Magnetic Resonance Imaging May Be Able to Identify the Origin of Neuroendocrine Tumor Liver Metastases.

OBJECTIVES: The aim of the study was to discriminate hepatic metastases from pancreatic neuroendocrine tumors (pNET) and hepatic metastases from midgut neuroendocrine tumors (mNET) with magnetic resonance imaging (MRI). METHODS: MRI examinations of 24 patients with hepatic metastases from pNET were quantitatively and qualitatively assessed by 2 blinded readers and compared to those obtained in 23 patients with hepatic metastases from mNET. Inter-reader agreement was calculated with kappa and intraclass correlation coefficient (ICC). Sensitivity, specificity, and accuracy of each variable for the diagnosis of hepatic metastasis from pNET were calculated. Associations between variables and primary tumor (i.e., pNET vs. mNET) were assessed by univariate and multivariate analyses. A nomogram was developed and validated using an external cohort of 20 patients with pNET and 20 patients with mNET. RESULTS: Interobserver agreement was strong to perfect (k = 0.893-1) for qualitative criteria and excellent for quantitative variables (ICC: 0.9817-0.9996). At univariate analysis, homogeneity on T1-weighted images was the most discriminating variable for the diagnosis of pNET (OR: 6.417; p = 0.013) with greatest sensitivity (88%; 21/24; 95% CI: 68-97%). At multivariate analysis, tumor homogeneity on T1-weighted images (p = 0.007; OR: 17.607; 95% CI: 2.179-142.295) and target sign on diffusion-weighted images (p = 0.007; OR: 19.869; 95% CI: 2.305-171.276) were independently associated with pNET. Nomogram yielded a corrected AUC of 0.894 (95% CI: 0.796-0.992) for the diagnosis of pNET in the training cohort and 0.805 (95% CI: 0.662-0.948) in the validation cohort. CONCLUSIONS: MRI provides qualitative features that can help discriminate between hepatic metastases from pNET and those from mNET.

Meglumine diatrizoate esophagogram after peroral endoscopic myotomy (POEM): identification of imaging findings associated with clinical complications and longer hospital stay.

OBJECTIVES: Esophageal peroral endoscopic myotomy (POEM) is the treatment of reference of major obstructive esophageal motility disorders but the detection of early complications remains challenging. Our aim was to report the radiological findings on meglumine diatrizoate esophagograms after esophageal POEM and identify variables associated with patient outcomes. METHODS: The imaging and clinical files of 106 patients who underwent POEM for achalasia or other major obstructive esophageal motility disorders were retrospectively analyzed. Post POEM esophagograms were reviewed for the presence of pneumoperitoneum, pleural effusion, extraesophageal contrast leakage, and dislocated clips. Associations between length of hospital stay and radiological findings were searched for using a Cox multivariate analysis. RESULTS: A total of 106 patients (M/F = 56/50; mean age = 50 ± 2 [SD] years) underwent 106 POEM procedures with a meglumine diatrizoate esophagogram on postoperative day 1. Overall median hospital stay was 3 days (range 1-20 days). Pneumoperitoneum, pleural effusion, extraesophageal contrast leakage, and dislocated clips were observed in 90/106 (84.9%), 12/106 (11.3%), 4/106 (3.8%), and 0/106 (0%) patients, respectively. At multivariate analysis, pleural effusion (p = 0.005; adjusted hazard ratio [aHR] = 0.35 [95% CI 0.17-0.73]) and extraesophageal contrast leakage (p = 0.039; aHR = 0.27 [95% CI 0.08-0.94]) were associated with a prolonged hospital stay. Pneumoperitoneum was not associated with unfavorable outcome (p = 0.99). CONCLUSIONS: Pneumoperitoneum is a common finding after POEM and is not indicative of unfavorable patient outcome. Conversely, post POEM pleural effusion and extraesophageal contrast leakage are associated with a longer hospital stay. KEY POINTS: • Water-soluble esophagogram is a valid diagnostic modality to diagnose early complications after esophageal endoscopic myotomy for esophageal motility disorders. • At multivariate analysis, pleural effusion and extraesophageal contrast leakage are associated with a prolonged hospital stay after peroral endoscopic myotomy. • Pneumoperitoneum is not associated with unfavorable outcome after peroral endoscopic myotomy.

Do we still need a diverticuloscope for the flexible endoscopic septotomy of Zenker's diverticulum?

BACKGROUND AND AIM: Zenker's diverticulum (ZD) is the most common type of diverticulum in the esophagus. The endoscopic septotomy of the diverticular wall has become a widely accepted treatment modality, but the recurrence rate is unclear. Our aim was to assess short-term and long-term success rates after flexible endoscopic septotomy for the treatment of ZD. METHODS: All consecutive patients treated at our department for a ZD between November 2014 and September 2018 were included. Endoscopic septotomy was conducted using a diverticuloscope or a distal attachment cap. Data were retrospectively analyzed from a prospectively collected database. We collected data concerning patients, endoscopic procedures, and short-term clinical outcomes. All patients were reached by phone between October and December 2018 to assess long-term results. RESULTS: Seventy-seven patients were referred to our department for a ZD. Sixty patients were treated using a diverticuloscope and 17 patients with a distal attachment cap. For all 77 patients, the myotomy was technically successful. Three patients treated with a diverticuloscope reported complications. Initial treatment success was 93%. After a mean (±SEM) follow up of 23 ± 2 months, 66% of patients had persistent clinical remission. The rate of long-term treatment success was 72% in treatment-naïve and 50% in previously treated patients (P = 0.13). Treatment success was 68% in patients treated with the diverticuloscope versus 60% in the group treated with a cap (P = 0.75). CONCLUSION: The flexible endoscopic septotomy for the treatment of ZD is a safe and effective treatment of ZD, with or without a diverticuloscope.

Tumour growth increased following antiangiogenic interruption: the challenge of tumour evaluation.

Vascular endothelial growth factor inhibitors, led by bevacizumab, are considered the cornerstone of the therapy in metastatic colorectal carcinoma. We present the case of a patient with metastatic colorectal cancer who experienced rapid tumour growth with liver broad invasion after the withdrawal of an antivascular endothelial growth factor therapy, aflibercept. The rebound effect caused by the residual tumour inducing a regrowth after an initial controlled disease has already been stressed in mice and metastatic colorectal cancer patients following bevacizumab interruption. The use of liver volume evaluation was consistent with the Response Evaluation Criteria in Solid Tumours 1.1 criteria evaluation and might be a useful tool in patients with more than a half liver invasion. We describe for the first time the case of a major liver disease progression, confirmed by Response Evaluation Criteria in Solid Tumours 1.1 criteria and liver volume evaluation, after an antiangiogenic interruption in second line.

Reliability and diagnostic accuracy of qualitative evaluation of diffusion-weighted MRI combined with conventional MRI in differentiating between complete and partial anterior cruciate ligament tears.

OBJECTIVES: To assess the reliability and diagnostic accuracy of qualitative evaluation of apparent diffusion coefficient (ADC) mapping with magnetic resonance imaging (MRI) in differentiating between complete and partial anterior cruciate ligament (ACL) tears. METHODS: This prospective study protocol was approved by the institutional ethics review board and informed consent was obtained from all the patients. Eighty-five patients (35 women and 50 men, mean age 34.1 years) with recent (<4 months) knee trauma with suspected ACL injury underwent conventional MRI (T1-weighted and T2-weighted sequences with fat saturation) associated with ADC mapping. MR images were read qualitatively without and then with ADC mapping by three radiologists, with analysis of direct signs of a traumatic ACL tear and a second-reading. Dynamic X-rays (43 patients) or arthroscopies (42 patients) were used as reference standards. RESULTS: For complete ACL tear diagnosis (67 patients), sensitivity and specificity were 87% and 50% respectively with conventional MRI, and 96% and 94% respectively with ADC mapping (P < 0.01 for specificity). Inter-observer correlations between musculoskeletal radiologists were almost perfect (κ = 0.81) with ADC mapping and fair with conventional MRI on the second-reading. CONCLUSIONS: ADC mapping associated with conventional MR sequences is a reproducible method to better differentiate complete and partial ACL tears.

Comparison between CT-enterography and MR-enterography for the diagnosis of right-sided deep infiltrating endometriosis of the bowel.

OBJECTIVE: To compare computed tomography-enterography (CTE) and magnetic resonance-enterography (MRE) in the detection of right-sided bowel deep infiltrating endometriosis (DIE). MATERIALS AND METHODS: Fifty women with DIE who underwent preoperatively CTE and MRE were included. CTE and MRE were first analyzed separately by two independent readers who analyzed five bowel segments (cecum, appendix, ileocecal junction, distal ileum and proximal small bowel [i.e., proximal ileum and jejunum]) for the presence of DIE and then interpreted in consensus. CTE, MRE and CTE with MRE were compared in terms of sensitivity, specificity and accuracy. Interobserver agreement was assessed with kappa (κ) test. RESULTS: Using the reference standard 25 out 250 bowel segments were involved by DIE in 18 women and 225 were free of DIE. Sensitivity, specificity, and accuracy of CTE were 60% (95% confidence interval [CI]: 39-79), 93% (95% CI: 89-96) and 90% (95% CI: 85-93) for Reader 1, respectively, and 52% (95% CI: 31-72), 99% (95% CI: 97-100) and 94% (95% CI: 91-97) for Reader 2, with no differences in sensitivity (P = 0.564) and specificity (P = 0.181) between readers and fair interobserver agreement (κ = 0.37). For MRE these figures were 52% (95% CI: 31-72), 92% (95% CI: 88-95) and 88% (95% CI: 84-92) for Reader 1 and 60% (95% CI: 39-79), 99% (95% CI: 96-100) and 95% (95% CI: 91-97) for Reader 2, with no differences in sensitivity (P = 0.157) and specificity (P = 0.061) between readers and fair interobserver agreement (κ = 0.31). Significant differences in sensitivity (20%; 95% CI: 7-41) were found between CTE + MRE vs. CTE alone for Reader 1 and vs. MRE alone for Reader 2 (P = 0.041 for both) CONCLUSION: CTE and MRE have not different sensitivities and convey only fair interobserver agreement but are highly specific for the diagnosis of right-sided bowel DIE. CTE and MRE are complementary because they improve the detection of DIE implants when used in combination.

CT antegrade colonography to assess proctectomy and temporary diverting ileostomy complications before early ileostomy takedown in patients with low rectal endometriosis.

OBJECTIVE: The purpose of this study is to describe an imaging method based on a CT technique, CT antegrade colonography, for the evaluation of low anastomosis and to evaluate the value of CT antegrade colonography before early ileostomy closure after proctectomy in low rectal endometriosis. MATERIALS AND METHODS: One hundred ninety-five patients referred for low rectal endometriosis underwent proctectomy and were eligible for early ileostomy closure. All patients underwent standard antegrade fluoroscopy (n=77) or CT antegrade colonography (n=118) 8 days after surgery. The negative predictive values, positive predictive values, sensitivity, specificity, and likelihood ratio of standard antegrade fluoroscopy and CT antegrade colonography in detecting anastomotic leakage and abscesses were assessed. The reference standard for positive and negative examinations was based on clinical follow-up, imaging, surgical, or interventional procedure findings. RESULTS: Negative and positive predictive values for detecting anastomotic leakage were 100% (95% CI, 96.8-100%) and 100% (95% CI, 39.8-100%), respectively, for CT antegrade colonography and 98.6% (95% CI, 92.4-100%) and 100% (95% CI, 54.1-100%), respectively, for standard antegrade fluoroscopy. The negative and positive predictive values for detecting abscess were 100% (95% CI, 96.8-100%) and 100% (95% CI, 47.8-100%), respectively, for CT antegrade colonography and 97.3% (95% CI, 90.8-99.7%) and 100% (95% CI, 2.5-100%), respectively, for standard antegrade fluoroscopy. CONCLUSION: CT antegrade colonography may play a major role in the evaluation of low anastomosis protected by an ileostomy after proctectomy in low rectal endometriosis, leading to the development of a new strategy with early restoration of the intestinal continuity.

Effectiveness of MR enterography for the assessment of small-bowel diseases beyond Crohn disease.

The use of cross-sectional imaging techniques for the noninvasive evaluation of small-bowel disorders is increasing. The effectiveness of magnetic resonance (MR) enterography for the evaluation of Crohn disease, in particular, is well described in the literature. In addition, MR enterography has an evolving though less well documented role to play in the evaluation of other small-bowel diseases, including various benign and malignant neoplasms arising in isolation or in polyposis syndromes such as Peutz-Jeghers, inflammatory conditions such as vasculitis and treatment-induced enteritis, infectious processes, celiac disease, diverticular disease, systemic sclerosis, and bowel duplication. MR enterography may be useful also for the evaluation of intermittent and low-grade small-bowel obstructions. Advantages of MR imaging over computed tomography (CT) for enterographic evaluations include superb contrast resolution, lack of associated exposure to ionizing radiation, ability to acquire multiplanar primary image datasets, ability to acquire sequential image series over a long acquisition time, multiphasic imaging capability, and use of intravenous contrast media with better safety profiles. MR enterography also allows dynamic evaluations of small-bowel peristalsis and distensibility of areas of luminal narrowing and intraluminal masses by repeating sequences at different intervals after administering an additional amount of the oral contrast medium. Limitations of MR enterography in comparison with CT include higher cost, less availability, more variable image quality, and lower spatial resolution. The advantages and disadvantages of MR enterography performed with ingestion of the oral contrast medium relative to MR enteroclysis performed with infusion of the oral contrast medium through a nasoenteric tube are less certain.

Development of a New Index to Assess Small Bowel Inflammation Severity in Crohn's Disease Using Magnetic Resonance Enterography.

Background: The severity of small bowel (SB) inflammation in Crohn's disease (CD) patients is a key component of the therapeutic choice. We aimed to develop a SB-CD Magnetic Resonance Enterography (MRE) index of Inflammation Severity (CDMRIS). Methods: Each gastroenterologist/radiologist pair in 13 centers selected MREs from 6 patients with SB-CD stratified on their perceived MRE inflammation severity. The 78 blinded MREs were allocated through balanced incomplete block design per severity stratum to these 13 pairs for rating the presence/severity of 13 preselected items for each SB 20-cm diseased segment. Global inflammation severity was evaluated using a 100-cm visual analog scale. Reproducibility of recorded items was evaluated. The CDMRIS was determined through linear mixed modeling as a combination of the numbers of segments with lesions highly correlated to global inflammation severity. Results: Four hundred and forty-two readings were available. Global inflammation severity mean ± SD was 21.0 ± 16.2. The independent predictors explaining 54% of the global inflammation severity variance were the numbers of segments with T1 mild-moderate and severe intensity of enhancement, deep ulceration without fistula, comb sign, fistula, and abscess. Unbiased correlation between CDMRIS and global inflammation severity was 0.76. Conclusions: The CDMRIS is now available to evaluate the severity of SB-CD inflammation. External validation and sensitivity-to-change are mandatory next steps.

Chronic liver disease: systemic and splanchnic venous flow mapping with optimized cine phase-contrast MR imaging validated in a phantom model and prospectively evaluated in patients.

PURPOSE: To validate magnetic resonance (MR) imaging cine phase-contrast blood flow mapping in vitro and in patients with chronic liver disease, with or without portal hypertension, and to assess the accuracy of azygos, splanchnic, and systemic blood flow measured with MR imaging in the detection of high-risk esophageal varices and compare these measurements with endoscopic evaluation, the reference standard. MATERIALS AND METHODS: The local ethics committee approved this study. Patients gave written informed consent. Two phantoms were used to validate the MR imaging phase-contrast flow sequence. Patients with liver cirrhosis (n = 59), chronic liver disease without cirrhosis (n = 12), and nodular regenerative hyperplasia (NRH) (n = 11), and healthy control subjects with no liver disease (n = 25) were included. The patients underwent upper digestive system endoscopy. Mean abdominal aorta, portal venous, and azygos blood flow was measured on MR images, which were reviewed by two blinded observers to determine the presence and grade of esophageal varices. The reproducibility and intra- and interobserver variability of the blood flow measurements were assessed with intraclass correlation coefficients (ICCs). The performance of the MR blood flow measurements in staging high-risk varices was determined with receiver operating characteristic curve analysis. The correlation between MR visual analysis and endoscopic grading was assessed by using κ statistics. RESULTS: MR flow rate measurements had excellent correlations with actual flow values in vitro (ICC > 0.990 for phantoms 1 and 2). Mean aortic flow was significantly higher in patients with cirrhosis than in control subjects (P < .001). Mean azygos flow was significantly higher in patients with cirrhosis than in patients with chronic liver disease without cirrhosis (P = .005) and control subjects (P < .001). Low intra- and interobserver variability (ICC > 0.990 for each blood flow type) and high reproducibility (ICC > 0.850 for each blood flow type) were demonstrated. The optimal cutoff mean azygos flow value was 2.3 mL/sec for varices with grades of 2 or higher. CONCLUSION: MR imaging azygos flow measurement appears to be a promising technique for detecting high-risk esophageal varices in patients with portal hypertension.

Endoscopic ultrasound efficacy in staging gastric linitis plastica lesion: a retrospective multicentric French study.

BACKGROUND: Endoscopic ultrasound (EUS) is a key imaging technique in gastric cancer (GC). The aim of this study was to evaluate the performance of EUS in the staging of parietal and lymph node involvement in linitis plastica (LP) compared to "classical" GC. METHODS: A retrospective multicentric French study was conducted on patients with no metastatic LP and operated by gastrectomy. A 2/1 matching based on pTNM stage and center was performed with GC. RESULTS: Forty-three patients were included, sixteen patients in the LP group and 27 in the control group. Sensitivity and specificity of EUS for diagnosis of T3-T4 parietal invasion were 77% and 100% respectively in the LP group and 89% and 56% respectively in the control group. Sensitivity and specificity of EUS for diagnosis of lymph node involvement were 73% and 80%, respectively in the LP group and 88% and 50%, respectively in the control group. Patients from LP group had significantly more advanced histological lesion, and frequent undiagnosed peritoneal carcinomatosis. CONCLUSIONS: This study evaluated for the first time in a European population, the preoperative EUS performance in LP. Our study identified a similar sensitivity and specificity of the EUS in LP compared to "classical" GC paving for a broader use of EUS in preoperative settings.

Clinical impact of routine CT esophagogram after peroral endoscopic myotomy (POEM) for esophageal motility disorders.

Background and study aims Per oral endoscopic myotomy (POEM) of the lower esophageal sphincter has become a major treatment for esophageal motility disorders, especially achalasia. POEM can result in esophageal bleeding or perforation and pleural and mediastinal effusion. Early routine computed tomography (CT) esophagogram is frequently performed to assess these adverse events (AEs) before resuming oral food intake. We sought to evaluate the value of routine CT esophagogram on postoperative day (POD) 1 after POEM. Patients and methods This single-center retrospective study was performed in a tertiary referral center for interventional digestive endoscopy. We included consecutive patients with POEM and routine CT esophagogram on POD 1 between July 2018 and July 2019. Results Fifty-eight patients were included in the study, 79 % of whom had achalasia. Twenty patients (34 %) presented post-endoscopic AEs, including two patients with severe AEs requiring intensive care admission (one compressive pneumothorax and one mediastinitis); no deaths occurred. Of the 58 CT esophagograms performed, only one was normal. The 57 others (98 %) showed at least one abnormal finding: pneumoperitoneum or retroperitoneal air (91 %), pneumomediastinum (78 %), pleural effusion (34 %), pneumothorax (14 %), pneumonia (7 %), pericardial effusion (2 %), and mediastinal collection (2 %). CT esophagograms revealed AEs and modified therapeutic management in eight patients of 58 (14 %), all of whom had clinical symptoms prior to CT. Conclusions POD 1 CT esophagogram after POEM for esophageal motility disorders diagnosed clinically meaningful AEs in 14 % of patients, all associated with persistent clinical symptoms. Routine use of CT esophagogram after POEM in asymptomatic patients is questionable.

Utility of CT to Differentiate Pancreatic Parenchymal Metastasis from Pancreatic Ductal Adenocarcinoma.

Purpose: To report the computed tomography (CT) features of pancreatic parenchymal metastasis (PPM) and identify CT features that may help discriminate between PPM and pancreatic ductal adenocarcinoma (PDAC). Materials and methods: Thirty-four patients (24 men, 12 women; mean age, 63.3 ± 10.2 [SD] years) with CT and histopathologically proven PPM were analyzed by two independent readers and compared to 34 patients with PDAC. Diagnosis performances of each variable for the diagnosis of PPM against PDAC were calculated. Univariable and multivariable analyses were performed. A nomogram was developed to diagnose PPM against PDAC. Results: PPM mostly presented as single (34/34; 100%), enhancing (34/34; 100%), solid (27/34; 79%) pancreatic lesion without visible associated lymph nodes (24/34; 71%) and no Wirsung duct enlargement (29/34; 85%). At multivariable analysis, well-defined margins (OR, 6.64; 95% CI: 1.47-29.93; p = 0.014), maximal enhancement during arterial phase (OR, 6.15; 95% CI: 1.13-33.51; p = 0.036), no vessel involvement (OR, 7.19; 95% CI: 1.512-34.14) and no Wirsung duct dilatation (OR, 10.63; 95% CI: 2.27-49.91) were independently associated with PPM. The nomogram yielded an AUC of 0.92 (95% CI: 0.85-0.98) for the diagnosis of PPM vs. PDAC. Conclusion: CT findings may help discriminate between PPM and PDAC.

Endoscopic treatment of Zenker's diverticulum by complete septotomy: initial experience in 19 patients.

Background and study aims Endoscopic treatment of Zenker's Diverticulum (ZD) using a flexible endoscope and a diverticuloscope consists of myotomy of the cricopharyngeus muscle, sparing the lower part of the diverticular septum. However, recurrence occurs in up to 54 % of patients at 4 years. We assessed the feasibility and safety of a complete septotomy in endoscopic treatment of ZD. Patients and methods We conducted a retrospective analysis of a prospectively collected database at a single referral center. All consecutive patients treated by complete resection of the diverticular wall were included. The endoscopic technique used a distal attachment cap and division of the ZD septum using a Dual Knife or a Triangle Tip knife in endocut mode, until the esophageal muscularis propria was seen and no residual diverticulum remained. Symptoms were evaluated using the Augsburger questionnaire. Results Nineteen patients, 10 of whom were men with mean age 79 ±â€Š12 years, were treated by complete septotomy for a symptomatic ZD with a median size of 2.5 cm (range 1-5 cm). The clinical success rate was 100 % and the complication rate was 10 % (one pneumonia and one atrial fibrillation). Median hospital stay was 2 days (range 1-3 days). On Day 1 esophagogram, no extraesophageal contrast leakage was seen, periesophageal CO 2 was still visible in two patients, and complete ZD regression was seen in 63 % of patients. The 6-month clinical success rate was 100 %, with two patients lost to follow-up, and a median symptom score of 0 (range 0-4). After a mean ± SD follow-up of 9 ±â€Š5 months, the clinical success rate was 94 % (16/17). Conclusion Complete endoscopic septotomy is a feasible and safe therapeutic modality in patients with symptomatic ZD that does not require use of a diverticuloscope, and with good short-term efficacy. The complete regression of the diverticulum observed on Day 1 in 63 % of patients could be a marker of long-term clinical success.

Contribution of magnetic resonance imaging to the management of esophageal diseases: A systematic review.

PURPOSE: Currently available imaging modalities used to investigate the esophagus are irradiating or limited to the analysis of the esophageal lumen. Magnetic resonance imaging (MRI) is a non-invasive and non-radiating imaging technique that provides high degrees of soft tissue contrast. Newly developed fast MRI sequences allow for both morphological and functional assessment of the esophageal body and esophagogastric junction. The purpose of this systematic review was to identify the contribution of MRI to the diagnosis and management of esophageal diseases, such as gastroesophageal reflux, esophageal motility disorders, esophageal neoplasms, and portal hypertension. METHODS: We performed a systematic search of the Medline (via Ovid), EMBASE (via Ovid), PubMed and Cochrane Library databases from inception to December 2018 inclusively, using the MESH major terms "magnetic resonance imaging" AND "esophagus". RESULTS: The initial search retrieved 310 references, of which 56 were found to be relevant for the study. References were analysed and classified in different subheadings: MRI protocols for the esophagus, gastroesophageal reflux disease, achalasia and other esophageal motility disorders, esophageal cancer, portal hypertension and other esophageal conditions. CONCLUSION: MR Esophagography might become a non-invasive, non-irradiating technique of choice following diagnostic esophagogastroduodenoscopy for the assessment of esophageal diseases.

[Focus on Achalasia]. / Prise en charge de l'achalasie.

The pathophysiology of achalasia is largely unknown, and involves the destruction of ganglion cell in the esophageal myenteric plexus. High-resolution esophageal manometry is the key investigation. Endoscopic pneumodilatation and laparoscopic Heller myotomy have comparable short-term success rates, around 90%. The main complication after pneumodilatation is esophageal perforation, occurring in about 1% of cases. Peroral endoscopic myotomy is a promising treatment modality, however with frequent post-procedural gastroesophageal reflux.

Computed tomography scan efficacy in staging gastric linitis plastica lesion: a retrospective multicentric French study.

BACKGROUND: Computed tomography (CT) scan is a key imaging technique in the staging of gastric adenocarcinoma and therapeutic management of patients. The aim of this study was to evaluate the performance of CT scan in the staging of parietal and metastatic invasion in gastric linitis plastica group. METHODS: A retrospective multicentric French study was conducted from January 2006 to December 2015 on patients with no metastatic gastric linitis plastica and operated by gastrec-tomy. A 2/1 matching based on pTNM stage and center was performed. RESULTS: Fifty patients were included in the linitis plastica group and 100 in the control group. Patients from the linitis group were significantly different from those from the control group with a lower age at diagnosis, a more advanced histological lesion, a more frequent undiagnosed peritoneal carcinomatosis, and a higher risk of R1 resection. Sensitivity and specificity of CT scan for the diagnosis of lymph node involvement were 44% and 75%, respectively, in the linitis plastica group and 55% and 60%, respectively, in the control group. The sensitivity and specificity of CT scan for the T3-T4 parietal invasion were 26% and 100%, respectively, in the linitis group and 40% and 72%, respectively, in the control group. CONCLUSION: CT scan has an equal sensitivity and specificity for the evaluation of lymph node and parietal involvement in gastric adenocarcinoma, including linitis plastica. CT scan remains the cornerstone of preoperative evaluation in gastric adenocarcinoma, including linitis plastica. However, CT presents a lack of sensitivity to diagnose low-volume peritoneal carcinomatosis.

[Usefulness of small-bowel capsule endoscopy in gastrointestinal bleeding]. / Intérêt de l'exploration de l'intestin grêle dans les hémorragies digestives.

In France, upper gastrointestinal haemorrhages have an estimated annual incidence of 143 cases per 100,000 inhabitants. Classically, two types of digestive hemorrhage are described: acute and chronic digestive hemorrhages. Upper endoscopy is carried out in case of hematemesis or melena. It requires that the patient has been fasting for at least 6hours for solids and 3hours for liquids. The main etiologies of hemorrhagic hemorrhage of the origin are the vascular abnormalities, inflammatory or drug-induced ulcerations, intestinal tumors, Meckel's diverticulum, and Dieulafoy ulcer. The modalities of exploration of the small intestine before digestive hemorrhage are the wireless capsule, a reference examination for the exploration of the small intestine, enteroscopy, therapeutic examination, entero-CT or MRI, and 99mTc-labeled red blood cell scintigraphy. In this review, we will discuss the different etiologies of the digestive haemorrhage of intestinal origin and propose a management algorithm.

Diagnosis of non-occlusive acute mesenteric ischemia in the intensive care unit.

BACKGROUND: Non-occlusive mesenteric ischemia (NOMI) is a common complication and accounts for a major cause of death in critically ill patients. The diagnosis of NOMI with respect to the eventual indications for surgical treatment is challenging. We addressed the performance of the diagnostic strategy of NOMI in the intensive care unit, with emphasis on contrast-enhanced abdominal CT-scan. METHODS: This was a retrospective monocenter study. Patients with clinically suspected acute mesenteric ischemia were included if a comprehensive diagnostic workup was carried out including surgical and/or endoscopic digestive explorations. Patients with evidence of occlusive mesenteric ischemia were excluded. A definite diagnosis of NOMI only relied on surgical or endoscopic findings. Abdominal CT-scans were reviewed by two radiologists blinded from the final diagnosis. RESULTS: A diagnosis of NOMI could be definitely confirmed or ruled out through surgical or endoscopic explorations of the digestive tract in 147 patients. With respect to their clinical characteristics, only a history of atrial fibrillation was an independent predictor of NOMI (odds ratio 8.3, 95% confidence interval 2.0-35.2, p = 0.004). Among them, 114 patients (75 with and 39 without NOMI) had previously been subjected to contrast-enhanced abdominal CT-scan. Portal venous gas, pneumatosis intestinalis and, to a lesser extent, abnormal contrast-induced bowel wall enhancement were poorly sensitive, but exhibited good specificities of 95, 85 and 71%, respectively. Nineteen out of 75 patients (25.3%) without any suggestive radiological signs finally exhibited mesenteric ischemia, including ten with intestinal necrosis. CONCLUSIONS: The performance of abdominal CT-scan for the diagnosis of NOMI is limited. Radiological signs of advanced-stage ischemia are good predictors of definite mesenteric ischemia, while their absence should not be considered sufficient to rule out the diagnosis.

[Focus on Crohn's disease]. / Prise en charge de la maladie de Crohn.

Crohn's disease is an inflammatory bowel disease that affects the entire digestive tract, from the mouth to the anus. The inflammatory disease is transmural and may be complicated by abscesses, fistulas, strictures. Budesonide is used as first-line treatment for a first episode of ileitis. Thiopurines and methotrexate are used as immunosuppressive maintenance therapy. Anti-tumour necrosis factors (TNF) alpha therapy is used as induction and maintenance therapy in case of severe flares or corticodependence. Combination of immunosuppressive therapy and anti-TNF-alpha (combotherapy) prevents the appearance of specific anti drug antibodies. Combotherapy is used in case of severe disease. The goal of the treatment is to achieve clinical remission, endoscopic mucosal healing, and to prevent the occurrence of complications such as strictures, fistulas or abscesses. Anoperineal lesions are found in 10% of the patients at diagnosis. Surgical treatment is indicated for severe medical treatment-resistant patients or complications such as symptomatic stenosis, fistula or abscess unresponsive to medical treatment or immediately complicated.