Marc Giovannini

Treatment of peritoneal carcinomatosis from colorectal cancer: impact of complete cytoreductive surgery and difficulties in conducting randomized trials.

BackgroundColorectal peritoneal carcinomatosis (PC) is a frequent and very lethal event. However, cure may be possible with maximal cytoreductive surgery associated with early postoperative intraperitoneal chemotherapy (EPIC).MethodsBetween 1996 and 2000, we conducted a two-center prospective randomized trial comparing EPIC plus systemic chemotherapy with systemic chemotherapy alone, both after complete cytoreductive surgery of colorectal PC. Only 35 patients could be included among the 90 who were theoretically required, mainly because of patient dissatisfaction with the inclusion criteria. For this reason, the trial was stopped prematurely.ResultsAnalysis of these 35 patients showed that complete resection of PC resulted in a 2-year survival rate of 60%—far above the classic 10% survival rate among patients with colorectal PC treated with systemic chemotherapy and symptomatic surgery. In this small series, EPIC did not demonstrate any advantage for survival.ConclusionsThis supports the use of complete cytoreductive surgery in selected patients and calls for a prospective randomized trial comparing adjuvant systemic chemotherapy with intraperitoneal chemohyperthermia after complete resection.

EUS-FNA predicts 5-year survival in pancreatic endocrine tumors.

BACKGROUND Pancreatic endocrine tumors (PETs) differ in clinical behavior and prognosis. Determination of malignant potential through specimens obtained by EUS-FNA can help in the management of these patients. OBJECTIVE To determine the value of EUS-FNA for diagnosing PETs and for classifying their underlying malignant potential based on the World Health Organization (WHO) classification. DESIGN Single-center, retrospective, cohort study. SETTING Tertiary referral hospital. PATIENTS This study involved 86 consecutive patients (44 men, mean age 58 +/- 14 years) who had been diagnosed with PETs and submitted to EUS-FNA from January 1999 to August 2008. INTERVENTION EUS-FNA of a pancreatic mass and/or a metastasis site. Immunohistochemistry on microbiopsies or on monolayer cytology was routinely used. The lesions were classified as recommended by the WHO. MAIN OUTCOME MEASUREMENTS EUS-FNA sensitivity and 5-year survival rate. RESULTS Overall, in 90% (77 of 86) of patients in this study, PET was diagnosed with EUS-FNA. The sensitivity did not vary with tumor size, type, location, or the presence of hormonal secretion. Of 86 patients, 30 (35%) were submitted to surgical resection. The kappa correlation index between the WHO classification obtained by EUS-FNA and by surgery was 0.38 (P = .003). Major discrepancies were found in the group of patients diagnosed with endocrine tumor of uncertain behavior by EUS-FNA, because 72% turned out to have well-differentiated endocrine carcinoma. Sixteen patients (27%) died during a mean follow-up period of 34 +/- 27 months. The 5-year survival rates were 100% for endocrine tumors, 68% for well-differentiated endocrine carcinomas, and 30% for poorly differentiated endocrine carcinomas (P = .008, log-rank test). LIMITATIONS Retrospective design, selection bias, and small sample size. CONCLUSIONS This largest single-center experience to date demonstrated the accuracy of EUS-FNA in diagnosing and determining the malignant behavior of PETs. EUS-FNA findings predict 5-year survival in patients with PETs.

Cost of radiofrequency ablation in the treatment of hepatic malignancies.

OBJECTIVES Our primary objective was to assess the cost of radio-frequency ablation (RFA) of hepatic malignancies and to compare it to hospital reimbursement paid in the French Prospective Payment System (PPS). PATIENTS AND METHODS A series of 305 patients were enrolled into a prospective study. All resources used during the RFA-related hospital stay were recorded. Costs were assessed from the perspective of the health care providers and computed for four groups of patients: percutaneous RFA in an outpatient setting (group Ia, N=44), percutaneous RFA in an inpatient setting (group Ib, N=94), laparoscopic RFA (group II, N=44) and intraoperative RFA combined with resection (group III, N=120). RESULTS Mean hospital costs were estimated at euro 1581 (group Ia), euro 3824 (group Ib), euro 8194 (group II) and euro 12967 (group III). Costs per stay without intensive care in these groups were respectively euro 1581, euro 3635, euro 6622 and euro 10905 and reimbursement (intensive care excluded) was euro 560, euro 3367, euro 9084 and euro 11780. CONCLUSION In the French PPS, the cost of RFA is covered by lump sums paid to hospitals exclusively for intraoperative and laparoscopic RFA. For percutaneous RFA, which is the most frequent approach, reimbursement is highly insufficient.

Treatment of pancreatic pseudocyst and pancreatic abscess using a therapeutic endoscopic ultrasound device.results in 18 patients

The purpose of this study is to evaluate a new technic of cystogastro or duodenostomy for pancreatic pseudo-cyst (PPC) or pancreatic abscesses (PA) entirely guided by endoscopic ultrasound (BUS) and using interventional echoendoscopes. Patients and methods : A cystogastrostomy was performed in 17 patients and a cystoduodenostomy in 1 patient for 7 PPC and II PA. For 16/17 patients, the gastroscopy did not reveal extrinsic compression allowing selection of the puncture site. The origin of the PPC was an alcoholic chronic pancreatitis in 3 cases and an acute pancreatitis due to lithiasis in 2 cases and a hyperlipidemia in 2 cases. The origin of the 11 PA was post-operative acute pancreatitis. The mean size of the 17 pancreatic cysts was respectively 7.5 ern (410 cm).The EUS device was the FG 38X manufactured by Pentax-Hitachi. The FG 38X is an interventional echoendoscope with a working channel of 3.2 mm of diameter .Technique of EUS guided cystogastrostomy : 1/locating the PPC and the contact zone between the gastric wall and the cyst wall. 2/ Color doppler assessment of the stomach wall showed no vascularization in this contact zone 3/ A needle-knife was introduce through the working channel and used to performed EUS guided transgastric puncture of the cyst 4/ The metal part of the needle-knife was withdrawn leaving the teflon catheter in the cyst 5/ A guide wire is introduce through the teflon catheter in the cyst 6/ Under this guide-wire a 6.5 or 7 F naso-cystic drain or a 8.5 F stent was placed within the cyst. Results : No complication occurred. The placement of the nasocystic drain or the 8.5 F stent was successful respectively in 11/12 cases and 5/5 cases. The drain was removed after 5 -10 days and the stent 3 months later. In one case, it was no possible to place the drain and only an aspiration was performed. One recurrence of the 7 pseudo-cyst and 2 relapses of the 11 PA have been observed with a mean follow-up of 24 months (14-32 months).Conclusion : This experience suggest that this technique allows more accurate drainage of the PPC or PA without extrinsic compression with a lower risk of perforation and haemorrhage.

Diagnostic and therapeutic value of the endoscopic ultrasound (EUS) guided biopsy. Results in 522 patients

The aim of this study was to evaluate the impact of the EUS-guided biopsy in the diagnostic approach and the therapeutic decision. Patients and methods: From January 1992 to November 1997, 522 patients (317 men and 205 women) with a mean age of 68.7 years (range: 15-78 years) underwent an EUS-guided biopsy for mediastinal mass or lymph nodes in 119 cases, sus mesocolic lymph nodes in 72 cases, peri-rectal or peri-colonic lymph nodes or masses in 40 cases, pancreatic tumors in 186 cases, large gastric folds with negative endoscopic biopsy in 31 cases, small liver metastasis in 33 cases, sub-mucosal tumors in 16 cases, adrenal metastasis in 6 cases, ascitis and pleura| effusion in 15 cases and gallbladder tumors in 4 cases. The EUS endoscopes used are the FG 32UA, the FG-36X, the EG-36-30 and the FG 38-X manufactured by Pentax. Results. Patient tolerance was excellent, Five complications (0.9%) were observed: 3 episodes of fever disappearing with antibiotics, 2 acute pancreatitis without complications. The sensitivity, the specificity, the positive predictive value, the negative predictive value and the accuracy of the EUS-guided biopsy for the diagnosis of malignancy were 83.2%, 99.1%, 99.7%, 62.8% and 87.7% respectively. With regards to the diagnostic approach, the EUS-guided biopsy has allowed to make a diagnosis without having recourse to an invasive technique (mediastinoscopy or laparotomy) in 208 cases (39.8%). For the therapeutic attitude, the EUS-guided biopsy reassessed the stage of the esophageal, gastric, pancreatic and rectal tumor in 65 cases. Moreover, the EUS-guided biopsy has modified the treatment of pancreatic tumor in 19 cases showing a neuroendocrine lesion. Conclusion: in this study, the EUS-guided biopsy has modified the diagnostic and the therapeutic approach in 292/522 cases (55.9%) especially for the isolated mediastinal or abdominal lymph nodes or masses, the pancreatic tumor and for the distant lymph nodes staging of GI cancer.

EUS-Guided Bilio-Pancreatic Drainage

EUS-guided biliary drainage is an option to treat obstructive jaundice when ERCP drainage fails. This procedure is an alternative to surgical and percutaneous transhepatic biliary drainage, and only possible with the continuous development and improvement of EUS scopes and accessories. The development of linear array EUS scopes in the early 1990s brought a new approach to diagnostics and a therapeutic dimension to EUS capabilities, opening the possibility to perform punctures under direct EUS guidance. Despite the high success rate and low morbidity of biliary drainage obtained by ERCP, difficulty can occur in the presence of stent tumor ingrowth, tumor obstructing the intestinal lumen, periampullary diverticula and anatomic variation. The EUS technique starts with performing the puncture and contrast injection of the left biliary tree. From the duodenum, a direct common bile duct puncture is performed. Dilatation of the punctured tract is required using a bougie or balloon dilator and a plastic or metallic stent is introduced. The technical success of hepaticogastrostomy is near 98 %, and complications occur in 20 %. To prevent bile leakage we have used the 2 stent technique: the first stent introduced is a long uncovered metallic stent (8 or 10 cm) and a second fully covered stent (6 cm) is deployed within the first stent to bridge the bile duct and the stomach. The overall success rate of choledochoduodenostomy is 92 % with complications in 14 %. Over the last 10 years, this technique has been mainly performed in referral centers by groups experienced in ERCP, and this seems to be a general guideline for safer execution of this procedure.

Endomicroscopie confocale intra-ductale (EMID) : résultats d’une étude de phase I-II chez des patients présentant une sténose de la voie biliaire principale

L’endomicroscopie est l’adaptation en endoscopie digestive de la microscopie optique traditionnelle, grâce a l’integration de microscopes miniaturises permettant l’etude de la muqueuse digestive a l’echelon cellulaire. Du point de vue technique, il s’agit d’illuminer lamuqueuse digestive prealablementmarquee par une molecule fluorescente a l’aide d’un laser argon de faible puissance, et de selectionner les photons provenant du meme plan focal dans une zone d’interet, afin de creer une section optique de cette zone d’interet.

Echo-endoscopie : comment j'explore le pancréas

RésuméL’exploration du pancréas par échoendoscopie que ce soit avec une sonde linéaire ou circulaire nécessite une technique rigoureuse et systématique. Nous rapportons dans cet article la technique d’exploration en utilisant une sonde linéaire sagittale et celle utilisant une sonde circulaire transversale.SummaryThe EUS examination of the pancreas need a very precise technique even to use radial or linear EUS probe. We report in this paper the different tricks using curvay linear or transversal radial probe.