ABSTRACT
BACKGROUND AND STUDY AIMS: In France, in about 5% of cases colonoscopies are incomplete or temporarily contraindicated.We tested the diagnostic yield of colon capsule endoscopy (CCE) in these patients. PATIENTS AND METHODS: In a prospective study, in 17 French centers, inclusion criteria were colonoscopy failure or general disease that excluded colonoscopy with anesthesia. Patients underwent CCE using the first-generation PillCam Colon capsule. The main end point was CCE diagnostic yield, defined as identification of a colorectal lesion that directly explained symptoms or necessitated a diagnostic or therapeutic examination. A secondary objective was to test a simplified Movi-Prep colon cleansing. Follow-up to identify missed symptomatic cancer was scheduled. RESULTS: CCE showed positive findings in 36 patients (diagnostic yield 33.6 %), among whom 23 subsequently underwent therapeutic intervention. Among 64 patients with negative capsule findings, 9 had a complementary procedure showing adenomas in only 1 case. CCE was incomplete in 7/107 patients. Colonoscopy was done in one patient to retrieve a capsule retained in the left colon, and sigmoidoscopy in 11 because the rectum was not reached. No colorectal cancer was diagnosed during the follow-up period. Colon cleansing with MoviPrep was rated good or excellent in 75.9% of cases. CONCLUSION: This study shows the feasibility and the usefulness of CCE in the situation of colonoscopy failure or contraindication. The colon capsule modality should be tested against other available approaches, such as virtual colonoscopy or repeat colonoscopy by an expert.
Subject(s)
Anesthesia , Capsule Endoscopy , Colonoscopy , Adult , Aged , Aged, 80 and over , Contraindications , Feasibility Studies , Female , France , Humans , Male , Middle Aged , Prospective Studies , Treatment FailureABSTRACT
BACKGROUND AND STUDY AIMS: Patients with Lynch syndrome are at increased risk of developing small-bowel adenocarcinoma, which usually has a bad prognosis and needs to be diagnosed early. Our aim was to evaluate the yield of capsule endoscopy and CT enteroclysis in this situation. PATIENTS AND METHODS: We performed a prospective, blinded, comparative study of capsule endoscopy and CT enteroclysis in five academic centers. Thirty-five consecutive asymptomatic patients with Lynch syndrome, all with one proven deleterious mutation, were included. A double reading was performed blind for both types of examination. RESULTS: Histologically confirmed small-bowel neoplasms were diagnosed in three patients (8.6â%): one adenocarcinoma (T3N0M0) and two adenomas with low-grade dysplasia. Capsule endoscopy identified all neoplasms. CT enteroclysis raised suspicion of one neoplasm (adenocarcinoma) but missed the two others. Concordance between the two capsule readings was high with a κ value of 0.78 (95â%CI 0.55 to 1.0), which was not the case for CT enteroclysis, where the κ value was 0.15 (95â%CI -0.27 to 0.58). CONCLUSION: Curable early or advanced neoplasms in asymptomatic patients with Lynch syndrome using capsule endoscopy can be detected with a better reproducibility than with CT enteroclysis. The clinical usefulness of systematic small-bowel screening in these patients should be confirmed through large prospective studies.
Subject(s)
Adenocarcinoma/diagnosis , Adenoma/diagnosis , Capsule Endoscopy , Colorectal Neoplasms, Hereditary Nonpolyposis/complications , Intestinal Neoplasms/diagnosis , Intestine, Small , Adenocarcinoma/diagnostic imaging , Adenoma/diagnostic imaging , Adult , Aged , Contrast Media/administration & dosage , Female , Humans , Intestinal Neoplasms/diagnostic imaging , Intestinal Neoplasms/etiology , Intestine, Small/diagnostic imaging , Male , Middle Aged , Prospective Studies , Reproducibility of Results , Single-Blind Method , Tomography, X-Ray ComputedABSTRACT
BACKGROUND AND STUDY AIM: A video capsule similar to that used in small-bowel capsule endoscopy is now available for esophageal exploration. The aim of our study was to compare the accuracy of upper endoscopy (esophageal gastroduodenoscopy [EGE]) with esophageal capsule endoscopy (ECE) in patients at risk of esophageal squamous cell cancer (SCC). PATIENTS AND METHODS: 68 patients at risk of SCC secondary to a history of head and neck neoplasia were included in this comparison of techniques for detecting SCC and dysplasia. ECE was done using the first generation Pillcam ESO and EGE was performed in accordance with the usual practice of each center, followed by examination with 2 % Lugol staining and biopsy of unstained areas (39 neoplasia comprising 5 low grade dysplasia, 8 high grade dysplasia and 26 SCC). RESULTS: Compared with EGE with and without Lugol staining, the sensitivities of ECE for neoplasia diagnosis were 46 % and 54 %, respectively. On a per-patient basis, the sensitivity, specificity, and positive and negative predictive value of ECE were 63 %, 86 %, 77 % and 76 %, respectively, compared with EGE without staining, and 61 %, 86 %, 77 % and 73 % compared with EGE with iodine staining. Neither the ECE transit time nor the distance between the esopharyngeal line and the neoplastic lesion differed between the 21 false-negative and 18 true-positive cases diagnosed by ECE; the only difference was a smaller median diameter among false negatives ( P < 0.001). CONCLUSION: In a cohort at high risk for esophageal SCC, ECE is not sensitive enough to diagnose neoplastic lesions.
Subject(s)
Capsule Endoscopy/methods , Carcinoma, Squamous Cell/diagnosis , Endoscopy, Gastrointestinal/methods , Esophageal Neoplasms/diagnosis , Adult , Aged , Diagnosis, Differential , Female , Follow-Up Studies , Humans , Male , Middle Aged , Reproducibility of Results , Sensitivity and SpecificityABSTRACT
OBJECTIVES: Esophagogastroduodenoscopy (EGD) is the standard method for the diagnosis of esophago-gastric varices. The aim of this prospective multicenter study was to evaluate the PillCam esophageal capsule endoscopy (ECE) for this indication. METHODS: Patients presenting with cirrhotic or noncirrhotic portal hypertension underwent ECEfollowed by EGD at the time of diagnosis. Capsule recordings were blindly read by two endoscopists. RESULTS: A total of 120 patients (72 males, mean age: 58 years; mean Child-Pugh score: 7.2) were included. Esophageal varices were detected in 74 patients. No adverse event was observed after either EGD or ECE. Seven (6%) patients were unable to swallow the capsule. The mean recording time was 204 s (range 1-876). Sensitivity, specificity, negative predictive value, and positive predictive value of ECE for the detection of esophageal varices were 77%, 86%, 69%, and 90%, respectively. Sensitivity, specificity, negative and positive predictive values of ECE for the indication of primary prophylaxis (esophageal varices > or = grade 2 and/or red signs) were 77, 88, 90, and 75%, respectively, and 85% of the patients were adequately classified for the indication (or not) of prophylaxis. Interobserver concordance for ECE readings was 79.4% for the diagnosis of varices, 66.4% for the grading of varices, and 89.7% for the indication of prophylaxis. CONCLUSIONS: This large multicenter study confirms the safety and acceptable accuracy of ECE for the evaluation of esophageal varices. ECE might be proposed as an alternative to EGD for the screening of portal hypertension, especially in patients unable or unwilling to undergo EGD.
Subject(s)
Capsule Endoscopy/methods , Endoscopy, Digestive System/methods , Esophageal and Gastric Varices/diagnosis , Hypertension, Portal/diagnosis , Adult , Aged , Esophageal and Gastric Varices/etiology , Feasibility Studies , Female , Humans , Hypertension, Portal/complications , Male , Middle Aged , Observer Variation , Patient Satisfaction , Probability , Prospective Studies , Risk Assessment , Safety , Sensitivity and Specificity , Severity of Illness Index , Single-Blind MethodABSTRACT
Evaluation of tumour size modifications in response to treatment is a critical issue in the management of advanced malignancies. In 1981, the World Health Organization (WHO) established guidelines for tumour response assessment. These WHO1981 criteria were recently simplified in a revised version, named RECIST (Response Evaluation Criteria in Solid Tumours), which uses unidimensional instead of bidimensional measurements, a reduced number of measured lesions, withdrawal of the progression criteria based on isolated increase of a single lesion, and different shrinkage threshold for definitions of tumour response and progression. In order to validate these new guidelines, we have compared results obtained with both classifications in a prospective series of 91 patients receiving chemotherapy for metastatic colorectal cancer. Data from iterative tomographic measurements were fully recorded and reviewed by an expert panel. The overall response and progression rates according to the WHO1981 criteria were 19% and 58%, respectively. Using RECIST criteria, 16 patients were reclassified in a more favourable subgroup, the overall response rate being 28% and the progression rate 45% (non-weighted kappa concordance test 0.72). When isolated increase of a single measurable lesion is not taken into account for progression with the WHO1981 criteria, only 7 patients were reclassified and the kappa test was satisfying, i.e. > or =0.75, for the whole population as well as for each of the responding and progressive subgroups. Since it provides concordant results with a simplified method, the use of RECIST criteria is recommended for evaluation of treatment efficacy in clinical trials and routine practice.
Subject(s)
Adenocarcinoma/drug therapy , Adenocarcinoma/secondary , Antineoplastic Agents/therapeutic use , Colorectal Neoplasms/pathology , Practice Guidelines as Topic , Adenocarcinoma/pathology , Aged , Disease Progression , Female , Health Status Indicators , Humans , Male , Middle Aged , Prospective Studies , Survival Rate , Treatment OutcomeABSTRACT
AIMS: Computed tomography (CT) is the reference technique for evaluating response to chemotherapy. The potential helpfulness of tumour markers is debated. MATERIALS AND METHODS: From March 1997 to January 1999, 91 consecutive patients receiving chemotherapy for metastatic colorectal carcinoma underwent whole-body spiral CT, estimates of anti-carcinoembryonic antigen (CEA) and CA19-9 every 8 weeks. RESULTS: CEA and CA19-9 levels were above normal in 78 (85.7%) and 61 (67.5%) patients, respectively. Tumour response evaluation according to the RECIST criteria was obtained at 8-week evaluation in 83 (91%) patients. The positive predictive values (PPV) for response of a decrease of the marker levels were 53.8 for CEA and 41.7 for CA19-9 using a 30% decrease threshold, and 60/52.2, respectively, using a 50% decrease threshold. Meaningful PPV values (> 90%) for progression of an increase of the marker levels were only obtained using the 200% increase threshold for CEA alone or a combination of CEA and CA 19-9. A 100% CEA increase between baseline and the 8-week evaluation was correlated to overall survival (P = 0.0023). The need for a radiological confirmation of tumour progression could be avoided by the systematic dosage of tumour markers at baseline and after 8 weeks of treatment only in a sub-population of 13% of the patients with a 200% increase of CEA or CA 19-9 at 8 weeks. CONCLUSIONS: CEA, CA 19-9, or both should be used with caution for tumour response evaluation to chemotherapy in addition to CT in metastatic colorectal carcinoma.
Subject(s)
Antineoplastic Combined Chemotherapy Protocols/therapeutic use , Biomarkers, Tumor/analysis , CA-19-9 Antigen/analysis , Carcinoembryonic Antigen/analysis , Colorectal Neoplasms/drug therapy , Colorectal Neoplasms/pathology , Aged , Disease Progression , Female , Humans , Male , Middle Aged , Predictive Value of Tests , Sensitivity and Specificity , Survival Analysis , Tomography, Spiral Computed , Treatment OutcomeABSTRACT
A 39 years old homosexual male suffering from chronic type B hepatitis superinfected by HDV, and positive for anti-HIV1 was treated with zidovudine associated with high doses of recombinant interferon alpha for onset of an extensive cutaneous Kaposi sarcoma. Other than the long-lasting disappearance of Kaposi's lesions, this therapy was followed by complete recovery from hepatitis B and D. Serological and hepatic clearance of both viruses was marked by two successive cytolytic peaks separated by a 9 month interval. The patient's immunologic status has remained stable at 30 months. To our knowledge, such a success had never been reported in the literature and the clearance of both hepatitis B and D viruses in an AIDS patient stands in sharp contrast with the usual rapidly progressive evolution of those triple coinfections. This phenomenon illustrates the potential benefits of zidovudine in association with high dose of interferon alpha in HIV patients suffering from hepatitis D.
Subject(s)
Acquired Immunodeficiency Syndrome/complications , Hepatitis B/therapy , Hepatitis D/therapy , Interferon Type I/therapeutic use , Zidovudine/therapeutic use , Adult , Drug Therapy, Combination , Hepatitis B/complications , Hepatitis D/complications , Humans , Interferon Type I/administration & dosage , Male , Opportunistic Infections/complications , Opportunistic Infections/therapy , Recombinant Proteins , Sarcoma, Kaposi/etiology , Sarcoma, Kaposi/therapy , Skin Neoplasms/etiology , Skin Neoplasms/therapy , Zidovudine/administration & dosageABSTRACT
The progress recently made in liver transplantation requires an estimation of the potential number of cases per year in France. The study of French Death Rate per age group, compared with either formal, discutable or aleatory indications of transplantation, is a valuable basis for that calculation. It confirms the relative scarcity of the potential number of liver transplantations, which can be estimated at between 2 or 3 per year and per million inhabitants.
Subject(s)
Liver Diseases/surgery , Liver Transplantation , Adult , Child , Evaluation Studies as Topic , France , Humans , Liver Diseases/mortality , Statistics as TopicABSTRACT
OBJECTIVES: The aim of this study was to assess the morbidity and efficacy of endoscopic variceal ligation for the prophylaxis of rebleeding from oesophageal varices. METHODS: Forty-five patients with cirrhosis (Child's class: A: 18, B: 16, C: 11) and recent (< 48 h) variceal bleeding were included. Eleven of the patients were included after failure of sclerotherapy. All patients were treated by endoscopic ligation until the complete eradication of oesophageal varices. The mean follow-up was 8.7 +/- 6.8 months. RESULTS: Oesophageal varices were eradicated in 40 patients (89%) after an average of 2 sessions (range: 1-5). In a subset of 11 patients treated after failure of sclerotherapy, 8 (73%) had complete eradication of oesophageal varices. Six of the 45 patients (13%) had recurrence of haemorrhage, due to post-ligation ulcerations in 5 cases and to rupture of oesophageal varices in one case. The rate of complications was 7%. Of the 40 patients whose oesophageal varices were eradicated, 7 (17%) were lost for follow up, and another treatment was performed in 4 (10%): liver transplantation in 2, and transjugular intrahepatic portosystemic shunt in 2. Recurrence of oesophageal varices after eradication was observed in 3 (10%) of the remaining 29 patients after a follow-up of 8.9 +/- 12.9 months. Of these 3 patients, only one (3%) presented with recurrence of haemorrhage due to ruptured oesophageal varices. Three patients (7%) died before eradication of oesophageal varices from causes unrelated to the technique. CONCLUSION: This study confirms that endoscopic ligation is effective for eradication of oesophageal varices, with a low morbidity. This technique appears to be a method of choice in the prophylaxis of rebleeding from oesophageal varices, especially when sclerotherapy is ineffective.
Subject(s)
Endoscopy/methods , Esophageal and Gastric Varices/complications , Gastrointestinal Hemorrhage/prevention & control , Liver Cirrhosis, Alcoholic/complications , Liver Cirrhosis/complications , Adult , Aged , Aged, 80 and over , Female , Follow-Up Studies , Gastrointestinal Hemorrhage/etiology , Gastrointestinal Hemorrhage/mortality , Humans , Ligation , Liver Cirrhosis/virology , Male , Middle Aged , Postoperative Complications , Prospective Studies , Recurrence , Rupture, Spontaneous/complicationsABSTRACT
AIM AND METHODS: The aim of this prospective, randomized, study performed in 60 outpatients was to compare 2 precolonoscopy bowel preparations: oral sodium phosphate (NaP) versus standard polyethylene glycol-based lavage solution (PEG). None of the patients met any of NaP exclusion criteria. All patients were prepared on the day prior to colonoscopy. A patient-questionnaire and measure of serum electrolytes (calcium, phosphate, sodium, potassium), pulse and blood pressure were used to assess tolerance and acceptability of the preparation. The quality of colon cleansing was judged by blinded endoscopists. RESULTS: Patient's tolerance to NaP was superior to PEG: NaP preparation was easier to drink and feelings of abdominal plenitude occurred in a smaller proportion of patients. A potassium decrease, a sodium increase and hyperphosphatemia were observed in the NaP group but without clinical events. PEG preparation seemed to allow a better cleansing ability compared with NaP but this difference was not statistically significant. CONCLUSIONS: NaP solution was better tolerated and accepted by patients. Colonic preparation quality compared to PEG is still to be discussed depending on the intake schedule. A biochemical data check seems necessary on account of significant serum electrolytes changes induced by NaP preparation.
Subject(s)
Colonoscopy , Phosphates , Polyethylene Glycols , Preoperative Care , Adult , Aged , Female , Humans , Male , Middle Aged , Phosphates/adverse effects , Polyethylene Glycols/adverse effects , Prospective Studies , SolutionsABSTRACT
OBJECTIVE: The aim of this study was to assess the feasibility and efficacy of transjugular intrahepatic portosystemic shunts for refractory variceal bleeding, uncontrolled by sclerotherapy or endoscopic ligation. METHODS: 11 patients (mean age: 52 years) with cirrhosis admitted for refractory haemorrhage from ruptured oesophageal varices were included in this study. Eight patients were Child-Pugh class C. All patients were actively bleeding. RESULTS: All the procedures were successful. Variceal haemorrhage stopped within 24 h. There was no mortality during the procedure. Early complications such as rebleeding (18%) and thrombosis (18%) occurred. Thirty days mortality was 27%. Follow-up in the 8 surviving patients was 19.5 +/- 8 months. Three patients developed recurrent bleeding, from non-variceal sources in 2. In 4 surviving patients, occlusion of the shunt was treated with dilatation or insertion of a second stent. The incidence of hepatic encephalopathy was 25%. Five patients subsequently underwent liver transplantation. Among the 3 patients ineligible for transplantation, one died of hepatocellular carcinoma after 10 months. The 2 others were alive after 19 and 25 months, respectively. CONCLUSIONS: These results suggest that transjugular intrahepatic portosystemic shunt is a safe and effective procedure of portal decompression in patients with refractory variceal bleeding. Prospective trials comparing this percutaneous procedure and surgical treatment are required.
Subject(s)
Esophageal and Gastric Varices/complications , Gastrointestinal Hemorrhage/surgery , Liver Cirrhosis, Alcoholic/complications , Portasystemic Shunt, Surgical/methods , Adult , Aged , Female , Follow-Up Studies , Gastrointestinal Hemorrhage/diagnostic imaging , Gastrointestinal Hemorrhage/etiology , Gastrointestinal Hemorrhage/mortality , Humans , Male , Middle Aged , Portography , Postoperative Complications , Recurrence , Rupture, SpontaneousABSTRACT
One case of small bowel's intussuception has been found in one patient with abdominal pains. Since 13 years this patient has a Peutz-Jeghers syndrome. A resection of the small bowel has been performed followed by total intraoperative enteroscopy. Besides small bowel, Peutz-Jeghers syndrome can affect many organs with an increased risk for cancer for patients affected by this genetic disease.
Subject(s)
Intussusception/etiology , Jejunal Diseases/etiology , Peutz-Jeghers Syndrome/complications , Humans , Intussusception/diagnostic imaging , Intussusception/surgery , Jejunal Diseases/diagnostic imaging , Jejunal Diseases/surgery , Male , Middle Aged , Peutz-Jeghers Syndrome/diagnostic imaging , Peutz-Jeghers Syndrome/surgery , Risk Factors , Tomography, X-Ray ComputedABSTRACT
Several clinical situations may justify surgery for hiatal hernia. The approach varies depending on whether the problem is a mechanical complication or a gastro-oesophageal reflux responsible for oesophagitis, peptic stenosis, chest pain, respiratory disorders or Barrett's oesophagus. Recurrence of reflux after surgery raises even more complex problems. Evaluation by modern exploratory techniques helps in establishing precise indications for the operation which must, be reserved to selected cases.
Subject(s)
Hernia, Diaphragmatic/surgery , Hernia, Hiatal/surgery , Esophageal Neoplasms/etiology , Esophagitis, Peptic/etiology , Gastroesophageal Reflux/etiology , Gastrointestinal Hemorrhage/etiology , Heart Diseases/etiology , Hernia, Hiatal/complications , Humans , Otorhinolaryngologic Diseases/etiology , Postoperative Complications , Recurrence , Respiration Disorders/etiology , Stomach Volvulus/etiologyABSTRACT
BACKGROUND: Abdominal tuberculosis is rarely encountered in developed countries, representing less than 1% of all forms of tuberculosis. There has however been a revival over the last few years. CASE REPORTS: The initial diagnoses suspected in two young multiparous patients who had immigrated to France were malignant lymphoma and ovarian carcinoma. After the final diagnosis of abdominal tuberculosis was made, the clinical course rapidly improved. DISCUSSION: Any abdominal organ may be involved in this localization of tuberculosis, but symptoms are not specific and diagnosis can often be missed. Tumor-forming abdominal mass is an exceptional finding and often mimics malignancy. Clinicians should be aware of this localization, particularly in light of epidemiological features, and examine all modern diagnostic procedures.
Subject(s)
Abdomen , Abdominal Neoplasms/diagnosis , Tuberculosis/diagnosis , Adult , Diagnosis, Differential , Female , HumansABSTRACT
Intra operative radiation therapy is a new look at an old idea (Rich). In relation with the first experience at the Croix-Rousse Hospital with orthovoltage, a review of technical choices, surgical problems, and biological questions is presented. The analysis of literature about accumulated clinical results suggest that local control in recurrence, residual, or inoperable tumor can be obtained by combined surgery IOR, and external beam irradiation. This short experience demonstrate the feasibility of the treatment as a routine and emphasizes the need for continued study.
Subject(s)
Gastrointestinal Neoplasms/radiotherapy , Intraoperative Care , Radiotherapy, High-Energy , Adult , Aged , Combined Modality Therapy , Female , Gastrointestinal Neoplasms/surgery , Humans , Male , Middle Aged , Particle Accelerators , Radiotherapy Dosage , Radiotherapy, High-Energy/instrumentationSubject(s)
Aneurysm, False/complications , Bile Ducts, Intrahepatic/diagnostic imaging , Hemobilia/etiology , Hepatic Artery , Thromboangiitis Obliterans/complications , Aneurysm, False/diagnostic imaging , Aneurysm, False/therapy , Embolization, Therapeutic , Humans , Male , Middle Aged , Tomography, X-Ray ComputedABSTRACT
BACKGROUND AND STUDY AIMS: The long-term outcome for patients with obscure bleeding after capsule endoscopy (CE) is still unclear. In this study, the clinical outcome was used as the gold standard to determine the sensitivity and specificity of CE and push enteroscopy (PE) in the diagnosis of small-bowel lesions in patients with obscure bleeding. PATIENTS AND METHODS: Fifty-eight patients from a previous prospective study (comparing PE and CE) were included; the patients were contacted after 1 year. The final diagnosis, bleeding status, new gastrointestinal examinations, and treatments performed were recorded. On the basis of these data, each case was classified into true/false positive or true/false negative findings at PE and CE. The results were compared with the initial classification of lesions observed at CE: highly relevant (P2) and less relevant (P0, P1) lesions. RESULTS: Follow-up data were available for 56 patients. According to the defined true/false positive and negative cases, the sensitivity and specificity values for CE and PE were 92 % and 48 %, and 80 % and 69 %, respectively ( P < 0.01 for the difference between CE and PE). Highly relevant (P2) lesions observed at CE were more frequently classified into true-positive cases (15 of 18 versus seven of 22; P < 0.01) and led more frequently to therapeutic decisions (11 of 18 versus five of 22; P = 0.02) in comparison with less relevant lesions (P0, P1). CONCLUSIONS: CE is a highly sensitive examination for the detection of small-bowel lesions in patients with obscure gastrointestinal bleeding, with a specificity lower than that of PE when the clinical outcome is used as the gold standard.