Factors associated with the efficacy and safety of endoscopic dilatation of symptomatic strictures in Crohn's disease: a retrospective cohort study.

OBJECTIVE: Endoscopic balloon dilatation (EBD) is a standard treatment for intestinal strictures in Crohn's disease (CD). No evidence-based guidelines exist regarding the balloon diameter or the balloon pressure to be used, with recent studies suggesting the use of a smaller diameter than classically used. We sought to analyze the factors associated with safety and efficacy of EBD in CD strictures, particularly looking at balloon diameter and dilatation pressure. METHODS: We conducted a monocentric retrospective study of patients who underwent EBD between 2005 and 2020. RESULTS: Our endoscopy department performed EBD in 94 CD patients during the considered period. The mean size of balloon dilatation was 16 mm (±2.5; including 21 patients with balloon <14 mm) and the mean dilatation pressure was 5.3 atm (±1.5). No perforation was observed. Over a median follow-up of 5.6 years, the probability of being operated was 5.4% at 1 year and 10.4% at 3 years. Smaller height (HR = 0.90, p = 0.022) and a higher BMI (HR = 1.23, p = 0.014) were associated with the risk of operation. The probability of being operated or redilated was 30.1% at 1 year and 52.5% at 3 years. No factor was significantly associated with this risk. The size of the balloon had no impact on outcomes. CONCLUSION: In this retrospective cohort, including a significant proportion of CD patients dilated with balloon <14 mm, no perforation was observed and the size of the balloon or the dilatation pressure had no impact on the risk of surgery or redilatation.

[Locally advanced pancreatic adenocarcinoma with biliary compression: need for early drainage]. / Adénocarcinome obstructif localement avancé de la tête du pancréas : importance du drainage biliaire précoce.

The incidence of pancreatic cancer is increasing, but proportion of resectable cases and survival do not increase. Then, our care strategies have to be optimized. Chemotherapy is the principal treatment of locally advanced pancreatic cancer. When the tumour triggers biliary obstruction, chemotherapy-associated morbidity increases, and biliary drainage becomes crucial. Gold-standard is endoscopic retrograde cholangiography, which could be impossible when duodenum or papilla are involved by the tumour. Other options are percutaneous radiologic drainage, surgical double by-pass or EUS-guided drainage. When EUS-guided procedures are available, they are proposed today as the best options.

Devant l'augmentation d'incidence du cancer du pancréas, sans accroissement du pourcentage de formes résécables ni de la survie, nos stratégies de prise en charge doivent être optimisées à tous les niveaux. Le traitement du cancer localement avancé du pancréas repose sur la chimiothérapie. En cas d'ictère, les effets secondaires de la chimiothérapie risquent d'être majorés, un drainage biliaire doit être réalisé. La technique de référence est la cholangiographie rétrograde endoscopique, qui s'avère impossible en cas d'envahissement duodénal ou papillaire. Il faut alors se tourner vers le drainage radiologique percutané, la chirurgie de double dérivation et, plus récemment, le drainage échoguidé. Lorsque la technique échoguidée est disponible et maîtrisée, ses avantages la positionnent devant le drainage percutané et la chirurgie.

[Interest of confocal endomicroscopy for the management of chronic inflammatory bowel disease]. / Endomicroscopie confocale dans la prise en charge des maladies inflammatoires chroniques de l'intestin.

Inflammatory bowel diseases are chronic diseases whose long-term evolution depends on the depth of remission. Their clinical and endoscopic evaluation is imperfect. The development of confocal endomicroscopy allows microscopic images to be obtained in vivo. These microscopic data are correlated with the activity of the disease. They predict a possible relapse of the disease and also predict the response to treatment with a biological agent, which allows to modify the therapy before the relapse or to make a rational choice between the different biological agents before introducing a new treatment.

Les maladies inflammatoires intestinales sont des maladies chroniques dont l'évolution au long cours dépend de la profondeur de la rémission. Leur évaluation clinique et endoscopique est imparfaite. Le développement de l'endomicroscopie confocale permet d'obtenir des images microscopiques in vivo qui sont corrélées à l'activité de la maladie. Ces données microscopiques permettent de prédire une éventuelle rechute de la maladie et la réponse au traitement par un agent biologique, ce qui amène à modifier la thérapeutique avant la rechute ou de réaliser un choix rationnel entre les différents agents biologiques avant d'instaurer un nouveau traitement.

[Esophago-gastric complications after ablation in atrial fibrillation]. / Complications œsogastriques de la thermoablation dans le cadre de la fibrillation auriculaire.

Atrial-esophageal fistula (AOF) after ablation in atrial fibrillation has a fatal outcome. Fully documented in 2004, AOF has never completely disappeared despite technological evolvements. Survival depends on early recognition and treatment. Gastroscopy allows early detection of esophageal lesions. We summarize here AOF mechanisms, evoking symptoms and treatment ; contribution of gastroscopy in early detection ; and finally symptoms from vagal and phrenic nerve injuries. This information is useful for emergency doctors, gastroenterologists / endoscopists, and general practitioners.

La fistule atrio-œsophagienne (FAO) est une complication dramatique de la thermoablation des foyers ectopiques responsables de fibrillation auriculaire. Depuis sa description en 2004, la FAO n'a pas complètement disparu malgré les évolutions technologiques, comme en témoignent des publications récentes. Néanmoins, reconnue et traitée rapidement, son pronostic s'améliore considérablement. La gastroscopie permet la détection de lésions œsophagiennes (LO) dès les premières 24 heures. Nous résumons les mécanismes et symptômes de la FAO, ainsi que sa prise en charge, le rôle de la gastroscopie dans la détection précoce des LO, et les complications liées à l'atteinte des nerfs vague et phréniques. Ces informations peuvent être utiles aux urgentistes, aux gastroentérologues et aux généralistes.

On-site comparison of an enzymatic detergent and a non-enzymatic detergent-disinfectant for routine manual cleaning of flexible endoscopes.

Background and study aims Flexible endoscopes are potential vectors of pathogen transmission to patients that are subjected to cleaning and high-level disinfection after each procedure. Efficient manual cleaning is a prerequisite for effective high-level disinfection. The goal of this study was to demonstrate the impact of the cleaning chemistry in the outcome of the manual cleaning of endoscopes. Materials and methods Twelve endoscopes were included in this study: four colonoscopes, four gastroscopes, two duodenoscopes and two bronchoscopes. This study was designed with two phases; in each of them, the manual cleaning procedure remained identical, but a different detergent was used: a non-enzymatic detergent-disinfectant (NEDD) and an enzymatic detergent (ED). Biopsy and suction channels of endoscopes were sampled using 10 mL of physiological saline at two points: before and after manual cleaning, and adenosine triphosphate (ATP) was measured on each sample. In total, 208 procedures were analyzed for the NEDD phase and 253 for the ED phase. Results For each endoscope type, cleaning endoscopes with ED resulted in larger median decrease in ATP than with NEDD: respectively 99.43 % and 95.95 % for bronchoscopes ( P  = 0.0007), 99.28 % and 96.93 % for colonoscopes ( P  < 0.0001) and 98.36 % and 95.36 % for gastroscopes ( P  < 0.0001). In addition, acceptability rates of endoscopes based on defined post-manual cleaning ATP thresholds (200, 150, 100 or 50 relative light units) for all endoscope types were significantly higher with ED compared to NEDD. Conclusions With all other parameters of manual cleaning remaining unchanged, the enzymatic chemistry of ED provided more consistent and improved cleaning of endoscopes compared to NEDD. Therefore, choice of the detergent for endoscope cleaning has an impact on the outcome of this process.

Belgian consensus on chronic pancreatitis in adults and children: statements on diagnosis and nutritional, medical, and surgical treatment.

Chronic pancreatitis (CP) is an inflammatory disorder characterized by inflammation and fibrosis, resulting in a progressive and irreversible destruction of exocrine and endocrine pancreatic tissue. Clinicians should attempt to classify patients into one of the six etiologic groups according to the TIGARO classification system. MRI/MRCP, if possible with secretin enhancement, is considered the imaging modality of choice for the diagnosis of early-stage disease.In CP, pain is the most disabling symptom, with a significant impact on quality of life. Pain should be assessed using the Izbicki score and preferably treated using the "pain ladder" approach. In painful CP, endoscopic therapy (ET) can be considered as early as possible. This procedure can be combined with extracorporeal shock-wave lithotripsy (ESWL) in the presence of large (> 4 mm), obstructive stone(s) in the pancreatic head, and with ductal stenting in the presence of a single main pancreatic duct (MPD) stricture in the pancreatic head with a markedly dilated MPD. Pancreatic stenting should be pursued for at least 12 months in patients with persistent pain relief. On-demand stent exchange should be the preferred strategy. The simultaneous placement of multiple, side-by-side, pancreatic stents can be recommended in patients with MPD strictures persisting after 12 months of single plastic stenting. We recommend surgery in the following cases: a) technical failure of ET ; b) early (6 to 8 weeks) clinical failure ; c) definitive biliary drainage at a later time point; d) pancreatic ductal drainage when repetitive ET is considered unsuitable for young patients; e) resection of an inflammatory pancreatic head when pancreatic cancer cannot be ruled out; f) duodenal obstruction. Duodenopancreatectomy or oncological distal pancreatectomy should be considered for patients with suspected malignancy. Pediatricians should be aware of and systematically search for CP in the differential diagnosis of chronic abdominal pain. As malnutrition is highly prevalent in CP patients, patients at nutritional risk should be identified in order to allow for dietary counseling and nutritional intervention using oral supplements. Patients should follow a healthy balanced diet taken in small meals and snacks, with normal fat content. Enzyme replacement therapy is beneficial to symptomatic patients, but also in cases of subclinical insufficiency. Regular follow-up should be considered in CP patients, primarily to detect subclinical maldigestion and the development of pancreatogenic diabetes. Screening for pancreatic cancer is not recommended in CP patients, except in those with the hereditary form.