Intravenous nitroglycerin for prevention of pancreatitis after therapeutic endoscopic retrograde cholangiography: a randomized, double-blind, placebo-controlled multicenter trial.

BACKGROUND AND STUDY AIMS: Several studies have suggested that nitroglycerin promotes pancreatic drainage and thereby helps to prevent pancreatitis occurring after endoscopic retrograde cholangiography (ERC). We performed a multicenter, double-blind, randomized, placebo-controlled trial to evaluate the efficacy of intravenous nitroglycerin for preventing acute pancreatitis in moderate- to high-risk patients undergoing ERC. PATIENTS AND METHODS: The patients underwent therapeutic ERC for gallstone removal, bile duct stenosis, or sphincter of Oddi dysfunction (SOD). They were randomly allocated to receive an intravenous nitroglycerin bolus of 0.1 mg, then 35 microg/kg per minute intravenously (maximum dose 9 mg) for 6 h, or an identical placebo regimen. Serum amylase and lipase levels were determined before and 24 h after ERC. RESULTS: The study was terminated after the interim analysis. The intention-to-treat population consisted of 208 patients enrolled in 20 centers, of whom 105 received nitroglycerin and 103 placebo therapy. Post-ERC pancreatitis (mild/moderate/severe) occurred in 25 patients, comprising 10 (3/5/2) in the nitroglycerin arm and 15 (5/6/4) in the placebo arm (OR 0.62, 95 % CI 0.26 - 1.45; P = 0.26). Pancreatitis-related hospital stays were similar in the two groups (median 4 days, range 2 - 13 days in the nitroglycerin group; median 5 days, range 2 - 20 days in the placebo group). The incidence of pancreatitis in patients with SOD did not differ between the groups (4/11 in the nitroglycerin arm, and 4/15 in the placebo arm). Adverse events were more frequent in the nitroglycerin group and led to cessation of drug infusion in 10 patients in the nitroglycerin arm and in 2 patients in the placebo arm ( P = 0.019). CONCLUSION: In this study, nitroglycerin offered a limited and clinically nonsignificant benefit for the prevention of post-ERC pancreatitis. Its use did not improve the technical success rate of ERC.

Colonic angiodysplasia. Clinical, endoscopic, arteriographic signs and histopathological correlations.

The main clinical, endoscopic and radiographic findings in thirty documented cases of colonic angiodysplasia or vascular ectasia are described. We emphasise the association with colonic diverticulosis and cardiovascular pathology, describe the histological changes, summarize the present physiopathological hypothesis, and consider the various therapeutic approaches.

[Alveolar echinococcosis in the French province of Ardennes: isolated case or new focus?]. / L'échinococcose alvéolaire dans le département français des Ardennes: cas isolés ou nouveau foyer?

The first three autochthonous cases of alveolar echinococcosis were diagnosed in the Ardennes area (France). This is the most occidental localization of this disease in Northern Europe. The authors discuss these cases with an epidemiological regard. They are looking for relationships with natural parasitic cycle in the neighbouring country Belgium and their consequences on local public health in the future.

[Mesenteric cystic lymphangioma in children. Apropos of a case revealed by anemia]. / Les lymphangiomes kystiques mésentériques chez l'enfant. A propos d'un cas révélé par une anémie.

A case of mesenteric cystic lymphangioma revealed by hypochromic anemia and abdominal pain, secondary to an intracystic hemorrhage is reported in a 4-year old child. Etiology, pathology, diagnosis, treatment and prognosis of mesenteric lymphangioma in children are reviewed.

[Cancer at confluence of the superior bile ducts with proliferating form. Nosologic, diagnostic and therapeutic aspects. Apropos of a case]. / Cancer du confluent biliaire supérieur à forme bourgeonnante. Particularités nosologiques, diagnostiques et thérapeutiques. A propos d'un cas.

The authors report a case of fungating cholangiocarcinoma of the porta hepatis, revealed by jaundice in a 73-year- old cholecystectomized female. The diagnosis of obstruction of the hepatic duct junction suspected by ultrasonography and computed tomography was confirmed intraoperatively. Disobstruction was followed by laterolateral choledocoduodenostomy. An early recurrence required a second disobstruction with surgical then endoscopic insertion of a drain, with 23 months of satisfactory survival. The discussion is focused on hilar fungating cholangiocarcinoma. The extrahepatic (Klatskin tumor) or intrahepatic origin of these lesions, the circumstances and morphological investigations for the diagnosis are discussed. Particularities of the treatment are mentioned, with emphasis on the possible participation of the endoscopist for choledocho or hepaticoduodenostomy.

[Hemorrhagic Meckel's diverticulum. The place of abdominal scintigraphy with technetium 99m. Apropos of a case with gastric and pancreatic heterotopia]. / Diverticule de Meckel hémorragique. Place de la scintigraphie abdominale au technetium 99m. A propos d'une observation avec hétérotopie gastrique et pancréatique.

A 12 year old child presented with a hemorrhagic Meckel's diverticulum, gastric heterotopia without identifiable ulceration and a totally aberrant pancreas. The diagnostic value of 99m-technetium abdominal scintigraphy in patients with Meckel's diverticula and gastric heterotopia, as well as the limits of this investigation, are discussed.

[Congenital diverticulum of the lower choledochus. Apropos of a case with intraduodenal development]. / Diverticule congénital du bas-cholédoque. A propos d'un cas à développement intra-duodénal.

The onset of subicterus in a patient revealed the presence of a congenital diverticulum of lower common bile duct of intraduodenal development. A part from the rarity of this lesion this case is of interest due to the complete range of ultrasound, endoscopic and CT scan imaging performed, the association of a common mesentery and the surgical technique employed. The latter comprised exeresis by transduodenal approach and a side-to-side choledocho-duodenal anastomosis through the intermediary of the diverticular sleeve. The nosology and differential diagnosis of diverticulum of lower common bile duct are discussed and data from a literature review used to describe diagnostic, etiopathogenic and histopathologic aspects as well as complications and treatment of this type of congenital dilatation of lower biliary tract.

[Gallstone duodenal obstruction or Bouveret's syndrome. Apropos of two cases]. / Obstruction duodénale lithiasique ou syndrome de Bouveret. A propos de deux observations.

Bouveret's syndrome is a rare form of Gallstone Ileus, characterized by its duodenal site after migration through a cholecysto-duodenal fistula in almost all cases. The two cases reported emphasize the interest of endoscopy in its early diagnosis. A therapeutic schema is proposed, based upon a systematic initial endoscopic extraction trial. The surgical treatment when needed is discussed in its modalities, and adapted to a reasonable evaluation of general and local conditions.

[Study of the annual mortality statistics in a general surgical ward with digestive and vascular orientation at a general hospital center]. / Etude d'une statistique annuelle de mortalité dans un service de chirurgie générale à orientation digestive et vasculaire de centre hospitalier général.

Quality of care has been evaluated in this study by the criterion of mortality in a Digestive and Vascular Surgery unit. The analysis over a one-year period concerned 34 dead patients among 1298 entered and 1,108 operated patients who underwent 1,248 operations. The causes of death have been studied in the 3 groups: non operated (5 patients), digestive (20 patients), vascular (9 patients), with distinction of emergency surgery. Therapeutic habits have been systematically reexamined and considered either adapted or to be modified. Punctual conclusions of such a study are interesting for the medico-surgical team but also for the nursing team. Transparency of mortality for a whole team is a factor of progress by the periodical reappraisal of the therapeutic habits based upon accurate data, and by the better collaboration in the team.

[Cancer of the anus arising within condylomata acuminata. Apropos of 2 cases. Review of the literature]. / Cancer de l'anus développé sur condylome acuminé. A propos de deux cas. Revue de la littérature.

Two cases of squamous carcinoma of the anus developing from condylomata acuminata are reported. The general characteristics of condylomata acuminata are reviewed: viral etiology due to HPV virus, histological appearance and role in the the genesis of certain cancers. The association of condylomata acuminata and cancer of the anus is more particularly studied in a review of the literature: etiology, anatomoclinical aspects, treatment and current state of knowledge concerning the oncogenic role of HPV virus at this site.

[Angiodysplasia of the right colon: a frequent cause of lower digestive tract hemorrhage. Apropos of 13 cases]. / L'angiodysplasie colique droite: une cause fréquente d'hémorragie digestive basse. A propos de 13 cas.

13 observations of right hemorrhagic colic angiodysplasia were detected in less than 5 years: 9 times with proctorrhagia of varying amounts, 4 times with an endoscopic aetiological evaluation of iron deficiency anemia. Colonoscopy revealed lesions in 11 patients out of 13 in the form of erythematous spots of vascular hemorrhagic appearance in 5 cases. The arteriography was positive in 5 of the 7 cases where it was performed. Treatment was endoscopic 6 times, by follow-up electrocoagulation, 2 times, by right hemicolectomy. The latter was carried out immediately in 2 other cases. In 5 cases, iron treatment was all that was necessary. These right colic angiodysplasias are often an unknown cause of digestive hemorrhage or iron deficiency anemia. The difficult diagnosis depends on the colonoscopy performed by an operator accustomed to this type of lesion. It is carried out in emergency in cases of acute bleeding. Sometimes an arteriography is also performed. Endoscopic treatment may be an alternative to standard surgical treatment in elderly high-risk patients.

[A case of acute cardiac insufficiency caused by 5-fluorouracil]. / Un cas d'insuffisance cardiaque aiguë due au 5 fluoro-uracile.

The authors report a case of acute cardiac failure linked to 5 fluoro-uracil. The toxicity seen most commonly involves ischemia. The pathophysiological mechanisms are discussed as well as the role played by pharmacokinetic characteristics in the occurrence of adverse reactions. 5 fluoro-uracil (5 FU) is a compound widely used in the treatment of ENT, breast and gastrointestinal carcinomas. The finding of dose-effect relationship may lead the clinician to use different modes of administration. Continuous administration at high dose 3 g/m2/day from D1 to D5) in combination or not with cisplatin, or continuously at low dose (300 mg/m2/day from D1 to D31) can reduce hematopoietic toxicity but, in contrast, increases gastrointestinal toxicity.