[Barrett's oesophagus: endoscopic diagnosis and follow-up]. / Endobrachyoesophage: diagnostic endoscopique et surveillance.

Barrett's oesophagus (BO), or replacement of the squamous mucosa by a specialized intestinal metaplasia due to gastro-oesophageal reflux disease (GORD), predisposes to adenocarcinoma. It is estimated that 6 to 12% of patients undergoing GI endoscopy have short BO (< 3 cm), and 1% have a long BO. Macroscopic diagnosis of BO is sometimes difficult and, in case of doubt, endoscopy should be redone after a period of efficient anti-secretory treatment. Diagnosis of BO is histological and should be confirmed by biopsies. The incidence of adenocarcinoma is globally estimated at 0.5% patient by year of follow-up, and exists for both short and long BO. Due to this low incidence, screening for BO is only justified in patients at high risk for adenocarcinoma (male gender, age > 50 ans, old GORD in a young patient). Low-grade dysplasia (LGD) then high-grade dysplasia (HGD) precedes adenocarcinoma. Histological diagnosis of LGD is difficult: the main cause of confusion is inflammation so diagnosis of LGD must be confirmed after a 3-month high-dose anti-secretory treatment. Diagnosis of HGD is easier but multiple biopsies are needed to determine the focal or multifocal disposition of HGD. The benefit of follow-up of BO is debated. Aged patients should be followed only if dysplasia is present. When dysplasia is absent, an endoscopic control with biopsies is desirable within 3 to 5 years. In case of dysplasia, the latter must be confirmed by another examination of biopsies, particularly in case of suspicion of HGD and after antisecretory treatment. In case of LGD, endoscopy with biopsies should be redone 6 months later to screen for HGD, then every year if LGD is confirmed. In case of HGD, the 5-year risk of cancer is 60% so surgical or endoscopic treatment is usually proposed. If HGD follow-up is decided, it should be performed on a 3- to 6-month basis.

Intraductal papillary mucinous tumors of the pancreas confined to secondary ducts show less aggressive pathologic features as compared with those involving the main pancreatic duct.

Intraductal papillary mucinous tumors (IPMTs) of the pancreas are rare tumors characterized by a malignant potential. Because of the progress of imaging procedures, smaller cystic pancreatic lesions are now detected and some of them correspond to IPMTs that involve ectatic pancreatic branch ducts but spare the main pancreatic duct. To investigate differences in morphology and clinical behavior of branch and main duct types of IPMT, a surgical series of 43 cases was studied. All pathologic specimens of IPMT, surgically resected in our institution between October 1987 and July 1998, were analyzed. In all cases, the entire pancreatic specimen was systematically examined. IPMT of the branch type was found in 13 (30%) patients, whereas IPMT of main pancreatic duct type that involved the main pancreatic duct and branch ducts was observed in 30 (70%) patients. Patients with IPMT of the branch type were younger (median age, 55 yrs vs 64 yrs), and all but one of the lesions were located in the head and neck of the pancreas (vs 17 of 30 patients with the main duct type). The size of the cysts ranged from 4 to 55 mm, and the major duct showed a mild dilation in most cases. In contrast to the main pancreatic duct type, which showed invasive carcinoma and in situ carcinoma in 11 (37%) of 30 patients and 6 (20%) of 30 patients, respectively, IPMT of the branch type showed significantly less aggressive histologic lesions with five (39%) patients with simple hyperplasia, six (46%) patients with atypical hyperplasia, and two (15%) patients with in situ carcinoma. No invasive carcinoma was observed in this group. IPMT of the branch type occurs in younger patients and is associated with less aggressive histologic features than is the main pancreatic duct type. Our findings raise the difficult issue of clinical management of IPMT of the branch type as a distinctive group.

Intraductal papillary mucinous tumors of the pancreas: pancreatic resections guided by preoperative morphological assessment and intraoperative frozen section examination.

BACKGROUND: We undertook this study to assess the results of a policy of limited pancreatic resections for intraductal papillary-mucinous tumors (IPMT), guided by a standardized preoperative morphological assessment and the frozen section histologic examination of pancreatic resection margins. METHODS: From 1991 to 1998, there were 41 patients who underwent resection of IPMT in our center after standardized morphological preoperative assessment, including abdominal computed tomography scans, endoscopic retrograde cholangiopancreatography, and endoscopic ultrasonography. All patients but one underwent a partial pancreatic resection. RESULTS: Preoperative assessment had an 89% diagnostic accuracy for IPMT. It detected malignant transformation with a 67% sensitivity and a 95% specificity, but failed to correctly assess ductal extension of the disease in 17 cases (41%). The diagnostic accuracy of frozen section histologic examination of the pancreatic resection margin was 92%. There was no recurrence in case of in situ carcinoma when epithelial lesions were completely resected (8 cases) nor in lower grades of dysplasia (23 cases). Conversely, recurrence was constant in invasive carcinoma (10 cases) regardless of the status of the pancreatic margin. CONCLUSIONS: Frozen section histologic examination of the pancreatic resection margin is useful and reliable to ensure a complete resection of IPMT by a partial resection that prevents recurrence of noninvasive lesions.

Are endoscopic procedures able to predict the benignity of ampullary tumors?

BACKGROUND: Malignant ampullary tumors (AT) require pancreatico-duodenectomy (PD) for curative treatment whereas benign AT can be appropriately treated by local resection. This study evaluated the accuracy of endoscopic exploration combining side-viewing duodenoscopy (SVD) with forceps biopsies, endoscopic sphincterotomy (ES), and endoscopic ultrasonography (EUS) to distinguish benign AT from malignant one. PATIENTS AND METHODS: Twenty-six patients with AT had preoperative SVD with forceps biopsies, including 9 with ES, and EUS. Nodal status was evaluated by EUS in all patients, but could not evaluate parietal spread in 6 in whom ES was previously done. Results of endoscopic examination were compared with pathologic examination after resection (2 local excisions for 2 benign AT, and 24 PD for 20 malignant and 4 benign AT). RESULTS: Accuracy of histologic examination of the 26 biopsies of the papilla was 69%. After ES, accuracy of intra-ampullary biopsies was 77%. The EUS had a 75% accuracy for the parietal spread (tumor limited to ampulla or not) and a 69% accuracy for the nodal status. In 11 patients, all explorations were consistent with a benign lesion, but 6 of these patients had a histologically proven malignancy, including one with nodal metastases and two with duodenal involvement. CONCLUSIONS: Side-viewing duodenoscopy with biopsies, even after ES, combined with EUS is not accurate enough to preoperatively ensure that an AT is benign. Indication for a local resection based on these explorations alone is not safe.

[Occurrence and nature of hyperamylasemia in chronic alcoholics]. / Prévalence et nature de l'hyperamylasémie chez les alcooliques chroniques.

The purpose of this work was: a) the prospective study of the prevalence of hyperamylasemia in 100 patients with chronic alcoholism; b) the determination of the serum isoamylase distribution in patients with hyperamylasemia by an inhibitor assay; c) the search of the origin of elevated serum isoamylase S. Moderate hyperamylasemia was found in 15 patients. The importance of alcohol abuse, the prevalences of cirrhosis and smokers were not statistically different from those observed in normoamylasemic patients. After one week of hospitalization, serum amylase was still elevated in 11 of 14 alcoholic patients. Hyperamylasemia was due to an increase in the isoamylase P in 5 cases, in the isoamylase S in 7 cases, and in both forms in 3 cases. Activities of serum lipase and isoamylase P were roughly parallel. Only two out of 8 patients with elevated isoamylase P had chronic pancreatitis. The salivary origin of elevated isoamylase S was suspected in only one out of 10 patients. This work shows that the origin of moderate hyperamylasemia, observed in alcoholic patients, is often extrapancreatic. It is suggested that the dosage of serum lipase simpler than that of isoamylases, may be routinely used in chronic alcoholic patients for diagnostic purposes.

[Stenosis of the left hepatic duct with intrahepatic lithiasis: treatment by the percutaneous transhepatic approach]. / Sténose du canal hépatique gauche avec lithiase intrahépatique: traitement par voie percutanée transhépatique.

The authors report the case of a 78-year-old woman suffering from cholangitis secondary to intrahepatic biliary stricture and intrahepatic lithiasis. Successful management consisted of successive percutaneous transhepatic internal-external biliary drainage, balloon dilatation of the stricture and gallstone mobilisation and removal through the stricture. No complications were noted.

[Pancreatic cystadenoma: diagnostic value of ultrasonics and x-ray computed tomography]. / Cystadénomes pancréatiques: intérêt diagnostique de l'échographie et de la tomodensitométrie.

We report six cases of pancreatic cystadenoma (three mucinous cysts, three microcystic adenomas). All patients were women. The mean age at the time of diagnosis was 50 years (with a range from 24 to 70 years). The mean age of patients having mucinous cysts (36.6 years) was lower than that of patients having microcystic adenomas (63.3 years). Abdominal pain was the first symptom in five patients. A palpable abdominal mass was found in three cases. The type of the tumor was demonstrated by ultrasonography and computed tomography and was confirmed by laparotomy in five cases. The tumors involved the body and tail of the pancreas. A distal pancreatectomy was performed in five cases, with a splenectomy in four cases. The post-operative course was uneventful. One patient was not operated. The histological examination of the three mucinous cysts showed benign tumors. This study emphasizes the usefulness of ultrasonography and computed tomography for the diagnosis of pancreatic cystadenomas. Surgical therapy is mandatory for mucinous cysts because of their potential malignancy, but a careful follow-up might be proposed for poor-risk patients having a microcyst adenoma, since this tumor is benign.

[Pancreatic intraductal adenoma, adenomatosis and adenocarcinoma]. / Adénomes, adénomatoses et adénocarcinomes pancréatiques intra-canalaires.

Three cases of adenomatous lesions of the pancreatic ducts are reported. There was 1 case each of adenoma of the main pancreatic duct, adenomas of the uncinate process and diffuse adenomatosis of the cephalic pancreatic ducts with ampullary involvement. On ultrasound and computerized tomography, the main pancreatic duct was enlarged in all cases, associated in 2 cases with a mass in the head of the pancreas, and in 1 case, with pseudocystic dilation of the uncinate process ducts. At duodenoscopy, the papilla was tumoral in 1 case, enlarged with mucous flow in 1 case and normal in the third case in which cytologic examination of secretions disclosed glandular cells. Endoluminal lesions were diagnosed by endoscopic retrograde pancreatography in 2 cases and on gross pathologic examination in 1 case. Treatment was surgical: cephalic pancreatoduodenectomy in 2 cases and local resection in 1 case, which relapsed 3 years later. At pathology, lesions were benign in all 3 cases including 1 case of severe dysplasia. On the basis of these 3 cases and a review of the literature, distinctive features of pancreatic endoluminal adenomas and adenocarcinomas are specified. Pancreatic resection is mandatory because of the risk of pancreatic obstruction and malignant degeneration.

[Intestinal lymphangiectasis secondary to cicatricial fibrosis of mesenteric nodes: a nosologic entity?]. / Les lymphangiectasies intestinales dues à la fibrose cicatricielle des ganglions mésentériques: un cadre nosologique à retenir?

Exsudative enteropathy was suspected in a 27-year-old man with lower limb edema, hypoprotidemia and hypoalbuminemia. Gastrointestinal mucosa, kidney, liver, and heart were normal. Laparoscopy showed diffuse small intestine lymphangiectasia. This diagnosis was confirmed by the microscopic examination of several biopsies obtained at laparotomy. Pathological examination of peritoneal, lymph nodes, and liver biopsies showed fibrous thickening of the peritoneum and fibrosis of the lymph nodes. Our patient has been followed for 16 years. Substantial improvement of clinical symptoms was obtained by following a special salt-free diet containing short-chain triglycerides. However biochemical abnormalities have persisted. Exsudative enteropathy due to intestinal lymphangiectasia may be observed in heart and liver diseases as well as in malignant affections of mesenteric lymph nodes. If these conditions are excluded, intestinal lymphangiectasia may be considered as a primitive lymph vessel malformation. The discovery of primitive intestinal lymphangiectasia in an adult cannot be attributed to congenital abnormalities alone. Fibrosis encountered in some cases suggests that an inflammatory process of unknown origin may trigger the onset of intestinal lymphangiectasia.

[Diarrhea with malabsorption and exudative enteropathy caused by intestinal myeloid involvement in a patient with myeloproliferative syndrome]. / Diarrhée avec malabsorption et entéropathie exsudative par infiltration myéloïde intestinale au cours d'un syndrome myéloprolifératif.

A 41-year-old woman with a myelodysplastic syndrome complained of diarrhea with malabsorption and protein-losing enteropathy after splenectomy. No cause was found and various therapeutic regimens were not effective. Pathological examination of biopsies from stomach, small intestine, and large bowel showed infiltrations interpreted as inflammatory on routine technics. Blast cell infiltration was found on electron microscopy. Treatment by citarabine induced normalization of leukocytosis, and diarrhea disappeared. Six months after the onset of illness, she developed acute myeloblastic leukemia and died of infectious pneumonia. Blastic infiltration of the lamina propria could be responsible for the determinism of symptoms, because of the lack of another etiology, the intensity of the blastic infiltration and the effect of cytotoxic therapy, even in the absence of new biopsies.

[Pharyngeal dysphagia and polymyositis]. / Dysphagie haute et polymyosite.

We report the case of a 70 year-old woman admitted for pharyngeal dysphagia. The diagnosis of polymyositis was made on manometry and histopathological neuromuscular biopsy findings. There were no inflammatory syndrome, muscular enzyme increase or electromyographic abnormalities. The patient was initially treated by prednisone (1 mg/kg/d) with success, but relapsed 12 weeks later and then was put on azathioprine (2 mg/kg/d). Pharyngeal dysphagia can be the only clinical manifestation of polymyositis, usually a systemic disease.

[Intraductal papillary mucinous tumors of the pancreas. Clinical and morphological aspects in 30 patients]. / Tumeurs intra-canalaires papillaires mucineuses pancréatiques. Aspects cliniques et morphologiques chez 30 malades.

AIM: Intraductal papillary-mucinous tumors of the pancreas are rare and characterized by a malignant potential. The aim of this study was to clarify their clinical presentation and the performance of different imaging procedures to determine malignancy and tumor extent. METHODS: Medical records and radiographs of 30 patients with histologically confirmed intraductal papillary-mucinous tumor of the pancreas were reviewed retrospectively. Imaging procedures were compared with pathological data of resected pancreas to evaluate their performances. RESULTS: The most frequent symptom was acute pancreatitis (37%). The onset of symptoms preceded the diagnosis by 2.5 years. Diabetes mellitus and diarrhea were respectively detected in 33 and 23% of the cases. The combination of CT scan, endoscopic retrograde cholangiopancreatography and endosonography allowed correct diagnosis of intraductal papillary-mucinous tumor of the pancreas in 100% of the cases. Tumor extent could be accurately determined considering the location of cystic dilatation of the pancreatic ducts, the presence of intraductal material or parietal irregularity. Actuarial 2-year survival rate was 43% in patients with malignant tumors. Radiological factors predicting malignancy were: vascular invasion, common bile duct dilatation, stricture of the main pancreatic duct and the presence of solid component in the tumor. CONCLUSION: The combination of CT scan, ERCP and endosonography provide accurate diagnosis of intraductal papillary-mucinous tumor of the pancreas as well as assessment of tumor extent and malignancy.

[Endoscopic ultrasonic diagnosis and cancer of the esophagus. Results of a prospective comparative study with x-ray computed tomography in 51 surgically treated patients]. / Echoendoscopie et cancer de l'oesophage. Résultats d'une étude prospective et comparative avec la tomodensitométrie chez 51 malades opérés.

To investigate whether endoscopic ultrasonography could improve the preoperative staging of esophageal carcinoma we prospectively studied 56 tumors in 51 patients between March 1987 an March 1988. The results for assessing local and regional extension and preoperative staging were compared with those of computed tomography, surgery, and pathological findings. When the procedure was complete (n = 25) the accuracy of parietal spread assessment was 85.7 percent; sensitivity for nodal involvement was 83.3 percent versus 50 percent for computed tomography with an accuracy of 97.6 percent versus 96.4 percent; the discrimination between superficial and advanced cancer was 100 percent; the accuracy for preoperative staging using the Japanese classification was 84 percent. When the procedure was not complete (stenosis), endoscopic ultrasonography was complementary to computed tomography: local invasion of anatomical structures (n = 16) was better assessed by combined endoscopic ultrasonography and computed tomography (n = 11) than by endoscopic ultrasonography (n = 8) or computed tomography (n = 6) alone. We conclude that endoscopic ultrasonography is the best procedure for staging esophageal carcinoma without stenosis; further miniaturization of the transducer is necessary to improve results in the case of narrow stenosis.

[Echoendoscopy: a new technic for studying esophago-gastric subepithelial tumors and extrinsic compression]. / L'échoendoscopie: une nouvelle technique d'exploration des tumeurs sous-épithéliales et des compressions extrinsèques oeso-gastriques.

The value of endoscopic ultrasonography in the diagnosis of subepithelial tumors and extrinsic compression of the esophagus and the stomach was evaluated in 34 patients with 21 subepithelial tumors and 13 extrinsic compressions. Endoscopic ultrasonography was always performed after axial-vision fiberscopy anal routine biopsy specimens were obtained. Computed tomography was also done in all cases of extrinsic compression. Distinction between subepithelial tumor and extrinsic compression was made in all patients by endoscopic ultrasonography and in 5 cases by fiberscopic examination with biopsy specimens. Localization and intramural spread of subepithelial tumors were correctly determined in 12 of 13 cases by endoscopic ultrasonography (diagnostic accuracy: 92 percent). The echoendoscopic semiology of 21 subepithelial tumors was retrospectively established. The histologic nature of some of these tumors can be suggested by these signs. Endoscopic ultrasonography is superior to computed tomography in the evaluation of esogastric extrinsic compressions, particularly in the diagnosis of posterior mediastinal carcinomatosis and of tumoral invasion of the deep parietal layers. We conclude that endoscopic ultrasonography is currently the best procedure in the assessment of subepithelial tumors and extrinsic compressions of the esophagus and the stomach.

[Digestive lymphomatous polyposis: study of a case diagnosed by rectal biopsy]. / Polypose lymphomateuse digestive: étude d'une observation diagnostiquée par biopsie rectale.

We report a case of gastrointestinal lymphomatous polyposis revealed by a rectal tumor. Numerous polypoid lesions, 5 to 20 mm in diameter, were found at various levels of the gastrointestinal tract. Microscopic examination of gastric, duodenal, colic and rectal specimens led to the diagnosis of small cleaved-cell type lymphoma. The immunohistochemical study showed a monotypic surface staining of the lymphomatous cells with anti-IgM, IgD, kappa, C3b, and CD5 antibodies. This type of lymphoma is rare and presents as multifocal polyposis of the gastrointestinal tract. Only histologic and immunohistologic studies can establish diagnosis. Gastrointestinal lymphomatous polyposis is classified as a low-grade malignant lymphoma, with frequent nodal, hepatosplenic, bone marrow, and blood involvement. Chemotherapy is the appropriate treatment.

[A rapid method for continuous flow measurement of cholesterol contained in high density lipoproteins (HDL) (author's transl)]. / Méthode de dosage rapide du cholestérol des lipoprotéines de haute densité (HDL) en flux continu.

The authors utilized a reagent containing concanavalin A, a vegetal lecithin, to selectively precipitate lipoproteins containing apoprotein B, a component of VLDL, LDL, and Lp (a) which are well known for their atherogenic risk. During this precipitation "true" high density lipoproteins remain in solution. HDL cholesterol determination which constitutes an indirect indication of HDL activity or concentrations is performed by an enzymatic method using an automated continuous flow technique carried out on an Auto Analyzer II (Technicon Corp.). This rapid, easy determination obtains results comparable to other methods, particularly those chosen by the Société Française de Biologie Clinique (French Society of Clinical Biology). This technique should permit all laboratories to confirm an atherogenic index.

[The role of endoscopic treatment of complications of chronic pancreatitis]. / La place du traitement endoscopique dans les complications de la pancréatite chronique.

This review outlines the indications and results of endoscopic management in the complications of chronic pancreatitis. Symptomatic obstructions of the main pancreatic duct can be treated by endocanalar prosthesis in case of fibrous stenosis and by extracorporeal shock wave lithotripsy in case of intraductal obstructive stones. Symptomatic or large pseudocysts have to be treated and may be treated by placement of transgastric or transduodenal endoprosthesis for pseudocysts protuding into the digestive tract and by using transpapillary endoprosthesis for communicating pseudocysts. Endoscopic treatment of ductal disruptions is difficult and generally requires combined techniques. Symptomatic biliary stenosis can be temporary treated using biliary endoprothesis. Short and long term results and complications of these different procedures are analysed. In the absence of controlled studies, the role of endoscopic treatment in comparison to surgical treatment is not well defined. Present indications for either approach can be discussed on an individual basis.

[Intraductal papillary mucinous tumors of the pancreas: diagnosis, treatment and prognosis]. / Tumeurs intracanalaires papillaires mucineuses du pancréas. Diagnostic, traitement et pronostic.

Intraductal papillary and mucinous tumors of the pancreas (IPMT) have been recently well defined histologically. Recent reports have described their diagnostic and therapeutic modalities. The malignant potential of these lesions warrants their surgical resection. The main difficulty of their management is the pre-operative assessment of ductal extension and grade of dysplasia. Despite the use of various imaging modalities (ultrasound, endoscopic ultrasonography, CT scan, retrograde pancreatography, pancreatic MRI), examination of the pancreatic margin on frozen section remains mandatory to ensure complete resection of epithelial lesions. This usually requires partial pancreatic resection. The long-term outcome is favourable for lesions with no invasive component. Recurrence in case of invasive malignant transformation appear to be more frequent than previously reported.

[Results of endoscopic ultrasonography in the preoperative assessment of rectal cancer]. / Résultats de l'échoendoscopie dans le bilan pré-opératoire du cancer du rectum.

Endoscopic transrectal ultrasonography is performed with an ultrasonic transducer (7.5 MHz or 12 MHz) in the tip of a side viewing endoscope. Its accuracy to assess the depth of rectal cancer invasion was prospectively studied in 27 patients. The ultrasonic examination was correct in 23 cases; in 4 cases, the stricturing tumour could not be passed by the probe. The depth of invasion was correctly appreciated in 24 of the 27 cases (accuracy of 89%). The 6 superficial lesions were all correctly detected with endoscopic transrectal ultrasonography. Therefore, endoscopic transrectal ultrasonography appears to be a very promising method in the pretherapeutic staging of rectal cancer.