Frequency and severity of ileal adenomas in familial adenomatous polyposis after colectomy.

BACKGROUND AND STUDY AIMS: The high cumulative risk of colorectal cancer in patients with familial adenomatous polyposis (FAP) justifies prophylactic colectomy with either ileorectal (IRA) or ileal-pouch-anal anastomosis (IPAA). Our aim was to evaluate retrospectively the frequency of and time interval to adenoma development in the ileal mucosa of patients with both types of surgery. PATIENTS AND METHODS: Retrospective study of 44 FAP patients with IRA (n = 21) and IPAA (n = 23). All patients were followed with a standardized procedure including chromoscopy and biopsies of visible polyps. In patients with IRA, specific attention was paid to the ileal mucosa above the anastomosis. RESULTS: In the IPAA group, 18/23 patients (78 %) presented with visible polyps [histology: 16 (70 %) had adenoma with low-grade dysplasia; 1 (4 %) had adenoma with high-grade dysplasia; 1 had normal mucosa]. The mean interval between colectomy and the diagnosis of adenoma was 4.7 +/- 3.3 years. In the IRA group, 16/21 patients (77 %) presented visible polyps in the ileal mucosa [adenoma with low-grade dysplasia in 8 patients (38 %), with high-grade dysplasia in 2 (10 %), and lymphoid nodular hyperplasia in 6]. The mean interval between colectomy and adenoma diagnosis was significantly shorter in the IPAA than in the IRA group (4.76 +/- 3.3 vs. 16.4 +/- 8.5 years, P< 0.0001). CONCLUSION: Our results show a high frequency of adenomas in the ileal mucosa of patients with IPAA and IRA (74 % and 48 % respectively), with evolution into high-grade dysplasia in 6.7 % of cases.

Long-term follow-up of patients with endoscopic treatment of sporadic adenomas of the papilla of vater.

BACKGROUND AND STUDY AIMS: Knowledge about the long-term outcome of patients after endoscopic treatment of ampullary adenomas remains poor, although surgical series have suggested that the initial endoscopic evaluation of these diseases might overlook cancer foci developed in adenomas. The aim of this study was to evaluate retrospectively the long-term outcome in patients with ampullary adenomas treated endoscopically, with a focus on the possible development of cancer. PATIENTS AND METHODS: The study included 24 patients (median age 59 years, range 34 - 84) with macroscopically benign adenomas of the papilla of Vater treated using mainly laser photodestruction between 1983 and 1996. Medical, endoscopic, surgical, and histological reports were reviewed. Patients and general practitioners were contacted to determine patient outcome when endoscopic follow-up had been discontinued. RESULTS: Endoscopic remission (macroscopic and histological) was achieved in 16 patients (66.6 %) with one recurrence (6.2 %) during a mean endoscopic follow-up of 66 months (4-168 months). Endoscopic treatment was discontinued in five (20.8 %) patients (with minimal residual adenoma and advanced age and/or severe unrelated disease), and failed in three patients (12.5 %) (failure of Nd:YAG laser in one case, severe pancreatitis and pancreatic duct ingrowth in one case each). After a mean clinical follow-up of 81 months (8-172 months), two patients (8.3 %) had undergone pancreaticoduodenectomy; eight (33.3 %) had died from unrelated diseases; and 14 (58.3 %) were alive and asymptomatic without any evidence of ampullary cancer. CONCLUSIONS: Long-term follow-up revealed no case of advanced ampullary cancer and suggested that endoscopic treatment was satisfactory for the large majority of patients with ampullary adenomas.

Value of endobiliary brush cytology and biopsies for the diagnosis of malignant bile duct stenosis: results of a prospective study.

BACKGROUND: Before considering a nonsurgical method of management of a bile duct stenosis, a tissue diagnosis is highly desirable. In a prospective study we have evaluated the feasibility and reliability of endobiliary brush cytology and biopsies performed at the time of endoscopic retrograde cholangiography. METHODS: Two hundred thirty-three consecutive patients underwent an attempt at endobiliary brush cytology and biopsies of bile duct stenosis when no mass was detected on ultrasound and CT scan. RESULTS: The material for cytology was sufficient for analysis in 210 cases (90%) and biopsies were obtained in 128 cases (55%). One hundred fifteen patients had both cytology and biopsies (49%). For the diagnosis of malignant stenosis, the sensitivity was 35% for cytology, 43% for biopsies, and 63% for the combination of cytology and biopsies. For both cytology and biopsies, the specificity was 97%. In the cases of cancer primarily involving the bile ducts, the sensitivity was 86% when combining both cytology and biopsies. CONCLUSIONS: Endobiliary sampling is technically difficult and has a limited sensitivity for the diagnosis of malignant biliary stenosis. Biopsies should be combined with cytology to increase the sensitivity.

Endoscopic stenting for pain relief in chronic pancreatitis: results of a standardized protocol.

BACKGROUND: Pancreatic endoscopic stenting aims to relieve abdominal pain due to chronic pancreatitis. Optimal treatment modalities and post-treatment effects have still to be determined. The object of this study was to investigate the results of a standardized protocol of endoscopic stenting. METHODS: Twenty-three patients with abdominal pain due to chronic pancreatitis and stricture of the distal main pancreatic duct were treated according to the following protocol: after balloon dilation of the stenosis, a 10F stent was placed into the main pancreatic duct and then exchanged every 2 months, the total duration of drainage being 6 months. RESULTS: Use of analgesics could be discontinued in 17 patients (74%) on termination of drainage, and in 12 patients (52%) 1 year later. These results were significantly associated with reduction of main pancreatic duct diameter and resolution of stricture, but were not influenced by abstinence from alcohol and pancreatic enzyme supplementation. CONCLUSIONS: Pancreatic duct stenting results in short-term clinical improvement in patients with chronic pancreatitis and proximal main pancreatic duct stricture. Persistence of advantageous clinical results is to be expected in 50% of cases and when strictures have resolved.

Biopsies of the ampullary region in patients suspected to have sphincter of Oddi dysfunction.

Tumors of the ampulla of Vater that develop within the ampulla can go unrecognized during endoscopic examination. Patients with intra-ampullary tumors may present with a clinical picture very similar to that of sphincter of Oddi dysfunction. We wished to determine what percentage of patients initially diagnosed with sphincter of Oddi dysfunction are later found to have an intra-ampullary neoplasm. Sixty-nine consecutive patients were considered to have sphincter of Oddi dysfunction and subsequently were treated with endoscopic sphincterotomy. No gallstones were found in the gallbladder or bile duct. Patients returned for biopsies of the ampulla at least 10 days after the endoscopic sphincterotomy. Three patients (4.3%) were found to have ampullary adenocarcinoma. Thirty-six had normal results of biopsy analysis and 30 had inflammatory or fibrotic changes on biopsy specimens. No objective criteria (clinical, biologic, endoscopic, or radiographic) that would help to distinguish between an ampullary tumor and sphincter of Oddi dysfunction were identified. Biopsies of the ampulla should be performed in all patients suspected of having sphincter of Oddi dysfunction and treated by endoscopic sphincterotomy.

Pulsed dye laser lithotripsy of bile duct stones.

Efficacy and safety of pulsed dye laser lithotripsy was tested in 25 consecutive patients in whom bile duct stones could not be extracted after endoscopic sphincterotomy. The patients had one to six (mean, 1.8) bile duct stones (diameter, 10-35 mm; mean, 18 mm) located in the common bile duct (18 cases), the intrahepatic bile ducts (6 cases), or in a long cystic duct stump (1 case). Different approaches were tested depending on the presence of a T tube and on the localization of the bile duct stones. When a T tube was present (7 cases), the lithotripsy was performed under direct vision using a choledochoscope inserted through the T-tube tract. In 18 patients without a T tube in place, the lithotripsy was performed under fluoroscopy using a retrograde approach in case of common bile duct stones (14 cases) or under choledochoscopy using a percutaneous transhepatic approach in case of intrahepatic bile duct stones (4 cases). Fragmentation of all the bile duct stones and a complete bile duct clearance were obtained in all 11 cases with procedures performed under direct vision as compared with only 5 of 14 cases with procedures under fluoroscopic control. Moreover, 6 of the 9 failures using the latter approach were offered another session using a choledochoscope inserted through a percutaneous transhepatic tract and were also successfully treated. No complication related to the laser beam was noted. It is concluded that pulsed dye laser lithotripsy of bile duct stones (that are unable to be removed by standard endoscopic techniques) is safe and efficacious provided that it is performed under direct vision. Technical refinements are needed before this procedure can be reliably performed under fluoroscopy.

Extracorporeal lithotripsy of bile duct stones using ultrasonography for stone localization.

In 19 patients, extraction of bile duct stones through the papilla using a Dormia basket or a mechanical lithotripter was not possible following endoscopic sphincterotomy. After the insertion of a nasobiliary drain, extracorporeal lithotripsy was performed with intravenous sedation using an ultrasonographic stone localization system. The number and location of stones were first determined by retrograde cholangiography. At the time of lithotripsy, saline was injected in the bile ducts to modify the acoustic impedance of tissues surrounding the stones, and subsequent ultrasonography was effective in localizing all stones present in 4 of 5 (80%) patients with intrahepatic stones, and 13 of 14 (93%) with common bile duct stones. In 10 patients (53%), fragmentation was satisfactory and the bile ducts were cleared completely. The mean single stone diameter was significantly smaller in successful cases of fragmentation compared with failures (22.8 +/- 6.6 mm vs. 40 +/- 10 mm). The results in patients with multiple stones were significantly worse than those in patients with single stones of similar size (25% vs. 100% successful fragmentation). Reasons for this difference in results included the small size of the focal area and the reduced ability of ultrasonography (1) to adequately visualize multiple calculi individually and (2) to assess the degree of stone destruction. Care was taken to first await the resolution of infection or the correction of coagulation abnormalities when present; no morbidity following extracorporeal lithotripsy was observed. Despite its 3-step approach (endoscopic sphincterotomy, lithotripsy, and endoscopic extraction), the need for only intravenous sedation and the absence of patient immersion in water render this technique attractive for elderly and frail patients.

Endoscopic treatment of biliary tract fistulas.

Endoscopic therapy was attempted in 24 patients with spontaneous or postoperative persistent biliary fistulas. Endoscopic retrograde cholangiography demonstrated the site of the fistula in 22 cases. Sphincterotomy or biliary stent placement resulted in rapid resolution of the fistula in 16 of 24 patients. Failures were attributed to exclusion of the injured intrahepatic bile duct in two cases, insufficient dilation of a bile duct stricture in one, the large size of the bile duct defect in two, and associated lesions in three (cirrhosis, arterial trauma, subhepatic abscess). Endoscopic management of biliary fistulae requires: (1) visualization of the location of the fistula by retrograde cholangiography especially in case of an intrahepatic lesion, (2) prior percutaneous drainage of associated subhepatic or subphrenic abscesses, and (3) appropriate relief of distal biliary obstruction in order to reduce the intraductal biliary pressure. The outcome is uncertain when endoprostheses are used to bridge large bile duct defects.

Contribution of endoscopy to diagnosis and treatment of tumors of the ampulla of Vater.

In a series of 52 patients presenting with tumors of the ampulla of Vater, endoscopic procedures, especially endoscopic sphincterotomy and snare biopsies, permitted histologic classifications as follows: adenocarcinoma: 50%, adenoma: 35%, and adenoma with cancer: 15%. In 37% of cases, the papilla was normal endoscopically and the tumor was detected only after sphincterotomy. Destruction of adenomas by snare resection, laser photoradiation, or both after sphincterotomy was attempted in 11 patients. Subsequent biopsies revealed persistence or recurrence of adenomatous tissue in only one case and complete destruction of adenomas, with a mean duration of follow-up of 39 months, in the 10 other cases. Palliative treatment by endoscopic procedures was performed in 21 patients and was effective for a mean of 45 months for adenomas and for a mean of 6 months for adenocarcinomas, with a mortality of 10%. To avoid repeated sphincterotomy in patients requiring palliative treatment, the data support the early use of endobiliary prostheses. Endoscopic palliative treatment is not indicated, however, for infiltrative tumors that can induce rapid duodenal obstruction.

Retrograde biliary ultrathin endoscopy enhances biopsy of stenoses and lithotripsy.

Forceps biopsies of biliary stenoses are difficult to direct under fluoroscopy and for this reason may give spurious results. In addition, fluoroscopy does not prevent the electrohydraulic lithotripsy (EHL) probe from damaging the bile duct wall. Retrograde biliary endoscopy with the ultrathin endoscope (UTE) was tested in 12 patients to guide biopsies and in 6 patients to guide EHL. Results of biopsies were confirmed by surgery or the disease course in each of the 12 patients. Only one stone could not be fragmented and removed because the EHL probe could not be properly placed. The diagnosis of biliary stenosis may be markedly enhanced by using a UTE although at the risk of an endoscopic sphincterotomy and subsequent biliary infection. EHL with UTE is difficult and time consuming but further technical development may make it more practical immediately following sphincterotomy.

Biliary lithiasis: combined endoscopic and surgical treatment.

A combined endoscopic and surgical procedure was performed in 69 patients suffering from gallbladder lithiasis with suspected associated lithiasis of the common bile duct (CBD). The procedure was spread over two days: Day 1 - Endoscopic retrograde cholangiopancreatography (ERCP) revealed choledocholithiasis in 50 cases and papillary sclerosis in 4 cases. In 15 patients, the common bile duct was found to be normal. Fifty-four endoscopic sphincterotomies were performed. Among the 50 cases of choledocholithiasis, endoscopic removal of the stones was judged complete in 44 cases and incomplete in the other 6. Day 2 - Cholecystectomy was carried out in all the patients. Peroperative cholangiography confirmed the results of the pre-operative ERCP with respect to the CBD in all the patients except one, and a choledochotomy was necessary in 6 patients. Results were as follows: The average length of hospitalization was 12.4 days. No residual choledocholithiasis was noted. The morbidity of the procedure was 7.2%, and the mortality 1.4% unrelated to the technique. The diagnostic and therapeutic significance of the procedure is discussed.

Laser treatment of tumors of the papilla of Vater.

Tumors of the papilla of Vater, should be separated from periampullary tumors. They are not always malignant, and recent data from endoscopy series, and pathology studies, supports the adenoma-carcinoma sequence at this level. Adenomas are tubular or villous and are classified according to the degree of dysplasia. The endoscopic pattern separates exophytic tumors, sessile and easily detected, from intracanalar tumors usually detected after sphincterotomy. The malignancy of an exophytic tumor is suspected when it is ulcerated or large (over 3 cm), and is easily confirmed by biopsies. The typing of intracanalar tumors is more difficult. In a 5-year period, an ampullary tumor was detected by ERCP in 52 patients: the tumor was exophytic in 33 and intracanalar in 19. Adenocarcinoma was confirmed in 26 and adenoma in 26, resulting in a 50% ratio. Among the adenomas, 18 were fully benign and 8 had a superficial cancer focus. Therapeutic procedures included: laser photodestruction in 16, snare resection in 16, sphincterotomy in 47, stenting in 8, surgical bypass in 7, cephalic duodenopancreatectomy in 16. The 16 patients treated by laser (Nd:YAG mainly) included 8 adenomas: a complete tumor destruction was obtained in 7 (follow up from 14 to 53 months). Adenomatous recurrence was observed at 2 years in one patient. In 8 other patients the tumor was an adenocarcinoma; Laser photodestruction failed to completely destroy the tumor in 1 patient (operative control), in 7 others it was adopted as a complement to sphincteromy and stenting in palliation, but was not found very effective.(ABSTRACT TRUNCATED AT 250 WORDS)

[Laser treatment of villous rectal tumors]. / Traitement laser des tumeurs villeuses rectales.

The treatment of villous rectal tumors with the Nd: YAG laser is characterized by its great effectiveness (almost 90% of complete eradication in our series of 100 cases), and by its great tolerance. It may be applied to all patients regardless of their condition. In case of running villous tumors, complete destruction is more difficult to obtain and the laser method must be weighed against the risks and advantages of radical surgery. The problems raised by frequent foci of adenocarcinoma, which characterize large villous lesions, is minimized by a strict therapeutic protocol: in fact, the foci are superficial in the majority of the cases and they do not decrease the percentage of complete destruction; in other cases, it is possible, by repeated histological controls, in case of persisting positive biopsies, to modify, in time, the choice of treatment.

Evaluation of a combined percutaneous-endoscopic procedure for the treatment of choledocholithiasis and benign papillary stenosis.

In 19 patients suffering from choledocholithiasis or papillary stenosis, retrograde cholangiography or sphincterotomy failed because of anatomic abnormalities. In such cases, sphincterotomy was then performed with the assistance of a percutaneous catheter. Two complications were observed: moderate bleeding from the transhepatic drain, and a retroperitoneal perforation needing surgery. This combined procedure is very efficient, but gives rise to complications of both the transhepatic and endoscopic routes.

Endoscopic retrograde cholangiography and sphincterotomy for complicated hepatic hydatid cyst.

We report on the results of 20 endoscopic cholangiographies indicated for hepatic hydatid disease: 14 for pre-operative investigation and 6 for post-surgical complications. In 4 out of 14 cases, endoscopic retrograde cholangiography (ERC) was not an effective procedure for the pre-operative diagnosis of complicated hepatic hydatid cyst in the biliary tract. Endoscopic sphincterotomy was performed without complications in 9 patients and permitted pre- or post-surgical removal of intrabiliary hydatid fragments in 6, successful treatments of 2 post-surgical external biliary fistulae and in association with transhepatic drainage, improvement of the clinical and biological course of one case of secondary sclerosing cholangitis. Endoscopic sphincterotomy might be indicated not only in the case of ERC diagnosis of complicated hepatic hydatic cyst, but also in the case of isolated cholangitis in patients with hepatic hydatid disease, and for complications of surgical treatment.