Double-type metallic stents efficacy for the management of post-operative fistulas, leakages, and perforations of the upper gastrointestinal tract.

INTRODUCTION: The management of post-operative anastomotic leakage and fistulas of the upper GI tract remains challenging. Fully covered stents are used despite a high risk of migration because of a better removability. The goal of our study was to evaluate the effectiveness of this new type of endoscopic stent in this indication. The secondary objective was to determine the ability of withdrawing this stent. METHODS: Thirty-six patients treated for upper GI fistula using a double-type metallic stent (DTMS) (Taewoong, Korea) for a benign indication were included in this retrospective study. This stent associates an outer uncovered metallic stent, decreasing the risk of migration, to an inner fully covered stent that ensured its tightness. The DTMS was removed after 4 weeks of treatment. RESULTS: Twenty-four patients had a post-operative fistula (15 sleeve gastrectomies), eight had an anastomotic leakage, and four had an esophageal perforation. Seventeen patients underwent a previous failed stenting, and fourteen had an associated treatment with OTSC clips. A final complete healing was achieved in twenty-six patients (72%). For patients with fistulas, the overall success rate was 66.6% (16/24) mostly in case of post sleeve fistula (80%), and it was 75% (6/8) for patients with anastomotic leakages (3/4). We reached a primary success (one session) in twenty-one cases (58.3%), and a second session was required in five cases. All the stents were removed without complications after a median stenting time of 32 [20-71] days. The spontaneous migration rate was 16.6%. CONCLUSION: This new double-type stent is a new and efficient way to treat post-operative fistulas and leakages in the upper GI tract. The stents were always removable despite the external uncovered part with a low migration rate.

Intramural esophageal dissection due to pharyngeal abscess treated by endoscopic esophageal transection: a case report.

Intramural esophageal dissection is a rare disorder characterized by extensive laceration between the mucosal and submucosal layers of the esophageal wall, but without perforation. The etiology of intramural dissection of the esophagus remains uncertain. Conservative management is usually considered adequate. Only one case of circumferential intramural esophageal dissection has been reported previously. We report here on a case due to an infectious cause (paryngeal abscess) that is also an unusual example of circumferential intramural esophageal dissection, which was then treated by endoscopic transection of the true internal esophageal wall and bougienage dilation.

[Chromoendoscopy in inflammatory bowel disease]. / Coloration et maladies inflammatoires chroniques de l'intestin (MICI).

The risk of colorectal cancer in case of IBD-related pancolitis reaches 2% after 10 years follow-up, 8% after 20 years up to 18% at 30 years, and was probably over-estimated in the first series. Chromoendoscopy appears to be helpful in the surveillance of IBD, and moreover recommended, using carmine indigo or methylene blue with a well-standardized procedure. Its place regarding other techniques like virtual coloration has to be clarified with randomized studies. The chromoendoscopy allows the operator to perform targeted biopsies, which appear to be more efficient for the detection of dysplasia than systematic biopsies performed every 10 cm. Nevertheless, it is too soon to remove systematic biopsies from scientific recommendations.

What is the outcome for patients presenting with severe acute pancreatitis requiring a hospital stay of more than one month?

OBJECTIVE: The aim of this study was to investigate the clinical progression of patients who had severe acute pancreatitis (AP) and a stay in hospital of more than a month. METHODS: A total of 24 patients (median age: 57 years) were included in this eight-year retrospective study. Cure was defined as the restoration of the pancreatic parenchyma, and the disappearance of all pseudocysts and pancreatic fistulae. Data including the duration of hospital stay, disease severity and pancreatic sequelae were also collected. RESULTS: The median total duration of the hospital stay was 67 days. The overall mortality rate was 20.8%, whereas the mortality rate due to AP was 12.5%. The average healing period was 7.7 months. On univariate analysis, patients who also had respiratory diseases, chronic alcoholism, necrotizing superinfection, pseudocyst, food intolerance and/or hospital-acquired infection took significantly longer to heal. After cure, we observed pancreatic and/or hepatic duct stenoses in 50% of cases, and the onset or aggravation of diabetes in 25%. CONCLUSION: In patients hospitalized for more than one month because of necrotizing AP, the rate of mortality is around 20%, with a final hospital stay of two months and a healing period of more than seven months. In addition, half of the patients presented with pancreatic or biliary sequelae.

[Endoscopic management of severe pancreatic and biliary diseases in children]. / Prise en charge endoscopique des affections biliopancréatiques compliquées chez l'enfant.

Endoscopic treatment of pancreatic pseudocysts and choledocal lithiasis is a first-line treatment in adults. Nevertheless, due to technical difficulties such a management is not always feasible in children. This series reports our results in the management of pancreatic and biliary diseases in children. Seven children, two months to 12 years old, underwent endoscopic management of pancreatic and biliary diseases. Two of them had choledocal lithiasis with jaundice or acute pancreatitis, two had pancreatic pseudocyst due to abdominal traumatism, two had chronic pancreatitis with a communicating pseudocyst in one case, and one had a biliary leakage after traumatism. All the endoscopic treatments were performed under general anesthesia. In six cases, the duodenoscope was a regular one with a large operating channel (Olympus TJF 160; Japan) employed for children aged 33 months to 12 years. In the case of the two months child, a "rendez-vous" technique was performed with a percutaneous approach of the common bile duct followed by an endoscopic sphincteroclasy using an axial endoscope allowing the extraction of a choledocal stone. In two cases, post-traumatic pancreatic pseudocysts (eight and 12 year-old children) were managed with the transgastric insertion of two double pig-tail stents. In two cases, children with chronic pancreatitis (38 months and 12 years old) were managed with pancreatic sphincterotomy. Biliary leakage in an 11-year-old child was managed with biliary sphincterotomy and stenting. All the children became symptom-free without any procedural complications with an 11 months median follow-up. Endoscopic treatment of pancreatic and biliary diseases is possible in children like in adults with the same procedures and results.

[Endoscopic management of postoperative pancreatic collections]. / Prise en charge endoscopique des collections pancréatiques postopératoires.

INTRODUCTION: Treatment of pancreatic postoperative collections are usually managed with a multidisciplinary team. Different managements are possible: abstention, external drainage, endoscopic treatment or surgery. METHODS: We report on a case series of five patients with a postoperative pancreatic collection, endoscopically managed. Patients underwent all a CT scan associated or not with endoscopic ultrasonography. RESULTS: An endoscopic cystenterosotomy was performed in all the cases, with two double pig tail stents sometimes associated with nasocystic drainage for clearing the cyst lumen and with transpapillary drainage in one case. All the procedures were successful and patients healed in all the cases with the disappearance of the radiological image within a 33 days to three months range with one complication due to superinfection of the drained cyst, endoscopically managed with a nasocystic catheter. CONCLUSION: Therapeutic endoscopy, with a multidisciplinary approach, is a promising way to manage postoperative pancreatic collections.

Long-term healing of Crohn's anal fistulas with fibrin glue injection.

BACKGROUND: Injecting fibrin glue has proved to be an effective means of treating anal fistulas (AF). There has been some debate, however, as to whether this technique should be used on the AF often involved in Crohn's disease (CD). AIM: To assess the effectiveness of injecting heterologous fibrin glue as a means of treating AF refractory to immunosuppressive treatment in patients with CD. METHODS: Fourteen CD patients (five men and nine women, average age 42 years) presenting with refractory AFs were included in this study. Heterologous fibrin glue was injected into the fistula tract under general anaesthesia under continuous endosonographic monitoring using a 7.5-MHz blind linear probe. The patients were followed up clinically and ultrasonographically for 3 months after the procedure, and then at regular intervals. RESULTS: Three months after the fibrin glue injection, the fistulas had completely dried up in 10 patients (71%), the leakage had decreased in one patient (7%), and no improvement was observed in the other three patients (21%). Endosonographic findings showed that the fistula tract had completely disappeared in two cases (14%). The fistula tract was found to be non-permeable in eight cases (57%), and no change in the fistula was observed in four patients (29%). At the end of the follow-up period [average 23.4 months (12-26 months)], the leakage had completely dried up in eight of the 14 patients (57%). No side effects were observed. CONCLUSION: Nearly 2 years after the use of a heterologous fibrin glue to treat an AF, over half of the patients with CD showed clinical signs of remission. Because it is easy to use and harmless as well as being effective, this method provides a good alternative to classical methods of surgical treatment.

[Crohn's disease and small intestine adenocarcinoma]. / Maladie de Crohn et adénocarcinome du grêle.

INTRODUCTION: The relationship between digestive neoplasia and Crohn's disease remains debated but several cases of carcinoma have been reported in the past 10 years. EXEGESIS: We report two cases of intestinal adenocarcinoma found in young people. Patients were asymptomatic during 15 years after the diagnosis of inflammatory bowel disease and presented a sudden occlusive syndrome. Carcinoma was observed incidentally at gross examination, and histopathological study showed dysplasia adjacent to neoplasia. Despite adequate surgical resection, death occurred quickly. CONCLUSION: Crohn's carcinoma should be suspected in patients with long-standing disease, poor symptomatology, and stenosis. Intestinoscopy surveillance remains illusory because inflammatory stenosis is often present and infiltrative neoplasia is invisible. Thus, it is important to be vigilant in this clinical presentation.

[Risk factors for Crohn's disease relapse after treatment of intestinal stenosis]. / Facteurs de récidive de la maladie de Crohn après traitement des sténoses intestinales.

BACKGROUND: Postoperative recurrences of Crohn's disease (CD) has been widely investigated in previous studies. Nevertheless, the risk factors for CD recurrence in patients presenting with intestinal stenosis are not clearly identified. PATIENTS AND METHOD: Thirty consecutive patients out of a cohort of 134 patients with CD presented with an intestinal stenosis diagnosed between 1995 and 1999. Epidemiological, clinical, and therapeutic data were carefully recorded. A univariate analysis followed by stepwise descending discriminant analysis was performed. RESULTS: Sixteen patients (53%) underwent surgery, six received steroid therapy, eight were given antibiotics, and seven took immunosuppressive drugs. The mean follow-up after medical or surgical management was 2.8 years. Thirteen patients (43%) had CD relapse during the follow-up. Considering the univariate analysis, the existence of a previous appendectomy and the persistence of tobacco consumption were significantly associated with the risk of CD relapse during the follow-up. The stepwise descending discriminant analysis identified three independant factors: tobacco consumption (p = 0.007), previous appendicectomy (p = 0.04) and duration of the follow-up (p = 0.02). CONCLUSION: The CD relapse after the management of small bowel stenosis occurred in 43% of the patients within a mean follow-up of 2.8 years. The significant factors associated with the risk of CD relapse were tobacco consumption, previous appendectomy and duration of the follow-up.

[Non-operative management of a hepatic pseudoaneurysm and a biloma complicating a blunt abdominal trauma]. / Traitement conservateur d'un traumatisme hépatique fermé compliqué d'un pseudoanévrisme et de biliomes.

Hepatic artery pseudoaneurysm and bilioma are rare complications of blunt abdominal trauma in children. We report a case in an 11-year-old patient after a hepatic and splenic blunt trauma following a car accident. The initial evolution was simple with haemodynamic stability. On Day 12, a pseudoaneurysm was discovered on an abdominal magnetic resonance imaging whereas the patient presented a major pain syndrome and an icteric cholestase. Embolisation was realised a few hours later in emergency because of a haemorrhagic shock. On Day 26, an endoscopic retrograde cholangiopancreatography highlighted two bilary leaks: one extrahepatic, the other intrahepatic. The first one was treated with a stent and the second one needed three drains: two peritoneal and one in the biloma. The characteristic of this case relies on the association of two complications. It underlines the need of multidiscipline and non-operative management of pediatric blunt hepatic trauma.

Value of endorectal ultrasonography for diagnosing rectovaginal septal endometriosis infiltrating the rectum.

BACKGROUND AND STUDY AIMS: Rectovaginal septal endometriosis (RVSE) can pose serious therapeutic problems when there is infiltration of the rectal septum (which occurs in approximately half of the cases). The aim of this study was to assess the value of endoscopic ultrasonography in diagnosing rectal wall involvement by pelvic endometriosis. PATIENTS AND METHODS: A prospective study was carried out from May 1998 to March 2003 at a single hospital center. The 30 patients included in the study presented with suspected RVSE and underwent systematic anorectal endoscopic ultrasonographic exploration prior to the surgical intervention. The endoscopic ultrasonography was carried out under general anesthesia with a 7.5-MHz miniprobe equipped with a distal balloon. RESULTS: The anorectal endoscopic ultrasonographic examination (EUS) showed the presence of endometriosis in the rectovaginal septum in 26 patients (88 %), in the uterosacral ligaments in 10 patients (33 %), and in the ovaries in two patients (6 %). At EUS, the nodules were infiltrating the rectal wall in 17 patients (56 %). The surgical exploration demonstrated endometriosis in the rectovaginal septum in 26 cases, the uterosacral ligaments in 22 cases, and the ovaries in 16 cases. The rectal wall was completely infiltrated in 12 cases and only partly in four cases, and intestinal tract resection was required in 10 cases. The sensitivity, specificity, and positive and negative predictive value of anorectal endoscopic ultrasonography as a means of diagnosing endometriosis of the rectovaginal septum and infiltration of the rectal wall were found to be 96 %, 100 %, 100 % and 83 %, and 92 %, 66 %, 64 % and 92 %, respectively; and the diagnostic accuracy was at 96 % and 80 %, respectively. The sensitivity for detecting nodules in the uterosacral ligaments or in the ovaries was 42 % and 14 %, respectively, leading to diagnostic accuracy rates of 56 % and 53 %. CONCLUSIONS: In terms of its sensitivity and its negative predictive value, anorectal endoscopic ultrasonography is a very effective means of detecting endometriosis of the rectovaginal septum and assessing possible infiltration of the rectal wall. However, this method is not as accurate for nodules located far from the EUS probe, as is the case with the uterosacral ligaments and ovaries.

Prospective comparison of endosonography, magnetic resonance imaging and surgical findings in anorectal fistula and abscess complicating Crohn's disease.

BACKGROUND: Endosonography and magnetic resonance imaging (MRI) are promising methods for evaluating perineal and anorectal fistulas or abscesses. The aim of this study was to compare the results of anal endosonography (AES), MRI and surgical exploration in the assessment of anorectal fistula or abscess complicating Crohn's disease. METHODS: Twenty-two patients with Crohn's disease, seven men and 15 women of mean age 38 (range 17-67) years, were included in this prospective study. All patients underwent AES (linear probe 7 MHz), MRI and operative assessment. RESULTS: AES and MRI demonstrated 14 and nine abscesses respectively, whereas 11 abscesses were confirmed by surgical exploration in ten patients. The sensitivity of AES and MRI as means of evaluating anorectal abscesses was 100 and 55 per cent respectively. The agreement per patient was 86 per cent (19 of 22) for AES and 59 per cent (14 of 22) for MRI. AES and MRI demonstrated 26 and 14 fistulas respectively, whereas 27 fistulas were confirmed during surgical exploration in 16 patients. The sensitivity of AES and MRI was 89 and 48 per cent respectively. The level of agreement per patient was 82 per cent (18 of 22) for AES and 50 per cent (11 of 22) for MRI. CONCLUSION: AES with a linear probe is more accurate than MRI in detecting anorectal abscesses complicating Crohn's disease, and much more accurate in the evaluation of complex fistulas.

Complications of endoscopic sphincterotomy: results from a single tertiary referral center.

BACKGROUND AND STUDY AIMS: Complications of endoscopic sphincterotomy (ES) have been assessed in recent multicenter studies. The aim of this series was to report and identify risk factors for complications of ES at a single tertiary referral center. PATIENTS AND METHODS: Between 1996 and 2000, 1159 consecutive endoscopic retrograde cholangiopancreatographies (ERCP) procedures were performed and their related complications were assessed. A total of 658 patients (57 %) underwent ES. All the clinical, radiological and biological data were carefully recorded within the 30 days following the procedure. Multivariate analysis was performed using a stepwise logistic model. RESULTS: The morbidity rate for ES was 7.7 %, being moderate to severe in 5 %. Morbidity included acute pancreatitis (3.5 %), perforations (1.8 %), sepsis (1.2 %) and bleeding (1.2 %). The 30-day mortality was 0.9 %. In the 1159 ERCP procedures, 231 patients underwent precut papillotomy (20 %) followed by sphincterotomy in 174 cases. Using logistic regression analysis, the risk factors for ES were precut papillotomy (relative risk, RR 2.76), confidence interval, (CI 1.39 - 5.49) and the presence of sphincter of Oddi dysfunction (RR, 7.72, CI 3.2 - 18.4). CONCLUSIONS: In this single-center series, we found a complication rate of ES in about 7 %, comparable to that in multicenter series. Precut papillotomy and sphincter of Oddi dysfunction were the main independent risk factors for ES.

Pseudotumorous chronic pancreatitis associated with inflammatory bowel disease.

Chronic pancreatitis associated with inflammatory bowel disease is now considered as extraintestinal manifestation of that disease. The clinical and radiological features of the new entity are markedly different from those of chronic calcifying pancreatitis. We report the case of a 68-year-old man presenting with a pseudotumorous chronic pancreatitis associated with ulcerative colitis. Diagnosis was made after endoscopic retrograde cholangiopancreatography (ERCP) and cytological analysis of stenosis brushings and was confirmed by the clinical evolution. Existence of IBD-associated pancreatitis with pseudotumorous features has to be taken into account in order to avoid inappropriate pancreatic resection.

Early refeeding after endoscopic biliary or pancreatic sphincterotomy: a randomized prospective study.

BACKGROUND AND STUDY AIMS: Patients who have undergone endoscopic sphincterotomy (ES) are usually left to fast for arbitrary reasons until they are examined on the following day. The aim of this study was to check whether this systematic fasting after ES is actually justified. PATIENTS AND METHODS: A blinded randomized prospective study, involving 146 patients, was carried out from January 1999 to September 2001. All patients undergoing biliary and/or pancreatic endoscopic sphincterotomy during this period were randomly allocated to one of two groups: group 1 patients were re-fed 4 hours after ES, and the group 2 patients were only re-fed 24 hours after the procedure. These two groups were comparable for clinical and procedural data except for stenting. RESULTS: Eight patients in group 1 (11 %) and 26 patients in group 2 (37 %) suffered from abdominal pain which resolved with analgesic drug treatment (P = 0.01). Eight patients in the first group(11 %) and five patients in the second group (7 %) had to be given major opiate analgesics (P = 0.56). Refeeding resulted in abdominal pain in five patients in group 1 and 13 in group 2 (P = 0.04). The serum amylase and lipase levels increased significantly after refeeding in group 1, but lipasemia did not increase significantly in group 2. No significant differences in post-ES complications were observed between the two groups. The mean hospital stay was significantly shorter in group 1 : 2.6 days on average, vs. 3.8 days in group 2 (P = 0.03). CONCLUSIONS: In the absence of any perforation of the digestive tract or immediate severe acute pancreatitis, early refeeding could be helpful to decrease pain and shorten the hospital stay in patients who have undergone endoscopic sphincterotomy.