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GRECCAR 17 will be the first prospective and randomized trial to assess a tailored policy in the use of defunctioning stoma after TME according to the personalized risk of anastomotic leakage. The tailored use of defunctioning stoma after TME for rectal cancer should improve both the quality of life of patients and the anorectal function, without any impact on anastomotic leakage. Moreover, for the healthcare system, this new approach could be a cost-effective strategy, leading to a decrease in healthcare expenses.
The main objective is to compare the impact of tailored defunctioning stoma after TME for rectal cancer versus the systematic use of defunctioning stoma on the evolution of the specific Quality Of Life (QLQC30) during the 12 months after surgery.
The introduction of Total Mesorectal Excision (TME) as the surgical procedure of choice for low and mid rectal cancer has led to decrease local recurrence and improved oncological results. Postoperative morbidity remains a major issue, and the most feared complication is anastomotic leakage. The systematic use of a defunctioning stoma during 3 months to protect low colorectal anastomosis (below than 7 cm from the anal verge) is the standard of practice after TME surgery in order to decrease risks of anastomotic leakage and urgent re-operations.
However, there have been a lot of controversies surrounding the role of defunctioning stoma mainly due to stoma-related complications, ranked from 20% to 60%, which may lead to prolonged inpatient care, urgent re-operation and devastating effects on quality of life (QOL) and healthcare expenses. Moreover, it has been reported that patients either without defunctioning stoma, or with early stoma closure (days 8-12 after TME) have a better functional outcomes than patients with systematic defunctioning stoma for 3 months.
The experimental arm (arm A) will benefit from a tailored use of defunctioning stoma after TME based on a 2-step process: i) to perform or not a defunctioning stoma according to the personalized risk of anastomotic leakage (defunctioning stoma only if Anastomotic Failure Observed Risk Score=[2-6]), ii) to perform an early stoma closure at day 8-12, according to clinical (fever), biological (CRP level days 2 and 4 postoperatively) and radiological postoperative assessment (CT-scan with colonic contrast retrograde enema day 7-8 postoperatively). The control arm (arm B) will benefit from systematic use of defunctioning stoma for 2-3 months after TME, according to French national and international guidelines.
Patients will be followed at 1, 4, 8 and 12 months after surgery, with chest, abdominal and pelvic scan and tumour markers.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Arm A: Tailored use of defunctioning stoma after TME | Experimental | The tailored use of defunctioning stoma includes two steps:
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| Arm B: Systematic use of defunctioning stoma | Active Comparator | Systematic use of defunctioning stoma for 3 months after TME according to French national guidelines |
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| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Tailored use of defunctioning stoma after TME | Procedure | Tailored use of defunctioning stoma after TME based on a 2-step process: i) to perform or not a defunctioning stoma according to the personalized risk of anastomotic leakage (defunctioning stoma only if Anastomotic Failure Observed Risk Score=[2-6]), ii) to perform an early stoma closure at day 8-12, according to clinical (fever), biological (CRP level days 2 and 4 postoperatively) and radiological postoperative assessment (CT-scan with colonic contrast retrograde enema day 7-8 postoperatively) |
| Measure | Description | Time Frame |
|---|---|---|
| Quality of life over the 12 months after surgery | The QLQ-C30 is a patient self-rating questionnaire (30 questions) that measures physical, role, social, emotional, and cognitive functions as well as overall QoL. Scores can be linearly transformed to provide a score from 0 to 100 REF. Higher scores represent better functioning on the functional scales and a higher level of symptoms of the symptom scales. The area under the quality of life curve will be measured over the 12 months after rectal surgery, with measurement time points at 1, 4, 8 and 12 months. | At 1, 4, 8, and 12 months of follow-up |
| Measure | Description | Time Frame |
|---|---|---|
| Proportion of anastomotic leakage | Proportion of patients with an anastomotic leakage will be assessed by a clinical exam (with a rectal examination) at 1 month and with a clinical exam (with a rectal examination) and a CT scan at 4 months after rectal surgery | At 1 and 4 months after the rectal surgery |
| The PF, RF, CF, EF, SF, FA, PA, NV, QL Dimensions of the QLQ-C30 questionnaire |
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Inclusion Criteria:
Exclusion Criteria:
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| Name | Role | Phone | Extension | |
|---|---|---|---|---|
| Christophe LAURENT | Contact | (0)5 57 65 67 69 | +33 | christophe.laurent@chu-bordeaux.fr |
| Benjamin FERNANDEZ | Contact | benjamin.fernandez@chu-bordeaux.fr |
| Name | Affiliation | Role |
|---|---|---|
| Christophe LAURENT | University Hospital, Bordeaux | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| CHU Amiens-Picardie - Service de Chirurgie Digestive | Recruiting | Amiens | France |
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| Systematic use of defunctioning stoma | Procedure | Systematic use of defunctioning stoma for 2-3 months after TME, according to French national and international guidelines |
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| At 1, 4, 8 and 12 months after the rectal surgery |
| The urinary frequency | The QLQ-CR29 (Quality of life of rectal cancer patients with 29 questions) has five functional and 18 symptom scales. It contains four subscales (urinary frequency (UF), blood and mucus in stool (BMS), stool frequency (SF), and body image (BI)) and 19 single items. Urinary frequency is measured with items 1 and 2 of the questionnaire. The score can range from 0 to 100. Higher scores represent better functioning on the functional scales and a higher level of symptoms of the symptom scales. | At 1, 4, 8, and 12 months post-surgery |
| Blood or mucus in stools | The QLQ-CR29 (Quality of life of rectal cancer patients with 29 questions) has five functional and 18 symptom scales. It contains four subscales (urinary frequency (UF), blood and mucus in stool (BMS), stool frequency (SF), and body image (BI)) and 19 single items. The blood or mucus in stools is measured with items 8 and 9 of the questionnaire. The score can range from 0 to 50. Higher scores represent better functioning on the functional scales and a higher level of symptoms of the symptom scales. | At 1, 4, 8, and 12 months post-surgery |
| Stool frequency | At 1, 4, 8, and 12 months post-surgery |
| Body image dimensions of the QLQ-CR29 questionnaire | The QLQ-CR29 (Quality of life of rectal cancer patients with 29 questions) has five functional and 18 symptom scales. Scores can be linearly transformed to provide a score from 0 to 100. Higher scores represent better functioning on the functional scales and a higher level of symptoms of the symptom scales. | At 1, 4, 8, and 12 months post-surgery |
| Rate of defunctioning stoma | Proportion of patients who have a defunctioning stoma. It will be assessed at the time of the consultation at 1 month with the collection of the adverse events (AE) and the serious adverse events (SAE) | At 1 month after the rectal surgery |
| Low Anterior Resection Syndrome score (LARS score) | The LARS questionnaire (low anterior resection score) evaluates bowel function. Five questions regarding incontinence for flatus and liquid stools, frequency, clustering and urgency for defecation are taken into account. The score ranges from 0 to 42 is divides into no LARS (0 to 20 points), minor LARS (21 to 29 points), and major LARS (30 to 42 points). | At 1, 4, 8 and 12 months after the rectal surgery |
| Anal Incontinence (Wexner score) | The WEXNER score assesses the importance of anal incontinence, it varies from 0 to 20, 20 corresponding to total anal incontinence | At 1, 4, 8 and 12 months after the rectal surgery |
| International Index of Erectile Function (IIEF)-5 | Measured in male patients | At 1, 4, 8 and 12 months after the rectal surgery |
| Female Sexual Function Index (FSFI) scale scores | Measured in female patients. The Female Sexual Function Index (FSFI) is a 19-item self-report inventory designed to assess female sexual function. It comprises six domains: desire, arousal ,lubrication orgasm, satisfaction, pain. The maximum score for each domain is 6.0, obtained by summing item responses and multiplying by a correction factor. The total composite sexual function score is a sum of domain scores and ranges from 2.0 (not sexually active and no desire) to 36.0. | At 1, 4, 8 and 12 months after the rectal surgery |
| Urinary symptom profil (USP) | The Urinary symptom profil (USP) assesses urinary symptoms among men and women with stress, urge (from 0 to 9), overactive bladder (from 0 to 9), or urinary obstructive symptoms (from 0 to 9). The maximum corresponding to a bad result. | At 1, 4, 8, 12 months after the rectal surgery |
| Postoperative morbidity (Clavien-Dindo score I-IV) | This is a classification in order to rank a complication (surgical or medical morbidity) in an objective and reproducible manner. It consists of 7 grades (I, II, IIIa, IIIb, IVa, IVb and V). The introduction of the subclasses a and b allows a contraction of the classification into 5 grades (I, II, III, IV and V) depending on the size of the population observed or the of the focus of a study. It varies from 1 to 5, 5 corresponding to the death at the patient. | At 1 and 4 months after the rectal surgery |
| Postoperative mortality (Clavien-Dindo score V) | This is a classification in order to rank a complication (surgical or medical morbidity) in an objective and reproducible manner. It consists of 7 grades (I, II, IIIa, IIIb, IVa, IVb and V). The introduction of the subclasses a and b allows a contraction of the classification into 5 grades (I, II, III, IV and V) depending on the size of the population observed or the of the focus of a study. It varies from 1 to 5, 5 corresponding to the death at the patient. | At 1 and 4 months after the rectal surgery |
| Proportion to work return after TME in active workers | This endpoint is referring to the capability of active patients to resume their professional activity after surgery. In order to better describe this endpoint the investigators want to measure together the proportion of patients resuming their activity, and the time until resumption of professional activity. | Through study completion, an average of 1 year |
| Time to work return after TME in active workers | This endpoint is referring to the capability of active patients to resume their professional activity after surgery. In order to better describe this endpoint the investigators want to measure together the proportion of patients resuming their activity, and the time until resumption of professional activity. | Through study completion, an average of 1 year |
| Quality of life over the 12 months after surgery | The Quality of life of cancer contains 30 questions (QLQ-C30). This is a patients self-rating questionnaire that measures physical, role, social, emotional, and cognitive functions as well as overall QoL. Scores can be linearly transformed to provide a score from 0 to 100.Higher scores represent better functioning on the functional scales and a higher level of symptoms of the symptom scales. | QLQ-C30 is assessed at 1, 4, 8 and 12 months after the rectal surgery |
| Incremental cost-utility ratio defined as an incremental cost / Quality-Adjsuted Life Year (QALY) gained | Costs will be measured through the French Health Data Hub database. QALYs will be measured using the and EQ-5D-5L questionnaire. | From surgery to 12 months after surgery |
| Total budgetary impact for French healthcare insurance system of spreading selective ostomy practice in France | 5-year financial model | From surgery to 12 months after surgery |
| Indirect Costs (€) for French Healthcare insurance scheme of sickness leaves | Measured through SNDS database (Système National des Données de Santé) and data from our study on sickness leaves and times to return to work | From surgery to 12 months after surgery |
| Changes in microbiome composition and diversity from baseline to 1 month | Data will be rarefied using the samples with the smallest number of reads and then subjected to alpha-diversity analysis employing Faith's phylogenetic diversity. Kruskal-Wallis will be calculated between all groups together and for pairwise comparisons. To find significant differences at the genera taxonomy level, ANCOM tests will be used to identify features that are differentially abundant across sample groups. | From baseline to Month 1 |
| CHRU de Besançon - Service de Chirurgie Générale, Digestive et Cancérologique - Unité de Transplantation Hépatique | Not yet recruiting | Besançon | France |
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| CHU de Bordeaux - Service de Chirurgie Digestive et Endocrinienne - Unité Colorectale | Recruiting | Bordeaux | France |
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| Clinique Tivoli Ducos - Service de Chirurgie Digestive | Recruiting | Bordeaux | France |
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| CHU de Clermont-Ferrand - Service de Chirurgie Digestive et Hépato-biliaire | Not yet recruiting | Clermont-Ferrand | France |
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| APHP - Hôpital Beaujon - Service de Chirurgie Digestive | Not yet recruiting | Clichy | France |
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| CHU Grenoble Alpes - Service de Chirurgie Digestive | Recruiting | La Tronche | France |
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| APHP - Hôpital Bicêtre - Service de Chirurgie Générale et Digestive | Recruiting | Le Kremlin-Bicêtre | France |
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| CHU de Lille - Service de Chirurgie Générale et Digestive | Recruiting | Lille | France |
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| Centre Lyonnais de Chirurgie Digestive | Recruiting | Lyon | France |
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| APHM - Hôpital La Timone - Service de Chirurgie Digestive et Générale | Recruiting | Marseille | France |
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| APHM - Hôpital Nord - Service de Chirurgie Digestive | Recruiting | Marseille | France |
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| Hôpital Européen de Marseille - Service de Chirurgie Digestive | Recruiting | Marseille | France |
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| Institut Paoli Calmette - Service de Chirurgie Digestive | Recruiting | Marseille | France |
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| Institut du Cancer de Montpellier - Service de Chirurgie Digestive | Not yet recruiting | Montpellier | France |
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| APHP - HEGP- Service de Chirurgie Digestive | Recruiting | Paris | France |
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| APHP - Hôpital Saint Antoine - Service de Chirurgie Digestive | Recruiting | Paris | France |
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| APHP - Hôpital Saint-Louis - Service de Chirurgie Viscérale, Cancérologique et Endocrinienne | Not yet recruiting | Paris | France |
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| GH Diaconesses Croix Saint-Simon - Service de Chirurgie Digestive | Recruiting | Paris | France |
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| Groupe Hospitalier Paris St. Joseph - Service de Chirurgie Digestive et Obésité | Not yet recruiting | Paris | France |
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| Hospices Civils de Lyon - Sevice de Chirurgie Digestive | Recruiting | Pierre-Bénite | France |
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| CHU de Rennes - Service de Chirurgie Hépatobiliaire et Digestive | Not yet recruiting | Rennes | France |
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| CHU de Rouen - Service de Chirugie Digestive | Recruiting | Rouen | France |
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| CHRU de Strasbourg - Service de Chirurgie Générale et | Recruiting | Strasbourg | France |
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| CHU de Toulouse - Service de Chirurgie Digestive | Not yet recruiting | Toulouse | France |
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| CHRU de Tours - Service de Chirurgie Digestive Oncologique et Colorectale | Recruiting | Tours | France |
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| CHRU de Nancy - Service de Chirugie Digestive, Hépatobiliaire, endocrinienne et Cancérologique | Recruiting | Vandœuvre-lès-Nancy | France |
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| Institut Gustave Roussy - Service de Chirurgie Viscérale Oncologique | Recruiting | Villejuif | France |
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| ID | Term |
|---|---|
| D012004 | Rectal Neoplasms |
| ID | Term |
|---|---|
| D015179 | Colorectal Neoplasms |
| D007414 | Intestinal Neoplasms |
| D005770 | Gastrointestinal Neoplasms |
| D004067 | Digestive System Neoplasms |
| D009371 | Neoplasms by Site |
| D009369 | Neoplasms |
| D004066 | Digestive System Diseases |
| D005767 | Gastrointestinal Diseases |
| D007410 | Intestinal Diseases |
| D012002 | Rectal Diseases |
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