3 years ago

Le syndrome de résection antérieure du rectum. Quels messages délivrer aux praticiens et aux patients en 2018 ?

T. Sarcher, B. Dupont, A. Alves, B. Menahem

Publication date: October 2018

Source: Journal de Chirurgie Viscérale, Volume 155, Issue 5

Author(s): T. Sarcher, B. Dupont, A. Alves, B. Menahem

Résumé

La prise en charge multidisciplinaire du cancer du rectum sous-péritonéal a permis de repousser les limites de la conservation sphinctérienne, sans péjorer le pronostic carcinologique. Les séquelles fonctionnelles digestives, dont l’ensemble des symptômes est regroupé sous le terme syndrome de résection antérieure du rectum (SRA), sont devenues une préoccupation de plus en plus fréquente des patients et des praticiens. De physiopathologie complexe, le SRA associe à des degrés divers une poly-exonération, une incontinence aux gaz et/ou aux selles, une impériosité, des troubles de la discrimination et de l’évacuation. Le « LARS » score, validé en 2012, est actuellement utilisé pour évaluer précisément la sévérité du SRA et son impact sur la qualité de vie. Si ce SRA s’améliore au cours des deux premières années, il persiste au-delà, chez près de 60 % des patients et dans sa forme sévère chez un patient sur deux. Les facteurs de risque indépendants de SRA sévère les plus fréquemment rapportés incluent la radiothérapie néo-adjuvante, l’étendue de la résection (exérèse totale du mésorectum, y compris la résection inter-sphinctérienne), l’absence de réservoir colique et la survenue d’une fistule anastomotique. En l’absence de complications chirurgicales et/ou de récidive locale, les praticiens disposent d’un arsenal thérapeutique permettant d’améliorer le résultat fonctionnel des patients, incluant des mesures hygiéno-diététiques, des régulateurs du transit, la réhabilitation multimodale (biofeedback, électrostimulation) et enfin la neuro-modulation sacrée. Bien que solution ultime, la stomie définitive est à proposer en cas d’échec. Une meilleure connaissance de l’histoire naturelle du SRA, de ces facteurs de risque ainsi que de ses alternatives thérapeutiques permettra à l’avenir une meilleure information et prise en charge de nos patients.

Summary

Multidisciplinary management of infra-peritoneal rectal cancer has pushed back the frontiers of sphincter preservation, without impairment of carcinological outcome. However, functional intestinal sequelae, grouping together several symptoms known under the name of anterior resection syndrome (ARS), have emerged and become an increasingly frequent concern for both patients and physicians. The pathophysiology is complex: ARS is a combination in various degrees of stool frequency, incontinence for flatus and/or stools, urgency, and disorders in discrimination and evacuation. The “Low Anterior Resection Score” (LARS), validated in 2012, is currently used to evaluate the severity of ARS and its impact on quality of life. While ARS can show improvement over the first two years, symptoms persist for longer than two years in nearly 60% of patients and in half of these patients, ARS is considered severe. The most frequently reported independent risk factors of severe ARS include neo-adjuvant radiation therapy, the extent of resection (total mesorectal excision that includes inter-sphincteric resection), absence of colonic pouch and anastomotic leak. In the absence of surgical complications and/or local recurrence, physicians can draw from a wide therapeutic armamentarium in order to improve the functional outcome of patients, including diet and life-style modifications, gut motility regulators, multimodal rehabilitation (biofeedback, electro-stimulation) and sacral nerve modulation. Permanent colostomy is an alternative of last resort, proposed only when all other solutions fail. A better understanding of the natural history of ARS, its risk factors as well as the array of therapeutic alternatives should provide better patient information and optimize management.

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