Initial cholecystectomy vs sequential common duct endoscopic assessment and subsequent cholecystectomy for suspected gallstone migration: a randomized clinical trial.

IMPORTANCE: The optimal management of treatment for patients at intermediate risk of a common duct stone (including increased liver function tests but bilirubin <4 mg/dL and no cholangitis) is a matter of debate. Many stones migrate spontaneously into the duodenum, making preoperative common duct investigations unnecessary. OBJECTIVE: To compare strategies of cholecystectomy first vs a sequential endoscopic common duct assessment and cholecystectomy for the management of patients with an intermediate risk of a common duct stone. The main objective was to reduce the length of stay and the secondary objectives were to reduce the number of common duct investigations, morbidity, and costs. DESIGN, SETTING, AND PARTICIPANTS: Interventional, randomized clinical trial with 2 parallel groups performed between June 2011 and February 2013, with a patient follow-up of 6 months. The trial comprised a random sample of 100 adult patients admitted to Geneva University Hospital, Geneva, Switzerland, for acute gallstone-related conditions with an intermediate risk of a common duct stone. Fifty patients were randomized to each group. INTERVENTIONS: Cholecystectomy first with intraoperative cholangiogram for the study group and endoscopic common duct assessment and clearance followed by cholecystectomy for the control group. MAIN OUTCOMES AND MEASURES: Length of initial hospital stay (primary end point), number of common duct investigations and morbidity and mortality within 6 months after initial admission, and quality of life at 1 and 6 months after discharge (EQ-5D-5L [EuroQol Group, 5-level] questionnaire). RESULTS: Patients who underwent cholecystectomy as a first step had a significantly shorter length of hospital stay (median, 5 days [interquartile range {IQR}, 1-8] vs median, 8 days [IQR, 6-12]; P < .001), with fewer common duct investigations (25 vs 71; P < .001), no significant difference in morbidity or quality of life. CONCLUSIONS AND RELEVANCE: Among patients at intermediate risk of a common duct stone, initial cholecystectomy compared with sequential common duct endoscopy assessment and subsequent surgery resulted in a shorter length of stay without increased morbidity. If these findings are confirmed, initial cholecystectomy with intraoperative cholangiogram may be a preferred approach. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT01492790.

Use of glasgow-blatchford bleeding score reduces hospital stay duration and costs for patients with low-risk upper GI bleeding.

BACKGROUND AND STUDY AIMS: Upper gastrointestinal (UGI) bleeding is a frequent cause of hospitalization. Its severity may be assessed before endoscopy using the Glasgow-Blatchford Bleeding Score (GBS), a score validated to identify patients requiring clinical intervention. The aim of this study was to assess whether the GBS was effective for shortening hospital stay and reducing costs in patients with an UGI bleeding predicted at low risk of requiring clinical intervention. PATIENTS AND METHODS: Consecutive outpatients presenting with UGI bleeding at our hospital were prospectively included. In the observational study phase, UGI endoscopy was performed in all patients according to routine clinical practice. In the interventional study phase, patients with a GBS of 0 were discharged with an appointment for an outpatient UGI endoscopy. All patients had follow-up at 7 and 30 days. Need for clinical intervention was defined as performance of endoscopic hemostasis, blood transfusion or surgery. Results Two-hundred and eight patients were included, 104 in each study phase; complete follow-up was obtained in 201 patients. GBS varied from 0 to 18, with 15 (14 %) and 11 (11 %) patients having a GBS of 0 in the observational and interventional study phase, respectively. For patients with a GBS of 0, hospital stay was shorter (6 versus 19 h, P < 0.01), and costs were lower (845 EUR versus 1272 EUR, P = 0.002) in the interventional versus the observational study phase. For patients with a GBS > 0, hospital stay duration did not significantly differ between study phases (189 versus 207 h, P = 0.726). No adverse event was observed in the patients sent home with a GBS of 0 during the interventional study phase. Conclusions Implementing the GBS as a tool for triage of hospital outpatients who present with UGI bleeding allowed us to identify those who could safely be discharged for ambulatory management. Implementing this change in the hospital strategy significantly shortened hospital stay and decreased management costs.

Common bile duct adenocarcinoma in a patient with situs inversus totalis: report of a rare case.

BACKGROUND: Situs inversus totalis represents an unusual anomaly characterized by a mirror-image transposition of the abdominal and thoracic viscera. It often occurs concomitantly with other disorders that make difficult diagnosis and management of abdominal pathology. The relationship between situs inversus totalis and cancer remains unclear. CASE PRESENTATION: We describe a 33-year old Guinean man with situs inversus totalis who presented with obstructive jaundice. Imaging and endoscopic modalities demonstrated a mass of distal common bile duct which biopsy identified an adenocarcinoma. The patient was successfully treated by cephalic pancreaticoduodenectomy followed by adjuvant chemoradiation and he is doing well without recurrence 8 months after surgery. CONCLUSION: The occurrence of bile duct adenocarcinoma in patient with situs inversus totalis accounts as a rare coincidence. In this setting, when the tumor is resectable, surgical management should be considered without contraindication and must be preceded by a careful preoperative staging.

Single-operator, single-session EUS-guided anterograde cholangiopancreatography in failed ERCP or inaccessible papilla.

BACKGROUND: ERCP may be challenging or may fail in certain situations, including postsurgical anatomy, periampullary diverticula, ampullary tumor invasion, and high-grade strictures. OBJECTIVE: To report a large experience with EUS-guided anterograde cholangiopancreatography (EACP) to facilitate ductal access or perform direct EUS-guided therapy in patients with postsurgical anatomy or failed ERCP. DESIGN: Retrospective cohort study. SETTING: Tertiary referral center. PATIENTS: Ninety-five consecutive patients with failed ERCP or inaccessible papilla over a 4-year period. INTERVENTIONS: EACP techniques involved ductal puncture and ductography, followed by either guidewire advancement for rendezvous ERCP in patients with duodenoscope accessible papilla or direct drainage in altered anatomy. For failures, crossover to the alternate EACP technique was performed when appropriate. MAIN OUTCOME MEASUREMENTS: Technical success rates and complications. RESULTS: EACP procedures were attempted in 95 of 2566 ERCP procedures (3.7%). EUS-guided cholangiography (n = 70) and pancreatography (n = 25) were successful in 97% and 100%, respectively. EUS-guided rendezvous ERCP was successful in 75% of biliary procedures and in 56% of pancreatic procedures. Direct EUS-guided therapy was successful in 86% and 75% of biliary and pancreatic procedures, respectively. Direct interventions included pancreaticogastrostomy (n = 10), anterograde stent across stricture (n = 10), hepaticogastrostomy (n = 8), and choledochoduodenostomy (n = 1). Ten complications (10.5%) related to EACP or subsequent rendezvous ERCP included pancreatitis (n = 5), hematoma (n = 1), bile leak (n = 1), bacteremia (n = 1), pneumoperitoneum (n = 1), and perforation (n = 1). LIMITATIONS: Single-center experience; retrospective study. CONCLUSIONS: EACP complements ERCP and allows successful pancreaticobiliary therapy in a large proportion of patients with failed ERCP or difficult-to-access papilla.

[Barrett's esophagus: new screening methods and new endoscopic therapy]. / Oesophage de Barrett: nouvelles méthodes de dépistage et nouveaux traitements endoscopiques.

New endoscopic techniques allow, for the diagnosis, to better identify dysplastic lesions using "virtual" chromoendoscopy (without replacing systematic biopsies), and for the treatment, to resect large superficial lesions or ablate the entire Barrett's mucosa (the latter technique uses radiofrequency and does not provide any specimen). Endoscopic resection allows (1) to more accurately stage the lesion than biopsies, (2) to be curative in case of high grade dysplasia or intramucosal carcinoma. Radiofrequency ablation of the entire metaplastic mucosa is recommended after resection of neoplastic lesions with a curative intent (to avoid recurrences) or as first line treatment in case of dysplasia without visible lesion. In practical, if neoplasia is detected during screening endoscopy, a careful (chromoendoscopy) examination is required to orient patient's management (resection and/or radiofrequency ablation).

Endoscopic ultrasound-guided anterograde cholangiopancreatography.

Endoscopic retrograde cholangiopancreatography (ERCP) may fail in 10-15% of cases. A growing percentage of such cases are due to the inaccessible papilla after gastric bypass surgery for the treatment of obesity. Endoscopic ultrasonography (EUS) offers an alternative route of access to the bile and pancreatic ducts. Using the curved linear array echoendoscope, access to the bile and pancreatic ducts is possible under real-time EUS guidance. The route of access is 'anterograde', in contrast to the 'retrograde' approach of ERCP. We have coined the term "EUS-guided anterograde cholangiopancreatography (EACP)" to cover the spectrum of EUS-guided techniques for accessing and draining the bile and pancreatic ducts. These techniques are reviewed in this paper. The literature has validated the feasibility of EACP but complication rates have been high; the safety profile of EACP must improve. This will require tools, designed for EUS-guided applications, that enable safer transenteric access and drainage.

[Endoscopic resection of digestive tumors: indications, quality criteria and results]. / Résection endoscopique des tumeurs digestives: indications, critères de qualité et résultats.

Endoscopic resection of digestive tumors: indications, quality criteria and results In the past decade, two developments have changed the approach to superficial digestive tumors: 1) new endoscopic techniques allow "en bloc" resection of superficial tumors with almost no limit in tumor diameter and 2) the risk of lymph node metastases is better stratified (e.g., in the colon, the risk of lymph node metastasis is negligible for superficial malignant invasion of the submucosa). Endoscopic submucosal dissection (ESD) allows "en bloc" resection of large laterally-spreading tumors, in contrast with prior resection techniques (endoscopic mucosal resection - EMR) that required piecemeal resection for large tumors. As a result, relapse rate is lower with ESD compared to EMR. Pathological examination is also more reliable with "en bloc" specimens; it must precisely assess resection margins and the depth of malignant invasion.

Endoscopic treatment in chronic pancreatitis, timing, duration and type of intervention.

Endoscopic treatment of chronic pancreatitis (CP) aims to relieve pain by draining the main pancreatic duct (MPD) and to treat loco-regional complications. Half of patients have complete pain relief five years after treatment, with best results obtained if treatment is performed early after the first pain attack. If MPD obstruction is caused by calcifications, ambulatory extracorporeal shock wave lithotripsy has become a first-line treatment (9-30% of patients require ERCP during follow-up). If MPD obstruction is caused by stricture(s), insertion of single plastic stent is effective but it requires multiple ERCPs for stent exchanges; other protocols are being investigated. Pseudocysts represent an excellent indication for endoscopic treatment with long-term results similar to those of surgery; endosonography-guided techniques allow treatment of almost any pancreatic pseudocyst. Biliary strictures related to CP are challenging due to a high relapse rate and requirement for multiple ERCP sessions. Significant progress has recently been made with new protocols of temporary biliary stenting (multiple simultaneous plastic stents or covered metallic stents).

Use of the front-view forward-array echoendoscope to evaluate right colonic subepithelial lesions.

BACKGROUND: Endosonographic evaluation and sampling of right colonic subepithelial lesions is technically difficult. OBJECTIVE: To evaluate the feasibility, safety, and tissue yield of a prototype front-view, forward-array, curved linear array echoendoscope in the evaluation and sampling of right colonic subepithelial lesions. SETTING: Tertiary referral center. DESIGN: Procedural and outcome data on all patients undergoing EUS evaluation of right-sided colonic and pericolonic lesions were collected during a 1-year study period. MAIN OUTCOME MEASUREMENTS: Patient demographics, clinical indication, EUS findings, EUS-FNA yield, technical success, and procedural complications. RESULTS: A total of 15 patients underwent EUS examination of right-sided colonic lesions with the prototype echoendoscope. The lesions were located in the cecum (n = 12) and the ascending colon (n = 3). The cecum was reached in all examinations within 10 minutes. Twelve patients had subepithelial lesions detected during colonoscopy. Findings included 6 extrinsic compressions from an adjacent normal structure, 1 calcified lymph node, 1 ovarian cyst, 1 prolapsed appendiceal orifice, 1 GI stromal tumor, 1 appendiceal mucocele, and 1 lymphoma. Two patients were evaluated for a pericolonic lesion seen on CT; findings included focal diverticulitis and a metastatic lymph node. In the patient evaluated for an infiltrative mass with previous nondiagnostic biopsies, colonic histoplasmosis was diagnosed. FNA was performed in 6 patients and provided diagnostic samples in 5 (83%). No procedure- or FNA-related complications were reported. CONCLUSIONS: Endosonographic evaluation and sampling of right-sided colonic subepithelial lesions with the prototype front-view, forward-array, curved linear array echoendoscope is feasible and safe. The yield of FNA is high, consistent with applications in the upper GI tract.

[Drug-induced pancreatitis]. / Pancréatites médicamenteuses.

Drug-induced pancreatitis represents 2% of acute pancreatitis. The incidence is rising with more than 260 substances that have been incriminated so far. The important steps for the diagnosis are the exclusion of the other causes of acute pancreatitis, the chronology between the introduction of the drug, the appearance of the symptoms and the resolution of the complaints and the elevation of pancreatic enzymes after discontinuation of the treatment as well as the documentation in the literature of similar cases. The degree of the evidence is classified by the strength of the association (definite, probable and possible) and the number of reported cases. The prognosis is in most cases good, but rare cases of death have been reported.

[Minimally invasive treatment of obesity with the intragastric balloon: a review]. / Traitement endoscopique de l'obésité: le point sur le ballon intragastrique.

Obesity is currently one of the most important problems in public health because of its prevalence and potential complications. The National Institute of Health (NIH) recommends to decrease body weight by about 10% because this initial weight loss can significantly decrease the severity of obesity-associated risk factors. The intragastric balloon (IB) was developed as a temporary aid to obtain such a weight loss and to induce a modification of eating habits. Results are encouraging in terms of weight loss, and improvement of co-morbidity. The best results have been obtained in patients with a body mass index (weight/size2) comprised between 30 and 40 kg/m 2, but superobese patients may also be good candidates for IB therapy before bariatric surgery. Overall complications are estimated to develop in about 3% of cases.

Control of severe hemorrhage using C-clamp and arterial embolization in hemodynamically unstable patients with pelvic ring disruption.

INTRODUCTION: Hemorrhage is the leading cause of death in patients with a pelvic fracture. The majority of blood loss derives from injured retroperitoneal veins and broad cancellous bone surfaces. The emergency management of multiply injured patients with pelvic ring disruption and severe hemorrhage remains controversial. Although it is well accepted that the displaced pelvic ring injury must be rapidly reduced and stabilized, the methods by which control of hemorrhagic shock is achieved remain under discussion. It has been proposed to exclusively use external pelvic ring stabilization for control of hemorrhage by producing a 'tamponade effect' of the pelvis. However, the frequency of clinically important arterial bleeding after external fixation of the pelvic ring remains unclear. We therefore undertook this retrospective review to attempt to answer this one important question: How frequently is arterial embolization necessary to control hemorrhage and restore hemodynamic stability after external pelvic ring fixation? MATERIALS AND METHODS: We performed a retrospective review of 55 consecutive patients who presented with unstable types B and C pelvic ring fractures. Those patients designated as being in hemorrhagic shock (defined as a systolic blood pressure less than 90 mmHg after receiving 2 L of intravenous crystalloid) were treated by application of the pelvic C-clamp. Patients who remained in hemorrhagic shock, or were determined to be in severe shock (defined as mandatory catecholamines or more than 12 blood transfusions over 2 h), underwent therapeutic angiography within 24 h in order to control bleeding. RESULTS: Fourteen patients were identified as being hemodynamically unstable (ISS 30.1 +/- 11.3 points) and were treated with a C-clamp. In those patients with persistent hemodynamic instability, arterial embolization was performed. After C-clamp application, 5 of 14 patients required therapeutic angiography to control bleeding. Two patients died, one from multiple sources of bleeding and the other from an open pelvic fracture (total mortality 2/14, 14%). CONCLUSIONS: Although the C-clamp is effective in controlling hemorrhage, one must be aware of the need for arterial embolization to restore hemodynamic stability in a select subgroup of patients.