Philippe Lévy

Diagnosis of choledocholithiasis by endoscopic ultrasonography

BACKGROUND/AIMSnEndoscopic ultrasonography is a promising procedure for the diagnosis of extrahepatic cholestasis. Accuracy for the diagnosis of choledocholithiasis by ultrasonography and computed tomography were prospectively compared with endoscopic ultrasonography in 62 consecutive patients.nnnMETHODSnFinal diagnosis was determined by endoscopic retrograde cholangiography with or without sphincterotomy or intraoperative cholangiography with or without choledochoscopy. All of the patients had abdominal ultrasonography, computed tomography, endoscopic ultrasonography, and either an endoscopic retrograde (n = 40) or intraoperative cholangiography (n = 32) performed.nnnRESULTSnCholedocholithiasis was confirmed in 22 patients. Thirteen patients had a stone with a diameter < 1 cm, and 14 had a nonenlarged common bile duct. Endoscopic ultrasonography was more sensitive (97%) than ultrasonography (25%; P < 0.0001) and computed tomography (75%; P < 0.02). Specificity and positive predictive value were not significantly different. Negative predictive value of endoscopic ultrasonography (97%) was better than that of ultrasonography (56%; P < 0.0001) and computed tomography (78%; P < 0.02). Results were unchanged after six patients in whom the absence of choledocholithiasis was considered probable after follow-up were excluded. Endoscopic ultrasonography results did not depend on stone diameter or common bile duct dilatation.nnnCONCLUSIONSnEndoscopic ultrasonography appears to be the best diagnostic tool for the diagnosis of choledocholithiasis compared with other noninvasive procedures.

Splenic and portal venous obstruction in chronic pancreatitis. A prospective longitudinal study of a medical-surgical series of 266 patients.

The aim of this study was a prospective search for splenoportal venous obstruction (SPVO) in a medical-surgical series of 266 patients with chronic pancreatitis who were followed up a mean time of 8.2 years. SPVO was systematically searched for using ultrasonography and then confirmed by angiography or computed tomography. SPVO was found in 35 patients (13.2%) but was symptomatic in only two. Initial obstruction involved the splenic vein in 22 patients, the portal vein in 10, and the superior mesenteric vein in three. Since venous obstruction extended from the splenic to the portal vein in five patients, the prevalence of portal obstruction was 5.6% (15/266). Acute pancreatitis and pseudocysts were the probable cause of SPVO in 91.4% of our cases. Half the cases of splenic venous obstruction were related to pseudocysts of the caudal pancreas. Esophageal varices were found in two patients and gastric varices in four at the time of diagnosis and during follow-up. At the end of follow-up, 12 patients had undergone splenopancreatectomy (N=11) or splenectomy (N=1). Only one patient was operated on for massive esophageal variceal bleeding, and another patient died due to intractable colic variceal bleeding. In four of six patients operated on with portal vein obstruction, surgery was difficult due to venous collaterals. Ten patients were not operated on and 13 patients operated on were not treated for SPVO. The mean follow-up after diagnosis of SPVO for these final 23 patients was 28.9 months. None of these patients bled. We concluded that in chronic pancreatitis: (1) the prevalence of SPVO is 13.2%; (2) SPVO should be systematically searched for in patients with acute pancreatitis or pseudocysts, especially if therapeutic decisions would be modified by a diagnosis of SPVO; (3) the risk of digestive variceal bleeding is lower than previously reported; and (4) portal vein obstruction seems to be riskier than splenic vein obstruction, especially if surgery is needed.

Serum levels of pancreatitis-associated protein as indicators of the course of acute pancreatitis

BACKGROUND/AIMSnThe pancreatitis-associated protein (PAP) is undetectable in normal pancreatic secretion and overexpressed in the acute phase of pancreatitis. We investigated whether serum PAP could be an indicator of the course of acute pancreatitis.nnnMETHODSnSerum PAP was retrospectively monitored in 98 patients with acute pancreatitis during their stay in the hospital. Patients were classified according to the severity of their disease as group I (< or = 1 complication), group II (> or = 2 complications), or group III (lethal pancreatitis).nnnRESULTSnAt admission, 34% of patients, all from group I, had normal PAP values (< 10 micrograms/L). None of them developed complications. They had a significantly shorter stay in the hospital than patients with elevated PAP (6.2 days vs. 14.9 days). In all patients, serum PAP increased after admission to a maximum, which correlated significantly to the severity of the disease. Average peak values were 22.2 micrograms/L and 240.0 micrograms/L in group I patients with normal or high PAP at admission, 963.0 micrograms/L and 1436.0 micrograms/L in groups II and III. Serum PAP decreased steadily during recovery.nnnCONCLUSIONSnMonitoring serum PAP in patients with acute pancreatitis would provide (1) at admission, selection of most patients who will not develop complications; (2) a dynamic assessment of severity; and (3) anticipation of the patients recovery.

Detection of serum HBV-DNA by polymerase chain reaction (PCR) in patients before reactivation of chronic hepatitis B

Reactivation of chronic hepatitis B is characterized by the reappearance of HBV-DNA in serum. The purpose of the study was to determine whether, before reactivation, HBV-DNA would be detectable in serum, using a sensitive procedure of detection, namely polymerase chain reaction (PCR). We studied 17 patients with chronic hepatitis B who experienced an episode of reactivation, defined by the reappearance of HBV-DNA in serum. None of these 17 sera had HBV-DNA demonstrable by dot-blot hybridization nor liquid hybridization in sera collected before reactivation. Using PCR, HBV-DNA was detected, before reactivation, in 13 of the 17 episodes of reactivation tested with Southern-blot and hybridization. HBV-DNA was not detectable with PCR in the serum of four patients who subsequently experienced an episode of reactivation. In conclusion, our results show low level HBV replication before reactivation in most, but not all, HBs-positive, HBV-DNA-negative patients. This suggests that reactivation may occur even in patients with no HBV-DNA demonstrable in serum with PCR prior to reactivation.

Acute infusions of bile salts increase biliary excretion of iron in iron-loaded rats

The mechanisms of biliary excretion of iron are not well known. The aim of this study was to examine the effect of choleresis induced by several agents on biliary iron excretion in iron-loaded rats. Iron overload was obtained with a diet supplemented by 3% iron carbonyl during a 6-week period. Bile was collected with an external bile fistula. Biliary iron concentration was measured by atomic absorption spectrophotometry, and hepatic iron concentration was measured by a chemical method. Compared with controls, iron overload resulted in a 14-fold increase in hepatic iron concentration but only a 3.9-fold increase in biliary iron output. In iron-loaded rats, taurocholate infusion caused a 1.8-fold significant increase in biliary iron output. Dehydrocholate, given at the same dose, induced a significant but less pronounced (1.3-fold) increase in biliary iron output in spite of a higher bile flow. Taurochenodeoxycholate, tauroursodeoxycholate, and tauro-7-ketolithocholate induced an increase in biliary iron output similar to that observed with taurocholate. The canalicular bile salt-independent choleretic dihydroxydibutyl ether caused a significant but less pronounced increase in biliary iron output (1.4-fold). These results confirm that in iron-loaded rats biliary iron excretion is increased much less than hepatic iron concentration. They show that in iron loaded rats (a) bile salts can increase biliary iron secretion, and (b) this increase is related in part to choleresis and in part to bile salts themselves. This increase may be related to an interaction of iron with bile salt monomers and/or micelles.

Traité de pancréatologie clinique

Louvrage ,, bactEries lactiques et probiotiques ~, Edit6 par Franqois Marie Luquet et Georges Corrieu aborde les applications des bactEries lactiques dans les produits laitiers frais (yaourts simples et produits aux propriEtEs probiotiques), les aspects rEglementaires et les allegations que ces produits peuvent utiliser en Europe (celles sur les maladies Etant ~ ce jour interdites m~me en presence de preuves scientifiques afin de garder une frontiEre entre aliments et mEdicaments) et les effets cliniques des probiotiques incluant un chapitre sur limmunitE et un sur la santE cardiovasculaire. PrEcis et bien rEfErencE, cet ouvrage est une bonne base pour le mEdecin, le chercheur et lindustriel intEressEs par les applications alimentaires, preventives ou curatives des bactEries lactiques et par une vision prospective.

Comment on: Enucleation: A treatment alternative for branch duct intraductal papillary mucinous neoplasms

To the Editors: We read with interest the article by Kaiser et al. regarding one of the “hot” and controversial topics in the treatment of intraductal papillary mucinous neoplasms of the pancreas (IPMN): management of small asymptomatic branch-duct IPMN. Analyzing their experience with 115 patients planned for enucleation and operated on during a 10-year period, they concluded that enucleation, when possible, should be considered instead of standard resections as an important, function-preserving alternative. The present study emphasizes previous experience, including that from our group. In our study of 91 patients published in 2014, we demonstrated that enucleation---but more widely parenchyma-sparing pancreatectomies, including enucleation, resection of the nuncinate process (also called an inferior pancreatic head resection) and central pancreatectomy can be performed safely for presumed noninvasive IPMN with a favorable anatomic location. To go beyond their results, we would like to point out the 36% technical failure rate of planned enucleation, leading to a standard anatomic resection. Half (51%) of the conversions were for cephalic lesions, which led to the need for pancreatoduodenectomy. In view of the high mortality reported nationwide, as high as 10% in Germany, we believe that technical failure of enucleation should be as low as possible to avoid unnecessary standard pancreatectomy, especially pancreatoduodenectomy. Because the natural history of branch-duct IPMN remains difficult to predict and the disease seems mostly to be indolent, even when presenting with some “worrisome” features, the risk/benefit of pancreatectomy for noninvasive lesions is questionable, especially in high-risk patients or in the case of disease associated with a low risk of malignant transformation. In such a setting, we believe that advising enucleation for branch-duct IPMN with a 36% rate of technical failure leading to pancreatoduodenectomy in right-sided localizations is debatable. To limit the inability of being able to perform the planned enucleation, we believe strongly that magnetic resonance imaging with magnetic resonance cholangiopancreatography and endoscopic ultrasonography should be performed routinely in the preoperative workup of these selected patients. These examinations are the most relevant to determine the exact duct size and the proximity of the main duct to the lesions and may have prevented up to half of the conversions to standard pancreatectomies reported by Kaiser et al. Indeed, in our experience, such an extensive preoperative workup increased the accuracy of indications of parenchyma-sparing pancreatectomies with an 89% feasibility rate (90% for enucleations) and a 3% rate of misdiagnosed minimally invasive carcinoma. Kaiser et al also reported a 46% rate of postoperative pancreatic fistula (POPF), including an 11% rate of grade B and a 16% of grade C POPF, respectively. We also observed a higher rate of POPF (51%) after enucleation of branch-duct IPMN, which is probably related, in this “ductal-surgery” to the need to suture the communicating duct during enucleation of branch-duct IPMN, compared with solid tumors, such as neuroendocrine tumors. More interestingly, Kaiser et al reported that the rate of grade B and C POPF in patients who had intraoperative conversion was 27%, which is greater than the 9% recently reported by the same group in upfront pancreatoduodenectomy for IPMN, suggesting that an unplanned pancreatoduodenectomy is associated with greater morbidity. In an intention-to-treat analysis, failure to enucleate a small, asymptomatic, branch-duct IPMN, if converted to other parenchymal-sparing procedures, such as a selective uncinate resection or a central pancreatectomy, should not be considered as a true failure. In contrast, a standard resection, and especially a pancreatoduodenectomy for small, asymptomatic, branch-duct IPMN, should be considered with the utmost caution.