Cost-effectiveness analysis of stent type in endoscopic treatment of gastric leak after laparoscopic sleeve gastrectomy.

BACKGROUND: Gastric leak is the most feared surgical postoperative complication after sleeve gastrectomy. An endoscopic procedure is usually required to treat the leak. No data are available on the cost-effectiveness of different stent types in this procedure. METHODS: Between April 2005 and July 2016, patients with a confirmed gastric leak undergoing endoscopic treatment using a covered stent (CS) or double-pigtail stent (DPS) were included. The primary objective of the study was to assess overall costs of the stent types after primary sleeve gastrectomy. Secondary objectives were the cost-effectiveness of each stent type expressed as an incremental cost-effectiveness ratio (ICER); the incremental net benefit; the probability of efficiency, defined as the probability of being cost-effective at a threshold of €30 000, and identification of the key drivers of ICER derived from a multivariable analysis. RESULTS: One hundred and twelve patients were enrolled. The overall mean costs of gastric leak were €22 470; the mean(s.d.) cost was €24 916(12 212) in the CS arm and €20 024(3352) in the DPS arm (P = 0·018). DPS was more cost-effective than CS (ICER €4743 per endoscopic procedure avoided), with an incremental net benefit of €25 257 and a 27 per cent probability of efficiency. Key drivers of the ICER were the inpatient ward after diagnosis of gastric leak (surgery versus internal medicine), type of institution (private versus public) and duration of hospital stay per endoscopic procedure. CONCLUSION: DPS for the treatment of gastric leak is more cost-effective than CS and should be proposed as the standard regimen whenever possible.

[A case of pancreatic schwannoma successfully treated by enucleation]. / Schwannome pancréatique traité avec succès par énucléation : à propos d'un cas.

Benign pancreatic schwannoma is a very rare cystic and solid tumor, which poses a diagnostic and therapeutic challenge. Herein, we present a case of 4-cm solitary benign schwannoma of pancreatic uncinate process, with pancreas divisum, incidentally discovered in a 53-year-old woman. Preoperative diagnosis was established by endoscopic ultrasound and fine needle aspiration. Simple enucleation of the tumor from the surrounding parenchyma was successfully performed. No complications were found after the operation.

Endoscopic or surgical ampullectomy for intramucosal ampullary tumor: the patient populations are not the same.

PURPOSE: To evaluate and compare the results of endoscopic ampullectomy (EA) and surgical ampullectomy (SA) for benign tumors. MATERIAL AND METHOD: From 2005 to 2018, 66 patients were eligible for ampullectomy (adenoma, ultrasound grading≤T1, N0). The principal endpoint was the rate of complete resection: R0 resection without local recurrence and no recurrence after a single operative procedure and with final pathology confirming the operative indications. Secondary endpoints were: morbidity, mean length of stay (LOS), preoperative and final pathology results, complete (or incomplete) resection, mean duration of follow-up, local recurrence rate and late complications (biliary stricture). RESULTS: Among the 41 patients eligible for EA, 36 ampullectomies were performed, while five were referred for SA because of intracanalar invasion that had not been diagnosed initially. The rate of complete treatment was 48% (13/27), the morbidity was 10%; the LOS was 3.3days; no adenomatous lesion was found on the definitive pathology in 9 patients (25%). The resection was R1 in 30% but there were no R2 resections. The median duration of follow-up was 20months, the rate of local recurrence was 22% and the rate of late biliary stricture was 2%. Among the 30 patients who were eligible for SA, (25 plus the five referred by endoscopists after intracanalar invasion was found), SA was eventually performed in 24: five patients were converted to pancreatoduodenectomy, one patient was found to have metastatic disease and had no resection. An extemporaneous frozen-section pathology examination was performed in 22 of the 24 SA patients and confirmed healthy margins on the bile ducts and pancreatic ducts. The rate of complete treatment was 71% (17/24), morbidity was 35%; LOS was 10days; seven patients (29%) were found to have invasive adenocarcinoma, and six of these (86%) underwent subsequent pancreatoduodenectomy. None of the resections were R1 or R2; median follow-up was 21months; there was no local recurrence; biliary stricture rate was 8%. CONCLUSION: The short-term and long-term results of patients undergoing endoscopic or surgical ampullectomy are different. The lesions resected by EA were less advanced, with simpler postoperative course. The lesions for which SA was performed were more advanced, and had more morbid sequelae, but with a better rate of complete treatment and better long-term results.

[Surgical management of resectable hilar cholangiocarcinoma]. / Prise en charge chirurgicale du cholangiocarcinome hilaire résécable.

Hilar cholangiocarcinoma is a cancer with a poor long-term survival rate (20% at five years), even after curative resection (R0: surgical margins free of tumour). Recent advances have been made in the preoperative management of these patients: clinical imaging, such as magnetic resonance cholangiography, biliary drainage according to the type of hilar obstruction or laparoscopic assessment before portal vein embolization. Extended hemihepatectomy has recently been recognized as the standard curative treatment for hilar bile-duct cancer with concomitant resection of the portal-vein bifurcation as a radical resective procedure. Neoadjuvant-photodynamic therapy could be a new approach to treating hilar cholangiocarcinoma decreasing tumour margins, which is a major prognostic factor.

[Gastric calcifying fibrous pseudotumor, a rare mesenchymal tumor of the stomach]. / La pseudotumeur fibreuse calcifiante gastrique, une tumeur rare de l'estomac.

We report a case of calcifying fibrous pseudotumor fortuitously discovered on abdominal CT-scan in a 50 year-old woman presenting with metrorragia. CT-scan showed a 2 cm hypodense nodular tumor of the gastric wall with granular calcifications. Upper endoscopy showed a nodular tumor along the lesser curvature of the gastric body, covered by normal gastric mucosa and biopsies were negative. A diagnosis of gastric stromal tumor was suspected and a partial gastrectomy was performed. On gross examination surgical specimen showed a firm, whitish nodular tumor measuring 2 cm in diameter. On microscopic examination the tumor was composed of whorls of dense hyalinized collagen bundles with a few fibroblasts. There were psammomatous calcifications and nodular aggregates of mononuclear inflammatory cells. Immunohistochemically, spindle cells stained for vimentin. They did not stain for smooth muscle actin, desmin, CD34, CD117, S100 protein, Ki-67 and ALK-1. Surgical resection of the tumor was complete. Patient has no evidence of disease with a follow-up of 12 months. Only seven cases of gastric calcifiying fibrous pseudotumors have been reported in the literature. These benign tumors are usually incidentally discovered. They have characteristic imaging and microscopic features and appear as a distinct clinicopathologic entity different from stromal tumors.

[Acinar cell carcinoma of the pancreas: a rare tumor with particular clinical and paraclinical presentation]. / Carcinome à cellules acineuses du pancréas : une tumeur rare avec des caractéristiques cliniques et paracliniques particulières.

Acinar cell carcinoma of the pancreas is a rare tumour with specific clinical and paraclinical presentation. Its management is not well codified resulting from its low frequency.

Conservative endoscopic management for pancreatic trauma.

Traumatic pancreatic injuries are rare: their severity correlates with main pancreatic duct involvement. We report the case of a 5-year-old child who presented with complete disruption of the main pancreatic duct, treated successfully with an endoscopically inserted double pigtail stent.

Idiopathic retroperitoneal fibrosis and primary biliary cirrhosis. A new association?

We encountered a case of primary biliary cirrhosis in a nonalcoholic man who had been operated on for idiopathic retroperitoneal fibrosis 20 years previously. Chronic pancreatitis was also detected on endoscopic retrograde examination. After several episodes of digestive bleeding due to ruptured esophageal varixes, the patient died of massive hemorrhage. Postmortem examination showed stage 3 primary biliary cirrhosis and a thick retroperitoneal fibrous plaque, consisting of densely fibrotic areas of collagen with rare vessels and mononuclear cells. We suggest that idiopathic retroperitoneal fibrosis may be a new autoimmune disorder associated with primary biliary cirrhosis and that primary biliary cirrhosis is a potential cause of portal hypertension, cholestasis, or both in the course of idiopathic retroperitoneal fibrosis.

[Pancreas divisum and the dominant dorsal duct syndrome]. / Pancréas divisum et syndrome du canal pancréatique dorsal dominant.

Pancreas divisum, the most frequent congenital malformation of the pancreas, results from the absence of embryologic fusion of the dorsal and ventral pancreatic ducts which keep an autonomy of drainage. The dorsal pancreatic duct is dominant and drains the major part of the pancreatic fluid through a non adapted accessory papilla. The high prevalence of pancreas divisum in patients presenting recurrent acute pancreatitis, the presence of obstructive pancreatitis electively located on the dorsal pancreatic duct and the results of the treatments targeted on the accessory papilla are the arguments pleading for the pathogenic character of the pancreas divisum. Currently, the diagnosis of pancreas divisum is based on magnetic resonance imaging. For symptomatic patients (after exclusion of patients with intestinal functional disorders), results of endoscopic sphincterotomy or surgical sphincteroplasty are favourable in 75% of patients with recurrent acute pancreatitis. They are worse in patients with chronic pain. Surgical sphincteroplasty must be discussed in the same manner as the endoscopic treatment for sometimes avoiding multiplication of the procedures.

Action of dopamine on the exocrine pancreatic secretion of the intact dog.

The effects of dopamine and domperidone, a dopamine antagonist, have been studied on the exocrine secretion of the dog pancreas. The purpose of this study was to see if dopamine acted on enzyme secretion and if its action was merely 'pharmacological' or had a physiological role. Conscious Beagle dogs, fitted with Thomas cannulae were studied following infusions of dopamine 125-1000 micrograms kg-1 h-1. During dopamine infusion, a secretory peak lasting 10 min was observed. This was followed by a stable plateau which was approximately 1/3 of the peak. The pattern of water, bicarbonate and protein secretion was similar. The maximum effect was obtained with 500 micrograms kg-1 h-1 dopamine. The stimulatory action of dopamine was blocked by domperidone, without any detected effect on the central nervous system, but not by propranolol or phenoxybenzamine. Domperidone 10 micrograms kg-1 almost completely suppressed the secretory response to the maximally effective dose of dopamine. This inhibition was not competitive. Atropine decreased the secretory response to dopamine. The protein response was not observed when dopamine was infused against a background infusion of secretin. This suggests that the effect of dopamine on protein secretion could be due to a wash-out phenomenon. The maximally effective dose of domperidone, 10 micrograms kg-1, did not modify the pancreatic response to a solid meal. Thus, in the non-anaesthetized dog, the effect of dopamine on water and bicarbonate secretion has been confirmed. It is concluded that dopamine had no detectable action on protein secretion and that the physiological role of dopamine with respect to pancreatic secretion is still questionable.

Prophylactic antibiotics in treatment of severe acute alcoholic pancreatitis.

Infectious complications currently account for 80% of deaths from acute pancreatitis. The aim of this study was to evaluate the necessity for prophylactic antibiotics in patients with severe acute pancreatitis. Twenty-three consecutive patients suffering from acute alcoholic pancreatitis with computed tomography demonstrating two or more fluid collections were randomly assigned to one of two groups receiving either nonantibiotic treatment or prophylactic antibiotics (ceftazidime, amikacine, and metronidazole for 10 days). Sepsis was always diagnosed by positive cultures. Seven episodes of severe sepsis occurred (pancreatic infection and septic shock) in the nonantibiotic group, and no infection occurred in the prophylactic antibiotic group (p < 0.03). In conclusion, the use of prophylactic antibiotics in severe alcoholic acute pancreatitis significantly reduces the incidence of severe infection.

Fibrotic stricture of the extrapancreatic biliary tract: a new complication of acute pancreatitis. Two cases.

Two cases of fibrotic stricture of the extrapancreatic common bile duct were observed 3 and 5.5 months after severe acute alcoholic pancreatitis. The diagnosis was made by endoscopic retrograde cholangiography in both cases. Although colonic or ureteric stenosis have been reported after acute pancreatitis, this is the first report of extrapancreatic biliary stricture occurring after acute pancreatitis. The strictures could have arisen by either an enzymatic or ischemic mechanism. Outcome was favorable after surgical hepaticojejunostomy.

[Pancreatic-portal fistula and subcutaneous fat necrosis]. / Fistule pancréatico-portale et cytostéatonécrose sous-cutanée.

The pancreaticoportal fistula is a very uncommon complication of pancreatic diseases, mostly occurring in the course of chronic pancreatitis. From 2 findings of pancreaticoportal fistula and a literature review, we emphasize in this study the frequency of subcutaneous fat necrosis during pancreaticoportal fistula, the pathogenic role of the pancreaticoportal fistula to induce a subcutaneous fat necrosis by means of a massive enzyme release in the systemic circulation, the protective role of portal thrombosis, and finally the diagnostic and therapeutic value of endoscopic retrograde cholangio-pancreatography in pancreaticoportal fistula.

[Endoscopic treatment of a pancreatic-pleural fistula. Apropos of a case]. / Traitement endoscopique d'une fistule pancréatico-pleurale. A propos d'un cas.

Pancreaticopleural fistula is a rare complication of pancreatic diseases. It results from communication between a pancreatic duct and the pleural space, either directly, or through a pseudocyst. The treatment is medical or surgical. We report a case of pancreaticopleural fistula occurring in a man suffering from chronic pancreatitis, and treated by endoscopy.

[Seroprevalence of viral hepatitis A in at the Amiens University Hospital]. / Séroprévalence de l'hépatite virale A au CHU d'Amiens.

OBJECTIVES AND METHODS: The epidemiology of viral hepatitis A has been evolved in the past few years, resulting in an increasing number of people without immunity to this virus. Health care workers are usually considered to be a group at risk of contamination by hepatitis A. A sero-epidemiologic study was performed in 525 members of the Pediatry, Gastroenterology, Internal medicine, Digestive radiology, kitchen and maintenance department staffs in the Amiens University Hospital. The aim of this study was to describe the epidemiology of hepatitis A and to estimate the level of occupational hazard it represents in the hospital. RESULTS: Age, low education level, country of origin in an endemic region and more than 2 siblings or children were significantly associated with the presence of anti-HAV antibodies. The prevalence of 50% was similar to that observed in other hospitals, but lower than that found in the general population. Seroprevalence was not higher in departments exposed to stools (Pediatry, Digestive endoscopy and laboratories) than in others. A higher rate of seroprevalence was observed in kitchen and maintenance staffs than in medical, laboratory and Radiology staffs, in Internal medicine than in the Gastroenterology Department, and in the laboratory than in Radiology Department. These differences disappeared after adjustment for extraprofessional parameters which appeared to be most important for hepatitis A epidemiology. CONCLUSIONS: The hospital occupational hazard for hepatitis A virus did not seem higher than that observed in the general population.

[Hepatic disorders related to Lyme disease. Study of two cases and a review of the literature]. / L'atteinte hépatique dans la maladie de Lyme. Etude de deux cas et revue de la littérature.

We report two cases of Lyme disease, revealed by hepatic damage in a 71- and a 59-year old man. In the first case, the disease was revealed by febrile jaundice whereas, in the second case, results of liver tests showed cytolytic and cholestatic abnormalities with fever. Lyme disease is a zoonosis due to infection by Borrelia burdorferi transmitted by ticks. The multiple phases of the disease explain the polymorphism of the clinical manifestations. Usually, extrahepatic symptoms are first observed, including neurological tropisms of Borrelia burdorferi. On the contrary, hepatic impairment due to Lyme disease is rare, often asymptomatic and with biological manifestations only.

[Acute pancreatitis caused by papillary adenoma of the distal common bile duct. Treatment by endoscopic excision]. / Pancréatite aiguë due à un adénome papillaire du bas cholédoque. Traitement par exérèse endoscopique.

We report the case of a 66 year-old man who developed acute necrotizing pancreatitis. The usual etiologies of acute pancreatitis were easily excluded. Endoscopic retrograde cholangiopancreatography demonstrated a 10 mm diameter filling defect in the distal common bile duct. After endoscopic sphincterotomy, a polypoid tumour which appeared to arise from the common bile duct was delivered through the wound. Diathermic resection of the tumor was performed. Microscopic examination disclosed papillary adenoma, without histologic signs of malignancy. Follow-up was favorable.

[Hepatitis due to ajmaline. Report of cases and review of the literature]. / Hépatite à l'ajmaline. Description de 4 observations et revue de la littérature.

The authors report the cases of 4 patients with jaundice following the administration of ajmaline. The disease had a pseudo- angiocholitic onset with fever, chills and pruritus in the 4 patients and abdominal pains in 2 patients. Serum transaminase activity and serum alkaline phosphatase activity were increased in the 4 patients. Blood eosinophilia was found in 3 patients. Liver lesions included predominantly centrilobular cholestasis, mild hepatocytic lesions, and portal inflammation. After the interruption of the drug administration, recovery occurred in the 4 patients. Two patients resumed the intake of ajmaline; transient hepatitis recurred in these 2 patients.

[Percutaneous cholecystostomy. A study of 30 patients]. / Cholécystostomie percutanée. Une étude chez 30 malades.

OBJECTIVE AND METHODS: The treatment of acute cholecystitis or angiocholitis is often difficult in elderly or very ill patients. The aim of this retrospective study was to assess the efficacy and the results of ultrasound guided percutaneous cholecystostomy in patients with acute cholecystitis or biliary tract obstruction and anesthetic or surgical contraindications. RESULTS: Thirty patients (25-93 years, 16 men and 14 women) were included in this study. Ultrasound guided percutaneous cholecystostomy was successful on the septic syndrome in 27 patients; endoscopic sphincterotomy was performed in 6 patients after clinical improvement. A failure of the procedure on sepsis was observed in 3 patients: cholecystectomy was performed after cardiac improvement in one patient, and 2 patients died. Two other patients died of extradigestive diseases. No serious complication related to cholecystostomy was observed. CONCLUSION: Ultrasound guided percutaneous cholecystostomy is a safe and simple procedure. It can be done at bedside and has low morbidity and mortality. It can be considered as a definitive treatment, or a temporary one with secondary surgical or endoscopic management.

[Acute pancreatitis induced by drugs derived from 5-aminosalicylic acid: case report and review of the literature]. / Pancréatites aiguës induites par les médicaments dérivés de l'acide 5-aminosalicylique: un cas et revue de la littérature.

The pancreatic toxicity of oral 5-aminosalicylic acid (5ASA) derivatives used for the treatment of inflammatory bowel diseases remains controversial. A new case of mesalazine-induced acute pancreatitis (AP), with positive rechallenge, and an analysis of the previous published cases are presented. Twenty-nine patients (17 women, 12 men), aged 26.4 +/- 9.9 (12-43) years, were involved, receiving sulfasalazine (n = 11), mesalazine (n = 16), olsalazine (n = 1) or 5ASA without further informations (n = 1), for ulcerative colitis (n = 15), Crohn's disease (n = 13) or another indication (n = 1). The AP occurred in the first month of treatment in 71.4 per cent of the cases (n = 28). The clinical course was essentially benign in most of the cases. Recurrence of AP after rechallenge was observed in 17 of the 19 cases, even if the molecule, the dose or the form were modified. These results show that all 5ASA derivatives are potentially pancreatotoxic. An AP must be considered when an occurrence or increase of abdominal pain occurs during such therapy and warrants serum amylase assay and discontinuation of the drug.