data support that systematic drainage of the abdominal cavity in digestive surgery is a non-beneficial and obsolete practice, except following pancreatectomy where the consensus appears to indicate the usefulness of short-term drainage. While the level of evidence is high for liver resections, new randomized controlled trials are awaited regarding gastric, pancreatic and rectal surgery.
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Affiliation(s)
- M Messager
- Service de Chirurgie Digestive et Générale, Centre Hospitalier Régional Universitaire de Lille, Hôpital Claude-Huriez, Place de Verdun, 59037 Lille cedex, France
| | - C Sabbagh
- Service de Chirurgie Digestive et Oncologique, CHU d'Amiens, Amiens, France
| | - Q Denost
- Service de Chirurgie Colorectale, Hôpital Saint-André, CHU de Bordeaux, Bordeaux, France
| | - J M Regimbeau
- Service de Chirurgie Digestive et Oncologique, CHU d'Amiens, Amiens, France
| | - C Laurent
- Service de Chirurgie Colorectale, Hôpital Saint-André, CHU de Bordeaux, Bordeaux, France
| | - E Rullier
- Service de Chirurgie Colorectale, Hôpital Saint-André, CHU de Bordeaux, Bordeaux, France
| | - A Sa Cunha
- Service de Chirurgie Digestive, Hôpital Paul-Brousse, Villejuif, France
| | - C Mariette
- Service de Chirurgie Digestive et Générale, Centre Hospitalier Régional Universitaire de Lille, Hôpital Claude-Huriez, Place de Verdun, 59037 Lille cedex, France.
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Denost Q, Quintane L, Buscail E, Martenot M, Laurent C, Rullier E. Short- and long-term impact of body mass index on laparoscopic rectal cancer surgery. Colorectal Dis 2013; 15:463-9. [PMID: 23534683 DOI: 10.1111/codi.12026] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
AIM Obesity is associated with increased technical difficulty in laparoscopic surgery. However, its impact has been measured mainly for colectomy but not specifically for rectal excision. The aim of the study was to assess the impact of body mass index (BMI) on technical feasibility and oncological outcome of laparoscopic rectal excision for cancer. METHOD A total of 490 patients treated by laparoscopic rectal excision for rectal cancer from January 1999 to June 2010 were included. Seventy per cent had had preoperative radiochemotherapy. Patients were separated into four groups according to BMI (kg/m(2) ): < 20, 20-25, 25-30 and ≥ 30. The impact of BMI on conversion, surgical morbidity, quality of excision (Quirke mesorectal grade and circumferential resection margin) and long-term oncological outcome was determined. RESULTS Among the 490 patients BMI was < 20 in 43, 20-25 in 223, 25-30 in 177 and ≥ 30 in 47. Mortality (overall 1%) and morbidity (overall 19%) were similar between the groups. Conversion in the four groups was 5%, 14%, 23% and 32% (P = 0.001). The quality of mesorectal excision and circumferential margins did not differ between the groups. The 5-year local recurrence rates (0%, 4.6%, 5.3% and 5.9% respectively; P = 0.823) and the overall and disease-free survival were not significantly influenced by BMI. CONCLUSION In laparoscopic surgery for rectal cancer, BMI influenced the risk of conversion but not surgical morbidity, quality of surgery and survival. This suggests that all patients, including obese patients, are suitable for laparoscopic surgery.
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Affiliation(s)
- Q Denost
- CHU Bordeaux, Saint-Andre Hospital, Digestive Surgery, Bordeaux, F-33075, France
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Abstract
AIM Laparoscopic sphincter-saving surgery has been investigated for rectal cancer but not for tumours of the lower third. We evaluated the feasibility and efficacy of laparoscopic intersphincteric resection for low rectal cancer. METHOD From 1990 to 2007, patients with rectal tumour below 6 cm from the anal verge and treated by open or laparoscopic curative intersphincteric resection were included in a retrospective comparative study. Surgery included total mesorectal excision with internal sphincter excision and protected low coloanal anastomosis. Neoadjuvant treatment was given to patients with T3 or N+ tumours. Recurrence and survival were evaluated by the Kaplan-Meier method and compared using the Logrank test. Function was assessed using the Wexner continence score. RESULTS Intersphincteric resection was performed in 175 patients with low rectal cancer: 110 had laparoscopy and 65 had open surgery. The two groups were similar according to age, sex, body mass index, ASA score, tumour stage and preoperative radiotherapy. Postoperative mortality (zero) and morbidity (23%vs 28%; P = 0.410) were similar in both groups. There was no difference in 5-year local recurrence (5%vs 2%; P = 0.349) and 5-year disease-free survival (70%vs 71%; P = 0.862). Function and continence scores (11 vs 12; P = 0.675) were similar in both groups. CONCLUSION Intersphincteric resection did not alter long-term tumour control of low rectal cancer. The safety and efficacy of the laparoscopic approach for intersphincteric resection are suggested by a similar short- and long-term outcome as obtained by open surgery.
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Affiliation(s)
- C Laurent
- CHU Bordeaux, Saint André Hospital, Department of Digestive Surgery, Bordeaux, France Université Victor Segalen Bordeaux 2, Bordeaux, France.
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Abstract
Rectal excision is the standard in rectal cancer treatment. The morbidity of rectal excision, together with the low rate of positive lymph nodes in patients with a good response after radiochemotherapy, raises the challenging concept of organ preservation. Patients with a complete response can benefit from a nonoperative strategy based on a strict follow up. Those with a complete or subcomplete response can be treated by local excision. Limitations in accurately assessing a complete response by conventional and modern imaging modalities suggest that local excision is more appropriate for the majority of patients when organ preservation is being considered. The encouraging results of retrospective series of local excision in downstaged clinical T2/T3 low rectal cancer after radiochemotherapy, however, need to be confirmed by the ongoing multicentre phase II United States and phase III French trials before routinely proposing organ preservation in patients with a good response.
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Affiliation(s)
- E Rullier
- Department of Surgery, Saint-Andre Hospital, Victor Segalen University of Bordeaux, Bordeaux, France.
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Gallas S, Michot F, Faucheron JL, Meurette G, Lehur PA, Barth X, Damon H, Mion F, Rullier E, Zerbib F, Sielezneff I, Ouaïssi M, Orsoni P, Desfourneaux V, Siproudhis L, Mathonnet M, Menard JF, Leroi AM. Predictive factors for successful sacral nerve stimulation in the treatment of faecal incontinence: results of trial stimulation in 200 patients. Colorectal Dis 2011; 13:689-96. [PMID: 20236144 DOI: 10.1111/j.1463-1318.2010.02260.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
AIM Sacral nerve stimulation (SNS) has a place in the treatment algorithm for faecal incontinence (FI). However, after implantation, 15-30% of patients with FI fail to respond for unknown reasons. We investigated the effect of SNS on continence and quality of life (QOL) and tried to identify specific predictive factors of the success of permanent SNS in the treatment of FI. METHOD Two hundred consecutive patients (six men; median age = 60; range 16-81) underwent permanent implantation for FI. The severity of FI was evaluated by the Cleveland Clinic Score. Quality of life was evaluated by the French version of the American Society of Colon and Rectal Surgeons (ASCRS) quality of life questionnaire (FIQL). All patients underwent a preoperative evaluation. After permanent implantation, severity and QOL scores were reevaluated after six and 12 months and then once a year. RESULTS The severity scores were significantly reduced during SNS (P = 0.001). QOL improved in all domains. At the 6-month follow-up, the clinical outcome of the permanent implant was not affected by age, gender, duration of symptoms, QOL, main causes of FI, anorectal manometry or endoanal ultrasound results. Only loose stool consistency (P = 0.01), persistent FI even though diarrhoea was controlled by medical treatment (P = 0.004), and low stimulation intensity (P = 0.02) were associated with improved short-term outcomes. Multivariate analysis confirmed that loose stool consistency and low stimulation intensity were related to a favourable outcome. CONCLUSION Stool consistency and low stimulation intensity have been identified as predictive factors for the short-term outcome of SNS.
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Affiliation(s)
- S Gallas
- ADEN EA 3234 ⁄ IFR MP 23, Rouen University Hospital, Grenoble, France
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Maggiori L, Rullier E, Meyer C, Portier G, Faucheron JL, Panis Y. Randomized controlled trial of pelvic calcium alginate following rectal cancer surgery. Br J Surg 2010; 97:479-84. [DOI: 10.1002/bjs.6917] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Abstract
Background
The aim of this randomized controlled trial was to assess the possible benefit of using a new haemostatic agent (Hémoionic®) in the pelvic cavity in sphincter-saving surgery for rectal cancer.
Methods
Eighty-five patients undergoing elective sphincter-saving rectal resection for cancer were randomized into Hémoionic® (41 patients) and control (44) groups. In both groups, a pelvic suction drain was left in place for as long as the daily output exceeded 20 ml. The primary endpoint was volume of fluid collected by the suction drain; secondary endpoints were duration of drainage, and postoperative mortality and morbidity rates.
Results
The mean total drainage volume was significantly lower in the Hémoionic® group (453 ml versus 758 ml in control group; P = 0·031). There was no significant difference between groups in duration of drainage and morbidity. The mortality rate was four of 41 in the Hémoionic® group and one of 44 in the control group (P = 0·192).
Conclusion
Hémoionic® may reduce the drainage volume after sphincter-saving surgery for rectal cancer, but offers no clinical advantage. Registration number: ISRCTN79721331 (http://www.isrctn.org).
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Affiliation(s)
- L Maggiori
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif, Beaujon Hospital, Assistance Publique–Hôpitaux de Paris, Clichy, France
| | - E Rullier
- Department of Digestive Surgery, Saint-André Hospital, Bordeaux, France
| | - C Meyer
- Department of Digestive Surgery, Hautepierre Hospital, Strasbourg, France
| | - G Portier
- Department of Digestive Surgery, Purpan Hospital, Toulouse, France
| | - J L Faucheron
- Department of Digestive Surgery, Michallon Hospital, Grenoble, France
| | - Y Panis
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif, Beaujon Hospital, Assistance Publique–Hôpitaux de Paris, Clichy, France
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Leroi AM, Damon H, Faucheron JL, Lehur PA, Siproudhis L, Slim K, Barbieux JP, Barth X, Borie F, Bresler L, Desfourneaux V, Goudet P, Huten N, Lebreton G, Mathieu P, Meurette G, Mathonnet M, Mion F, Orsoni P, Parc Y, Portier G, Rullier E, Sielezneff I, Zerbib F, Michot F. Sacral nerve stimulation in faecal incontinence: position statement based on a collective experience. Colorectal Dis 2009; 11:572-83. [PMID: 19508514 DOI: 10.1111/j.1463-1318.2009.01914.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Since the first paper published by Matzel et al., in 1995, on the efficacy of sacral nerve stimulation (SNS) in patients with faecal incontinence, the indications, the contraindications, the stimulation technique and follow up of implanted patients have changed. The aim of this article was to provide a consensus opinion on the management of patients with faecal incontinence treated with SNS. METHOD Recommendations were based on a critical review of the literature when available and on expert opinions in areas with insufficient evidence. RESULTS We have reviewed the indications and contraindications, proposed an algorithm for patient management showing the place of SNS. The temporary test technique, the implantation technique, the patient follow up and the approach in case of treatment failure were discussed. CONCLUSION We hope not only to provide a guide on patient management to clinical practitioners interested in SNS but also to harmonize our practices.
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Affiliation(s)
- A M Leroi
- ADEN EA 3234/IFRMP 23, Faculté de Médecine de Rouen, France.
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Leblanc F, Laurent C, Rullier E. [Not Available]. J Chir (Paris) 2008; 145S4:12S40-12S43. [PMID: 22793984 DOI: 10.1016/s0021-7697(08)74721-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
F. Leblanc, C. Laurent E. Rullier Lymph node dissection is a standard part of surgical resection of rectal cancer which helps to avoid local recurrence and allows for accurate staging of the disease. Three types of lymph node dissection have been considered. Mesorectal lymphadenectomy should remove the mesorectum systematically and should extend at least 5cm distal to the tumor. Inferior mesenteric lymphadenectomy should extend at least to the origin of the left colic artery. Lateral lymphadenectomy removing iliac and obturator nodes results in complications and has not been shown to improve survival; it is not routinely recommended. Omission of lymph node dissection is only proposed for the smallest T1 tumors with favorable histology.
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Leblanc F, Laurent C, Rullier E. [Not Available]. J Chir (Paris) 2008; 145:12S40-12S43. [PMID: 22794071 DOI: 10.1016/s0021-7697(08)45008-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
F. Leblanc, C. Laurent E. Rullier Lymph node dissection is a standard part of surgical resection of rectal cancer which helps to avoid local recurrence and allows for accurate staging of the disease. Three types of lymph node dissection have been considered. Mesorectal lymphadenectomy should remove the mesorectum systematically and should extend at least 5cm distal to the tumor. Inferior mesenteric lymphadenectomy should extend at least to the origin of the left colic artery. Lateral lymphadenectomy removing iliac and obturator nodes results in complications and has not been shown to improve survival; it is not routinely recommended. Omission of lymph node dissection is only proposed for the smallest T1 tumors with favorable histology.
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Leblanc F, Laurent C, Rullier E. [Can lymph node dissection for rectal cancer ever be omitted?]. J Chir (Paris) 2008; 145 Spec no. 4:12S40-12S43. [PMID: 19194357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Lymph node dissection is a standard part of surgical resection of rectal cancer which helps to avoid local recurrence and allows for accurate staging of the disease. Three types of lymph node dissection have been considered. Mesorectal lymphadenectomy should remove the mesorectum systematically and should extend at least 5 cm distal to the tumor. Inferior mesenteric lymphadenectomy should extend at least to the origin of the left colic artery. Lateral lymphadenectomy removing iliac and obturator nodes results in complications and has not been shown to improve survival; it is not routinely recommended. Omission of lymph node dissection is only proposed for the smallest T1 tumors with favorable histology.
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Affiliation(s)
- F Leblanc
- Service de chirurgie digestive, hôpital Saint-André, Bordeaux
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Abstract
BACKGROUND No long-term advantage of the laparoscopic approach has been demonstrated in colorectal surgery. This study compared the risk of incisional hernia between laparoscopic and open surgery for rectal cancer. METHODS Between 1994 and 2004, patients who had restorative mesorectal excision for rectal cancer by laparoscopy were compared with those treated by open surgery. Follow-up was prospective, and incisional hernia was considered to be any abdominal wound dehiscence occurring at the midline, extraction, trocar or ileostomy site. Cumulative risks of hernia were evaluated by the Kaplan-Meier method and compared with the log rank test. RESULTS Some 155 patients had a laparoscopic and 165 an open procedure. The two groups were similar in terms of age, sex, body mass index, tumour stage, loop ileostomy and morbidity. The conversion rate was 20.6 per cent. The rate of incisional hernia in all patients was 11.4 per cent at 1 year, 21.1 per cent at 2 years and 23.7 per cent at 5 years. The rate of hernia at 5 years was significantly lower in the laparoscopic than in the open group (13.0 versus 33.0 per cent; P < 0.001). The rate of hernia due specifically to the laparoscopic procedure (extraction and trocar sites) was ten times less than that after a primary or secondary open procedure (2.1 versus 16.1-33.1 per cent; P < 0.001). CONCLUSION The laparoscopic approach decreases the risk of long-term incisional hernia following restorative mesorectal excision for rectal cancer. The benefit is most apparent in patients without conversion or postoperative complication.
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Affiliation(s)
- C Laurent
- Department of Surgery, Saint-Andre Hospital, Victor-Segalen University, Bordeaux, France.
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Laurent C, Leblanc F, Gineste C, Saric J, Rullier E. Laparoscopic approach in surgical treatment of rectal cancer. Br J Surg 2007. [PMID: 17668915 DOI: 10.1002/bjs.588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND High rates of conversion to open operation and morbidity have been reported after laparoscopic total mesorectal excision (TME) with sphincter preservation for rectal cancer. This study examined risk factors for conversion and morbidity to determine which patients with rectal cancer could benefit from a laparoscopic resection. METHODS Two hundred patients (117 men) with mid and low rectal cancer treated by laparoscopic TME were studied. The impact of clinical and pathological characteristics on conversion and complications was assessed by multivariable analysis. RESULTS Reconstruction after TME included 79 low colorectal and 121 coloanal anastomoses. Conversion was necessary in 31 patients (15.5 per cent), and was independently associated with sex, type of anastomosis and intraoperative rectal fixity. Postoperative morbidity in 50 patients (25.0 per cent) was independently associated with sex and type of anastomosis. Men with a stapled anastomosis had a threefold higher rate of conversion (13 (34 per cent) of 38 versus 18 (11.1 per cent) of 162; P < 0.001) and morbidity (22 (58 per cent) versus 28 (17.3 per cent); P < 0.001) than other patients. CONCLUSION Laparoscopic TME is a good option for women and for men treated by coloanal anastomosis. Technical improvement of laparoscopic stapling is needed before the laparoscopic approach can be offered to all patients.
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Affiliation(s)
- C Laurent
- Department of Surgery, Saint-Andre Hospital, 33075 Bordeaux, France.
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Abstract
Abstract
Background
High rates of conversion to open operation and morbidity have been reported after laparoscopic total mesorectal excision (TME) with sphincter preservation for rectal cancer. This study examined risk factors for conversion and morbidity to determine which patients with rectal cancer could benefit from a laparoscopic resection.
Methods
Two hundred patients (117 men) with mid and low rectal cancer treated by laparoscopic TME were studied. The impact of clinical and pathological characteristics on conversion and complications was assessed by multivariable analysis.
Results
Reconstruction after TME included 79 low colorectal and 121 coloanal anastomoses. Conversion was necessary in 31 patients (15·5 per cent), and was independently associated with sex, type of anastomosis and intraoperative rectal fixity. Postoperative morbidity in 50 patients (25·0 per cent) was independently associated with sex and type of anastomosis. Men with a stapled anastomosis had a threefold higher rate of conversion (13 (34 per cent) of 38 versus 18 (11·1 per cent) of 162; P < 0·001) and morbidity (22 (58 per cent) versus 28 (17·3 per cent); P < 0·001) than other patients.
Conclusion
Laparoscopic TME is a good option for women and for men treated by coloanal anastomosis. Technical improvement of laparoscopic stapling is needed before the laparoscopic approach can be offered to all patients.
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Affiliation(s)
- C Laurent
- Department of Surgery, Saint-Andre Hospital, 33075 Bordeaux, France.
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Laurent C, Rullier E. [Intersphincteric rectal resection]. J Chir (Paris) 2007; 144:225-230. [PMID: 17925717 DOI: 10.1016/s0021-7697(07)89520-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
- C Laurent
- Service de Chirurgie Digestive, Hôpital Saint-André, 1 rue Jean Burguet, Bordeaux cedex
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Abstract
PURPOSE Many considerations, such as morbidity, sexual and urinary dysfunction, or risk of definitive stoma have led to the increased popularity of local therapy in the therapeutic strategy for rectal cancer. However, its role in curative intent is still controversial with oncologic long-term results lower than those obtained by radical surgery. METHODS MEDLINE, EMBASE, LILACS, Abstract books, and reference lists from reviews were searched with English language publications to review the current status of evidence for local therapy in rectal cancer, looking especially at the oncologic results and patient selection. We have focused on the new strategies combining neoadjuvant and adjuvant treatment to explain their place in the management of rectal cancer. RESULTS AND CONCLUSIONS The key to potentially curative local treatment for rectal cancer is patient selection by identifying the best candidates with preoperative tumor staging and clinical and pathologic assessment of favorable features. Low-risk T1 is suitable for local excision alone. Limited data suggest that adjuvant chemoradiotherapy may be helpful in patients with unfavorable T1 and T2 lesions, achieving a local recurrence rate<20 percent. However, the efficacy of salvage surgery after local excision is uncertain.
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Affiliation(s)
- F Bretagnol
- Department of Colorectal Surgery, John Radcliffe Hospital, Oxford, United Kingdom.
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Rullier A, Laurent C, Capdepont M, Vendrely V, Bioulac-Sage P, Rullier E. Quel est l’impact pronostique de la réponse tumorale ou down staging dans les cancers du rectum localement avancés ? Ann Pathol 2006. [DOI: 10.1016/s0242-6498(06)78437-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Rullier A, Laurent C, Capdepont M, Vendrely V, Bioulac-Sage P, Rullier E. La réponse tumorale dans les cancers du rectum localement avancés : quelle classification utiliser et dans quel but ? Ann Pathol 2006. [DOI: 10.1016/s0242-6498(06)78438-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Rouanet P, Rivoire M, Lelong B, Rullier E, Dravet F, Mineur L, Vanseymortier L, Pocard M, Faucheron J, Gourgou S, Saint Aubert B. Sphincter preserving surgery after preoperative treatment for ultra-low rectal carcinoma. A French multicenter prospective trial: GRECCAR 1. J Clin Oncol 2006. [DOI: 10.1200/jco.2006.24.18_suppl.3527] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
3527 Background: GRECCAR 1 is a phase III randomised multicenter trial which compared two preoperative treatments for low rectal carcinoma which should be classicaly treated by abdominoperineal resection (Eligibility: distance between the tumor [T] and the levator ani [LA] less than 2 cm). Methods: Between 2001 and 2005, 207 patients with rectal adenocarcinomas were included in 13 French centers. The average distance between the tumor and the levator ani was 0.8 cm. 72% of the tumors were classified T3 with 60% of N1 on pre treatment endorectal ultrasonography. The mean lenght of the tumors was 5 cm on colonoscopy. Preoperative treatment randomisation was made between high dose radiation (HDR: 45 + 18 Gy: 106 patients) and radio-chemotherapy (RTCT: 45 Gy + 5FU continuous infusion: 101 patients). All surgeons performed homogeous technique for intersphincteric resection. Results: Conservative rate was 83% (HDR) and 86% (RTCT) (p: 0.64) with 84% (140/168) of intersphincteric resection. Conservative rate did not differ according to the distance T-LA: 0 cm: 84% / 1–2 cm: 84% and 3 cm: 91%. No post operative mortality was noticed with a 15% post operative morbidity rate, same in the two arms. Sterilized specimen rate was respectively 7% and 12.5% (p: 0.29), the mean inferior safety margin and radial margin was 1 cm and 4 mm, same in the two groups as the 90% R0 resection rate. On specimen, nodal involvement rate was 5.6% for pT0–1, 29% for pT2 and 56% for pT3–4. No difference was seen for down-staging between the two groups (p: 0.59). With a 22 months follow up, we noticed 92% rate of stoma closure in the conservative group. Seven patients had a local recurrence and 25 metastases with 12 patient’s death. Conclusions: GRECCAR 1 is the first prospective randomized trial which shows an 85% rate of sphincter conservative surgery due to down staging induced by preoperative tretament. No significant difference was seen between HDR and RTCT with a trend for more morbidity in the first group. Intersphincteric resection is a safe technical procedure in order to preserv the striated sphincter with sufficient lateral and inferior margins. No significant financial relationships to disclose.
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Affiliation(s)
- P. Rouanet
- CRLC Val d’Aurelle, Montpellier, France; Centre Leon Berard, Lyon, France; Institut Paoli Calmettes, Marseille, France; Hôpital Saint Andre, Bordeaux, France; Centre René Gauducheau, Nantes, France; Institut Sainte Catherine, Avignon, France; Centre Oscar Lambret, Lille, France; Institut Gustave Roussy, Paris, France; CHU, Grenoble, France; Centre Val d’Aurelle, Montpellier, France
| | - M. Rivoire
- CRLC Val d’Aurelle, Montpellier, France; Centre Leon Berard, Lyon, France; Institut Paoli Calmettes, Marseille, France; Hôpital Saint Andre, Bordeaux, France; Centre René Gauducheau, Nantes, France; Institut Sainte Catherine, Avignon, France; Centre Oscar Lambret, Lille, France; Institut Gustave Roussy, Paris, France; CHU, Grenoble, France; Centre Val d’Aurelle, Montpellier, France
| | - B. Lelong
- CRLC Val d’Aurelle, Montpellier, France; Centre Leon Berard, Lyon, France; Institut Paoli Calmettes, Marseille, France; Hôpital Saint Andre, Bordeaux, France; Centre René Gauducheau, Nantes, France; Institut Sainte Catherine, Avignon, France; Centre Oscar Lambret, Lille, France; Institut Gustave Roussy, Paris, France; CHU, Grenoble, France; Centre Val d’Aurelle, Montpellier, France
| | - E. Rullier
- CRLC Val d’Aurelle, Montpellier, France; Centre Leon Berard, Lyon, France; Institut Paoli Calmettes, Marseille, France; Hôpital Saint Andre, Bordeaux, France; Centre René Gauducheau, Nantes, France; Institut Sainte Catherine, Avignon, France; Centre Oscar Lambret, Lille, France; Institut Gustave Roussy, Paris, France; CHU, Grenoble, France; Centre Val d’Aurelle, Montpellier, France
| | - F. Dravet
- CRLC Val d’Aurelle, Montpellier, France; Centre Leon Berard, Lyon, France; Institut Paoli Calmettes, Marseille, France; Hôpital Saint Andre, Bordeaux, France; Centre René Gauducheau, Nantes, France; Institut Sainte Catherine, Avignon, France; Centre Oscar Lambret, Lille, France; Institut Gustave Roussy, Paris, France; CHU, Grenoble, France; Centre Val d’Aurelle, Montpellier, France
| | - L. Mineur
- CRLC Val d’Aurelle, Montpellier, France; Centre Leon Berard, Lyon, France; Institut Paoli Calmettes, Marseille, France; Hôpital Saint Andre, Bordeaux, France; Centre René Gauducheau, Nantes, France; Institut Sainte Catherine, Avignon, France; Centre Oscar Lambret, Lille, France; Institut Gustave Roussy, Paris, France; CHU, Grenoble, France; Centre Val d’Aurelle, Montpellier, France
| | - L. Vanseymortier
- CRLC Val d’Aurelle, Montpellier, France; Centre Leon Berard, Lyon, France; Institut Paoli Calmettes, Marseille, France; Hôpital Saint Andre, Bordeaux, France; Centre René Gauducheau, Nantes, France; Institut Sainte Catherine, Avignon, France; Centre Oscar Lambret, Lille, France; Institut Gustave Roussy, Paris, France; CHU, Grenoble, France; Centre Val d’Aurelle, Montpellier, France
| | - M. Pocard
- CRLC Val d’Aurelle, Montpellier, France; Centre Leon Berard, Lyon, France; Institut Paoli Calmettes, Marseille, France; Hôpital Saint Andre, Bordeaux, France; Centre René Gauducheau, Nantes, France; Institut Sainte Catherine, Avignon, France; Centre Oscar Lambret, Lille, France; Institut Gustave Roussy, Paris, France; CHU, Grenoble, France; Centre Val d’Aurelle, Montpellier, France
| | - J. Faucheron
- CRLC Val d’Aurelle, Montpellier, France; Centre Leon Berard, Lyon, France; Institut Paoli Calmettes, Marseille, France; Hôpital Saint Andre, Bordeaux, France; Centre René Gauducheau, Nantes, France; Institut Sainte Catherine, Avignon, France; Centre Oscar Lambret, Lille, France; Institut Gustave Roussy, Paris, France; CHU, Grenoble, France; Centre Val d’Aurelle, Montpellier, France
| | - S. Gourgou
- CRLC Val d’Aurelle, Montpellier, France; Centre Leon Berard, Lyon, France; Institut Paoli Calmettes, Marseille, France; Hôpital Saint Andre, Bordeaux, France; Centre René Gauducheau, Nantes, France; Institut Sainte Catherine, Avignon, France; Centre Oscar Lambret, Lille, France; Institut Gustave Roussy, Paris, France; CHU, Grenoble, France; Centre Val d’Aurelle, Montpellier, France
| | - B. Saint Aubert
- CRLC Val d’Aurelle, Montpellier, France; Centre Leon Berard, Lyon, France; Institut Paoli Calmettes, Marseille, France; Hôpital Saint Andre, Bordeaux, France; Centre René Gauducheau, Nantes, France; Institut Sainte Catherine, Avignon, France; Centre Oscar Lambret, Lille, France; Institut Gustave Roussy, Paris, France; CHU, Grenoble, France; Centre Val d’Aurelle, Montpellier, France
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Rutten H, Sebag-Montefiore D, Glynne-Jones R, Rullier E, Peeters M, Brown G, Van Cutsem E, Ricci S, Van de Velde CJ, Quirke P. Capecitabine, oxaliplatin, radiotherapy, and excision (CORE) in patients with MRI-defined locally advanced rectal adenocarcinoma: Results of an international multicenter phase II study. J Clin Oncol 2006. [DOI: 10.1200/jco.2006.24.18_suppl.3528] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
3528 Background: The addition of chemotherapy to preoperative radiotherapy (RT) may reduce distant recurrence and increase tumor resectability. The CORE study evaluated oxaliplatin, capecitabine, and RT (XELOX-RT) followed by total mesorectal excision (TME), then adjuvant XELOX in patients (pts) with MRI-defined locally advanced rectal cancer. Methods: MRI inclusion criteria: tumor beyond mesorectal fascia, tumor ≤2 mm from mesorectal fascia, or T3/4 tumor <5 cm from anal verge. Chemoradiation (CRT) was 45 Gy RT (1.8 Gy/dose) 5 days/wk for 5 wks, weekly oxaliplatin 50 mg/m2, and twice-daily capecitabine 825 mg/m2 on each day of RT. Surgery was 6–8 wks after completing XELOX-RT. Pts with R0-R1 resection were to receive XELOX for 6 cycles. Central radiologic and histopathologic review were key study components. Processes to determine histopathologic response and circumferential resection margin (CRM) were predefined. The primary endpoint was pCR rate (planned n=70 evaluable pts). Results: Between July 2003 and Dec 2004, 87 pts were enrolled; 85 pts received XELOX-RT and 79 had TME. Seventy pts (82%) had R0-R1 resection, with a 67% R0 rate (n=57) by Quirke methodology (CRM >1 mm). The pCR rate was 13% (10/78 pts assessable for tumor response; 95% CI, 5.46–20.34%). Tumor regression grading showed excellent response in 35% and poor response in 64% of pts. Of 60 pts evaluated by central MRI review for response by RECIST, the overall response rate was 70% (7% complete; 63% partial response). Preoperative grade (G) 3/4 adverse events (% of pts; evaluable n=85) included diarrhea 16% (12% G3), sensory neuropathy 1% (G3), neutropenia 1% (G3), and hand-foot syndrome 1% (G3). More than 90% of pts received full dose radiotherapy. Conclusions: Significant tumor regression and a high R0 resection rate were achieved using a CRT regimen of preoperative oxaliplatin, capecitabine, and 45 Gy RT, with acceptable toxicity. Central histopathologic and radiologic review data, together with safety and efficacy results for both preoperative CRT and postoperative chemotherapy, will be presented. [Table: see text]
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Affiliation(s)
- H. Rutten
- Catharina Hospital, Eindhoven, The Netherlands; Cookridge Hospital, Leeds, United Kingdom; Mount Vernon Cancer Center, Northwood, United Kingdom; Saint-Andre Hospital, Bordeaux, France; University Hospital Ghent, Ghent, Belgium; Royal Marsden Hospital, Sutton, United Kingdom; University Hospital Gasthuisberg, Leuven, Belgium; S. Chiara Hospital, Pisa, Italy; Leiden University Medical Center, Leiden, The Netherlands; Leeds University, Leeds, United Kingdom
| | - D. Sebag-Montefiore
- Catharina Hospital, Eindhoven, The Netherlands; Cookridge Hospital, Leeds, United Kingdom; Mount Vernon Cancer Center, Northwood, United Kingdom; Saint-Andre Hospital, Bordeaux, France; University Hospital Ghent, Ghent, Belgium; Royal Marsden Hospital, Sutton, United Kingdom; University Hospital Gasthuisberg, Leuven, Belgium; S. Chiara Hospital, Pisa, Italy; Leiden University Medical Center, Leiden, The Netherlands; Leeds University, Leeds, United Kingdom
| | - R. Glynne-Jones
- Catharina Hospital, Eindhoven, The Netherlands; Cookridge Hospital, Leeds, United Kingdom; Mount Vernon Cancer Center, Northwood, United Kingdom; Saint-Andre Hospital, Bordeaux, France; University Hospital Ghent, Ghent, Belgium; Royal Marsden Hospital, Sutton, United Kingdom; University Hospital Gasthuisberg, Leuven, Belgium; S. Chiara Hospital, Pisa, Italy; Leiden University Medical Center, Leiden, The Netherlands; Leeds University, Leeds, United Kingdom
| | - E. Rullier
- Catharina Hospital, Eindhoven, The Netherlands; Cookridge Hospital, Leeds, United Kingdom; Mount Vernon Cancer Center, Northwood, United Kingdom; Saint-Andre Hospital, Bordeaux, France; University Hospital Ghent, Ghent, Belgium; Royal Marsden Hospital, Sutton, United Kingdom; University Hospital Gasthuisberg, Leuven, Belgium; S. Chiara Hospital, Pisa, Italy; Leiden University Medical Center, Leiden, The Netherlands; Leeds University, Leeds, United Kingdom
| | - M. Peeters
- Catharina Hospital, Eindhoven, The Netherlands; Cookridge Hospital, Leeds, United Kingdom; Mount Vernon Cancer Center, Northwood, United Kingdom; Saint-Andre Hospital, Bordeaux, France; University Hospital Ghent, Ghent, Belgium; Royal Marsden Hospital, Sutton, United Kingdom; University Hospital Gasthuisberg, Leuven, Belgium; S. Chiara Hospital, Pisa, Italy; Leiden University Medical Center, Leiden, The Netherlands; Leeds University, Leeds, United Kingdom
| | - G. Brown
- Catharina Hospital, Eindhoven, The Netherlands; Cookridge Hospital, Leeds, United Kingdom; Mount Vernon Cancer Center, Northwood, United Kingdom; Saint-Andre Hospital, Bordeaux, France; University Hospital Ghent, Ghent, Belgium; Royal Marsden Hospital, Sutton, United Kingdom; University Hospital Gasthuisberg, Leuven, Belgium; S. Chiara Hospital, Pisa, Italy; Leiden University Medical Center, Leiden, The Netherlands; Leeds University, Leeds, United Kingdom
| | - E. Van Cutsem
- Catharina Hospital, Eindhoven, The Netherlands; Cookridge Hospital, Leeds, United Kingdom; Mount Vernon Cancer Center, Northwood, United Kingdom; Saint-Andre Hospital, Bordeaux, France; University Hospital Ghent, Ghent, Belgium; Royal Marsden Hospital, Sutton, United Kingdom; University Hospital Gasthuisberg, Leuven, Belgium; S. Chiara Hospital, Pisa, Italy; Leiden University Medical Center, Leiden, The Netherlands; Leeds University, Leeds, United Kingdom
| | - S. Ricci
- Catharina Hospital, Eindhoven, The Netherlands; Cookridge Hospital, Leeds, United Kingdom; Mount Vernon Cancer Center, Northwood, United Kingdom; Saint-Andre Hospital, Bordeaux, France; University Hospital Ghent, Ghent, Belgium; Royal Marsden Hospital, Sutton, United Kingdom; University Hospital Gasthuisberg, Leuven, Belgium; S. Chiara Hospital, Pisa, Italy; Leiden University Medical Center, Leiden, The Netherlands; Leeds University, Leeds, United Kingdom
| | - C. J. Van de Velde
- Catharina Hospital, Eindhoven, The Netherlands; Cookridge Hospital, Leeds, United Kingdom; Mount Vernon Cancer Center, Northwood, United Kingdom; Saint-Andre Hospital, Bordeaux, France; University Hospital Ghent, Ghent, Belgium; Royal Marsden Hospital, Sutton, United Kingdom; University Hospital Gasthuisberg, Leuven, Belgium; S. Chiara Hospital, Pisa, Italy; Leiden University Medical Center, Leiden, The Netherlands; Leeds University, Leeds, United Kingdom
| | - P. Quirke
- Catharina Hospital, Eindhoven, The Netherlands; Cookridge Hospital, Leeds, United Kingdom; Mount Vernon Cancer Center, Northwood, United Kingdom; Saint-Andre Hospital, Bordeaux, France; University Hospital Ghent, Ghent, Belgium; Royal Marsden Hospital, Sutton, United Kingdom; University Hospital Gasthuisberg, Leuven, Belgium; S. Chiara Hospital, Pisa, Italy; Leiden University Medical Center, Leiden, The Netherlands; Leeds University, Leeds, United Kingdom
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Bretagnol F, Lelong B, Laurent C, Moutardier V, Rullier A, Monges G, Delpero JR, Rullier E. The oncological safety of laparoscopic total mesorectal excision with sphincter preservation for rectal carcinoma. Surg Endosc 2005; 19:892-6. [PMID: 15920688 DOI: 10.1007/s00464-004-2228-x] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2004] [Accepted: 01/17/2005] [Indexed: 12/19/2022]
Abstract
BACKGROUND Although experience of laparoscopic treatment of rectal carcinoma has been reported, there is no evidence of its oncological safety because most procedures included partial mesorectal excision or abdominoperineal excision and quality of surgery is lacking. The aim of this study was to assess the oncological results of laparoscopic total mesorectal excision with sphincter preservation for rectal carcinoma. METHODS From 2000 to 2003, 144 patients underwent laparoscopic total mesorectal excision with low colorectal or coloanal anastomosis for mid and low rectal adenocarcinoma. There were 88 men and 56 women, with a median age of 65 years. The tumor was located at 5.5 cm (range 1-12) from the anal verge and was classified uT1T2 in 25 cases and uT3 in 119 cases. One hundred twenty patients received preoperative radiotherapy. RESULTS Postoperative mortality and morbidity were 1% and 34% respectively. Conversion was 14% (n = 20). Macroscopic assessment of the specimen (n = 92) showed an intact mesorectum in 88% of the cases. The distal margin and the circumferential margin were safe in 98% and 94% of the cases, respectively. A complete microscopic excision, i.e., R0 resection, was achieved in 134 cases (93%). Pathological data were similar to those of an open match group. With a median follow-up of 18 months, there was no port-site recurrence and two patients had local recurrence (1.4%). The 3-year overall and disease- free survival rates were 89% and 77%, respectively. CONCLUSIONS A high quality of surgical excision can be achieved by the laparoscopic dissection, suggesting that this approach in treatment of rectal carcinoma is oncologically safe.
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Affiliation(s)
- F Bretagnol
- Department of Surgery, Saint-Andre Hospital, 33075 1 rue Jean Burquet, Bordeaux, France
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Rullier A, Laurent C, Capdepont M, Vendrely V, Le Bail B, Bioulac-Sage P, Rullier E. La dégénérescence colloïde influence-t-elle la survie des cancers du rectum traités par radiothérapie ? Ann Pathol 2004. [DOI: 10.1016/s0242-6498(04)94099-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Laurent C, Sa Cunha A, Couderc P, Rullier E, Saric J. Influence of postoperative morbidity on long-term survival following liver resection for colorectal metastases. Br J Surg 2003; 90:1131-6. [PMID: 12945082 DOI: 10.1002/bjs.4202] [Citation(s) in RCA: 159] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Survival after resection of colorectal liver metastases may be influenced by the patient, the primary tumour and the liver metastases. Postoperative morbidity is associated with poor survival in several cancers. The aim of this retrospective study was to evaluate prognostic factors of survival after resection of colorectal liver metastases, including postoperative morbidity. METHODS From 1985 to 2000, 311 consecutive patients with liver metastases from colorectal cancer underwent resection with curative intent. Univariate and multivariate analyses were performed to assess the influence of age, sex, site and stage of the colorectal tumour, disease-free interval, number, size and distribution of metastases, type of hepatectomy, pedicular clamping, resection margin, blood transfusion, postoperative morbidity and adjuvant chemotherapy on overall and disease-free survival. RESULTS The postoperative mortality and morbidity rates were 3 and 30 per cent respectively. The 3- and 5-year overall survival rates were 53 and 36 per cent respectively. Both overall and disease-free survival rates were independently associated with nodal status of the colorectal tumour, number of metastases and postoperative morbidity. Patients with postoperative morbidity had an overall and disease-free 5-year survival rate half that of patients with no morbidity: 21 versus 42 per cent for overall survival (P < 0.001) and 12 versus 28 per cent for disease-free survival (P = 0.001) respectively. CONCLUSION Long-term survival can be altered by postoperative morbidity after resection of colorectal liver metastases by increasing the risk of tumour recurrence. This justifies optimizing the surgical treatment of colorectal liver metastases to decrease postoperative morbidity and the use of efficient adjuvant treatments in patients with postoperative morbidity.
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Affiliation(s)
- C Laurent
- Department of Surgery, Hôpital Saint-André, 33075 Bordeaux, France.
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Bretagnol F, Rullier E, Couderc P, Rullier A, Saric J. Technical and oncological feasibility of laparoscopic total mesorectal excision with pouch coloanal anastomosis for rectal cancer. Colorectal Dis 2003; 5:451-3. [PMID: 12925079 DOI: 10.1046/j.1463-1318.2003.00521.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM The aim of this study was to evaluate the technical and oncological feasibility of laparoscopic total mesorectal excision (TME) with coloanal anastomosis for mid and low rectal cancer. METHODS During a 2-year period, 50 patients underwent laparoscopic TME with coloanal anastomosis for rectal carcinoma located at a median of 4.5 (range 2-11) cm from the anal verge. Pre-operative radiotherapy was used in 46 patients. Intersphincteric dissection was combined with the laparoscopic procedure to achieve sphincter preservation. RESULTS Conversion to a laparotomy was necessary in six patients. Postoperative mortality and morbidity were 2% and 28%, respectively. Morbidity was lower in patients operated on during the second part of the study, who had extraction of the rectal specimen through a small laparotomy incision, than in those operated on during the first part of the study when removal of the specimen was by transanal extraction. Oncological quality of excision was safe in 44 patients with intact or almost intact rectal fascia in 88% and R0 resection in 90%. At a median follow-up of 18 months, there was no local or port-site recurrence. CONCLUSION This study confirms our preliminary results of oncological feasibility of laparoscopic TME with sphincter preservation for mid and low rectal cancer, and showed that morbidity can be decreased by using a standardized surgical procedure.
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Affiliation(s)
- F Bretagnol
- Department of Surgery, Saint-André Hospital, 33075 Bordeaux, France
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Rullier E, Laurent C. Advances in surgical treatment of rectal cancer. MINERVA CHIR 2003; 58:459-7. [PMID: 14603158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
UNLABELLED Increased understanding of the natural history of the disease, standardization of surgery and new procedures have led to significant advances in the treatment of rectal cancer. Anatomical dissection of the mesorectum permits optimal local control and volume cases may further improve oncological RESULTS Autonomic pelvic nerves are preserved by the technique of total mesorectal excision (TME) and adapted anterior dissection plans improve preservation of genito-urinary functions. Sphincter preservation can be achieved by a conventional anterior resection for high and mid-rectal tumours, and by the technique of intersphincteric resection for low tumours. A J-pouch or a recently-designed coloplasty pouch must be associated with coloanal anastomoses in order to improve functional results and loop ileostomy is recommended to decrease early postoperative morbidity. Local excision constitutes an alternative to major surgery in patients with a low-risk early rectal cancer. Neoadjuvant treatments have a role in local control of the disease after TME surgery and in new strategies of sphincter-saving procedures. The place of anorectal reconstruction and that of laparoscopy are also discussed.
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Affiliation(s)
- E Rullier
- Service of Digestive Surgery, Saint-André Hospital, Bordeaux, France.
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Rullier E, Sa Cunha A, Couderc P, Rullier A, Gontier R, Saric J. Laparoscopic intersphincteric resection with coloplasty and coloanal anastomosis for mid and low rectal cancer. Br J Surg 2003; 90:445-51. [PMID: 12673746 DOI: 10.1002/bjs.4052] [Citation(s) in RCA: 150] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The feasibility of laparoscopic rectal resection in patients with mid or low rectal cancer was studied prospectively with regard to quality of mesorectal excision, autonomic pelvic nerve preservation and anal sphincter preservation. METHODS Laparoscopic rectal excision was performed in 32 patients (21 men) with rectal carcinoma located 5 cm from the anal verge. Most patients had T3 disease and received preoperative radiotherapy. The surgical procedure was performed 6 weeks after radiotherapy and included total mesorectal excision, intersphincteric resection, transanal coloanal anastomosis with coloplasty and loop ileostomy. RESULTS Three patients needed conversion to a laparotomy. Postoperative morbidity occurred in ten patients, related mainly to coloplasty. Macroscopic evaluation showed an intact mesorectal excision in 29 of 32 excised specimens; microscopically, 30 of the 32 resections were R0. Sphincter preservation was achieved in 31 patients. The hypogastric nerves and pelvic plexuses were identified and preserved in 24 of the 32 patients. Sexual function was preserved in ten of 18 evaluable men. CONCLUSION A laparoscopic approach can be considered in most patients with mid or low rectal cancer.
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Affiliation(s)
- E Rullier
- Department of Surgery, Saint-André Hospital, Bordeaux, France.
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Bresler L, Reibel N, Brunaud L, Sielezneff I, Rouanet P, Rullier E, Slim K. [Dynamic graciloplasty in the treatment of severe fecal incontinence. French multicentric retrospective study]. Ann Chir 2002; 127:520-6. [PMID: 12404846 DOI: 10.1016/s0003-3944(02)00828-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
UNLABELLED The aim of this study was to retrospectively assess the safety and efficacy of dynamic graciloplasty performed in 5 French surgical centers involved in the treatment of fecal incontinence. PATIENTS AND METHODS Between March 1994 and March 2000, a total of 24 patients were treated with dynamic graciloplasty for fecal incontinence excluding case of anal reconstruction for cancer. Intramuscular leads and neurostimulators were implanted to stimulate the transposed gracilis. Continence and safety were evaluated using patients' records during hospitalisation and during the out-patient visit or further hospitalisation. RESULTS No death occurred. A successful functional outcome was reported for 19 patients (79%) during the follow up period. Twenty-two complications occurred including wound. Wound infection in 6 patients and tendon detachment in 4. One patient presented with an infected anal erosion leading to material explantation. CONCLUSION Dynamic graciloplasty is an effective procedure for patients with refractory fecal incontinence. However, the procedure has significant morbidity which seems to be correlated with the surgeons' experience. Moreover, this procedure should now be compared to the artificial anal sphincter.
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Affiliation(s)
- L Bresler
- Service de chirurgie générale et digestive, CHU Brabois Nancy, rue du Morvan, 54511 Vandoeuvre-les-Nancy, France.
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Abstract
Rectal excision followed by low anastomosis is associated with high bowel frequency, urgency and faecal incontinence. These functional disorders results from the loss of the rectal pouch and may be also related to the damage of the anal sphincter or the loss of normal anorectal sensation. Formation of a colonic J pouch reduces the severity of the symptoms of the anterior resection syndrome mainly by decreasing bowel frequency. Creation of a J pouch may also improve the healing of coloanal anastomoses. However, there is no evidence of the role of the colonic J pouch in long term functional outcome of coloanal anastomoses. Moreover, the size of the J pouch increases with time and this may induce evacuation difficulties. Finally, the J pouch cannot be used in all patients, because of technical difficulties especially in obese men. Because the results after colonic J pouch are not perfect, new colonic pouches are developed. The caecal pouch is performed by using an ileocoecal interposition graft between the sigmoid and the anus. The transverse coloplasty is similar to that of stricturoplasty. The side-to-end coloanal anastomosis, giving a colonic blind end, is an other type of pouch. The first procedure seems technically complex with no demonstrated advantage. The second procedure is easy to construct and may be performed in all patients; however, there is a potential higher risk of leakage and functional results must be evaluated. The third procedure showed few advantages compared to a straight anastomosis.
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Affiliation(s)
- E Rullier
- Service de chirurgie digestive, hôpital Saint-André, 33075 Bordeaux, France
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49
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Bouras N, Caudry M, Saric J, Bonnel C, Rullier E, Trouette R, Demeaux H, Maire JP. [Conformal therapy of locally advanced cholangiocarcinoma of the main bile ducts]. Cancer Radiother 2002; 6:22-9. [PMID: 11899677 DOI: 10.1016/s1278-3218(01)00144-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE Retrospective study of 23 patients treated with conformal radiotherapy for a locally advanced bile duct carcinoma. PATIENTS AND METHODS Eight cases were irradiated after a radical resection (R0), because they were N+; seven after microscopically incomplete resection (R1); seven were not resected (R2). A dose of 45 of 50 Gy was delivered, followed by a boost up to 60 Gy in R1 and R2 groups. Concomitant chemotherapy was given in 15 cases. RESULTS Late toxicity included a stenosis of the duodenum, and one of the biliary anastomosis. Two patients died from cholangitis, the mechanism of which remains unclear. Five patients are in complete remission, six had a local relapse, four developed a peritoneal carcinosis, and six distant metastases. Actuarial survival rate is 75%, 28% and 7% at 1, 3 and 5 years, respectively (median: 16.5 months). Seven patients are still alive with a 4 to 70 months follow-up. Survival is similar in the 3 small subgroups. The poor local control among R0N+ cases might be related to the absence of a boost to the "tumor bed". In R1 patients, relapses were mainly distant metastases, whereas local and peritoneal recurrences predominated in R2. CONCLUSION Conformal radiochemotherapy delivering 60 Gy represents a valuable palliative approach in locally advanced biliary carcinoma.
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Affiliation(s)
- N Bouras
- Service de radiothérapie, hôpital Saint-André, CHU de Bordeaux, 1, rue Jean-Burguet, 33075 Bordeaux, France
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Laurent C, Rullier E, Feyler A, Masson B, Saric J. Resection of noncolorectal and nonneuroendocrine liver metastases: late metastases are the only chance of cure. World J Surg 2001; 25:1532-6. [PMID: 11775186 DOI: 10.1007/s00268-001-0164-7] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Resection of liver colorectal metastases allows a 5-year survival in 25% to 35% of patients. The outcome of patients with noncolorectal metastases is unknown because of the heterogeneity of this group. The aim of this retrospective study was to evaluate predictive factors of survival in patients who underwent resection of noncolorectal and nonneuroendocrine (NCRNE) liver metastases. From 1980 to 1997, 284 patients underwent hepatectomy for liver metastases of whom 39 (25 men and 14 women, mean age 55 years) had curative resection for NCRNE liver metastases. No patients had extrahepatic disease. The primary tumors were gastrointestinal (n = 15), genitourinary (n = 12) and miscellaneous (n = 12). The mean number of metastases was 1.8, and the mean size of the lesions was 51 mm. The median disease-free interval was 27 months. Twenty patients had a major hepatectomy and 19 a minor resection, with simultaneous resection of the primary in 6 cases. Overall survival was evaluated using the Kaplan-Meier method. There was no operative mortality, and 8% morbidity. The survival at 1, 3, and 5 years was 81, 40, and 35%, respectively. Patients with a disease-free interval higher than 24 months had a greater survival rate than those with a disease-free interval of less than 24 months (100% vs. 10%; p = 0.0004). Survival was not significantly influenced by age, sex, type of primary tumor, number, size and localization of metastases, type of hepatectomy, or blood transfusion. Resection of NCRNE liver metastases should be justified for patients without extrahepatic disease and resectable metastases, especially for those who have a disease-free interval of more than 24 months.
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Affiliation(s)
- C Laurent
- Department of Surgery, Saint-André Hospital, Bordeaux, France
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