Endoscopic submucosal dissection in a European setting. A multi-institutional report of a technique in development.

BACKGROUND AND STUDY AIMS: Endoscopic submucosal dissection (ESD) is a technique for "en bloc" resection of superficial tumors of the gastrointestinal tract. In France, experience with this technique is still limited. We wanted to assess the development of ESD in France, with special attention to short term outcomes. PATIENTS AND METHODS: Members of the Société Française d'Endoscopie Digestive (SFED) who declared performing ESD reported their cases prospectively on a voluntary basis. Demographic, clinical, and technical data, and the results of immediate complications were collected. Case reports were completed prospectively by each investigator before pooled analysis. RESULTS: A total of 188 consecutive case reports were collected from 16 centers. The median case mix per center was 6 patients (range 1-43). The lesion sites treated by ESD were the stomach (n = 75), esophagus (n = 27), duodenum (n = 1), cecum (n = 2), right colon (n = 3), transverse colon (n = 5), sigmoid (n = 3), and rectum (n = 72). The median size of the lesions was 26 mm (range 2-150 mm). En bloc resection was achieved in 77.1% of cases, with complete R0 resection in 72.9%. Histopathology results showed high grade dysplasia or superficial cancer in 71.2%. The median duration of ESD was 105 minutes (range 20-450 minutes). The short term morbidity was 29.2% including 34 cases of perforation (18.1%), and 21 hemorrhages (11.2%) during the 24 hours following ESD, 89% of which were managed conservatively or endoscopically. CONCLUSION: In this early experience, the feasibility of ESD appeared to be good but R0 resection and complication rates did not match those reported by Japanese authors and must be improved by an extended practice.

Miss rate for colorectal neoplastic polyps: a prospective multicenter study of back-to-back video colonoscopies.

BACKGROUND AND STUDY AIM: Polyp miss rates during colonoscopy have been calculated in a few tandem or back-to-back colonoscopy studies. Our objective was to assess the adenoma miss rate while limiting technique or operator expertise biases, i. e. by performing a large multicenter study, with same-day back-to-back video colonoscopy, done by two different operators in randomized order and blinded to the other examination. PATIENTS AND METHODS: 294 patients at 11 centers were included. Among the 286 analyzable tandem colonoscopies, miss rates were calculated in both a lesion- and patient-based analysis. Each of these rates was determined for polyps overall, for adenomas, and then for lesions larger than 5 mm, and for advanced adenomas. Univariate and logistic regression analysis were performed to define independent variables associated with missed polyps or adenomas. RESULTS: The miss rates for polyps, adenomas, polyps > or = 5 mm, adenomas > or = 5 mm, and advanced adenomas were, respectively, 28 %, 20 %, 12 %, 9 % and 11 %. None of the masses with a carcinomatous (n = 3) or carcinoid component (n = 1) was missed. The specific lesion miss rates for patients with polyps and adenomas were respectively 36 % and 26 % but the corresponding rates were 23 % and 9.4 % when calculated for all 286 patients. The diameter (1-mm increments) and number of polyps (> or = 3) were independently associated with a lower polyp miss rate, whereas sessile or flat shape and left location were significantly associated with a higher miss rate. Adequacy of cleansing, presence of diverticula, and duration of withdrawal for the first procedure were not associated with adenoma miss rate. CONCLUSIONS: We confirm a significant miss rate for polyps or adenoma during colonoscopy. Detection of flat polyps is an issue that must be focused on to improve the quality of colonoscopy.

[Value of MRCP for diagnosis of biliary complications after liver transplantation]. / Evaluation de la cholangiographie par résonance magnétique dans le diagnostic des complications biliaires après transplantation hépatique.

PURPOSE: To assess the value of MRCP in the detection of biliary complications after orthotopic liver transplantation. MATERIALS AND METHODS: 27 transplanted patients with suspected biliary complication underwent a total of 34 MR and direct cholangiography procedures. MRCP were reviewed by 2 independent reviewers blinded to clinical and laboratory findings. The biliary tract was divided into 7 segments, and all lesions were evaluated using this segmental anatomy. Each segment was evaluated for the presence of dilatation, stenosis and intra-ductal debris. MRCP results were compared to results frpm direct cholangiography. RESULTS: 216 (98%) of 221 biliary segments could be evaluated on MRCP, with good to excellent visualization in 179 (80%) cases. Segmental analysis showed sensitivity, specificity and accuracy values of 85%, 81% and 83% for the detection of biliary stenosis, 82%, 81% and 81% for the detection of biliary dilatation, and 60%, 88% and 80% for the detection of inyraductal debris. CONCLUSION: MRCP is accurate for the detection of biliary stenosis and dilatation in patients after liver transplantation and provides an alternative to direct cholangiography.

Management of intraductal papillary mucinous tumours of the pancreas.

OBJECTIVE: To focus attention on the management and outcome of patients with intraductal papillary mucinous tumours of the pancreas. DESIGN: Retrospective study and analysis of published reports. SETTING: University hospital, France. SUBJECTS: 111 patients (101 published cases and our own 10 cases) divided in two groups: the first including malignant tumours (n = 46), and the second group benign or in situ tumours (n = 61). In 4 patients the type of tumour was not known. MAIN OUTCOME MEASURE: Resectability, mortality and recurrence. RESULTS: More men had benign or in situ tumours [48/61 (79%) compared with 28/46 (61%), p = 0.054]. Pancreatitis was more common among benign than malignant tumours [34/61 (58%) compared with 21/46 (46%), p = 0.33]. In group I, 39 patients had diabetes. A total of 107 patients were operated on: pancreaticoduodenectomy (n = 54, 50%), distal pancreatectomy (n = 25, 23%), total pancreatectomy (n = 4,4%), bypass (n = 2,2%). The type of resection was not mentioned in 22 records (21%). Four patients were not operated on because of their poor general condition. The resectability rate was 98% (105/107). Eleven patients had died at the time of publication. Hospital mortality rate was 3% (n = 3), mainly because 2 of the 4 who had total pancreatectomy died. With a median follow-up of 37 months, recurrence was 5% (n = 5). CONCLUSION: Intraductal papillary mucinous tumours of the pancreas are well known distinctive pancreatic tumours that are usually intraductal but may develop into invasive carcinoma. They should be resected, and have a good prognosis and low recurrence rate.

Diagnostic and therapeutic aspects of endoscopic retrograde cholangiography in papillomatosis of the bile ducts: analysis of five cases.

BACKGROUND: Biliary papillomatosis is an uncommon disease, the definitive diagnosis and treatment of which generally require surgery. In the present study, we described the diagnostic and therapeutic aspects of endoscopic retrograde cholangiography in five such patients. METHODS: Since 1982, five patients with biliary papillomatosis have been admitted to our unit. All these patients underwent endoscopic retrograde cholangiography. RESULTS: Endoscopic examination of the ampulla of Vater showed a dilated papillary orifice with mucin discharge in all five patients. Biliary papillomatosis was diagnosed from the following features: multiple filling defects in the lumen of the biliary system in four patients and several supple stenoses in one patient. Histologic examination of biliary specimens taken after endoscopic sphincterotomy showed typical lesions of papillomatosis in the five patients. Palliative endoscopic treatment was performed in three patients. CONCLUSION: This case series reports the typical endoscopic retrograde cholangiography and endoscopic biopsy findings in biliary papillomatosis. For inoperable patients, endoscopic palliative evacuation of mucus and debris and/or stent placement are of benefit.

Posttraumatic pancreatic fistula cured by endoprosthesis in the pancreatic duct.

We report a case of pancreatic fistula attributable to posttraumatic rupture of the main duct that was undiagnosed before ERCP and was cured instantaneously by endoscopic placement of an endoprosthesis in the pancreatic duct after failure of conventional medical treatment.

[Palliative endoscopic treatment of adenocarcinoma of Vater's ampulla: medium and long-term results]. / Traitement endoscopique palliatif des adénocarcinomes de l'ampoule de Vater: résultats à moyen et long terme.

The palliative endoscopic treatment of tumors of the ampulla of Vater provides good short-term symptomatic results, while long-term results remain unknown. This study to assessed the course of 17 patients with carcinoma of the ampulla of Vater treated palliatively by endoscopy and monitored for a 5-year-period. From january 1985 to december 1989, 35 patients were diagnosed as having carcinoma of the ampulla of Vater. For 18 of them, curative surgery was performed, while for the 17 remaining 17 patients, palliative endoscopic treatment was proposed because of metastatic extension or surgical risk. Endoscopic treatment always included endoscopic sphincterotomy, and, in some cases, insertion of a biliary endoprosthesis. All patients were monitored until death or the end of follow-up on September 30, 1990. Endoscopic sphincterotomy was performed in 13 of the 17 patients, either alone in 10 cases, or with prosthesis in the other 3 cases. For the 4 other patients, endoscopic sphincterotomy could not be performed (large tumor in 2 cases, presence of duodenal diverticulum in 2 other cases). The 13 patients who underwent endoscopic treatment experienced rapid symptomatic improvement. Jaundice and cholangitis consistently recurred within a period of 1 to 44 weeks regardless of initial treatment. All recurrences except one, were successfully retreated by endoscopy (enlargement of initial sphincterotomy in 6 cases, insertion or replacement of prosthesis in 12 cases).(ABSTRACT TRUNCATED AT 250 WORDS)

[Prevention of recurrent hemorrhage caused by the rupture of esophageal varices in cirrhotic patients. A controlled study of propranolol and clip ligation of the esophagus]. / Prévention de la récidive hémorragique par rupture de varices oesophagiennes chez le cirrhotique. Etude contrôlée comparant le propranolol et la ligature de l'oesophage sur clip.

Among the various treatments of ruptured oesophageal varices two seem to be effective: oral propranolol therapy and ligation of the oesophagus on clip. In this controlled study these two methods were compared in a series of 55 patients hospitalized for ruptured oesophageal varices. After haemodynamic stability was obtained, the patients were allocated at random to either propranolol therapy (n = 28) or surgery (n = 27). Twenty-one per cent of these patients belonged to group C of Child's classification and 54 per cent to group A. The parameters studied were similar in both groups. Five patients were excluded from the study: 2 in the medical group when it appeared that propranolol was contra-indicated and 3 in the surgical group who died before the operation; however, these 5 patients were taken into account in a second statistical evaluation. Nineteen out the 26 patients under propranolol (73 per cent) had rebleeding (within the first 10 days in 3 cases). In the surgical group recurrent bleeding was observed in 4 out of the 24 patients (17 per cent), and 4 other patients died post-operatively. The difference in favour of the surgical group was highly significant (P less than 0.001), and it remained significant (P less than 0.05) when the 5 patients who could not be treated were included into the calculations. Cox's multivariate analysis showed that patients in Child's C group had a poorer prognosis.