Jacques Devière

Interleukin-10 production during septicaemia

Interleukin-10 is produced during incubation of human whole blood with bacterial lipopolysaccharide (LPS) and down-regulates tumour necrosis factor-alpha production in this in-vitro model of endotoxaemia. 39 out of 69 (57%) patients with gram-negative (n = 25) or gram-positive septicaemia (n = 44) had increased plasma interleukin-10 (range 12-2740 pg/mL), whereas interleukin-10 was undetectable in 29 out of 33 control patients without infection and in 20 healthy volunteers. Patients with septic shock (n = 21) had higher interleukin-10 (main 58 pg/mL) than septicaemic patients without shock (11 pg/mL, p < 0.001). We conclude that interleukin-10 is produced during sepsis and might be involved in the control of the inflammatory response induced by bacterial products.

Endoscopic management of cysts and pseudocysts in chronic pancreatitis: long-term follow-up after 7 years of experience

Endoscopic cystoenterostomy was performed in 33 patients with chronic pancreatitis. Endoscopic cystoduodenostomy (ECD) was done in 22 cases of symptomatic paraduodenal cysts and endoscopic cystogastrostomy (ECG) in 11 cases of retrogastric pseudocysts. The success rates were 96% for ECD and 100% for ECG. The relapse rate was 9% after ECD and 19% after ECG. No significant complications were observed after successful ECD and clinical relief of pain was achieved in 20 patients. ECD was an effective and definitive treatment for 19 of the 22 cases. Two complications of ECG were gastric hemorrhage and iatrogenic pseudocyst infection. In two ECG patients, percutaneous drainage was required. ECG alone was a definitive treatment for 8 of the 11 cases. When restricted to the precise morphological indication (paraintestinal cyst bulging into the duodenal or gastric lumen), ECD is the first choice for treatment of paraduodenal cysts, whereas ECG is an alternative procedure for the drainage of retrogastric pseudocysts, offering at least results as good as percutaneous drainage.

Long-term follow-up of patients with hilar malignant stricture treated by endoscopic internal biliary drainage

Seventy patients with biliary obstruction secondary to hilar tumors underwent attempted endoscopic internal biliary drainage using large transpapillary stents between December 1981 and March 1986. Placement of one or more stents was successful in 68. The type of stricture and mode of treatment were more important in determining subsequent survival than the type of tumor. In type II and III malignant strictures of the bifurcation of the common hepatic duct and the main hepatic duct, use of two or more stents to achieve complete drainage of the biliary system improves survival compared to incomplete drainage (176 vs. 119 days) and reduces procedure-related mortality and the incidence of early and late cholangitis. Patients with hilar tumors causing type II and III strictures treated with placement of multiple stents have at least as good a prognosis as patients with tumor involving only the common hepatic duct treated with use of a single stent. Once ERCP is performed and palliative endoscopic management of bifurcation tumors is begun, it must completed as soon as possible.

Efficacy of Radiofrequency Ablation Combined With Endoscopic Resection for Barrett's Esophagus With Early Neoplasia

BACKGROUND & AIMS Radiofrequency ablation (RFA) is safe and effective for eradicating intestinal metaplasia and neoplasia in patients with Barretts esophagus. We sought to assess the safety and efficacy of RFA in conjunction with baseline endoscopic resection for high-grade intraepithelial neoplasia (HGIN) and early cancer. METHODS This multicenter, prospective cohort study included 24 patients (mean age, 65 years; median Barretts esophagus, 8 cm), with Barretts esophagus of < or =12 cm containing HGIN or early cancer, from 3 European tertiary-care medical centers. Visible lesions were endoscopically resected, followed by serial RFA. Focal escape endoscopic resection was used if Barrett tissue persisted despite RFA. Complete response, defined as all biopsies negative for intestinal metaplasia and neoplasia, was assessed during endoscopy with 4-quadrant biopsies taken every 1 cm of the original Barretts segment 2 months after the patient was last treated. RESULTS Twenty-three patients underwent pre-RFA endoscopic resection for visible lesions; 16 patients had early cancer and 7 patients had HGIN. The worst residual histology results, pre-RFA (after any endoscopic resection) were: HGIN (10 patients), low-grade intraepithelial neoplasia (11 patients), and intestinal metaplasia (3 patients). Neoplasia and intestinal metaplasia were eradicated in 95% and 88% of patients, respectively; after escape endoscopic resection in 2 patients, rates improved to 100% and 96%, respectively. Complications after RFA included melena (n = 1) and dysphagia (n = 1). After additional follow-up (median, 22 months; interquartile range, 17.2-23.8 months) no neoplasia recurred. CONCLUSIONS This European multicenter study to show that early neoplasia in Barretts esophagus can be effectively and safely treated with RFA, in combination with prior endoscopic resection of visible lesions.

Capsule endoscopy versus colonoscopy for the detection of polyps and cancer.

BACKGROUND An ingestible capsule consisting of an endoscope equipped with a video camera at both ends was designed to explore the colon. This study compared capsule endoscopy with optical colonoscopy for the detection of colorectal polyps and cancer. METHODS We performed a prospective, multicenter study comparing capsule endoscopy with optical colonoscopy (the standard for comparison) in a cohort of patients with known or suspected colonic disease for the detection of colorectal polyps or cancer. Patients underwent an adapted colon preparation, and colon cleanliness was graded from poor to excellent. We computed the sensitivity and specificity of capsule endoscopy for polyps, advanced adenoma, and cancer. RESULTS A total of 328 patients (mean age, 58.6 years) were included in the study. The capsule was excreted within 10 hours after ingestion and before the end of the lifetime of the battery in 92.8% of the patients. The sensitivity and specificity of capsule endoscopy for detecting polyps that were 6 mm in size or bigger were 64% (95% confidence interval [CI], 59 to 72) and 84% (95% CI, 81 to 87), respectively, and for detecting advanced adenoma, the sensitivity and specificity were 73% (95% CI, 61 to 83) and 79% (95% CI, 77 to 81), respectively. Of 19 cancers detected by colonoscopy, 14 were detected by capsule endoscopy (sensitivity, 74%; 95% CI, 52 to 88). For all lesions, the sensitivity of capsule endoscopy was higher in patients with good or excellent colon cleanliness than in those with fair or poor colon cleanliness. Mild-to-moderate adverse events were reported in 26 patients (7.9%) and were mostly related to the colon preparation. CONCLUSIONS The use of capsule endoscopy of the colon allows visualization of the colonic mucosa in most patients, but its sensitivity for detecting colonic lesions is low as compared with the use of optical colonoscopy. (ClinicalTrials.gov number, NCT00604162.)

Intramucosal adenocarcinoma arising under squamous re-epithelialisation of Barrett's oesophagus.

BACKGROUND Eradication of Barretts mucosa by thermal or photoablation combined with high doses of proton pump inhibitors is a potentially attractive strategy in the management of this preneoplastic condition. However, major concerns of this method are the persistence of residual metaplastic glands beneath the new squamous epithelium and the absence of any knowledge of its impact on long term outcome. CASE REPORT The case of an intramucosal adenocarcinoma diagnosed 18 months after apparently complete squamous re-epithelialisation achieved using argon plasma coagulation and high dose omeprazole (40 mg/daily) is reported in a 68 year old patient presenting initially with a Barretts oesophagus without dysplasia. Intramucosal adenocarcinoma was located under the new squamous layer and presented as a bulging area covered by the squamous epithelium. It probably originates from residual metaplastic glands after therapy although a pre-existing tumour cannot be definitely excluded. CONCLUSION This observation might question future application of this experimental endotherapy in non-dysplastic Barretts oesophagus. It suggests that the residual glands might still be premalignant and that the early diagnosis of neoplastic changes might be compromised by the squamous re-epithelialisation.

The interleukin‐17 pathway is involved in human alcoholic liver disease

Immune dysregulations in alcoholic liver diseases are still unclear, especially regarding alcoholic hepatitis inflammatory burst. Interleukin‐17 (IL‐17) is known to enhance neutrophil recruitment. We studied the IL‐17 pathway in alcoholic cirrhosis and alcoholic hepatitis. Patients with alcoholic liver disease were compared with patients with chronic hepatitis C virus (HCV) infection or autoimmune liver disease and with healthy controls. IL‐17 plasma levels and peripheral blood mononuclear cell secretion were assessed by enzyme‐linked immunosorbent assay (ELISA) and T cell phenotype by flow cytometry. IL‐17 staining and co‐staining with CD3 and myeloperoxidase were performed on liver biopsy specimens. IL‐17 receptor expression was studied on liver biopsies and in human hepatic stellate cells as well as their response to recombinant IL‐17 by chemotaxis assays. IL‐17 plasma levels were dramatically increased in alcoholic liver disease patients. Peripheral blood mononuclear cells of patients with alcoholic liver disease produced higher amounts of IL‐17, and their CD4+ T lymphocytes disclosed an IL‐17–secreting phenotype. In the liver, IL‐17–secreting cells contributed to inflammatory infiltrates in alcoholic cirrhosis, and alcoholic hepatitis foci disclosed many IL‐17+ cells, including T lymphocytes and neutrophils. In alcoholic liver disease, liver IL‐17+ cells infiltrates correlated to model for end‐stage liver disease score, and in alcoholic hepatitis to modified discriminant function. IL‐17 receptor was expressed in alcoholic liver disease by hepatic stellate cells, and these cells recruited neutrophils after IL‐17 stimulation in a dose‐dependent manner through IL‐8 and growth related oncogen α (GRO‐α) secretion in vitro. Conclusion: Human alcoholic liver disease is characterized by the activation of the IL‐17 pathway. In alcoholic hepatitis, liver infiltration with IL‐17–secreting cell infiltrates is a key feature that might contribute to liver neutrophil recruitment. (Clinical trials number NCT00610597). (HEPATOLOGY 2009;49:646–657.)

European Society of Gastrointestinal Endoscopy (ESGE) Guideline: Prophylaxis of post-ERCP pancreatitis

Pancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). Risk factors for post-ERCP pancreatitis (PEP) are both patient-related and procedure-related. Identification of patients at high risk for PEP is important in order to target prophylactic measures. Prevention of PEP includes administration of nonsteroidal inflammatory drugs (NSAIDs), use of specific cannulation techniques, and placement of temporary pancreatic stents. The aim of this guideline commissioned by the European Society of Gastrointestinal Endoscopy (ESGE) is to provide practical, graded, recommendations for the prevention of PEP.

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.

Biliary stenting: indications, choice of stents and results: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline.

This article is part of a combined publication that expresses the current view of the European Society of Gastrointestinal Endoscopy about endoscopic biliary stenting. The present Clinical Guideline describes short-term and long-term results of biliary stenting depending on indications and stent models; it makes recommendations on when, how, and with which stent to perform biliary drainage in most common clinical settings, including in patients with a potentially resectable malignant biliary obstruction and in those who require palliative drainage of common bile duct or hilar strictures. Treatment of benign conditions (strictures related to chronic pancreatitis, liver transplantation, or cholecystectomy, and leaks and failed biliary stone extraction) and management of complications (including stent revision) are also discussed. A two-page executive summary of evidence statements and recommendations is provided. A separate Technology Review describes the models of biliary stents available and the stenting techniques, including advanced techniques such as insertion of multiple plastic stents, drainage of hilar strictures, retrieval of migrated stents and combined stenting in malignant biliary and duodenal obstructions.The target readership for the Clinical Guideline mostly includes digestive endoscopists, gastroenterologists, oncologists, radiologists, internists, and surgeons while the Technology Review should be most useful to endoscopists who perform biliary drainage.