EUS-guided biliary drainage with electrocautery-enhanced lumen-apposing metal stent placement should replace PTBD after ERCP failure in patients with distal tumoral biliary obstruction: a large real-life study.

AIMS: In cases of malignant distal biliary obstruction, ERCP is the preferred technique for bile duct drainage. In case of failure, the alternative techniques are percutaneous transhepatic biliary drainage (PTBD) and more recently endoscopic ultrasound-guided biliary drainage. A new type of stent called the electrocautery-enhanced lumen-apposing metal stent (EC-LAMS) has been developed to enable the performance of biliary-enteric anastomosis under EUS-guidance in a single step, without prior bile duct puncture or the need for a guidewire. The aim of our study was to compare the real-life efficacies of PTBD and EUS-BD with the EC-LAMS for cases of ERCP failure in patients with malignant biliary obstruction. METHODS: We performed a monocentric retrospective study comparing PTBD and EUS-BD with the use of electrocautery-enhanced lumen-apposing metal stent in the context of a malignant distal biliary obstruction after ERCP failure. RESULTS: 95 patients were included (50 in EUS-BD group and 45 in PTBD group). The main etiology of malignant obstruction was adenocarcinoma of the head of pancreas (85%). There was a significant difference in favor of endoscopic ultrasound-guided biliary drainage using electrocautery-enhanced lumen-apposing metal stent for the following criteria: clinical success: 89.3% vs. 45.5%; p < 0.0001; procedure-related adverse event rate: 2.12% vs. 22.7%; p = 0.003; duration of post-drainage hospitalization: 3.5 vs. 8.2 days; p < 0.0001, overall survival (median survival): 118.2 vs. 42 days; p = 0.012, overall cost of the strategy per patient: 5098 vs. 9363 euros; p < 0.001. CONCLUSION: Our results are in favor of EUS-BD using electrocautery-enhanced lumen-apposing metal stent in case of ERCP failure for a distal tumor biliary obstruction. Operators performing ERCP for distal tumor biliary obstruction must learn this backup procedure because of its superiority over percutaneous transhepatic biliary drainage in terms of clinical success, safety, cost, and overall survival.

[Non-cirrhotic ascites: pathophysiology, diagnosis and etiology]. / L'ascite non liée à la cirrhose : physiopathologie, diagnostic et étiologies.

Ascites, in 20% of cases, is not linked to liver cirrhosis. The pathophysiology is most often different. The understanding of these pathophysiological mechanisms can lead to etiologic diagnosis. The diagnostic approach is mainly based on the biological study of ascites, especially protein concentration and albumin gradient between serum and ascites. In Western countries, tumors and heart diseases are the predominant causes, while developing countries are mainly concerned by infectious diseases, among which tuberculosis is the leading cause. Other uncommon causes must be recognized, as ascites may be the presenting feature of the disease. Their knowledge will facilitate the therapeutic approach.

[Unilateral adrenal hematoma in adults. Contribution of MRI in follow-up]. / Hématome surrénalien unilatéral de l'adulte. Apport de l'IRM dans le suivi évolutif.

We describe a case of unilateral and spontaneous adrenal hematoma. Initial and follow up MRI examinations showed serial modifications typical of hematoma and allowed to exclude a preexisting non hyperfunctioning tumor. MRI findings modified the therapeutic attitude, a voiding surgery.

[Parathyroid adenoma as an ectopic carotid mass. Apropos of a case]. / Adénome parathyroídien en position carotidienne ectopique. A propos d'un cas.

Authors report a case of parathyroid adenoma as lateral palpable cervical mass, with serious hypercalcemia. MRI and ultrasound investigations were performed preoperatively. No other pathological parathyroid gland was found. Surgical treatment did not include the exploration of the four parathyroid glands. Long term follow-up is necessary.

[Pneumatosis cystoides intestinalis. Apropos of a case]. / La pneumatose kystique intestinale. A propos d'un cas.

Pneumatosis cystoides intestinalis is most frequently characterised by the presence of gaseous cysts, in the intra-parietal, subserous or sub-mucous zones of the colon. This complaint, with symptoms of non specific colic and the cause of chronic pain, generally progresses favourably but can be responsible for surgical complications. Characteristic signs are detected on an plain abdominal X-ray and by colonoscopy. The diagnosis can be established by CT or by ultrasonography but needs carefully trained operators. CT remains the most successful technique for the initial diagnosis and subsequent follow-up. Ultrasonography can also be used for follow-up. As the lesions regress rapidly, the diagnosis must established rapidly, otherwise the disorder might easily be incorrectly diagnosed.

[Physicochemical analysis of subcutaneous calcifications in a case of Thibierge-Weissenbach syndrome]. / Analyse physicochimique de calcifications sous-cutanées dans un cas de syndrome de Thibierge-Weissenbach.

A physicochemical study of subcutaneous calcium deposits was performed in a patient with typical Thibierge-Weissenbach syndrome which had begun, ten years previously, with Raynaud's phenomenon and sclerodactylia. Calcium deposits had progressively developed, forming large plates on the arms, flanks and thighs. In the course of the disease they had become ulcerated, exuding a white, chalky material. X-ray films and xerograms demonstrated the extent of these deposits. The calcium-phosphorus balance was normal, and the other clinical and laboratory examinations were concordant with a diagnosis of Thibierge-Weissenbach syndrome (calcinosis). Only systemic corticosteroid therapy slowed down the pathological process; calcium chelating agents (diphosphonate) proved ineffective. The physicochemical study showed that the deposits consisted of carbonated apatite type B with the following formula: Ca8.0(PO4)4.1(CO3)1.2(HPO4)0.8 The mineral substance seemed to be less reactive and more stable than normal bone. This would account for the total lack of effectiveness of all treatments, notably calcium chelating agents, on the course of the deposits. Treatments usually produce bone demineralization before they influence the calcium deposits. This study provides much more detailed information than was hitherto available on calcium deposits and on carbonate ion contents in the apatite phase. The presence of carbonates increases the solubility and reactivity of calcium apatite.

Crystallographic identification of a calcium deposit in calcified pericarditis associated with articular chondrocalcinosis.

In a case of CPPD crystal deposition disease of the pseudorheumatoid type and of long duration, calcified constrictive pericarditis developed and was surgically treated. Analysis of the calcium deposit in the pericardium was carefully made by infrared absorption, x-ray diffraction, and thermogravimetry. It revealed that the deposit was composed of B-type carbonated apatite. Previously, both calcium pyrophosphate dihydrate (CPPD) and apatite crystals, either in the same place or in different tissues, have been reported in the same patient. These observations raise the possibility that the same metabolic error might lead to both types of crystal deposition.

[Crystal chemistry of two cases of subdeltoid calcification]. / Etude cristallochimique de deux calcifications sous-deltoidïennes.

We studied the mineral phase of two cases of subdeltoid calcification by thermogravimetry, infrared spectometry and X ray diffraction. We have shown that these were phosphates deficient in calcium ions with an apatite structure. They contained both carbonate ions and HPO4 ions in variable proportions from one sample to another. These phosphates are very similar both by their structure and their composition to phosphates in bony tissue. They differ by the fact that they are better crystallised than the latter.

[Tuberculosis of the uterus and adnexae. A retrospective study that has lasted 20 years (author's transl)]. / Tuberculose utéro-annexielle. Etude rétrospective durant les 20 dernières années.

The frequency of tuberculosis has considerably lessened and its localisation in the female genital organs has benefited by this happy result of immunisation by B.C.G. We have had 60 cases and carried out an analytical study on them and compared them with those of other authors. Great progress in therapy has allowed us to plan a coherent attitude by taking note of the normal way in which tuberculosis evolves and the correct measures for treating it in the uterus and adnexae.

[Cauterization of the uterine cervix: electrocauterization and cryotherapy]. / A propos de la coagulation du col utérin. Electrocoagulation, cryothérapie.

The authors review the controversies that still continue concerning electrocauterization of the uterine cervix. They emphasize the value of colposcopy in the evaluation of the cervix. This examination is indispensable in selecting the cases for treatment: ectropion and benign malpighian dysplasias are clear indications for cauterization. Contraindications and technical problems are discussed. The indications are given for bipolar biactive, and bipolar monoactive electrocauterization, respectively, or for electroresection by means of a metallic loop. The different cicatrization times after electrocauterization are reviewed as well as the possibility of sequelae: in certain cases sequelae can be more or less avoided by previous therapeutic precautions and by careful attention to the duration of cauterization. Cauterization of the uterine cervix by cryotherapy seems to be worthy of particular consideration: the first results are reported. It seems to be simpler to use than diathermocauterization and in the great majority of cases the results seem to have been good.