Isabelle Boytchev

Endoscopy-associated transmission of carbapenem-resistant Klebsiella pneumoniae producing KPC-2 β-lactamase

Service de Bacteriologie-Virologie, INSERM U914: ‘Emerging Resistance to Antibiotics’, Hopital de Bicetre, Assistance PubliqueHopitaux de Paris, Universite Paris-Sud, 94275 Le Kremlin-Bicetre, France; Service d’Hepato-gastro-enterologie, Hopital de Bicetre, Assistance Publique-Hopitaux de Paris, Universite Paris-Sud, 94275 Le Kremlin-Bicetre, France; Service de chirurgie digestive, Hopital de Bicetre, Assistance Publique-Hopitaux de Paris, Universite ParisSud, 94275 Le Kremlin-Bicetre, France

Efficacy and safety of extracorporeal shock wave lithotripsy for chronic pancreatitis.

Abstract Introduction: There is still uncertainty regarding the efficacy and optimal modalities of extracorporeal shock wave lithotripsy (ESWL) in the treatment of chronic pancreatitis. The aims of the present study were to assess the safety and the efficacy of ESWL, either alone or followed by therapeutic endoscopic retrograde cholangiopancreatography (adjuvant ERCP) and to determine predictive factors of efficacy, in a real-life setting. Patients and methods: This study included all consecutive patients who underwent an ESWL in a single University Hospital between 2001 and 2012. The indication for ESWL was obstructive stone(s) of the main pancreatic duct resulting in either painful chronic pancreatitis or recurrent acute pancreatitis. Success was defined by resolution of pain, no analgesic treatment, no acute pancreatitis and no surgical treatment for chronic pancreatitis 6 months after the ESWL. Results: One hundred and forty-six patients were studied; 6/146 (4%) had a complication of ESWL. Among the 132 patients in whom follow-up was completed, 91 (69%) had an adjuvant ERCP. After 6 months of follow-up, 100/132 (76%) patients achieved success. In multivariate analysis, the single significant predictive factor of the success of the ESWL treatment was chronic pain (p = 0.03). Patients who had chronic pain and needed opioid treatment had less chance of success than patients without chronic pain (OR 95%CI 0.31 [0.07–1.14]). We found no difference in the success rates between patients who underwent adjuvant ERCP and those who had ESWL only (p = 0.93). Conclusion: This study shows that the ESWL is a safe and effective treatment for patients with chronic pancreatitis and obstructive stones within the main pancreatic duct. Systematic association with therapeutic ERCP appears to provide no additional benefit and is therefore not recommended.

Effects of biliary obstruction on the penetration of ciprofloxacin and cefotaxime.

Objective To evaluate the biliary penetration of ciprofloxacin and cefotaxime in patients with obstructed bile ducts and to determine simple predictive markers of effective biliary concentrations of these drugs. Methods Sixty-two patients treated with endoscopic biliary drainage were prospectively included in a nonrandomized way and received intravenous ciprofloxacin (200 mg twice daily) or cefotaxime (1 g three times a day) for more than 24 h before exploration. Blood and bile samples were collected at the time of drainage. Ciprofloxacin and cefotaxime concentrations were measured using high-performance liquid chromatography. Biliary penetration was assessed by the bile-to-plasma ratio of the concentrations of both antibiotics. Results Biliary penetration ranged from 0.06 to 42.7 for ciprofloxacin and from 0.01 to 1.14 for cefotaxime. The ratio was more than one in only 10 patients (35%) and three patients (9%) in ciprofloxacin and cefotaxime groups, respectively. Biliary concentration of the drug was more than 10 times the minimal inhibitory concentration in only 10 patients (35%) and in 12 patients (35%) in ciprofloxacin and cefotaxime groups, respectively. Serum bilirubin, alkaline phosphatase or gamma-glutamyl-transpeptidase were not good predictive markers of the biliary diffusion of the antibiotics. Conclusion In patients with obstructed bile ducts, the biliary penetration of ciprofloxacin is poor and reaches effective biliary concentrations in a minority of patients. Cefotaxime biliary penetration is even poorer. No liver test can predict accurately the biliary penetration of the drugs.

La thérapie photodynamique en gastroentérologie: quoi de neuf en 2009 ?

RésuméEn gastroentérologie, la thérapie photodynamique (PDT) est un traitement anti-néoplasique qui repose sur la destruction d’un tissu tumoral, sensibilisé par un photosensibilisant administré par voie générale, par une lumière laser. Le Photofrin® (Axcan Pharma, Canada) est le photosensibilisant le plus utilisé. L’illumination laser, sans effet thermique, est délivrée circonférentiellement par un diffuseur cylindrique à l’extrémité d’une fibre optique passée dans le canal opérateur d’un endoscope. Après concertation multidisciplinaire, les cancers superficiels de l’œsophage chez des patients inaccessibles à un autre traitement, avec une récidive post-radiothérapie, la dysplasie sévère en muqueuse de Barrett, et le cholangiocarcinome inopérable, dans le but de prolonger la survie des patients traités palliativement par drainage biliaire, sont ses principales indications. Notre propos est de discuter les modalités et les résultats de la PDT dans le but d’optimiser sa réalisation.AbstractIn gastroenterology, photodynamic therapy is an anti-neoplastic treatment based on photosensitization of neoplasms, following the administration of a photosensitizer, prior to laser light-induced tissue destruction. Photofrin® (Axcan Pharma, Canada) is the photosensitizer usually used. Light is delivered circumferentially at subthermal threshold rates using cylindrical diffusing quartz fibre, usually passed through the channel of an endoscope under general anaesthesia. After a pluridisciplinary meeting, superficial oesophageal cancers in patients that are unsuitable for any other treatment, with a recurrence after radiotherapy, severe dysplasia in Barrett’s oesophagus and cholangiocarcinoma unfit for surgery, with the aim of prolonging life in patients treated with palliative biliary prosthesis, are its main indications. This paper aims to discuss its modalities and results in order to achieve PDT in the best possible conditions.