[Endoscopic treatment of Zenker's diverticulum using CO2 laser. 17 cases]. / Traitement endoscopique du diverticule de Zenker associé au laser CO2. Dix-sept cas.

OBJECTIVES: Various treatment regimens have been used for the management of Zenker's diverticulum. These include surgery (transcervical diverticulectomy, myotomy) and endoscopic treatment with rigid instruments or flexible endoscope. The aim of this study is to report the results of the treatment of Zenker's diverticulum with rigid endoscope applied CO2 laser and to compare them with other types of treatment. PATIENTS AND METHODS: Between May 1991 and November 1996, 17 patients (8 males, 9 females) with symptomatic Zenker's diverticulum underwent endoscopic treatment under short general anesthesia applied CO2 laser. The mean age of the patients was 73.2 years (range: 54 to 97 yrs). All patients had significant symptoms such as dysphagia (15 patients out of 17). All patients were clinically evaluated after the procedure. RESULTS: The endoscopic incision was performed in one session per patient. Symptoms and dysphagia disappeared in all patients except one (dysphagia). Two complications (one cervical emphysema, one fistula) were managed clinically. Mortality was 0%. Mean follow-up was 17 months. There was no recurrence of dysphagia, all patients remained asymptomatic. CONCLUSIONS: Rigid endoscopic treatment of symptomatic Zenker's diverticulum applied with laser CO2 is an efficient and safe method. It should be considered as an alternative therapy for Zenker's diverticulum, especially for patients at a high surgical risk.

[Hepatitis caused by clometacin (Dupéran). Retrospective study of 30 cases. A model of autoimmune drug-induced hepatitis?]. / Hépatites à la clométacine (Dupéran). Etude rétrospective de 30 cas. Un modèle d'hépatite auto-immune médicamenteuse?

Thirty cases of clometacin-induced hepatitis were retrospectively collected over a nine-year period in hepatogastroenterological units of non university, public hospitals. There was a strong female predominance (90 percent). Clometacin (Dupéran) was taken because of arthritis in 8 out of 10 cases. Administration was continuous in 85 percent of cases and median duration was 445 days. median dose was 450 mg per day. Jaundice, fatigue, and weight loss were the most frequent symptoms, but edema, ascites and palmar erythema were not uncommon. Thrombopenia (38 percent) was the most frequent hematologic abnormality. Renal failure, always with benign course, was present in 1/4 of cases. Biochemical disorders indicated hepatocellular and cholestatic hepatitis in 3/4 and 1/4 of cases respectively. Hypoprothrombinemia below 50 percent was noted in 1 out of 6 cases, and was associated with death in half cases. Gamma-globulins were increased in 80 percent of cases, with a predominant increase of IgG. Antinuclear or anti-smooth muscle antibodies were present in 60 percent of cases, whereas antimitochondrial and antimicrosomes were absent. Histopathological examination of the liver biopsy specimens obtained in 25 patients showed acute hepatitis in 8 and chronic active hepatitis with fibrosis in 17--including 6 patients with cirrhosis; there were no epidemiological, clinical (except ascites), or biochemical differences between these two groups. Four of the 7 patients tested had HLA B8 antigens; they all had chronic active hepatitis, with autoantibodies in 3 cases. Median duration of hospitalization was 21 days. Hepatitis was directly responsible for death in 3 patients; biochemical sequelae (hypergammaglobulinemia or anicteric cholestasis) were present in 8 patients, 2 of whom most likely had cirrhosis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Primary prevention of digestive hemorrhage, caused by rupture of esophageal varices, by endoscopic sclerotherapy in patients with liver cirrhosis. Multicenter randomized controlled study]. / Prophylaxie primaire des hémorragies digestives par rupture de varices oesophagiennes par sclérothérapie endoscopique chez le malade atteint de cirrhose. Etude contrôlée randomisée multicentrique.

The severity of esophageal variceal bleeding in cirrhotic patients justifies prophylactic therapy. A multicenter controlled study was carried out in Languedoc in 116 cirrhotic patients with esophageal varices and no history of bleeding. Patients were randomly assigned to two groups: 60 control patients without therapy; 56 patients treated by endoscopic sclerotherapy (209 sessions). The mean follow-up was 20 +/- 11 months. Esophageal varices disappeared in 35 patients (62.5%) or became smaller in 10 other patients (18%). Varices reappeared in 9 of these 35 patients within 3 months. Minor (fever, dysphagia, stenosis) or major complications (variceal bleeding, bacterial peritonitis) were noted in 26 patients (46%). Esophageal variceal bleeding occurred in 13 of the treated patients and in 10 control patients. Actuarial curves of bleeding and survival were similar for both groups. Twenty controls and 21 treated patients died during the study. In conclusion, prophylactic sclerotherapy of esophageal varices should not be performed in cirrhotic patients, considering lack of efficacy and high rate of side effects.

[Distal mesenteric arteritis: a rare complication of D. methylsergide treatment (author's transl)]. / Une artérite mésentérique distale. Complication rare du traitement par le D. méthylsergide.

A patient developed typical abdominal angina due to mesenteric arteritis secondary to D. methylsergide (Desernil) treatment. Multiple regular distal stenoses were revealed by arteriography, but these had completely disappeared 5 months after discontinuing treatment. Histology demonstrated fibrosis of the three tunicae with hyperelastosis. Six analogous cases due to D. methylsergide or ergotamine tartrate have been reported in the published literature, rapid regression occurring in all of them after interruption of treatment.

[Myocarditis or subendocardial myocardial infarction: role of MRI illustrated by a case report]. / Myopéricardite ou nécrose sous-endocardique: apport de l'imagerie par résonance magnétique illustré par un cas clinique.

A 50-year-old male patient treated with mesalazine for Crohn's disease was admitted in our unit for a chest pain, associated with nonspecific ST depression or ECG and troponin elevation. Coronarography showed minimal changes while SPECT imagery suggested a posterobasal subendocardial infarction, so that the diagnosis was unclear between ischemic disease and mesalazine-induced myocarditis. Eventually, MRI demonstrated clearly a subendocardial posterior infarction eliciting the diagnosis of mesalazine-induced myocarditis. This case report illustrates, in our opinion, that MRI is of invaluable interest in evaluating the characteristics of myocardium, and must be the cornerstone in the diagnosis of myocardial diseases.

Randomised trial comparing three different schedules of infusional 5FU and raltitrexed alone as first-line therapy in metastatic colorectal cancer. Final results of the Fédération Francophone de Cancérologie Digestive (FFCD) 9601 trial.

LV5FU2 with high-dose leucovorin (LV), weekly infusional 5-fluorouracil (5FU) (AIO schedule) and raltitrexed have been demonstrated to be active agents in first-line treatment of colorectal cancer. We performed a 4-arm randomised trial to compare (1) a low-dose intravenous bolus of LV (20 mg/m2), followed by an intravenous bolus of 5FU (400 mg/m2), followed by a 22-hour continuous infusion of 5FU (600 mg/m2) on day 1 and day 2/2 weeks (ldLV5FU2 arm), (2) a weekly continuous infusion of high-dose 5FU (2.6 g/m2/week) for 6 weeks followed by a rest week (HD-FU arm) and (3) raltitrexed (Tomudex arm; 3 mg/m2/3 weeks) to standard LV5FU2. From 1997 to 2001, 294 patients were included. The 4 arms were well balanced for sex ratio, age, WHO performance status, the primary tumour site and prior adjuvant chemotherapy. Treatment was stopped due to low accrual. Two toxicity-related deaths were observed in the Tomudex arm. The treatments gave rise to different rates of grade 3-4 neutropenia (3, 4, 11 and 14% of the patients in the LV5FU2, ldLV5FU2, HD-FU and Tomudex arms, respectively, p = 0.028), leucopenia and vomiting. At least one episode of grade 3-4 toxicity was observed in 27, 25, 38 and 47% of the patients in the LV5FU2, ldLV5FU2, HD-FU and Tomudex arms, respectively (p = 0.016). An objective response was observed in 28, 21, 22 and 10% of the patients in the LV5FU2, ldLV5FU2, HD-FU and Tomudex arms, respectively (p = 0.04). Progression-free survival (PFS) of the patients in the Tomudex arm was statistically lower compared to that of patients treated with LV5FU2 or ldLV5FU2 (combined group; p = 0.013, log rank test). In conclusion, Tomudex is more toxic and yields shorter PFS than infusional 5FU. Despite the early closure of the study and the lack of power of the comparison, it seems that ldLV5FU2 could be considered as an active, easier and less expensive option for the treatment of metastatic colorectal cancer compared to classic LV5FU2 or weekly HD-FU.

[Prescribing tiapridal for headache and other painful conditions]. / Comment prescrire le tiapridal dans les céphalalgies et autres algies.

Tiapridal a new molecule of the benzamide family, raises the pain-threshold level in the mesolimbic system. It has been shown to be effective in 66% of cases of headaches and pain resistant to therapy, and 75% of patients with nausea and vomiting associated with headaches. The average dosage is between 150 and 300 mg or day (1/2 to 1 tablet, 3 times a day). The product is extremely well-tolerated. Somnolence, the most frequent side-effect was noted in 17% of cases. Because of its excellent tolerance it can be prescribed in debilitated patients, alcoholics, and the elderly.

[Coxarthrosis due to contusion]. / La coxarthrose par contusion

Can a contusion cause coxarthrosis in the absence of both fracture and dislocation? Yes. To demonstrate this the authors report 6 cases that fulfil the following conditions: (1) Simple but violent contusion affecting the greater trochanter or the knee (dashboard accident) or a forced movement, such as in doing the splits; (2) immediate or slightly delayed pain, generally of short duration (a few weeks); (3) absence of coxarthrogenic malformations and absence of pre-existing signs of a pathological hip condition; (4) progressive coxarthrosis on the side of the contusion; (5) chronological relation between the development of the coxarthrosis images and the date of the contusion; (6) subjects less than 35 years of age, in order to eliminate cases with latent primary pre-coxarthrosis. The average age of the six patients at the start of the coxarthrosis was 24.7 years (range: 13 to 33 years); there were four men and two women. In five of the six cases a violent contusion in the trochanter region was involved as a result of a fall on a hard surface or a traffic accident. In one case a forced movement on landing from a jump was involved. Evolution in three periods is usual: the hip is painful either immediately or after a few weeks (particularly on rising after a period in bed for multiple injuries). This post-traumatic pain lasts from ten days to one month, rarely longer. It is followed by a period free of pain that may last from five months to ten years (average: five years). Subsequently there is pain every day and the onset of the limp associated with coxarthrosis. Radiographically the reduction of the joint space and/or the osteophytosis appears after three months to two years (average: one year). However, there may not be any pain associated with these lesions for a long time. The authors propose that the first five conditions enumerated above represent the essential medico-legal conditions of coxarthrosis by contusion. The restriction as regards age (No 6) was introduced only to show clearly the existence of post-contusive coxarthrosis. However, even if one or more of the medico-legal conditions are not fulfilled the imputability may still be valid. Some such cases are discussed.

[Acute cholecystitis in periarteritis nodosa. 8 cases]. / Les cholécystites aiguës de la périartérite noueuse. Huit observations.

OBJECTIVES: Analyze clinical manifestations and laboratory findings in patients with periarteritis nodosa who developed acute cholecystitis in order to determine their value for prognosis and management. PATIENTS AND METHODS: We report 8 cases of acute cholecystitis which revealed or occurred as a complication of periarteritis nodosa. These were 4 men and 4 women, mean age 50 years. Periarteritis nodosa was diagnosed on the basis of histological evidence and/or clinical expression. Complimentary explorations included: sonography of the biliary tree, cholecystogram or cholangiogram in addition to diagnostic work-up for periarteritis nodosa. RESULTS: The clinical or sonographic presentation was similar to common cases of cholecystitis. However, no stone were observed in 2/8 cases. Histologically, the gall bladder showed characteristic vascular lesions suggestive of periarteritis nodosa in 7 out of 8 cases (no operation in 1 case). Cholecystitis was the inaugural sign in 2 cases. Surgery was performed for lithiasic forms. Medical management with methylprednisolone i.v. was used successfully in the alithiasic forms. In the 2 cases with inaugural solitary acute cholecystitis. lithiasis was found in the surgical specimen in 1 case; the pathology examination gave the etiological diagnosis. There was no lithiasis in one case with inaugural cholecystitis. CONCLUSIONS: The development of acute cholecystitis in patients with periarteritis nodosa is uncommon but should be treated surgically in case of lithiasis or when the cholecystitis is the inaugural sign. Unlike digestive tract involvement, periarteritis nodosa does not aggravate the clinical course. Alithiasic forms may be treated medically with corticosteroids. In our opinion, therapeutic abstention, sometimes proposed in patients with necrotizing angiitis of the gall bladder, is not always indicated as some patients can benefit from medical treatment of the underlying periarteritis nodosa.