Emmanuel Cuillerier

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.

Outcome after surgical resection of intraductal papillary and mucinous tumors of the pancreas

OBJECTIVE:Treatment of intraductal papillary and mucinous tumors of pancreas (IPMT) usually requires surgery. The objective of this study was to evaluate the risk of recurrence in patients after surgery according to the histological nature of the neoplasm and the type of surgery.METHODS:The outcome of 45 patients who underwent partial pancreatectomy (n = 35) or total pancreatectomy (n = 10) for IPMT was studied according to the nature of the neoplasm (invasive carcinoma or noninvasive neoplasm), type of surgery (partial or total pancreatectomy), and lymph nodes status.RESULTS:The overall 3-yr actuarial survival rate was 83%. Death occurred in seven of 20 (35%) patients with invasive carcinoma and in one of 26 (4%) patients with noninvasive tumors (p < 0.05). There were two recurrences in the seven patients with noninvasive neoplasm who underwent partial pancreatectomy with involved resection margins, and none in the 13 patients with disease-free margins. In patients with invasive carcinoma, there was one recurrence after total pancreatectomy, six after partial pancreatectomy with disease-free margins and six after partial pancreatectomy with involved margins. In patients with invasive carcinoma, total pancreatectomy and the absence of lymph nodes involvement were independently associated with a low risk of recurrence.CONCLUSIONS:IPMT may be managed as follows: 1) in patients with noninvasive neoplasms, partial pancreatic resection should be guided by frozen section examination until disease-free margins are obtained; and 2) in patients with invasive carcinoma, total pancreatectomy seems most likely to cure the patient, but should be discussed according to the general status and the age.

Right colonic involvement is associated with severe forms of ischemic colitis and occurs frequently in patients with chronic renal failure requiring hemodialysis

OBJECTIVE:The aim of this study was to identify factors associated with severe outcome in patients with ischemic colitis.METHODS:The files of 60 consecutive inpatients (34 women, 26 men, mean age 67 yr) with ischemic colitis were reviewed. The following data were analyzed: age, sex, smoking, medications, history of cardiovascular disease, metabolic disease, chronic renal failure and hemodialysis, the time elapsed between the first symptoms and the diagnosis, and the site and extension of their colonic involvement. Patients were divided into two groups according to outcome: those with severe disease, including those who died from ischemic colitis (n = 3) or who required surgical resection (n = 21); and those with mild forms of colitis who were treated successfully without surgery (n = 36). The two groups were compared by means of univariate and multivariate analysis to identify factors associated with unfavorable outcomes. Only patients who had a complete examination of the colon (n = 51) were entered into the statistical analysis.RESULTS:By univariate analysis, chronic renal failure (p = 0.03), hemodialysis (p = 0.01), short delay between symptoms and diagnosis (p = 0.01), and right colonic involvement (p = 0.002) were significantly more common in the patients with severe colitis. By logistic regression, right colonic involvement was the only factor independently associated with severity (p = 0.01). Right-sided lesions were present in 82% of patients on dialysis but in only 26% of patients not on dialysis (p = 0.0005).CONCLUSIONS:Right colonic involvement is associated with severe forms of ischemic colitis and occurs frequently in patients with chronic renal failure requiring hemodialysis.

Push enteroscopy in celiac sprue and refractory sprue

BACKGROUND The aim of this study was to determine in patients with sprue whether jejunal endoscopy improves the diagnostic yield or provides information that may modify management, when compared with evaluation limited to the duodenum. METHODS From January 1994 to June 1998, a total of 31 patients (6 men, 25 women, mean age 41 years) were prospectively evaluated by push enteroscopy. They were divided into two groups: (1) celiac disease at different stages of activity (n = 23) and (2) refractory sprue (n = 8). The endoscopic and histologic findings in the duodenum and in the jejunum were compared. RESULTS Celiac disease: In 19 patients, endoscopic and histologic findings in the duodenum and jejunum were similar; in four patients villous atrophy was more severe in the duodenum than in the jejunum. Refractory sprue: In 5 of 8 patients, enteroscopy revealed ulcerative jejunitis, whereas ulcerations were found in the duodenum in only one case. CONCLUSION In refractory sprue, push enteroscopy with jejunal biopsies was of diagnostic value in 50% of cases demonstrating ulcerative jejunitis, whereas it did not modify the management of patients with responsive celiac disease.

Black esophagus associated with herpes esophagitis

Black esophagus is defined as a dark, pigmented esophagus at endoscopy together with histologic mucosal necrosis.1 It is a rare entity, first described at autopsy.1,2 The etiology remains unknown but is most likely multifactorial, even though most reports have suggested an ischemic pathogenesis.1-7 An esophageal viral infection has been proposed but never confirmed.8 We report here a case of black esophagus associated with a proven herpetic infection that healed after antiviral therapy.

Clinical Impact of Push Enteroscopy in Patients With Gastrointestinal Bleeding of Unknown Origin

BACKGROUND & AIMS Despite the frequent use of push enteroscopy (PE), little is known of its clinical impact. The aim of this study was to evaluate the impact of PE on diagnostic and therapeutic management of patients with gastrointestinal bleeding of unknown origin. METHODS Seventy-five consecutive patients (mean age, 56 y) referred for PE were included in this 1-year prospective study. Indications for PE were overt bleeding in 46 patients (61%) and iron-deficiency anemia in 29 patients (39%). Before the procedure, the prescribing physicians were asked to fill out a questionnaire listing the theoretical patient management plan (diagnostic procedures and/or treatment) as if PE were not available. One month after PE, the same physicians were asked about: (1) diagnostic procedures performed after PE, (2) the final diagnosis, and (3) their opinion of the usefulness of PE in clinical management. The clinical impact of PE on diagnostic and/or therapeutic management was assessed by 3 study physicians. RESULTS Responses to the 2 questionnaires were obtained for all patients. The diagnostic yield of PE was 32% (24 of 75). The clinical impact of PE (changes in diagnostic and/or therapeutic management) was 55% (n = 41). PE was perceived as helpful by the prescribing physicians in 55% of cases. PE tended to influence patient management more in cases of overt bleeding than in cases of occult bleeding (63% vs. 41%; P = 0.06). CONCLUSIONS PE influenced the clinical management of more than half the patients with GI bleeding of unknown origin, and was particularly useful in patients with overt bleeding.

Is push enteroscopy useful in patients with malabsorption of unclear origin

OBJECTIVE:The aim of this study was to determine the diagnostic value of push enteroscopy in patients with chronic diarrhea and malabsorption of unclear origin.METHODS:From January, 1997, to September, 1999, 16 consecutive patients with chronic diarrhea and biological signs of intestinal malabsorption but no evidence of celiac disease were explored by push enteroscopy. Previous duodenal histological findings had been normal in seven patients and abnormal but inconclusive in nine patients. Endoscopic and histological findings in the duodenum and in the jejunum were compared.RESULTS:Push enteroscopy with jejunal biopsy yielded a diagnosis in comparison with duodenal biopsy in two of 16 (12%) patients, respectively, in two of the nine (22%) patients with abnormal but inconclusive findings on duodenal biopsy, and none of the seven patients with normal duodenal histology. In the two patients in whom jejunal biopsy had diagnostic value but duodenal biopsy did not, the final diagnoses were invasive intestinal lymphoma and microsporidiosis.CONCLUSION:Push enteroscopy had diagnostic value in only 12% of patients with malabsorption of unclear origin, all of whom had had abnormal but inconclusive duodenal histological findings. Push enteroscopy with jejunal biopsy appears to have limited diagnostic value in patients with chronic diarrhea and malabsorption, especially when duodenal biopsies are histologically normal.

Predictive factors of positive findings in patients explored by push enteroscopy for unexplained GI bleeding

BACKGROUND The diagnostic yield of push enteroscopy (PE) in patients with unexplained overt GI bleeding is about 30%. The aim of this study was to assess for predictive factors of positive findings. METHODS A total of 182 patients referred to two endoscopic centers (European Georges Pompidou Hospital [Paris, France] and Erasmus Hospital [Brussels, Belgium]) for unexplained overt GI bleeding (melena [57%], hematochezia [26%], or hematochezia associated with melena [17%]) were included in this retrospective study. Predictive factors associated with positive findings at upper PE were studied by using uni- and multivariate analysis. RESULTS The overall diagnostic yield of upper PE was 34% (62/182), but lesions were found beyond the second duodenum in 25% of the patients (45/182). Factors significantly associated with positive findings at upper PE were the following. (1) In univariate analysis: the presence of melena, Hb level <7 g/dL, blood transfusion >4 units per patient, chronic renal failure, disorder of hemostasis or effective anticoagulant treatment, history of intestinal arteriovenous malformation, and age > 65 years. (2) In multivariate analysis: chronic renal failure and presence of melena. If only jejunal lesions were considered, chronic renal failure was the only predictive factor associated with positive findings at upper PE in multivariate analysis. The severity of GI bleeding did not reach statistical significance ( p = 0.06). Delay between GI bleeding and PE, number of previous standard endoscopies and previous episodes of bleeding were not associated with positive findings in upper PE. CONCLUSIONS In patients with unexplained overt GI bleeding, upper PE has a higher diagnostic yield in patients with chronic renal failure and patients with melena (vs. hematochezia).

Metastatic jejunal VIPoma: beneficial effect of combination therapy with interferon-α and 5-fluorouracil

The VIPoma syndrome is rare. It is usually caused by a neuroendocrine tumor located in the pancreas. Somatostatin analogs and interferon-α can be helpful in the symptomatic control of the disease, but the efficacy of chemotherapy in metastatic disease is limited. We report the case of a 32-yr-old patient who had a primary intestinal VIPoma with peritoneal carcinomatosis and hepatic metastases. Somatostatin analogs and conventional chemotherapy regimens were not effective on VIPoma syndrome and tumor progression. The combination of 5- fluorouracil and interferon-α was associated with a major clinical improvement and tumor regression. Further investigations should evaluate the place of such a combination as a first line treatment for patients with metastatic neuroendocrine tumors.

⁎4745 Clinical impact of push-enteroscopy:prospective study.

The aim of this study was to evaluate the impact of PE on diagnostic and therapeutic patient management. Methods: Sixty-eight patients (41M, 27F, mean age 52 y) referred for PE were included in this ongoing prospective study between May 1998 and August 1999. Indications for PE were: overt GI bledding (n=32,47%)and isolated iron deficiency anemia (n=14, 21%) of unkown origin, small bowel radiological abnormalities (n=8, 12%), malabsorption and/or chronic diarrhea (n=9, 13%), other indications (n=5, 7%). Before the procedure, the requesting physicians were asked to fill out a questionnaire listing the theoretical patient management plans (diagnostic procedures and/or treatment) as PE would have not been available. One month after PE, the same physicians were asked about: 1) the diagnostic procedures performed after PE, 2) the final diagnostic, 3) the impact of PE regarding changes in diagnostic and therapeutic management. Results: Responses to the 2 questionnaires were obtained for 97% of patients. The diagnostic yield of PE was 35% (n=24). PE modified the diagnostic management in 40% (n=27) of patients and therapeutic management in 32% (n=22)(medical treatment 10 pts, endoscopic treatment 8 pts, surgery 4 pts). As a whole, PE had clinical implications (changes in the diagnostic and/or therapeutic management) in 54% (n=37) of patients. The clinical impact of PE was greater in case of overt intestinal bleeding (56% of patients) than in isolated iron deficiency anemia (36% of patients). Updated data will be presented at the meeting. Conclusion: PE is perceived as useful by requesting physicians. Changes in management plan occurred in more than half of the patients explored by PE when diagnostic yield was 35%.