HVORDAN BØR VI HÅNDTERE SENFØLGER EFTER ENDETARMSKRÆFT. Søren Laurberg Professor of Surgery Aarhus University Hospital Denmark

Transkript

1 HVORDAN BØR VI HÅNDTERE SENFØLGER EFTER ENDETARMSKRÆFT Søren Laurberg Professor of Surgery Aarhus University Hospital Denmark

2 DET ER BLEVET UFATTELIGT MEGET BEDRE 1943: 300 RC surgery at 121 hospitals 30 day mortality 65% APR longterm survival 2013: 360 RC surgery at 3 hospitals (2.0 mill) 30 day mortality 3% Anastomosis Longterm survival

3 kirurgi KRÆFT I ENDETARM 30% preop (kemo)-strålebehandling % stomi Vi viste: pt har hyppigt problemer efter behandling ( >50%) værst første år- værre hvis præop strålebehandling Low Anterior Resection Syndrom (LARS)

4 Hvad manglede Tarm bøvl mange komponenter, men hvad betyder noget for pt Simpelt uniform instrument baseret på pt International validering Hvad betyder noget? Hvorfor får nogle bøvl og hvorfor værre efter strålebehandling Kan vi hjælpe pt?

5 LARS SCORE WE NEED A SCORE Wexner etc are useless!! MUST BE SIMPLE RELATED TO QUALITY OF LIFE MUST BE VALIDATED

6 cover all aspects Pt. perspective (impact quality of live) Incidence and impact Easy useful

7 Developed a questionaire 17 questions

8 DEVELOP A SCORE CROSS SECTIONAL STUDY ALL RECTAL CANCER /RADICAL RESECTION/DK/ QUESTIONAIRE 2009

9

10 4. CLUSTERING OF STOOLS

11 5. URGENCY

12 VALIDATE IT INTERNATIONALLY Danish, German, Spanish and Swedish Total n=808

13 FOCUS -STEPS FOCUS translation Convergent validity (LARS vs. QoL) Discriminative validity Reliability (reproduciblity/agreement) 13/24

14 Metode Oversættelse: forward and back translation: Til engelsk af 2 englændere Original dansk version Dansk kontrol version Engelsk version A Engelsk version B Af A og B dannes en foreløbig Engelsk version Engelsk A+B version Tilbage til dansk af dansker 14/24

15 Metode: oversættelse 15/24

16 conclusion: LARS score validated 4 european populations of rectal cancer patients (Juul et al Ann. Surg. 2013) 5- linguistic versions semantic equivalent (incl. english) LARS score convergent validity LARS score discriminativ validity LARS score reliability 16/24

17 Conclusion > 40 % major LARS Major impact: Neoadjuvant therapy TME-type surgery risk of Minor impact: Female gender major LARS Age 64 years Risk of major LARS independent of type of neoadjuvant regimen Funding:

18 ONGOING LARS STUDIES PROSPECTIVE COHORT RANDOMISED STUDIES EORTC AND LARS DOCTORS VERSUS PT PERSPECTIVE PATHOPHYSIOLOGY TREATMENT

19 Overesti mate

20 Exercise 2 Underes timate

21 o Rectal cancer specialists, regardless of subgroup, do not have a very thorough understanding of the patient s experience of LARS o Patients: urgency and clustering

22 ONGOING LARS STUDIES PROSPECTIVE COHORT RANDOMISED STUDIES EORTC AND LARS DOCTORS VERSUS PT PERSPECTIVE PATHOPHYSIOLOGY TREATMENT

23 TME SURGERY-why LARS? 1. RECTUM IS REMOVED A reservoir and conduit 2. ANAL CANAL Interplay with rectum gone Damage (mechanical- innervation) 3. LEFT COLON denervated

24 NEOADJUVANT THERAPY and TME Disturbed sensory response neorectum No change in biomechanical properties resting pressure

25 TIME FOR A CHANCE FOCUS ON BOWEL DYSFUNCION 1 inform the patient 2 document it before and after 3 avoid it Nerve sparring surgery ( robotic??) resections (local / watch full waiting) neoadjuvant therapy 4 treat it Much more research

26 BEHANDLING I PROTOKOL Konservativ Hvis manglende effekt Trans Anal Irrigation ( TAI) Sacral Nerve Stimulation (SNS)

27 TRANSANAL IRRIGATION

28 SCINTIGRAPHY før skylning efter skylning

29 PNE Method 3-week test period with external stimulator Permanent stimulator implanted if > 50 % reduction of incontinence episodes

30 SNS

31 TAI and SNS fails: Antegrad Irrigation Water: ml 45 min. (30-60) Interval 1-3 days

32 SCINTIGRAPHY før skylning efter skylning

33 Senfølger endetarmskræft Tarm bøvl Blære Sex Kroniske smerter Fraktur risiko? MEGET MERE FORSKNING KB,Boel fonden, regional sygehusvæsen Frie forskningsråd: håbløs