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Côlon & Rectum

, Volume 10, Issue 1, pp 12–27 | Cite as

Recommandations pour la pratique clinique Cancer du rectum

Question 2 Quels sont les critères de qualité de l’exérèse chirurgicale ?
  • V. Bridoux
  • C. de ChaisemartinEmail author
  • L. Beyer
  • N. Goasguen
  • C. Sabbagh
  • N. Guedj
  • P. Dartigues
  • A. Bardier
Dossier Thématique / Thematic File
  • 129 Downloads

Résumé

Les principales avancées thérapeutiques dans la chirurgie du cancer du rectum au cours de ces deux dernières décennies se sont attachées à garantir la qualité de l’exérèse chirurgicale synonyme de meilleure survie sans récidive et de meilleure survie globale. La technique d’exérèse extrafasciale du mésorectum developpé par Heald dans les années 80 est aujourd’hui le standard chirurgical bien qu’il n’y ait jamais eu d’étude randomisée la comparant à la chirurgie classique. Depuis de nouvelles voies d’abord ont été développées : l’abord laparoscopique, l’approche robotique, et l’abord trans-périnéal premier. L’exérèse rectale par laparoscopie assure un résultat oncologique au moins équivalent à l’exérèse par laparotomie pour les tumeurs T1 à T3 faibles. Cet abord apporte également un bénéfice en termes de durée d’hospitalisation et de pertes sanguines au prix cependant d’une durée opératoire plus longue. L’approche robotisée, est faisable et sûre mais engendre un surcoût alors qu’elle n’apporte aucun bénéfice significatif pour le patient. Un abord périnéal premier peut être proposé chaque fois qu’il est nécessaire de réaliser une anastomose colo-anale manuelle, notamment dans les situations difficiles (bassin étroit, sexe masculin, obésité, tumeurs volumineuses) mais compte-tenu de l’absence de données concernant les résultats fonctionnels et oncologiques, l’exérèse totale du mesorectum par voie transanale ne peut-être actuellement recommandée. L’évaluation de l’exérèse nécessite une collaboration étroite entre le chirurgien et le pathologiste. En effet, l’examen histologique de la pièce de résection rectale permet la stadification TNM, une estimation du pronostic et de poser l’indication d’un traitement adjuvant.

Mots clés

Cancer du rectum ETM Qualité de l’exérèse Marge circonférentielle Grade du mésorectum Voie d’abord chirurgicale Examen histologique 

Abstract

The main therapeutic advances in surgery for rectal cancer during the past two decades have focused on ensuring the quality of surgical excision. The extrafascial mesorectum resection developed by Heald in the 80’s is now the standard surgical although no randomized study was done comparing it to conventional surgery. Since this time, new surgical approaches have been developed: laparoscopy, robotic approach, and trans-anal approach. Laparoscopy provides oncologic outcome equivalent to resection by laparotomy for tumors T1, T2 and T3 low. Laparoscopy also provides a benefit in terms of hospital stay and blood loss at the price, however of a longer operative time. The robotic approach is feasible but generates an additional cost while it provides no significant benefit for the patient. A perineal approach first, can be offered whenever it is necessary to perform a manual colo-anal anastomosis, especially in difficult situations (narrow pelvis, male gender, obesity, large tumors) but in view of the lack of data for functional and oncological results, endoscopic trans anal total mesorectal excision (ETAP) may not currently be recommended. The evaluation of the excision requires close collaboration between the surgeon and the pathologist. Indeed, the pathological examination of rectal specimen allows the TNMstadification, an estimation of the prognosis and provide the indication of an adjuvant chemotherapy.

Keywords

Rectal cancer TME Audit of surgical quality Circumferential margin Macroscopic assessment of mesorectum Surgical approach Pathologic assessment 

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Copyright information

© Springer-Verlag France 2015

Authors and Affiliations

  • V. Bridoux
    • 1
  • C. de Chaisemartin
    • 2
    Email author
  • L. Beyer
    • 3
  • N. Goasguen
    • 4
  • C. Sabbagh
    • 5
  • N. Guedj
    • 6
  • P. Dartigues
    • 7
  • A. Bardier
    • 8
  1. 1.Service de chirurgie digestiveCHU Charles NicoleRouenFrance
  2. 2.Service de chirurgie oncologique 1Institut Paoli CalmettesMarseilleFrance
  3. 3.Service de chirurgie digestiveHôpital NordMarseilleFrance
  4. 4.Service de chirurgie digestiveHôpital de la Croix Saint SimonParisFrance
  5. 5.Service de chirurgie digestiveCHU AmiensAmiensFrance
  6. 6.Service d’anatomo-pathologieHôpital BeaujonParisFrance
  7. 7.Service d’anatomo-pathologieInstitut Gustave RoussyParisFrance
  8. 8.Service d’anatomo-pathologieHôpital de la Pitié SalpêtrièreParisFrance

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