[Endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography performed during the same anesthesia session]. / Echo-endoscopie et cholangio-pancréatographie rétrograde endoscopique dans un même temps anesthésique.

OBJECTIVES: To evaluate the feasibility, results and importance of a diagnostic and therapeutic biliary and pancreatic exploration associating endoscopic ultrasonography and endoscopic retrograde cholangio-pancreatography during the same anaesthesia session. METHODS: From November 1997 to October 1998, 179 patients (83 males, 96 females), mean age 62 years (range 22 to 95 years), were investigated in our gastroenterology unit for biliary or pancreatic disorders. Two hundred and sixty two examinations were performed by a single physician for patients under general anaesthesia. In 87 cases (42%), endoscopic retrograde cholangio-pancreatography was performed immediately without prior endoscopic ultrasonography; these patients were not included. When endoscopic retrograde cholangio-pancreatography followed endoscopic ultrasonography, it was performed during the same anaesthesia session. RESULTS: In 118 cases, endoscopic ultrasonography was performed first, followed by endoscopic retrograde cholangio-pancreatography 57 times (48%). The sensitivity of endoscopic ultrasonography was 96.5% and the success of therapeutic endoscopic retrograde cholangio-pancreatography was 100%. Endoscopic retrograde cholangio-pancreatography was necessary for 83% of patients with angiocholitis, 60% with cholestasis, 45% with acute biliary pancreatitis and only 28% with common bile duct stone migration. CONCLUSION: To decrease the number of anaesthesia sessions, endoscopic ultrasonography--endoscopic retrograde cholangio-pancreatography during same anaesthesia session appears to be particularly interesting for the diagnosis and treatment of biliary and pancreatic disorders, in terms of cost, accuracy, morbidity and patient comfort.

[Conservation of the left pancreas in rupture of the pancreatic isthmus. Apropos of 3 cases]. / Conservation du pancréas gauche dans les ruptures de l'isthme pancréatique. A propos de trois cas.

AIM OF THE STUDY: To report three cases of neck pancreatic disruption caused by blunt abdominal trauma and to emphasize the advantages of conservative surgery with internal drainage. PATIENTS AND RESULTS: In two cases, one with hemoperitoneum, and the other with intraperitoneal fluid collection with 1,323 U/mL of amylase, laparotomy showed a complete disruption of the neck of the pancreas. The pancreatic head side was sutured whereas the left side was anastomosed to a Roux-en-Y jejunal loop. The clinical results were good at 8 and 6 months after surgery, respectively. For the third patient, a pancreatic trauma (which was suspected on a CT. Scan), was not confirmed at laparotomy. In the postoperative course, the amount of fluid drainage was important and the endoscopic retrograde pancreatography (ERCP) showed a disruption of the neck of the pancreas. An endoprosthesis was placed into the duct of Wirsung. Three months later, the patient complained of pain, and a migration of the prosthesis was detected by X-ray examination. It was not possible to place another endoprosthesis because of a stenosis of the duct. A resection of the neck of the pancreas was performed, the cephalic side was sutured and the left side anastomosed to the posterior gastric wall. Eight months after surgery, the clinical result was good and glycemia was normal. CONCLUSION: In blunt abdominal trauma, if a pancreas injury is suspected upon clinical presentation an ERCP, or moreover a magnetic resonance imaging, is indicated. When there is no disruption of the Wirsung duct, a simple peritoneal drainage should suffice. In cases with partial disruption, an endoprosthesis may give good results. In patients with a complete disruption, as in the three cases reported, a suture of the head side of the pancreas, and an internal drainage of the left side with a Roux-en-Y jejunal loop (or more easily with the stomach), are indicated.

[Percutaneous cholecystostomy. A study of 30 patients]. / Cholécystostomie percutanée. Une étude chez 30 malades.

OBJECTIVE AND METHODS: The treatment of acute cholecystitis or angiocholitis is often difficult in elderly or very ill patients. The aim of this retrospective study was to assess the efficacy and the results of ultrasound guided percutaneous cholecystostomy in patients with acute cholecystitis or biliary tract obstruction and anesthetic or surgical contraindications. RESULTS: Thirty patients (25-93 years, 16 men and 14 women) were included in this study. Ultrasound guided percutaneous cholecystostomy was successful on the septic syndrome in 27 patients; endoscopic sphincterotomy was performed in 6 patients after clinical improvement. A failure of the procedure on sepsis was observed in 3 patients: cholecystectomy was performed after cardiac improvement in one patient, and 2 patients died. Two other patients died of extradigestive diseases. No serious complication related to cholecystostomy was observed. CONCLUSION: Ultrasound guided percutaneous cholecystostomy is a safe and simple procedure. It can be done at bedside and has low morbidity and mortality. It can be considered as a definitive treatment, or a temporary one with secondary surgical or endoscopic management.

[Adult idiopathic ductopenia. 1 case]. / Ductopénie idiopathique de l'adulte. Un cas.

Idiopathic adult ductopenia is very rare. We report one case in a 30-year-old man, whose clinical course was characterized by jaundice and pruritus. Laboratory investigations revealed cholestasis and polyclonal hypergammaglobulinemia. Serum antinuclear, antimitochondrial, and anti-smooth muscle antibodies and serological markers for viral hepatitis were negative. Endoscopic retrograde cholangiography showed no liver or biliary tract abnormalities. Histological examination of a liver specimen showed a vanishing bile duct syndrome and moderate portal infiltration with lympho-histiocytic cells; there were no granulomas. Liver transplantation was performed due to rapid development of cirrhosis. The differential diagnosis of idiopathic adult ductopenia with small duct primary sclerosing cholangitis, auto-immune cholangiopathy, and non syndromic paucity of intrahepatic bile ducts is unclear.

[Duodenal hematoma, acute pancreatitis, and hemoperitoneum after endoscopic hemostasis for duodenal ulcer]. / Hématome duodénal, pancréatite aiguë et hémopéritoine après hémostase endoscopique d'un ulcère duodénal.

Therapeutic endoscopy is followed by complications in less than 5% of cases. We report a case of an intramural duodenal hematoma after local endoscopic injection of 28 mL of adrenaline 1/10,000 for a bleeding duodenal peptic ulcer. This hematoma was associated with acute pancreatitis and was revealed by a hemoperitoneum.

Cirrhosis: a new, but expected cause of biliary sludge.

BACKGROUND/AIMS: Biliary sludge is increasingly recognized as a natural stage in gallstone formation. Logically, cirrhosis, a well-documented cause of black pigment cholelithiasis, should be another condition predisposing to the development of sludge. The aim of this study was to assess the prevalence of biliary sludge in an unselected population and to test the hypothesis that cirrhosis could be one of the causes of sludge. METHODS: We reviewed the clinical findings and ultrasonograms of 2138 patients, hospitalized or not, consecutively seen in our department between January 1993 and December 1994. Sonograms showing biliary sludge mixed with stones were excluded. Three hundred and eighty-eight of the 2138 were cirrhotic patients. RESULTS: The overall prevalence of biliary sludge was 4%. Sludge was found in 44 of 388 (11%) of the cirrhotic patients (alcoholism, n = 39; chronic viral B hepatitis, n = 3; hemochromatosis, n = 1; and cryptogenic, n = 1), compared with 42 of 1750 (2%) noncirrhotic patients (p < 0.000001). Thirteen cirrhotic patients received intravenous alimentation for 2 to 17 days, 8 were given somatostatin for variceal bleeding, and 7 have previously had 1 to 5 sessions of endoscopic sclerotherapy of esophageal varices with polidocanol. CONCLUSIONS: This study convincingly demonstrates that cirrhosis must be added to the growing list of conditions associated with biliary sludge.

[Ambulatory ultrasound-guided puncture in abdominal tumoral pathology. Study of 131 cases]. / Ponction échoguidée ambulatoire en pathologie tumorale abdominale. Etude de 131 cas.

OBJECTIVES AND METHODS: Outpatient ultrasound guided liver biopsy is usually reserved for diffuse pathologies. The aim of this study was to assess the feasibility and results of 131 ultrasound guided biopsies of 128 abdominal lesions in 104 patients (69 men and 35 women, mean age: 59). Twenty four cysts were punctured (18 pancreatic cysts, 4 liver cysts and 2 unspecified abdominal cysts) and 104 solid tumors were biopsied (80 liver tumors, 9 pancreatic tumors, 5 portal vein obstructions, 4 unspecified abdominal tumors, 3 stomach tumors and 3 lymphadenopathies). RESULTS: The feasability of outpatient ultrasound guided biopsy was 100%. The etiology of 22 cysts (91.6%) and the histology of 100 solid tumors (96.2%) were determined. No side effects were observed, and all patients left the hospital 6 hours after this procedure. No later hospitalisations were necessary. CONCLUSION: This study suggests that outpatient ultrasound guided needle aspiration or biopsy of liver tumors or other abdominal tumors can be performed. Thus, this procedure could be less expensive and more acceptable, while preserving reliability and safety.

[Endoscopic treatment of a pancreatic-pleural fistula. Apropos of a case]. / Traitement endoscopique d'une fistule pancréatico-pleurale. A propos d'un cas.

Pancreaticopleural fistula is a rare complication of pancreatic diseases. It results from communication between a pancreatic duct and the pleural space, either directly, or through a pseudocyst. The treatment is medical or surgical. We report a case of pancreaticopleural fistula occurring in a man suffering from chronic pancreatitis, and treated by endoscopy.

[Portal thrombosis and liver cirrhosis. Value of ultrasound-guided puncture-biopsy of the thrombus]. / Thrombose portale et cirrhose. Intérêt de la ponction-biopsie échoguidée du thrombus.

OBJECTIVES AND METHODS: Portal vein thrombosis which occurs in the course of cirrhosis, associated or not with hepatocellular carcinoma, can be either cruoric or neoplastic. The aim of this study was to assess the feasibility and the results of ultrasound guided biopsy of portal vein thrombosis in 21 patients with cirrhosis (20 men and 1 woman; mean age 66 +/- 9 years), who were hospitalized between May 1989 and November 1993. Ultrasound guided biopsies of the cirrhotic liver, of the portal vein thrombosis and, when present, of a hepatic nodular lesion were performed. The diagnosis of hepatocellular carcinoma was made if the histological examination of the hepatic and portal biopsy samples were positive or if serum concentrations of alpha-fetoprotein were higher than 500 IU/mL. RESULTS: All portal vein thrombosis biopsies were successfully performed. No side-effects were observed. Before ultrasound guided biopsy of the portal thrombosis, diagnosis of hepatocellular carcinoma was made in 15 cases, and diagnosis of cirrhosis in 6 cases. After histological examination of the portal sample, hepatocellular carcinoma was diagnosed in 19 cases and cirrhosis in 2 cases. Thus, in 19% of cases, ultrasound guided biopsy of the portal thrombus provided a definitive diagnosis. CONCLUSION: Ultrasound guided biopsy of the portal vein thrombosis must be performed before liver transplantation for cirrhosis or hepatocellular carcinoma to exclude the presence of a vascular neoplastic extension.