Endoscopic ultrasound (EUS)-guided transhepatic anterograde self-expandable metal stent (SEMS) placement across malignant biliary obstruction.

Endoscopic retrograde cholangiopancreatography (ERCP) with placement of self-expandable metal stents (SEMS) for palliation of malignant obstruction may not be possible in patients with an inaccessible biliary orifice. Endoscopic ultrasound (EUS)-guided drainage methods may be useful in this setting. This study aimed to determine the outcomes of EUS-guided anterograde SEMS placement across malignant strictures in patients with an inaccessible biliary orifice. Over a 2-year period, procedural and outcomes data on all patients undergoing EUS-guided anterograde SEMS drainage after failed ERCP were prospectively entered into a database and reviewed. Five patients underwent EUS-guided anterograde SEMS. Indications included: advanced pancreatic cancer (n = 3), metastatic cancer (n = 1), and anastomotic stricture (n = 1). The biliary orifice could not be reached endoscopically due to duodenal stricture (n = 4) or inaccessible hepaticojejunostomy (n = 1). EUS-guided punctures were performed transgastrically into left intrahepatic ducts (n = 4) or transbulbar into the common bile duct (n = 1). Guide wires were passed and SEMS were successfully deployed across strictures in an anterograde fashion in all patients. Jaundice resolved and serum bilirubin levels decreased in all cases. No procedure-related complications were noted during a mean follow-up of 9.2 months. EUS-guided anterograde SEMS placement appears to be a safe and efficient technique for palliation of biliary obstruction in patients with an endoscopically inaccessible biliary orifice. The procedure can be performed at the time of failed standard ERCP, and provides an alternative drainage option to percutaneous or surgical decompression and to EUS-guided creation of bilioenteric fistulae.

[Interventional endoscopic ultrasound: an evolving technique]. / Echoendoscopie interventionnelle: une technique en pleine évolution.

The availability of smaller instruments with larger working channels and higher imaging resolution has led to important development of endoscopic ultrasound (EUS) techniques these past years. From a purely diagnostic instrument, EUS guided fine needle aspiration has become a well recognized technique to acquire tissue in the mediastinum and the upper abdomen, more and more complex therapeutic procedures are now performed. It is now possible to precisely inject therapeutic agents under EUS guidance, drain intraabdominal collections and drain previously inaccessible obstructed pancreatic and bile ducts. The currently accepted indications of interventional endosonography and the technique currently under evaluation will be discussed.

[Endoscopic management of benign biliary strictures]. / Prise en charge endoscopique des sténoses billaires bénignes.

Endoscopic management of benign biliary strictures has significantly changed in recent years. Excluding a malignant etiology remains the first, critical, step; significant progress is being made to increase diagnostic accuracy of bile duct stricture sampling, although negative predictive value does not reach 100%. The currently preferred treatment consists of stricture dilation followed by placement of multiple temporary plastic stents. Drawbacks of this technique include repetition of endoscopic procedures and a small risk of cholangitis. Larger diameter covered self-expandable metal biliary stents seem to be a promising alternative. In this review, we will discuss the various etiologies of benign biliary strictures, their clinical presentation, the diagnostic tools and the endoscopic treatment.

Long-term quality of life after endoscopic dilation of strictured colorectal or colocolonic anastomoses.

BACKGROUND: Endoscopic balloon dilation is the first-line treatment for benign colorectal anastomotic strictures. We aimed to objectively assess its long-term results. METHODS: Gastrointestinal symptoms and health-related quality of life (HRQoL) were assessed at long-term after balloon dilation of anastomotic strictures in 31 consecutive patients (excluding those with inflammatory bowel disease) as well as and controls, using the validated Gastrointestinal Quality of Life Index (GIQLI). Most colectomies had been performed for benign diseases, with anastomoses located at the colorectal junction. RESULTS: Completed surveys were collected from 81 subjects, including 27 study patients (response rate 87%), 27 surgical controls matched for age, gender, and indication of colectomy, and 27 healthy subjects. At a mean of 3.9 +/- 2.3 years after the first endoscopic balloon-dilation, study patients self-reported significantly more gastrointestinal symptoms than controls; these included frequent and urgent bowel movements, bloating, food restriction (p < or = 0.001, all comparisons), diarrhea, excessive passage of gas through the anus (p < 0.01, all comparisons), constipation, and abdominal pain (p < 0.05, all comparisons). Health-related quality of life was significantly impaired in study patients versus surgical controls and healthy subjects (GIQLI scores, 104 +/- 20, 119 +/- 24, and 121 +/- 16, respectively; p = 0.005). Impaired HRQoL subdimensions included gastrointestinal symptoms (p < 0.001), stress by treatment (p < 0.05), and emotional status (p = 0.08). HRQoL was independent of the delay between stricture dilation and the survey. Follow-up endoscopy (performed in 21/27 [78%] study patients, including the 7 patients with the lowest HRQoL, and 19 [70%] surgical controls) disclosed anastomoses larger than 13 mm in all cases. CONCLUSIONS: Health-related quality of life is significantly impaired at long-term after standard balloon-dilation of benign anastomotic colorectal strictures as a result of gastrointestinal symptoms and stress by treatment. This impairment might be related to the fact that an anastomotic diameter > or = 13 mm, although commonly used to define successful endoscopic treatment, is insufficient to provide long-term symptom relief in some patients, or to other, yet to be identified, factors.

[Clinical management of a patient with alcoholic cirrhosis]. / Le suivi clinique d'un patient atteint de cirrhose alcoolique.

Prolonged abstinence from alcohol is crucial in the management and prognosis of a patient with alcoholic cirrhosis. It is also important to prevent complications such as variceal bleeding, hepatocellular and extrahepatic cancers, and malnutrition. Liver transplantation should be considered in patients with persistent liver failure in spite of complete cessation of alcohol consumption. We provide some recommendations in commonly encountered clinical situations for compensated and decompensated alcoholic cirrhosis.