Medical treatment for sphincter of oddi dysfunction: can it replace endoscopic sphincterotomy?

AIM: To report the results of a medical management of sphincter of oddi dysfunction (SOD) after an intermediate follow-up period. METHODS: A total of 59 patients with SOD (2 men and 57 women, mean age 51 years old) were included in this prospective study. After medical treatment for one year, the patients were clinically re-evaluated after an average period of 30 mo. RESULTS: The distribution of the patients according to the Milwaukee's classification was the following: 11 patients were type 1, 34 were type 2 and 14 were type 3. Fourteen patients underwent an endoscopic sphincterotomy (ES) after one year of medical treatment. The median intermediate follow-up period was 29.8 ± 3 mo (3-72 mo). The initial effectiveness of the medical treatment was complete, partial and poor among 50.8%, 13.5% and 35%, respectively, of the patients. At the end of the follow-up period, 37 patients (62.7%) showed more than 50% improvement. The rate of improvement in patients who required ES was not significantly different compared with the patients treated conservatively (64.2% vs 62.2%, respectively). CONCLUSION: Our study confirms that conservative medical treatment could be an alternative to endoscopic sphincterotomy because, after an intermediate follow-up period, the two treatments show the same success rates.

Endoanal ultrasonography-assisted percutaneous transperineal management of anorectal sepsis.

PURPOSE: We aimed to analyze the feasibility and efficacy of a new transperineal access to treat anorectal sepsis (fistulae and abscesses) under endoanal ultrasonography guidance. METHODS: Twenty-five patients (80% Crohn disease) were included retrospectively. Twenty-one patients had fistulae (perianal, urethroanal, and anovaginal) treated by injection of heterologous fibrin glue and cyanoacrylate. Four patients with abscesses were treated by irrigation-injection of normal saline solution and an aminoglycoside antibiotic. RESULTS: Twenty-five patients underwent 32 treatment sessions. At 4 weeks' evaluation, 19 patients (90.5%) with anal fistulae ultimately achieved a 4-week short-term success. Of these, 5 patients (26%) showed resolution of symptoms and persistent occlusion of the fistula track at long-term follow-up (>6 mo). At 4-week follow-up, the treatment of abscesses was successful in 3 of 4 cases. However, a relapse was observed in 2 cases after a mean period of 3 months. No serious adverse events were observed. CONCLUSIONS: Endoanal ultrasonography-assisted percutaneous transperineal injection represents a sphincter-sparing alternative to the surgical route, with interesting outcomes and excellent tolerability for the treatment of anorectal sepsis.

Can papillary carcinomas be treated by endoscopic ampullectomy?

BACKGROUND: The utility of endoscopic ampullectomy versus surgical ampullectomy remains a topic of debate, particularly for the treatment of malignant tumors. The goal of this study was to prospectively establish the outcomes of endoscopic ampullectomy, with focus on carcinoma. METHODS: From February 2002 to December 2008, 61 patients underwent endoscopic ampullectomy. The ampulloma was discovered fortuitously in the majority of cases (43 patients, 70%). All patients had had an echoendoscopy revealing a T1N0 lesion without invasion of the orifice. RESULTS: Forty-three patients (70%) underwent a monobloc resection. Histological analysis revealed a low-grade dysplastic adenoma in 21 patients (35%), a high-grade dysplastic adenoma in 11 patients (18%), no dysplasia in 16 patients (26%), an adenocarcinoma in 10 patients (16%), and a well-differentiated endocrine carcinoma in 3 patients (5%). Among the ten patients with adenocarcinoma, four with adenocarcinoma of poor prognosis were treated by pancreaticoduodenectomy (PD) with R0 resection, of whom one patient had no more lesion. Two intramucosal adenocarcinomas were cured by endoscopic ampullectomy without any recurrence. Four patients received palliative care after endoscopic ampullectomy due to cephalic pancreatico-duodenectomy contraindication. For the three patients with well-differentiated endocrine carcinomas, one was treated by PD with R0 resection and two were treated solely by endoscopic ampullectomy, without recurrence. Eleven patients (18%) presented with complications. The complication rate was 30.5% for carcinomas versus 14.5% for benign tumors (p < 0.05). CONCLUSION: Endoscopic ampullectomy allows for the oncologic resection of well-differentiated intramucosal carcinomas with negative margins. The risk of complications is greater for papillary carcinomas.

Endoscopic management of colonic perforation owing to angiogenesis inhibitors.

Angiogenesis inhibitors have markedly improved, in combination with chemotherapy, the outcome of patients with metastatic solid tumors. Bevacizumab, the brand name of which is Avastin, is the first monoclonal antibody IgG1 used against the vascular endothelial growth factor involved in tumor proliferation. Gastrointestinal perforation is a well-known adverse event of bevacizumab therapy. Its surgical management is still controversial because of the high mortality rate of surgery. Here, we report a 48-year-old man with a history of metastatic renal cancer, who developed colonic perforation secondary to bevacizumab. This patient was treated successfully with endoscopic stenting.