Emmanuel Paul Peten

Endoscopic bilateral metal stent placement for malignant hilar stenoses: identification of optimal technique ☆

BACKGROUND The aim of this study was to identify factors that facilitate bilateral insertion of metal stents in malignant hilar stenoses, for which plastic stents often result in incomplete drainage and subsequent cholangitis. METHODS Between January 1994 and April 1998, we collected 45 cases of advanced (Bismuth stage II or higher) hilar malignant stenoses. The insertion technique was progressively modified and the success rate in the early period (1994 to 1995) was compared with that of a later period (1996) and the most recent period (1997 to 1998). RESULTS Overall success rate was 73.3% (33 of 45). The success rates for the three periods were 50%, 67%, and 88% (p = 0.008), respectively. Cholangitis occurred in 3 of the patients with unilateral stents compared with 1 with bilateral stents. CONCLUSION We have described a technique for endoscopic insertion of bilateral metallic stents for malignant hilar stenoses that results in high (>88%) and reproducible success rates.

A new source of drug-induced acute pancreatitis: codeine

A variety of drugs have been reported to cause acute pancreatitis during the past 40 years. We report the first series of four cases of acute pancreatitis related to codeine ingestion. Four patients (three female, mean age 50.2 yr) presented with clinical, biochemical, and radiological evidence of acute pancreatitis. All four had ingested a therapeutic dose of codeine 1–3 h before the onset of abdominal symptoms. Unintentional rechallenge occurred in three cases and was followed by recurrence of acute pancreatitis in all three. All patients made a full recovery. All four patients had had a previous cholecystectomy. The likely underlying pathophysiological mechanism is codeine-induced spasm of the sphincter of Oddi combined with sphincter of Oddi dysfunction related to a previous cholecystectomy. Codeine ingestion leads to acute pancreatitis in some individuals. Previous cholecystectomy seems to predispose to codeine-induced pancreatitis.

Controlled transperitoneal percutaneous cecostomy as a therapeutic alternative to the endoscopic decompression for Ogilvie's syndrome.

Acute colonic pseudo-obstruction, the so-called Ogilvies syndrome, results in massive colonic dilation without mechanical obstruction. In most cases, a conservative treatment with or without endoscopic decompression is sufficient. In rare cases of relapses or failures, a cecostomy has to be performed. A surgical cecostomy is associated with high morbidity and mortality. However, a percutaneous cecostomy could be an interesting alternative treatment. We report the case of a 67-yr-old male with colonic pseudo-obstruction for which both the conservative and the endoscopic treatments were unsuccessful. A percutaneous cecostomy was performed, and for the first time in this indication, a transperitoneal access was used with the help of nylon T-fasteners.

Prevalence of Cholelithiasis (Results of an Epidemiologic Investigation in Vidauban, Southeast France)

Cholelithiasis leads to 80,000 cholecystectomiesbeing performed every year in France, but its prevalenceis still unknown. The aim of this study was to assessthe prevalence and risk factors of cholelithiasis in a random population of 1027 women and 727men over the age of 30 in a small town in the southeastof France. Detailed clinical history, dietaryinvestigation, and gallbladder ultrasound were collected for each subject and assessed by univariateanalysis. A regression model was used in themultivariate analysis to detect the relative risk ofcholelithiasis. Cholelithiasis was found in 130individuals (global prevalence 13.9%). The relative riskfor lithiasis was higher in women compared to men(1.89). Age (P < 0.0001) and body mass index (BMI)>25 (P = 0.013) were also significant risk factors. Neither pregnancy nor oral contraceptive useproved to be risk factors. Typical biliary colic painwas the only symptom significantly associated withcholelithiasis (P < 0.0001). These results show that the prevalence of gallstones in France issimilar to that in Denmark and Italy.

Cholelithiasis and Dietary Risk Factors (An Epidemiologic Investigation in Vidauban, Southeast France)

Dietary risk factors have been implicated in thedevelopment of cholelithiasis. The aim of this study wasto determine in a homogeneous French population whethera particular type of diet may be lithogenic. Seventy-six subjects over 30 years of age (26men, 50 women) with cholelithiasis detected byultrasound were selected from a population sample of 830subjects by drawing lots using the polling list. These were matched by 76 control subjects withoutcholelithiasis randomly selected from the samepopulation. Univariate analysis was significant for ahigh calorie diet >2500 kcal/day (OR = 3.62, P =0.0065), a diet rich in carbohydrates with a consumption≥55 g/day (OR = 2.98, P = 0.0067), and a diet rich intotal lipids (OR = 4,97, P = 0.023) or saturated fattyacids (OR = 3.06, P = 0.0146). An alcohol consumption equivalent to 20-40 g/day was protective (P =0.018). Multivariate analysis confirmed these results.Our study suggests that a change in dietary habits bylimiting excess calories, saturated fats and carbohydrates could reduce the incidence ofcholelithiasis.

Gallbladder Volume in Adults and Its Relationship to Age, Sex, Body Mass Index, Body Surface Area and Gallstones

Background/Aims: The role of a large gallbladder volume with regard to a predisposition for gallstones is unknown. It is possible that an increase in gallbladder volume could result in impaired gallbladder motility and bile stasis. We looked for factors affecting gallbladder volume in a random population in the southeast of France. Methods: To assess the relationship between gallbladder volume and gallstones, 528 subjects over the age of 30 were studied (72 with lithiasis). Age, sex, body mass index, body surface area and gallbladder volume were collected for each subject. A linear regression analysis was performed to look for significant variables. Results: The overall adjusted prevalence of cholelithiasis was 13.9% in our population. On linear regression analysis, two variables (age and surface area) were found to be independently correlated with gallbladder volume. Gallbladder volume was significantly increased in subjects over 50 years (p < 0.001). There was a positive correlation between gallbladder volume and body surface area (r = 0.33, p < 0.001). In this study, the presence or absence of gallstones did not significantly affect the gallbladder volume. Conclusions: We report that there is dilatation of the gallbladder with age and with an increase in body surface area. Whether this could represent risk factors for the occurrence of gallstone remains uncertain.

Long term treatment of biliary stricture due to chronic pancreatitis with a metallic stent

The exact role of endoprostheses in the management of chronic pancreatitis-associated biliary strictures has not yet been clearly established. We report an unusual case of a patient with this condition who was treated for an unexpectedly long term with a self-expanding metallic endoprosthesis. There has only been one previous report of the use of metallic stents in this situation. It appears that metallic endoprostheses may have a role to play in the management of selected patients who have chronic pancreatitis-associated bile duct stricture.

Traitement endoscopique palliatif des sténoses colorectales malignes par prothèses métalliques: résultats chez 41 patients

RésuméButLa colostomie de décharge est la prise en charge thérapeutique admise de l’occlusion rectocolique d’origine tumorale. Le but de cette étude était d’évaluer la faisabilité et l’efficacité du traitement endoscopique des sténoses malignes colo-rectales par prothèses métalliques expansives chez des patients non opérables.Patients et méthodesEntre septembre 1994 et septembre 2002, 41 patients consécutifs (21 femmes, âge moyen de 69,5 ans, extrême 41–92 ans) présentant une occlusion colo-rectale d’origine néoplasique non opérable ont été traités de manière palliative par pose d’endoprothèse métallique auto-expansive. L’occlusion avait pour étiologie une atteinte tumorale colo-rectale primitive dans 32 cas et une atteinte carcinomateuse péritonéale compressive pour les 9 autres patients. Le niveau de l’occlusion était rectal dans 11 cas, sigmoïdien dans 26 cas, transverse colique dans 2 cas, à l’angle colique gauche dans un cas et à l’angle colique droit pour le dernier. Les prothèses utilisées étaient de type Enterai Wallstent®, Colonic Z stent®, Ultraflex precision® ou encore de type Choo stent®.RésultatsL’insertion prothétique était possible chez 37 patients (90,2 %) et permettait de manière constante la levée de l’occlusion. Huit de ces 37 patients présentaient un stent perméable après un suivi moyen de 23,5 semaines. L’évolution fut la suivante pour les 29 autres patients: 22 patients avaient une prothèse perméable au moment de leur décès, 2 prothèses étaient envahies par la tumeur nécessitant un second traitement endoscopique (insertion d’un second stent), 5 prothèses (14,7 %) avaient migré de manière spontanée sans récidive de l’occlusion et un stent avait été retiré pour un ténesme rectal à la suite de sa pose.ConclusionL’insertion endoscopique de prothèses métalliques auto-expansives est un traitement efficace et bien toléré des sténoses malignes colo-rectales. La complication la plus fréquente est la migration survenant quel que soit le modèle de prothèse utilisé.SummaryBackground and study aimsDiverting colostomy is the classical approach in malignant colorectal obstruction. The aim of our study was to assess the feasibility and the effectiveness of endoscopic treatment of malignant occluding colorectal cancers using selfexpanding metallic stents in nonsurgically treated patients.Patients and methodsBetween September 1994 and September 2002, 41 consecutive patients (21 females, mean age 69.5 years, range 41 –92) with malignant colorectal occlusion or subocclusion and without any curative surgery possibility, had palliative treatment with one or several endoscopic metallic stents. Colorectal cancer was the cause of occlusion in 32 patients, and in 9, peritoneal carcinomatosis with colonie invasion was present. The level of occlusion was rectal in 11 cases, sigmoid in 26 cases, transverse colon in 2 cases, splenic flexure in one case and right angle in another case. Prostheses were either Enterai Wallstent, colonie Z stent, Ultraflex stent precision or Choo stent.ResultsPlacement of expandable stents was possible in 37 cases (90.2 %) and always relieved the bowel occlusion. Eight out of these 37 patients were still alive with a permeable stent after a mean follow up of 23.5 weeks. The evolution was as follows for the remaining 29 patients: 22 had a permeable stent at their death, two stents were invaded by tumor and were treated with a second stent, 5 stents had a spontaneous migration without reocclusion and one prosthesis was removed because of rectal tenesmus.ConclusionEndoscopically inserted selfexpandable metal stents are an efficient palliative treatment of malignant colorectal obstruction. The most frequent complication is spontaneous migration occurring with various stent models.

Traitement endoscopique palliatif des sténoses duodénales malignes par prothèses métalliques

ConclusionsLa pose de prothèses métalliques par voie endoscopique au niveau du duodénum représente une alternative thérapeutique efficace et bien tolérée au traitement chirurgical palliatif des obstructions duodénales d’origine néoplasique. Les dispositifs récents permettant une pose au travers du canal opérateur d’un endoscope facilitent et sécurisent l’insertion. Cette alternative intéresse particulièrement les patients déjà porteurs d’endoprothèse biliaire palliative qui développent secondairement une sténose duodénale.