[Barrett's oesophagus: endoscopic diagnosis and follow-up]. / Endobrachyoesophage: diagnostic endoscopique et surveillance.

Barrett's oesophagus (BO), or replacement of the squamous mucosa by a specialized intestinal metaplasia due to gastro-oesophageal reflux disease (GORD), predisposes to adenocarcinoma. It is estimated that 6 to 12% of patients undergoing GI endoscopy have short BO (< 3 cm), and 1% have a long BO. Macroscopic diagnosis of BO is sometimes difficult and, in case of doubt, endoscopy should be redone after a period of efficient anti-secretory treatment. Diagnosis of BO is histological and should be confirmed by biopsies. The incidence of adenocarcinoma is globally estimated at 0.5% patient by year of follow-up, and exists for both short and long BO. Due to this low incidence, screening for BO is only justified in patients at high risk for adenocarcinoma (male gender, age > 50 ans, old GORD in a young patient). Low-grade dysplasia (LGD) then high-grade dysplasia (HGD) precedes adenocarcinoma. Histological diagnosis of LGD is difficult: the main cause of confusion is inflammation so diagnosis of LGD must be confirmed after a 3-month high-dose anti-secretory treatment. Diagnosis of HGD is easier but multiple biopsies are needed to determine the focal or multifocal disposition of HGD. The benefit of follow-up of BO is debated. Aged patients should be followed only if dysplasia is present. When dysplasia is absent, an endoscopic control with biopsies is desirable within 3 to 5 years. In case of dysplasia, the latter must be confirmed by another examination of biopsies, particularly in case of suspicion of HGD and after antisecretory treatment. In case of LGD, endoscopy with biopsies should be redone 6 months later to screen for HGD, then every year if LGD is confirmed. In case of HGD, the 5-year risk of cancer is 60% so surgical or endoscopic treatment is usually proposed. If HGD follow-up is decided, it should be performed on a 3- to 6-month basis.

Endoscopic palliation of malignant gastric outlet obstruction using self-expandable metallic stents: results of a multicenter study.

BACKGROUND AND STUDY AIMS: Gastric outlet obstruction is a late event in the natural history of biliopancreatic tumours. Metallic self-expanding stents inserted under endoscopic and fluoroscopic guidance can be used for palliation. The aim of this study was to evaluate the feasibility, efficacy, and complications of endoscopic duodenal stenting in patients with malignant gastric outlet obstruction. PATIENTS AND METHODS: Between August 1998 and November 2001, 63 patients (31 women, 32 men; mean age 73 +/- 12) presenting with clinical symptoms of duodenal obstruction underwent endoscopic stenting with large metallic prostheses. Complications and clinical outcome were assessed both retrospectively and prospectively. RESULTS: Of the patients, 58 needed one duodenal stent and two overlapping stents were required in five patients. Stenting was immediately successful in 60/63 patients (95%). At the time of the duodenal procedure, 25 previously inserted biliary stents were still patent; biliary stenting was attempted during the same procedure in 18 patients; and 20 patients had no biliary stricture. There was no procedure-related mortality. There were complications in 30 % of patients: 13 stent obstructions, 4 stent migrations and 2 duodenal perforations (treated surgically). For 44 patients (70%) there were no minor or major digestive problem during their remaining lifetime. An exclusively peroral diet was possible in 58 patients (92%), but was considered satisfactory (solid or soft) in 46/63 patients (73%). Of the patients, 53 (84 %) died between 1 and 64 weeks after the duodenal stenting (median survival 7 weeks). CONCLUSIONS: Endoscopic stenting for the palliation of malignant gastric outlet obstruction is feasible and well-tolerated in most patients. Most dysfunctions can be managed endoscopically.

Intraductal papillary and mucinous pancreatic tumour: a new extracolonic tumour in familial adenomatous polyposis.

Familial adenomatous polyposis (FAP) is characterised by the development of numerous colorectal adenomatous polyps. Other extracolonic benign or malignant lesions have been reported previously in association with FAP but precancerous lesions in the pancreas have never been described. We report the first case of intraductal papillary and mucinous pancreatic tumour (IPMT) in a patient with FAP. A 48 year old man with a well documented past history of FAP was admitted for epigastric pain, weight loss, and new onset diabetes mellitus. Spiral computed tomography scan revealed a large tumour in the pancreatic head with upstream main pancreatic duct dilatation. Endoscopic ultrasonography confirmed these data. Mucous secretion was seen at duodenoscopy and a lesion in the main pancreatic duct was confirmed by retrograde pancreatography. The patient underwent a pancreaticoduodenectomy for suspected IPMT. Histological examination of the resected specimen confirmed an IPMT with in situ carcinoma. Twelve months after resection, the patient remained free of tumour relapse. Genetic analysis showed loss of the wild allele of the adenomatous polyposis coli gene in IPMT, causing inactivation of both alleles and demonstrating that IPMT was not incidental in this patient. IPMT should be included in the extracolonic localisation of FAP.

Intraductal papillary mucinous tumors of the pancreas confined to secondary ducts show less aggressive pathologic features as compared with those involving the main pancreatic duct.

Intraductal papillary mucinous tumors (IPMTs) of the pancreas are rare tumors characterized by a malignant potential. Because of the progress of imaging procedures, smaller cystic pancreatic lesions are now detected and some of them correspond to IPMTs that involve ectatic pancreatic branch ducts but spare the main pancreatic duct. To investigate differences in morphology and clinical behavior of branch and main duct types of IPMT, a surgical series of 43 cases was studied. All pathologic specimens of IPMT, surgically resected in our institution between October 1987 and July 1998, were analyzed. In all cases, the entire pancreatic specimen was systematically examined. IPMT of the branch type was found in 13 (30%) patients, whereas IPMT of main pancreatic duct type that involved the main pancreatic duct and branch ducts was observed in 30 (70%) patients. Patients with IPMT of the branch type were younger (median age, 55 yrs vs 64 yrs), and all but one of the lesions were located in the head and neck of the pancreas (vs 17 of 30 patients with the main duct type). The size of the cysts ranged from 4 to 55 mm, and the major duct showed a mild dilation in most cases. In contrast to the main pancreatic duct type, which showed invasive carcinoma and in situ carcinoma in 11 (37%) of 30 patients and 6 (20%) of 30 patients, respectively, IPMT of the branch type showed significantly less aggressive histologic lesions with five (39%) patients with simple hyperplasia, six (46%) patients with atypical hyperplasia, and two (15%) patients with in situ carcinoma. No invasive carcinoma was observed in this group. IPMT of the branch type occurs in younger patients and is associated with less aggressive histologic features than is the main pancreatic duct type. Our findings raise the difficult issue of clinical management of IPMT of the branch type as a distinctive group.

[The role of endoscopic treatment of complications of chronic pancreatitis]. / La place du traitement endoscopique dans les complications de la pancréatite chronique.

This review outlines the indications and results of endoscopic management in the complications of chronic pancreatitis. Symptomatic obstructions of the main pancreatic duct can be treated by endocanalar prosthesis in case of fibrous stenosis and by extracorporeal shock wave lithotripsy in case of intraductal obstructive stones. Symptomatic or large pseudocysts have to be treated and may be treated by placement of transgastric or transduodenal endoprosthesis for pseudocysts protuding into the digestive tract and by using transpapillary endoprosthesis for communicating pseudocysts. Endoscopic treatment of ductal disruptions is difficult and generally requires combined techniques. Symptomatic biliary stenosis can be temporary treated using biliary endoprothesis. Short and long term results and complications of these different procedures are analysed. In the absence of controlled studies, the role of endoscopic treatment in comparison to surgical treatment is not well defined. Present indications for either approach can be discussed on an individual basis.

Intraductal papillary mucinous tumors of the pancreas: pancreatic resections guided by preoperative morphological assessment and intraoperative frozen section examination.

BACKGROUND: We undertook this study to assess the results of a policy of limited pancreatic resections for intraductal papillary-mucinous tumors (IPMT), guided by a standardized preoperative morphological assessment and the frozen section histologic examination of pancreatic resection margins. METHODS: From 1991 to 1998, there were 41 patients who underwent resection of IPMT in our center after standardized morphological preoperative assessment, including abdominal computed tomography scans, endoscopic retrograde cholangiopancreatography, and endoscopic ultrasonography. All patients but one underwent a partial pancreatic resection. RESULTS: Preoperative assessment had an 89% diagnostic accuracy for IPMT. It detected malignant transformation with a 67% sensitivity and a 95% specificity, but failed to correctly assess ductal extension of the disease in 17 cases (41%). The diagnostic accuracy of frozen section histologic examination of the pancreatic resection margin was 92%. There was no recurrence in case of in situ carcinoma when epithelial lesions were completely resected (8 cases) nor in lower grades of dysplasia (23 cases). Conversely, recurrence was constant in invasive carcinoma (10 cases) regardless of the status of the pancreatic margin. CONCLUSIONS: Frozen section histologic examination of the pancreatic resection margin is useful and reliable to ensure a complete resection of IPMT by a partial resection that prevents recurrence of noninvasive lesions.

[Intraductal papillary mucinous tumors of the pancreas: diagnosis, treatment and prognosis]. / Tumeurs intracanalaires papillaires mucineuses du pancréas. Diagnostic, traitement et pronostic.

Intraductal papillary and mucinous tumors of the pancreas (IPMT) have been recently well defined histologically. Recent reports have described their diagnostic and therapeutic modalities. The malignant potential of these lesions warrants their surgical resection. The main difficulty of their management is the pre-operative assessment of ductal extension and grade of dysplasia. Despite the use of various imaging modalities (ultrasound, endoscopic ultrasonography, CT scan, retrograde pancreatography, pancreatic MRI), examination of the pancreatic margin on frozen section remains mandatory to ensure complete resection of epithelial lesions. This usually requires partial pancreatic resection. The long-term outcome is favourable for lesions with no invasive component. Recurrence in case of invasive malignant transformation appear to be more frequent than previously reported.

Intraductal papillary and mucinous tumors of the pancreas: accuracy of preoperative computed tomography, endoscopic retrograde pancreatography and endoscopic ultrasonography, and long-term outcome in a large surgical series.

BACKGROUND: Few data are available on the accuracy of preoperative imaging or on long-term outcome after surgery for intraductal papillary and mucinous tumors of the pancreas. The aims of this study were to assess the following: (1) the accuracy of preoperative computed tomography, endoscopic retrograde pancreatography, and endoscopic ultrasonography for determination of tumor invasion and pancreatic extension as compared with surgical findings; (2) the long-term outcome after surgery. METHODS: Forty-seven patients who underwent surgery between 1980 and 1995 for pathologically diagnosed intraductal papillary and mucinous tumors were included in this study. The findings of available computed tomography (n = 25), endoscopic retrograde pancreatography (n = 29), and endoscopic ultrasonography (n = 21) were reviewed by experienced clinicians blinded to pathologic diagnosis to assess tumor invasion and pancreatic extension. Pathologic specimens were reviewed by experienced pathologists. Postoperative follow-up data were analyzed. RESULTS: Histologic features of invasive carcinoma were found in 43% of patients, severe dysplasia in 21%, and mild or moderate dysplasia in 36%. The overall accuracy of computed tomography, endoscopic retrograde pancreatography, and endoscopic ultrasonography in distinguishing between invasive and noninvasive tumors were, respectively, 76%, 79%, and 76%. The overall 3-year disease-free survival rate was 63%, but it was 21% among patients with invasive carcinoma at surgery (p < 0.001). CONCLUSIONS: This study emphasizes the need for early surgical resection in patients with suspected intraductal papillary and mucinous tumors of the pancreas because of the high frequency of invasive carcinoma and the inadequacy of preoperative imaging for assessing malignancy.

Are endoscopic procedures able to predict the benignity of ampullary tumors?

BACKGROUND: Malignant ampullary tumors (AT) require pancreatico-duodenectomy (PD) for curative treatment whereas benign AT can be appropriately treated by local resection. This study evaluated the accuracy of endoscopic exploration combining side-viewing duodenoscopy (SVD) with forceps biopsies, endoscopic sphincterotomy (ES), and endoscopic ultrasonography (EUS) to distinguish benign AT from malignant one. PATIENTS AND METHODS: Twenty-six patients with AT had preoperative SVD with forceps biopsies, including 9 with ES, and EUS. Nodal status was evaluated by EUS in all patients, but could not evaluate parietal spread in 6 in whom ES was previously done. Results of endoscopic examination were compared with pathologic examination after resection (2 local excisions for 2 benign AT, and 24 PD for 20 malignant and 4 benign AT). RESULTS: Accuracy of histologic examination of the 26 biopsies of the papilla was 69%. After ES, accuracy of intra-ampullary biopsies was 77%. The EUS had a 75% accuracy for the parietal spread (tumor limited to ampulla or not) and a 69% accuracy for the nodal status. In 11 patients, all explorations were consistent with a benign lesion, but 6 of these patients had a histologically proven malignancy, including one with nodal metastases and two with duodenal involvement. CONCLUSIONS: Side-viewing duodenoscopy with biopsies, even after ES, combined with EUS is not accurate enough to preoperatively ensure that an AT is benign. Indication for a local resection based on these explorations alone is not safe.

[Intraductal papillary mucinous tumors of the pancreas. Clinical and morphological aspects in 30 patients]. / Tumeurs intra-canalaires papillaires mucineuses pancréatiques. Aspects cliniques et morphologiques chez 30 malades.

AIM: Intraductal papillary-mucinous tumors of the pancreas are rare and characterized by a malignant potential. The aim of this study was to clarify their clinical presentation and the performance of different imaging procedures to determine malignancy and tumor extent. METHODS: Medical records and radiographs of 30 patients with histologically confirmed intraductal papillary-mucinous tumor of the pancreas were reviewed retrospectively. Imaging procedures were compared with pathological data of resected pancreas to evaluate their performances. RESULTS: The most frequent symptom was acute pancreatitis (37%). The onset of symptoms preceded the diagnosis by 2.5 years. Diabetes mellitus and diarrhea were respectively detected in 33 and 23% of the cases. The combination of CT scan, endoscopic retrograde cholangiopancreatography and endosonography allowed correct diagnosis of intraductal papillary-mucinous tumor of the pancreas in 100% of the cases. Tumor extent could be accurately determined considering the location of cystic dilatation of the pancreatic ducts, the presence of intraductal material or parietal irregularity. Actuarial 2-year survival rate was 43% in patients with malignant tumors. Radiological factors predicting malignancy were: vascular invasion, common bile duct dilatation, stricture of the main pancreatic duct and the presence of solid component in the tumor. CONCLUSION: The combination of CT scan, ERCP and endosonography provide accurate diagnosis of intraductal papillary-mucinous tumor of the pancreas as well as assessment of tumor extent and malignancy.

Chronic esophagitis dissecans: an unrecognized clinicopathologic entity?

BACKGROUND: We report the clinical and histologic features of a distinctive form of chronic esophagitis for which we propose the term chronic esophagitis dissecans. METHODS: The study group included five patients diagnosed at Hôpital Beaujon, Clichy, from 1988 to 1994. Clinical and endoscopic examinations were performed. Samples of esophageal biopsy specimens were analyzed by histologic and ultrastructural examinations and by immunohistochemistry with antibodies directed against cell adhesion molecules. RESULTS: All patients were elderly (mean age, 66 years). They presented the following combination of clinical and endoscopic features: (1) long-standing history of chronic dysphagia, without symptoms of reflux, (2) shedding of mucosal fragments, occurring spontaneously or after mechanical trauma, (3) existence of localized esophageal strictures, (4) lack of concurrent chronic cutaneomucous lesions. Two patients presented with thymoma. Histologic examination showed evidence of mucosal blistering, in the absence of significant inflammatory lesions. Altered cell-cell adhesion was suggested by the reduced number of desmosomes on ultrastructural examination and the decreased expression of immunoreactive intercellular adhesion molecule E-cadherin. CONCLUSION: Chronic esophagitis dissecans likely represents a hitherto unrecognized clinicopathologic entity and must be added to the causes of chronic dysphagia.

Endoscopic sphincterotomy in patients with liver cirrhosis.

BACKGROUND: Nonsurgical alternatives in biliary diseases have not been studied in large series of patients with cirrhosis. Our aim was to determine the indications and results of endoscopic treatment in this subset of patients. METHODS: Fifty-two patients (36 men, 16 women-Child-Pugh Class A, 18; B, 22; C, 12) aged 63 +/- 18 years underwent endoscopic sphincterotomy (ES) between 1988 and 1993. Antibiotic prophylaxis was routinely carried out and coagulopathy was corrected before ES when required. The data were collected retrospectively up to 30 days after ES. RESULTS: ES succeeded in 98% of the patients (12 cases of needle-knife papillotomy). Twenty-nine patients (55.7%) had choledocholithiasis, 18 had biliary strictures (12 malignant), and 5 had pancreatic or other biliary diseases. Five days after ES, morbidity was 13.5% and mortality was 7.7%. At 1 month, morbidity was 22.9% and mortality 12.5%. Only endoscopic procedures and Ineffective drainage were seen to be significant risk factors or morbidity. The results of the subgroup of cirrhotic patients with choledocholithiasis (n = 29) were compared with those of matched noncirrhotic patients (n = 58). The cirrhotic and noncirrhotic patients treated for choledocholithiasis showed similar results for stone clearance, morbidity, and mortality. CONCLUSION: ES is a safe and effective procedure for treating choledocholithiasis in cirrhotic patients. ES can therefore be considered as an alternative to surgery in Child class A and B patients and must be preferred for Child class C patients with life-threatening biliary complications.

Effects of octreotide on biliary lipid composition and occurrence of cholesterol crystals in patients with acromegaly. A prospective study.

Treatment with the somatostatin analog octreotide is associated with increased gallstone formation. The mechanism of formation of these stones is unclear. The purpose of this study was to examine the effect of a three-month treatment with octreotide on biliary lipid composition and the occurrence of cholesterol crystals in patients with acromegaly. Thirteen patients with active acromegaly, aged 24-76 years, received octreotide (100 micrograms three times daily) for three months. Fasting gallbladder bile was obtained during upper gastrointestinal endoscopy after ceruletide stimulation. Bile was studied before and at the end of the treatment period (N = 7), only before (N = 4), or only at the end of treatment (N = 2). Before treatment, all bile samples but one were supersaturated with cholesterol. However, none contained cholesterol crystals on microscopic examination. At the end of the treatment period, all but two samples were supersaturated with cholesterol. Three of nine samples contained cholesterol crystals, a proportion significantly higher than before treatment. The relative proportions of bile acids, cholesterol, and phospholipids, and the mean cholesterol saturation index were not different before and during treatment. Follow-up ultrasonography showed the occurrence of gallstones in four patients, including the three patients who had cholesterol crystals. We conclude that: (1) fasting gallbladder bile of patients with acromegaly is frequently supersaturated with cholesterol; (2) treatment with octreotide does not increase cholesterol saturation index, but may induce the occurrence of cholesterol crystals. The data are consistent with the view that gallstones induced by octreotide are cholesterol stones and suggest that the drug may impair gallbladder motility and/or decrease cholesterol nucleation time.

[Pharyngeal dysphagia and polymyositis]. / Dysphagie haute et polymyosite.

We report the case of a 70 year-old woman admitted for pharyngeal dysphagia. The diagnosis of polymyositis was made on manometry and histopathological neuromuscular biopsy findings. There were no inflammatory syndrome, muscular enzyme increase or electromyographic abnormalities. The patient was initially treated by prednisone (1 mg/kg/d) with success, but relapsed 12 weeks later and then was put on azathioprine (2 mg/kg/d). Pharyngeal dysphagia can be the only clinical manifestation of polymyositis, usually a systemic disease.

[Upper functional dysphagia. Apropos of 33 cases]. / Dysphagies fonctionnelles hautes. A propos de 33 cas.

Upper functional dysphagia, occurring in the absence of tumoral obstruction, includes swallowing disorders caused by a disturbance of the reflex, velopharyngoesophageal time of deglutition. Thirty-three patients with such disorders have been studied. Fourteen suffered from a neurologic affection (including 4 brainstem tumors and 6 cerebrovascular neurologic disease), 10 from myopathy, 9 from a localized affection of the upper sphincter of the esophagus. Diverticula were excluded from this study. The exploration resorted to fiberendoscopy of esophageal follow-through, pharyngoesophageal manometry, radiocinema, and MRI for some of the latter patients. Cricopharyngeal myotomy was carried out in 16 of these patients, with good results in 10 and failures in 6. The role of the various additional examinations and of myotomy is discussed.

[Diarrhea with malabsorption and exudative enteropathy caused by intestinal myeloid involvement in a patient with myeloproliferative syndrome]. / Diarrhée avec malabsorption et entéropathie exsudative par infiltration myéloïde intestinale au cours d'un syndrome myéloprolifératif.

A 41-year-old woman with a myelodysplastic syndrome complained of diarrhea with malabsorption and protein-losing enteropathy after splenectomy. No cause was found and various therapeutic regimens were not effective. Pathological examination of biopsies from stomach, small intestine, and large bowel showed infiltrations interpreted as inflammatory on routine technics. Blast cell infiltration was found on electron microscopy. Treatment by citarabine induced normalization of leukocytosis, and diarrhea disappeared. Six months after the onset of illness, she developed acute myeloblastic leukemia and died of infectious pneumonia. Blastic infiltration of the lamina propria could be responsible for the determinism of symptoms, because of the lack of another etiology, the intensity of the blastic infiltration and the effect of cytotoxic therapy, even in the absence of new biopsies.