[Screening for preneoplastic lesions of the upper gastrointestinal tract]. / Dépistage des lésions prénéoplasiques du tube digestif haut.

Preneoplastic lesions of the esophagus and stomach are cellular abnormalities that have the potential to develop into cancer over time. They are detected during endoscopy and can be classified according to their specific cellular characteristics. Their treatment depends on the severity of the lesion and the individual factors of each patient. Treatment options may include regular endoscopic monitoring, treatment to reduce the risk of progression to cancer (anti-reflux therapy, antibiotics for H. pylori eradication), or endoscopic removal of the lesion. It is important to discuss any concerns about these lesions with a gastroenterologist and to follow recommendations for proper screening and treatment.

Les lésions prénéoplasiques de l'œsophage et de l'estomac sont des anomalies cellulaires ayant le potentiel de se développer en cancer au fil du temps. Elles sont détectées lors d'une endoscopie et peuvent être classées en fonction de leurs caractéristiques cellulaires spécifiques. Leur traitement dépend de la gravité de la lésion et des facteurs individuels de chaque patient. Les options de traitement peuvent inclure la surveillance endoscopique régulière, la prise de traitement permettant de réduire le risque de progression vers le cancer (traitement antireflux, antibiotique pour l'éradication de H. pylori) ou l'ablation endoscopique de la lésion afin de prévenir sa progression vers un cancer. Il est important de discuter avec un gastroentérologue de toute préoccupation concernant ces lésions et de suivre les recommandations de dépistage et de traitement appropriées.

Outcome of endoscopic vacuum therapy for duodenal perforation.

BACKGROUND: Duodenal defects are complex clinical situations, and their management is challenging and associated with high mortality. Besides surgery, endoscopic treatment options exist, but the size and location of the perforation can limit their application. We present a retrospective study, demonstrating a successful application of endoscopic vacuum therapy (EVT) for duodenal leaks. METHODS: We performed a retrospective study of all patients who underwent EVT for duodenal perforations between 2016 and 2021 at two tertiary centers. We analyzed demographic and clinical patient characteristics, surgical outcomes, leak characteristics, sponge-related complications, and success rate. RESULTS: Indications for treatment with EVT in the duodenum consisted of leak after duodenal suture of a perforated ulcer (n = 4), iatrogenic perforation after endoscopic resection (n = 2), iatrogenic perforation during surgery (n = 2), and anastomotic leak after upper gastrointestinal surgery (n = 2). EVT was used as a first-line treatment in seven patients and as a second-line treatment in three patients. EVT was successfully applied in all interventions (n = 10, 100%). Overall, EVT lead to definitive closure of the defects in eight out of ten patients (80%). No severe EVT-related adverse events occurred. CONCLUSION: EVT is safe and technically feasible, so it emerges as a promising endoscopic treatment option for duodenal leaks. However, multidisciplinary collaboration and management are important to reduce the occurrence of postoperative complications, and to improve recovery rates.

Evaluation of 30-day mortality in patients undergoing gastrointestinal endoscopy in a tertiary hospital: a 3-year retrospective survey.

OBJECTIVE: Despite international guidelines recommendations to use mortality as a quality criterion for gastrointestinal (GI) procedures, recent studies reporting these data are lacking. Our objective was to report death causes and rate following GI endoscopies in a tertiary university hospital. DESIGN: We retrospectively reviewed all GI procedures made between January 2017 and December 2019 in our tertiary hospital in Switzerland. Data from patients who died within 30 days of the procedure were recorded. RESULTS: Of 18 233 procedures, 251 patients died within 30 days following 345 (1.89%) procedures (244/9180 gastroscopies, 53/5826 colonoscopies, 23/2119 endoscopic ultrasound, 19/911 endoscopic retrograde cholangiopancreatography, 6/197 percutaneous endoscopic gastrostomies). Median age was 70 years (IQR 61-79) and 173/251 (68.92%) were male. Median Charlson Comorbidity Index was 5 (IQR 3-7), and 305/345 procedures (88.4%) were undertaken on patients with an ASA score ≥3. Most frequent indications were suspected GI bleeding (162/345; 46.96%) and suspected cancer or tumourous staging (50/345; 14.49%). Major causes of death were oncological progression (72/251; 28.68%), cardiopulmonary failure or cardiac arrest of unkown origin (62/251; 24,7%) and liver failure (20/251; 7.96%). No deaths were caused by complications such as perforation or bleeding. CONCLUSIONS: Progression of malignancies unrelated to the procedure was the leading cause of short-term death following a GI procedure. After improvements in periprocedural care in the last decades, we should focus on patient selection in this era of new oncological and intensive care therapies. Death rate as a quality criterion is subject to caution as it depends on indication, setting and risk benefit ratio.

[Endoscopic submucosal dissection: advances and perspectives]. / Dissection sous-muqueuse endoscopique : avancées et perspectives.

Endoscopic submucosal dissection (ESD) is a mini-invasive technique allowing to resect superficial lesions of the digestive tract and maintaining organ function. High technical expertise is required as well as a network approach with referring physicians, pathologists, radiologists, surgeons and oncologists. Rigorous selection of cases as well as endoscopic management of potential complications (hemorrhage, perforation) is mandatory. Therefore, ESD should preferably be performed in expert centers with high volumes of cases, in order to maintain competency and offer optimal patient's management. Most frequent indications in the Western world are early cancers of the esophagus, stomach and colon as well as non-non-lifting polyps and gastrointestinal stromal tumors (GIST).

La dissection sous-muqueuse (DSM) est une technique permettant la résection des lésions superficielles du tube digestif, de façon mini-invasive, afin de conserver la fonction de l'organe atteint. L'expertise technique aboutissant à ce geste doit s'accompagner d'un travail en réseau associant médecins référents, pathologistes, radiologues, chirurgiens et oncologues. Elle nécessite une sélection rigoureuse des indications, ainsi que la maîtrise des complications éventuelles (hémorragie, perforation) et doit préférablement être réalisée en centre expert, avec un volume suffisant de cas afin de maintenir la compétence. Les indications les plus fréquentes en Occident concernent les cancers super­ficiels de l'œsophage, de l'estomac et du côlon ainsi que les polypes ne se soulevant pas lors de l'injection sous-muqueuse et les tumeurs stromales gastro-intestinales (GIST).

[Management of a cystic lesion of the pancreas discovered incidentally]. / Prise en charge d'une lésion kystique du pancréas de découverte fortuite.

Pancreatic cysts (PC) are common and often discovered incidentally. The distinction between PC is essential, because of the potential malignancy of some lesions requiring surgical resection. The clinical orientation will depend on the clinical history and the radiological characteristics. Indeed, in front of all PCs, it is essential to characterize them using cross-sectional imaging (MRI) in order to highlight the worrisome features requiring further examinations by endoscopic ultrasonography and fine needle aspiration of the cysts to guide the diagnosis. Referral to an expert center will allow to propose to each patient an adequate approach: surgical resection, surveillance according to the recommendations or therapeutic abstention.

Les lésions kystiques du pancréas (LKP) sont fréquentes et souvent découvertes de manière fortuite. La distinction entre les différentes LKP est primordiale, en raison du potentiel dégénératif de certaines lésions. L'orientation clinique dépendra des antécédents personnels, du profil clinique et des caractéristiques radiologiques. Devant tout kyste du pancréas, il est primordial de caractériser les LKP à l'aide d'une imagerie en coupe (IRM) afin de mettre en évidence les signes péjoratifs nécessitant un complément d'examen par écho-endoscopie digestive (EED) avec ponction du liquide intrakystique afin de guider le diagnostic. L'orientation vers un centre expert permettra de proposer une attitude adaptée à la lésion et au patient : résection chirurgicale, surveillance selon les recommandations ou abstention thérapeutique.

Study protocol of a phase II study to evaluate safety and efficacy of neo-adjuvant pembrolizumab and radiotherapy in localized rectal cancer.

BACKGROUND: Reshaping the tumor microenvironment by novel immunotherapies represents a key strategy to improve cancer treatment. Nevertheless, responsiveness to these treatments is often correlated with the extent of T cell infiltration at the tumor site. Remarkably, microsatellite stable rectal cancer is characterized by poor T cell infiltration and, therefore, does not respond to immune checkpoint blockade. To date, the only available curative option for these patients relies on extensive surgery. With the aim to broaden the application of promising immunotherapies, it is necessary to develop alternative approaches to promote T cell infiltration into the tumor microenvironment of these tumors. In this regard, recent evidence shows that radiotherapy has profound immunostimulatory effects, hinting at the possibility of combining it with immunotherapy. The combination of long-course chemoradiotherapy and immune checkpoint inhibition was recently shown to be safe and yielded promising results in rectal cancer, however short-course radiotherapy and immune checkpoint inhibition have never been tested in these tumors. METHODS: Our clinical trial investigates the clinical and biological impact of combining pembrolizumab with short-course radiotherapy in the neo-adjuvant treatment of localized rectal cancer. This phase II non-randomized study will recruit 25 patients who will receive short-course preoperative radiotherapy (5 Gy × 5 days) and four injections of pembrolizumab starting on the same day and on weeks 4, 7 and 10. Radical surgery will be performed three weeks after the last pembrolizumab injection. Our clinical trial includes an extensive translational research program involving the transcriptomic and proteomic analysis of tumor and blood samples throughout the course of the treatment. DISCUSSION: Our study is the first clinical trial to combine short-course radiotherapy and immune checkpoint inhibition in rectal cancer, which could potentially result in a major breakthrough in the treatment of this cancer. Additionally, the translational research program will offer insights into immunological changes within the tumor and blood and their correlation with patient outcome. Taken together, our work will help optimizing future treatment combinations and, possibly, better selecting patients. TRIAL REGISTRATION: This study was registered with www. CLINICALTRIAL: gov : NCT04109755 . Registration date: June, 2020.

Mapping of etiologies of computed tomography-proven acute colitis: a prospective cohort study.

Our objective was to describe the etiologies of acute colitis and to identify patients who require diagnostic endoscopy. Patients with symptoms of gastrointestinal infection and colonic inflammation on CT were prospectively included. Those immunosuppressed, with history of colorectal cancer or inflammatory bowel disease (IBD), were excluded. Microbiological analysis of the feces was performed using PCR assays BD-Max and FilmArray (GI panel,) and fecal cultures. Fecal calprotectin was determined. Patients with negative BD-Max underwent colonoscopy. One hundred and seventy-nine patients were included. BD-Max was positive in 93 patients (52%) and FilmArray in 108 patients (60.3%). Patients with infectious colitis (n = 103, 57.5%) were positive for Campylobacter spp. (n = 57, 55.3%), Escherichia coli spp. (n = 8, 7.8%), Clostridioides difficile (n = 23, 22.3%), Salmonella spp. (n = 9, 8.7%), viruses (n = 7, 6.8%), Shigella spp. (n = 6, 5.8%), Entamoeba histolytica (n = 2, 1.9%) and others (n = 4, 3.9%). Eighty-six patients underwent colonoscopy, which was compatible with ischemic colitis in 18 patients (10.1%) and IBD in 4 patients (2.2%). Fecal calprotectin was elevated in all patients, with a mean concentration of 1922.1 ± 2895.6 µg/g, and was the highest in patients with IBD (8511 ± 9438 µg/g, p < 0.001). After exclusion of patients with infectious etiology, a fecal calprotectin > 625 µg/g allowed identifying patients with IBD with an area under ROC curve of 85.1%. To conclude, computed tomography-proven colitis was of infectious etiology in 57.5% of patients. The main pathogens identified were Campylobacter spp. (55.3%), Clostridioides difficile (22.3%) and Salmonella spp. (8.7%). Ischemic colitis (10.1%) and IBD (2.2%) were seldom represented. No colorectal cancer was found.

Recent advances in the management of autoimmune pancreatitis in the era of artificial intelligence.

Autoimmune pancreatitis (AIP) is a type of immune-mediated pancreatitis subdivided into two subtypes, type 1 and type 2 AIP. Furthermore, type 1 AIP is considered to be the pancreatic manifestation of the immunoglobulin G4 (IgG4)-related disease. Nowadays, AIP is increasingly researched and recognized, although its diagnosis represents a challenge for several reasons: False positive ultrasound-guided cytological samples for a neoplastic process, difficult to interpret levels of IgG4, the absence of biological markers to diagnose type 2 AIP, and the challenging clinical identification of atypical forms. Furthermore, 60% and 78% of type 1 and type 2 AIP, respectively, are retrospectively diagnosed on surgical specimens of resected pancreas for suspected cancer. As distinguishing AIP from pancreatic ductal adenocarcinoma can be challenging, obtaining a definitive diagnosis can therefore prove difficult, since endoscopic ultrasound fine-needle aspiration or biopsy of the pancreas are suboptimal. This paper focuses on recent innovations in the management of AIP with regard to the use of artificial intelligence, new serum markers, and new therapeutic approaches, while it also outlines the current management recommendations. A better knowledge of AIP can reduce the recourse to surgery and avoid its overuse, although such an approach requires close collaboration between gastroenterologists, surgeons and radiologists. Better knowledge on AIP and IgG4-related disease remains necessary to diagnose and manage patients.

[Management of foreign bodies ingestion]. / Prise en charge des corps étrangers digestifs.

Foreign bodies ingestion is a common event, with a potential morbidity and mortality. In the majority of cases, the foreign bodies pass through the digestive tract without any complication. An endoscopy for removal of the foreign body is necessary in 10 to 20 % of cases and a surgical intervention is required in < 1 % of cases. In this article, we describe the clinical presentation, the potential complications, as well as the timing and endoscopic technics of foreign bodies retrieval, essentially based on the European Society of Gastrointestinal Endoscopy recommendations.

L'ingestion de corps étrangers est un événement fréquent, potentiellement grevée d'une morbi-mortalité et engendrant des coûts importants. Dans la majorité des cas, les corps étrangers suivent le tube digestif sans complication. Une endoscopie est nécessaire dans 10 à 20 % des cas et une intervention chirurgicale pour extraction du corps étranger/complications dans moins de 1 % des cas. Dans cet article, nous traitons de la prise en charge des corps étrangers chez l'adulte et passons en revue leur présentation clinique, leurs complications potentielles, ainsi que les délais et modalités de la prise en charge endoscopique basée essentiellement sur les recommandations de la Société européenne d'endoscopie digestive.

Safety of Endoscopic Ultrasound-Guided Fine-Needle Aspiration for Pancreatic Solid Pseudopapillary Neoplasm Before Surgical Resection: A European Multicenter Registry-Based Study on 149 Patients.

OBJECTIVES: The results of only a few endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for pancreatic solid pseudopapillary neoplasm (SPN) have been published, and the safety of the procedure has never been investigated. Our study compared the recurrence rate in patients with and without preoperative EUS-FNA. METHODS: This European multicenter registry-based study was conducted in 22 digestive units, and retrospectively included all patients who underwent complete resection of a pancreatic SPN from 2000 to 2018. Patients with and without initial EUS-FNA were compared, and postsurgery recurrence and the associated risk factors were evaluated. RESULTS: A complete resection of a pancreatic SPN was performed in 149 patients (133 women, 89%), with a mean age of 34 (standard deviation, 14) years. There were no significant differences between the with (78 patients) and without (71 patients) EUS-FNA groups, except for age and tumor size and location.Preoperative EUS-FNA allowed pancreatic SPN diagnosis in 63/78 cases (81%). After a mean follow-up of 43 (standard deviation, 36) months, recurrence was noted in 4 patients (2.7%). Preoperative EUS-FNA was not correlated with recurrence, but an older age (P = 0.005) was significant. CONCLUSIONS: Preoperative EUS-FNA does not affect pancreatic SPN recurrence. In this series, old age was significantly correlated with recurrence.

[Innovations in endoscopy]. / Innovations en endoscopie.

Digestive endoscopy has met an enormous progress over the last decade, both in terms of diagnosis and treatment of gastro-intestinal diseases. This review article presents the role of confocal endomicroscopy in the management of pancreatic cysts. Moreover, it resumes the most important novel therapeutic endoscopic techniques, some already available in expert centers such as G-POEM or biliary drainage by Axios stent system and spiral enteroscopy, as well as techniques undergoing validation such as the radiofrequency ablation of pancreatic tumors and the bariatric and metabolic endoscopy techniques.

L'endoscopie digestive a connu de grandes avancées au cours de la dernière décennie, à la fois sur les plans diagnostique et thérapeutique. Cet article fait le point sur le rôle de l'endomicroscopie confocale dans les kystes pancréatiques et sur plusieurs techniques d'endoscopie thérapeutique, certaines déjà disponibles dans les centres experts comme le G-POEM (pylorotomie endoscopique), le drainage biliaire par prothèse d'apposition et l'entéroscopie spiralée motorisée, ou encore en cours de développement, comme l'ablation par radiofréquence des tumeurs pancréatiques ou l'endoscopie bariatrique et métabolique.

[Gastric intestinal metaplasia and cancer risk: how to follow ?] / Métaplasie intestinale gastrique et risque de cancer: quelle surveillance ?

In 2019, gastric cancer still has high mortality. Gastric intestinal metaplasia (IGM) is an intermediate step in the process of carcinogenesis of intestinal adenocarcinoma. Gastroscopy with biopsies can detect the presence of MIG. Characterization in terms of intensity and distribution allows to stratify the risks and to target the population in which surveillance endoscopies are indicated for the purpose of detecting endoscopic resectable neoplasia in endoscopy.

Le cancer gastrique a encore en 2019 une mortalité élevée. La métaplasie intestinale gastrique (MIG) est une étape intermédiaire dans le processus de cancérogenèse de l'adénocarcinome de type intestinal. La gastroscopie avec biopsies permet de détecter la présence de MIG. Sa caractérisation en termes d'intensité et de distribution permet de stratifier les risques et de cibler la population chez qui des endoscopies de surveillance sont indiquées dans le but de détecter les néoplasies superficielles résécables en endoscopie.

Impact of peroral cholangioscopy on the management of indeterminate biliary conditions: a multicentre prospective trial.

BACKGROUND AND AIMS: Single-operator cholangioscopy (SOC) can help diagnose biliopancreatic conditions. The impact of SOC on patient outcome has never been specifically addressed. PATIENTS AND METHODS: Consecutive patients bearing indeterminate biliary strictures (IDBS), or primary sclerosing cholangitis (PSC) with suspected cholangiocarcinoma, were included. Patients with IDBS had at least one previous inconclusive endoscopic retrograde cholangio pancreatography (ERCP) + cytology. Primary endpoint was the difference in adequacy of management planned before and after SOC with regard to final diagnosis obtained after surgery or 24 months follow-up. DESIGN: Prospective open-label multicentre trial. RESULTS: 61 patients were included (IDBS: 48; PSC: 13); 70.5% had a benign lesion (IDBS 66.7%, PSC 84.6%). The management adequacy rate was significantly higher after SOC than before SOC overall (p<10-5), in IDBS (p<0.001) and PSC (p<0.05) patients. SOC induced changes in the management of the majority of patients in all groups (60.3%). The overall sensitivity of combined visual impression and biopsy ranged from 52% to 63.6% depending on investigator or independent expert rating (κ 0.92-0.96), whereas specificity, positive and negative predictive values of SOC were, respectively, 100%, 100% and 83.6%. Patient management observed at the end of follow-up was consistent with that anticipated after SOC in 88.5% overall. CONCLUSION: Despite a moderate sensitivity for the diagnosis of malignancy, SOC has a dramatic impact on the management of patients with IDBS and PSC with suspected carcinoma. Cholangioscopy might be implemented in the workup of selected patients with challenging diagnosis, when a significant impact on outcome (essentially resection vs conservative management) is to be expected.

Biliary Involvement in Type 2 Autoimmune Pancreatitis.

Autoimmune pancreatitis (AIP) is a rare condition classified in 2 subtypes. Their distinction relies on a combination of clinical, serological, morphological and histological features. Type 1 is a pancreatic manifestation of IgG4-related disease characterized by multiorgan infiltration by IgG4 plasmocytes. In this condition, hepatobiliary infiltration is frequent and often mimics cholangiocarcinoma or primary sclerosing cholangitis. On the other hand, type 2 is commonly limited to the pancreas. Herein, we describe the case of a patient who presented a type 2 AIP associated with cholangiopathy, a condition not described in the established criteria. He first developed a pancreatitis identified as type 2 by the typical histopathological features and lack of IgG4 in the serum and tissue. Despite a good clinical response to steroids, cholestasis persisted, identified by MR cholangiography as a stricture of the left hepatic duct with dilatation of the intrahepatic bile duct in segments 2 and 3. Biliary cytology was negative. Evolution was favorable but after steroid tapering a few months later, the patient suffered from recurrence of the pancreatitis as well as progression of biliary attempt, suspicious for cholangiocarcinoma. As the investigations again ruled out neoplastic infiltration or primary sclerosing cholangitis, azathioprine was initiated with resolution of both pancreatic and biliary attempts.

[How to deal with drug-induced diarrhoea]. / Diarrhée médicamenteuse : comment s'orienter ?

Diarrhoea is a frequent drug adverse event, implicating a number of different treatments. It occurs in an acute setting or even several months after the beginning of the treatment and different pathophysiological mechanisms are involved. It must be proactively suspected and promptly treated, however this diagnosis is often mentioned only after multiple diagnostic tests. In this review we aim to offer a practical approach to promptly identify drug-induced diarrhoea, recognise most common implicated drugs and establish the best clinical management.

La diarrhée est un effet secondaire fréquent de nombreux médicaments à travers des mécanismes physiopathologiques divers. Elle peut survenir dans un délai d'apparition variable et devrait être suspectée et prise en charge rapidement. Ce diagnostic est cependant souvent évoqué tardivement après de multiples investigations. Dans cet article, nous revoyons les différentes classes de médicaments incriminés, les examens complémentaires à réaliser en cas de suspicion de diarrhée médicamenteuse, et nous proposons une approche pratique de prise en charge.

Esophageal pulmonary fistula - a rare complication of radiation therapy: a case report.

BACKGROUND: Esophageal respiratory fistulae are abnormal communications between the esophagus and the respiratory system. They are either congenital or acquired. Most acquired esophageal respiratory fistulae are of the esophageal tracheal and esophageal bronchial type and are caused by infections or malignant neoplasms, whereas esophageal pulmonary fistulae are rare. CASE PRESENTATION: We report a case of a 72-year-old Caucasian man with squamous cell carcinoma of the lung presenting with abrupt-onset dyspnea during localized mediastinal radiotherapy. His laboratory test results suggested major respiratory infection. A chest x-ray revealed left apical lung radiopacity along with excavated lesions, consistent with secondary tumor infection. No clinical improvement was observed despite antibiotic treatment. A contrast-enhanced computed tomographic scan of the chest confirmed persistent lung infection with unfavorable progression and air in the mediastinum; the latter suggested a fistula from the upper third of the esophagus to the upper left pulmonary lobe. Videofluoroscopy confirmed the diagnosis of an acquired esophageal pulmonary fistula. The patient underwent endoscopy, and an esophageal self-expandable metallic stent was deployed. CONCLUSIONS: Esophageal pulmonary fistulae must be suspected whenever patients undergoing local mediastinal radiotherapy present with acute pulmonary complications, particularly pneumonia resistant to antibiotic treatment. Esophageal pulmonary fistulae are diagnosed by means of radiological imaging. Because esophageal respiratory fistulae are acute life-threatening conditions, prompt treatment with an endoscopically placed covered stent proves vital.

[Bariatric surgery : complications and endoscopic treatment]. / Chirurgie bariatrique : complications et traitements endoscopiques.

Obesity is a major public health issue. Surgery is the most effective treatment to obtain weight loss, stabilize weight status and decrease comorbidities. Yet post-operative complications can be serious and their treatment can also be a real challenge. The low invasive nature of endoscopy makes it an alternative to surgery. It can be used to diagnose and treat digestive hemorrhage, ulcers, stenosis, anastomotic leakage or fistula. This article aims to review the different bariatric surgical techniques, complications and their specific endoscopic treatment options.

L'obésité constitue un problème de santé publique majeur. La chirurgie demeure le traitement le plus efficace afin de favoriser la perte de poids, stabiliser le statut pondéral et diminuer les comorbidités chez ces patients. Les complications postopératoires peuvent cependant être graves et leurs traitements représentent un réel défi. Le caractère peu invasif de l'endoscopie en fait une alternative à privilégier face à la chirurgie. Elle permet de diagnostiquer et de traiter les hémorragies digestives, les ulcères, les sténoses, les lâchages anastomotiques ou encore les fistules. Dans cet article, nous passerons en revue les différentes techniques chirurgicales bariatriques, les complications qu'elles peuvent induire et les traitements endoscopiques qu'il est possible de réaliser.

Complete endoscopic sphincterotomy with vs. without large-balloon dilation for the removal of large bile duct stones: randomized multicenter study.

Background and study aims Endoscopic sphincterotomy plus large-balloon dilation (ES-LBD) has been reported as an alternative to endoscopic sphincterotomy for the removal of bile duct stones. This multicenter study compared complete endoscopic sphincterotomy with vs. without large-balloon dilation for the removal of large bile duct stones. This is the first randomized multicenter study to evaluate these procedures in patients with exclusively large common bile duct (CBD) stones. Methods Between 2010 and 2015, 150 patients with one or more common bile duct stones ≥ 13 mm were randomized to two groups: 73 without balloon dilation (conventional group), 77 with balloon dilation (ES-LBD group). Mechanical lithotripsy was subsequently performed only if the stones were too large for removal through the papilla. Endoscopic sphincterotomy was complete in both groups. Patients could switch to ES-LBD if the conventional procedure failed. Results There was no between-group difference in number and size of stones. CBD stone clearance was achieved in 74.0 % of patients in the conventional group and 96.1 % of patients in the ES-LBD group (P < 0.001). Mechanical lithotripsy was needed significantly more often in the conventional group (35.6 % vs. 3.9 %; P < 0.001). There was no difference in terms of morbidity (9.3 % in the conventional group vs. 8.1 % in the ES-LBD group; P = 0.82). The cost and procedure time were not significantly different between the groups overall, but became significantly higher for patients in the conventional group who underwent mechanical lithotripsy. The conventional procedure failed in 19 patients, 15 of whom underwent a rescue ES-LBD procedure that successfully cleared all stones. Conclusions Complete endoscopic sphincterotomy with large-balloon dilation for the removal of large CBD stones has similar safety but superior efficiency to conventional treatment, and should be considered as the first-line step in the treatment of large bile duct stones and in rescue treatment.Trial registered at ClinicalTrials.gov (NCT02592811).

[Multidisciplinary management of localized rectal cancer]. / Prise en charge multidisciplinaire du cancer localisé du rectum.

Rectal cancer remains a frequent pathology, with a good prognosis, according to a proper management. During the last decades, we have been confronted with important improvements, notably regarding the diagnosis and the treatment. In the era of highly specialized medicine, it is clear that the management must be multidisciplinary, incorporating not only the surgeon, the oncologist and the radiation oncologist, but also the radiologist, the gastroenterologist, and the pathologist. We aim to review the recent concepts and the future developments in the management of rectal cancer.

Le cancer du rectum demeure une pathologie fréquente, dont le pronostic est heureusement bon. Ces dernières décennies, nous avons été confrontés à plusieurs avancées importantes, que ce soit au niveau du diagnostic ou du traitement. Sa prise en charge fait partie intégrante de la médecine hautement spécialisée, et il est devenu clair que l'approche se doit d'être multidisciplinaire, incorporant aussi bien le chirurgien, l'oncologue et le radio-oncologue, que le radiologue, le gastroentérologue et le pathologue. Dans cet article, les concepts récents ainsi que les perspectives futures sont analysés.

The expansion of endoscopic submucosal dissection in France: A prospective nationwide survey.

INTRODUCTION: Early reports of endoscopic submucosal dissection (ESD) in Europe suggested high complication rates and disappointing outcomes compared to publications from Japan. Since 2008, we have been conducting a nationwide survey to monitor the outcomes and complications of ESD over time. MATERIAL AND METHODS: All consecutive ESD cases from 14 centers in France were prospectively included in the database. Demographic, procedural, outcome and follow-up data were recorded. The results obtained over three years were compared to previously published data covering the 2008-2010 period. RESULTS: Between November 2010 and June 2013, 319 ESD cases performed in 314 patients (62% male, mean (±SD) age 65.4 ± 12) were analyzed and compared to 188 ESD cases in 188 patients (61% male, mean (±SD) age 64.6 ± 13) performed between January 2008 and October 2010. The mean (±SD) lesion size was 39 ± 12 mm in 2010-2013 vs 32.1 ± 21 for 2008-2010 (p = 0.004). En bloc resection improved from 77.1% to 91.7% (p < 0.0001) while R0 en bloc resection remained stable from 72.9% to 71.9% (p = 0.8) over time. Complication rate dropped from 29.2% between 2008 and 2010 to 14.1% between 2010 and 2013 (p < 0.0001), with bleeding decreasing from 11.2% to 4.7% (p = 0.01) and perforations from 18.1% to 8.1% (p = 0.002) over time. No procedure-related mortality was recorded. CONCLUSIONS: In this multicenter study, ESD achieved high rates of en bloc resection with a significant trend toward better outcomes over time. Improvements in lesion delineation and characterization are still needed to increase R0 resection rates.