Review of current therapy of pancreatic pseudocysts.

BACKGROUND AND AIMS: Therapeutic interventions for complicated pancreatitis, especially in pseudocysts and walled-off necroses as a sequel of necrotizing pancreatitis, have a long history. Originally a stronghold of classical surgery and radiology, in the last two decades this was increasingly supplemented by endoscopy, often with adjuvant percutaneous drainage, mostly reducing open surgery to a salvage intervention in case of failure and complication. This study aims to evaluate and compare the current therapeutic options for pancreatic fluid collections, especially pseudocysts. METHODS: Systematic literature search via MedLine and Pubmed was performed with comprehensive tabulations of original publications of the endoscopic, surgical and percutaneous therapeutic interventions in pancreatic pseudocysts and WON in the last 27 years. Only studies including more than 10 cases were further analysed. The results with regard to complications, outcome, recurrence and mortality were analysed for each approach, the risk of bias was assessed and a conclusive statement was made. RESULTS: The initial literature search identified 46 studies. 12 studies had to be excluded because the number of individuals included was too low. 34 endoscopic, 8 surgical and 8 percutaneous studies were further analysed, leading to a number of 2485 patients in this review. The short-term clinical success was 85 % for the endoscopic approach, 83 % for surgery and 67 % for the percutaneous intervention. The complication rates were 16 %, 45 % and 34 % for endoscopic, surgical and percutaneous therapy, respectively. Typical complications were hemorrhage, infection, perforation and, especially in the percutaneous approach, pancreatocutaneous fistulisation. CONCLUSION: According to the high success and low complication rates the endoscopic intervention appears as the most efficient method. But each method has its own indications, restrictions and therefore patient groups. Therefore it is reasonable to consider all the available methods in a productive interdisciplinary manner for the ultimate benefit of the patient in the future.

[Acute pancreatitis]. / Akute Pankreatitis.

Acute pancreatitis is a potentially fatal disease with individually differing expression of systemic involvement. For this reason early diagnosis with subsequent risk stratification is essential in the clinical management of this frequent gastroenterological disorder. Severe forms of acute pancreatitis occur in approximately 20 % of cases often requiring intensive care monitoring and interdisciplinary therapeutic approaches. In the acute phase adequate fluid replacement and sufficient analgesic therapy is of major therapeutic importance. Concerning the administration of antibiotics and the nutritional support of patients with acute pancreatitis a change in paradigms could be observed in recent years. Furthermore, endoscopic, radiological or surgical interventions can be necessary depending on the severity of the disease and potential complications.

Selective tissue elevation by pressure for endoscopic mucosal resection of colorectal adenoma: first clinical trial.

BACKGROUND: Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection of large lateral spreading tumors currently are technically limited by complications such as bleeding, perforation, and disturbed large procedural sites, leading to incomplete resection and secondary surgery. Further technical improvements are necessary. The authors previously demonstrated the effectiveness of a focused water jet for elevation of the lamina submucosa in animal studies. For the first time, the clinical application of selective tissue elevation by pressure (STEP) for the treatment of colorectal adenomas as a prospective single-arm human trial is presented. METHODS: This trial evaluated 59 patients who had primary colorectal adenomas with diameters exceeding 12 mm classified as 0-IIa or 0-IIb according to Paris classification. A submucosal cushion was created with a flexible water jet applicator using the Helix HydroJet. The adenoma was subsequently resected with a mucosal resection snare. All results were recorded. The resected specimens were assessed histologically. RESULTS: A total of 59 patients underwent resection of 70 lesions with a maximum diameter of 80 mm (mean, 27 mm). Submucosal elevation with the water jet dissector was possible in all cases and locations from the pectinate line to the ileocecal valve. Of the 70 lesions, 64 (91%) were resected completely in one session. Histologically, the resected specimens were found to be adenocarcinomas (n = 2, 3%), adenomas with high-grade intraepithelial neoplasia (n = 24, 34%), adenomas with low-grade intraepithelial neoplasia (n = 38, 54%), and hyperplastic polyps (n = 6, 9%). Hemostasis during the resection was necessary in 24 cases (34%). No perforation required surgical intervention. CONCLUSION: This first clinical trial to analyze STEP technique demonstrated that STEP used to elevate large mucosal lesions in any location is feasible and facilitates EMR for colorectal adenoma.

Sex differences in obstructive sleep apnoea in an elderly French population.

Obstructive sleep apnoea (OSA) affects females and males differently, and increases in prevalence with age. The aim of the present study was to characterise clinical, anthropometric and polygraphic sex differences in a large elderly OSA population. A total of 641 subjects aged 68 yrs were examined. Measurements of fat mass, using dual-energy X-ray absorptiometry (DEXA) and polygraphy, were obtained in all subjects. An apnoea/hypopnoea index (AHI) of >15 events·h⁻¹ identified the presence of OSA. OSA was diagnosed in 57% of the sample, 34% having a mild form and 23% having an AHI of >30 events·h⁻¹. Females with OSA exhibited a lower AHI, less severe hypoxaemia and greater peripheral fat mass, and frequently reported anxiety and depression. Comparison of females with and without OSA did not reveal significant differences in clinical, anthropometric and DEXA data. After adjustment for body mass index, hypertension, diabetes, smoking, anxiety and depression, logistic regression analysis revealed that the presence of hypertension was significantly associated with OSA risk in females (OR 1.52, p = 0.04). In a general community healthy population, the prevalence of undiagnosed OSA in females increases with age, with a risk similar to that in males. In females, the clinical spectrum, anthropometric data and fat distribution appear to be more sex-related than OSA-dependent. The occurrence of OSA contributes to hypertensive risk in elderly females.

Management of osteoporosis in fracture liaison service associated with long-term adherence to treatment.

SUMMARY: Adherence to osteoporosis treatment is not satisfactory. Our study evaluated persistence and compliance with these treatments prescribed specifically in the context of a fracture liaison service (FLS), an internal health care network, and showed that this type of organization in our institution was associated with high level of adherence. INTRODUCTION: Medical management of patients with a fragility fracture has been improved by health care internal network or FLS organized in large hospitals. However, treatment effectiveness is not only related to larger initiation rate but also to better long-term adherence. Therefore, we evaluated persistence and compliance in the context of osteoporosis treatment initiated in our institution's FLS, among postmenopausal women with a peripheral fragility fracture. METHODS: Patients with a specific osteoporosis treatment prescribed while visiting our FLS were contacted by phone to answer an evaluation questionnaire. A simplified questionnaire was sent to their general physicians when we were not able to reach patients on the phone. RESULTS: Of the 279 selected patients, 155 were evaluated. Of them, 90.3% had actually started their treatment and 80% were still under treatment after 1 year. After 27.4 ± 11.7 months of follow-up, 67.7% of patients were persistent with their treatment. In addition, 87% of the persistent patients declared to respect both treatment posology and administration conditions. Occurrence of adverse events was the first cause of treatment interruption within the first 6 months. CONCLUSIONS: Our data showed a high level of persistence with osteoporosis treatment when initiation was performed in an FLS, even on a long-term basis. Since follow-up and renewal of treatment were under routine daily practise, our study underlines how important the first prescription conditions are and provides additional interest in medical care network such as FLS.

Temporary cystogastrostomy with self-expanding metallic stents for pancreatic necrosis.

Conventional endoscopic drainage of symptomatic pancreatic pseudocysts has its limitations when the content of the collection is nonfluid. This leads to obstruction of placed flap stents; it requires the placement of an irrigation catheter and repeated implantation of several stents. Herein we describe the temporary use of a special self-expanding partially covered metal mesh stent, which was designed to keep the pancreaticogastrostomy open for drainage of walled-off necrosis and for further endoscopic necrosectomies. The stent has a diameter of 20-25 mm and a length of 50 mm and was placed following the first transgastric removal of necrotic masses. After a treatment period of 7-11 days involving 2-3 endoscopic procedures we achieved clinical success, defined as complete removal of necrotic masses, in all cases without major complications.

[Toluidin blue in gastrointestinal endoscopy]. / Toluidinblau in der gastrointestinalen Endoskopie.

For decades, methylene blue has been used in gastrointestinal endoscopy as an absorbing dye, it was, however, not approved for that purpose and has now been withdrawn from the market. A possible substitute is toluidine blue, an acidophilic, metachromatic dye that selectively stains cell nuclei; accordingly, since 2007, toluidine blue has been approved as a topical diagnostic agent in chromoendoscopy. Cells with increased DNA synthesis are stained more intensively so that not only malignant cells but also erosions, ulcerations and inflammatory areas are stained with toluidine blue because of the increased reparative cellular processes. Up to now, absolutely no studies have been carried out with regard to the effectiveness of toluidine blue in gastrointestinal endoscopy. We report on a consecutive series of 364 endoscopic applications of toluidine made on the basis of various indications. Besides the known indications (e. g., chromoendoscopy in case of Barrett's oesophagus), we mostly used toluidine blue, diluted in hydroxyethylstarch (HAES), for submucosal injections of flat adenomas prior to endoscopic mucosal resection or endoscopic submucosal dissection, in order to precisely determine the extension of visible lesions. Local and systemic adverse reactions have not been observed. A demarcation of the lesions can be made as effectively as with methylene blue.

Implications of peroxisome proliferator-activated receptors (PPARS) in development, cell life status and disease.

The past several years have seen an increasing interest in the peroxisome proliferator-activated receptors (PPARs). These transcriptional factors belong to the superfamily of the steroid/thyroid/retinoid receptors. They are activated by fatty acids or their metabolites as well as by different xenobiotic peroxisome proliferators. These receptors are expressed in both the embryo and the adult organism. They have been implicated in cell proliferation, differentiation and apoptosis. In this review, we will attempt to point out some of the more salient features of this expression pattern during development and the different steps of cell life. The current understanding of how PPARs are involved in some human diseases will also be described.

Effects of 1- and 6-month spaceflight on bone mass and biochemistry in two humans.

The bone mineral density and the biochemical parameters exploring bone cell activities were analyzed in two cosmonauts who spent 1 and 6 months, respectively, in the Russian MIR station. Measurements were performed before the flight, after the flight, and after a recovery period. At the end of the first month, peripheral QCT measurements indicated a slight decrease of trabecular bone mass in the distal tibial metaphysis. However, after 6 months of spaceflight, a more marked loss of trabecular and cortical bones was observed in the tibia, and was still significant after 6 month recovery in the trabecular compartment, whereas a decrease was no longer observed in the cortical envelope. No change was observed in either compartment of the distal radius at any time. Ultrasound BUA of the calcaneus was greatly reduced by the first month, followed by a more dramatic decrease after month 6. Ultrasound SOS detected no change. Parameters reflecting bone formation activity appeared to be depressed after both missions. In contrast, no dramatic change in resorption parameters was observed, except for a trend toward an increase in pyridinoline. In conclusion, the lower weight-bearing bones appeared more sensitive than the upper ones in terms of spaceflight-induced bone loss. This probably explained the absence of marked systemic biochemical data changes. This study further suggests that recovery in the tibial trabecular compartment 6 months after landing was not completed after a 6 month mission.

Differential expression of peroxisome proliferator-activated receptors (PPARs) in the developing human fetal digestive tract.

We investigated the spatiotemporal distributions of the different peroxisome proliferator-activated receptor (PPAR) isotypes (alpha, beta, and gamma) during development (Week 7 to Week 22 of gestation) of the human fetal digestive tract by immunohistochemistry using specific polyclonal antibodies. The PPAR subtypes, including PPARgamma, are expressed as early as 7 weeks of development in cell types of endodermal and mesodermal origin. The presence of PPARgamma was also found by Western blotting and nuclease-S1 protection assay, confirming that this subtype is not adipocyte-specific. PPARalpha, PPARbeta, and PPARgamma exhibit different patterns of expression during morphogenesis of the digestive tract. Whatever the stage and the gut region (except the stomach) examined, PPARgamma is expressed at a high level, suggesting some fundamental role for this receptor in development and/or physiology of the human digestive tract.

Bone changes in 6-mo-old rats after head-down suspension and a reambulation period.

In mature rats experiencing 14-day head-down suspension or 14-day head-down suspension followed by 28-day reambulation, the hindlimb long bones, humerus, and skull were removed for the determination of morphometry and bone mineral content (BMC) and density (BMD) with dual-energy X-ray absorptiometry, dry and ash weights, and calcium content. The bones of the animals in the control groups (killed at days 0, 14, and 42) had their own maturation rate. The body weights of suspended animals were lower than those of the control animals. Suspension does not appear to impair the long-bone elongation rate. However, the tibia of suspended rats exhibited a lower calcium content, ash weight, BMC, and BMD. Similar trends were observed in the femur. In the humerus, no significant change was observed. In the skull, the values of the suspended rats were similar to those of the control rats. At the end of the reambulation period, the body weights showed no difference between the control and experimental animals. The bone alterations were not completely reversible compared with their respective controls. In the tibia, BMC and BMD were always decreased. In the femur, trends toward low values were still visible. The skull showed a decrease in BMC and ash and dry weights. This unexpected finding suggested that importance of a rapid decrease in cephalad fluid shift at the time of desuspension. Finally, we showed that dual-energy X-ray absorptiometry measurement is sufficiently accurate to detect intergroup differences.

Sexually transmitted diseases as major causes of ectopic pregnancy: results from a large case-control study in France.

OBJECTIVE: To evaluate the current impact of sexually transmitted diseases (STDs) and their consequences on the occurrence of ectopic pregnancy (EP). DESIGN: Case-control study. SETTING: Fifteen maternity hospitals in the Rhône-Alpes region, France. SUBJECTS: Six hundred twenty-four women with EP diagnosed from October 1988 to December 1991 and 1,247 controls who delivered liveborn children during the same period. MAIN OUTCOME MEASURES: Information on risk factors included behavioral, clinical, and serological indicators of STDs and other known risk factors of EP. RESULTS: Logistic regression identified several indicators of STDs as strong and independent risk factors for EP: previously treated STD without history of salpingitis; history of probably pelvic inflammatory disease (PID) and, especially, history of confirmed PID; previous STDs of the sexual partner; and Chlamydia trachomatis seropositivity. The adjusted attributable fractions of EP for previous symptomatic STDs, symptomatic STDs of the sexual partner, and C. trachomatis seropositivity were 20%, 3.5%, and 25.2%, respectively, giving a total of 43% of EP cases attributable to infectious factors. CONCLUSIONS: Our findings and previous epidemiological and biological evidence suggest that STD is a major cause of EP. The evidence is particularly strong in the case of C. trachomatis infection. An effective way of dramatically reducing the EP rate would be to prevent STD through education programs sensitizing young women to the complications of STD and public health measures promoting the use of protective methods such as condoms.

Histological grading in gastric cancer by Goseki classification: correlation with histopathological subtypes and prognosis.

BACKGROUND: Many different classification systems have been proposed for the histological classification and grading of gastric cancer. In 1992 Goseki described a novel classification system for gastric cancer based on tubular differentiation and mucus in the cytoplasm. The aim of the study was to compare the Goseki classification with the currently used classification systems and to define the prognostic significance of the Goseki classification system. PATIENTS AND METHODS: The present study analyzed material from 200 gastric carcinoma patients who underwent gastrectomy with curative intention. All specimens were categorized to UICC-classification, WHO-classification, Laurén classification, tumor differentiation and Goseki classification. The median follow-up for surviving patients was 3.75 years (range, 0.14-11.52). RESULTS: According to the Goseki classification 32% of patients were classified as group I, 11.5% as group II, 9.5% as group III and 48% as group IV. The Goseki classification was found to correlate with the WHO and Lauren classification as well as with conventional grading. Goseki classification as well as tumor differentiation, Lauren and WHO classification did not have prognostic value for survival. Only the UICC system presented as an independent prognostic factor in multivariate analysis (p < 0.000001). CONCLUSION: In our series Goseki classification correlated with conventional classification systems, but not with survival.

Exposure to organic solvents during pregnancy and oral clefts: a case-control study.

Prior studies on the relationship between maternal exposure to organic solvents in relation to oral clefts have been inconsistent. We re-examined this relationship in a case-control study conducted in the Rhône-Alpes region of France during the years 1985 to 1989. For each case, we selected two controls without congenital anomalies in the same delivery unit born during the same month. We interviewed each mother within the first five days after delivery about previous reproductive history and exposures during the first two months after conception. If the mother had an occupational activity at that time, we asked her occupational physician to confirm the exposures. We compared maternal exposure to any organic solvent between 200 infants with cleft lip and/or cleft palate and 400 controls and the estimated odds ratio was 1.62 (95% CI 1.04-2.52). Then we compared exposures to nine subgroups of solvents. Only the ratio associated with halogenated aliphatic solvents (4.40, 95% CI 1.41-16.15) was significantly different from unity. Control of potential confounders-sex of child, family history, maternal epilepsy-did not alter this odds ratio estimate.

[Inferior vena cava thrombosis responsible for chronic Budd-Chiari syndrome during hepatic and digestive amyloidosis]. / Thrombose de la veine cave inférieure responsable d'un syndrome de Budd-Chiari chronique au cours d'une amylose hépatique et digestive.

The case of a 39 year old woman with amyloidosis of the liver and the digestive tract presenting with obstruction of the inferior vena cava is reported. Computed tomography after bolus injection of contrast material revealed a typical patchy fan-shaped image, of hepatic vein obstruction. The association of Budd-Chiari's syndrome with amyloidosis may be related to the increased risk of thrombosis observed in the latter disease.

Laparoscopic treatment of bastro-esophageal reflux disease.

Gastro-esophageal reflux disease (GERD), with or without hiatal hernia, is the consequence of a functional disturbance of the lower sphincter of the esophagus. This dysfunction is more and more often seen in populations with Western eating habits. According to recent reports, 10 percent of the patients suffer from constant heartburn, 30 percent from discontinuous heartburn demanding active treatment. Finally, a great number of non-digestive symptoms, either pulmonary, E.N.T., or cardiac, are also connected with GERD. In the early 1970s, medical treatment was not very effective, hence the popularity of open surgery. Although the results were satisfactory, postoperative sequelae, in particular parietal ones, could not be avoided. The reason is that a large laparotomy is necessary to gain access to the esophageal hiatus, which always involves potential risks of postoperative incisional hernia.

[Candida spondylodiscitis. Report of 2 personal cases and 28 cases from the literature]. / Spondylodiscites à Candida. A propos de 2 observations personnelles et de 28 observations de la littérature.

Vertebral osteomyelitis caused by Candida spp. has recently been described and seems to be rare since only 30 cases have been published so far. Its clinical, laboratory and radiological features are identical with those on non-tuberculous bacterial spondylitis. It develops in subjects with poor general condition who underwent multiple surgical operations or received prolonged antibiotic therapy. The finding of Candida at needle biopsy of the since clinches the diagnosis. Serological tests might provide an earlier diagnosis and, above all, enable therapeutic effectiveness to be evaluated. In 27 of the 30 cases reported here, cure was obtained by prolonged infusions of antifungal drugs, chiefly amphotericin B and/or 5-fluorocytosine.

[Sterility and Chlamydia infection. Risk factors]. / Stérilité et infection à Chlamydia. Etude des facteurs de risque.

The authors distributed a questionnaire to 89 patients who consulted them for sterility for reply by themselves. The blame for chlamydia trachomatis infection as a cause of sterility was worked out as a level of IgG above 1/8. The risk factors for being infected with chlamydia trachomatis is above all the number of sexual partners; the odds ratio of 2,68 being significant for those who had more than one partner. The age of marriage and the age at first intercourse do not count. The prevention of the consequences of infection depends on education about the risks and screening for infection when the partner is changed.

[Apparently primary thoracic hemangiopericytoma. Apropos of 12 cases]. / Hémangiopéricytomes thoraciques apparemment primitifs. A propos de 12 observations.

Twelve cases of apparently primary thoracic hemangiopericytoma are reported: 7 intrapulmonary and 5 extrapulmonary. These cases, taken together with 75 others already published, serve as a basis to describe the characteristics of thoracic hemangiopericytomas. Intrapulmonary forms raise the problem of a single peripheral X-ray lesion, often detected in a routine film, with no accompanying endoscopic abnormality. Extrapulmonary forms also take the form of a well defined tumor with diaphragmatic or mediastinal parietal connections. Up to the present, the diagnosis has always been made at thoracotomy. It is probable that a preoperative diagnosis will be possible in the future by transbronchial biopsy. Silver stains and the use of the electron microscope form the basis of histological diagnosis. However it is not possible to distinguish by histology between benign and malignant forms, nor between primary or metastatic hemangiopericytomas. It is for this reason that doubt will long persist as to the primary nature of the tumor and only prolonged survival of patients after excision confirms that the lesion was indeed primary. Treatment is essentially surgical. New high energy radiotherapy techniques and new possibilities in chemotherapy (using adriamycin) should improve the prognosis in those forms which run a malignant course. However the standard therapeutic strategy for these rare tumors has yet to be defined.