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.

Antireflux versus conventional self-expanding metallic Stents (SEMS) for distal esophageal cancer: results of a multicenter randomized trial.

INTRODUCTION: Self-expanding metal stents (SEMS) are commonly used in the palliation of dysphagia in patients with inoperable esophageal carcinoma. However, they predispose to gastroesophageal reflux when deployed across the gastroesophageal junction. The aims of this study were to: 1) assess the influence of the antireflux valve on trans-prosthetic reflux (primary outcome); and 2) compare the results of SEMS with and without antireflux valve in terms of reflux symptoms, quality of life (QOL), improvement of dysphagia and adverse events (secondary outcomes). PATIENTS AND METHODS: Thirty-eight patients were enrolled in nine centers. Carcinomas were locally advanced (47 %) or metastatic. After randomization, patients received either a covered SEMS with antireflux valve (n = 20) or a similar type of SEMS with no antireflux device but assigned to standard proton pump inhibitor therapy and postural advice (n = 18). Trans-prosthetic reflux was assessed at day 2 using a radiological score based on barium esophagography performed after Trendelenburg maneuver and graded from 0 (no reflux) to 12 (maximum). Monthly telephone interviews were conducted for Organisation Mondiale de la Santé (OMS) scoring from 0 (excellent) to 5 (poor), QOL assessment (based on the Reflux-Qual Simplifié scoring system) from 0 (poor) to 100 (excellent), dysphagia scoring from 0 (no dysphagia) to 5 (complete dysphagia) and regurgitation scoring from 0 (no regurgitation) to 16 (maximum). RESULTS: No difference was noted in terms of age, sex, size of lesion, prosthesis length or need for dilation prior to SEMS placement. No difficulty in placing SEMS nor complications were noted. Radiological scores of reflux were found to be significantly lower in patients with an antireflux stent compared to the conventional stent and associated measures. The regurgitation scores were significantly decreased in patients with antireflux stents during the first 2 months after stent placement and thereafter, they were similar in the two groups. QOL and dysphagia were improved in both groups. Survival rates were comparable in the two groups. CONCLUSIONS: No difference was observed between the two types of SEMS regarding the palliation of dysphagia and improvement of QOL. However, SEMS with an antireflux valve were more effective in preventing trans-prosthetic gastroesophageal reflux but at the cost of an increased likehood of minor adverse events (migrations and/or obstruction of the SEMS).

[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.

[Early oesophageal cancer: epidemiology diagnosis and management]. / Cancers superficiels de l'oesophage: épidémiologie, diagnostic et traitement.

In Europe, oesophageal cancers are diagnosed at an early stage in less than 10% of the cases. They are superficial tumours whose invasion is limited to the mucosae and the submucosa. Synchronous node invasion is the most important prognosis factor. Oesophagectomy is the benchmark treatment. Nowadays, endoscopic resection is a validated curative therapeutic alternative. Accurate endoscopic evaluation using chemical or virtual colouring as well as an echoendoscopy, followed by an expert pathological review, must be conducted beforehand. It can be realised for good prognosis tumours after evaluation of the synchronous node invasion or its risk. After completion, regular endoscopic follow-ups are compulsory to detect local relapse.

Self-expanding plastic stent removed after radiochemotherapy for advanced esophageal cancer.

Endoscopic evaluation after chemoradiotherapy (CR) is impossible with an esophageal stent in place. The main study objective was to evaluate self-expanding plastic stent (SEPS) removal post-CR. Secondary end-points were the improvement of dysphagia and patients' quality of life. From October 2008 to March 2011, 20 dysphagic patients who suffered from advanced esophageal cancer were enrolled in a multicenter, prospective study. SEPS was inserted prior to CR and then removed endoscopically. SEPS efficiency (dysphagia score) and tolerance, as well as the patients' quality of life (European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire validated for the esophagus), were monitored. Continuous variables were compared using a paired t-test analysis for matched data. A P-value of less than 0.05 was considered statistically significant. Twenty patients (15 men and 5 women), aged 61.5 years (±9.88) (range 43-82 years), with adenocarcinoma (n = 12) and squamous cell carcinoma (n = 8), were enrolled. SEPS were successfully inserted in all patients (100%). There was one perforation and three episodes of migration. All of these complications were medically treated. The mean dysphagia score at the time of stent placement was 2.79 (0.6). Mean dysphagia scores obtained on day 1 and day 30 post-SEPS placement were 0.7 (0.9) (P < 0.0001) and 0.45 (0.8) (P < 0.0001), respectively. Quality of Life Questionnaire validated for the esophagus score showed an improvement in dysphagia (P = 0.01) and quality of oral feeding (P = 0.003). All SEPS were removed endoscopically without complications. In two patients, the stent was left in place due to metastatic disease. SEPS are extractable after CR of esophageal cancer. Early stenting by SEPS prior to and during CR may reduce dysphagia and improve quality of oral alimentation.

[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 prevalence of right-sided colonic diverticulosis and diverticular haemorrhage.

AIM: The study was performed to determine the prevalence of right-sided diverticular disease in a western population and whether it is more likely to bleed than disease on the left side. METHOD: From January 2004 to June 2005, 796 consecutive patients were referred for total colonoscopy to 17 physicians. Data obtained included age, gender, and presence and localization of diverticula. This population was compared with a cohort of 133 consecutive patients who were admitted for colonic diverticular bleeding. RESULTS: Three-hundred and eighteen (40%) of the 796 patients presented with noncomplicated diverticulosis. Of these, 103 (32.4%) had right-sided diverticula. In univariate analysis, the presence of right diverticula in patients admitted for diverticular bleeding was about twice as frequent as in patients who had diverticula with no bleeding (65.2% vs 32.4%; P = 0.0001). In multivariate analysis, the right localization of the diverticulosis was associated with a risk of bleeding, which was independent of the patients' age (P = 0.0001, OR = 3.6). CONCLUSION: The prevalence of colonic diverticula increased from < 10% in adults under 40 years of age to about 75% in those over 75 years of age. Of these patients, nearly one-third presented with right-sided involvement. Right-sided localization was associated with a significant risk of bleeding, which was independent of the patients' age.

Fully covered self-expanding metal stents for benign colonic strictures.

BACKGROUND AND STUDY AIMS: Uncovered self-expanding metal stents offer effective relief for colonic obstruction. The aim of this study was to determine the effectiveness of fully covered self-expanding metal stents (FCSEMSs) in the treatment of benign colonic strictures. PATIENTS AND METHODS: All patients presenting with a symptomatic benign colonic stricture (occlusion or subocclusion) during a 6-year study period were treated with FCSEMSs. The stents were placed and removed 4 - 6 weeks later at one of 10 endoscopy centers. The efficacy of the stent (clinical and radiological signs of colonic decompression within 48 hours), technical success, stent retrieval, safety, and recurrence of symptoms were evaluated during follow-up. Univariate and multivariate analyses were performed to identify variables associated with clinical success, stent migration, and symptom recurrence. RESULTS: The study included 43 patients (24 men, 19 women; mean age 67.6 ± 10.4) with occlusive (n = 18) or subocclusive symptoms (n = 25) due to anastomotic (n = 40), post-ischemic (n = 2), or post-radiation (n = 1) strictures. Insertion was successful in all patients. Clinical success was obtained in 35 patients (81 %). Migration was observed in 27 patients (63 %). The median duration of stenting was 21 days (95 %CI 17.8 - 35.4 days). Multivariate analysis showed that stents more than 20 mm wide migrated significantly less often. Recurrence of obstructive symptoms was observed in 23 patients (53 %), irrespective of migration. No predictive factors for recurrence or clinical efficacy were found. CONCLUSIONS: FCSEMSs for treatment of symptomatic benign colonic strictures are safe and effective, despite a high rate of spontaneous migration.

Endoscopic submucosal dissection in a European setting. A multi-institutional report of a technique in development.

BACKGROUND AND STUDY AIMS: Endoscopic submucosal dissection (ESD) is a technique for "en bloc" resection of superficial tumors of the gastrointestinal tract. In France, experience with this technique is still limited. We wanted to assess the development of ESD in France, with special attention to short term outcomes. PATIENTS AND METHODS: Members of the Société Française d'Endoscopie Digestive (SFED) who declared performing ESD reported their cases prospectively on a voluntary basis. Demographic, clinical, and technical data, and the results of immediate complications were collected. Case reports were completed prospectively by each investigator before pooled analysis. RESULTS: A total of 188 consecutive case reports were collected from 16 centers. The median case mix per center was 6 patients (range 1-43). The lesion sites treated by ESD were the stomach (n = 75), esophagus (n = 27), duodenum (n = 1), cecum (n = 2), right colon (n = 3), transverse colon (n = 5), sigmoid (n = 3), and rectum (n = 72). The median size of the lesions was 26 mm (range 2-150 mm). En bloc resection was achieved in 77.1% of cases, with complete R0 resection in 72.9%. Histopathology results showed high grade dysplasia or superficial cancer in 71.2%. The median duration of ESD was 105 minutes (range 20-450 minutes). The short term morbidity was 29.2% including 34 cases of perforation (18.1%), and 21 hemorrhages (11.2%) during the 24 hours following ESD, 89% of which were managed conservatively or endoscopically. CONCLUSION: In this early experience, the feasibility of ESD appeared to be good but R0 resection and complication rates did not match those reported by Japanese authors and must be improved by an extended practice.

[An uncommon use of argon plasma coagulation: endoscopic transection of self-expanding metallic stents]. / Une utilisation peu usuelle mais efficace du plasma d'argon : la section des prothèses métalliques expansives.

Migration, distal malposition or fracture of self-expanding metallic biliary or esophageal stents rarely occur but may lead to stent dysfunction, mucosal trauma secondary to impaction or friction on the digestive wall. We report our experience of using argon plasma to endoscopically cut three metallic biliary and esophageal self-expanding stents to restore permeability or to treat impaction of the stent after migration, malposition or fracture.

[External radiotherapy and photodynamic therapy for esophageal carcinoma: a dangerous association?]. / Radiothérapie externe et photothérapie dynamique des cancers de l'oesophage: une association dangereuse ?

A 60-year-old man presented an oesophageal transmural necrosis fistulised in the trachea following curative photodynamic therapy (PDT) for a superficial recurrence of an oesophageal carcinoma, initially treated by radiochemotherapy. Two stents, a tracheal and an oesophageal one, were placed. Eight months later the patient is in complete remission with only mild swallowing problems. This complication, although unusual, has already been described by other teams with the association of radiochemotherapy and PDT. The present case study suggests that illumination dose should be lowered in this indication.

[Extrahepatic digestive surgery in the cirrhotic patient]. / La chirurgie digestive extra-hépatique chez le cirrhotique.

Extra-hepatic abdominal surgery is associated with a high degree of risk in cirrhosis patients. Thus mortality is between 8 and 67% and morbidity between 28 and 47%. The chief complications are hepatic insufficiency, sepsis and visceral failure (cardiac, renal and pulmonary). The risk differs according to the organ operated upon, it is less after ordinary cholecystectomy than following gastrectomy or partial colectomy. Herniorrhaphy was a good immediate prognosis. Prognostic factors are above all the presence of ascites, emergency surgery, clotting factors and hypoalbuminemia; mortality is of the order of 10% for child class A but 75% for class C. Improved results thus would require better patient selection and intensive preparation during the peri-operative period with in particular, prophylactic antibiotics in the case of contaminated surgery.

[Extrahepatic digestive surgery in cirrhotic patients: mortality, morbidity and preoperative prognostic factors]. / La chirurgie digestive extra-hépatique chez le cirrhotique: mortalité, morbidité, facteurs pronostiques pré-opératoires.

The purpose of this work was to study postoperative mortality and morbidity with respect to preoperative prognostic factors in 67 patients with alcoholic or posthepatitis cirrhosis. Surgical procedures involved the biliary tract (n = 20), stomach (n = 16), colon or rectum (n = 12), and hernia (n = 7). Thirteen preoperative clinical and biological variables were subjected to mono- and multivariate statistical analysis. The mortality rate was 23 p. 100. There was no statistical difference between the three main surgical procedures. No patients died after herniorrhaphy. The rate of morbidity was 37 p. 100. The most common complications were sepsis, organ failure, and ascites. Three preoperative variables were found to be different between survivors and non survivors: ascites, prothrombin time and the Child-Pugh score. Multidimensional analysis demonstrated that the only variable to have an independent unfavorable prognostic value was albuminemia. These results suggest that postoperative mortality following extrahepatic abdominal surgery in cirrhotic patients is: 1) especially high after digestive procedures, 2) increased by ascites, low prothrombin time and high Child-Pugh score. Only hypoalbuminemia had a significant independent explanatory value regarding prognosis.