{"id":1783,"date":"2004-10-01T01:00:00","date_gmt":"2004-10-01T00:00:00","guid":{"rendered":"https:\/\/angh.net\/abstracts\/traitement-chirurgical-de-la-maladie-de-crohn\/"},"modified":"2018-10-20T18:39:34","modified_gmt":"2018-10-20T16:39:34","slug":"traitement-chirurgical-de-la-maladie-de-crohn","status":"publish","type":"post","link":"https:\/\/angh.net\/abstracts\/traitement-chirurgical-de-la-maladie-de-crohn\/","title":{"rendered":"TRAITEMENT CHIRURGICAL DE LA MALADIE DE CROHN."},"content":{"rendered":"

2004<\/strong><\/p>\n

Yves Panis
\nService de chirurgie g\u00e9n\u00e9rale et digestive, H\u00f4pital Lariboisi\u00e8re
\n2, rue Ambroise Par\u00e9, 75475 Paris Cedex 10<\/em><\/p>\n

Gastroent\u00e9rologie <\/strong>– \u00a00000-00-00 –\u00a0CF –<\/p>\n

________________________________<\/p>\n

La chirurgie est n\u00e9cessaire chez plus de 80 % des patients atteints de maladie de Crohn (MC). Quel que soit le type d\u2019intervention r\u00e9alis\u00e9e, celle-ci ne gu\u00e9rira pas le patient, qui sera expos\u00e9 \u00e0 long terme \u00e0 une r\u00e9cidive sur l\u2019intestin restant, et ce dans la majorit\u00e9 des cas. Le traitement chirurgical des l\u00e9sions intestinales dues \u00e0 la MC doit donc ob\u00e9ir \u00e0 deux crit\u00e8res essentiels: n\u2019op\u00e9rer que les formes compliqu\u00e9es et r\u00e9sistantes au traitement m\u00e9dical, et pratiquer une r\u00e9section intestinale la plus limit\u00e9e possible, enlevant les seules l\u00e9sions responsables des sympt\u00f4mes observ\u00e9s. Une \u00e9tude randomis\u00e9e a d\u00e9montr\u00e9 que le taux de r\u00e9cidive sur l\u2019intestin restant \u00e9tait similaire en cas de marge de s\u00e9curit\u00e9 de 2cm ou de 12 cm apr\u00e8s r\u00e9section il\u00e9ocaecale. Chez les patients op\u00e9r\u00e9s \u00e0 plusieurs reprises, il est parfois utile de r\u00e9aliser des stricturoplasties multiples, technique qui permet de lever les st\u00e9noses sans n\u00e9cessiter de r\u00e9section intestinale.
\nLa laparoscopie a \u00e9t\u00e9 recemment propos\u00e9e, avec des r\u00e9sultats \u00e9quivalents ou meilleurs que ceux de la laparotomie, pour le traitement chirurgical de la MC. Plusieurs arguments plaident pour son utilisation dans la MC: (a) le moindre traumatisme de la paroi chez les sujets jeunes (o\u00f9 le soucis esth\u00e9tique est important); (b) le risque \u00e9lev\u00e9 d’interventions it\u00e9ratives; (c) la r\u00e9duction de la douleur postop\u00e9ratoire et de la dur\u00e9e d’hospitalisation permettant une reprise plus rapide de l’activit\u00e9 professionnelle.
\nAujourd\u2019hui, la mortalit\u00e9 est quasi-nulle apr\u00e8s r\u00e9section intestinale pour MC. La morbidit\u00e9 concerne principalement les complications septiques et en premier lieu les d\u00e9sunions anastomotiques. Une analyse mutlivari\u00e9e retrouvait 4 facteurs de risque ind\u00e9pendants demorbidit\u00e9: une albumin\u00e9mie < 30g\/L, une corticoth\u00e9rapie pr\u00e9op\u00e9ratoire, et un abc\u00e8s ou une fistule d\u00e9couvert en perop\u00e9ratoire.
\nLa r\u00e9cidive survient dans l\u2019immense majorit\u00e9 des cas sur l\u2019anastomose il\u00e9ocolique et le gr\u00eale sus-anastomotique. Dans une s\u00e9rie r\u00e9cente portant sur plus de 1900 patients avec MC, 71% \u00e9taient op\u00e9r\u00e9s au moins une fois dans les 10 ans suivant le diagnostic de MC. Une r\u00e9cidive clinique \u00e9tait not\u00e9 chez 33% des patients \u00e0 5 ans et 44% \u00e0 10 ans. En analyse multivari\u00e9e, les facteurs de risque ind\u00e9pendants de r\u00e9cidive clinique \u00e9taient: le sexe f\u00e9minin (RR=1,2), une localisation sur le gr\u00eale ou il\u00e9o-colique (versus colorectal) (RR=1,8), et l'existence d'une fistule p\u00e9rin\u00e9ale (RR=1,4). Le r\u00f4le du tabac est aussi actuellement bien d\u00e9montr\u00e9e et impose de fortement sugg\u00e9rer au patient d'arr\u00e9ter de fumer en cas de MC (op\u00e9r\u00e9 ou non). Enfin, il est admis que l'aspect endoscopique 1 an apr\u00e8s l'intervention permet de pr\u00e9voir le risque ul\u00e9t\u00e9rieure de r\u00e9cidive.
\nEn conclusion, la grande majorit\u00e9 des patients porteurs d\u2019une maladie de Crohn, quel qu\u2019en soit la localisation, n\u00e9cessitera au cours de l\u2019\u00e9volution de la maladie un traitement chirurgical. La connaissance du risque \u00e9lev\u00e9 de r\u00e9cidive justifie que la chirurgie soit r\u00e9serv\u00e9e aux formes compliqu\u00e9es, r\u00e9sistantes au traitement m\u00e9dical. Cette chirurgie doit \u00eatre \u00e9conome en terme de r\u00e9section intestinale. Enfin, ce risque \u00e9lev\u00e9 de r\u00e9cidive postop\u00e9ratoire doit maintenant faire proposer un traitement m\u00e9dical postop\u00e9ratoire pr\u00e9ventif des rechutes, notamment par les d\u00e9riv\u00e9s salicyl\u00e9s, et les immunosuppresseurs.<\/p>\n","protected":false},"excerpt":{"rendered":"

2004 Yves Panis Service de chirurgie g\u00e9n\u00e9rale et digestive, H\u00f4pital Lariboisi\u00e8re 2, rue Ambroise Par\u00e9, 75475 Paris Cedex 10 Gastroent\u00e9rologie – \u00a00000-00-00 –\u00a0CF – ________________________________ La chirurgie est n\u00e9cessaire chez plus de 80 % des patients atteints de maladie de Crohn (MC). Quel que soit le type d\u2019intervention r\u00e9alis\u00e9e, celle-ci ne gu\u00e9rira pas le patient, […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_exactmetrics_skip_tracking":false,"_exactmetrics_sitenote_active":false,"_exactmetrics_sitenote_note":"","_exactmetrics_sitenote_category":0,"footnotes":""},"categories":[4],"tags":[15],"class_list":["post-1783","post","type-post","status-publish","format-standard","hentry","category-gastroenterologie","tag-15"],"yoast_head":"\nTRAITEMENT CHIRURGICAL DE LA MALADIE DE CROHN. - Abstracts des congr\u00e8s de l'ANGH<\/title>\n<meta name=\"description\" content=\"ANGH R\u00e9sum\u00e9s congr\u00e8s H\u00e9patologie Gastroent\u00e9romogie Hepatology Gastroenterology Etudes cliniques Clinical study\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/angh.net\/abstracts\/traitement-chirurgical-de-la-maladie-de-crohn\/\" \/>\n<meta property=\"og:locale\" content=\"fr_FR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"TRAITEMENT CHIRURGICAL DE LA MALADIE DE CROHN. - 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