Endoscopic or surgical ampullectomy for intramucosal ampullary tumor: the patient populations are not the same.

PURPOSE: To evaluate and compare the results of endoscopic ampullectomy (EA) and surgical ampullectomy (SA) for benign tumors. MATERIAL AND METHOD: From 2005 to 2018, 66 patients were eligible for ampullectomy (adenoma, ultrasound grading≤T1, N0). The principal endpoint was the rate of complete resection: R0 resection without local recurrence and no recurrence after a single operative procedure and with final pathology confirming the operative indications. Secondary endpoints were: morbidity, mean length of stay (LOS), preoperative and final pathology results, complete (or incomplete) resection, mean duration of follow-up, local recurrence rate and late complications (biliary stricture). RESULTS: Among the 41 patients eligible for EA, 36 ampullectomies were performed, while five were referred for SA because of intracanalar invasion that had not been diagnosed initially. The rate of complete treatment was 48% (13/27), the morbidity was 10%; the LOS was 3.3days; no adenomatous lesion was found on the definitive pathology in 9 patients (25%). The resection was R1 in 30% but there were no R2 resections. The median duration of follow-up was 20months, the rate of local recurrence was 22% and the rate of late biliary stricture was 2%. Among the 30 patients who were eligible for SA, (25 plus the five referred by endoscopists after intracanalar invasion was found), SA was eventually performed in 24: five patients were converted to pancreatoduodenectomy, one patient was found to have metastatic disease and had no resection. An extemporaneous frozen-section pathology examination was performed in 22 of the 24 SA patients and confirmed healthy margins on the bile ducts and pancreatic ducts. The rate of complete treatment was 71% (17/24), morbidity was 35%; LOS was 10days; seven patients (29%) were found to have invasive adenocarcinoma, and six of these (86%) underwent subsequent pancreatoduodenectomy. None of the resections were R1 or R2; median follow-up was 21months; there was no local recurrence; biliary stricture rate was 8%. CONCLUSION: The short-term and long-term results of patients undergoing endoscopic or surgical ampullectomy are different. The lesions resected by EA were less advanced, with simpler postoperative course. The lesions for which SA was performed were more advanced, and had more morbid sequelae, but with a better rate of complete treatment and better long-term results.

Cost-effectiveness analysis of stent type in endoscopic treatment of gastric leak after laparoscopic sleeve gastrectomy.

BACKGROUND: Gastric leak is the most feared surgical postoperative complication after sleeve gastrectomy. An endoscopic procedure is usually required to treat the leak. No data are available on the cost-effectiveness of different stent types in this procedure. METHODS: Between April 2005 and July 2016, patients with a confirmed gastric leak undergoing endoscopic treatment using a covered stent (CS) or double-pigtail stent (DPS) were included. The primary objective of the study was to assess overall costs of the stent types after primary sleeve gastrectomy. Secondary objectives were the cost-effectiveness of each stent type expressed as an incremental cost-effectiveness ratio (ICER); the incremental net benefit; the probability of efficiency, defined as the probability of being cost-effective at a threshold of €30 000, and identification of the key drivers of ICER derived from a multivariable analysis. RESULTS: One hundred and twelve patients were enrolled. The overall mean costs of gastric leak were €22 470; the mean(s.d.) cost was €24 916(12 212) in the CS arm and €20 024(3352) in the DPS arm (P = 0·018). DPS was more cost-effective than CS (ICER €4743 per endoscopic procedure avoided), with an incremental net benefit of €25 257 and a 27 per cent probability of efficiency. Key drivers of the ICER were the inpatient ward after diagnosis of gastric leak (surgery versus internal medicine), type of institution (private versus public) and duration of hospital stay per endoscopic procedure. CONCLUSION: DPS for the treatment of gastric leak is more cost-effective than CS and should be proposed as the standard regimen whenever possible.

Conservative endoscopic management for pancreatic trauma.

Traumatic pancreatic injuries are rare: their severity correlates with main pancreatic duct involvement. We report the case of a 5-year-old child who presented with complete disruption of the main pancreatic duct, treated successfully with an endoscopically inserted double pigtail stent.

Is there a place for pigtail drains in the management of gastric leaks after laparoscopic sleeve gastrectomy?

Laparoscopic sleeve gastrectomy (LSG) has a specific morbidity profile in which gastric leak (GL) is the main complication. With a view to defining a standardized protocol for GL management, the present retrospective study sought to describe the clinical patterns of post-LSG GL and treatment of the latter in our university medical center. From July 2004 to December 2010, 25 patients were included. GL was described in terms of clinical presentation, time to onset, and location in the staple line. Treatment of GL with pharmacologic, radiologic, endoscopic, and/or surgical procedures was always validated by a multidisciplinary care team. "Treatment success" was defined as the absence of contrast agent leakage on CT and endoscopy after removal of covered metallic stent or pigtail drains. Systemic inflammation and peritonitis were the main signs for early-onset GL (56%), whereas pulmonary symptoms and intra-abdominal abscesses revealed delayed-onset GL (44%). Surgery was always performed for early-onset GL. In the total study population, the median number of endoscopic procedures was five (range, 1-11) per patient, of covered SEMS was three (range, 1-8), and of pigtail drains was three (range, 1-4). Nine (36%) patients presented endoscopic-related complications. Four (16%) patients with treatment failure underwent radical surgery. The mortality rate was 4% (n = 1). The management of post-LSG GL is challenging. Surgery was always performed for early-onset GL, whereas treatment of delayed-onset GL was based on endoscopy. Pigtail drains required fewer procedures per patient, were better tolerated, and had lower morbidity-mortality than covered SEMS.

[A case of pancreatic schwannoma successfully treated by enucleation]. / Schwannome pancréatique traité avec succès par énucléation : à propos d'un cas.

Benign pancreatic schwannoma is a very rare cystic and solid tumor, which poses a diagnostic and therapeutic challenge. Herein, we present a case of 4-cm solitary benign schwannoma of pancreatic uncinate process, with pancreas divisum, incidentally discovered in a 53-year-old woman. Preoperative diagnosis was established by endoscopic ultrasound and fine needle aspiration. Simple enucleation of the tumor from the surrounding parenchyma was successfully performed. No complications were found after the operation.

[Surgical management of resectable hilar cholangiocarcinoma]. / Prise en charge chirurgicale du cholangiocarcinome hilaire résécable.

Hilar cholangiocarcinoma is a cancer with a poor long-term survival rate (20% at five years), even after curative resection (R0: surgical margins free of tumour). Recent advances have been made in the preoperative management of these patients: clinical imaging, such as magnetic resonance cholangiography, biliary drainage according to the type of hilar obstruction or laparoscopic assessment before portal vein embolization. Extended hemihepatectomy has recently been recognized as the standard curative treatment for hilar bile-duct cancer with concomitant resection of the portal-vein bifurcation as a radical resective procedure. Neoadjuvant-photodynamic therapy could be a new approach to treating hilar cholangiocarcinoma decreasing tumour margins, which is a major prognostic factor.

[Acinar cell carcinoma of the pancreas: a rare tumor with particular clinical and paraclinical presentation]. / Carcinome à cellules acineuses du pancréas : une tumeur rare avec des caractéristiques cliniques et paracliniques particulières.

Acinar cell carcinoma of the pancreas is a rare tumour with specific clinical and paraclinical presentation. Its management is not well codified resulting from its low frequency.

[Gastric calcifying fibrous pseudotumor, a rare mesenchymal tumor of the stomach]. / La pseudotumeur fibreuse calcifiante gastrique, une tumeur rare de l'estomac.

We report a case of calcifying fibrous pseudotumor fortuitously discovered on abdominal CT-scan in a 50 year-old woman presenting with metrorragia. CT-scan showed a 2 cm hypodense nodular tumor of the gastric wall with granular calcifications. Upper endoscopy showed a nodular tumor along the lesser curvature of the gastric body, covered by normal gastric mucosa and biopsies were negative. A diagnosis of gastric stromal tumor was suspected and a partial gastrectomy was performed. On gross examination surgical specimen showed a firm, whitish nodular tumor measuring 2 cm in diameter. On microscopic examination the tumor was composed of whorls of dense hyalinized collagen bundles with a few fibroblasts. There were psammomatous calcifications and nodular aggregates of mononuclear inflammatory cells. Immunohistochemically, spindle cells stained for vimentin. They did not stain for smooth muscle actin, desmin, CD34, CD117, S100 protein, Ki-67 and ALK-1. Surgical resection of the tumor was complete. Patient has no evidence of disease with a follow-up of 12 months. Only seven cases of gastric calcifiying fibrous pseudotumors have been reported in the literature. These benign tumors are usually incidentally discovered. They have characteristic imaging and microscopic features and appear as a distinct clinicopathologic entity different from stromal tumors.

[Pancreas divisum and the dominant dorsal duct syndrome]. / Pancréas divisum et syndrome du canal pancréatique dorsal dominant.

Pancreas divisum, the most frequent congenital malformation of the pancreas, results from the absence of embryologic fusion of the dorsal and ventral pancreatic ducts which keep an autonomy of drainage. The dorsal pancreatic duct is dominant and drains the major part of the pancreatic fluid through a non adapted accessory papilla. The high prevalence of pancreas divisum in patients presenting recurrent acute pancreatitis, the presence of obstructive pancreatitis electively located on the dorsal pancreatic duct and the results of the treatments targeted on the accessory papilla are the arguments pleading for the pathogenic character of the pancreas divisum. Currently, the diagnosis of pancreas divisum is based on magnetic resonance imaging. For symptomatic patients (after exclusion of patients with intestinal functional disorders), results of endoscopic sphincterotomy or surgical sphincteroplasty are favourable in 75% of patients with recurrent acute pancreatitis. They are worse in patients with chronic pain. Surgical sphincteroplasty must be discussed in the same manner as the endoscopic treatment for sometimes avoiding multiplication of the procedures.

[Self expanding metallic stent in the management of malignant colonic obstruction]. / L'endoprothèse colique métallique expansive (ECM) dans les occlusions coliques d'origine tumorale.

INTRODUCTION: Fifteen to thirty percent of colonic cancers are diagnosed at acute colic obstruction stage. In this situation surgery is associated with a high morbi-mortality. The self-expandable metallic stents (SEM) have two objectives: (a) resolution of the obstructive to allow secondary planified radical surgical procedure; (b) palliative in the event of advanced disease. PATIENTS AND METHODS: From May 2001 to December 2002, 11 patients, mean age 75 +/- 8 years, presenting with acute colic obstruction were initially treated by SEM placed by endoscopy. Four patients were classified score ASA 4. Ten patients had a colonic cancer, and a patient presented a peritoneal carcinomatosis from an ovarian carcinoma. Overall five patients had a carcinomatosis. Stenosis, mean length 4 +/- 3 cm, were located on the left colon. In five patients the SEM was proposed as a palliative treatment. RESULTS: Successfully placement of SEM was obtained in 10 (91%) patient without perforation. Three complications (bleeding, reobstruction, migration) were observed. Clinical success (colonic decompression within 96 h without endoscopic or surgical reintervention) was observed in nine out of ten (90%) patients. Six patients had a SEM with curative attempt allowing (i) colonic resection (9 +/- 2 days) without stomy (one postoperative death) in five patients; (ii) a colo-colic derivation for diffuse carcinomatosis discovered peroperatively. A diverting colostomy was carried out in two of the four patients (j6, j30) (reobstruction, migration) for whom the SEM had been proposed as palliative treatment. CONCLUSIONS: This study confirms that SEM and surgery are not competitive but complementary techniques. When the SEM is placed with curative attempt, it allows resolution of the obstructive syndrome and secondary planified radical surgical procedure under better conditions. The results observed in the palliative SEM group suggested to reconsider this indication.

[The treatment of biliary stenosis with metallic stents: the need for multidisciplinary decision making]. / Traitement de la sténose biliaire par prothèse métallique: nécessité d'une décision multidisciplinaire.

A patient presented with a cholangiocarcinoma of the common bile duct; it was initially considered unresectable leading to the placement of the metallic stent whose upper end extended beyond the convergence of the hepatic ducts. The metallic biliary stent became obstructed and so encrusted as to be unremovable; the patient required a left hepatectomy with resection of the stent and the biliary convergence in addition to a pancreatoduodenectomy in order to resect his primary lesion This difficult situation emphasizes that, whenever there is doubt as to the resectability of a biliary lesion, the decision to place a metallic stent should be the fruit of a thorough medico-surgical discussion; where there is any doubt, a plastic stent which is more easily removable should be placed.

[Physiology of intestinal absorption]. / Physiologie de l'absorption intestinale.

Hydrolysis of dietary constituents is necessary to allow nutrients absorption by the small intestinal enterocytes. The digestion process takes place in the intestinal lumen, in the brush border membrane, in the enterocyte, and is mediated by a large number of hydrolases secreted in the gastrointestinal tract or produced by the epithelial cells and localized in the brush border. Nutrients are essentially absorbed via a transcellular route across enterocyte cell membranes to enter bloodstream or lymphatic circulation. Transport of nutrients across apical or basolateral membranes occur by active or facilitated mechanisms involving specific transporters. Water, electrolytes and small molecules can be partly absorbed via paracellular pathway. Tight junction permeability is regulated by osmolarity of intercellular space, definite nutrient concentrations in lumen, and activity of brush border membrane transporters.

Pancreatic concentrations of cefepime.

The concentrations of cefepime in pancreatic pseudocyst fluid (n = 4), pancreatic tissue (n = 4) and pancreatic fistula fluid (n = 1), and simultaneous plasma concentrations, were measured after intravenous administration of a single 2 g dose to nine patients. Mean plasma concentration was 27.4 mg/L between 120 and 200 min after the end of infusion. Mean pancreatic cefepime concentration was 6.3 mg/L in pseudocyst and 10.7 mg/L in pancreatic tissue. Cefepime was detected by 30 min after the end of the perfusion in pancreatic fistulae fluid, and persisted at 8 h. We conclude that cefepime is a potentially useful antibiotic in prevention and treatment of pancreatic infection.

[Hepatic disorders related to Lyme disease. Study of two cases and a review of the literature]. / L'atteinte hépatique dans la maladie de Lyme. Etude de deux cas et revue de la littérature.

We report two cases of Lyme disease, revealed by hepatic damage in a 71- and a 59-year old man. In the first case, the disease was revealed by febrile jaundice whereas, in the second case, results of liver tests showed cytolytic and cholestatic abnormalities with fever. Lyme disease is a zoonosis due to infection by Borrelia burdorferi transmitted by ticks. The multiple phases of the disease explain the polymorphism of the clinical manifestations. Usually, extrahepatic symptoms are first observed, including neurological tropisms of Borrelia burdorferi. On the contrary, hepatic impairment due to Lyme disease is rare, often asymptomatic and with biological manifestations only.