Ileal or Anastomotic Location of Lesions Does Not Impact Rate of Postoperative Recurrence in Crohn's Disease Patients Classified i2 on the Rutgeerts Score.

BACKGROUND: The Rutgeerts score with 5 grades of severity (i0-i4) is a suitable endoscopic model to predict clinical recurrence following ileocolonic resection in Crohn's disease (CD). Definition of grade i2 includes lesions confined to the ileocolonic anastomosis (i2a) or moderate lesions on the neo-terminal ileum (i2b). The aim of the present study was to evaluate the probability of clinical recurrence in i2a and i2b patients. METHODS: This multicenter retrospective study included all CD patients classified i2 at the first postoperative ileocolonoscopy. The primary outcome was to evaluate the probability of clinical recurrence in patients classified i2a and i2b. The secondary outcome was to compare the rate of global recurrence of CD. RESULTS: Fifty patients were included: 23 were classified i2a and 27 were classified i2b. The median duration of follow-up was 40 (18.0-80.4) months in the i2a group and 53.5 (25.0-69.0) months in the i2b group (p = 0.9). The probability of clinical recurrence was not significantly different between patients classified i2a and i2b (p = 0.64). Median time to clinical recurrence after the first ileocolonoscopy and probability of global CD recurrence were not different between the two groups (p ≥ 0.19). CONCLUSIONS: The rate of clinical postoperative recurrence is not different in i2a and i2b patients. These results suggest that the same therapeutic strategy should be used in all patients classified i2 on the Rutgeerts score whatever the location of postoperative CD recurrence.

[Treatment of thoracic anastomotic leaks after oesophagectomy with self-expanding and extractible covered stent]. / Traitement des fistules anastomotiques intrathoraciques apres esophagectomie par prothese couverte autoexpansive extractible.

We report a case of a thoracic anastomotic leak after oesophagectomy for cancer treated by surgical debridement, drainage and an endoscopically placed self-expanding stent. Intrathoracic, covered oesophageal stents appears to reduce leak-morbidity after oesophagectomy and may be considered as a cost-effective treatment alternative.

Impact of Intragastric Balloon Before Laparoscopic Gastric Bypass on Patients with Super Obesity: a Randomized Multicenter Study.

BACKGROUND: Super obese patients are recommended to lose weight before bariatric surgery. The effect of intragastric balloon (IGB)-induced weight loss before laparoscopic gastric bypass (LGBP) has not been reported. The aim of this prospective randomized multicenter study was to compare the impact of preoperative 6-month IGB with standard medical care (SMC) in LGBP patients. METHODS: Patients with BMI >45 kg/m2 selected for LGBP were included and randomized to receive either SMC or IGB. After 6 months (M6), the IGB was removed and LGBP was performed in both groups. Postoperative follow-up period was 6 months (M12). The primary endpoint was the proportion of patients requiring ICU stay >24 h; secondary criteria were weight changes, operative time, hospitalization stay, and perioperative complications. RESULTS: Only 115 patients were included (BMI 54.3 ± 8.7 kg/m2), of which 55 underwent IGB insertion. The proportion of patients who stayed in ICU >24 h was similar in both groups (P = 0.87). At M6, weight loss was significantly greater in the IGB group than in the SMC group (P < 0.0001). Three severe complications occurred during IGB removal. Mean operative time for LGBP was similar in both groups (P = 0.49). Five patients had 1 or more surgical complications, all in the IGB group (P = 0.02). Both groups had similar hospitalization stay (P = 0.59) and weight loss at M12 (P = 0.31). CONCLUSION: IGB insertion before LGBP induced weight loss but did not improve the perioperative outcomes or affect postoperative weight loss.

Photodynamic therapy for early oesophageal cancer.

BACKGROUND: Photodynamic therapy is an endoscopic treatment of early cancers based on the photosensitisation of neoplasms following the administration of a photosensitiser prior to laser light-induced tissue destruction. AIM: To assess the results of photodynamic therapy using Photofrin(Axcan Pharma Inc., Quebec, Canada) in patients with an early oesophageal cancer. PATIENTS: Twenty-four patients with early oesophageal cancer presenting as a not well-demarcated irregular dyschromic area of mucosa and unsuitable for any other treatment underwent photodynamic therapy. RESULTS.: Seventy-five per cent were successfully treated; three of them recurred and two died from head and neck cancer. To date, 54% of patients are alive without recurrence; the average follow-up is 21 months. There were one oesophageal lethal perforation and six stenosis. Results of photodynamic therapy were limited in this series by three failures, three recurrences and three deaths from previous head and neck cancers. CONCLUSION: This study provides some promising data for photodynamic therapy of oesophageal carcinomas in selected patients. It also emphasises the need for a best delivery device of laser light.

Developmental mucin gene expression in the gastroduodenal tract and accessory digestive glands. I. Stomach. A relationship to gastric carcinoma.

Studies were undertaken to provide information regarding cell-specific expression of mucin genes in stomach and their relation to developmental and neoplastic patterns of epithelial cytodifferentiation. In situ hybridization was used to study mRNA expression of eight mucin genes (MUC1-4, MUC5AC, MUC5B, MUC6, MUC7) in stomach of 13 human embryos and fetuses (8-27 weeks' gestation), comparing these with normal, metaplastic, and neoplastic adult tissues. These investigations have demonstrated that MUC1, MUC4, MUC5AC, MUC5B, and MUC6 are already expressed in the embryonic stomach at 8 weeks of gestation. MUC3 mRNA expression can be observed from 10.5 weeks of gestation. MUC2 is expressed at later stages, concomitant with mucous gland cytodifferentiation. Normal adult stomach is characterized by strong expression of MUC1, MUC5AC, and MUC6, less prominent MUC2, and sporadic MUC3 and MUC4, without MUC5B and MUC7. Intestinal metaplasia is characterized by an intestinal-type pattern with MUC2 and MUC3 mRNA expression. Gastric carcinomas exhibit altered mucin gene expression patterns with disappearance of MUC5AC and MUC6 mRNAs in some tumor glands, abnormal expression of MUC2, and reappearance of MUC5B mRNAs. In conclusion, we have observed that patterns of mucin gene expression in embryonic and fetal stomach could show similarities with some gastric carcinomas in adults. Differences in mucin gene expression in developmental, metaplastic, and neoplastic stomach compared to normal adult stomach suggest a possible regulatory role for their products in gastric epithelial cell proliferation and differentiation.

Pouchitis is associated with mucosal imbalance between interleukin-8 and interleukin-10.

BACKGROUND: Mucosal lesions of pouchitis are characterized by a neutrophil infiltrate. Interleukin (IL)-8 is the main mediator involved in neutrophil recruitment and is down-regulated by IL-10. AIM: To look for an imbalance between IL-8 and IL-10 in patients with pouchitis. PATIENTS/METHODS: 18 patients having an ileoanal pouch for ulcerative colitis were studied. Eleven had pouchitis defined by the pouchitis disease activity index of > or =7 points and 7 had no history of pouchitis. Biopsies taken at the site of inflammation or in the normal mucosa were scored for the histologic lesions, the intensity of neutrophil infiltration, and the presence of crypt abscesses. Mucosal IL-8 and IL-10 mRNA were quantified by competitive polymerase chain reaction. RESULTS: IL-8, IL-10, and IL-10/IL-8 mRNA were similar in patients with or without pouchitis. IL-8 mRNA levels were significantly higher in patients with a histologic score >2 (p = 0.01) and in patients with crypt abscesses (p = 0.01). IL-10/IL-8 mRNA was significantly lower in patients having a histologic score >2 (p = 0.019), a neutrophil infiltration > or =10% (p = 0.013), and crypt abscesses (p = 0.01). CONCLUSION: Histologic lesions of pouchitis are associated with a mucosal imbalance between IL-8 and IL-10. IL-10 could be proposed as a new treatment for pouchitis.

Noninvasive imaging of insulinomas and gastrinomas with endoscopic ultrasonography and somatostatin receptor scintigraphy.

BACKGROUND: Classic morphological techniques are of limited value for imaging endocrine duodenopancreatic tumors, and invasive procedures such as intraarterial stimulation are often used. Two noninvasive procedures, endoscopic ultrasonography (EUS) and somatostatin receptor scintigraphy (SRS), were recently described with promising results. METHODS: In this study we correlated the results of preoperative EUS (n = 34) and SRS (n = 30) with operative findings in patients with histologically proven insulinoma (n = 20) or gastrinoma (n = 21). RESULTS: The sensitivity and positive predictive value (PPV) of EUS were respectively 77% and 94% for pancreatic tumors (insulinomas and gastrinomas), 40% and 100% for duodenal gastrinomas, and 58% and 78% for metastatic lymph nodes. The sensitivity and PPV of SRS for insulinoma were 60% and 100%, respectively. In patients with gastrinoma, the sensitivity and PPV of SRS were respectively 25% and 100% for pancreatic gastrinomas, 72% and 100% for duodenal gastrinomas or periduodenal metastatic lymph nodes, and 67% and 80% for liver metastasis. In patients with multiple endocrine neoplasia, neither one of the two techniques detected all tumors. Overall sensitivity of combined EUS and SRS was 89% for insulinoma (n = 9) and 93% for gastrinoma (n = 14). CONCLUSIONS: EUS and SRS for gastrinomas and insulinomas should be considered as the initial preoperative imaging procedures and may render invasive procedures unnecessary for most patients.

In vivo pH measurement and imaging of tumor tissue using a pH-sensitive fluorescent probe (5,6-carboxyfluorescein): instrumental and experimental studies.

This study evaluated the effectiveness of dual-wavelength ratio fluorescence imaging using a pH-dependent indicator (5,6-carboxyfluorescein, 5,6-CF) for in vivo pH mapping of tissue. A prototype version of a highly sensitive fluorescence imaging device consisting of a modified xenon lamp, an image-intensified camera and a digital image-processing system has been developed. 5,6-Carboxyfluorescein was used because its fluorescence emission increases as a function of pH in the physiological (6.0-7.4) pH range. The ratio of fluorescence intensities obtained with the imaging system has been calibrated using aqueous 5,6-CF standards at various pH values. Because the pH of interstitial fluid of malignant tumors tends to be lower than that of normal tissue and can be depressed by glucose administration, experiments were performed on 10 CDF mice bearing lymphoid leukemia P388 grafted subcutaneously. The range of linearity of the calibration curve was obtained between 5.3 and 6.7 with a measured pKa value of 5.93. Consequently the maximum sensitivity was observed in this range. The calculated pH from ratio images was 6.21 +/- 0.12 in tumorous tissue. This value was equivalent to those obtained at the same time using microelectrodes (6.2 +/- 0.3). These experiments showed that a dose of 5 mg/kg 5,6-CF and an excitation power density of 2.5 mW/cm2 are sufficient to give a fluorescent pH image of tumors. The limitation of 5,6-CF for the in vivo mapping of tissue results from its low pKa and consequent range of sensitivity.(ABSTRACT TRUNCATED AT 250 WORDS)

Characterization of tumorous and normal tissue using a pH-sensitive fluorescence indicator (5,6-carboxyfluorescein) in vivo.

The pH of the interstitial fluid of malignant tumours tends to be lower than that of normal tissue and is depressed by glucose administration. This study aimed to evaluate the effectiveness of dual-wavelength fluorometry using a pH-dependent indicator (5,6-carboxyfluorescein: 5,6-CF) for the detection of tumour areas in vivo. 5,6-CF has two main characteristics: it has two wavelengths of maximum absorbance (465 and 490 nm) and its fluorescence emission (maximum, 515 nm) increases as a function of pH in the physiological pH range of 6-7.4. The experimental study was performed on 28 CDF mice bearing lymphoid leukaemia P388 grafted subcutaneously. The tissue pH values were evaluated from the ratio of the fluorescence intensities (I490/I465) on the basis of a calibration curve linking pH measurements performed within the tissue using a microelectrode and values of the fluorescence intensity ratio. The fluorescence intensity reached its maximum value 60 min after 5,6-CF and glucose administration, followed by a plateau (90 min) when the ratios remained constant at 1.79 +/- 0.05 for normal tissue and 1.35 +/- 0.04 for tumour tissue (p less than 0.005). These results were correlated with the pH measurements in accordance with the calibration curve. This study validates the relevance of dual-wavelength fluorometry using a pH-dependent indicator to characterize in vivo normal and tumour tissues after glucose administration.

[Ganglio-esophageal fistula revealed by hematemesis: a rare complication of silicotuberculosis]. / Fistule ganglio-oesophagienne révélée par une hématémèse: complication rare d'une silico-tuberculose.

We report a case of fistula between a silicotic mediastinal lymph node and the esophagus with protrusion of a stiff and darkish concretion into the oesophageal lumen. The patient, a 68-year-old coal miner, presented with cough since a few months and the lesion was revealed by haematemesis. The general course was rapidly favourable. Association with tuberculosis was recognized only a few months later.

[Absence of subrenal inferior vena cava revealed by rupture of duodenal varices in an adult]. / Absence de veine cave inférieure sous-rénale révélée par une rupture de varices duodénales chez un adulte.

This report concerns a case of absence of caudal inferior vena cava revealed by gastrointestinal bleeding from isolated duodenal varices by an adult. The diagnosis of duodenal varices was performed by ultrasonographic endoscopy. Development of duodenal varices in absence of portal hypertension is uncommon. Involvement of cavo-portal collateral circulation in case of inferior vena cava obstruction is unusual and duodenal varices are still more rarely encountered. Diagnosis was ultimately supported by femoral venous angiography showing the absence of inferior vena cava and a venous return from the right lumbar vein into the portal vein via the duodenal varices. The absence of caudal portion of inferior vena cava is more probably related to neo-natal thrombosis than to a true atresia.

[Palliative treatment of cancer of the esophagus and cardia by laser photo-ablation]. / Traitement palliatif des cancers de l'oesophage et du cardia par photoablation laser.

The results of the palliative treatment by laser photo-ablation for esophageal and gastric cancers in 79 nonsurgical patients are reported. The aim of treatment was to relieve dysphagia in 60 patients with an obstructive tumor, to maintain esophageal lumen patency in 8 patients with a nonobstructive tumor, and to completely destroy 11 small tumors. The success rate in the patients with dysphagia was 78 p. 100. Functional improvement lasted as long as patients survived with further treatment required once or twice a month. The best results were obtained in exophytic, non circumferential lesions, and in adenocarcinomas of the esophagogastric junction. The localization at the upper third of the esophagus was associated with poor prognosis. The complication rate was 6.6 p. 100. Eight of the 11 small lesions were completely destroyed, but radiation therapy had been associated in four cases with invasive cancer, one of which recurred after 6 months. No complications occurred in this last group of patients.

[Pancreatic-portal fistula. A rare complication of chronic pancreatitis]. / La fistule pancréatico-portale. Une complication rare de la pancréatite chronique.

We report a 40-year-old patient with complication of chronic pancreatitis as a pancreatico-portal fistula. The patient had subcutaneous nodular fat necrosis of the lower limbs resembling Weber-Christian syndrome, and amylasic ascitis. The diagnosis was established with retrograde endoscopic cholangio-pancreatography which found three pancreatic pseudocysts and a communication with the portal venous system. A portal thrombosis with cavernum was studied with color echo-Doppler and arteriography. The echo-endoscopy was performed for the first time in this complication and its significance estimated. The evolution was quickly and spontaneously favourable. That is a very rare complication of chronic pancreatitis and an expectant conservative management can be adopted.

[Hepatic calcifications revealing epithelioid hemangioendothelioma]. / Calcifications hépatiques révélatrices d'un hémangioendothéliome épithélioïde.

This report concerns a case of hepatic epithelioid hemangioendothelioma presenting with liver enlargement, multiple hepatic calcifications on the plain abdominal film and bilateral interstitial pneumonia. Epithelioid hemangioendothelioma is an unusual soft tissue tumor of "intermediate malignancy" characterized by a multicentric involvement of the liver and originating from endothelial cells. Histopathologic diagnosis may be difficult because of possible confusion with sclerosing epithelial tumors.

[Blue rubber bleb nevus syndrome. 3 cases treated with a Nd:YAG laser and bipolar electrocoagulation]. / Blue rubber bleb nevus syndrome. Trois cas traités par laser Nd:YAG et électrocoagulation bipolaire.

This report concerns three patients with "blue rubber bleb nevus syndrome" presenting with recurrent digestive tract hemorrhage. Tuberous angiomas of the digestive tract associated with typical skin lesions as described by Bean led to diagnosis. Endoscopic coagulation with Nd:YAG laser and bipolar electrocoagulation "Bicap" of gastric and colonic angiomas was performed successfully without complication but did not avoid hemorrhagic recurrence originating from lesions located in the small bowel, as demonstrated during laparotomy in one case.