Long-term follow-up after biliary stent placement for postcholecystectomy bile duct strictures: a multicenter study.

BACKGROUND AND STUDY AIMS: Endoscopic stenting is a recognized treatment of postcholecystectomy biliary strictures. Large multicenter reports of its long-term efficacy are lacking. Our aim was to analyze the long-term outcomes after stenting in this patient population, based on a large experience from several centers in France. METHODS: Members of the French Society of Digestive Endoscopy were asked to identify patients treated for a common bile duct postcholecystectomy stricture. Patients with successful stenting and follow-up after removal of stent(s) were subsequently included and analyzed. Main outcome measures were long-term success of endoscopic stenting and related predictors for recurrence (after one stenting period) or failure (at the end of follow-up). RESULTS: A total of 96 patients were eligible for inclusion. The mean number of stents inserted at the same time was 1.9±0.89 (range 1-4). Stent-related morbidity was 22.9% (n=22). The median duration of stenting was 12 months (range 2-96 months). After a mean follow-up of 6.4±3.8 years (range 0-20.3 years) the overall success rate was 66.7% (n=64) after one period of stenting and 82.3% (n=79) after additional treatments. The mean time to recurrence was 19.7±36.6 months. The most significant independent predictor of both recurrence and failure was a pathological cholangiography at the time of stent removal. CONCLUSION: Endoscopic stenting helps to avoid surgery in more than 80% of patients bearing postcholecystectomy common bile duct strictures. However, a persistent anomaly on cholangiography at the time of stent removal is a strong predictor of recurrence and may lead to consideration of surgery.

A machine learning tool for re-planning and adaptive RT: A multicenter cohort investigation.

PURPOSE: To predict patients who would benefit from adaptive radiotherapy (ART) and re-planning intervention based on machine learning from anatomical and dosimetric variations in a retrospective dataset. MATERIALS AND METHODS: 90 patients (pts) treated for head-neck cancer (H&N) formed a multicenter data-set. 41 H&N pts (45.6%) were considered for learning; 49 pts (54.4%) were used to test the tool. A homemade machine-learning classifier was developed to analyze volume and dose variations of parotid glands (PG). Using deformable image registration (DIR) and GPU, patients' conditions were analyzed automatically. Support Vector Machines (SVM) was used for time-series evaluation. "Inadequate" class identified patients that might benefit from replanning. Double-blind evaluation by two radiation oncologists (ROs) was carried out to validate day/week selected for re-planning by the classifier. RESULTS: The cohort was affected by PG mean reduction of 23.7±8.8%. During the first 3weeks, 86.7% cases show PG deformation aligned with predefined tolerance, thus not requiring re-planning. From 4th week, an increased number of pts would potentially benefit from re-planning: a mean of 58% of cases, with an inter-center variability of 8.3%, showed "inadequate" conditions. 11% of cases showed "bias" due to DIR and script failure; 6% showed "warning" output due to potential positioning issues. Comparing re-planning suggested by tool with recommended by ROs, the 4th week seems the most favorable time in 70% cases. CONCLUSIONS: SVM and decision-making tool was applied to overcome ART challenges. Pts would benefit from ART and ideal time for re-planning intervention was identified in this retrospective analysis.

Treatment of Leaks Following Sleeve Gastrectomy by Endoscopic Internal Drainage (EID).

BACKGROUND: Leaks are considered one of the major complications of laparoscopic sleeve gastrectomy (LSG) with a reported rate up to 7 %. Drainage of the collection coupled with SEMS deployment is the most frequent treatment. Its success is variable and burdened by high morbidity and not irrelevant mortality. The aim of this paper is to suggest and establish a new approach by endoscopic internal drainage (EID) for the management of leaks. METHODS: Since March 2013, 67 patients presenting leak following LSG were treated with deployment of double pigtail plastic stents across orifice leak, positioning one end inside the collection and the other end in remnant stomach. The aim of EID is to internally drain the collection and at the same time promote leak healing. RESULTS: Double pigtails stent were successfully delivered in 66 out of 67 patients (98.5 %). Fifty patients were cured by EID after a mean time of 57.5 days and an average of 3.14 endoscopic sessions. Two died for event not related to EID. Nine are still under treatment; five failure had been registered. Six patients developed late stenosis treated endoscopically. CONCLUSIONS: EID proved to be a valid, curative, and safe mini-invasive approach for treatment of leaks following SG. EID achieves complete drainage of perigastric collections and stimulates mucosal growth over the stent. EID is well tolerated, allows early re-alimentation, and it is burdened by fewer complications than others technique. Long-term follow-up confirms good outcomes with no motility or feeding alterations.

Perinatal mortality and morbidity in premature birth.

In a study carried out in 100 cases of premature birth in Section "A" of the Department of Gynecology and Obstetrics of the University of Turin, the authors report a perinatal mortality rate of 5.4%. Perinatal morbidity was found to be very high (68.2%). These findings--which are perfectly in line with those reported in the literature--explain why premature birth is one of the most important topics of research in modern obstetrics.

[Laparoscopic cholecystectomy and lithiasis of the common bile duct: prospective study on the importance of preoperative endoscopic ultrasonography and endoscopic retrograde cholangiography]. / Cholécystectomie laparoscopique et lithiase de la voie biliaire principale: étude prospective sur l'intérêt de l'écho-endoscopie et de la cholangiographie rétrograde endoscopique préopératoires.

OBJECTIVES: Laparoscopic cholecystectomy is the standard treatment of symptomatic gallstones. At present, no consensus has been reached on the diagnostic and therapeutic methods of concomitant common bile duct stones. Systematic preoperative endoscopic ultrasonography followed, if necessary, by endoscopic retrograde cholangiography and sphincterotomy during the same anesthetic procedure could be a diagnostic and therapeutic alternative for common bile duct stones making possible a laparoscopic cholecystectomy without intraoperative investigation of the common bile duct. METHODS: One hundred and twenty-five patients underwent a prospective endoscopic ultrasonographic evaluation prior to laparoscopic cholecystectomy for symptomatic gallstones. Fourty-four patients (35%) had at least one predictive factor for common bile duct stones. Endoscopic ultrasonography and cholecystectomy were performed on the same day. Endoscopic ultrasonography was followed by endoscopic retrograde cholangiography and sphincterotomy by the same endoscopist in case of common bile duct stones on endoscopic ultrasonography. Patients were routinely followed up between 3 and 6 months and one year after cholecystectomy. RESULTS: Endoscopic ultrasonography suggested common bile duct stones in 21 patients (17%). Endoscopic ultrasonography identified a stone in 17 of 44 patients (38.6%) with predictor of common bile duct stones and only in 4 of 81 patients (4.9%) without predictor of common bile duct stone. Among these 21 patients, one patient was not investigated with endoscopic retrograde cholangiography because of the high risk of sphincterotomy, 19 patients had a stone removed after sphincterotomy, one patient had no visible stone neither on endoscopic retrograde cholangiography, nor on exploration of the common bile duct after sphincterotomy. Endoscopic ultrasonography was normal in 104 patients (83%). However, two patients in this group were investigated with endoscopic retrograde cholangiography because endoscopic ultrasonography was incomplete in one case and because endoscopic ultrasonography was normal in the second case but a stone in the left hepatic duct was detected by ultrasonography. A stone was removed after endoscopic sphincterotomy in these two patients. In the group of 102 patients without stone, 91 out of 92, continued to be asymptomatic during a median follow-up of 8.5 months. One patient with symptoms one month after cholecystectomy underwent endoscopic sphincterotomy but no stone was found. CONCLUSIONS: Systematic preoperative endoscopic ultrasonography followed, if necessary with endoscopic retrograde cholangiography and sphincterotomy is a diagnostic and therapeutic alternative for common bile duct stones making possible a laparoscopic cholecystectomy without intraoperative investigation of the common bile duct for all patients. This alternative is only justifiable in patients with predictor of common bile duct stones.

[Endoscopy in tumors of the Oddi region. Diagnostic and therapeutic possibilities]. / Endoscopie dans les tumeurs de la région oddienne. Possibilités diagnostiques et thérapeutiques.

Between 1976 and 1983, 92 patients (mean age: 70 years) with ampullary or periampullary tumors, were evaluated by endoscopic procedures. The ampulla appeared malignant in 66 p. 100 of cases, enlarged but not obviously malignant in 15 p. 100 and normal in 18 p. 100. In one case, a tight duodenal stenosis prevented the endoscopist from seeing the ampulla. ERCP was performed in 70 patients and the common bile duct was opacified in 63 cases; it was dilated in 60 patients. Two types of tumors could be distinguished: 67 p. 100 grew within the duodenum and were seen by duodenoscopy and 33 p. 100 grew outside the duodenum and ERCP opacified a dilated common bile duct above a stenotic region; in these cases, diagnosis was established by biopsies performed through the ampulla, after endoscopic sphincterotomy (EST). Biopsy specimens were obtained in 67 p. 100 of cases and yielded a diagnosis of adenocarcinoma in 59 p. 100, questionable carcinoma in 15 p. 100, benign tumor in 16 p. 100 and normal mucosa in 10 p. 100. In 8 patients with the preoperative diagnosis of non-malignant tumor, operative biopsies finally revealed carcinoma in 7. EST or infundibulotomy was performed in 42 patients with 2 deaths from hemorrhage and cholangitis. Twenty-three patients received only EST as final treatment with complete disappearance of jaundice and/or cholangitis in 70 p. 100. Our results confirm the efficacy of duodenoscopy, ERCP and EST in the diagnosis and sometimes in the treatment of ampullary and periampullary tumors.

[Fascioliasis of the common bile duct: endoscopic ultrasonographic diagnosis and endoscopic sphincterotomy]. / Distomatose de la voie biliaire principale: diagnostic écho- endoscopique et traitement par sphinctérotomie endoscopique.

Two cases of biliary fasciolasis are reported. The patients presented with biliary pain and/or acute pancreatitis. Pre-operative ultrasound endoscopy showed main bile duct dilation and linear elongated echogenic structures in the common bile duct lumen. Endoscopic retrograde cholangiography and endoscopic sphincterotomy were performed. Parasites were endoscopically removed resulting in disappearance of symptoms and biological abnormalities. Serological tests and pathological examination confirmed the presence of Fasciola hepatica. During follow-up, stool examination failed to show any Fasciola hepatica eggs, and in one case, serology became negative. This report emphasizes the value of ultrasound endoscopy in the diagnosis of unsuspected biliary fasciolasis. This report also confirms the therapeutic role of endoscopic sphincterotomy in patients with obstructive biliary fasciolasis.

[Results of endoscopic sphincterotomy in common bile duct lithiasis]. / Résultats de la sphinctérotomie endoscopique pour lithiase de la voie biliaire principale.

Endoscopic sphincterotomy (ES) was attempted in 409 patients with common bile duct stone(s) (CBDS). The mean age of patients was 72.0 +/- 0.8 years (m +/- SEM); 47 p. 100 presented risk factors; 57 p.100 had previously been cholecystectomized while 43 p. 100 had not. On an average, patients in the former group were older (80 +/- 0.7 years) than in the latter 65.4 +/- 1.0 years, p less than 0.001). The procedure was successful in 98 p. 100 of the patients, after a standard ES in 78.5 p. 100 or after different technical artifices in 21.5 p. 100. The vacuity of the CBD was obtained in 96.5 p. 100 of the cases. During the first month after the ES, 13 p. 100 of the patients had complications and 4 p. 100 died; 37 complications (9 p. 100) were related to the ES and were responsible for death in 4 patients: 18 episodes of bleeding at the site of ES, 7 acute pancreatitis, 6 cholangitis, 4 retroperitoneal perforations and 2 other complications. The occurrence of these complications was closely related to the technique of ES being more frequent after technical artifices than after a standard ES (p less than 0.001). On the other hand, these complications occurred independently of the age of patients or of previous cholecystectomy. Seventeen complications (4 p. 100) did not depend directly on ES and were responsible for death in 14 patients (3 p. 100): pneumopathy, pulmonary embolism.(ABSTRACT TRUNCATED AT 250 WORDS)

[Granular cell tumor of the common bile duct. Contribution of endoscopic ultrasonography in 2 cases]. / Tumeurs à cellules granuleuses de la voie biliaire principale. Apport de l'écho-endoscopie dans 2 cas.

We report two cases of granular cell tumors involving the common bile duct in patients presenting with obstructive jaundice. Pre-operative endoscopic ultrasonography showed short asymmetric stricture with small well delimited hypoechoic mass in the distal common bile duct wall and proximal dilatation. These tumors were misdiagnosed as a bile duct carcinoma in one case and biliary metastasis of a melanoma in the other. Histological examination of the resected specimen showed granular cell tumors. A review of the previously reported cases shows that preoperative diagnosis is uncommon. It should be considered when endoscopic ultrasonography performed for biliary obstruction in a young woman shows a small and well limited hypoechoic mass.

[Value of echotomography for the diagnosis of lithiasis of the common bile duct]. / Valeur de l'échotomographie pour le diagnostic de lithiase de la voie biliaire principale.

The accuracy of ultrasonography (US) for the diagnosis of cholelithiasis and for dilatation of the intra- and extra-hepatic biliary tree is well known. However, the value of US for the diagnosis of common bile duct stones remains poorly defined. We performed a prospective study in 100 patients who were referred for endoscopic retrograde cholangiopancreatography (ERCP); all the examinations were carried out by the same sonographist in the 24 h preceding the ERCP. Fifty patients had choledocholithiasis, 20 patients had obstruction of the bile ducts without lithiasis and the common bile duct (CBD) was free in 30 patients. The sensitivity of US for the diagnosis of choledocholithiasis was 40 p. 100, the specificity 90 p. 100. The positive and negative predictive values of the "CBD stone" sign was 80 p. 100 and 60 p. 100 respectively. In a total of 30 false negatives, the CBD could not be explored in 4 cases, dilatation of the CBD was missed in one case, and obstruction of the CBD by an other disease was diagnosed in 2; in all the other cases, US was able to appreciate the CBD size as well as the ERCP. In the 20 patients with an obstructed CBD but without choledocholithiasis, US diagnosed a stone in 5 cases. Age, serum bilirubin, existence of a previous cholecystectomy, technical difficulties, stone size were comparable in patients with true positive tests and in patients with false negative tests. However the diagnosis of choledocholithiasis was more frequently achieved in patients with dilated CBD over 10 mm (p less than 0.05) and in patients with multiple stones.(ABSTRACT TRUNCATED AT 250 WORDS)

[Inflammatory fibroid polyps of the colon]. / Polypes fibro-inflammatoires du côlon.

Inflammatory fibroid polyp is an uncommon lesion involving the stomach, the small bowel and occasionally the colon. Inflammatory fibroid polyp is a large polypoid lesion arising from the submucosa. It has no malignant potential although extensive infiltration may occur. The main histological characteristics are diffuse inflammatory infiltrate with eosinophils and highly vascularized fibrocytic stroma. Immunohistochemistry is always positive for vimentine and negative for S 100 and desmin. We report four cases of inflammatory fibroid polyps, 3 of which mimicked carcinoma of the colon. Exploratory laparotomy and histopathological examination of the resected specimen were necessary to confirm definitive diagnosis. In the last case, diagnosis was established by histological examination of an endoscopically-removed colonic polyp.

[MRI cholangiography with rapid spin-echo technique: prospective evaluation of 20 patients]. / Cholangio-IRM en écho de spin rapide: évaluation prospective chez 20 patients.

PURPOSE: To evaluate a MR cholangiographic technique using a non breath-hold fast spin-echo technique in patients with suspected bile duct obstruction. MATERIAL AND METHODS: Twenty patients with suspected bile duct obstruction were prospectively investigated with MR cholangiography using a T2-weighted non breath-hold fast spin-echo technique (TR = 8000-9000 mse, effective TE = 120-266 msec, ETL = 16-32, acquisition time = 1-3 min) with a body coil. Results of MR cholangiography were compared to those obtained with endoscopic retrograde cholangiography (n = 20 patients) and endoscopic sonography (n = 12 patients) that were considered as reference. RESULTS: MR cholangiography provided high-quality images in 19 out of 20 cases (95%). MR cholangiography had 100% sensitivity, 100% specificity and 100% accuracy in the diagnosis of bile duct dilation. MR cholangiography had 73% sensitivity, 75% specificity and 73% accuracy in the diagnosis of bile duct obstruction. MR cholangiography failed to depict small stones (< 3 mm) of the main bile duct in 4 cases in which no bile duct dilatation was found. CONCLUSION: MR cholangiography using a non breath-hold fast spin-echo technique depicts bile duct dilatation with a degree of accuracy comparable to that achieved with endoscopic examination. In the absence of bile duct dilatation, small stones of the main bile duct may be undetected with MR cholangiography.

[Colorectal villous tumors. Treatment by electro-resection and laser photocoagulation. 134 cases]. / Tumeurs villeuses colo-rectales. Traitement par électro-résection et photocoagulation au laser. 134 observations.

Endoscopic snare resection prior to Nd:YAG laser photocoagulation was used to treat benign colorectal villous adenoma. One hundred and thirty four patients were included in the study: 72 with surgical contraindications, 61 for whom surgical resection appeared to be too drastic and 1 who refused surgery. Treatment sessions were repeated every fifteen days until total tumour destruction was achieved. A carcinoma was detected in biopsy specimens obtained during endoscopic treatment of seven patients. Eight patients were lost to follow up. Treatment results could be analysed in 119 patients. A successful treatment was achieved in 108 patients. Tumour destruction was complete in 85.4 percent of the cases with lesions of at least 4 cm in diameter and in 94.3 percent of the cases with smaller lesions. During the average 101 weeks follow up period, 15.7 percent of the patients with total tumour destruction had recurrence. The risk of recurrence was correlated with the number of initial treatment sessions and previous surgical treatment. It would appear that endoscopic resection prior to Nd:YAG laser photocoagulation is a safe and effective method for the destruction of colorectal villous adenomas.

[Prevention of hemorrhagic recurrences caused by rupture of esophageal varices, with endoscopic ligation. Prospective study of 50 patients]. / Prévention par ligatures élastiques des récidives hémorragiques par rupture de varices oesophagiennes. Etude prospective de 50 patients.

OBJECTIVES: Endoscopic sclerotherapy is effective to prevent bleeding of oesophageal varices but is associated with frequent adverse effects. Endoscopic ligation represents a new endoscopic alternative treatment to sclerotherapy. The purpose of this study was to assess efficacy and safety of endoscopic variceal ligation in 50 consecutive patients with cirrhosis who had recently bled from oesophageal varices. METHODS: Patients were followed from 6 to 1140 days (median 310 days). Nine patients were bleeding actively when ligation was performed. RESULTS: Eleven patients (22%) had 13 recurrent bleedings requiring blood transfusion during follow-up. Six recurrences occurred during the first month (3 from bleeding varices, 3 treatment-induced); seven recurrences occurred latter (6 from bleeding varices, 1 treatment-induced). Varices were eradicated in 33 patients (66% of all patients, 82% of patients who survived more than 30 days). Variceal eradication was achieved in 2-9 endoscopic ligation sessions (median 3). Eighteen patients died during the study; one died from bleeding. No patient developed major complications; five patients only complained of mild dysphagia for 24 to 48 hours. CONCLUSION: Endoscopic ligation is a safe and effective method to prevent recurrent bleeding from oesophageal varices.