Mehdi Kaassis

Interobserver agreement on endoscopic diagnosis of bleeding peptic ulcers

BACKGROUND The aim of this prospective study was to evaluate the interobserver agreement of stigmata of recent hemorrhage of bleeding peptic ulcers. METHODS Sixty-one consecutive adult patients were enrolled in the study and nine (three junior and six senior) endoscopists reviewed standardized video recordings of endoscopic examinations. Interobserver agreement was evaluated using the kappa (kappa) index, intraclass correlation coefficient, and proportion of agreement. Observer bias and poorly trained observers were investigated. RESULTS Interobserver agreement was very good for oozing (kappa = 0.68), good for clot (kappa = 0.51), poor for spurting (kappa = 0.29) and visible vessels (kappa = 0.33), and excellent for the absence of stigmata (kappa = 0.82). Observer bias sometimes occurred and the number of poorly trained observers was low. The kappa indexes were significantly better in senior than in junior investigators: 0.48 +/- 0.16 versus 0.37 +/- 0.26, respectively, p < 0.05. The agreement between the in vivo evaluation and video tape recordings (intraobserver agreement) was good (kappa = 0.60 +/- 0.19). There was no training phenomenon between the first and the second half of the patient group. CONCLUSIONS The endoscopic classification of bleeding ulcers might be simplified by limiting grading to a few classes. Special attention should be paid to the training of endoscopists.

Hemodynamic effects of terlipressin and octreotide administration alone or in combination in portal hypertensive rats

BACKGROUND/AIMS The action sites and kinetic effects of octreotide and terlipressin may be different. Therefore, we studied the hemodynamic effects of acute administration of these drugs alone or in combination in rats with portal hypertension due to portal vein ligation. METHODS In a first study performed in anesthetized rats, hemodynamics were measured before and after drug administration (placebo, octreotide: 8 microg x kg(-1) x h(-1) for 30 min, terlipressin: 50 microg/kg bolus, terlipressin + octreotide at the same doses). The second study, performed in conscious rats, included the same groups and drug doses; hemodynamics were measured every 10 min for 1 h. The third study tested the effect of preinfusion of octreotide on responsiveness to terlipressin. RESULTS Terlipressin produced more marked systemic effects than octreotide by decreasing heart rate and cardiac output and increasing mean arterial pressure. Terlipressin produced a greater decrease in portal pressure than octreotide: placebo: -3+/-5%, terlipressin: -42+/-8%, octreotide: -16+/-10%, combination: -44+/-8% (conscious rats at 20 min, p<10(-4)). The decrease in portal pressure was immediate and lasted at least 60 min with both drugs. Octreotide significantly decreased spleno-renal shunt blood flow (% variation): placebo: -6+/-8, terlipressin: -15.5+/-20, octreotide: -22.5+/-20, combination: -27+/-10 (p<10(-2)). Octreotide preinfusion significantly increased the responsiveness of arterial pressure and heart rate to terlipressin. CONCLUSIONS Terlipressin decreases portal pressure significantly more than octreotide, while only octreotide significantly decreases collateral blood flow. Simultaneous administration of these drugs does not have significant additive effects but has complementary effects. The preadministration of octreotide alters systemic response to terlipressin.

Spleno-renal shunt blood flow is an accurate index of collateral circulation in different models of portal hypertension and after pharmacological changes in rats

BACKGROUND/AIMS Recently, we developed a new method to measure collateral blood flow in rats: splenorenal shunt (SRS) blood flow (BF). The aims were to evaluate the reproducibility of SRSBF measurement in different models of portal hypertension, and to investigate the ability of SRSBF to disclose pharmacological changes. METHODS Hemodynamics were determined in anesthetized rats with secondary biliary, CCl4 or DMNA cirrhosis and portal vein ligation (PVL) under baseline and pharmacological (octreotide, vapreotide) conditions. The main measurements performed were: SRSBF by the transit time ultrasound (TTU) method and % portosystemic shunts (PSS) by the microsphere method. RESULTS SRSBF was 6 to 10 times higher in portal hypertensive rats and was similar in the different models of cirrhosis but was higher in portal vein ligated rats than in cirrhotic rats (1.1+/-0.7 vs 0.6+/-0.7 ml x min(-1) x 100 g(-1), p=0.01). SRSBF was correlated with mesenteric %PSS (r=0.61, p<0.01), splenic %PSS (r=0.54, p<0.05), portal pressure (r= 0.32, p<0.05) and the area of liver fibrosis (r=0.33, p<0.05). Octreotide significantly decreased SRSBF (-23+/-20%, p<0.01 vs placebo: -6+/-8%, NS). Vapreotide significantly decreased SRSBF but not mesenteric or splenic %PSS compared to placebo. The variations in SRSBF (-26+/-32%) and in splenic %PSS (0+/-15%) with vapreotide were significantly different (p<0.05) and not correlated (r=-0.1, NS). CONCLUSIONS Determination of SRSBF by TTU is an accurate way to measure collateral blood flow in different models of intra- and extra-hepatic portal hypertension in rats. Its sensitivity provides accurate measurement of pharmacological changes, unlike the traditional estimation of %PSS by the microsphere method.

3535 Asa classification and lymph node extent at endosonography are independent predictive factors of survival of patients with esophageal cancer.

Although endoscopic ultrasonography (EUS) and CT-scan are frequently used to stage esophageal cancer, no multivariate study has confirmed their independent prognostic value. Aims.To isolate pretherapeutic prognostic factors of esophageal cancer and to calculate a simple predictive model of survival. Methods. 69 clinical, endoscopic, radiological, CT and EUS variables were prospectively collected in 110 patients with esophageal cancer from 1993 to 1996. A monovariate analysis was realized with a Cox model, then a first multivariate analysis eliminated redundant factors in each set of variables. The final multivariate analysis included all significant variables, with adjustment on the type of treatment given in a set of patients with a non stenotic tumor and in the overall set. Results. Monovariate analysis: 12 variables were related to the prognosis. Among these, the multivariate analysis isolated only 2 independent prognostic factors in cases of non stenotic tumors: the ASA classification (P=0.001 ; RR=2.5) and the number of mediastinal lymph nodes on EUS (p=0.0005 ; RR=1.2). By combining these 2 factors, a simple prognostic score was elaborated, distinguishing 3 sets of patients with different prognosis (see Table). In the overall set of patients, the analysis retrieved the same factors, but also the size of LN in the peri-aortic area and the LN status in the lower mediastinal area (N0, N1, Nx). However, this finding had a poor application in clinical practice. Conclusions. The prognosis of esophageal cancer can be simply predicted with one clinical factor and one EUS factor, independent of the type of treatment given and of CT scan. The systematic application of EUS in case of stenotic tumor is questionable. Predictive model of survival at 2 years as a function of ASA and number of lymph nodes at EUS ASA 1 ASA 2 ASA 3 No of LN=3 90 % 50 % 5 % No of LN >3 50 % 5 % 5 % LN : lymph nodes

4483 Argon plasma coagulation is an effective and well tolerated treatment for rectal bleeding due to chronic radiation proctitis.

The treatment of rectal bleeding due to radiation proctitis is difficult to manage. Argon Plasma Coagulation (APC) is a technique of electrocoagulation which appears to be an effective and low-cost alternative to laser therapy. Aims. Our aim was to evaluate the efficacy and tolerance of APC for treatment of bleeding radiation-induced proctitis. Patients. We retrospectively analyzed the charts of 16 patients with chronic radiation proctitis. The mean age was 73.5 years (range: 62-80). Primary tumor was a prostatic cancer (No=15) and a uterine cancer (No=1). The mean time of onset of symptoms after radiotherapy was 15 months (range: 6-36). All patients complained of intermittent or daily rectal bleeding, of whom 3 needed blood transfusions. After a first colonoscopic evaluation, the patients underwent APC therapy at 1 month intervals. Argon gas flow was set at 0.6 L/min with an electrical power of 40 Watts. Results. All patients were improved by APC and a mean of 3.7 sessions (range: 2-8) was necessary for symptoms relief. During a mean follow-up of 7 months (range: 2-21 months), rectal bleeding did not recur in 7 patients (43.7%); in the other 9 patients (56.3%), bleeding was significantly reduced to occasional and negligible spotting (1 bleeding episode per week). No patient required transfusion after treatment. Immediate tolerance was good and no long-term treatment-related complication was observed. Conclusions. APC is an effective, safe and well tolerated treatment for rectal bleeding due to chronic radiation proctitis and might be considered as a first-line therapy for radiation proctitis.

⁎4642 Plastic or metallic stents for inoperable malignant strictures of the common bile duct? results of a randomised prospective study.

The systematic use of metallic stents (MS) is hampered by their price compared to plastic stents (PS) in biliary obstruction. Aims. 1- to compare cost and efficacy of plastic stents (PS) and metallic stents (MS) in the treatment of inoperable malignant strictures of the common bile duct, 2- to define predictive factors of survival of patients with inoperable malignant biliary stricture. Patients. 118 patients (mean age 75 yrs) with an inoperable malignant stricture of the common bile duct were randomized to receive PS or MS. The characteristics of the 2 groups were comparable. Comparisons were made with chi-2 tests and survival rates compared with a Cox model. Results. There was no significant difference of survival between the 2 groups. Time for first obstruction was longer in patients with PS (median not reached vs 5 months, p=0.007). Number of additional days of hospitalization (173), of days with antibiotics (237), of ERCPs (20) and of abdominal ultrasonographies (18) were significantly higher in the group treated with PS. By multivariate analysis, 2 variables were independent prognostic factors of survival: the ASA classification (p=0.03 ; RR=1.5) and the number of liver metastases (p