[An uncommon use of argon plasma coagulation: endoscopic transection of self-expanding metallic stents]. / Une utilisation peu usuelle mais efficace du plasma d'argon : la section des prothèses métalliques expansives.

Migration, distal malposition or fracture of self-expanding metallic biliary or esophageal stents rarely occur but may lead to stent dysfunction, mucosal trauma secondary to impaction or friction on the digestive wall. We report our experience of using argon plasma to endoscopically cut three metallic biliary and esophageal self-expanding stents to restore permeability or to treat impaction of the stent after migration, malposition or fracture.

[Carcinomatous mediastinitis secondary to carcinoma of the bladder]. / Médiastinite carcinomateuse secondaire à un carcinome vésical.

INTRODUCTION: This is the first reported case of a histologically-proved mediastinal metastatic site of a transitional cell carcinoma of the bladder. CASE: A 61-year-old woman who had undergone a total cystectomy 3 years earlier for transitional cell carcinoma was hospitalized for dysphagia. Endoscopy showed impassable stenosis beginning 25 cm below the dental arch, without any developing endoluminal lesion. Histologic analysis of the biopsy samples identified transitional cell carcinoma infiltration of the muscularis and deep mucosa of the esophagus. DISCUSSION: Three years after a diagnosis of bladder cancer, invasion of the paraesophageal lymph nodes was accompanied by infiltration of the esophageal muscularis and contiguous mucosa. Esophageal stenoses by carcinomatous mediastinitis are rare; when they occur, it is usually secondary to breast cancer. They are generally treated endoscopically, which entails a risk of perforation.

Multimodal therapy with intravenous biweekly leucovorin, 5-fluorouracil and irinotecan combined with hepatic arterial infusion pirarubicin in non-resectable hepatic metastases from colorectal cancer (a European Association for Research in Oncology trial).

BACKGROUND: The purpose of this study was to evaluate the tolerance and efficacy of combining i.v. irinotecan, 5-fluorouracil (5-FU) and leucovorin (LV) with hepatic arterial infusion (HAI) of pirarubicin in non-resectable liver metastases from colorectal cancer. PATIENTS AND METHODS: Thirty-one patients were included in a phase II trial with i.v. irinotecan/5-FU/LV administered every 2 weeks, combined with HAI pirarubicin 60 mg/m(2) on day 1 every 4 weeks. In most cases HAI was administered via a percutaneous catheter. RESULTS: The main grade 3/4 toxicity was neutropenia, encountered in 78% of the patients. When all patients were considered in the analysis, tumour response rate was 15 out of 31 [48%; 95% confidence interval (CI) 32% to 65%]. Liver resection was made possible in 11 patients (35%; 95% CI 21% to 53%). There were no toxic death. Median overall survival was 20.5 months, and median progression-free survival was 9.1 months. In patients with completely resected metastases, median overall survival was not reached and median progression-free survival was 20.2 months. CONCLUSION: The multimodality approach used in the present study was well-tolerated and yielded dramatic responses. An aggressive approach combining i.v. and HAI chemotherapy deserves further investigation.

Endoscopic palliation of malignant gastric outlet obstruction using self-expandable metallic stents: results of a multicenter study.

BACKGROUND AND STUDY AIMS: Gastric outlet obstruction is a late event in the natural history of biliopancreatic tumours. Metallic self-expanding stents inserted under endoscopic and fluoroscopic guidance can be used for palliation. The aim of this study was to evaluate the feasibility, efficacy, and complications of endoscopic duodenal stenting in patients with malignant gastric outlet obstruction. PATIENTS AND METHODS: Between August 1998 and November 2001, 63 patients (31 women, 32 men; mean age 73 +/- 12) presenting with clinical symptoms of duodenal obstruction underwent endoscopic stenting with large metallic prostheses. Complications and clinical outcome were assessed both retrospectively and prospectively. RESULTS: Of the patients, 58 needed one duodenal stent and two overlapping stents were required in five patients. Stenting was immediately successful in 60/63 patients (95%). At the time of the duodenal procedure, 25 previously inserted biliary stents were still patent; biliary stenting was attempted during the same procedure in 18 patients; and 20 patients had no biliary stricture. There was no procedure-related mortality. There were complications in 30 % of patients: 13 stent obstructions, 4 stent migrations and 2 duodenal perforations (treated surgically). For 44 patients (70%) there were no minor or major digestive problem during their remaining lifetime. An exclusively peroral diet was possible in 58 patients (92%), but was considered satisfactory (solid or soft) in 46/63 patients (73%). Of the patients, 53 (84 %) died between 1 and 64 weeks after the duodenal stenting (median survival 7 weeks). CONCLUSIONS: Endoscopic stenting for the palliation of malignant gastric outlet obstruction is feasible and well-tolerated in most patients. Most dysfunctions can be managed endoscopically.

Discrimination of three mutational events that result in a disruption of the R122 primary autolysis site of the human cationic trypsinogen (PRSS1) by denaturing high performance liquid chromatography.

BACKGROUND: R122, the primary autolysis site of the human cationic trypsinogen (PRSS1), constitutes an important "self-destruct" or "fail-safe" defensive mechanism against premature trypsin activation within the pancreas. Disruption of this site by a missense mutation, R122H, was found to cause hereditary pancreatitis. In addition to a c.365G>A (CGC>CAC) single nucleotide substitution, a c.365 through 366GC>AT (CGC>CAT) gene conversion event in exon 3 of PRSS1 was also found to result in a R122H mutation. This imposes a serious concern on the genotyping of pancreatitis by a widely used polymerase chain reaction-restriction fragment length polymorphism assay, which could only detect the commonest c.365G>A variant. MATERIALS AND METHODS: DNA samples containing either the known c.365G>A or c.365 through 366GC>AT variant in exon 3 of PRSS1 were used as positive controls to establish a denaturing high performance liquid chromatography (DHPLC) assay. RESULTS: DHPLC could readily discriminate the two known different mutational events resulting in the R122H mutation. More importantly, under the same experimental conditions, it identified a further mutational event that also occurs in the R122 primary autolysis site but results in a different amino acid substitution: c.364C>T (CGC>TGC; R122C). CONCLUSIONS: A rapid, simple, and low-cost assay for detecting both the known and new mutations occuring in the R122 primary autolysis site of PRSS1 was established. In addition, the newly found R122C variant represents a likely pancreatitis-predisposing mutation.

A comparison of Ultraflex Diamond stents and Wallstents for palliation of distal malignant biliary strictures.

OBJECTIVE: The objective of this study was to compare the effectiveness of the Ultraflex Diamond stent and the Wallstent for the drainage of distal malignant biliary strictures. METHODS: The results obtained in 23 consecutive patients in whom the insertion of a Ultraflex Diamond stent had been attempted were compared with those obtained in 23 patients matched for age, gender, serum bilirubin, and diagnosis who had been treated with Wallstents. RESULTS: Biliary drainage was obtained in 100% of cases. More than one stent was required in 4% and 12% of patients treated with Ultraflex Diamond stents and Wallstents, respectively (p > 0.05). The first stent inserted did not provide adequate biliary drainage in four patients, because of the impaction of the proximal end of Wallstents into the bile duct wall (n = 2) and obstruction of the stent lumen by tumor tissue (one in each group). Procedure-related morbidity and mortality were 4%. Patients were followed-up for a mean of 228 days (range, 1 to 1262 days). During follow-up, bile duct obstruction relapsed in 5/22 and 6/21 patients treated with Ultraflex Diamond stents and Wallstents, respectively. Life table analysis of bile duct patency was similar with both stent models. CONCLUSIONS: Ultraflex Diamond stents are easy to insert and provide a high success rate of biliary drainage with minimal complication. Although long-term patency rates obtained with this stent were similar to those observed with Wallstents, no firm conclusion can be drawn in this regard due to the relatively small number of patients studied.

[Comparison of quantifying Helicobacter pylori gastric infection by culture, histology and C13 urea breath test]. / Comparaison de la quantification de l'infection gastrique à Helicobacter pylori par culture, histologie, et test respiratoire à l'urée marquée au 13C.

OBJECTIVES: In Helicobacter pylori infection, the bacterial burden may play a role in the pathogenesis of gastric or duodenal ulcerated lesions. It could also influence the results of antimicrobial therapy. No simple test has been validated to quantify Helicobacter pylori density. The aim of this study was to determine the value of histology and/or 13C-urea breath test to quantify the infection as compared with quantitative culture, taken as a reference method. PATIENTS AND METHODS: Biopsies samples were taken from the antrum at endoscopy in 72 patients. Thirty-seven patients with positive urease test at 20 minutes were enrolled in the study. Bacterial density was evaluated from biopsies by quantitative culture and semi-quantitative histological examination (score from 0 to 3). The bacterial density was evaluated as well by 13C-urea breath test from the proportion of 13CO2 in exhaled air (delta 13CO2) at 20, 40, and 60 minutes as compared with the basal level. RESULTS: The bacterial density, evaluated by quantitative culture ranged from 5 CFU to 110,000 CFU per mg of tissue. By histology, a score 1 was found in 5 patients, a score 2 in 17, and a score 3 in 15. delta of 13CO2 measured by 13C-urea breath test ranged from 0.2 to 117.5, from 0.2 to 102, and from 0.6 to 66.7 at 20, 40 and 60 minutes respectively. The quantity of bacteria measured by culture was not significantly higher for these with a score of 3 as compared with those with a pooled score of 1 and 2 (P < 0.05). No significant correlation was found between the results of quantitative culture and these of breath test. CONCLUSION: In practice, evaluation of bacterial burden by a histological score seems only accurate for the most severe density (score 3). The 13C-urea breath test does not allow a reliable quantitative evaluation.

[Comparison of push-type endoscopy and barium transit study of the small intestine in digestive bleeding and unexplained iron-deficiency anemia]. / Comparaison de l'entéroscopie poussée et du transit baryté de l'intestin grêle dans les saignements digestifs et les anémies ferriprives inexpliqués.

OBJECTIVES: A radiological examination of the small bowel is often performed in case of gastrointestinal bleeding of obscure origin. More recently, push-type enteroscopy has been reported as a valuable tool in this indication. The purpose of this study was to compare the diagnosis efficiency of these two procedures. METHODS: From February 1994 to February 1996, 40 patients (mean age: 52 years) with obscure gastrointestinal bleeding (iron-deficiency anemia without obvious cause of blood loss or malabsorption: n = 17; macroscopic gastrointestinal bleeding: n = 23) were examined by small bowel follow-through and push-type enteroscopy (jejunoscopy n = 19; double way examination n = 21). Each patient had negative upper and lower gastrointestinal tract endoscopies prior to small bowel examinations. RESULTS: Small bowel follow-through revealed only one lesion potentially responsible for blood loss (2.5%), corresponding to a jejunal leiomyoma. Push-type enteroscopy detected small bowel lesions potentially responsible for blood loss in 6 patients (15%). The lesions were located in the jejunum in 5 cases (arteriovenous malformations: n = 3; metastasis: n = 1; leiomyoma: n = 1), in the ileum in 1 case (leiomyoma). The efficiency of push-type enteroscopy for the detection of a small bowel lesion was of 22% in case of macroscopic bleeding and of 6% in case of iron-deficiency anemia. Push-type enteroscopy also revealed lesions previously undetected by gastroscopy or colonoscopy in 8 patients (20%). CONCLUSION: Push-type enteroscopy was more effective than small bowel follow-through to detect the origin of obscure gastrointestinal bleeding. Push-type enteroscopy revealed a cause of bleeding in 35% of patients, located in the small bowel in only 15% of the patients.

Symptomatic hepatic cysts: treatment with single-shot injection of minocycline hydrochloride.

PURPOSE: To assess the efficacy of percutaneous minocycline hydrochloride sclerotherapy in symptomatic hepatic cysts. MATERIALS AND METHODS: From November 1992 to June 1994, seven of eight consecutive adults with large symptomatic hepatic cysts (diameter, 55-130 mm) were treated with a single intracystic injection of minocycline hydrochloride in an ambulatory procedure. Five patients had a solitary cyst, and two had polycystic liver disease. The target cyst was punctured under ultrasound guidance and local anesthesia with a 22-gauge Chiba needle. Half of the cyst content was aspirated before injection of 100-500 mg of minocycline hydrochloride diluted in 5-25 mL of saline. The minocycline hydrochloride was left in the cyst at the end of the procedure. RESULTS: After a mean follow-up of 28 months (range, 24-42 months), all five patients with solitary cysts were asymptomatic and four had documented complete cyst regression; the two patients with multiple hepatic cysts showed only transient clinical improvement. CONCLUSION: Single-shot injection of minocycline hydrochloride is an effective treatment for symptomatic solitary hepatic cysts but is less effective in polycystic liver disease.

Terlipressin may influence the outcome of hepatorenal syndrome complicating alcoholic hepatitis.

Hepatorenal syndrome is a frequent complication associated with extremely short survival in cirrhotic patients with alcoholic hepatitis. Vasopressin analogs have been reported to induce transient regression of hepatorenal syndrome in patients with cirrhosis. However, treatment withdrawal was followed by early recurrences in every case. We report the case of a 68-yr-old woman with severe alcoholic hepatitis complicated by hepatorenal syndrome. Terlipressin induced a prolonged recovery of renal function that was associated with improvement in hepatic function.