Impact of intravenous lipid emulsion infusion on the stratum corneum barrier function in patients receiving parenteral nutrition.

The importance of the lipid matrix of stratum corneum (SC) in epidermal barrier function is well documented. Intravenous lipid emulsions (ILE) provide essential fatty acids (EFAs), main components of the SC lipid matrix. The objective of this study was to investigate the influence of ILE upon SC barrier function. The skin barrier was assessed by measuring transepidermal water loss (TEWL). Patients receiving lipid-containing parenteral nutrition (LCPN) were compared to patients receiving lipid-free PN (LFPN). In addition, a before/after LCPN introduction study was set up to limit the influence of inter-individual variability. Twenty-six patients receiving LCPN and seven patients receiving LFPN were included. Median age was not significantly different between the two groups. The TEWL of the LCPN group (9.05 g/m2/h) was significantly lower than the TEWL of the LFPN group (12.1 g/m2/h; Wilcoxon test: p = 0.016). The relative variation of TEWL before and after ILE treatment of 5 studied patients was 21.29 ± 10.28 %. ILE improve epidermal barrier function when compared to lipid-free parenteral treatments. Results of the before/after study confirm this conclusion and the usefulness of ILE intake for preventing excessive TEWL. SC barrier function improvement could be a choice criterion between the different ILE generations, in particular in burn patients and premature neonates.

Is diabetes a risk factor for central venous access port-related bloodstream infection in oncological patients?

It was a dogma that patients with diabetes mellitus (DM) are at increased risk of infection or death associated with an infection. However, in cancer patients, this has not been well investigated. The aim was to investigate whether diabetic patients with cancer are at high risk of central venous access port (CVAP)-related bloodstream infection (BSI), and to analyse mortality after CVAP-BSI. A total of 17 patients with type 1 DM (T1DM), 66 with type 2 DM (T2DM) and 307 non-diabetic patients were included. Each patient was followed up until the first late CVAP-BSI or for a maximum for 1 year in the absence of a CVAP-BSI. Fifty-three CVAP-BSIs occurred in 66,528 catheter-days. The cumulative incidence of CVAP-BSI was not higher in T1DM (5.9 %; p = 0.17) and T2DM (19.7 %; p = 0.70) compared with the non-diabetic patients (12.7 %). However, in patients with CVAP-BSI, the 1-month crude mortality rate was higher in DM patients (42.9 % vs. 15.4 %; p = 0.04), whereas the mortality in patients without CVAP-BSI was similar in both groups of patients (19.8 % vs. 17.1 %; p = 0.58). Of the 12 deaths that occurred within 1 month of CVAP-BSI, 16.66 % was attributable to CVAP-BSI. The predictive factor of 1-month mortality was DM (p = 0.04). Parenteral nutrition (PN) was independently associated with CVAP-BSI in diabetic patients (p = 0.001). In this study, diabetes did not increase the risk of CVAP-BSI, but mortality was higher in diabetic patients who had a CVAP-BSI. This suggests, in addition to medical treatment, CVAP should be withdrawn after infection onset.

Contrast-enhanced harmonic endoscopic ultrasound in solid lesions of the pancreas: results of a pilot study.

BACKGROUND AND STUDY AIMS: Distinguishing pancreatic adenocarcinoma from other pancreatic masses remains challenging with current imaging techniques. This prospective study aimed to evaluate the accuracy of a new procedure, imaging the microcirculation pattern of the pancreas by contrast-enhanced harmonic endoscopic ultrasound (CEH-EUS) with a new Olympus prototype echo endoscope. PATIENTS AND METHODS: 35 patients presenting with solid pancreatic lesions were prospectively enrolled. All patients had conventional B mode and power Doppler EUS. After an intravenous bolus injection of 2.4 ml of a second-generation ultrasound contrast agent (SonoVue) CEH-EUS was then performed with a new Olympus prototype echo endoscope (xGF-UCT 180). The microvascular pattern was compared with the final diagnosis based on the pathological examination of specimens from surgery or EUS-guided fine-needle aspiration (EUS-FNA) or on follow-up for at least 12 months. RESULTS: The final diagnoses were: 18 adenocarcinomas, 9 neuroendocrine tumors, 7 chronic pancreatitis, and 1 stromal tumor. Power Doppler failed to display microcirculation, whereas harmonic imaging demonstrated it in all cases. Out of 18 lesions with a hypointense signal on CEH-EUS, 16 were adenocarcinomas. The sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and accuracy of hypointensity for diagnosing pancreatic adenocarcinoma were 89 %, 88 %, 88 %, 89 %, and 88.5 %, compared with corresponding values of 72 %, 100 %, 77 %, 100 %, and 86 % for EUS-FNA. Of five adenocarcinomas with false-negative results at EUS-FNA, four had a hypointense echo signal at CEH-EUS. CONCLUSIONS: CEH-EUS with the new Olympus prototype device successfully visualizes the microvascular pattern in pancreatic solid lesions, and may be useful for distinguishing adenocarcinomas from other pancreatic masses.

[Liver malignancy in a patient with Wilson's disease]. / Maladie de Wilson et tumeur hépatique maligne.

Hepatocellular carcinoma and other tumours of the liver are extremely rare in Wilson's disease. We report a patient who presented with a cholangiocarcinoma associated with Wilson's disease. The literature review underlines that patients with Wilson's disease should be considered at risk of hepatocellular carcinoma, cholangiocarcinoma and undifferentiated carcinoma in the liver. Risk factors seem to be long disease duration and probably a poor observance to therapy. A liver imaging should be included in the follow-up of patients with Wilson's disease.

Acute fatal pulmonary embolism during cyanoacrylate injection in gastric varices.

We report a case of massive pulmonary embolism during cyanoacrylate glue endoscopic injection in a patient with gastric varices from portal hypertension. A review of the literature and results in an animal model show the physiopathology and risk factors associated with this endoscopic procedure.

Long-term results of liver transplantation for Wilson's disease.

UNLABELLED: Wilson's disease is a hereditary defect in hepatic copper metabolism, causing hepatic, neurological and/or psychiatric manifestations. For patients with severe disease, liver transplantation is the treatment of choice. The aim of this study was to report the long-term outcome of patients who underwent liver transplantation for Wilson's disease. PATIENTS AND METHODS: Thirteen patients with Wilson's disease, transplanted in Lyon France between January 1987 and May 2006, were including in this study: eight women and five men, aged eight to 53 years (median 20 years, seven children and six adults). The diagnosis of Wilson's disease was established before liver transplantation. RESULTS: The indication for liver transplantation was chronic (69%) or fulminant liver failure (31%). The median follow-up after liver transplantation was 10 years with 100% patient survival. Copper metabolism returned to normal in all patients. None of the patients with exclusive liver disease required chelation treatment after liver transplantation and none developed neurological symptoms of Wilson's disease. CONCLUSION: Liver transplantation totally reverses the abnormalities of copper metabolism and subsequent hepatic failure, but the course of neurological symptoms remains unpredictable. Long-term patient survival can be excellent without occurrence of neurological complications.

[Pseudoaneurysm of the hepatic artery: rare complication of chronic pancreatitis]. / Pseudoanevrisme de l'artere hepatique: complication rare au cours de l'histoire naturelle de la pancreatite chronique: à propos de deux cas.

Bleeding from a pseudoaneurysm is a rare complication of chronic pancreatitis. We present two cases of ruptured pseudoaneurysms of the hepatic arteries. The first case involved a pancreatic pseudocyst that ruptured in the duodenum and the second resulted in an intrahepatic hematoma that compressed the bile tract causing secondary hemobilia. Angiographic embolization was the primary treatment in both cases, with surgery for the first patient and later radiological drainage in the second. The hemorrhage was controlled in both cases despite the severe prognosis and high mortality in these cases.

Miniprobe EUS in the pretherapeutic assessment of early esophageal neoplasia.

BACKGROUND AND STUDY AIMS: The high-frequency endosonography miniprobe has been advocated prior to endoscopic treatment of superficial esophageal neoplasm. We conducted a retrospective study, which summarized our clinical experience with various miniprobe techniques in the assessment of early squamous cell carcinoma (SCC) and superficial adenocarcinoma on Barrett's mucosa (SAB). PATIENTS AND METHODS: A total of 106 superficial and naive esophageal lesions were included in this series (52 SAB, 54 SCC). The results of the miniprobe staging were compared with pathology in order to determine the accuracy of this technique in differentiating mucosal from submucosal infiltration. Secondary aims were a comparison between the frequencies (20- vs. 30-MHz) and coupling methods (water-filled lumen vs. balloon-sheathed catheter) used. RESULTS: Overall accuracy, sensitivity, and specificity to differentiate T1sm from T1 m tumors were 73.5 %, 62 %, and 76.5 %, respectively. Overdiagnosis occurred in 18.6 % of the lesions. No statistically significant difference was found in the accuracy of the miniprobe staging between the two lesion types (SCC and SAB) ( P = 0.65), and results were significantly poorer in the distal part of the esophagus ( P = 0.00039). No significant difference was found between the two frequencies ( P = 0.51). Water-filled lumen proved to be superior to the balloon-sheathed catheter ( P = 0.015). CONCLUSION: High-frequency miniprobe examination has a limited accuracy in the detection of submucosal invasion in early esophageal cancer. Further improvements in acoustic coupling and ultrasound technique are required to improve the miniprobe accuracy before its implementation into clinical routine.

Endoscopic mucosal resection for squamous premalignant and early malignant lesions of the esophagus.

UNLABELLED: BACK AND STUDY AIMS: Endoscopic mucosal resection (EMR) is used to treat premalignant and malignant digestive tract lesions. This report presents the efficacy and safety of EMR for squamous superficial neoplastic esophageal lesions. PATIENTS AND METHODS: A retrospective cohort study presented data from 51 patients with 54 lesions over an 8-year period, between November 1997 and September 2005. Dysplasas or mucosal (m) T1 carcinomas were treated with repeated EMR until there was a complete local remission. Patients with submucosal (sm) T1 carcinomas were treated with repeated EMR until there was a complete local remission. Patients with submucosal (sm) T1 carcinomas or more advanced stage were offered surgery or chemoradiotherapy. RESULTS: There was no mortality, perforation, or major hemorrhage, and there were three easily dilated stenoses. Of the patients, 16 had lesions graded as T1sm or more advanced and one patient was found to have normal tissue post EMR. Complete local remission was achieved in 31 of the 34 patients with dysplasia or T1 m cancers (91%). There was no distant relapse and there was local disease recurrence in eight of the 31 patients (26%). The 5-year survival rate was 95%. CONCLUSIONS: EMR for squamous superficial neoplastic lesions of the esophagus is safe and provides satisfactory survival results.

Histological benefit of retreatment by pegylated interferon alfa-2b and ribavirin in patients with recurrent hepatitis C virus infection posttransplantation.

We conducted a study to evaluate the efficacy of pegylated interferon/ribavirin in patients who did not respond to previous posttransplant recurrent HCV treatment with IFN/ribavirin combination. Twenty-seven patients were consecutively included in this study and retreated with pegylated interferon alfa-2b (1.5 microg/kg/week) with ribavirin (800-1000 mg daily) for 48 weeks for genotype 1 and 4 and 24 weeks for other genotypes. We compared them with 21 untreated patients enrolled during the same period. Primary endpoint was the SVR and secondary endpoint was histological evaluation 24 weeks after ending therapy. Twenty-seven patients started therapy but 2 (7%) stopped because of side effects. On an intent-to-treat basis, eight patients (30%) had an SVR. Cyclosporine as immunosuppressive therapy during antiviral therapy (p = 0.03) and EVR (p = 0.02) were significantly associated with viral clearance. In 46 patients in whom paired graft biopsies were available, fibrosis score was improved in 76% of treated patients versus 5% in untreated patients. Among treated patients, improvement of fibrosis was not correlated to SVR. Our data show that 30% of patients who have failed prior posttransplantation treatment achieved an SVR when retreated with pegylated interferon alfa-2b/ribavirin. More interesting is that fibrosis score was improved in 65% of treated patients despite failure of HCV eradication.

[Gastrojejunocolic fistula, report of two recent cases with original management]. / Fistule gastrojéjunocolique: prise en charge originale de deux patients.

Gastrojejunocolic fistulae, ultimate complication of anastomotic peptic ulceration, are presently uncommon. We report two recent cases of postoperative gastrojejunocolic fistulas (after duodenal ulcer surgery and total duodenopancreatectomy), which were complicated at time of diagnosis (acute peritonitis and liver cirrhosis) and required a two-stage treatment.

Diagnostic value of endoscopic capsule in patients with obscure digestive bleeding: blinded comparison with video push-enteroscopy.

BACKGROUND AND STUDY AIMS: This study was designed to prospectively compare the diagnostic yield of the M2A endoscopic capsule with that of video push-enteroscopy in exploring the small intestine in patients with obscure digestive bleeding. PATIENTS AND METHODS: Patients with either occult or overt obscure digestive bleeding and a negative endoscopic work-up underwent a double intestinal investigation, with video push-enteroscopy and a wireless capsule, performed blindly by separate examiners. The diagnostic yield for each technique was defined as the frequency of detection of clinically relevant intestinal lesions, i. e. those having the potential for bleeding. RESULTS: 60 patients (27 men, 33 women; age 58 +/- 18 years; hemoglobin 9.4 +/- 2.5 g/dl) were included, 32 with occult and 28 with overt bleeding. Results were analyzed for 58 patients, who completed both examinations. Lesions were detected in 43 patients: with both techniques in 19, only by capsule in 21, and, conversely, only by push-enteroscopy in 3 ( P = 0.04). Final diagnoses were as follows: a P2 lesion with high bleeding potential in 28 patients (19 angiomata, 6 ulcerations, 2 tumors, 1 case of intestinal varices); a P1 lesion with intermediate bleeding potential in 15 patients (2 patients with mucosal erosions, 13 patients with mucosal red spots); and there were normal findings from 15 procedures. No procedure induced any complication. CONCLUSION: The use of the wireless endoscopy capsule detects significantly more clinically relevant intestinal lesions than video push-enteroscopy in patients with obscure digestive bleeding, raising the diagnostic yield to 67.2 %. Its influence on the clinical outcome for patients needs further investigation.

Do normal findings at biliary endoscopic ultrasonography obviate the need for endoscopic retrograde cholangiography in patients with suspicion of common bile duct stone? A prospective follow-up study of 238 patients.

BACKGROUND AND STUDY AIMS: Biliary endoscopic ultrasonography (EUS) and endoscopic retrograde cholangiography (ERC) are equally accurate for the diagnosis of common bile duct (CBD) stone. The aim of this prospective 1-year follow-up study was to determine whether normal findings at initial EUS obviated the need for ERC. PATIENTS AND METHODS: During a 17-month period, all patients referred for biliary EUS because of suspicion of CBD stone, in whom EUS findings were normal were included in the study. Early (1-month) and late (1-year) follow-up details were obtained by mail or telephone. The clinical course and need for ERC were recorded. RESULTS: 238 patients were enrolled. During follow-up, 59 (25 %) patients underwent cholecystectomy, with (n=31) or without (n=28) cholangiography, and 30 patients underwent ERC (13 %). CBD stone was found in 14 (6 %) patients. Of these 30 patients, ERC was done in 15 cases in the first week after EUS, because of persistent suspicion of a CBD stone which was found in 10 patients. The 15 late ERC procedures (carried out more than 1 week after EUS) revealed only one CBD stone. The negative predictive value of EUS for the diagnosis of CBD stones was 95.4 %. CONCLUSIONS: Patients with suspicion of CBD stones but normal EUS findings have a low risk of needing ERC in a 1-year period.

Transjugular intra-hepatic portosystemic shunt for refractory variceal bleeding.

BACKGROUND: The most dramatic complication of portal hypertension in cirrhotic patients is oesophageal variceal bleeding. Moreover, patients with bleeding unresponsive to medical and endoscopic treatment have a poor prognosis. OBJECTIVE: The aim of this study was to evaluate the efficacy of early transjugular intra-hepatic portosystemic shunt (TIPS) in patients with refractory variceal bleeding. PATIENTS AND METHODS: TIPS was performed for 28 patients (17 were stage Child C), successfully in 26. Variceal bleeding was controlled in all but one successfully stented patient. RESULTS: There was no mortality associated with the procedure. The two patients with a failure of TIPS insertion died of persistent bleeding in the first 48 h after failed TIPS. The 40-day mortality rate was 25%. Five patients died (one from persistent bleeding from gastric varices and four from multi-organ failure). Using multivariate analysis, the only independent factor associated with early mortality was the total bilirubin value. Fifteen surviving patients were listed for liver transplantation: four deaths occurred, eight patients were transplanted in the 6 months after TIPS and three are still waiting. Among the six patients who survived but were ineligible for transplantation, two died and four are still alive. Two episodes of early rebleeding and eight of late rebleeding occurred. Actuarial survival was 75% at one year and 52% at two years. CONCLUSIONS: Early TIPS is an effective rescue therapy for controlling refractory variceal bleeding.

[Prospective randomized single-blind trial comparing oral sodium phosphate with polyethylene glycol for colonoscopy preparation]. / Etude prospective randomisée en simple aveugle comparant phosphate de sodium oral et polyéthylène glycol pour la préparation à la coloscopie.

AIM AND METHODS: The aim of this prospective, randomized, study performed in 60 outpatients was to compare 2 precolonoscopy bowel preparations: oral sodium phosphate (NaP) versus standard polyethylene glycol-based lavage solution (PEG). None of the patients met any of NaP exclusion criteria. All patients were prepared on the day prior to colonoscopy. A patient-questionnaire and measure of serum electrolytes (calcium, phosphate, sodium, potassium), pulse and blood pressure were used to assess tolerance and acceptability of the preparation. The quality of colon cleansing was judged by blinded endoscopists. RESULTS: Patient's tolerance to NaP was superior to PEG: NaP preparation was easier to drink and feelings of abdominal plenitude occurred in a smaller proportion of patients. A potassium decrease, a sodium increase and hyperphosphatemia were observed in the NaP group but without clinical events. PEG preparation seemed to allow a better cleansing ability compared with NaP but this difference was not statistically significant. CONCLUSIONS: NaP solution was better tolerated and accepted by patients. Colonic preparation quality compared to PEG is still to be discussed depending on the intake schedule. A biochemical data check seems necessary on account of significant serum electrolytes changes induced by NaP preparation.

Combined chemotherapy and radiotherapy followed by surgery in the treatment of patients with squamous cell carcinoma of the esophagus.

BACKGROUND: Surgery remains the treatment of choice for patients with esophageal squamous cell carcinoma (SCC), but survival rates have not improved over the past decades. The objective of this study was to evaluate the effect of multimodal therapy on resectability, on the overall and on disease free survival (DFS) rates, and on the laryngeal resection rate. METHODS: Fifty-five patients (49 men and 6 women) with a mean age of 58 +/- 8 years underwent combined modality treatment for esophageal SCC. The tumor location was in the upper one-third of the esophagus in 19 patients, the middle one-third in 22 patients, the lower one-third in 9 patients, and the upper and lower one-thirds in 5 patients. The intent of combined therapy was curative in 87.3% of patients and palliative in 12.7% of patients. Neoadjuvant treatment consisted of two courses of 5-fluorouracil and cisplatin on Days 1-5 and Days 21-25. Radiotherapy was commenced on Day 21 and consisted of 36 grays delivered in 12 fractions over 17 days. Surgery was performed on Day 60. RESULTS: Full neoadjuvant treatment was possible in 67.3% of patients and was uneventful in 56. 4% of patients. The resection rate was 96.4% (complete macroscopic resection with histologic clear margins [R0], 83.6%; complete macroscopic resection with microscopic disease at the resection margin [R1], 1.8%; and macroscopic residual disease [R2], 10.9%). The operative mortality rate was 0%, whereas the hospital mortality was 7.3%. Twenty-three patients had a complete macroscopic response, 12 of whom (21.8%) had a complete histopathologic response. The tumor stages according to the American Joint Committee on Cancer staging system were pT0N0 in 12 patients, Stage 0 in 8 patients, Stage IIa in 6 patients, Stage IIb in 6 patients, Stage III in 8 patients, and Stage IV in 13 patients. Laryngeal preservation was achieved in 8 of 12 patients in whom total pharyngolaryngoesophagectomy initially was indicated because of tumor response and an R0 resection. The overall survival rates at 1 year, 3 years, and 5 years were 61%, 39%, and 33%, respectively, and the DFS rates were 49%, 32%, and 29%, respectively. The respective survival rates for responders were 82%, 58%, and 53%, and the DFS rates were 68%, 54%, and 48%. CONCLUSIONS: Neoadjuvant treatment is tolerated well by most patients. Combination therapy increases the resectability rate and facilitates laryngeal preservation. Significant improvements in the actuarial survival rate and the DFS rate were observed in the group of patients who achieved partial and complete responses.

Influence of the interval between preoperative radiation therapy and surgery on downstaging and on the rate of sphincter-sparing surgery for rectal cancer: the Lyon R90-01 randomized trial.

PURPOSE: The optimal timing of surgery after preoperative radiotherapy in rectal cancer is unknown. The aim of this trial was to evaluate the role of the interval between preoperative radiotherapy and surgery. PATIENTS AND METHODS: Patients with rectal carcinoma accessible to rectal digital examination, staged T2 to T3, NX, M0, were randomized before radiotherapy (39 Gy in 13 fractions) into two groups: in the short interval (SI) group, surgery had to be performed within 2 weeks after completion of radiation therapy, compared with 6 to 8 weeks in the long interval (LI) group. Between 1991 and 1995, 201 patients were enrolled onto the study. RESULTS: A long interval between preoperative radiotherapy and surgery was associated with a significantly better clinical tumor response (53. 1% in the SI group v 71.7% in the LI group, P =.007) and pathologic downstaging (10.3% in the SI group v 26% in the LI group, P =.005). At a median follow-up of 33 months, there were no differences in morbidity, local relapse, and short-term survival between the two groups. Sphincter-preserving surgery was performed in 76% of cases in the LI group versus 68% in the SI group (P = 0.27). CONCLUSION: A long interval between preoperative irradiation and surgery provides increased tumor downstaging with no detrimental effect on toxicity and early clinical results. When sphincter preservation is questionable, a long interval may increase the chance of a successful sphincter-saving surgery.