Quality assurance and recommendations for quality assessment of screening colonoscopy in Belgium.

As population-wide screening for colorectal cancer is adopted by many western countries for all individuals aged 50-75. The success of screening colonoscopy programs is highly dependent on the quality of the procedures. High-quality complete endoscopy with excellent patient preparation and adequate withdrawal time is necessary for effectively reducing colon cancer risk. In Belgium formal quality assurance programs and principles of credentialing do not exist. The current reimbursement system for colonoscopy does not reward a careful performed examination but rapidly performed examinations at unnecessarily short intervals. There is a clear need for evidence-based quality measures to ensure the quality of screening colonoscopy. In this guideline review we present an overview of the literature concerning criteria for best practice and important quality indicators for colonoscopy. A summary of the latest guidelines is given. Our goal of this update is to provide practical guidelines for endoscopists performing screening colonoscopy. We hope to provide a broad consensus and an increasing adherence to these recommendations.

Chronic ischemic gastritis: case report of a difficult diagnosis and review of the literature.

Chronic ischemic gastritis is an unusual entity that is rarely distinguished from other forms of intestinal ischemia. On the basis of a case encountered and a subsequent review of the literature, the main features of this rare condition are described here. A better understanding and awareness of the disease should improve the diagnosis and ultimately also the prognosis.

Endovascular stent-graft placement in the descending aorta through an ascending aorto-bifemoral bypass.

PURPOSE: To report a combined conventional and endovascular strategy to treat a descending aorta anastomotic aneurysm. CASE REPORT: A 60-year-old man with previous obliteration of the infra renal aorta suffered from bilateral lower limb acute ischemia. Lower limb vascularization was provided by a previous thoraco-bifemoral bypass. Computed tomography and angiography revealed an aortic anastomotic false aneurysm and an embolic aspect of the first centimeters of the graft. Treatment combined revascularisation of the lower limbs by an ascending aorta bifemoral bypass through a median sternotomy and endovascular coverage of the false aneurysm by stent-graft placement in the descending aorta. Stent-grafts were introduced through a graft's limb and across the anastomosis in the ascending aorta. Imaging at 3 months revealed no endoleak and perfect patency of the bypass. CONCLUSION: This case illustrates how combined endovascular and conventional procedures can minimize surgical risks in complex cases.

[Results of surgical treatment for renal artery dysplasia]. / Résultats de la prise en charge chirurgicale des dysplasies des artères rénales.

PURPOSES: To retrospectively assess functional results of surgical treatment for renal artery dysplasia. PATIENTS AND METHOD: From January 1992 to December 2001, 11 symptomatic patients including 9 women (mean age 47 years, range 23-67), underwent surgery for renal artery dysplasia. Three patients presented with normalized hypertension, three others presented with isolated systolic hypertension, and the five remaining presented with grade II or III hypertension. Angiograms showed evidence of dysplasia of 16 renal arteries. Six arteries showed stenosis (37.5%), four aneurysms (25%), four both (25%), and two arteries showed wall irregularities (12.5%). Endovascular revascularizations were performed in five patients (45%) during the treatment of six renal arteries (37.5%). All endovascular procedures were angioplasties without any stent placement. Six patients (55%) underwent conventional procedures (in situ or ex-situ surgery) for the treatment of seven renal arteries (44%). RESULTS: In the short term, the treatment had a significant decrease on the systolic arterial pressure (p=0.019) and in the number of drugs used (p=0.009), but was not significant in the diastolic arterial pressure (p=0.084). The benefits persisted after two years of follow-up (PAS, p=0.023, PAD, p=0.047, drugs p=0.03). Benefits persisted in all of the six patients who had had hypertension for less than five years. There was 60% functional failure in the treatment of the five patients with a more than five years history of hypertension. CONCLUSION: This study confirms the short and long term's beneficial results of the surgical treatment of symptomatic renal artery dysplasia. Rapid care of those patients should optimize the functional results.

[Endovascular treatment for obstructive disease of the aortoiliac bifurcation by the kissing stent technique]. / Traitement endovasculaire par "kissing stent" des lésions oblitérantes du carrefour aorto-iliaque.

PURPOSE: To evaluate short and medium-term results of endovascular repair of the aortoiliac bifurcation for occlusive disease by the kissing stent technique. METHOD: Twenty patients were included in this retrospective study between May 1999 and November 2002 (13 men, mean age 58 years, range 42-86). Fifteen were treated for bilateral common iliac artery stenosis (75%), four for unilateral common iliac artery occlusion with or without controlateral stenosis (20%), and one for bilateral common iliac artery occlusion (5%). Each patient had a clinical examination and dupplex-scan prior to discharge, at three months, twelve months then yearly. RESULTS: All procedures were successful. Forty balloon expandable stents were deployed in the kissing position (mean length and diameter, 45 mm and 9 mm). Nine other stents were also deployed either in the abdominal aorta (one patient) either in the lower portion of the common iliac artery. Intra-operative complications were represented by one hematoma of the groin region treated surgically, one emboli of the femoral bifurcation treated by Forgarty balloon embolectomy, three dissections of the common iliac arteries treated by stenting, and one internal iliac artery occlusion not treated. Mean follow-up was 21 months (range 3-36). Three significant restenoses (>50%) were diagnosed during this period and one patient had an additional transluminal procedure. No intra-stent occlusion was found. Primary and secondary cumulative patencies at 12 and 36 months were respectively 94.7%, 84,4% and 100%, 89%. CONCLUSION: We confirm the feasibility, and the reliability of endovascular aorto-iliac kissing stent reconstruction in occlusive disease for selected patients.

Transcutaneous oxygen pressure measurements (tcpO2) at ankle during exercise in arterial claudication.

AIM: Although a time consuming technique, tcpO2 provides complementary information as compared to other tests. Simultaneous recording of systemic and peripheral oxygen pressure changes with exercise could be interesting to confirm that local hypoxemia is of arterial origin, but accuracy versus gold standard arteriography and objectively determined cut-off points to be used in arterial claudication at the ankle are not reported. EXPERIMENTAL DESIGN: retrospective plus prospective study. SETTING: institutional practice, ambulatory care. PATIENTS: 100 patients suffering stage 2 claudication (group A) were retrospectively studied to objectively define cut-off points derived from tcpO2 recordings to be used in exercise testing. Then, applicability and reproducibility of these cut-off points were analysed prospectively in another 50 patients (group B). INTERVENTION: tcpO2 was measured on both calves and with a chest reference electrode. Arteriography on each side was quoted positive for a diameter stenosis superior to 75% or occlusion on the aorto-popliteal axis or of all-3-calf arteries. RESULTS: The best performance was obtained with tcpO2 changes from rest at the calf normalised to eventual chest changes (DROP) during or following the treadmill test. Optimal cut-off point determined through ROC curve analysis for DROP was -15 mmHg in group A. Applying this cut-off point in group B provided a 86/84% sensitivity/specificity and showed excellent reproducibility. CONCLUSIONS: TcpO2 measurement on the calf during exercise could be useful in a selected population of patients with claudication of questionable vascular origin and/or when other non-invasive investigations cannot be performed.

[Very long-term outcome of 68 vena cava filters percutaneously implanted]. / Devenir à très long terme de 68 filtres caves implantés par voie percutanée.

Between January 1987 and December 1991, 68 consecutive patients aged 71.5 +/- 12.0 years underwent percutaneous implantation of a vena caval filter, mainly the LGM (N = 64). Fifty seven patients had pulmonary embolism, 61 had deep vein thrombosis of the lower limbs. The average follow-up interval was 4.9 +/- 3.3 years (7.0 +/- 2.7 years for the patients still alive). The follow-up included a telephonic enquiry to determine the date and cause of death, recurrent deep vein thrombosis and/or pulmonary embolism; surviving patients underwent clinical examination, plain abdominal X-ray with a lateral decubitus view and duplex ultrasonography of the lower limb veins to assess the patency of the filter. Fifty three per cent of the patients died. Four predictive factors for mortality were identified: a contra-indication to anticoagulant therapy, chronic post-embolic cor pulmonale, an indication of prophylactic implantation in the elderly and the presence of underlying malignant disease. There were 5.8% recurrences of pulmonary embolism, 26.1% of lower limb deep vein thrombosis and 25% of filter thrombosis. The only predictive factor of thrombosis was a proximal venous thrombus and was associated in 50% of filter thrombosis. Seventy per cent of the plain abdominal X-rays were abnormal with 9 displacements. 9 migrations and 10 closures of the filters. There was a significant correlation between closure on plain abdominal X-ray and caval thrombosis and between recurrent deep vein thrombosis and caval thrombosis. The frequency of long-term complications after implantation of a caval filter in this study suggests that interruption of the vena cava should be reserved for the only validated indications in the presence of a formal contra-indication to or failure of anticoagulant therapy. Other indications require evaluation with prospective randomised trials.

Percutaneous transluminal angioplasty for management of critical ischemia in arteries below the knee.

Percutaneous transluminal angioplasty (PTA) can be performed safely in arteries below the knee by using current coaxial catheters. This study includes 37 consecutive patients treated between March 1992 and March 1999 by PTA for limb-threatening infrageniculate occlusive artery disease. The mean duration of follow-up was 28 months. Limb salvage was achieved in 32 patients. The actuarial limb salvage rate at 2 years was 87 +/- 6%. This study shows that PTA was a viable alternative to surgical treatment for management of critical lower extremity ischemia in carefully selected patients. Limb salvage rates after PTA and conventional surgical revascularization seem comparable. Based on these findings, we recommend that PTA be attempted, whenever possible, for initial treatment of patients presenting critical, limb-threatening ischemia due to isolated or multiple stenoses of below-knee arteries.

Three-dimensional coronary artery MR imaging using prospective real-time respiratory navigator and linear phase shift processing: comparison with conventional coronary angiography.

Respiratory gating with navigator echo is a recent technique to detect diaphragm position in 3D magnetic resonance (MR) coronary angiography. The purpose of our study was to image proximal coronary arteries and to detect significant stenoses in patients with coronary artery diseases and to compare with contrast enhanced angiography results. Twenty patients with coronary artery diseases who were referred for conventional angiography underwent magnetic resonance angiography (MRA). Three-dimensional gradient echo volumes were acquired using cardiac and respiratory gating and fat suppression. Using reformatted oblique planes and maximum intensity projection technique, visualization coronary segments and detection of significant coronary stenoses were made. Eighty-three coronary segments were analyzed. The sensitivity and specificity were 65% and 93%, respectively. The corresponding positive and negative predictive values were 69% and 91%. This study shows the ability to image correctly coronary arteries and to identify proximal stenoses, but image quality need to be improved for an efficiency detection of coronary artery stenoses in clinical practice.

[Variations of coronary blood flow measured by intracoronary doppler in the acute phase of myocardial infarction before and after revascularization by angioplasty]. / Variations du flux sanguin coronaire mesuré par doppler intracoronaire à la phase aiguë de l'infarctus du myocarde avant et après revascularisation par angioplastie.

The authors studied the changes in coronary blood flow before, during and after reperfusion by angioplasty of the disease coronary vessel responsible for myocardial infarction using intracoronary Doppler. Forty patients aged 60.2 +/- 15.4 years, admitted for primary myocardial infarction (inferior: 22, anterior: 18) were included. Before reperfusion, the peak velocity of the collateral coronary circulation was 14.8 +/- 8.1 cm/s. The flow was bidirectional, mainly retrograde (N = 32), negative (N = 1) or positive (N = 5). The five Rentrop 0 patients had velocities similar to Rentrop 1, 2 or 3 patients (Rentrop 0: 14.9 +/- 6.4 cm/s; Rentrop 1: 12.3 +/- 9.9 cm/s; Rentrop 2: 15.2 +/- 8.2 cm/s; Rentrop 3: 17.5 +/- 6.3 cm/s). Patients with TIMI 3 reperfusion flow had the highest APV Doppler velocities (average peak velocities during the cardiac cycle) (APV TIMI 3 = 20.2 cm/s versus APV TIMI 1 and 2 = 10.9 cm/s, p = 0.05). After angioplasty, the APV was 18.7 +/- 10.4 cm/s (p < 0.001). Diastolic flow was dominant. Seventeen patients had retrograde systolic flow, 12 had minimal systolic flow and 17 had a steep diastolic deceleration slope. Intracoronary Doppler demonstrates the wide range of coronary flow in TIMI 3 flow patients, both from the morphological and the quantitative points of view, which seems to be independent of the presence of residual stenosis and could be related to abnormalities of the microcirculation. This could allow identification of a subgroup of patients at high risk and candidates for a complementary therapeutic intervention (intra-aortic balloon pumping...).

[Recurrent stomal hemorrhage treated by transjugular intrahepatic portosystemic anastomosis and embolization of stomal varices]. / Hémorragies stomiales récidivantes traitées par anastomose portosystémique intrahépatique transjugulaire et embolisation des varices stomiales.

Bleeding stomal varices is a rare complication of portal hypertension. We report the case of a cirrhotic patient, with a history of colonic adenocarcinoma, who had recurrent bleeding stomal varices. Treatment with transjugular intrahepatic portosystemic shunt and stomal varice embolization was performed because failure of medical treatment of portal hypertension and sclerotherapy. Twenty six months later only one stomal hemorrhage was noted. This suggests that transjugular intrahepatic portosystemic shunt and stomal varice embolization is effective in case of recurrent bleeding of stomal varices.

[Renovascular hypertension due to renal artery thrombosis]. / Hypertension artérielle rénovasculaire liée á une thrombose de l'artère rénale.

The authors report the case of a 74 year old woman admitted to hospital for severe hypertension with unilateral renal artery thrombosis. Recanalisation of the renal artery was obtained by transluminal angioplasty leading to rapid control of the hypertension. Dynamic renal scintigraphy with MAG 3 confirmed the viability of the kidney distal to the thrombosis and, secondarily, the functional recovery of the affected kidney.

Simultaneous discovery of bilateral intralobar and extralobar pulmonary sequestrations.

We describe the rare case of bilateral bronchopulmonary sequestrations, one intralobar and one extralobar, in a 22-year-old man. The coexistence of two forms of separated sequestrations with a common vascularization support the theory that intralobar as well as extralobar sequestrations are congenital malformations.

Chronic pain of vascular origin caused by a parietopulmonary fistula of the thoracic wall.

We describe the case history of a patient who suffered from dorsal thoracic nonpenetrating trauma after a fall, with rupture of the aortic isthmus treated by thoracotomy. Arteriovenous fistula between the thoracic wall and the lung, with hypervascularization of the left thoracic wall, was revealed by atypical chronic thoracic pain and a murmur. This case demonstrates that chronic thoracic pain of vascular origin must be considered.

[Early diagnosis of traumatic extra-pericardial luxation of the heart. Value of tomodensitometry. Apropos of a case]. / Diagnostic précoce de la luxation extrapéricardique du coeur d'origine traumatique. Intérêt de la tomodensitométrie. A propos d'un cas.

Heart luxation is a rare complication of chest trauma. The rupture of pericardium must be diagnosed as soon as possible, particularly before prolonged orthopaedic surgery for multitrauma, as a cardiac arrest may occur during anaesthesia. This report underlines the difficulties of diagnosis in a 40-year-old patient with head trauma, chest trauma and multiple fractures. The diagnosis was suspected on unstable blood pressure and left lung atelectasis. The computed tomography showed herniation of the left ventricle. Emergency thoracotomy showed the left rupture of pericardium with complete left heart dislocation. Orthopaedic operation was carried out three days later. Computed tomography in multitrauma patients, seems to be decisive for early diagnosis of heart luxation. Emergency thoracotomy is essential.

In situ thrombolysis for late occlusion of suprafemoral prosthetic grafts.

Low-dose urokinase was used to obtain in situ thrombolysis in the treatment of 20 late occlusions of suprafemoral prosthetic grafts in 19 patients. Aortofemoral or aortobifemoral bypasses with occlusion of one limb had been performed in nine patients, direct iliofemoral bypasses in six, crossover iliofemoral bypasses in two, and axillofemoral bypasses in three. Sixteen of the grafts were polytetrafluoroethylene and four were Dacron. Vascular surgery had been performed on an average of 3 years earlier. Thrombolysis was inhibited on an average of 3 days after onset of occlusion. The protocol called for penetration of the thrombus with a 5 F catheter inserted through a brachial (12 cases) or femoral (eight cases) route. After initial injection of 2500 units of urokinase a continuous infusion of urokinase was begun at a dose of 2500 units/hr and heparin at 100 units/kg/12 hr. Clinical, biochemical (fibrinogen and activated cephalin time every 6 hours), and arteriographic surveillance was carried out every 12 hours with progressive mobilization of the catheter until complete clearance of the artery. Clearance was achieved in all cases. Anteroposterior and occasionally lateral arteriograms with the hip joint in flexion were obtained. An organic cause amenable to treatment was found in 16 cases, including distal or proximal lesions (two and 10 cases, respectively) and elongation/kinking (four cases). Endoluminal angioplasty, stenting, or endarterectomy (six cases) and conventional procedures (10 cases) were also performed.(ABSTRACT TRUNCATED AT 250 WORDS)