Emmanuel Toussaint

Endotherapy for paraduodenal pancreatitis: A large retrospective case series

BACKGROUND AND STUDY AIMS Paraduodenal pancreatitis is histologically well defined but its epidemiology, natural history, and connection with chronic pancreatitis are not completely understood. The aim of this study was to review the endoscopic and medical management of paraduodenal pancreatitis. PATIENTS AND METHODS Medical records of all patients with paraduodenal pancreatitis diagnosed by magnetic resonance cholangiopancreatography (MRCP) or endoscopic ultrasonography (EUS) between 1995 and 2010 were retrospectively reviewed. Clinical features, imaging procedures, and treatments were investigated. The primary end point was the rate of clinical success, and the secondary end points were the radiological or endoscopic improvement, complication rate, and overall survival rate. RESULTS A total of 51 patients were included in the study (88.2 % alcohol abuse; median age 49 years [range 37 - 70]; 50 men). The most frequent symptoms at presentation were pain (n = 50; 98.0 %) and weight loss (n = 36; 70.6 %). Chronic pancreatitis was present in 36 patients (70.6 %), and 45 patients (88.2 %) had cysts. Other findings included stricture of the pancreatic duct (n = 37; 72.5 %), common bile duct (n = 29; 56.9 %), and duodenum (n = 24; 47.1 %). A total of 39 patients underwent initial endoscopic treatment: cystenterostomy (n = 20), pancreatic and/or biliary duct drainage (n = 19), and/or duodenal dilation (n = 6). For the patients with available follow-up (n = 41), 24 patients required repeat endoscopy and 9 patients required surgery after the initial endoscopic management. After a median follow-up of 54 months (range 6 - 156 months), complete clinical success was achieved in 70.7 % of patients, and the overall survival rate was 94.1 %. CONCLUSIONS This is the largest series concerning the management of paraduodenal pancreatitis using endotherapy as the first-line intervention. Although repeat endoscopic procedures were required in half of the patients, no severe complication was observed and surgical treatment was ultimately needed in less than 25 % of the patients.

Trans-fistulary endoscopic drainage for post-bariatric abdominal collections communicating with the upper gastrointestinal tract

BACKGROUND AND STUDY AIMS Diverse endoscopic methods, such as placement of temporary self-expandable stents, have proven effective for the treatment of post-bariatric surgery leaks. However, some patients do not respond to the usual endoscopic treatment. This study tested the efficacy of an alternative treatment strategy based on trans-fistulary drainage with double-pigtail plastic stents. PATIENTS AND METHODS We performed a retrospective analysis of patients with abdominal collections following bariatric surgery who were treated by trans-fistulary stenting between May 2007 and February 2015. Clinical success was defined as a sustained (> 4 months) clinical resolution (patient discharged from the hospital without antibiotics and able to resume a normal diet) and radiological response. Patient records, radiological images, and the hospital endoscopy database were reviewed. RESULTS A total of 33 patients (26 women/7 men, mean age 42 years [SD 11.2]) were included. Collections occurred after sleeve gastrectomy (n = 28) or after gastric bypass (n = 5). Fourteen patients were treated by trans-fistulary stenting as primary treatment, and 19 patients had undergone previous unsuccessful endoscopic treatment. No serious complication occurred during the drainage procedure. Clinical success was achieved in 26 patients (78.8 %). In two successfully treated patients, stents are still in place. Spontaneous stent migration occurred in 12 patients. In 12 patients, the stents were removed, either electively (n = 5) or because of complications (ulcerations n = 3, upper gastrointestinal symptoms n = 3, splenic hematoma n = 1). CONCLUSIONS Trans-fistulary drainage of post-bariatric abdominal collections is safe and associated with high success rates. This technique can be considered in previously untreated patients, when a collection is not properly drained percutaneously, or after failure of other endoscopic treatments.

Enteral access in adults.

Enteral feeding is widely used for hospitalized patients but is also used for ambulatory persons living at home or in home care settings. Aside from decisions that must be made about appropriate nutrient delivery, choices related to which type of enteral access will be used and the procedures for enteral access surveillance are extremely important. In this paper we review the various techniques for establishment of enteral access in adult patients. Prevention and treatment of potential complications are detailed. The use of protocols that are written by a multidisciplinary nutrition team is mandatory. It is also of vital importance to discuss treatment plans with the patient and care givers, to assure appropriate follow-up, and to consider ethical issues related to enteral feeding.

Percutaneous endoscopic jejunostomy in patients with gastroparesis following lung transplantation: feasibility and clinical outcome.

The aim of the present study was to describe success rates, complications, and outcome in patients who underwent percutaneous endoscopic jejunostomy (PEJ) because of gastroparesis due to previous lung transplantation. Between October 2008 and May 2011, 14 attempts at PEJ placement were made in 12 patients in our center. Of the 14 attempts, 11 were successful, giving a technical success rate of 78.6 %. Median duration of followup was8.5 months (2–15 months). No immediate complications were reported. Two severe complications occurred during follow up (one volvulus and one jejunocolic fistula). Jejunal nutrition was well tolerated in most of patients (9 /10). PEJ insertion is a feasible technique, which could help to provide nutritional support for patients with gastroparesis and previous lung transplantation.

Pancreatic Tuberculosis Diagnosed by EUS: One Disease, Many Faces

CONTEXT Pancreatic/para-pancreatic tuberculosis is an extremely rare clinical entity even in endemic regions. It can present as a cystic or solid pancreatic mass mimicking pancreatic malignancy. There are no specific imaging criteria and the clinical symptoms remain vague. Therefore, most cases are diagnosed after surgical exploration for presumed pancreatic neoplasia. CASE REPORT We report five cases of pancreatic tuberculosis each time with a different clinical presentation, in an occidental country setting where the diagnosis was done by EUS guided FNA (EUS-FNA). CONCLUSION EUS-FNA is a safe and promising technique for the diagnosis of pancreatic/para-pancreatic tuberculosis, avoiding unnecessary surgery.

The use of enteral access for continuous delivery of levodopa-carbidopa in patients with advanced Parkinson’s disease

Background Continuous delivery to the jejunum of levodopa-carbidopa is a promising therapy in patients with advanced Parkinson’s disease, as it reduces motor fluctuation. Percutaneous endoscopic gastrostomy and jejunal tube (PEG-J) placement is a suitable option for this. However, studies focused in PEG-J management are lacking. Objectives We report our experience regarding this technique, including technical success, adverse events and outcomes, in patients with advanced Parkinson’s disease. Methods Twenty-seven advanced Parkinson’s disease patients (17 men, median age: 64 years, median disease duration: 11 years) were included in a retrospective study from June 2007 to April 2015. The median follow-up period was 48 months (1–96). Results No adverse events were noted during and after nasojejunal tube insertion (to assess treatment efficacy). After a good therapeutic response, a PEG-J was placed successfully in all patients. The PEG tube was inserted according to Ponsky’s method. The jejunal extension was inserted during the same procedure in all patients. Twelve patients (44%) experienced severe adverse events related to the PEG-J insertion, which occurred after a median follow-up of 15.5 months. Endoscopy was the main treatment modality. Patients who experienced severe adverse events had a higher comorbidity score (p = 0.011) but were not older (p = 0.941) than patients who did not. Conclusions While all patients responded well to levodopa-carbidopa regarding neurological outcomes, gastro-intestinal severe adverse events were frequent and related to comorbidities. Endoscopic treatment is the cornerstone for management of PEG-J related events. In conclusion, clinicians and endoscopists, as well as patients, should be fully informed of procedure-related adverse events and patients should be followed in centres experienced in their management.

Feasibility of Immunohistochemistry on Endoscopic Ultrasound Fine-Needle Aspiration Samples for Evaluating Predictive Biomarkers in Pancreatic Cancer Management.

either wedged into an intercalated duct cell line or the intercalated duct cell line branching off from that intercalated duct, and there was scant intercellular space without a PAM-stained membrane in portions between endocrine cells and adjacent acinar cells, as well as those intercalated duct cells. The interface portions with scant intercellular space between peripheral islet cells and adjacent peripheral exocrine glands noted in LM observations were also observed with TEM, which revealed a lack of space and no basement membrane (Figs. 1E–G).

P261: Prévalence de la dénutrition et du risque de dénutrition chez les patients oncologiques hospitalisés dans 3 hôpitaux bruxellois

Introduction et but de l’etude La denutrition est frequente chez les patients oncologiques. Elle est associee a une moindre qualite de vie, une toxicite accrue des traitements et un mauvais pronostic. Cependant, les donnees epidemiologiques disponibles actuellement reposent essentiellement sur des etudes realisees « un jour donne ». Le but de cette etude est de determiner la prevalence de la denutrition et du risque de denutrition en pratique courante chez des patients oncologiques hospitalises, et d’identifier des facteurs de risque d’alteration de l’etat nutritionnel. Materiel et methodes Les donnees de tous les patients hospitalises ayant eu une premiere evaluation nutritionnelle en 2012 et 2013 dans nos 3 hopitaux ont ete analysees de maniere retrospective. Le risque de denutrition est determine par des scores valides (NRS-2002, MNA ou MUST). La denutrition est definie selon les criteres de l’HAS ou sur base du PG-SGA. Des variables demographiques (âge, sexe), oncologiques (type de cancer et de traitement), anthropometriques (IMC) et relatives a l’alimentation (appetit, troubles de deglutition, besoin d’assistance) ont ete extraites des evaluations nutritionnelles et incorporees dans une analyse multiva-riee pour identifier les facteurs de risque d’alteration de l’etat nutritionnel. Resultats et Analyse statistique Au total, 2 106 evaluations etaient exploitables. Sur l’ensemble de la population, 53 % des patients etaient denutris et 33 % a risque de denutrition. Seuls 14 % des patients presentaient donc un etat nutritionnel normal. En analyse univariee, le type de tumeur etait significativement associe a un l’etat nutritionnel. Conformement a des observations publiees precedemment, une alteration de celui-ci se retrouve le plus souvent en cas de tumeur de la sphere ORL, de tumeur de l’appareil respiratoire ou de tumeur digestive et le moins souvent en cas de cancer du sein. Par contre, en analyse multivariee, ni le type de cancer, ni le type de traitement, ni l’âge du patient n’influencent l’etat nutritionnel. La perte d’appetit est le facteur qui augmente le plus le risque de denutrition avec un Odds Ratio (OR) de 8,5. Les autres facteurs de risque significatifs sont le besoin d’aide pour s’alimenter (OR 4,4), les troubles de deglutition (OR 3,6), un IMC inferieur a 18,5 (OR 2,5) et le sexe masculin (OR 1,6). Le surpoids (OR 0,46) et l’obesite (OR 0,36) sont quant a eux significativement associes a un meilleur etat nutritionnel. Pour 1374 patients, le moment de la premiere consultation dietetique etait documente. Seuls 14 % d’entre eux etaient evalues au moment du diagnostic, alors que 72 % etaient vus pour la premiere fois en cours de traitement, 7 % apres le traitement et 6 % alors qu’ils etaient en soins palliatifs. Conclusion Cette etude montre que l’immense majorite des patients oncologiques hospitalises presente une alteration de l’etat nutritionnel justifiant une prise en charge specifique. Seule une minorite d’entre eux beneficient d’une evaluation nutritionnelle precoce. L’etat nutritionnel de ces patients est principalement determine par des facteurs interferant directement avec la prise alimentaire, alors que des facteurs oncologiques comme le type de cancer ou de traitement sont probablement de moindre importance.