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Côlon & Rectum

, Volume 10, Issue 1, pp 28–34 | Cite as

Recommandations pour la pratique clinique Cancer du rectum

Question 3 Comment diminuer les séquelles thérapeutiques et préserver la qualité de vie ?
  • S. KirzinEmail author
  • E. Duchalais
  • M. Rives
  • X. Game
  • G. Meurette
  • G. Portier
Dossier Thématique / Thematic File
  • 112 Downloads

Résumé

La proctectomie entraine des séquelles fonctionnelles associant à divers degrés des symptômes d’incontinence et des troubles de l’évacuation qui sont caractérisés dans le Low Anterior Resection Syndrome (LARS). Ces séquelles semblent d’autant plus importantes que l’exérèse rectale est complète. Elles affectent environ 50% des patients et ont un retentissement sur la qualité de vie. Elles sont accessibles à des traitements et doivent être évaluées dans la période postopératoire à l’aide du LARS score. Elles peuvent être prévenues par la réalisation d’un réservoir en J court qui améliore le résultat fonctionnel des patients à court et moyen terme ainsi que leur qualité de vie sans augmentation de la morbidité postopératoire. L’anastomose latéro-terminale est une alternative équivalente. Il n’existe pas à l’heure actuelle de preuve que l’abord laparoscopique améliore la qualité de vie comparativement à la laparotomie. Le maintien des fonctions sexuelle et urinaire nécessite la préservation des structures nerveuses, qui est compatible avec l’exérèse totale du mésorectum, si les impératifs carcinologiques le permettent. La radiothérapie néoadjuvante majore le risque de LARS majeur ainsi que le risque de séquelles génito-urinaires, ce qui doit conduire à une sélection stricte des indications. Il n’est pas démontré que la qualité de vie avec ou sans colostomie soit différente après traitement d’un cancer du rectum. Après amputation abdominopérinéale, la colostomie iliaque reste la référence. Des reconstructions alternatives par colostomie périnéale pseudo-continente ou associée à un procédé de Malone, voire une graciloplastie dynamisée sont une alternative possible chez des patients jeunes et sélectionnés.

Mots clés

Cancer du rectum Excision complète du mésorectum Syndrome de résection antérieure Dysfonction génito-urinaire Réservoir colique Radiothérapie Colostomie 

Abstract

Proctectomy leads to functional consequences associating both incontinence and evacuation symptoms that characterize the Low Anterior Resection Syndrom (LARS). Functional consequences are associated with the extent of rectal resection. Their prevalence is about 50% and they affect quality of life of patients. They should be evaluated with the LARS score and offered treatment. Colonic J pouch after coloanal anastomosis offers better functional outcomes in the mid term and better quality of life. The results of side to end anastomosis are equivalent to the colonic J pouch. There is currently no evidence of an improved quality of life after laparoscopic proctectomy when compared to the open approach. Genitourinary function preservation entails nerve sparing extra-fascial mesorectal excision where oncologically safe. Radiotherapy increases the risk for major LARS as well as genitourinary consequences and should lead to selected indications. There is no evidence for an improved quality of life after restorative proctectomy when compared to permanent stoma. Iliac stoma is the gold standard following abdominoperineal resection. Alternative reconstructions such as perineal pseudocontinent colostomy, perineal colostomy plus Malone or even total perineal reconstruction by means of dynamized graciloplasty should be offered to young selected patients.

Keywords

Rectal neoplasm Total mesorectal excision Low anterior resection syndrome Urogenital dysfunction Colonic pouch Radiotherapy Colostomy 

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Copyright information

© Springer-Verlag France 2015

Authors and Affiliations

  • S. Kirzin
    • 1
    Email author
  • E. Duchalais
    • 2
  • M. Rives
    • 3
  • X. Game
    • 4
  • G. Meurette
    • 2
  • G. Portier
    • 1
  1. 1.Service de chirurgie digestive, colorectale et oncologiqueCHU PurpanToulouseFrance
  2. 2.Service de chirurgie digestiveCHU Hôtel-DieuNantesFrance
  3. 3.Service de radiothérapieInstitut Universitaire du CancerToulouseFrance
  4. 4.Service d’urologie, Andrologie et transplantation rénaleCHU RangueilToulouseFrance

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