RESUMO
BACKGROUND AND AIMS: EUS-guided radiofrequency ablation (EUS-RFA) has been described as a potentially curative option for solid and cystic pancreatic neoplasms. We aimed to assess the safety and efficacy of pancreatic EUS-RFA in a large study population. METHODS: A retrospective study retrieving all consecutive patients who underwent pancreatic EUS-RFA during 2019 and 2020 in France was conducted. Indication, procedural characteristics, early and late adverse events (AEs), and clinical outcomes were recorded. Risk factors for AEs and factors related to complete tumor ablation were assessed on univariate and multivariate analyses. RESULTS: One hundred patients (54% men, 64.8 ± 17.6 years old) affected by 104 neoplasms were included. Sixty-four neoplasms were neuroendocrine neoplasms (NENs), 23 were metastases, and 10 were intraductal papillary mucinous neoplasms with mural nodules. No procedure-related mortality was observed, and 22 AEs were reported. Proximity of pancreatic neoplasms (≤1 mm) to the main pancreatic duct was the only independent risk factor for AEs (odds ratio [OR), 4.10; 95% confidence interval [CI), 1.02-15.22; P = .04). Fifty-nine patients (60.2%) achieved a complete tumor response, 31 (31.6%) a partial response, and 9 (9.2%) achieved no response. On multivariate analysis, NENs (OR, 7.95; 95% CI, 1.66-51.79; P < .001) and neoplasm size <20 mm (OR, 5.26; 95% CI, 2.17-14.29; P < .001) were independently related to complete tumor ablation. CONCLUSIONS: The results of this large study confirm an overall acceptable safety profile for pancreatic EUS-RFA. Close proximity (≤1 mm) to the main pancreatic duct represents an independent risk factor for AEs. Good clinical outcomes in terms of tumor ablation were observed, especially for small NENs.
Assuntos
Neoplasias Císticas, Mucinosas e Serosas , Tumores Neuroendócrinos , Neoplasias Pancreáticas , Ablação por Radiofrequência , Masculino , Humanos , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Feminino , Estudos Retrospectivos , Neoplasias Pancreáticas/cirurgia , Neoplasias Pancreáticas/patologia , Ablação por Radiofrequência/métodos , Tumores Neuroendócrinos/cirurgia , Fatores de RiscoRESUMO
BACKGROUND: Familial adenomatous polyposis (FAP) is a rare inherited syndrome that predisposes the patient to cancer. Treatment of FAP-related ampullary lesions is challenging and the role of endoscopic papillectomy has not been elucidated. We retrospectively analyzed the outcomes of endoscopic papillectomy in matched cohorts of FAP-related and sporadic ampullary lesions (SALs). METHODS: This retrospective multicenter study included 1422 endoscopic papillectomy procedures. Propensity score matching including age, sex, comorbidity, histologic subtype, and size was performed. Main outcomes were complete resection (R0), technical success, complications, and recurrence. RESULTS: Propensity score matching identified 202 patients (101 FAP, 101 SAL) with comparable baseline characteristics. FAP patients were mainly asymptomatic (79.2â% [95â%CI 71.2-87.3] vs. 46.5â% [95â%CI 36.6-56.4]); Pâ<â0.001). The initial R0 rate was significantly lower in FAP patients (63.4â% [95â%CI 53.8-72.9] vs. 83.2â% [95â%CI 75.8-90.6]; Pâ=â0.001). After repeated interventions (mean 1.30 per patient), R0 was comparable (FAP 93.1â% [95â%CI 88.0-98.1] vs. SAL 97.0â% [95â%CI 93.7-100]; Pâ=â0.19). Adverse events occurred in 28.7â%. Pancreatitis and bleeding were the most common adverse events in both groups. Severe adverse events were rare (3.5â%). Overall, 21 FAP patients (20.8â% [95â%CI 12.7-28.8]) and 16 SAL patients (15.8â% [95â%CI 8.6-23.1]; Pâ=â0.36) had recurrence. Recurrences occurred later in FAP patients (25 [95â%CI 18.3-31.7] vs. 2 [95â%CI CI 0.06-3.9] months). CONCLUSIONS: Endoscopic papillectomy was safe and effective in FAP-related ampullary lesions. Criteria for endoscopic resection of ampullary lesions can be extended to FAP patients. FAP patients have a lifetime risk of relapse even after complete resection, and require long-time surveillance.
Assuntos
Polipose Adenomatosa do Colo , Ampola Hepatopancreática , Neoplasias do Ducto Colédoco , Humanos , Ampola Hepatopancreática/cirurgia , Ampola Hepatopancreática/patologia , Estudos Retrospectivos , Pontuação de Propensão , Recidiva Local de Neoplasia/patologia , Polipose Adenomatosa do Colo/cirurgia , Polipose Adenomatosa do Colo/patologia , Resultado do Tratamento , Neoplasias do Ducto Colédoco/cirurgia , Neoplasias do Ducto Colédoco/patologiaRESUMO
INTRODUCTION: Ampullary neuroendocrine neoplasia (NEN) is rare and evidence regarding their management is scarce. This study aimed to describe clinicopathological features, management, and prognosis of ampullary NEN according to their endoscopic or surgical management. METHODS: From a multi-institutional international database, patients treated with either endoscopic papillectomy (EP), transduodenal surgical ampullectomy (TSA), or pancreaticoduodenectomy (PD) for ampullary NEN were included. Clinical features, post-procedure complications, and recurrences were assessed. RESULTS: 65 patients were included, 20 (30.8%) treated with EP, 19 (29.2%) with TSA, and 26 (40%) with PD. Patients were mostly asymptomatic (n = 46; 70.8%). Median tumor size was 17 mm (12-22), tumors were mostly grade 1 (70.8%) and pT2 (55.4%). Two (10%) EP resulted in severe American Society for Gastrointestinal Enterology (ASGE) adverse post-procedure complications and 10 (50%) were R0. Clavien 3-5 complications did not occur after TSA and in 4, including 1 postoperative death (15.4%) of patients after PD, with 17 (89.5%) and 26 R0 resection (100%), respectively. The pN1/2 rate was 51.9% (n = 14) after PD. Tumor size larger than 1 cm (i.e., pT stage >1) was a predictor for R1 resection (p < 0.001). Three-year overall survival and disease-free survival after EP, TSA, and PD were 92%, 68%, 92% and 92%, 85%, 73%, respectively. CONCLUSION: Management of ampullary NEN is challenging. EP should not be performed in lesions larger than 1 cm or with a endoscopic ultrasonography T stage beyond T1. Local resection by TSA seems safe and feasible for lesions without nodal involvement. PD should be preferred for larger ampullary NEN at risk of nodal metastasis.
Assuntos
Ampola Hepatopancreática , Neoplasias do Ducto Colédoco , Neoplasias Duodenais , Tumores Neuroendócrinos , Humanos , Ampola Hepatopancreática/cirurgia , Ampola Hepatopancreática/patologia , Pancreaticoduodenectomia/métodos , Prognóstico , Pancreatectomia , Neoplasias do Ducto Colédoco/cirurgia , Neoplasias do Ducto Colédoco/patologia , Neoplasias Duodenais/cirurgia , Tumores Neuroendócrinos/patologia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
INTRODUCTION: The aims of this retrospective multicenter study were to assess the technical success and adverse events of endoscopic retrograde cholangiopancreatography (ERCP) procedures in children in French and Belgian centers. METHODS: All children aged 1 day to 17 years who underwent ERCP between January 2008 and March 2019 in 15 tertiary care hospitals were retrospectively included. RESULTS: 271 children underwent 470 ERCP procedures. Clinical long-term follow-up was available for 72â% of our patients (340/470 procedures). The median age at intervention was 10.9 years. ERCP was therapeutic in 90â% (423/470) and diagnostic in cases of neonatal cholestasis in 10â% of the patients. The most common biliary indication was choledocholithiasis; the most common pancreatic indication was chronic pancreatitis. Biliary cannulation was successful in 92â% of cases (270/294); pancreatic cannulation in 96â% of cases (169/176); and planned therapeutic procedures in 92â% of cases (388/423). The overall complication rate was 19â% (65/340). The most common complication was post-ERCP pancreatitis (PEP) in 12â% of cases (40/340) and sepsis in 5â% (18/340). On univariate analyses, pancreatic stent removal was protective against PEP (odds ratio [OR] 0.1, 95â% confidence interval [CI] 0.01â-â0.75; Pâ=â0.03), and sepsis was associated with history of liver transplantation (OR 7.27, 95â%CI 1.7â-â31.05; Pâ=â0.01). Five patients had post-ERCP hemorrhage and two had intestinal perforation. All complications were managed with supportive medical care. There was no procedure-related mortality. CONCLUSION: Our cohort demonstrates that ERCP can be performed safely with high success rates in many pancreaticobiliary diseases of children. The rate of adverse events was similar to that in previous reports.
Assuntos
Coledocolitíase , Pancreatite , Cateterismo , Criança , Colangiopancreatografia Retrógrada Endoscópica , Humanos , Recém-Nascido , Pancreatite/epidemiologia , Pancreatite/etiologia , Estudos RetrospectivosRESUMO
BACKGROUND: Perivascular epithelioid cell tumor, an extremely rare mesenchymal tumor, could be ubiquitous but rarely arises from pancreas. Surgery is considered the most appropriate treatment. Nevertheless, activation of mTOR pathway seems to be a common pathogenic event in PEComas paving the way to chemotherapy by mTOR inhibitor. METHOD: A 17 year-old man presented a hypervascular tumor of 55â¯mm, located in the head of pancreas without bile duct or pancreatic duct compression. RESULTS: Histopathology showed epithelioid cells with clear or focally granular eosinophilic cytoplasm with melanocytic (HMB-45, Melan-A) and myoid markers which confirmed diagnosis of PEComa. Given the absence of worrisome feature, we ruled out surgery and decided to initiate treatment with Sirolimus, an mTOR inhibitor. After 3.5 years, we showed a significant reduction in size of the tumor. CONCLUSION: This first case of pancreatic PEComa treated by mTOR inhibitor without surgery suggests a good efficiency of this therapy.
Assuntos
Neoplasias Pancreáticas/tratamento farmacológico , Neoplasias de Células Epitelioides Perivasculares/tratamento farmacológico , Sirolimo/uso terapêutico , Serina-Treonina Quinases TOR/antagonistas & inibidores , Adolescente , Humanos , Imageamento por Ressonância Magnética , Masculino , Pâncreas/patologia , Neoplasias Pancreáticas/diagnóstico por imagem , Neoplasias Pancreáticas/patologia , Neoplasias de Células Epitelioides Perivasculares/diagnóstico por imagem , Neoplasias de Células Epitelioides Perivasculares/patologia , Transdução de Sinais/efeitos dos fármacos , Tomografia Computadorizada por Raios X , Resultado do TratamentoAssuntos
Neoplasias Esofágicas/diagnóstico por imagem , Linfoma de Zona Marginal Tipo Células B/diagnóstico por imagem , Idoso de 80 Anos ou mais , Anticorpos Monoclonais Murinos/uso terapêutico , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Ciclofosfamida/uso terapêutico , Transtornos de Deglutição/etiologia , Doxorrubicina/uso terapêutico , Neoplasias Esofágicas/complicações , Neoplasias Esofágicas/tratamento farmacológico , Neoplasias Esofágicas/patologia , Esofagoscopia , Gastroscopia , Humanos , Linfoma de Zona Marginal Tipo Células B/complicações , Linfoma de Zona Marginal Tipo Células B/tratamento farmacológico , Linfoma de Zona Marginal Tipo Células B/patologia , Masculino , Prednisona/uso terapêutico , Rituximab , Tomografia Computadorizada por Raios X , Vincristina/uso terapêuticoRESUMO
BACKGROUND: European guidelines recommends the use of cold snare polypectomy (CSP) for removal of diminutive colorectal polyps (DCP). However, for DCP < 4 mm cold biopsy forceps (CBF) may be optional. We aimed to compare the efficacy of CSP with CBF for removal of DCP in routine colonoscopy. METHODS: We conducted a multicenter non-inferiority randomized controlled trial. After screening, 123 patients were prospectively included and 180 DCPs were removed by either CBF or CSP after randomization (1:1). The primary end-point was the histological complete resection rate defined by negative additional biopsies taken from the edge of the polypectomy ulcer site. RESULTS: Among DCPs, 121 (67.2%) adenomas or sessile serrated lesions were considered for the analysis. Polyps were 4 [1-5] mm in size, mostly flat (55.4%) and located in the proximal colon (44.6%). The en bloc resection rate was higher in the CSP group than the CBF group (91.7% vs. 42.6%, p < 0.001). The histological complete resection rate was comparable in the two groups (93.33% vs 90.16%; p = 0.527), even for polyps < 4 mm (91.30% vs 91.30%; p = 1). All specimens were retrieved and there was no difference in terms of procedure times and adverse events. Finally, univariate analysis did not identify any potential factor associated with complete resection rate. CONCLUSION: In this study, CSP was comparable to CBF for the removal of DCP. Therefore, CBF may be considered as an alternative technique for resection of DCP, together with CSP, ClinicalTrials.gov registry (NCT04727918).
Assuntos
Pólipos do Colo , Biópsia/métodos , Pólipos do Colo/patologia , Pólipos do Colo/cirurgia , Colonoscopia/métodos , Humanos , Estudos Prospectivos , Instrumentos Cirúrgicos , Resultado do TratamentoRESUMO
Background: Endoscopic papillectomy is a minimally invasive treatment for benign tumors of the ampulla of Vater or early ampullary carcinoma. However, reported recurrence rates are significant and risk factors for recurrence are unclear. Objective: The aims of this study were to evaluate the efficacy and safety of endoscopic papillectomy and to identify risk factors for recurrence and adverse events. Methods: All patients who underwent endoscopic papillectomy at five tertiary referral centers between January 2008 and December 2018 were included. Recurrence was defined as the detection of residue on one of the follow-up endoscopies. Treatment success was defined as the absence of tumor residue on the last follow-up endoscopy. Results: A total of 227 patients were included. The resections were en bloc in 64.8% of cases. The mean lesion size was 20 mm (range: 3-80) with lateral extension in 23.3% of cases. R0 resection was achieved in 45.3% of cases. The recurrence rate was 30.6%, and 60.7% of recurrences were successfully treated with additional endoscopic treatment. Finally, treatment success was achieved in 82.8% of patients with a median follow-up time of 22.3 months. R1 resection, intraductal invasion, and tumor size > 2 cm were associated with local recurrence. Adverse events occurred in 36.6% of patients and included pancreatitis (17.6%), post-procedural hemorrhage (11.0%), perforation (5.2%), and biliary stenosis (2.6%). The mortality rate was 0.9%. Conclusion: Endoscopic papillectomy is an effective and relatively well-tolerated treatment for localized ampullary tumors. In this series, R1 resection, intraductal invasion, and lesion size > 2 cm were associated with local recurrence.
Assuntos
Neoplasias dos Ductos Biliares/cirurgia , Ablação por Cateter/métodos , Colestase/cirurgia , Tumor de Klatskin/cirurgia , Stents , Neoplasias dos Ductos Biliares/complicações , Colestase/etiologia , Feminino , Humanos , Tumor de Klatskin/complicações , Metais , Pessoa de Meia-Idade , Cuidados Paliativos , RecidivaAssuntos
Doenças do Ânus/patologia , Neoplasias do Ânus/patologia , Condiloma Acuminado/patologia , Pólipos Intestinais/patologia , Lesões Pré-Cancerosas/patologia , Adulto , Doenças do Ânus/cirurgia , Neoplasias do Ânus/virologia , Biópsia , Colonoscopia , Condiloma Acuminado/cirurgia , Condiloma Acuminado/virologia , Humanos , Pólipos Intestinais/cirurgia , Lesões Pré-Cancerosas/cirurgia , Lesões Pré-Cancerosas/virologiaAssuntos
Colangiopancreatografia Retrógrada Endoscópica/instrumentação , Infecção Hospitalar/prevenção & controle , Surtos de Doenças/prevenção & controle , Duodenoscópios/microbiologia , Controle de Infecções/métodos , Infecções por Pseudomonas/prevenção & controle , Pseudomonas aeruginosa/isolamento & purificação , HumanosRESUMO
BACKGROUND: Endoscopic submucosal dissection is currently regarded as the method of choice for the resection of superficial tumours. The objective of our study was to evaluate prospectively the efficiency of an endoscopic submucosal dissection training course using live anaesthetised pigs. METHODS: Fourteen novice endoscopists participated in three gastric endoscopic submucosal dissection training courses on anaesthetised pigs. Each trainee resected five 'fake' antral lesions. Resected specimen sizes, endoscopic submucosal dissection speeds and the complication rate were evaluated prospectively. RESULTS: Among the 70 procedures performed, 58 could be analysed. There was a strong increase in endoscopic submucosal dissection speed (from 9.7 mm2/minute to 30.4 mm2/minute) during the sessions, marked between the first two endoscopic submucosal dissections compared with the fourth and fifth. There was a significant relation between the surface area of the resected lesion and procedure speed (P < 0.0001). The complication rate was 8.6%. CONCLUSION: There is a clear benefit from endoscopic submucosal dissection training courses on animal models. Improved endoscopist capability is evident from the third endoscopic submucosal dissection. These data validate the indispensable nature of dedicated training courses and echo the European Society of Gastrointestinal Endoscopy proposition for multistep learning, beginning on animal models.
RESUMO
BACKGROUND AND STUDY AIMS: Adequate bowel preparation is key for the optimal quality of colonoscopy. The sodium phosphate laxatives used for preparation may induce gastric injuries. However, in vivo studies monitoring the effects of sodium phosphate on the gastric mucosa are currently lacking. We aimed to characterize the effects of sodium phosphate tablets (Colokit®; Mayoly Spindler, Chatou, France) on the gastric mucosa in a large-animal model. METHODS: Fourteen anesthetized pigs were used for this study. Fundic mucosal sites were analyzed at 1.5, 24, and 72 hours after the endoscopically guided application of sodium phosphate tablets (NaPT) and placebo tablets (PlaT) and were compared with unexposed sites. Different mucosal parameters were assessed with white light endoscopy, probe-based confocal laser endomicroscopy (pCLE), histology, and ex vivo permeability measurements. RESULTS: At 90 minutes after the application of NaPT, significant increases in epithelial irregularity and crypt pit intensity were observed with pCLE. These microscopic lesions persisted at 24 hours but were resolved at 72 hours. In addition, white light endoscopy revealed local exanthema in 57â% of the animals at 1.5 hours after NaPT application. Such lesions were observed in 22â% of the pigs at 24 hours and disappeared at 72 hours after application. After 1.5 hours, PlaT induced a slight but significant increase in epithelial irregularity, as well as architectural scores that were significantly lower than the ones induced by NaPT and that disappeared after 72 hours. CONCLUSIONS: The direct and prolonged gastric application of NaPT in pigs can induce acute superficial macroscopic and microscopic injuries that are reversible within 72 hours.
RESUMO
A case is reported of a 76-year-old man with a past history of atrial fibrillation. A radiofrequency ablation procedure was suggested following several failed cardioversion attempts. However, an esophagopericardial fistula complicated the procedure. This life-threatening complication was successfully managed using both the placement of a covered esophageal stent and surgical pericardial and mediastinal drainage. In fact, no persisting fistula could be detected when the esophageal stent was removed seven weeks later. Atrioesophageal and esophagopericardial fistulas are two of the most severe complications associated with cardiological radiofrequency ablation procedures. They are responsible for majority of the deaths associated with this procedure. Despite the extremely high morbimortality associated with cardiothoracic surgery in such conditions, this treatment is the gold-standard for the management of such complications. This case report emphasizes the importance and efficacy of the endoscopic approach as part of a multidisciplinary management approach to this serious adverse event following radiofrequency ablation for atrial fibrillation.
Assuntos
Fibrilação Atrial/cirurgia , Ablação por Cateter/efeitos adversos , Fístula Esofágica/cirurgia , Esofagoscopia , Fístula/cirurgia , Cardiopatias/cirurgia , Idoso , Drenagem , Fístula Esofágica/diagnóstico , Fístula Esofágica/etiologia , Esofagoscopia/instrumentação , Fístula/diagnóstico , Fístula/etiologia , Cardiopatias/diagnóstico , Cardiopatias/etiologia , Humanos , Masculino , Derrame Pericárdico/etiologia , Reoperação , Stents , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
A case is reported of a 40-year-old woman with a past history of bariatric surgery with vertical banding gastroplasty. Migrating band was observed during upper GI endoscopy performed for pyrosis. Before undergoing another bariatric intervention, migrated band had to be removed. This procedure was successfully performed endoscopically using argon plasma coagulation. No complication occurred. This case highlights that migrated band could be easily and safely removed without the need of specific or dedicated endoscopic tool.
Assuntos
Coagulação com Plasma de Argônio , Migração de Corpo Estranho/cirurgia , Gastroplastia/instrumentação , Gastroscopia , Adulto , Feminino , Humanos , PoliésteresRESUMO
BACKGROUND: Probe-based confocal laser endomicroscopy enables microscopic examination of the digestive mucosa. AIMS: (1) To identify and validate quantitative endomicroscopic criteria for evaluation of the colonic mucosa and (2) to compare these criteria between healthy and Crohn's disease patients in clinical remission. METHODS: Six healthy controls and ten Crohn's disease patients in clinical remission were included in this prospective study. Methylene blue-stained biopsies of the right colon and corresponding endomicroscopic images were analyzed. Major axis, minor axis, and major axis/minor axis ratio of crypt lumens were quantified. RESULTS: Quantitative assessment was performed on 21 ± 4 crypt lumens per patient. Major axis/minor axis ratio values measured with endomicroscopy or methylene blue-stained biopsies were linearly correlated (r=0.63, p=0.01). All macroscopically inflamed mucosa had values of major axis/minor axis ratio higher than the median of controls. Interestingly, 50% (3/6) of Crohn's disease patients with macroscopically normal mucosa had also a higher ratio than pooled controls. Histological analysis showed that 6/7 patients with major axis/minor axis ratio superior to 1.7 had microscopic inflammation. CONCLUSION: Probe-based confocal laser endomicroscopy allows quantitative analysis of colonic pit structure. Endomicroscopic analysis of major axis/minor axis ratio allows the detection of microscopic residual inflammation with greater accuracy than standard endoscopy in Crohn's disease patients in clinical remission.