[Achalasia: which treatment to choose in 2015?]. / Achalasie: queulle thérapie choisir en 2015 ?

Achalasia is a rare disorder, whose diagnostic Gold standard is high-resolution cesophageal manometry. The proposed treatment must take into account the patient's health condition and the type of achalasia determined by HRM. Heller's laparoscopic myotomy and pneumatic dilation are the first line treatments for most of the patients, whereas Botulinum toxin injections and pharmacologic therapy are only indicated for patients with a high surgical risk who cannot undergo first line treatments. Peroral endoscopic myotomy (POEM) is a recent and promising endoscopic technique reserved for expert endoscopy centers, whose exact role is still to be determined by randomized prospective studies. Oesophagectomy has only a marginal role in rare patients with extremely advanced achalasia or at risk of neoplastic degeneration.

[Self-expanding metallic stent in malignant colonic obstruction]. / Place de la prothèse métallique colique dans l'obstruction tumorale.

About 20% of colorectal cancers are complicated by intestinal obstruction. Self-expanding metallic stents (SEMS) permit desobstruction in over 90% of cases. In palliative setting, employing SEMS reduces hospitalisation time and permanent stoma rate with identical mortality rates compared to surgery. When using SEMS as bridge to surgery, higher primary and lower overall stoma rates are obtained with no significant mortality reduction by now. Of concern, procedure-related bowel perforation is frequent, especially among endoscopists lacking sufficient experience in colonic stenting.

[The role of probiotics in the treatment of inflammatory bowel diseases]. / Place des probiotiques dans le traitement des maladies inflammatoires intestinales.

The intestinal mucosa is the site of a fundamental interaction between a large amount of foreign substances, the immune system and bacteria that colonizes the mucosa. Many gastrointestinal diseases are due to an altered interaction between all these actors, particularly inflammatory bowel diseases. As such probiotics (bacteria providing a benefit to the host) could provide an interesting solution as a therapeutic agent. The evidences supporting such use are limited but there are still some quality randomized controlled trials. The purpose of this review is to discuss the most recent evidences from the literature on the use of probiotics in the treatment of inflammatory bowel diseases.

[Can antiplatelet therapy be continued in upper gastrointestinal bleeding?]. / Peut-on poursuivre un traitement antiagrégant en cas d'hémorragie digestive haute?

During a gastro-intestinal bleeding, treatment options regarding antiplatelet agents depend on the indication. In primary prevention, treatment can reasonably be stopped regarding the low expected benefit. In secondary prevention, experts recommend resuming treatment after a five-day interruption. In patients with a coronary stent, the decision is made on a case by case basis and requires close multidisciplinary collaboration between internists, cardiologists and gastroenterologists.

Underlying disease for percutaneous endoscopic gastrostomy tube placement predicts short- and long-term mortality.

Background: PEG (percutaneous endoscopic gastrostomy) is a well established endoscopic procedure for enteral feeding. However, patients with a shorter life expectancy will not benefit from PEG tube placement. Furthermore, some specific evolving diseases will never benefit from PEG. The aim of the study focuses on short and long term mortality rates after PEG tube placement in a referral gastroenterology centre (Geneva University Hospital). 219 patients were enrolled in this study. Patients and methods: All patients scheduled for a PEG procedure between January 2011 and December 2014 were included. Nine patient parameters were collected for further analysis as well as the main underlying disease requiring PEG tube placement. Patients were subsequently divided into 4 groups according to underlying disease: Group 1) swallowing disorders of neurologic origin; Group 2) swallowing disorders associated with upper digestive tract neoplasia ; Group 3) nutritional support for a non GI reason ; Group 4) Other. Results: 219 patients had undergone a PEG tube placement. 33 patients died within 60 days after the procedure. After one year, 71 patients died. Global survival was 870 days. The nutritional support group had the better survival rate with 1276 days compared to the swallowing groups and others. The multivariate analysis has highlighted the underlying disease as the only associated parameter with short and long term mortality. Conclusions: PEG tube placement is associated with high short and long term mortality depending on the underlying disease. We outlined the potential role of PEG tube insertion as a supportive transient approach for nutritional support.

Indications, results, and clinical impact of endoscopic ultrasound (EUS)-guided sampling in gastroenterology: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline.

This article is part of a combined publication that expresses the current view of the European Society of Gastrointestinal Endoscopy (ESGE) about endoscopic ultrasound (EUS)-guided sampling in gastroenterology, including EUS-guided fine needle aspiration (EUS-FNA) and EUS-guided trucut biopsy (EUS-TCB), of submucosal tumors, diffuse esophageal/gastric wall thickening, pancreatic solid masses and cystic-appearing lesions, mediastinal lesions unrelated to lung or esophageal cancer, cancer of the esophagus, stomach, and rectum, lymph nodes of unknown origin, adrenal gland masses, and focal liver lesions. False-positive cytopathological results and needle tract seeding are also discussed. The present Clinical Guideline describes the results of EUS-guided sampling in the different clinical settings, considers the role of this technique in patient management, and makes recommendations on circumstances that warrant its use. A two-page executive summary of evidence statements and recommendations is provided. A separate Technical Guideline describes the general technique of EUS-guided sampling, particular techniques to maximize the diagnostic yield depending on the nature of the target lesion, and sample processing. The target readership for the Clinical Guideline mostly includes gastroenterologists, oncologists, internists, and surgeons while the Technical Guideline should be most useful to endoscopists who perform EUS-guided sampling.

[Role of endoscopy in the management of obscure gastrointestinal bleeding]. / Rôle de l'endoscopie dans la prise en charge des saignements digestifs d'origine obscure.

Obscure gastrointestinal bleeding is defined as a blood loss in the digestive tract without etiology found at upper digestive endoscopy and colonoscopy. Small bowel lesions, in particular angiodysplasias, are the most frequent cause. Endoscopic examination of the small bowel can be performed using an enteroscope (with or without balloon) or a videocapsule. Videocapsule endoscopy is a minimally invasive procedure, and it allows complete small bowel exploration in 80% of cases (vs. 40-80% with balloon-aided enteroscopy). In practice, videocapsule endoscopy is the first line exam, followed by enteroscopy for biopsy sampling or treatment. In case of completely negative investigations and persistent bleeding, videocapsule endoscopy may be repeated, generally after repeat upper digestive endoscopy and colonoscopy.

[Endoscopic management of benign biliary strictures]. / Prise en charge endoscopique des sténoses billaires bénignes.

Endoscopic management of benign biliary strictures has significantly changed in recent years. Excluding a malignant etiology remains the first, critical, step; significant progress is being made to increase diagnostic accuracy of bile duct stricture sampling, although negative predictive value does not reach 100%. The currently preferred treatment consists of stricture dilation followed by placement of multiple temporary plastic stents. Drawbacks of this technique include repetition of endoscopic procedures and a small risk of cholangitis. Larger diameter covered self-expandable metal biliary stents seem to be a promising alternative. In this review, we will discuss the various etiologies of benign biliary strictures, their clinical presentation, the diagnostic tools and the endoscopic treatment.

[Interventional endoscopic ultrasound: an evolving technique]. / Echoendoscopie interventionnelle: une technique en pleine évolution.

The availability of smaller instruments with larger working channels and higher imaging resolution has led to important development of endoscopic ultrasound (EUS) techniques these past years. From a purely diagnostic instrument, EUS guided fine needle aspiration has become a well recognized technique to acquire tissue in the mediastinum and the upper abdomen, more and more complex therapeutic procedures are now performed. It is now possible to precisely inject therapeutic agents under EUS guidance, drain intraabdominal collections and drain previously inaccessible obstructed pancreatic and bile ducts. The currently accepted indications of interventional endosonography and the technique currently under evaluation will be discussed.

[Surgical strategy for early stage carcinoma of the esophagus]. / Chirurgische Strategie bei Frühkarzinomen des Ösophagus.

Early stage carcinomas of the esophagus are histologically differentiated into adenocarcinomas and squamous cell carcinomas and subdivided into mucosal (m1-3) and submucosal (sm1-3) carcinomas depending on the infiltration depth. While the prevalence of lymph node metastases in mucosal carcinomas is very low, the probability of lymph node metastases increases from submucosal infiltration with increasing depth. According to the current German S3 guidelines endoscopic resection is the recommended treatment strategy for mucosal adenocarcinoma without histological risk factors (lymphatic invasion [L1], venous invasion [V1], poorly differentiated [>G2], microscopic residual disease [R1] at the deep resection margin). For superficial submucosal infiltration (sm1) without histological risk factors endoscopic resection can also be carried out, whereby in this case the guidelines make a stronger recommendation for esophagectomy. For squamous cell carcinoma endoscopic resection is indicated for an infiltration depth up to middle layer mucosal carcinoma (m2) without histological risk factors. Outside of these criteria an esophageal resection should always be carried out. The surgical gold standard is a subtotal abdominothoracic esophagectomy with two-field lymphadenectomy. Alternative procedures are total esophagectomy in proximal esophageal carcinoma and transhiatal extended gastrectomy for carcinoma of the cardia. Limited proximal or distal esophageal resections can be performed in proximal or distal mucosal carcinoma without the possibility of endoscopic resection; however, partial resections are not superior in terms of functional results and are not oncologically equivalent due to limited lymphadenectomy. Minimally invasive procedures show good oncological results and reduce the morbidity of radical esophagectomy. Reduced morbidity might be an argument for surgical resection in borderline cases between endoscopic and surgical resection.

Targeted disruption of the beta-chemokine receptor CCR1 protects against pancreatitis-associated lung injury.

beta-Chemokines and their receptors mediate the trafficking and activation of a variety of leukocytes including the lymphocyte and macrophage. An array of no less than eight beta-chemokine receptors has been identified, four of which are capable of recognizing the chemokines MIP1alpha and RANTES. Genetic deletion of one of the MIP1alpha and RANTES receptors, CCR5, is associated with protection from infection with HIV-1 in humans, while deletion of the ligand MIP1alpha protects against Coxsackie virus-associated myocarditis. In this report we show that the deletion of another receptor for MIP1alpha and RANTES, the CCR1 receptor, is associated with protection from pulmonary inflammation secondary to acute pancreatitis in the mouse. The protection from lung injury is associated with decreased levels of TNF-alpha in a temporal sequence indicating that the activation of the CCR1 receptor is an early event in the systemic inflammatory response syndrome.

Vascular invasion in pancreatic cancer: evaluation of endoscopic ultrasonography, computed tomography, ultrasonography, and angiography.

PRINCIPLES: Current methods for detecting vascular invasion in pancreatic cancer can be inaccurate, invasive, and expensive. The aim of this study is to assess the value of current imaging modalities in determining vascular invasion by pancreatic cancer. METHODS: The results of Endoscopic Ultrasonography (EUS), Computed Tomography (CT), Ultrasonography (US), and Angiography performed in 170 patients, suffering from pancreatic cancer, were retrospectively studied and correlated with intra-operative findings and surgical anatomopathological diagnosis after resection. We assessed sensitivity, specificity, positive and negative predictive values, and accuracy for detecting vascular invasion. RESULTS: EUS turned out to be the most reliable imaging technique for detecting vascular invasion in pancreatic cancer, with a sensitivity of 55%, specificity of 90%, positive predictive value of 61.1%, negative predictive value of 87.5%, and accuracy of 82.2%. CT results were 39.4%, 90%, 52%, 84.4%, and 79.1% for the respective categories, with however, better results with multislice CT. The US results were 3.7% for the sensitivity, 96.3% for the specificity, 25% for the positive predictive value, 75.2% for the negative predictive value, and 73.4% for the accuracy. For angiography, the sensitivity, the specificity, the positive predictive value, the negative predictive value, and the accuracy were 52.6%, 72.3%, 43.5%, 79.1%, and 66.7% respectively. CONCLUSION: In this study, EUS was the most valuable imaging modality in assessing vascular invasion (especially for venous invasion) for pancreatic cancer, with an accuracy of more than 80%. A further prospective study should be carried out to evaluate the combination of imaging modalities for the detection of vascular involvement, especially with multi-slice CT which almost reached the performances obtained by EUS.

[Surgical treatment of duodenal stenosis in Crohn's disease]. / Maladie de Crohn révélée par une sténose duodénale. Stratégie chirurgicale.

Crohn's disease may involve any part of the alimentary tract, including the stomach and duodenum. We report herein the case of a 22 year-old male in whom Crohn disease was diagnosed due to weight loss in relation with a stenosis of the first and second parts of the duodenum. A gastrojejunostomy was performed with a good subsequent result. The initial management of a Crohn's disease with involvement of the duodenum is medical. When there is an indication for surgery, a gastroenterostomy is preferred, albeit with a high incidence of outlet obstruction and marginal ulceration.

[Barrett's esophagus: epidemiology diagnosis and treatment in 2005]. / CEsophage de Barrett: épidémiologie, diagnostic et thérapeutique en 2005.

Barrett's oesophagus is a complication of gastro-oesophageal reflux disease and should be considered as a major risk factor for the development of adenocarcinoma of the oesophagus. Each and every patient with Barrett's oesophagus should be enrolled in a endoscopic surveillance program. During the last years, the endoscopic treatment of high grade dysplasia or intramucosal adenocarcinoma (by mucosectomy) has been reported to be successful in relatively large series of patients. This therapeutic option is particularly useful for patients with a high operative risk. It can be applied for lesions detected at an early stage only (i.e., usually detected in the setting of a surveillance program). Therefore, non-operability is not considered as an exclusion criteria of such programs anymore.

Usefulness of endoscopic ultrasonography in patients with "idiopathic" acute pancreatitis.

PURPOSE: No underlying cause is found in as many as 30% of patients with acute pancreatitis. The aim of this study was to evaluate the usefulness of endoscopic ultrasonography in the diagnosis of biliary tract pathology or chronic pancreatitis in these patients. SUBJECTS AND METHODS: We evaluated 168 patients who were referred with idiopathic pancreatitis. Diagnoses obtained by endoscopic ultrasonography were prospectively compared with those obtained at surgery in 101 patients, by endoscopic cholangiopancreatography in 49 patients, or by bile crystal analysis and medical follow-up in 18 patients. RESULTS: Endoscopic ultrasonography was abnormal in 135 (80%) patients, 124 of whom had biliary tract disease. When the results of endoscopic ultrasonography were compared with those made after multidisciplinary investigations, endoscopic ultrasonography correctly identified the cause-most commonly biliary tract disease-of the "idiopathic" pancreatitis in 155 (92%) of the 168 patients. CONCLUSIONS: Endoscopic ultrasonography is valuable in determining the cause of acute pancreatitis in patients initially considered to have idiopathic pancreatitis.

Biliary migration of hepatocellular carcinoma fragment after transcatheter arterial chemoembolization therapy.

Occasional side-effects of transcatheter arterial chemoembolization therapy in hepatocellular carcinoma are essentially related to tissue necrosis. We report the case of a patient with hepatocellular carcinoma who experienced an acute common bile duct obstruction a few weeks after such a procedure, in the absence of obvious biliary tract invasion. An endoscopic sphincterotomy relieved the obstruction. At histology, the intra-biliary material was identified as a fragment of hepatocellular carcinoma. We discuss the causes of obstructive jaundice in the setting of hepatocellular carcinoma as well as in the specific situation of transcatheter arterial chemoembolization therapy.

Early prediction in acute pancreatitis: the contribution of amylase and lipase levels in peritoneal fluid.

CONTEXT: Predicting the severity of acute pancreatitis early in the course of the disease is still difficult. OBJECTIVE: The value of amylase and lipase levels in serum and peritoneal fluid might be of value in predicting the course of acute pancreatitis. DESIGN: Prospective study. PATIENTS: One-hundred and sixty-seven patients with acute pancreatitis as confirmed by computed tomography scan within 24 hours of admission were studied. MAIN OUTCOME MEASURES: Each patient was given an enzymatic score which reflected the predominance of serum or peritoneal levels of amylase and/or lipase. Enzymatic score was 0 if neither enzyme was predominant in the peritoneal fluid, 1 if amylase or lipase alone were predominant and 2 if both enzymes were predominant. The predictive value of the enzymatic score or computed tomography scan for a severe attack was determined. RESULTS: One-hundred and thirty-three attacks were graded as mild (79.6%) and 34 were considered as severe (20.4%). The frequency of severe acute pancreatitis significantly increased as the enzymatic score increased (5.4%, 12.5%, and 31.7% in 0, 1, and 2 enzymatic score patients, respectively; P<0.001). An enzymatic score greater than 0 predicted a severe outcome in 32 of 34 patients (sensitivity 94.1%, specificity 26.3%), whereas an enzymatic score of 2 predicted a severe attack in 26 of 34 patients (sensitivity 76.5%, specificity 57.9%). Edema on computed tomography scan was found in 97 of 129 mild attacks (specificity 75.2%) and necrosis in 25 of 33 severe attacks (sensitivity 75.8%), whereas all patients with severe attacks exhibited extrapancreatic acute fluid collection (sensitivity 100%, specificity 34.9%). CONCLUSIONS: Peritoneal dialysis is less predictive and more cumbersome than a computed tomography scan in the early prediction of acute pancreatitis.

Cytologic diagnosis of isolated pancreatic alveolar hydatid disease with immunologic and PCR analyses. A case report.

BACKGROUND: Alveolar hydatid disease (AHD) is a rare and severe parasitic infection caused by the larval stage of the fox tapeworm, Echinococcus multilocularis. AHD mainly involves the liver, and although it may extend progressively to the pancreas, isolated pancreatic localization has not been reported previously. CASE: A 68-year-old white female presented with a multicystic mass in the pancreas. Fine needle aspiration showed some protoscolices, free hooklets and fragments of laminated layer, which are pathognomonic features of echinococcosis. Serologic analyses by an enzyme-linked immunosorbent assay using Em2plus antigen showed high antibody reactivity of the patient's serum, which is indicative of an infection with E multilocularis. Diagnosis was finally confirmed by molecular and immunologic analyses of the cytologic material by polymerase chain reaction and direct immunofluorescence. CONCLUSION: This case illustrates the value of cytology in the identification of echinococcosis, particularly when it involves extrahepatic sites, where the risk of misdiagnosis may be related to its extremely rare occurrence. Precise parasitologic tying of E multilocularis in endemic areas is important.