Efficacy of endoscopic gastrojejunal bypass in obese Yucatan pigs: a comparative animal study

BACKGROUND

Natural orifice transluminal endoscopy surgery (NOTES) gastrojejunal anastomosis (GJA) with duodenal exclusion (DE) could be used as a less invasive alternative to surgical gastric bypass. The aim of this study was to compare the efficacy and safety of both methods for bariatric purpose.

METHODS

This was a prospective, experimental and comparative study on 27 obese living pigs, comparing 4 groups: GJA alone (group 1, G1), GJA + DE (group 2, G2), surgical gastric bypass (group 3, G3), control group (group 4, G4). GJA was endoscopically performed, using NOTES technic and LAMS, while DE was performed surgically for limb length selection. Animals were followed for 3 months. Primary outcome included technical success and weight change, while secondary endpoints included the rate of perioperative mortality and morbidity, histological anastomosis analysis and biological analysis.

RESULTS

Technical success was 100% in each intervention group. No death related to endoscopic procedures occurred in the endoscopic groups, while early mortality (< 1 month) was 57,1% in the surgical group, all due to anastomotic dehiscence. At 3 months, compared to baseline, mean weight change was + 3,1% in G1 (p = 0,46); -14,9% in G2 (p = 0,17); +5,6% in G3 (p = 0,38) and + 25% in G4 (p = 0,029). Histopathological analysis of endoscopic GJA showed complete fusion of different layers without leak or abscess.

CONCLUSIONS

Endoscopic GJA with DE provides the efficacy of bypass on weight control in an animal model. Next steps consist of the development of devices to perform exclusively endoscopically limb length selection and DE.

Multimodal necrosectomy with full combined endoscopic necrosectomy in the management of acute necrotizing pancreatitis

Transgastric and transduodenal endoscopic drainages and necrosectomy are minimally invasive and effective way for the treatment of infected necrosis in the setting of acute pancreatitis (AP), but are limited in case of large and distant collections or in case of altered anatomy. We present an exclusively endoscopic approach consisting of multimodal endoscopic necrosectomy. We included consecutive patients with severe AP and presenting with large and infected necrosis requiring one transgastric and at least one extra-gastric access, among which are percutaneous, transcolonic, and/or transgrelic access. All accesses and necrosectomy sessions were performed endoscopically with CO2 insufflation. Six consecutive patients were treated. The location of infected collections were perigastric (100%), right and left paracolonic (67% and 67%), and paraduodenal (33%). All patients had transgastric or transduodenal access, all had at least one percutaneous access (total: 7 accesses), one had one transcolonic access, and one had one transjejunal access. A median of 4 necrosectomy sessions (2-5) were performed. All patients recovered without additional surgical necrosectomy. Full endoscopic multimodal management of infected necrosis with step-up approach seems feasible, safe, and effective in very large collections.

A French National Study on Gastropleural and Gastrobronchial Fistulas After Bariatric Surgery: the Impact of Therapeutic Strategy on Healing

PURPOSE

Gastropleural and gastrobronchial fistulas (GPF/GBFs) are serious but rare complications after bariatric surgery whose management is not consensual. The aim was to establish a cohort and evaluate different clinical presentations and therapeutic options.

MATERIALS AND METHODS

A multicenter and retrospective study analyzing GPF/GBFs after bariatric surgery in France between 2007 and 2018, via a questionnaire sent to digestive and thoracic surgery departments.

RESULTS

The study included 24 patients from 9 surgical departments after initial bariatric surgery (21 sleeve gastrectomies; 3 gastric bypass) for morbid obesity (mean BMI = 42 ± 8 kg/m²). The GPF/GBFs occurred, on average, 124 days after bariatric surgery, complicating an initial post-operative gastric fistula (POGF) in 66% of cases. Endoscopic digestive treatment was performed in 79% of cases (n = 19) associated in 25% of cases (n = 6) with thoracic endoscopy. Surgical treatment was performed in 83% of cases (n = 20): thoracic surgery (n = 5), digestive surgery (n = 8), and combined surgery (n = 7). No patient died. Overall morbidity was 42%. The overall success rate of the initial and secondary strategies was 58.5% and 90%, respectively. The average healing time was approximately 7 months. Patients who had undergone thoracic surgery (n = 12) had more initial management failures (n = 9/12) than patients who had not (n = 3/12), p = 0.001.

CONCLUSION

Complex and life-threatening fistulas that are revealed late require a multidisciplinary strategy. Thoracic surgery should be reserved once the abdominal leak heals; otherwise, it is associated with a higher risk of failure.

Internal endoscopic drainage as first line or second line treatment in case of postsleeve gastrectomy fistulas

BACKGROUND AND STUDY AIMS

Management of post-sleeve gastrectomy fistulas (PSGF) recently has evolved, resulting in prioritization of internal endoscopic drainage (IED). We report our experience with the technique in a tertiary center.

PATIENTS AND METHODS

 This was a single-center, retrospective study of 44 patients whose PSGF was managed with IED, comparing two periods: after 2013 (Group 1; n = 22) when IED was used in first line and before 2013 (Group 2; n = 22) when IED was applied in second line. Demographic data, pre-endoscopic management, characteristics of fistulas, therapeutic modalities and outcomes were recorded and compared between the two groups. The primary endpoint was IED efficacy; the secondary endpoint was a comparison of outcomes depending on the timing of IED in the management strategy.

RESULTS

 The groups were matched in gender (16 female, 16 male), mean age (43 years old), severity of fistula, delay before treatment, and exposure to previous endoscopic or surgical treatments. The overall efficacy rate was 84 % (37/44): 86 % in Group 1 and 82 % in Group 2 (NS). There was one death and one patient who underwent surgery. The median time to healing was 226 ± 750 days (Group 1) vs. 305 ± 300 days (Group 2) (NS), with a median number of endoscopies of 3 ± 6 vs . 4.5 ± 2.4 (NS). There were no differences in number of nasocavity drains and double pigtail stents (DPS), but significantly more metallic stents, complications, and secondary strictures were seen in Group 2.

CONCLUSION

 IED for management of PSGF is effective in more than 80 % of cases whenever it is used during the therapeutic strategy. This approach should be favored when possible.

G-POEM with antro-pyloromyotomy for the treatment of refractory gastroparesis: mid-term follow-up and factors predicting outcome

BACKGROUND

Gastric peroral endoscopic pyloromyotomy (G-POEM) was introduced for treating refractory gastroparesis.

AIM

To present a series of patients focussed on clinical mid-term efficacy and predictive outcomes factors.

METHODS

This was a single centre study of 29 patients operated on between January 2014 and April 2016, with disturbed gastric emptying scintigraphy (GES) and/or elevated Gastroparesis Cardinal Symptoms Index (GCSI). The procedures were performed as previously described. The primary endpoint was the efficacy at 3 and 6 months, based on GCSI and symptoms. The secondary endpoints were GES evolution, procedure reproducibility and safety, and identification of predictive factors for success.

RESULTS

There were 10 men, 19 women (mean age 52.8±18). The technical success rate was 100% (average 47 minutes). There were two complications managed conservatively: one bleeding and one abscess. The median follow-up was 10±6.4 months. The clinical success rate was 79% at 3 months, 69% at 6 months, with a significant decrease in the mean GCSI compared to pre-operatively (3.3±0.9 vs 1±1.2 and 1.1±0.9 respectively). The GES (n=23) normalised in 70% of cases, with a significant improvement of the mean half emptying time and retention at 2 hours, and a discordance in 21% of the cases. In univariate analysis, diabetes and female gender were significantly associated with risk of failure, but not confirmed in multivariate analysis.

CONCLUSIONS

The mid-term efficacy of G-POEM reaches 70% at 6 months. The procedure remains reproducible and safe. Diabetes and female gender were predictive of failure.

Efficacy of the endoscopic management of postoperative fistulas of leakages after esophageal surgery for cancer: a retrospective series

BACKGROUND AND AIMS

Anastomotic leakages are severe and often lethal adverse events of surgery for esophageal cancer. The endoscopic treatment is growing up in such indications. The aim was to evaluate the efficacy and describe the strategy of the endoscopic management of anastomotic leakages/fistulas after esophageal oncologic surgery.

METHODS

Single-center retrospective study on 126 patients operated for esophageal carcinomas between 2010 and 2014. Thirty-five patients with postoperative fistulas/leakages (27 %) were endoscopically managed and included. The primary endpoint was the efficacy of the endoscopic treatment. The secondary endpoints were: delays between surgery, diagnosis, endoscopy and recovery; number of procedures; material used; and adverse events rate. Uni- and multivariate analyses were carried out to determine predictive factors of success.

RESULTS

There were mostly men, with a median age of 61.7 years ± 8.9 [43-85]. 48.6 % underwent Lewis-Santy surgery and 45.7 % Akiyama's. 71.4 % patients received neo-adjuvant chemo-radiation therapy. The primary and secondary efficacy was 48.6 and 68.6 %, respectively. The delay between surgery and endoscopy was 8.5 days [6.00-18.25]. Eighty-eight percentages of the patients were treated using double-type metallic stents, with removability and migration rates of 100 and 18 %, respectively. In the other cases, we used over-the-scope clips, naso-cystic drain or combined approach. The mean number of endoscopy was 2.6 ± 1.57 [1-10]. The mortality rate was 17 %, none being related to procedures. No predictive factor of efficacy could be identified.

CONCLUSIONS

The endoscopic management of leakages or fistulas after esophageal surgery reached an efficacy rate of 68.8 %, mostly using stents, without significant adverse events. The mortality rate could be decreased from 40-100 to 17 %.

Easy clip to treat anal fistula tracts: a word of caution

BACKGROUND AND AIMS

Closing the internal opening by a clip ovesco has been recently proposed for healing the fistula tract, but, to date, data on benefit are poorly analyzed. The aim was to report a preliminary multicenter experience.

MATERIALS AND METHODS

Retrospective study was undertaken in six different French centers: surgical procedure, immediate complications, and follow-up have been collected.

RESULTS

Nineteen clips were inserted in 17 patients (M/F, 4/13; median age, 42 years [29-54]) who had an anal fistula: 12 (71%) high fistulas (including 4 rectovaginal fistulas), 5 (29%) lower fistulas (with 3 rectovaginal fistulas), and 6 (35%) Crohn's fistulas. Out of 17 patients, 15 had a seton drainage beforehand. The procedure was easy in 8 (47%) patients and the median operative time was 27.5 min (20-36.5). Postoperative period was painful for 11 (65%) patients. A clip migration was noted in 11 patients (65%) after a median follow-up of 10 days (5.5-49.8). Eleven patients (65%) who failed had reoperation including 10 new drainages within the first month (0.5-5). After a mean follow-up of 4 months (2-7),, closing the tract was observed in 2 patients (12%) following the first insertion of the clip and in another one after a second insertion.

CONCLUSION

Treatment of anal fistula by placing a clip on the internal opening is disappointing and deleterious for some patients. A better assessment before dissemination is recommended.

Evaluation of feasibility, efficiency and safety of a pure NOTES gastrojejunal bypass with gastric outlet obstruction, in an in vivo porcine model

INTRODUCTION

Natural orifice transluminal endoscopic surgery (NOTES) gastrojejunal anastomosis (GJA) is a less invasive surgery for bariatric procedures and gastric outlet obstruction. The aim of this study was to evaluate the feasibility, efficacy, and safety of a pure NOTES gastrojejunal bypass using an in vivo porcine model.

MATERIAL AND METHODS

A prospective study was performed on nine swine. A double-channel scope was used. The intervention steps were: (i) gastric incision; (ii) peritoneal access; (iii) jejunal loop selection and mobilization into the stomach; (iv) stoma creation within the gastric wall and incision; (v) anastomosis suture and pylorus closure using a T-tag prototype. The animals were assessed clinically for 3 weeks including the weight gain. The patency of the GJA was assessed at necropsy and a histological analysis was performed.

RESULTS

We successfully performed all the procedures with a mean (standard deviation [SD]) operative time of 108 (26) minutes. We used a mean of 5.55 (1.30) stitches. There were no intraprocedural adverse events. Five animals survived up till euthanasia at 3 weeks (65 %). These showed a significant difference in weight curves of a loss of 3.2 kg compared with gain of 5.2 kg in a control group. Four pigs died from anastomotic dehiscence complicated by peritonitis.

CONCLUSION

Gastrojejunal bypass with a pure NOTES approach is feasible. This procedure is effective, resulting in a patent anastomosis and a significant weight loss. However, the anastomotic dehiscence is a major concern because of its mortality rate, and further studies including improvement of the suturing device and the technique are needed.

Fully covered self-expanding metal stents for benign colonic strictures

BACKGROUND AND STUDY AIMS

Uncovered self-expanding metal stents offer effective relief for colonic obstruction. The aim of this study was to determine the effectiveness of fully covered self-expanding metal stents (FCSEMSs) in the treatment of benign colonic strictures.

PATIENTS AND METHODS

All patients presenting with a symptomatic benign colonic stricture (occlusion or subocclusion) during a 6-year study period were treated with FCSEMSs. The stents were placed and removed 4 - 6 weeks later at one of 10 endoscopy centers. The efficacy of the stent (clinical and radiological signs of colonic decompression within 48 hours), technical success, stent retrieval, safety, and recurrence of symptoms were evaluated during follow-up. Univariate and multivariate analyses were performed to identify variables associated with clinical success, stent migration, and symptom recurrence.

RESULTS

The study included 43 patients (24 men, 19 women; mean age 67.6 ± 10.4) with occlusive (n = 18) or subocclusive symptoms (n = 25) due to anastomotic (n = 40), post-ischemic (n = 2), or post-radiation (n = 1) strictures. Insertion was successful in all patients. Clinical success was obtained in 35 patients (81 %). Migration was observed in 27 patients (63 %). The median duration of stenting was 21 days (95 %CI 17.8 - 35.4 days). Multivariate analysis showed that stents more than 20 mm wide migrated significantly less often. Recurrence of obstructive symptoms was observed in 23 patients (53 %), irrespective of migration. No predictive factors for recurrence or clinical efficacy were found.

CONCLUSIONS

FCSEMSs for treatment of symptomatic benign colonic strictures are safe and effective, despite a high rate of spontaneous migration.

Endoscopic ultrasound-guided vascular therapy: is it safe and effective?

Recent developments in therapeutic endoscopic ultrasound (EUS) have enabled new approaches to the management of refractory gastrointestinal bleeding, including EUS-guided sclerotherapy and vessel embolization. Few cases have been reported in the literature. Eight patients were admitted for severe, refractory gastrointestinal bleeding, seven of whom were actively bleeding. Causes of bleeding were gastric varices secondary to portal hypertension (n = 3); gastroduodenal artery aneurysm or fundal aneurysmal arterial malformation (n = 3); and Dieulafoy's ulcer (n = 2); the latter five patients having arterial bleeding. During the procedures, the bleeding vessel was punctured with a 19-gauge needle then injected with a sclerosing agent (cyanoacrylate glue [n = 6] or polidocanol 2 % [n = 2]) under Doppler control. The median follow-up time was 9 months (3 - 18 months). In all 10 endoscopic procedures were performed. The procedure was successful at the first attempt in seven out of eight patients (87.5 %). No clinical complications were observed, although in one case there was diffusion of cyanoacrylate in the hepatic artery. The seven successful cases all showed immediate and complete disappearance of the Doppler flow signal at the end of the procedure. This retrospective study highlights the utility of EUS-guided vascular therapy. However, more large randomized studies should be conducted to confirm these results.

Gene expression signature of advanced pancreatic ductal adenocarcinoma using low density array on endoscopic ultrasound-guided fine needle aspiration samples

AIMS

The purpose of this study was to investigate the clinical feasibility and utility of low-density array analysis on samples obtained from endoscopic ultrasound-guided fine needle aspiration biopsy in locally advanced and/or metastatic pancreatic ductal adenocarcinoma and chronic pancreatitis.

PATIENTS AND METHODS

In this prospective multicenter study, we quantified candidate gene expression in biopsies sampled from 44 locally advanced and/or metastatic pancreatic carcinoma and from 17 pseudotumoural chronic pancreatitis using dedicated low-density array microfluidic plates.

RESULTS

We first demonstrated that 18S gene expression is stable and comparable in normal pancreas and pancreatic cancer tissues. Next, we found that eight genes (S100P, PLAT, PLAU, MSLN, MMP-11, MMP-7, KRT7, KRT17) were significantly over expressed in pancreatic cancer samples when compared to pseudotumoural chronic pancreatitis (p value ranging from 0.0007 to 0.0215): Linear discriminative analysis identified S100P, PLAT, MSLN, MMP-7, KRT7 as highly explicative variables. The area under receiver operating curve establishes the clinical validity of the potential diagnostic markers identified in this study (values ranging from 0.69 to 0.76). In addition, combination of S100P and KRT7 gave better diagnosis performances (Area Under Receiver Operating Curve 0.81, sensitivity 81%, specificity 77%).

CONCLUSION

We demonstrate that molecular studies on EUS-guided FNA material are feasible for the identification and quantification of markers in PDAC patients diagnosed with non-resectable tumours. Using low-density array, we isolated a molecular signature of advanced pancreatic carcinoma including mostly cancer invasion-related genes. This work stems for the use of novel biomarkers for the molecular diagnosis of patient with solid pancreatic masses.

Long-term follow-up after biliary stent placement for postcholecystectomy bile duct strictures: a multicenter study

BACKGROUND AND STUDY AIMS

Endoscopic stenting is a recognized treatment of postcholecystectomy biliary strictures. Large multicenter reports of its long-term efficacy are lacking. Our aim was to analyze the long-term outcomes after stenting in this patient population, based on a large experience from several centers in France.

METHODS

Members of the French Society of Digestive Endoscopy were asked to identify patients treated for a common bile duct postcholecystectomy stricture. Patients with successful stenting and follow-up after removal of stent(s) were subsequently included and analyzed. Main outcome measures were long-term success of endoscopic stenting and related predictors for recurrence (after one stenting period) or failure (at the end of follow-up).

RESULTS

A total of 96 patients were eligible for inclusion. The mean number of stents inserted at the same time was 1.9±0.89 (range 1-4). Stent-related morbidity was 22.9% (n=22). The median duration of stenting was 12 months (range 2-96 months). After a mean follow-up of 6.4±3.8 years (range 0-20.3 years) the overall success rate was 66.7% (n=64) after one period of stenting and 82.3% (n=79) after additional treatments. The mean time to recurrence was 19.7±36.6 months. The most significant independent predictor of both recurrence and failure was a pathological cholangiography at the time of stent removal.

CONCLUSION

Endoscopic stenting helps to avoid surgery in more than 80% of patients bearing postcholecystectomy common bile duct strictures. However, a persistent anomaly on cholangiography at the time of stent removal is a strong predictor of recurrence and may lead to consideration of surgery.

[Chromoendoscopy in inflammatory bowel disease]

The risk of colorectal cancer in case of IBD-related pancolitis reaches 2% after 10 years follow-up, 8% after 20 years up to 18% at 30 years, and was probably over-estimated in the first series. Chromoendoscopy appears to be helpful in the surveillance of IBD, and moreover recommended, using carmine indigo or methylene blue with a well-standardized procedure. Its place regarding other techniques like virtual coloration has to be clarified with randomized studies. The chromoendoscopy allows the operator to perform targeted biopsies, which appear to be more efficient for the detection of dysplasia than systematic biopsies performed every 10 cm. Nevertheless, it is too soon to remove systematic biopsies from scientific recommendations.

Endoscopic ultrasound-guided fine-needle aspiration biopsy coupled with KRAS mutation assay to distinguish pancreatic cancer from pseudotumoral chronic pancreatitis

BACKGROUND AND STUDY AIMS

Differential diagnosis between pancreatic adenocarcinoma (PADC) and pseudotumoral forms of chronic pancreatitis remains difficult. Mutation of KRAS oncogene is present in 75% to 95% of PADC. This study aimed to evaluate whether the combined analysis of KRAS mutation with cytopathological findings from endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB) might improve discrimination between PADC and chronic pancreatitis.

PATIENTS AND METHODS

This prospective multicenter study included 178 patients with solid pancreatic masses (men 104, women 74; mean age 64.5 years). Cytopathological examination and KRAS mutation analysis (codon-12 and codon-13, restriction fragment length polymorphism [RFLP] and direct sequencing) were performed on EUS-FNAB material. Final diagnoses were obtained on EUS-FNAB analysis and/or a second biopsy and/or clinical follow-up and/or surgery: PADC, n = 129; chronic pancreatitis, n = 27; other pancreatic neoplasms, n = 16; and benign lesions, n = 6.

RESULTS

KRAS status analysis was successful in all EUS-FNAB samples. Codon-12 KRAS point mutation was found in 66% of PADC samples. No case of chronic pancreatitis displayed KRAS mutation. Sensitivity, specificity, positive and negative predictive values, and overall accuracy of cytopathology alone for diagnosis of PADC versus chronic pancreatitis were 83%, 100%, 100%, 56% and 86%, respectively. When KRAS mutation analysis was combined with cytopathology, these values reached 88%, 100%, 100%, 63% and 90% respectively.

CONCLUSION

Although the value of KRAS analysis in addition to EUS-FNAB is limited for distinguishing pancreatic mass lesions, when chronic pancreatitis presented as a pseudotumor a negative finding (wild-type KRAS), was useful in strongly suggesting a benign lesion.

What is the outcome for patients presenting with severe acute pancreatitis requiring a hospital stay of more than one month?

OBJECTIVE

The aim of this study was to investigate the clinical progression of patients who had severe acute pancreatitis (AP) and a stay in hospital of more than a month.

METHODS

A total of 24 patients (median age: 57 years) were included in this eight-year retrospective study. Cure was defined as the restoration of the pancreatic parenchyma, and the disappearance of all pseudocysts and pancreatic fistulae. Data including the duration of hospital stay, disease severity and pancreatic sequelae were also collected.

RESULTS

The median total duration of the hospital stay was 67 days. The overall mortality rate was 20.8%, whereas the mortality rate due to AP was 12.5%. The average healing period was 7.7 months. On univariate analysis, patients who also had respiratory diseases, chronic alcoholism, necrotizing superinfection, pseudocyst, food intolerance and/or hospital-acquired infection took significantly longer to heal. After cure, we observed pancreatic and/or hepatic duct stenoses in 50% of cases, and the onset or aggravation of diabetes in 25%.

CONCLUSION

In patients hospitalized for more than one month because of necrotizing AP, the rate of mortality is around 20%, with a final hospital stay of two months and a healing period of more than seven months. In addition, half of the patients presented with pancreatic or biliary sequelae.

Intravenous nitroglycerin for prevention of pancreatitis after therapeutic endoscopic retrograde cholangiography: a randomized, double-blind, placebo-controlled multicenter trial

BACKGROUND AND STUDY AIMS

Several studies have suggested that nitroglycerin promotes pancreatic drainage and thereby helps to prevent pancreatitis occurring after endoscopic retrograde cholangiography (ERC). We performed a multicenter, double-blind, randomized, placebo-controlled trial to evaluate the efficacy of intravenous nitroglycerin for preventing acute pancreatitis in moderate- to high-risk patients undergoing ERC.

PATIENTS AND METHODS

The patients underwent therapeutic ERC for gallstone removal, bile duct stenosis, or sphincter of Oddi dysfunction (SOD). They were randomly allocated to receive an intravenous nitroglycerin bolus of 0.1 mg, then 35 microg/kg per minute intravenously (maximum dose 9 mg) for 6 h, or an identical placebo regimen. Serum amylase and lipase levels were determined before and 24 h after ERC.

RESULTS

The study was terminated after the interim analysis. The intention-to-treat population consisted of 208 patients enrolled in 20 centers, of whom 105 received nitroglycerin and 103 placebo therapy. Post-ERC pancreatitis (mild/moderate/severe) occurred in 25 patients, comprising 10 (3/5/2) in the nitroglycerin arm and 15 (5/6/4) in the placebo arm (OR 0.62, 95 % CI 0.26 - 1.45; P = 0.26). Pancreatitis-related hospital stays were similar in the two groups (median 4 days, range 2 - 13 days in the nitroglycerin group; median 5 days, range 2 - 20 days in the placebo group). The incidence of pancreatitis in patients with SOD did not differ between the groups (4/11 in the nitroglycerin arm, and 4/15 in the placebo arm). Adverse events were more frequent in the nitroglycerin group and led to cessation of drug infusion in 10 patients in the nitroglycerin arm and in 2 patients in the placebo arm ( P = 0.019).

CONCLUSION

In this study, nitroglycerin offered a limited and clinically nonsignificant benefit for the prevention of post-ERC pancreatitis. Its use did not improve the technical success rate of ERC.

[Endoscopic management of postoperative pancreatic collections]

INTRODUCTION

Treatment of pancreatic postoperative collections are usually managed with a multidisciplinary team. Different managements are possible: abstention, external drainage, endoscopic treatment or surgery.

METHODS

We report on a case series of five patients with a postoperative pancreatic collection, endoscopically managed. Patients underwent all a CT scan associated or not with endoscopic ultrasonography.

RESULTS

An endoscopic cystenterosotomy was performed in all the cases, with two double pig tail stents sometimes associated with nasocystic drainage for clearing the cyst lumen and with transpapillary drainage in one case. All the procedures were successful and patients healed in all the cases with the disappearance of the radiological image within a 33 days to three months range with one complication due to superinfection of the drained cyst, endoscopically managed with a nasocystic catheter.

CONCLUSION

Therapeutic endoscopy, with a multidisciplinary approach, is a promising way to manage postoperative pancreatic collections.

[Endoscopic management of severe pancreatic and biliary diseases in children]

Endoscopic treatment of pancreatic pseudocysts and choledocal lithiasis is a first-line treatment in adults. Nevertheless, due to technical difficulties such a management is not always feasible in children. This series reports our results in the management of pancreatic and biliary diseases in children. Seven children, two months to 12 years old, underwent endoscopic management of pancreatic and biliary diseases. Two of them had choledocal lithiasis with jaundice or acute pancreatitis, two had pancreatic pseudocyst due to abdominal traumatism, two had chronic pancreatitis with a communicating pseudocyst in one case, and one had a biliary leakage after traumatism. All the endoscopic treatments were performed under general anesthesia. In six cases, the duodenoscope was a regular one with a large operating channel (Olympus TJF 160; Japan) employed for children aged 33 months to 12 years. In the case of the two months child, a "rendez-vous" technique was performed with a percutaneous approach of the common bile duct followed by an endoscopic sphincteroclasy using an axial endoscope allowing the extraction of a choledocal stone. In two cases, post-traumatic pancreatic pseudocysts (eight and 12 year-old children) were managed with the transgastric insertion of two double pig-tail stents. In two cases, children with chronic pancreatitis (38 months and 12 years old) were managed with pancreatic sphincterotomy. Biliary leakage in an 11-year-old child was managed with biliary sphincterotomy and stenting. All the children became symptom-free without any procedural complications with an 11 months median follow-up. Endoscopic treatment of pancreatic and biliary diseases is possible in children like in adults with the same procedures and results.

Endoscopic ultrasound teaching and learning

Scientific publications in the field of endoscopic ultrasound (EUS) are raising up since the last twenty years. The value of EUS is directly proportional to the training, skill and experience of the endosonographer. In a recent series, the lowest annual number of examinations requested per year might be around 200-250 procedures. For achieving competence in all the fields of EUS, they recommended a minimum of 150 supervised cases, 75 of them being devoted to pancreaticobiliary diseases and 50 to fine needle aspiration (FNA). Many studies have yet confirmed the importance of the learning curve to improve the EUS accuracy. The accuracy of EUS staging of esophageal cancer was significantly improved over an 8-year period for T staging from 64% to 90% but not for N staging. Considering pancreaticobiliary diseases, some series reported the influence of training on accuracy of EUS-guided FNA of pancreatic masses. Even if the exact type and modalities for EUS training remained to be determined, the usefulness of a period of training in a center performing more than 200 procedures per year is confirmed. Improving cognitive EUS learning and technique required theoretical teaching and practical teaching with observation during live demonstration and echoendoscope hands-on in humans with an expert supervision or with different simulator models. In France, formal EUS training has been underway since 1991, with a two-year intensive program including 4 weeks of theoretical training and 20 one-day practical sessions per year. This program was updated in 2004 to include 3 weeks of theoretical course work including numerous video sessions and 1 week of practical sessions. Theoretical courses are given primarily by gastroenterologists and EUS experts, but also by pathologists, surgeons, anatomists and radiologists. Practical sessions include 4 days of live demonstrations and computed-based simulator (EUS mentor; Simbionix, Tel Hashomer, Israel) and one day with a swine model. Simulators, either computed-based simulator, Erlangen model, or live pigs are believed to shorten the learning phase of EUS. The live pig model was chosen for EUS credentialing because it appears to be similar in many respects to the human anatomy, especially for the pancreas, portal and mesenteric vessels, celiac axis, left kidney and spleen. In addition, for trainees, it often appears more exciting and stimulating than virtual model. However, EUS training on a swine model is recognized to be the more expansive way for EUS teaching. Between the pre and post-test, EUS fellows significantly improved their competence for the visualization of anatomical structures i.e. vena cava, mesenteric/splenic vein, celiac axis, pancreas and bile duct. At the end of the day-session, trainees were mostly able to recognize and follow these anatomical structures with both endoscopes. Interventional EUS learning was also assessed. A significant decrease in procedural duration and a significant increase in FNA precision were demonstrated for the puncture of a hilar liver lymph node.

EUS training in a live pig model: does it improve echo endoscope hands-on and trainee competence?

BACKGROUND AND STUDY AIM

The learning curve for endoscopic ultrasonography (EUS) is known to be difficult, especially in the field of pancreatic and biliary diseases. The aim of this study was to assess the impact of a live pig model developed for EUS credentialing in France.

METHODS

A total of 17 trainees obtained hands-on EUS experience using a live pig model. Trainees were asked to visualize anatomical structures, to carry out fine-needle aspiration (FNA) on lymph nodes in the liver hilum, and to perform celiac neurolysis. Assessment of the FNA procedure or celiac neurolysis included measurement of time (seconds), evaluation of the precision of the puncture (mm), and existence of technical errors.

RESULTS

A significant improvement between a pre-test and post-test was observed for diagnostic procedures in the following anatomical areas: splenic mesenteric vein, vena cava, splenic mesenteric artery, celiac tree, pancreatic gland, and bile duct. For lymph node FNA, a significant improvement was observed in the duration of the procedure (84 seconds vs. 60 seconds; P = 0.01), and precision (4.2 mm vs. 1.8 mm; P = 0.009), but not for the rate of technical error (29% vs. 6%; not significant [n. s.]). For celiac neurolysis, a significant improvement was observed in procedure time (150 seconds vs. 84 seconds; P = 0.003), but not in the rate of technical error (6% vs. 6%; n. s.) or precision (4.2 mm vs. 2.8 mm; n. s.).

CONCLUSION

Teaching EUS with a live pig model significantly increased competence in diagnostic procedures with regard to visualizing anatomical structures, performance of FNA and, to a lesser extent, EUS-guided celiac neurolysis.

Results of a prospective randomised multicentre controlled trial comparing a new 2-L ascorbic acid plus polyethylene glycol and electrolyte solution vs. sodium phosphate solution in patients undergoing elective colonoscopy

BACKGROUND

Elective colonoscopy is used increasingly to screen at risk patients for colonic malignancy. Bowel preparation quality is a critical factor for successful screening. Preparations used include high doses of potent laxatives, e.g. sodium phosphate solution or high volume polyethylene glycol. Because of constraints and limited patient acceptability, there remains a need for a more acceptable bowel preparation with at least equivalent cleansing to existing preparations.

AIM

To determine if a 2-L polyethylene glycol solution with electrolytes and ascorbic acid (polyethylene glycol + ascorbic acid) produces equivalent bowel cleansing to sodium phosphate solution, and is acceptable to patients and well tolerated.

METHODS

This was a single blind, parallel group, equivalence study comparing polyethylene glycol + ascorbic acid with sodium phosphate solution in 352 patients undergoing elective colonoscopy. A blinded, independent expert scored a video recording of each colonoscopy. Patients completed a questionnaire reporting acceptability of the bowel preparation process.

RESULTS

Clinically successful bowel preparation was reported in 72.5% of cases prepared using polyethylene glycol + ascorbic acid and in 63.9% of cases prepared using sodium phosphate solution (treatment difference +8.6%, 95% confidence interval -2.3%, +19.4%). The new solution was well accepted and better tolerated than sodium phosphate solution.

CONCLUSIONS

The new 2-L solution of polyethylene glycol + ascorbic acid was at least as efficacious as sodium phosphate solution with comparable efficacy and a better tolerability profile.

Similar performance but higher cholecystitis rate with covered biliary stents: results from a prospective multicenter evaluation

BACKGROUND AND STUDY AIMS

Endoscopic biliary stenting is now a well-established treatment method in patients with unresectable malignant biliary obstruction. Despite advances with metal stents, the problem of stent occlusion has not yet been resolved. Covered metal stents could reduce the occlusion rate by preventing tumor ingrowth, but have not been well evaluated. A prospective multicenter study was therefore conducted to evaluate the efficacy and disadvantages of covered Wallstents.

PATIENTS AND METHODS

Covered Wallstents were implanted endoscopically in 62 patients with inoperable distal malignant biliary obstruction. Complications, stent patency, and patient survival were analyzed.

RESULTS

Stent insertion was achieved in 61 of the 62 patients (98.4 %). Procedure-related complications were observed in four patients, consisting of minor pancreatitis (n = 2) and abdominal pain due to stent expansion (n = 2). There was no procedure-related mortality. Seven patients died too early for proper assessment, so that a total of 54 patients were ultimately evaluated. Stent dysfunction occurred in 17 of the 54 patients (31.5 %). The reasons for dysfunction were proximal tumor overgrowth (n = 5), migration (n = 3), lithiasis or food impaction (n = 3), cholangitis without the need for a repeat biliary intervention (n = 5), and unknown (n = 1). The median period of stent patency was 142 days. No tumor ingrowth was observed. Acute cholecystitis was diagnosed in five patients (10 %) and was responsible for one death. Three stents were successfully removed.

CONCLUSIONS

Covered biliary metal stents are effective for the drainage of distal malignant biliary obstruction, with a dysfunction rate apparently similar to that of uncovered stents. However, the risk of acute cholecystitis appears to be a major concern with this type of stent in patients with gallbladder in situ. Further comparative studies are needed.

Long-term healing of Crohn's anal fistulas with fibrin glue injection

BACKGROUND

Injecting fibrin glue has proved to be an effective means of treating anal fistulas (AF). There has been some debate, however, as to whether this technique should be used on the AF often involved in Crohn's disease (CD).

AIM

To assess the effectiveness of injecting heterologous fibrin glue as a means of treating AF refractory to immunosuppressive treatment in patients with CD.

METHODS

Fourteen CD patients (five men and nine women, average age 42 years) presenting with refractory AFs were included in this study. Heterologous fibrin glue was injected into the fistula tract under general anaesthesia under continuous endosonographic monitoring using a 7.5-MHz blind linear probe. The patients were followed up clinically and ultrasonographically for 3 months after the procedure, and then at regular intervals.

RESULTS

Three months after the fibrin glue injection, the fistulas had completely dried up in 10 patients (71%), the leakage had decreased in one patient (7%), and no improvement was observed in the other three patients (21%). Endosonographic findings showed that the fistula tract had completely disappeared in two cases (14%). The fistula tract was found to be non-permeable in eight cases (57%), and no change in the fistula was observed in four patients (29%). At the end of the follow-up period [average 23.4 months (12-26 months)], the leakage had completely dried up in eight of the 14 patients (57%). No side effects were observed.

CONCLUSION

Nearly 2 years after the use of a heterologous fibrin glue to treat an AF, over half of the patients with CD showed clinical signs of remission. Because it is easy to use and harmless as well as being effective, this method provides a good alternative to classical methods of surgical treatment.

Value of endorectal ultrasonography for diagnosing rectovaginal septal endometriosis infiltrating the rectum

BACKGROUND AND STUDY AIMS

Rectovaginal septal endometriosis (RVSE) can pose serious therapeutic problems when there is infiltration of the rectal septum (which occurs in approximately half of the cases). The aim of this study was to assess the value of endoscopic ultrasonography in diagnosing rectal wall involvement by pelvic endometriosis.

PATIENTS AND METHODS

A prospective study was carried out from May 1998 to March 2003 at a single hospital center. The 30 patients included in the study presented with suspected RVSE and underwent systematic anorectal endoscopic ultrasonographic exploration prior to the surgical intervention. The endoscopic ultrasonography was carried out under general anesthesia with a 7.5-MHz miniprobe equipped with a distal balloon.

RESULTS

The anorectal endoscopic ultrasonographic examination (EUS) showed the presence of endometriosis in the rectovaginal septum in 26 patients (88 %), in the uterosacral ligaments in 10 patients (33 %), and in the ovaries in two patients (6 %). At EUS, the nodules were infiltrating the rectal wall in 17 patients (56 %). The surgical exploration demonstrated endometriosis in the rectovaginal septum in 26 cases, the uterosacral ligaments in 22 cases, and the ovaries in 16 cases. The rectal wall was completely infiltrated in 12 cases and only partly in four cases, and intestinal tract resection was required in 10 cases. The sensitivity, specificity, and positive and negative predictive value of anorectal endoscopic ultrasonography as a means of diagnosing endometriosis of the rectovaginal septum and infiltration of the rectal wall were found to be 96 %, 100 %, 100 % and 83 %, and 92 %, 66 %, 64 % and 92 %, respectively; and the diagnostic accuracy was at 96 % and 80 %, respectively. The sensitivity for detecting nodules in the uterosacral ligaments or in the ovaries was 42 % and 14 %, respectively, leading to diagnostic accuracy rates of 56 % and 53 %.

CONCLUSIONS

In terms of its sensitivity and its negative predictive value, anorectal endoscopic ultrasonography is a very effective means of detecting endometriosis of the rectovaginal septum and assessing possible infiltration of the rectal wall. However, this method is not as accurate for nodules located far from the EUS probe, as is the case with the uterosacral ligaments and ovaries.

[Pancreatic panniculitis with intraductal carcinoid tumor of the pancreas divisum]

BACKGROUND

The association of pancreatic diseases with panniculitis are rare. Various pancreatic diseases are described with panniculitis of which most frequent are pancreatitis and acinar cell carcinoma. We report a case of an acute nodular panniculitis whose etiologic assessment allow of discover an intraductal carcinoid tumour on a pancreas divisum.

CASE REPORT

A 45 year-old woman without notable medico-surgical history had suddenly presented with multiple cutaneous erythematous nodules on the legs associated with moderates arthralgia in the wrists and the ankles. There were no other clinical manifestations. Results of laboratory tests and chest X-ray were normal. Histologic exploration showed a centrolobular fat necrosis and suggestive pancreatic disease was confirmed by an increase in serum pancreatic enzymes. Ultrasound study and computerized tomography of the abdomen was without notable anomaly. Endoscopic ultrasound study of the pancreas and magnetic resonance imaging showed moderate distention of the pancreatic duct. Endoscopic retrograde cholangiopancreatography highlighted a small tumor in the accessory duct orifice of the pancreas divisum. Immunohistological study of tumor's biopsy showed a carcinoid tumor.

DISCUSSION

To our knowledge, this observation describes the first case of nodular panniculitis associated with carcinoid tumor of the pancreas. The detection of this tumor at an early stage, revealed by cutaneous fat necrosis, is probably due to the unusual anatomic site, on the accessory papilla of the pancreas divisum.

Coloproctectomie totale avec anastomose iléoanale en deux temps vidéoassistée. Expérience initiale de 12 cas

AIM OF THE STUDY

This study reports our early experience in two-stage video assisted restorative proctocolectomy (RPC).

PATIENTS AND METHODS

From May 1999 to May 2003, 12 video assisted RPCs were performed (mucosal ulcerative colitis: n = 11; familial adenomatous polyposis: n = 1). These patients were matched for age, gender, body mass index and indication for surgery, with 12 patients who underwent RPC by laparotomy (open group).

RESULTS

Median operative time was significantly longer in the video assisted RPC group (400 min; range: 360-490) vs open group (300 min; range: 210-390) (P = 0.003). A conversion in midline laparotomy (under the umbilicus) was necessary in 3/12 patients (25%) in the video assisted RPC group. Return to bowel function and oral intake occurred two days earlier after video assisted RPC (respectively, P = 0.009 and P = 0.0001) but length of stay was not significantly shorter in this group. A complication occurred in 3/12 patients (25%) in both groups, which lead to a reoperation in one patient in the open group (ns).

CONCLUSION

Two-stage videoassisted RPC is feasible at the cost of a lengthening of operative time, Nevertheless postoperative results after video assisted RPC are comparable to those obtained after RPC by laparotomy.

[Necrotizing enterocolitis during pregnancy in a woman operated on at six months of Hirschsprung's disease]

Necrotizing enterocolitis is a rare and severe complication of Hischsprung's disease. Aggravation of unknown or undertreated Hischsprung's disease may be seen during pregnancy. To our knowledge, the following case is the first combining those two elements: necrotizing enterocolitis in a 20 years old women operated on of Hischsprung's disease when she was six months. The final diagnosis was made 24 hours later. Definitive treatment was a three-stage ileal pouch-anal anastomosis.

Complications of endoscopic sphincterotomy: results from a single tertiary referral center

BACKGROUND AND STUDY AIMS

Complications of endoscopic sphincterotomy (ES) have been assessed in recent multicenter studies. The aim of this series was to report and identify risk factors for complications of ES at a single tertiary referral center.

PATIENTS AND METHODS

Between 1996 and 2000, 1159 consecutive endoscopic retrograde cholangiopancreatographies (ERCP) procedures were performed and their related complications were assessed. A total of 658 patients (57 %) underwent ES. All the clinical, radiological and biological data were carefully recorded within the 30 days following the procedure. Multivariate analysis was performed using a stepwise logistic model.

RESULTS

The morbidity rate for ES was 7.7 %, being moderate to severe in 5 %. Morbidity included acute pancreatitis (3.5 %), perforations (1.8 %), sepsis (1.2 %) and bleeding (1.2 %). The 30-day mortality was 0.9 %. In the 1159 ERCP procedures, 231 patients underwent precut papillotomy (20 %) followed by sphincterotomy in 174 cases. Using logistic regression analysis, the risk factors for ES were precut papillotomy (relative risk, RR 2.76), confidence interval, (CI 1.39 - 5.49) and the presence of sphincter of Oddi dysfunction (RR, 7.72, CI 3.2 - 18.4).

CONCLUSIONS

In this single-center series, we found a complication rate of ES in about 7 %, comparable to that in multicenter series. Precut papillotomy and sphincter of Oddi dysfunction were the main independent risk factors for ES.

Prognosis of malignant intraductal papillary mucinous tumours of the pancreas after surgical resection. Comparison with pancreatic ductal adenocarcinoma

BACKGROUND

Although the prognosis in malignant resectable intraductal papillary mucinous tumours of the pancreas (IPMT) is often considered more favourable than for ordinary pancreatic ductal adenocarcinoma, the long term outcome remains ill defined.

AIMS

To assess prognostic factors in patients with malignant IPMT after surgical resection, and to compare long term survival rates with those of patients surgically treated for ductal adenocarcinoma.

METHODS

Seventy three patients underwent surgery for malignant IPMT in four French centres. Clinical, biochemical, and pathological features and follow up after resection were recorded. Patients with invasive malignant IPMT were matched with patients with pancreatic ductal adenocarcinoma, according to age and TNM stages; survival rates after resection were compared.

RESULTS

Surgical treatment for IPMT were pancreaticoduodenectomy (n=46), distal (n=14), total (n=11), or segmentary (n=2) pancreatectomy. The operative mortality rate was 4%. IPMT corresponded to in situ (n=22) or invasive carcinoma (n=51). In the latter group, 17 had lymph node metastases. Overall median survival was 47 months. Five year survival rates in patients with in situ and invasive carcinoma were 88% and 36%, respectively. On univariate analysis, abdominal pain, preoperative high serum carbohydrate antigen 19.9 concentrations, caudal localisation, invasive carcinoma, lymph node metastases, peripancreatic extension, and malignant relapse were associated with a fatal outcome. Using multivariate analysis, lymph node metastases were the only prognostic factor (OR 7.5; 95% CI: 3.4 to 16.4). Overall five year survival rate was higher in patients with malignant invasive IPMT compared with those with pancreatic ductal carcinoma (36 v 21%, p=0.03), but was similar in the subset of stage II/III tumours.

CONCLUSIONS

The prognosis of patients with resected in situ/invasive stage I malignant IPMT is excellent. In contrast, prognosis of locally advanced forms is as poor as in patients with pancreatic ductal adenocarcinoma.

Early refeeding after endoscopic biliary or pancreatic sphincterotomy: a randomized prospective study

BACKGROUND AND STUDY AIMS

Patients who have undergone endoscopic sphincterotomy (ES) are usually left to fast for arbitrary reasons until they are examined on the following day. The aim of this study was to check whether this systematic fasting after ES is actually justified.

PATIENTS AND METHODS

A blinded randomized prospective study, involving 146 patients, was carried out from January 1999 to September 2001. All patients undergoing biliary and/or pancreatic endoscopic sphincterotomy during this period were randomly allocated to one of two groups: group 1 patients were re-fed 4 hours after ES, and the group 2 patients were only re-fed 24 hours after the procedure. These two groups were comparable for clinical and procedural data except for stenting.

RESULTS

Eight patients in group 1 (11 %) and 26 patients in group 2 (37 %) suffered from abdominal pain which resolved with analgesic drug treatment (P = 0.01). Eight patients in the first group(11 %) and five patients in the second group (7 %) had to be given major opiate analgesics (P = 0.56). Refeeding resulted in abdominal pain in five patients in group 1 and 13 in group 2 (P = 0.04). The serum amylase and lipase levels increased significantly after refeeding in group 1, but lipasemia did not increase significantly in group 2. No significant differences in post-ES complications were observed between the two groups. The mean hospital stay was significantly shorter in group 1 : 2.6 days on average, vs. 3.8 days in group 2 (P = 0.03).

CONCLUSIONS

In the absence of any perforation of the digestive tract or immediate severe acute pancreatitis, early refeeding could be helpful to decrease pain and shorten the hospital stay in patients who have undergone endoscopic sphincterotomy.

Anal endosonography for assessment of anal incontinence with a linear probe: relationships with clinical and manometric features

BACKGROUND AND AIMS

This study determined correlations of clinical and manometric features with those of anal endosonography (AES).

PATIENTS AND METHODS

Between 1996 and 1999 we examined 58 patients suffering from anal incontinence (AI) by AES using a linear probe and anorectal manometry following a standardized protocol.

RESULTS

Twelve of the 58 patients (21%) had a history of anal surgery. Of the 40 women who had under-gone at least one vaginal delivery 22 (55%) sustained an obstetric tear and 12 (30%) required forceps for delivery. A perineal descent was observed in 24 of 32 women with AI (75%) and urinary incontinence in 24 of 44 (54%). An anal sphincter defect was diagnosed in 45 of the 58 patients (77%). The internal anal sphincter defects occurring in 42 patients (72%) were significantly associated with a decrease in the resting anal pressure. The external anal sphincter defects occurring in 33 patients (57%) were significantly associated with a decrease in the voluntary anal contraction.

CONCLUSION

Considering AES and manometric findings, a good correlation was observed between internal sphincter defect and the resting anal pressure and between external sphincter defects and the voluntary anal contraction. AI is usually associated with a global perineal insufficiency requiring special attention in terms of both training and medical management.

[Infliximab therapy for Crohn's disease anoperineal lesions]

AIM OF THE STUDY

To retrospectively evaluate the efficacy, the duration of response, and the tolerance of Remicade in anoperineal Crohn's disease.

METHODS

Fifty patients with severe symptomatic and refractory anoperineal Crohn's lesions (38 fistulae and 29 cavitating ulcers and superficial fissures) were treated with 3 intravenous infusions of Remicade (5 mg/kg) at weeks 0, 2 and 6. Efficacy was assessed using Allan's functional score and proctologic examination at 8 weeks (W8) and 24 weeks (W24) after the first infusion.

RESULTS

At W8, a response was noted for 71% (27/38) of fistulae and 79% (23/29) of ulcers and fissures. Healing rates were 39% and 49%, respectively. Efficacy of Remicade at W8 did not vary according to sex, number and type of fistulae and other treatments. At W24, 58% (15/26) of patients with fistulae and 63% (10/16) of patients with ulcers or fissures had a response. The response rate at W24 was higher in patients having anoperineal Crohn's lesions for less than one year: 77% vs 32% (P=0.004). Median Allan's score significantly decreased from 3.9 before treatment to 1.7 at W2 (P<0.001), 1.3 at W6 and 0.8 at W8. Median duration of response was 9.5 months (range: 0.5-12.5) after last infusion and was not influenced by associated treatments including immunomodulators. The relapse rate at 1 year was 64% for the responders followed at least one year (n=21). Minor adverse events occurred during 12% of all infusions. Eight patients had an infection, including one pneumonia. Eight patients developed a perineal abscess 16 weeks (range: 4-32) after the first infusion.

CONCLUSION

Remicade is rapidly effective and well tolerated in anoperineal Crohn's lesions, but the high relapse rate stresses the need for long term therapeutic strategies in these patients.