Original Study: Transjugular Intrahepatic Portosystemic Shunt as a Bridge to Abdominal Surgery in Cirrhotic Patients.

BACKGROUND: Transjugular intrahepatic portosystemic shunt (TIPS) has been suggested to reduce portal hypertension-associated complications in cirrhotic patients undergoing abdominal surgery. The aim of this study was to compare postoperative outcome in cirrhotic patients with and without specific preoperative TIPS placement, following elective extrahepatic abdominal surgery. METHODS: Patients were retrospectively included from 2005 to 2016 in four centers. Patients who underwent preoperative TIPS (n = 66) were compared to cirrhotic control patients without TIPS (n = 68). Postoperative outcome was analyzed using propensity score with inverse probability of treatment weighting analysis. RESULTS: Overall, colorectal surgery accounted for 54% of all surgical procedure. TIPS patients had a higher initial Child-Pugh score (6[5-12] vs. 6[5-9], p = 0.043) and received more beta-blockers (65% vs. 22%, p < 0.001). In TIPS group, 56 (85%) patients managed to undergo planned surgery. Preoperative TIPS was associated with less postoperative ascites (hazard ratio = 0.330 [0.140-0.780]). Severe postoperative complications (Clavien-Dindo > 2) and 90-day mortality were similar between TIPS and no-TIPS groups (18% vs. 23%, p = 0.392, and 7.5% vs. 7.8%, p = 0.644, respectively). CONCLUSIONS: Preoperative TIPS placement yielded an 85% operability rate with satisfying postoperative outcomes. No significant differences were found between TIPS and no-TIPS groups in terms of severe postoperative complications and mortality, although TIPS patients probably had worse initial portal hypertension.

Safety of sofosbuvir-based regimens after liver transplantation: longitudinal assessment of renal function in the prospective ANRS CO23 CUPILT study.

BACKGROUND: In liver transplant recipients with hepatitis C virus recurrence, there is concern about renal safety of sofosbuvir-based regimens. Changes in serum creatinine or in the estimated glomerular filtration rate (eGFR) under treatment are used to look for possible renal toxicity. However, serum creatinine and eGFR are highly variable. AIM: To analyse renal function trajectory with numerous assays of serum creatinine over a long period of time. METHODS: In a multicentre cohort of 139 patients, the eGFR was obtained from serum creatinine using the Chronic Kidney Disease-Epidemiology Collaboration (CKD-EPI) equation. Slopes of eGFR were defined as a change in eGFR during a period divided by time. Pre-treatment, on-treatment and post-treatment periods were 9 months, 3-9 months and 4.5 months. Interactions between eGFR slopes and the pre-treatment eGFR, use of ribavirin or mycophenolate mofetil, and stage of fibrosis were addressed. On-treatment eGFR slopes were separated in tertiles. Pre- and post-treatment eGFR slopes were compared globally and according to tertiles. RESULTS: The post-treatment eGFR slope was significantly better than pre-treatment eGFR slope (+0.18 (IQR -0.76 to +1.32) vs -0.11 (IQR -1.01 to +0.73) mL/min/1.73 m2 /month, P = 0.03) independently of the pre-treatment eGFR (P = 0.99), ribavirin administration (P = 0.26), mycophenolate mofetil administration (P = 0.51) and stage of fibrosis (F3 and F4 vs lower stages, P = 0.18; F4 vs lower stages, P = 0.08; F4 Child-Pugh B and C vs lower stages, P = 0.38). Tertiles of on-treatment eGFR slopes were -1.71 (IQR -2.54 to -1.48), -0.78 (IQR -1.03 to -0.36) and +0.75 (IQR +0.28 to +1.47) mL/min/1.73 m2 /month. Pre- and post-treatment eGFR slopes were not significantly different according to tertiles (respectively, P = 0.34, 0.08, 0.73). CONCLUSION: The eGFR varies during treatment and gives a confusing picture of the renal safety of sofosbuvir-based regimens. In contrast, longitudinal assessment of the eGFR shows a rising trajectory over longer time, meaning that these therapies are safe for the kidneys in our cohort of liver transplant recipients.

Short- and long-term evolution of the endoluminal diameter of underdilated stents in transjugular intrahepatic portosystemic shunt.

PURPOSE: The purpose of this study was to evaluate the short- and long-term evolution of endoluminal diameter of covered metallic stents that were underdilated at the time of transjugular intrahepatic portosystemic shunt (TIPS) creation. MATERIEL AND METHODS: Sixteen patients (13 men, 3 women) with a mean age of 57.6years±7.9 (SD) were retrospectively included. All patients had had TIPS creation using a 10-mm diameter covered stent (VIATORR®) that was underdilated (i.e., 8mm) at the time of stent placement. Measurements of the mean circulating diameter of the stents were retrospectively performed on angiographic examinations every 6months up to 2years. RESULTS: The endoluminal stent diameter early enlarged from 8.96mm±1.12 (SD) to 10mm±1.45 (SD) after 6months (P=0.04) with no further significant changes over time after 12months (10.28mm±1.9mm), 18months (9.93±1.51mm) and 24months (9.92±0.9mm). CONCLUSION: Our results demonstrate a passive expansion of initially underdilated covered stents during the six months following TIPS creation. This should be taken into account regarding hepatic encephalopathy prevention during TIPS placement.

Neurologic Disorders in Immunocompetent Patients with Autochthonous Acute Hepatitis E.

Neurologic disorders, mainly Guillain-Barré syndrome and Parsonage­Turner syndrome (PTS), have been described in patients with hepatitis E virus (HEV) infection in industrialized and developing countries. We report a wider range of neurologic disorders in nonimmunocompromised patients with acute HEV infection. Data from 15 French immunocompetent patients with acute HEV infection and neurologic disorders were retrospectively recorded from January 2006 through June 2013. The disorders could be divided into 4 main entities: mononeuritis multiplex, PTS, meningoradiculitis, and acute demyelinating neuropathy. HEV infection was treated with ribavirin in 3 patients (for PTS or mononeuritis multiplex). One patient was treated with corticosteroids (for mononeuropathy multiplex), and 5 others received intravenous immunoglobulin (for PTS, meningoradiculitis, Guillain-Barré syndrome, or Miller Fisher syndrome). We conclude that pleiotropic neurologic disorders are seen in HEV-infected immunocompetent patients. Patients with acute neurologic manifestations and aminotransferase abnormalities should be screened for HEV infection.

Liver fibrosis staging with contrast-enhanced ultrasonography: prospective multicenter study compared with METAVIR scoring.

We prospectively assessed contrast-enhanced sonography for evaluating the degree of liver fibrosis as diagnosed via biopsy in 99 patients. The transit time of microbubbles between the portal and hepatic veins was calculated from the difference between the arrival time of the microbubbles in each vein. Liver biopsy was obtained for each patient within 6 months of the contrast-enhanced sonography. Histological fibrosis was categorized into two classes: (1) no or moderate fibrosis (F0, F1, and F2 according to the METAVIR staging) or (2) severe fibrosis (F3 and F4). At a cutoff of 13 s for the transit time, the diagnosis of severe fibrosis was made with a specificity of 78.57%, a sensitivity of 78.95%, a positive predictive value of 78.33%, a negative predictive value of 83.33%, and a performance accuracy of 78.79%. Therefore, contrast-enhanced ultrasound can help with differentiation between moderate and severe fibrosis.

[Portal hypertension and pregnancy]. / Grossesse et hypertension portale.

Pregnancy in patients with portal hypertension is rare but worrying for the clinician. Although the effects of portal hypertension during pregnancy have not been fully elucidated, there is an evident increase in morbidity, especially associated with cirrhosis, which justifies the idea of at-risk pregnancy and requires management by a multidisciplinary team. The prevention and treatment of gastrointestinal haemorrhage is quite similar to that in nonpregnant patients. Investigation and management of portal hypertension before and at the beginning of pregnancy can reduce the risks of foetal loss, restricted intra-uterine growth, premature birth and maternal mortality, which are closely related to gastrointestinal haemorrhage. The risks related to the underlying disease, such as liver failure with cirrhosis and thromboembolic risk with vascular diseases associated with thrombophilia must be taken into consideration. Generally, vaginal delivery with early analgesics for the mother assisted by an extraction device should be preferred to caesarean section, which must be reserved for obstetrical indications.

[Long-term evolution of achalasia of the lower esophageal sphincter and intestinal paraneoplasic pseudo-obstruction revealing small cell lung carcinoma]. / Evolution à long terme d'une achalasie du sphincter inférieur de l'esophage et d'une pseudo-obstruction intestinale paranéoplasiques révélatrices d'un carcinome pulmonaire à petites cellules.

We report a case of a small cell carcinoma of the lung revealed by chronic intestinal pseudo-obstruction associated with achalasia of the lower esophageal sphincter. Tumoral remission was achieved for more than 21 months after chemoradiotherapy but this did not prevent the paraneoplasic syndrome from persisting and medical treatment was not successful in treating the intestinal pseudo-obstruction or the dysphagia, which was not improved by esophageal dilation.

Evolution of clinical and radiological features at diagnosis of achalasia during a 19-year period in central France.

OBJECTIVES: Symptoms of achalasia are often misinterpreted, resulting in delayed diagnosis. The aims of our study were (1) to estimate the evolution of clinical and radiological features of a large population of achalasic patients between two successive periods; and (2) to determine the influence of symptoms on diagnostic delay. METHODS: Between 1980 and 1998, all achalasia patients treated in our unit were assessed at the time of manometric diagnosis for clinical and radiological features. These data were compared between two successive periods (1980-1994 and 1994-1998). Then, a correlation between the diagnostic delay, clinical and radiological data and symptoms was investigated. RESULTS: Three hundred and forty-five consecutive achalasia patients were assessed (mean age at diagnosis, 56 years; mean diagnostic delay, 5.7 years). The duration of the disease was correlated with the oesophageal diameter (P = 0.0001). Dysphagia, chest pain and heartburn were more frequent in young patients (respectively, P = 0.003, 0.0001 and 0.001). Women had 1.7 times the risk of men for suffering of chest pain (95% CI, 1.1 -2.6) and 2.2 times the risk for heartburn (95% CI, 1.2-4.0). Pulmonary involvement was more frequent when the oesophagus was dilated (P = 0.0002), and 3.4 times more frequent when associated with regurgitations (95% CI, 1.3-8.9). The oesophageal diameter was significantly smaller (38 vs 48 mm) in the last period, but we have not observed any significant shortening of the diagnostic delay. No symptoms influenced the diagnostic delay. CONCLUSIONS: Despite a smaller oesophageal diameter at the time of diagnosis, during the period 1994-1998, diagnostic delay was not reduced. No clinical features associated with late diagnoses could be identified.

[Pericardial extravasation as an indicator of congestive heart failure due to thiamine deficiency in a young adult]. / Epanchement péricardique révélateur d'une insuffisance cardiaque à débit élevé par carence en thiamine chez un adult jeune.

INTRODUCTION: Thiamine (B1) deficiency is one of the classical causes of congestive heart failure. Although in the western world and in other developed regions this disorder is generally associated with chronic alcoholism, it may also only occur as a result of a deficient diet. EXEGESIS: A young patient was admitted for electrocardiographic examination, and pericardial extravasation was recorded. The etiological assessment showed a case of congestive heart failure due to thiamine (B1) deficiency. A hemodynamic examination and investigation of thiamine blood levels confirmed this diagnosis. The patient's health status improved following thiamine administration, with complete and rapid regression of symptoms of congestive heart failure. CONCLUSION: Although cardiomyopathic beriberi is infrequent, it should systematically be taken into account in the etiology of congestive heart failure. The present study also notes that a dietary thiamine deficiency is uncommon, but should nevertheless be considered when other symptoms of denutrition are present.

[Gastric granulocytic sarcoma revealed by a massive digestive hemorrhage]. / Sarcome granulocytaire gastrique révélé par une hémorragie digestive massive.

We report the case of a 37-year-old-man having a chronic myelogenous leukemia, who presented, one month after a splenic acutization, massive gastrointestinal bleeding from ulcerated nodules of the gastric fundus. The histologic examination of one of these nodules showed granulocytic sarcoma. In spite of an endoscopic treatment by sclerotherapy with adrenalined serum, the death occurred during a hemorrhagic recurrence. This observation, which is the third case reported of gastric granulocytic sarcoma during the acutization of a myelogenous chronic leukemia, and the first revealed by fatal gastrointestinal bleeding, shows the particular gravity of gastrointestinal bleeding complicating granulocytic sarcoma.

Risk factors for immediate complications after progressive pneumatic dilation for achalasia.

OBJECTIVE: The aim of this retrospective study was to determine the risk factors of early complications after progressive pneumatic dilation for achalasia. METHODS: Five hundred four dilations were performed in 237 consecutive achalasic patients between 1980 and 1994 with the same technique: low-pressure pneumatic dilation every other day with balloons of increasing diameter until success criteria were obtained (depending on manometric examination and esophageal x-ray transit performed 24 h after each dilation). Clinical, radiographical, endoscopical, and manometrical data as technical procedure characteristics for patients with perforations or other early complications were compared with those without complications. RESULTS: We observed 15 complications (6% of patients): 7 perforations (3%), 3 asymptomatic esophageal mucosal tears, 4 esophageal hematomas, and 1 fever. Perforations occurred in 6 of 7 patients during the first dilation. The mean age was 68.5 yr in the group with complications versus 56.4 yr for the remainder (p < 0.05). Two deaths occurred in patients older than 90 yr. Instability of the balloon during dilations was noted in 8 of 15 cases of complications versus 57 of 222 patients (p < 0.05). No other data differed significantly. CONCLUSIONS: This study showed a low prevalence of early complications using this progressive technique. Patients with hiatal hernia, esophageal diverticulum, or vigorous achalasia may safely undergo progressive pneumatic dilation. Only patients older than 90 yr should be referred for progressive pneumatic dilation with caution. Most of perforations arose during the first dilation, but there was no predictive pretherapeutic factor of perforation.

[Hepatic artery ligation for liver metastasis of a acinar cell carcinoma of the pancreas revealed by a nodular panniculitis]. / Ligature de l'artère hépatique pour métastases hépatiques d'un carcinome à cellules acineuses du pancréas révélé par une panniculite nodulaire.

We report the case of a 67-year-old-man presenting with pancreatic acinar cell carcinoma revealed by dermatological manifestations of cytosteatonecrosis and treated by hepatic artery ligation. The pancreatic etiology of these lesions was suspected due to hyperlipasemia, and was confirmed by abdominal computerized tomography showing a pancreatic tumor and multiple liver nodules, and by histological examination of one of these lesions. Because of symptomatic treatment failure, rapid impairment of patient's general condition, and by analogy with the treatment of hepatic metastases of neuroendocrine tumors, hepatic artery ligation was performed. Lipasemia decreased markedly and symptoms disappeared for 45 days. Hepatic artery obstruction may be used for emergency treatment of secreting liver metastases.

[Low-grade gastric MALT lymphoma and helicobacter heilmannii (Gastrospirillum hominis]. / Lymphome gastrique de bas grade du MALT et Helicobacter heilmannii (Gastrospirillum hominis).

We report the fourth case of low-grade gastric MALT lymphoma associated to Helicobacter heilmannii. This spiral organism may be present in the gastric mucosa of animals where it is non pathogenic while, in humans, its presence is always associated with chronic gastritis. In this case, Helicobacter heilmannii was observed in the absence of Helicobacter pylori. Regression of endoscopic and histological lesions after Helicobacter heilmannii eradication suggests its role in gastric lymphoma. This observation underlines the need for searching for Helicobacter heilmannii by careful histological examination, in the absence of Helicobacter pylori, and the importance of its eradication in the treatment of gastric lymphoma.