Bertrand Brieau

Immune Checkpoint Inhibitor-Induced Colitis: Diagnosis and Management

Immune checkpoint inhibitors are monoclonal antibodies indicated for an increasing number of malignant diseases. These agents can cause specific side effects, which need to be anticipated while clear patterns of management need to be established. Immune checkpoint inhibitor-mediated gastrointestinal side effects, including diarrhea and colitis, occur in up to 30% of patients. Severe colitis can lead to severe dehydration or intestinal perforation. Endoscopic lesions and histopathological features of immune checkpoint inhibitor-induced colitis are similar to an inflammatory bowel disease (IBD) flare. Patients with immune checkpoint inhibitor-induced diarrhea and colitis are treated with corticosteroids. Infliximab can be used in cases of corticosteroid failure. Rectosigmoïdoscopy or colonoscopy should be performed when severe immune checkpoint inhibitor-induced colitis is suspected, but endoscopic investigations should not delay treatment. Specific patient education as well as co-operation between oncologists and gastroenterologists is essential.

Resection of Late Pulmonary Metastases from Pancreatic Adenocarcinoma: Is Surgery an Option?

ABSTRACT Patients with recurrences from pancreas adenocarcinoma have a poor survival rate despite new chemotherapy treatment options. Recurrences are mainly hepatic metastases or peritoneal dissemination and surgical treatment is not recommended. Late and single metachronous pulmonary recurrences are uncommon and may mimic primary lung carcinoma. We report two patients with late and unique pulmonary metastasis from pancreatic cancer. These two patients underwent surgical resection; three and five years later, they did not experience recurrences. Cases called for a surgical approach in late and unique pulmonary metastases from pancreatic cancer, and paved the way for a prolonged chemotherapy free period.

Addition of an antiangiogenic therapy, bevacizumab, to gemcitabine plus oxaliplatin improves survival in advanced biliary tract cancers

SummaryBackground The prognosis of patients with metastatic carcinoma of the biliary tract (mBTC) is poor and a systemic therapy with gemcitabine and platinum-based is the gold standard. The addition of bevacizumab to the chemotherapy might increase patients’ survival. Our aim was to assess and compare the efficacy of GEMOX (gemcitabine and oxaliplatin regimen) plus bevacizumab to GEMOX alone in mBTC. Methods Patients with mBTC who received the GEMOX-bevacizumab (nxa0=xa032; Group A) or GEMOX (nxa0=xa025; Group B) regimen as first-line treatment were compared. Treatment was repeated every two weeks until disease progression or unacceptable adverse effects occurred. The primary evaluation criterion was the progression-free survival (PFS). Results A quarter of patients (8/32) from Group A and a fifth of patients (13/25) from Group B had an objective response. The median PFS was 6.48xa0months and 3.72xa0months in Group A and B, respectively (pxa0=xa00.049). The median OS was 11.31xa0months and 10.34xa0months in Group A and B, respectively. Grade 3/4 sepsis was identified in 9.4% and 12% in Group A and B, respectively, (pxa0=xa00.64). Conclusion In mBTC, the addition of bevacizumab to GEMOX increased the progression-free survival and was associated with manageable toxicity. These data pave the way for further evaluation of antiangiogenic agents in mBTC.

Acute dysphagia and odynophagia revealing an unusual case of oesophageal anisakiasis

A 27-year-old male with no medical history was admitted to ur institution for acute dysphagia and odynophagia. Symptoms ppeared just after awakening, 12 h after a meal. Physical examiation was normal, and laboratory tests only showed leukocytosis 12,700/mm3) without eosinophilia. Because he had eaten underooked hake fillets the evening before, an oesophageal fishbone njury was suspected; upper gastrointestinal endoscopy was erformed 21 h after the meal revealing 8 spontaneously moving hite worms, adhering to the mucosa of the lower oesophagus ust above the Z-line and of the stomach (Fig. 1). The worms ere removed through the endoscope with a biopsy forceps; the

Submucosal tunneling endoscopic septum division for Zenker’s diverticulum: a reproducible procedure for endoscopists who perform peroral endoscopic myotomy

Zenker’s diverticulum is a rare disease occurring in less than 0.5% of the global population. Currently, the diverticuloscope-assisted diverticulotomy represents the traditional procedure, the diverticuloscope enabling better exposure of the muscular fibers. Although effective and safer than surgery, this technique could be complicated by perforation, which is reported in as many as 6.5 % of patients [1]. Recently, Li et al. reported a novel technique called the submucosal tunneling endoscopic septum division (STESD) [2], inspired by the peroral endoscopic myotomy (POEM) technique [3]. The theoretical advantage is to completely dissect the muscular septum without mucosal opening. This video case reports the second successful treatment of Zenker’s diverticulum using this new procedure. A 72-year-old woman underwent upper endoscopy for dysphagia, revealing a Zenker’s diverticulum 20cm from the incisors (▶Fig. 1), which was confirmed by esophagogram (▶Fig. 2). We performed the diverticulotomy using the STESD technique (▶Video 1) and a gastroscope (Fujinon, Tokyo, Japan) with cap. Submucosal incision was performed after submucosal injection, 3 cm above the diverticular septum. A tunnel was made using a 1.5mm FlushKnife (Erbe Elektromedizin, Tübingen, Germany) between the muscular layers and the mucosa until the muscular septum was reached, and then continued along both sides of the septum, to create a large endoscopic window. Thereafter, the diverticular septum was completely dissected (with spread coagulation) along its entire length. Finally, after hemostasis, the mucosal incision was closed by four clips. Intravenous antibiotics were continued for 2 days postoperatively, and the patient was discharged at Day 3. Symptoms had totally resolved 15 days later. In summary, STESD is a reproducible technique that is easily accessible to enE-Videos

Mirizzi’s syndrome in Roux-en-Y bypass patient successfully treated with cholangioscopically-guided laser lithotripsy via percutaneous gastrostomy

Obesity and bariatric surgery are major risk factors in gallstone disease. In patients with a past history of Roux-en-Y gastric bypass, Mirizzi’s syndrome is a challenging endoscopic situation because of the modified anatomy. Here we report the first case of a patient with a Roux-en-Y gastric bypass treated by intracorporeal lithotripsy with a digital single-operator cholangioscope following an endoscopic retrograde cholangiopancreatography (ERCP) using a percutaneous gastrostomy access.

Ascariasis seen by videocapsule endoscopy

A68‐YEAR‐OLDWOMAN, native to Madagascar, was referred to the Gastroenterology unit investigating an episode of melena in April 2015. She had a history of systemic sclerosis and Gougerot-Sj€ogren syndrome was diagnosed in 2014 without systemic treatment. Laboratory tests just showed anemia (10 g/dL), without eosinophilia nor other abnormality. She is living in metropolitan France since 1988, but returns annually to Madagascar. She made her last trip 1 year ago. She underwent gastric endoscopy and colonoscopy, which were normal. As the episodes of melena were still occurring, videocapsule endoscopy was done to determine the origin of the bleeding. The video showed no lesion of the

Tumeurs neuroendocrines de l’intestin grêle : actualités sur le traitement médical

CONTEXTnMid gut neuroendocrine tumors (NET) are rare tumors whose incidence is increasing. Curative surgery remains the gold standard for the treatment of NETs of the small intestine. Surgery should be considered as soon as possible even if a metastatic stage is diagnosed. The management of unresectable well-differentiated metastatic NETs of the small intestine recently changed with the publication of trials demonstrating the benefit of targeted therapies and metabolic radiotherapy, leading to a change of practices and update of French and international recommendations.nnnOBJECTIVEnThe objective of this review is to present the recent data consisting of three phase III studies, which modify the management of well-differentiated metastatic midgut NETs and make an inventory of the available treatment options.nnnDOCUMENTARY SOURCESnThe documentary sources used were gathered through the PubMed website using keyword searching (neurendocrine tumor, mid gut, treatment). We also referred to recommendations of the European Society of neuroendocrine tumors (ENETS) trials presented at ESMO Congress 2015 (European Society for Medical Oncology).nnnSTUDY SELECTIONnWe excluded studies of exclusive extra-digestive NETs, poorly differentiated NETs, surgical treatments and phase I studies.nnnRESULTSnWe discussed three randomized phase III trials: CLARINET, RADIANT and NETTER studies. These studies demonstrated the efficacy of respectively somatostatin analogues, mTOR inhibitors and metabolic radiotherapy.nnnCONCLUSIONnThis review highlights the validation by randomized studies of an mTOR inhibitor and metabolic radiotherapy in metastatic non-pancreatic digestive NETs unresectable well-differentiated grade of G1/2 in progression under somatostatin analogues.

May we challenge the ENETS guidelines in pancreatic neuroendocrine neoplasms? A quiz for French experts

INTRODUCTIONnRecent guidelines have been published by a consensus of international experts (2016 ENETS (European NeuroEndocrine Tumor Society) guidelines). Nevertheless, in case of pancreatic neuroendocrine neoplasms (panNEN) the ENETS guidelines fail to propose a unique strategy in some situations, due to the lack of high-level of evidence and the absence of formal agreement between the experts drawing up the guidelines.nnnMATERIAL AND METHODSnA survey of 25 questions on panNEN was sent to 104 French experts challenging the guidelines. Questions focused on clinical situations in localized G-1/2 panNEN, localized G-3 panNEN, metastatic G-1/2 panNEN, and metastatic G-3 panNEN for which multiple options were proposed by the ENETS guidelines.nnnRESULTSnFifty-seven experts (55%) have answered the survey. 18/25 questions obtained at least 50% similar responses, allowing a consensus or a position statement. Among the results, surgery of small panNEN is preferred to surveillance in young patients; the temozolomide-capecitabine combination is favored instead of streptozotocin-based chemotherapy for G-1/2 metastatic panNEN.nnnCONCLUSIONnFrench experts are mostly in line with the European guidelines, but some differences do exist. Whilst waiting for prospective studies, this survey helps physicians to propose standardized procedures and identifies situations where a step forward has been enabled by French experts. This questionnaire paves the way for a simplified therapeutic algorithm of panNEN.

Jejunojejunal intussusception after polypectomy by spiral enteroscopy in Peutz–Jeghers syndrome

Enteroscopy makes it possible to resect small-bowel polyps and avoid intestinal obstruction inpatientswithPeutz–Jeghers syndrome [1]. We report the case of a 54-year-old man with Peutz–Jeghers syndrome, referred to our center because of recurrent episodes of intestinal occlusion. Computed tomography showed a voluminous polyp in the proximal part of the jejunum causing small-bowel obstruction. While the patient was under general anesthesia, we performed a spiral enteroscopy (enteroscope EN-450T5; Fujifilm, Saitama, Japan) with good and fast progress until we reached the proximal part of the jejunum, where the polyp occupied the entire digestive lumen (● Fig.1a,b). A snare with Endocut current was used to resect the polyp after the submucosal injection of saline with 1:10000 diluted epinephrine (● Video 1). We did not use clips before the resection because the large, short foot of the polyp did not allow them to be placed. Moderate acute bleeding after the resection was stopped with epinephrine injection, and further bleeding was treated with four hemostatic clips (Resolution Clip; Boston Scientific, Natick, Massachusetts, USA) (● Fig.2). The hemoglobin levels were normal thereafter. After 24 hours, the patient had fever and leukocytosis (12000/mm3) without abdominal pain or vomiting. Abdominal computed tomography showed a jejunojejunal intussusception upstream of an area of edema of the intestinal wall (● Fig.3). The results of bacteriological sampling were negative. The patient received an intravenous antibiotic for 3 days (3g of cefotaxime per day). He recovered quickly without any endoscopic treatment and was discharged after 3 days. The advent of enteroscopy has improved our ability to conduct deep exploration of the small bowel and to resect voluminous polyps [2]. Peutz–Jeghers syndrome is a hereditary disorder characterized by areas of mucocutaneous pigmentation and hamartomatous polyps, mainly in the small bowel. Endoscopic polypectomy Fig.3 Abdominal computed tomography shows a jejunojejunal intussusception (arrow) upstream of an area of intestinal wall edema. Fig.2 Moderate acute bleeding after polyp resection was treated immediately with epinephrine injection, then the application of four hemostatic clips.