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Background and study aims In cases of inaccessible papilla, EUS-guided biliary drainage (EUS-BD) has been described as an alternative to calibrate benign biliary stenosis. However, few studies are available. Patients and methods This tw-center, retrospective study was designed to evaluate technical success and clinical success at 1 year. All patients who underswent EUS-BD without the rendezvous technique used for calibration of benign biliary stenosis were included from 2016 to 2022. Patients underwent EUS-hepaticogastrostomy (EUS-HGS) during the first session. Then, HGS was used to access the bile duct, allowing calibration of the stenosis: Dilation of the biliary stenosis and placement of double pigtail stents through the stenosis for 1 year. Results Thirty-six patients were included. Technical success was 89% (32/36), with four failures to cross the stenosis but EUS-HGS was performed in 100% of the cases. Nine patients were excluded during calibration because of oncological relapse in six and complex stenosis in three. Three patients had not yet reached 1 year of follow-up. Twenty patients had a calibration for at least 1 year. Clinical success after stent placement was considered in all cases after 1 year of follow-up. Thirteen patients underwent stent removal and no relapse occurred after 435 days of follow-up (SD=568). Global morbidity was 41.7% (15/36) with only one serious complication (needing intensive care), including seven cases of cholangitis due to intrabiliary duct obstruction and five stent migrations. No deaths were reported. Conclusions EUS-BD for calibration in case of benign biliary stenosis is an option. Dedicated materials are needed to decrease morbidity.
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2023 has been marked by numerous advancements in the fields of hepatology, liver transplantation, gastroenterology, and interventional endoscopy. These developments hold the promise of changing our daily practice while enhancing the diagnosis and treatment of various hepatic and gastroenterological conditions. Additionally, the European Association for the Study of the Liver (EASL) has issued recommendations for the management of hepatitis delta, acute-on-chronic liver failure, liver diseases of pregnancy, and intrahepatic cholangiocarcinoma. Risankizumab was approved by Swiss Authorities for patients with Crohn's disease and dupilumab was approved for patients with eosinophilic esophagitis. The European Society of Gastrointestinal Endoscopy (ESGE) has revised its recommendations regarding Barrett's esophagus.
2023 a été marquée par de nombreuses avancées dans le domaine de l'hépatologie, de la transplantation hépatique, de la gastroentérologie et de l'endoscopie interventionnelle. Ces développements promettent de changer notre pratique quotidienne dans le but d'améliorer le diagnostic et le traitement de nombreuses affections hépatiques et gastroentérologiques. En outre, la Société européenne d'hépatologie (EASL) a émis des recommandations pour la prise en charge de l'hépatite delta, de l'insuffisance hépatique aiguë sur chronique, des complications hépatiques de la grossesse et du cholangiocarcinome intrahépatique. Le risankizumab a été approuvé par Swissmedic pour le traitement de la maladie de Crohn et le dupilumab pour les patients avec Åsophagite à éosinophiles. La Société européenne d'endoscopie a mis à jour ses recommandations concernant l'Åsophage de Barrett.
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Insuficiência Hepática Crônica Agudizada , Neoplasias dos Ductos Biliares , Gastroenterologia , Feminino , Gravidez , Humanos , Ductos Biliares Intra-HepáticosRESUMO
Background: Current guidelines consider observation a reasonable strategy for G1 or G2 nonfunctional pancreatic neuroendocrine tumors (nf pNETs) ≤2 cm. We aimed to characterize their natural behavior and confront the data with the outcomes of patients undergoing upfront surgery. Methods: Data from patients with histologically confirmed nf pNETs ≤2 cm, managed at a single tertiary referral center between 2002 and 2020, were retrospectively reviewed. Results: Thirty-nine patients (mean age 62.1 years, 56% male) with 43 lesions (mean size 12.7±3.9 mm; 32 grade 1 [G1] and 7 grade 2 lesions [G2]) were managed by careful surveillance. Progression was observed in 15 lesions (35%; mean follow up 47 months). Six patients (18%) underwent secondary surgery because of an increase in tumor size or dilation of the main pancreatic duct; 3 of them had lymph node metastasis in the resected specimen. Surgery was followed by pancreatic fistula in 2/6 patients, 1 of whom died. Fourteen patients (mean age 59 years, 64.3% female, mean size of lesions 11.4±3.1 mm) underwent pancreatic surgery immediately after diagnosis. The surgery-associated complication rate was 57.1% (8/14). Of the 14 patients, 13 remained recurrence free (mean follow up 67 months). Recurrent metastatic disease was observed 3 years after pancreaticoduodenectomy (R0, 15 mm G2 lesion, 0 N+/8 N) in 1 patient. Conclusions: The behavior of small nf pNETs is difficult to predict, as there is evidence for malignant behavior in a subgroup of patients, even after surgical treatment. Optimal management remains challenging, as pancreatic surgery is associated with significant morbidity.
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BACKGROUND AND AIMS: The endoscopic workup of dysphagia can lead to the diagnosis of atypical esophagitis, with thickened esophageal mucosa, strictures, mucosal exudates, furrows, and sloughing. While these aspects suggest eosinophilic esophagitis, pathology might not report the presence of eosinophils, but rather chronic inflammation, with spongiosis, parakeratosis, and lymphocytic infiltrate. We aimed to report the management of this disease and assess the prevalence of associated dermatological conditions. METHODS: We retrospectively evaluated the medical records of our patients with non-eosinophilic stricturing esophagitis for clinical, endoscopy, and pathology data. Patients were evaluated by a dermatologist. A blood immunoassay and skin biopsy were performed if needed. RESULTS: Thirty-eight patients (twenty-six women) were included in the study. The median age at onset of symptoms was 56.5 years, with a median duration of symptoms of two years. Thirty-five patients presented with dysphagia at diagnosis and eighteen with weight loss. At endoscopy, a single esophageal stenosis was diagnosed in 19 patients, localized in the upper third in 22 patients. Thirty patients received endoscopic treatment (dilatation in 29/38 and local triamcinolone injection in 11/38 patients). In 21 patients, oral, skin or vulvo-anal lesions were found on dermatological examination. Nineteen patients received systemic treatment, including corticosteroids, immunosuppressive drugs and plasmapheresis. Five patients developed esophageal squamous cell carcinoma. CONCLUSION: The management of non-eosinophilic chronic stricturing esophagitis is challenging, because of a low contribution of esophageal biopsies and the refractory nature of the strictures. In our experience, a dermatological evaluation helped in 55% of cases to introduce a systemic treatment, leading to limit the use of endoscopic dilatation. Endoscopic follow-up is needed, considering the significant risk of esophageal squamous cell carcinoma.
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BACKGROUND: Endoscopic Ultrasound (EUS) represents the gold standard for initial drainage of pancreatic fluid collections (PFC) due to various etiologies. However, data concerning salvage EUS drainage after initial percutaneous drainage are limited. The purpose of our study was to evaluate the clinical outcomes and safety of EUS-guided drainage of pancreatic collections after failure of percutaneous drainage. METHODS: This retrospective study was conducted in a single, tertiary university center from August 2013 to January 2020. Indication was pancreatic collection after acute pancreatitis with PFC requiring EUS-guided drainage after failure of percutaneous drainage. RESULTS: Twenty-two patients with PFC after acute pancreatitis were included (mean age 64.1 ± 11.3 years) of which 4/22 (18.2%) had pancreatic pseudocyst and 18/22 (81.8%) presented with a walled-off necrosis. Seventy-six interventions were performed among the 22 patients. Lumen-Apposing Metal Stent (LAMS) were used in 5/22 (22.7%) and double pigtail plastic stents in 17/22 (77.3%) of interventions with a median number intervention of 3 per patient (range 1 to 7). Technical success rate was 98.7% (75/76) with an overall clinical success of 81.8% (18/22). Procedure related adverse events rate was 9.1% (2/22) including one bleeding and one pancreatic fistula. Two non-procedure related deaths were observed. CONCLUSION: EUS-guided pancreatic collection drainage is clinically effective and safe after clinical/technical failure of radiological percutaneous management.
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Pseudocisto Pancreático , Pancreatite , Humanos , Pessoa de Meia-Idade , Idoso , Pancreatite/etiologia , Pancreatite/cirurgia , Estudos Retrospectivos , Doença Aguda , Resultado do Tratamento , Pseudocisto Pancreático/diagnóstico por imagem , Pseudocisto Pancreático/cirurgia , Pseudocisto Pancreático/etiologia , Drenagem/métodos , Necrose/etiologia , Necrose/cirurgia , Ultrassonografia de IntervençãoRESUMO
Circumferential endoscopic resection (ER) of the esophageal mucosa could find its place in the treatment of dysplastic Barrett's esophagus or extensive squamous cell neoplasia. However, the occurrence of esophageal strictures remains a major complication after ER exceeding 75% of the circumference. The aim of this study was to assess the effect of a modified, pH = 2, self-assembling peptide matrix (4[Arg-Ala-Asp-Ala]) (SAP) on the development of esophageal stricture after circumferential ER in a swine model. We performed a circumferential ER in 35 swine under general anesthesia. Five animals were included in the control group, 11 animals received the SAP matrix immediately after the resection, and 11 received the SAP matrix associated to a local steroid immediately after the resection. Follow-up endoscopy and esophagogram were performed before slaughter and necropsy at day 14. Eight treated animals were kept alive until day 28. At day 14, 27% of the animals in the SAP group developed a symptomatic stricture versus 100% in the control group (P = 0.008) and 50% in the SAP-triamcinolone group (P = 0.11). Application of an SAP matrix after circumferential ER in the swine allowed a significant reduction of the incidence of symptomatic stricture at day 14. Adding triamcinolone brought no significant improvement.
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Esôfago de Barrett , Ressecção Endoscópica de Mucosa , Neoplasias Esofágicas , Estenose Esofágica , Animais , Ressecção Endoscópica de Mucosa/efeitos adversos , Mucosa Esofágica , Neoplasias Esofágicas/cirurgia , Estenose Esofágica/etiologia , Estenose Esofágica/prevenção & controle , Peptídeos , SuínosRESUMO
INTRODUCTION: Endoscopic ultrasonography (EUS) is advised in the workup of achalasia patients to rule out secondary achalasia or pseudoachalasia, and search for a typical esophageal wall thickening. The purpose of this study was to assess the clinical contribution of EUS findings in achalasia and other esophageal motility disorders (EMD). METHODS: We conducted a single center retrospective study at a tertiary referral centre. We included all patients with an EUS for the workup of a suspected EMD from January 2012 to December 2017. RESULTS: Sixty-nine patients were included, 52% were men, with a median (±SD) age of 61 ± 14 years. Median (±SD) Eckardt Score was 7 ± 2. EUS was normal in 26 (38%) patients, and showed an esophageal wall thickening in 43 (62%) patients. Three cases of secondary achalasia were diagnosed at mucosal biopsies: 2 esophageal carcinomas and one eosinophilic esophagitis. Esophageal wall thickening was not significantly associated with the type of EMD or achalasia subtype and there was no statistical correlation between the presence of a wall thickening at EUS and therapeutic outcomes. CONCLUSION: In our work, the presence of an esophageal wall thickening was not predictive of the type of EMD nor achalasia subtype or treatment outcome. The contribution of endoscopic ultrasonography in achalasia and other EMD seems limited.
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Endossonografia , Transtornos da Motilidade Esofágica/diagnóstico por imagem , Idoso , Acalasia Esofágica/diagnóstico por imagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
INTRODUCTION: Circumferential endoscopic submucosal dissection (ESD) allows to treat large esophageal superficial neoplasms, however with a high occurrence of severe esophageal strictures. In a previous work, we demonstrated that the application of a prototype of self-assembling peptide (SAP) matrix on esophageal wounds after a circumferential-ESD delayed the onset of esophageal stricture in a porcine model. The aim of this work was to consolidate these results using the commercialized version of this SAP matrix currently used as a hemostatic agent. ANIMALS AND METHODS: Eleven pigs underwent a 5 cm-long circumferential esophageal ESD under general anesthesia. Five pigs were used as a control group and six were treated with the SAP. In the experimental group, 3.5 mL of the SAP matrix were immediately applied on the ESD wound. Stricture rates and esophageal diameter were assessed at day 14 by endoscopy and esophagram, followed by necropsy and histological measurements of inflammation and fibrosis in the esophageal wall. RESULTS: At day 14, two animals in the treated group had an esophageal stricture without any symptom, while all animals in the control group had regurgitations and an esophageal stricture (33 vs. 100%, p = 0.045). In the treated group, the mean esophageal diameter at day 14 was 9.5 ± 1 mm vs. 4 ± 0.6 mm in the control group (p = 0.004). Histologically, the neoepithelium was longer in the SAP treated group vs. the control (3075 µm vs. 1155µm, p = 0.014). On immunohistochemistry, the expression of alpha smooth muscle actin was lower in the treated vs. control group. CONCLUSION: Apposition of a self-assembling peptide matrix immediately after a circumferential esophageal ESD reduced by 67% the occurrence of a stricture at day 14, by promoting reepithelialization of the resected area.
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Ressecção Endoscópica de Mucosa/métodos , Estenose Esofágica/prevenção & controle , Peptídeos/farmacologia , Animais , Mucosa Esofágica/patologia , Estenose Esofágica/patologia , Esofagoscopia/métodos , Esôfago/patologia , Feminino , Fibrose , Hemostáticos , Masculino , Modelos Animais , Peptídeos/uso terapêutico , Complicações Pós-Operatórias/prevenção & controle , Reepitelização/efeitos dos fármacos , SuínosRESUMO
Radiofrequency ablation is a recommended treatment option for residual Barrett's esophagus after endoscopic resection of a visible lesion. We herein report 3 cases of esophageal adenocarcinoma arising during the course of radiofrequency ablation, all of which were successfully resected by endoscopic submucosal dissection. Partial or suboptimal response to radiofrequency ablation or early recurrence of Barrett's mucosa after radiofrequency ablation should raise suspicion for adenocarcinoma and lead to consideration of en bloc resection by endoscopic submucosal dissection.
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Vascular endothelial growth factor inhibitors, led by bevacizumab, are considered the cornerstone of the therapy in metastatic colorectal carcinoma. We present the case of a patient with metastatic colorectal cancer who experienced rapid tumour growth with liver broad invasion after the withdrawal of an antivascular endothelial growth factor therapy, aflibercept. The rebound effect caused by the residual tumour inducing a regrowth after an initial controlled disease has already been stressed in mice and metastatic colorectal cancer patients following bevacizumab interruption. The use of liver volume evaluation was consistent with the Response Evaluation Criteria in Solid Tumours 1.1 criteria evaluation and might be a useful tool in patients with more than a half liver invasion. We describe for the first time the case of a major liver disease progression, confirmed by Response Evaluation Criteria in Solid Tumours 1.1 criteria and liver volume evaluation, after an antiangiogenic interruption in second line.
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Adenocarcinoma/irrigação sanguínea , Adenocarcinoma/patologia , Protocolos de Quimioterapia Combinada Antineoplásica/efeitos adversos , Neoplasias Colorretais/irrigação sanguínea , Neoplasias Colorretais/patologia , Adenocarcinoma/tratamento farmacológico , Protocolos de Quimioterapia Combinada Antineoplásica/administração & dosagem , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Bevacizumab/administração & dosagem , Bevacizumab/efeitos adversos , Neoplasias Colorretais/tratamento farmacológico , Fluoruracila/administração & dosagem , Fluoruracila/efeitos adversos , Humanos , Leucovorina/administração & dosagem , Leucovorina/efeitos adversos , Masculino , Pessoa de Meia-Idade , Neovascularização Patológica/tratamento farmacológico , Neovascularização Patológica/metabolismo , Neovascularização Patológica/patologia , Compostos Organoplatínicos/administração & dosagem , Compostos Organoplatínicos/efeitos adversos , Receptores de Fatores de Crescimento do Endotélio Vascular/administração & dosagem , Proteínas Recombinantes de Fusão/administração & dosagem , Proteínas Recombinantes de Fusão/efeitos adversos , Fator A de Crescimento do Endotélio Vascular/antagonistas & inibidores , Fator A de Crescimento do Endotélio Vascular/metabolismoRESUMO
The treatment of cirrhosis is based partly on the treatment of the causes and partly on the prevention and treatment of the complications. In cases of serious, life-threatening illness, a transplant must be envisaged.