Pierre Eisendrath

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.

Interleukin 10 reduces the incidence of pancreatitis after therapeutic endoscopic retrograde cholangiopancreatography

BACKGROUND & AIMS Prophylactic administration of interleukin (IL)-10 decreases the severity of experimental pancreatitis. Prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis in humans is a unique model to study the potential role of IL-10 in this setting. METHODS In a single-center, double-blind, randomized, placebo-controlled study, the effect of a single injection of 4 microg/kg (group 1) or 20 microg/kg (group 2) IL-10 was compared with that of placebo (group 0), all administered 30 minutes before therapeutic ERCP. The primary endpoint was the effect of IL-10 on serum levels of amylases and lipases measured 4, 24, and 48 hours after ERCP. The secondary objective was to evaluate changes in plasma cytokines (IL-6, IL-8, tumor necrosis factor) at the same time points and the incidence of acute pancreatitis in the 3 groups. Subjects undergoing a first therapeutic ERCP were eligible for inclusion. RESULTS A total of 144 patients were included. Seven were excluded based on intention to treat (n = 1) or per protocol (n = 6). Forty-five, 48, and 44 patients remained in groups 0, 1, and 2, respectively. The 3 groups were comparable for age, sex, underlying disease, indication for treatment, type of treatment, and plasma levels of C-reactive protein (CRP), cytokines, and hydrolases at baseline. No significant difference was observed in CRP, cytokine, and hydrolase plasma levels after ERCP. Forty-three patients developed hyperhydrolasemia (18 in group 0, 14 in group 1, and 11 in group 2; P = 0.297), and 19 patients developed acute clinical pancreatitis (11 in group 0, 5 in group 1, 3 in group 2; P = 0.038). Two severe cases were observed in the placebo group. No mortality related to ERCP was observed. Logistic regression identified 3 independent risk factors for post-therapeutic ERCP pancreatitis: IL-10 administration (odds ratio [OR], 0.46; 95% confidence interval [95% CI], 0.22-0.96; P = 0.039), pancreatic sphincterotomy (OR, 5.04; 95% CI, 1.53-16.61; P = 0.008), and acinarization (OR, 8.19; 95% CI, 1.83-36.57; P = 0.006). CONCLUSIONS A single intravenous dose of IL-10, given 30 minutes before the start of the procedure, independently reduces the incidence of post-therapeutic ERCP pancreatitis.

Self-expandable metal stents for the treatment of benign upper GI leaks and perforations.

BACKGROUND Self-expandable metal stents (SEMSs) have been suggested for the treatment of benign upper GI leaks and perforations. Nevertheless, uncomplicated removal remains difficult. Placement of a self-expandable plastic stent (SEPS) into an SEMS can facilitate retrieval. OBJECTIVES This study reviews our experience with sequential SEMS/SEPS placement in patients with benign upper GI leaks or perforations. DESIGN A retrospective review of the chart of each patient who underwent SEMS placement for benign upper GI leaks or perforations, including (1) fistula after bariatric surgery, (2) other postoperative fistulae, (3) Boerhaave syndrome, (4) iatrogenic perforations, and (5) other perforations. SETTING Single, tertiary center. PATIENTS Eighty-eight patients (37 male, average age 51.6 years, range 18-89 years). INTERVENTIONS SEMS placement and removal, with or without SEPS placement. MAIN OUTCOME MEASUREMENTS Feasibility of SEMS removal and successful treatment of lesions and short-term and long-term complications. RESULTS A total of 153 SEMSs were placed in 88 patients; all placements were successful. Six patients died (not SEMS-related deaths) and 6 patients were lost to follow-up with SEMSs still in place. Seventy-three of the remaining 76 patients had successful SEMS removal (96.1%). The rate of successful SEMS removal per stent was 97.8% (132/135). Resolution of leaks and perforations was achieved in 59 patients (77.6%) with standard endoscopic treatment, and in 64 patients (84.2%) after prolonged, repeated endoscopic treatment. Spontaneous migration occurred in 11.1% of stents, and there were minor complications (dysphagia, hyperplasia, rupture of coating) in 20.9% and major complications (bleeding, perforation, tracheal compression) in 5.9%. LIMITATIONS Retrospective design and highly selected patient population. CONCLUSIONS Use of SEMSs for the treatment of benign upper GI leaks and perforations is feasible, relatively safe, and effective, and SEMSs can be easily removed 1 to 3 weeks after SEPS insertion. Leaks and perforations were closed in 77.6% of cases.

Endoscopic removal of dysfunctioning bands or rings after restrictive bariatric procedures.

BACKGROUND Intragastric band migrations or dysfunctions are common long-term complications of both vertical banded gastroplasty (VBG) and laparoscopic adjustable gastric banding (Lap-Band) that classically require surgical treatment. OBJECTIVE In this series, we describe the endoscopic removal of partially eroded Lap-Bands or Silastic rings and noneroded dysfunctioning rings after VBG. DESIGN Case series. SETTING A European, tertiary-care academic center. PATIENTS This study involved 13 patients--3 with eroded Lap-Bands, 4 with eroded Silastic rings, and 6 with refractory outlet stoma stenosis after VBG. INTERVENTION Endoscopic removal was performed within 1 or 2 sessions, according to the presence and extent of band erosion at presentation, including optional placement of a self-expandable plastic stent across the band, followed about 6 to 8 weeks later by extraction with transsection, if needed, by using a wire-cutting system. MAIN OUTCOME MEASUREMENTS Technical success and safety. RESULTS One failure was caused by huge adhesion formation around a Lap-Band on the lesser curvature of the stomach and the left liver lobe. Twelve of 13 endoscopic removals were successful in 1 (n = 2) and 2 (n = 10) sessions. LIMITATIONS Highly selected patients (tertiary-case academic center). CONCLUSION Endoscopic removal of dysfunctioning bands or rings is safe and feasible by the use of a 1- or 2-step endoscopic procedure.

Clinical impact of biliary drainage and jaundice resolution in patients with obstructive metastases at the hilum.

OBJECTIVES:For patients presenting with progressive liver or lymph node metastases (LM) causing obstructive jaundice, survival without adequate biliary drainage is very brief. The aim of this study was to assess the impact of endoscopic drainage for biliary obstruction secondary to LM at the hilum on subsequent administration of chemotherapy and on patient outcome.METHODS:Thirty-five patients were studied and underwent insertion of plastic and/or metal stents, endoscopically (80%) or percutaneously and endoscopically (20%), to obtain complete resolution of jaundice. LM originated from colon (n = 16), gastric (n = 5), breast (n = 5), pancreatic (n = 3), and miscellaneous cancers (n = 6). Bile duct strictures were Bismuth type I–II in 13 patients and type III in 22.RESULTS:The overall rate of success (i.e., complete resolution of jaundice) was 86% after a median of three procedures per patient (range, 1–7). Pruritus, jaundice, nausea, abdominal pain, and anorexia improved significantly in 88, 86, 75, 66, and 50% of cases, respectively. Overall median survival was 4 months and was 6.5 versus 1.8 months (p < 0.05) in the groups of patients whose jaundice resolved completely versus incompletely. The type of stricture did not affect survival. Patients with colon and breast cancer who were eligible for second line chemotherapy after optimal drainage had the longest survival (12–16 months).CONCLUSIONS:In our patients with obstructive LM, endoscopic biliary drainage completely resolved jaundice in 86% and improved clinical symptoms and survival, thus enabling these patients to have additional chemotherapy.

Endotherapy for paraduodenal pancreatitis: A large retrospective case series

BACKGROUND AND STUDY AIMS Paraduodenal pancreatitis is histologically well defined but its epidemiology, natural history, and connection with chronic pancreatitis are not completely understood. The aim of this study was to review the endoscopic and medical management of paraduodenal pancreatitis. PATIENTS AND METHODS Medical records of all patients with paraduodenal pancreatitis diagnosed by magnetic resonance cholangiopancreatography (MRCP) or endoscopic ultrasonography (EUS) between 1995 and 2010 were retrospectively reviewed. Clinical features, imaging procedures, and treatments were investigated. The primary end point was the rate of clinical success, and the secondary end points were the radiological or endoscopic improvement, complication rate, and overall survival rate. RESULTS A total of 51 patients were included in the study (88.2 % alcohol abuse; median age 49 years [range 37 - 70]; 50 men). The most frequent symptoms at presentation were pain (n = 50; 98.0 %) and weight loss (n = 36; 70.6 %). Chronic pancreatitis was present in 36 patients (70.6 %), and 45 patients (88.2 %) had cysts. Other findings included stricture of the pancreatic duct (n = 37; 72.5 %), common bile duct (n = 29; 56.9 %), and duodenum (n = 24; 47.1 %). A total of 39 patients underwent initial endoscopic treatment: cystenterostomy (n = 20), pancreatic and/or biliary duct drainage (n = 19), and/or duodenal dilation (n = 6). For the patients with available follow-up (n = 41), 24 patients required repeat endoscopy and 9 patients required surgery after the initial endoscopic management. After a median follow-up of 54 months (range 6 - 156 months), complete clinical success was achieved in 70.7 % of patients, and the overall survival rate was 94.1 %. CONCLUSIONS This is the largest series concerning the management of paraduodenal pancreatitis using endotherapy as the first-line intervention. Although repeat endoscopic procedures were required in half of the patients, no severe complication was observed and surgical treatment was ultimately needed in less than 25 % of the patients.

Gut mucosal and plasma concentrations of glutamine: a comparison between two enriched enteral feeding solutions in critically ill patients

BackgroundAddition of glutamine to enteral nutrition formulas is consistently associated with a significant decrease in septic morbidity in critically ill patients, possibly related to the attenuation of gut dysfunction. This pilot study was undertaken to compare the effects of enteral administration of two glutamine-enriched formulas containing either additional free glutamine or glutamine-rich proteins, with a standard solution on plasma and mucosal concentrations of glutamine in patients admitted in the Department of Intensive Care.MethodsFollowing randomization, glutamine concentration was determined in endoscopically sampled duodenal biopsies and plasma, before and after a 7-day period of continuous administration of the designated solution.ResultsThe mucosal concentration of glutamine increased in the duodenal biopsies sampled from patients randomized to the solution containing the glutamine-rich proteins (from 3.6 ± 2.2 to 6.7 ± 5.2 micro-mol/g protein), but not from the others. There were no differences between the 3 groups in the plasma concentrations of glutamine, which remained stable over time.ConclusionThe source of supplemental glutamine can influence gut mucosal glutamine concentrations, suggesting differences in its availability or utilization.

Trans-fistulary endoscopic drainage for post-bariatric abdominal collections communicating with the upper gastrointestinal tract

BACKGROUND AND STUDY AIMS Diverse endoscopic methods, such as placement of temporary self-expandable stents, have proven effective for the treatment of post-bariatric surgery leaks. However, some patients do not respond to the usual endoscopic treatment. This study tested the efficacy of an alternative treatment strategy based on trans-fistulary drainage with double-pigtail plastic stents. PATIENTS AND METHODS We performed a retrospective analysis of patients with abdominal collections following bariatric surgery who were treated by trans-fistulary stenting between May 2007 and February 2015. Clinical success was defined as a sustained (> 4 months) clinical resolution (patient discharged from the hospital without antibiotics and able to resume a normal diet) and radiological response. Patient records, radiological images, and the hospital endoscopy database were reviewed. RESULTS A total of 33 patients (26 women/7 men, mean age 42 years [SD 11.2]) were included. Collections occurred after sleeve gastrectomy (n = 28) or after gastric bypass (n = 5). Fourteen patients were treated by trans-fistulary stenting as primary treatment, and 19 patients had undergone previous unsuccessful endoscopic treatment. No serious complication occurred during the drainage procedure. Clinical success was achieved in 26 patients (78.8 %). In two successfully treated patients, stents are still in place. Spontaneous stent migration occurred in 12 patients. In 12 patients, the stents were removed, either electively (n = 5) or because of complications (ulcerations n = 3, upper gastrointestinal symptoms n = 3, splenic hematoma n = 1). CONCLUSIONS Trans-fistulary drainage of post-bariatric abdominal collections is safe and associated with high success rates. This technique can be considered in previously untreated patients, when a collection is not properly drained percutaneously, or after failure of other endoscopic treatments.

Technical aspects of endoscopic ultrasound (EUS)-guided sampling in gastroenterology: European Society of Gastrointestinal Endoscopy (ESGE) Technical Guideline – March 2017

For routine EUS-guided sampling of solid masses and lymph nodes (LNs) ESGE recommends 25G or 22G needles (high quality evidence, strong recommendation); fine needle aspiration (FNA) and fine needle biopsy (FNB) needles are equally recommended (high quality evidence, strong recommendation).When the primary aim of sampling is to obtain a core tissue specimen, ESGE suggests using 19G FNA or FNB needles or 22G FNB needles (low quality evidence, weak recommendation).ESGE recommends using 10-mL syringe suction for EUS-guided sampling of solid masses and LNs with 25G or 22G FNA needles (high quality evidence, strong recommendation) and other types of needles (low quality evidence, weak recommendation). ESGE suggests neutralizing residual negative pressure in the needle before withdrawing the needle from the target lesion (moderate quality evidence, weak recommendation).ESGE does not recommend for or against using the needle stylet for EUS-guided sampling of solid masses and LNs with FNA needles (high quality evidence, strong recommendation) and suggests using the needle stylet for EUS-guided sampling with FNB needles (low quality evidence, weak recommendation).ESGE suggests fanning the needle throughout the lesion when sampling solid masses and LNs (moderate quality evidence, weak recommendation).ESGE equally recommends EUS-guided sampling with or without on-site cytologic evaluation (moderate quality evidence, strong recommendation). When on-site cytologic evaluation is unavailable, ESGE suggests performance of three to four needle passes with an FNA needle or two to three passes with an FNB needle (low quality evidence, weak recommendation).For diagnostic sampling of pancreatic cystic lesions without a solid component, ESGE suggests emptying the cyst with a single pass of a 22G or 19G needle (low quality evidence, weak recommendation). For pancreatic cystic lesions with a solid component, ESGE suggests sampling of the solid component using the same technique as in the case of other solid lesions (low quality evidence, weak recommendation).ESGE does not recommend antibiotic prophylaxis for EUS-guided sampling of solid masses or LNs (low quality evidence, strong recommendation), and suggests antibiotic prophylaxis with fluoroquinolones or beta-lactam antibiotics for EUS-guided sampling of cystic lesions (low quality evidence, weak recommendation). ESGE suggests that evaluation of tissue obtained by EUS-guided sampling should include histologic preparations (e. g., cell blocks and/or formalin-fixed and paraffin-embedded tissue fragments) and should not be limited to smear cytology (low quality evidence, weak recommendation).

Pancreatic Tuberculosis Diagnosed by EUS: One Disease, Many Faces

CONTEXT Pancreatic/para-pancreatic tuberculosis is an extremely rare clinical entity even in endemic regions. It can present as a cystic or solid pancreatic mass mimicking pancreatic malignancy. There are no specific imaging criteria and the clinical symptoms remain vague. Therefore, most cases are diagnosed after surgical exploration for presumed pancreatic neoplasia. CASE REPORT We report five cases of pancreatic tuberculosis each time with a different clinical presentation, in an occidental country setting where the diagnosis was done by EUS guided FNA (EUS-FNA). CONCLUSION EUS-FNA is a safe and promising technique for the diagnosis of pancreatic/para-pancreatic tuberculosis, avoiding unnecessary surgery.