Aymeric Becq

Predictive Factors of Intestinal Necrosis in Acute Mesenteric Ischemia: Prospective Study from an Intestinal Stroke Center

Objectives:To identify predictive factors for irreversible transmural intestinal necrosis (ITIN) in acute mesenteric ischemia (AMI) and establish a risk score for ITIN.Methods:This single-center prospective cohort study was performed between 2009 and 2015 in patients with AMI. The primary outcome was the occurrence of ITIN, confirmed by specimen analysis in patients who underwent surgery. Patients who recovered from AMI with no need for intestinal resection were considered not to have ITIN. Clinical, biological and radiological data were compared in a Cox regression model.Results:A total of 67 patients were included. The origin of AMI was arterial, venous, or non-occlusive in 61%, 37%, 2% of cases, respectively. Intestinal resection and ITIN concerned 42% and 34% of patients, respectively. Factors associated with ITIN in multivariate analysis were: organ failure (hazard ratio (HR): 3.1 (95% confidence interval (CI): 1.1–8.5); P=0.03), serum lactate levels >2 mmol/l (HR: 4.1 (95% CI: 1.4–11.5); P=0.01), and bowel loop dilation on computerized tomography scan (HR: 2.6 (95% CI: 1.2–5.7); P=0.02). ITIN rate increased from 3% to 38%, 89%, and 100% in patients with 0, 1, 2, and 3 factors, respectively. Area under the receiver operating characteristics curve for the diagnosis of ITIN was 0.936 (95% CI: 0.866–0.997) depending on the number of predictive factors.Conclusions:We identified three predictive factors for irreversible intestinal ischemic injury requiring resection in the setting of AMI. Close monitoring of these factors could help avoid unnecessary laparotomy, prevent resection, as well as complications due to unresected necrosis, and possibly lower the overall mortality.

Capsule endoscopy in young patients with iron deficiency anaemia and negative bidirectional gastrointestinal endoscopy

Background Recent data imply young patients (age ≤50 years) undergoing small-bowel (SB) capsule endoscopy (CE) for iron deficiency anaemia (IDA) show higher diagnostic yield (DY) for sinister pathology. We aimed to investigate DY of CE in a large cohort of young IDA patients, and evaluate factors predicting significant SB pathology. Materials and methods This was a retrospective, multicentre study (2010–2015) in consecutive, young patients (≤50 years) from 18 centres/12 countries, with negative bidirectional gastrointestinal (GI) endoscopy undergoing SBCE for IDA. Exclusion criteria: previous/ongoing obscure-overt GI bleeding; age <19 or >50 years; comorbidities associated with IDA. Data retrieved: SBCE indications; prior investigations; medications; SBCE findings; final diagnosis. Clinical and laboratory data were analysed by multivariate logistic regression. Results Data on 389 young IDA patients were retrieved. In total, 169 (43.4%) were excluded due to incomplete clinical data; data from 220 (122F/98M; mean age 40.5 ± 8.6 years) patients were analysed. Some 71 patients had at least one clinically significant SBCE finding (DY: 32.3%). They were divided into two groups: neoplastic pathology (10/220; 4.5%), and non-neoplastic but clinically significant pathology (61/220; 27.7%). The most common significant but non-neoplastic pathologies were angioectasias (22/61) and Crohn’s disease (15/61). On multivariate analysis, weight loss and lower mean corpuscular volume(MCV) were associated with significant SB pathology (OR: 3.87; 95%CI: 1.3–11.3; p = 0.01; and OR: 0.96; 95%CI: 0.92–0.99; p = 0.03; respectively). Our model also demonstrates association between use of antiplatelets and significant SB pathology, although due to the small number of patients, definitive conclusions cannot be drawn. Conclusion In IDA patients ≤50 years with negative bidirectional GI endoscopy, overall DY of SBCE for clinically significant findings was 32.3%. Some 5% of our cohort was diagnosed with SB neoplasia; lower MCV or weight loss were associated with higher DY for SB pathology.

Emerging indications of endoscopic radiofrequency ablation

Introduction Radiofrequency ablation (RFA) is a well-validated treatment of dysplastic Barretts esophagus. Other indications of endoscopic RFA are under evaluation. Results Four prospective studies (total 69 patients) have shown that RFA achieved complete remission of early esophageal squamous intra-epithelial neoplasia at a rate of 80%, but with a substantial risk of stricture. In the setting of gastric antral vascular ectasia, two prospective monocenter studies, and a retrospective multicenter study, (total 51 patients), suggest that RFA is efficacious in terms of reducing transfusion dependency. In the setting of chronic hemorrhagic radiation proctopathy, a prospective monocenter study and a retrospective multicenter study (total 56 patients) suggest that RFA is an efficient treatment. A retrospective comparative study (64 patients) suggests that RFA improves stents patency in malignant biliary strictures. Conclusions Endoscopic RFA is an upcoming treatment modality in early esophageal squamous intra-epithelial neoplasia, as well as in gastric, rectal, and biliary diseases.

Development and validation of an automated algorithm to evaluate the abundance of bubbles in small bowel capsule endoscopy

Background and study aims  Bubbles can impair visualization of the small bowel (SB) mucosa during capsule endoscopy (CE). We aimed to develop and validate a computed algorithm that would allow evaluation of the abundance of bubbles in SB-CE still frames. Patients and methods  Two sets of 200 SB-CE normal still frames were created. Two experienced SB-CE readers analyzed both sets of images twice, in a random order. Each still frame was categorized as presenting with < 10 % or ≥ 10 % of bubbles. Reproducibility (κ), sensitivity (Se), specificity (Sp), receiver operating characteristic curve, and calculation time were measured for different algorithms (Grey-level of co-occurrence matrix [GLCM], fractal dimension, Hough transform, and speeded-up robust features [SURF]) using the experts’ analysis as reference. Algorithms with highest reproducibility, Se and Sp were then selected for a validation step on the second set of frames. Criteria for validation were κ = 1, Se ≥ 90 %, Sp ≥ 85 %, and a calculation time < 1 second. Results  Both SURF and GLCM algorithms had high operating points (Se and Sp over 90 %) and a perfect reproducibility (κ = 1). The validation step showed the GLCM detector strategy had the best diagnostic performances, with a Se of 95.79 %, a Sp of 95.19 %, and a calculation time of 0.037 seconds per frame. Conclusion  A computed algorithm based on a GLCM detector strategy had high diagnostic performance allowing assessment of the abundance of bubbles in SB-CE still frames. This algorithm could be of interest for clinical use (quality reporting) and for research purposes (objective comparison tool of different preparations).

Traitement par radiofréquence de l’endobrachyœsophage

RésuméIntroductionL’endobrachyoesophage (EBO) consiste en une métaplasie intestinale (MI) oesophagienne, dont le risque majeur est l’évolution vers la dysplasie de bas grade (DBG) puis de haut grade (DHG) et finalement l’adénocarcinome oesophagien.IndicationsLa présence d’une DHG et/ou d’un cancer intramuqueux indique un traitement par radiofréquence (RF), précédée, si présence de nodules (usT1N0 en échoendoscopie), d’une résection endoscopique (mucosectomie ou dissection). La RF est en cours d’évaluation dans le contexte d’une DBG multifocale. L’EBO sans dysplasie relève de la surveillance endoscopique simple.RésultatsLa RF permet une rémission complète de la dysplasie tous grades confondus dans 92 % de cas en moyenne et une rémission complète de la MI dans 80 % des cas. Cette rémission est durable dans le temps. Le risque d’évolution vers l’adénocarcinome est alors diminué. La surveillance endoscopique et biopsique au long cours est recommandée. Dans le contexte de la DBG, une étude randomisée récente suggère fortement une diminution du risque de progression vers la DHG ou l’adénocarcinome à trois ans par la RF en comparaison de la surveillance simple. Cette indication est en cours d’évaluation en France. Les complications de la technique sont rares: sténoses oesophagiennes dans 0 à 10 % des cas, hémorragies graves et perforations dans moins de 1 %. Les limites de la RF sont le manque d’évaluation histologique du tissu détruit, la difficulté à appréhender le risque évolutif de la métaplasie résiduelle sous-épithéliale éventuelle, ainsi que le coût de la technique.ConclusionLa RF endoscopique est un traitement efficace au long cours et bien toléré de l’EBO avec DHG et/ou cancer intramuqueux. Ce traitement permet de diminuer le risque d’évolution vers l’adénocarcinome. Malgré une évaluation très favorable, l’indication dans l’EBO avec DBG multifocale n’est pas encore validée en France.AbstractIntroductionBarrett’s esophagus (BE) is defined as an intestinal metaplasia (IM) of the lower esophagus. BE may evolve from nondysplastic IM to low-grade dysplasia (LGD), high-grade dysplasia (HGD), and ultimately to esophageal adenocarcinoma.IndicationsBE with HGD or intramucosal adenocarcinoma requires radiofrequency ablation (RFA). Nodular BE should be treated by endoscopic mucosal resection or submucosal dissection of the nodular zone first (provided an endoscopic ultrasound has shown a usT1N0 lesion). RFA is currently being evaluated in the setting of BE with multifocal LGD. Nondysplastic BE requires endoscopic surveillance.ResultsThe mean rates of complete remission of dysplasia and IM after RFA are 92% and 80%, respectively. Remission is maintained over the years. The likelihood of cancer occurrence is subsequently diminished. Guidelines recommend long-term endoscopic surveillance with biopsies. In the setting of BE with LGD, a recent randomized controlled trial showed a reduced risk of HGD or neoplastic progression when treated by RFA compared with endoscopic surveillance. Esophageal stricture may occur in 0 to 10% of patients, severe hemorrhage and perforation are very rare (< 1%). Limitations of RFA are the lack of pathology assessment, the lack of data regarding buried metaplasia, and the cost of the procedure.ConclusionEndoscopic RFA is a long-term effective and safe treatment of BE with HGD or intramucosal adenocarcinoma. It reduces the likelihood of cancer occurrence. The use of RFA in cases of multifocal LGD has yet to be consensual, and is not validated yet in France.

Indications émergentes de la radiofréquence endoscopique

RésuméIntroductionLa radiofréquence (RF) est un traitement validé de l’endobrachyoesophage dysplasique. Cette revue de la littérature a pour objectif d’évaluer les techniques, l’efficacité et les effets indésirables de la RF endoscopique dans d’autres indications, émergentes.RésultatsQuatre études prospectives (total 69 patients) ont montré que la RF permettait d’obtenir une rémission complète de néoplasies intraépithéliales oesophagiennes malpighiennes en dysplasie de haut grade ou avec carcinome épidermoïde in situ dans 80 % des cas, avec cependant un risque substantiel de sténoses oesophagiennes proximales.Dans l’indication des ectasies vasculaires antrales de l’estomac, une étude pilote prospective (six patients), une étude prospective monocentrique ouverte (21 patients) et une étude rétrospective multicentrique (24 patients) montrent que la RF semble un traitement efficace en termes de diminution du recours aux transfusions.Une étude prospective ouverte monocentrique (39 patients) et une étude rétrospective multicentrique (17 patients) suggèrent que la RF est un traitement efficace de la rectopathie radique hémorragique chronique.Une étude rétrospective comparative (64 patients) montre que la radiofréquence améliore la durée de perméabilité des prothèses dans les situations de sténoses biliaires malignes. Une étude pilote suggère que la RF endobiliaire peut également être une option intéressante dans les sténoses biliaires bénignes réfractaires.Les données sont encore limitées concernant la radiofréquence lors de ponction sous échoendoscopie pour des cancers du pancréas localement avancés non réséquables et pour les traitements des adénopathies médiastinales.ConclusionLa radiofréquence endoscopique est une modalité thérapeutique qui ouvre de nouvelles perspectives dans la destruction des néoplasies intraépithéliales oesophagiennes malpighiennes à un stade précoce, dans le traitement hémostatique de lésions vasculaires digestives (ectasies vasculaires antrales de l’estomac et rectopathie radique hémorragique) et dans les maladies biliaires.AbstractIntroductionRadiofrequency ablation (RFA) is a standard of care for the destruction of dysplastic Barrett’s esophagus. New indications of endoscopic RFA are emerging. Results: Four prospective studies (total 69 patients) have evaluated RFA for the treatment of early esophageal squamous intraepithelial neoplasia In this setting, RFA achieved an eradication of dysplasia rate higher than 80%, but with a 15 to 29% risk of stricture.Two prospective monocentric studies, and one retrospective multicentric study (with a total of 51 patients), suggest that RFA is efficacious in terms of reducing transfusiondependency in patients with gastric antral vascular ectasia. A prospective monocentric study and a retrospective multicentric study (with a total of 56 patients) also suggest that RFA significantly increases haemoglobine rates, reduces patients symptoms and transfusion-dependency in patients with chronic hemorrhagic radiation proctopathy. In the setting of malignant biliary strictures, several studies suggest that RFA improves stents patency.ConclusionNew indications of endoscopic RFA are emerging for the treatment of early esophageal squamous intraepithelial neoplasia, of gastric antral vascular ectasia, of radiation proctopathy, and of biliary strictures.