Pierre-Nicolas D'Halluin

Wireless capsule endoscopy versus ileocolonoscopy for the diagnosis of postoperative recurrence of Crohn's disease: a prospective study.

Background and aims: Following ileocolonic resection for Crohn’s disease (CD), early endoscopic recurrence predicts recurrence of symptoms. The aim of the study was to compare ileocolonoscopy and wireless capsule endoscopy (WCE) for the detection of postoperative recurrence in CD. Methods: WCE and ileocolonoscopy were performed within six months following surgery in 32 prospectively enrolled patients. Two independent observers interpreted the results of WCE. Recurrence in the neoterminal ileum was defined by a Rutgeerts score ⩾1. When observers at WCE did not concur, WCE results were considered as either true negative or true positive and sensitivity and specificity were calculated according to both assumptions. Results: Recurrence occurred in 21 patients (68%) and was detected by ileocolonoscopy in 19 patients. Sensitivity was 90% and specificity 100%. Sensitivity of WCE was 62% and 76% and specificity was 100% and 90%, respectively, depending on assumptions. There was a correlation between the severity of the lesions measured by both methods (p<0.05). Lesions located outside the scope of conventional endoscopy were detected by WCE in two thirds of patients with excellent interobserver agreement (kappa >0.9) for all lesions with the exception of ulceration (kappa = 0.7). Conclusions: The sensitivity of WCE in detecting recurrence in the neoterminal ileum was inferior to that of ileocolonoscopy. In contrast, WCE detected lesions outside the scope of ileocolonoscopy in more than two thirds of patients. Additional follow up studies are needed to assess the clinical relevance of such lesions. At the present time, it seems that WCE cannot systematically replace ileocolonoscopy in the regular management of patients after surgery.

Esophageal Capsule Endoscopy vs. EGD for the Evaluation of Portal Hypertension: A French Prospective Multicenter Comparative Study

OBJECTIVES:Esophagogastroduodenoscopy (EGD) is the standard method for the diagnosis of esophago-gastric varices. The aim of this prospective multicenter study was to evaluate the PillCam esophageal capsule endoscopy (ECE) for this indication.METHODS:Patients presenting with cirrhotic or noncirrhotic portal hypertension underwent ECEfollowed by EGD at the time of diagnosis. Capsule recordings were blindly read by two endoscopists.RESULTS:A total of 120 patients (72 males, mean age: 58 years; mean Child–Pugh score: 7.2) were included. Esophageal varices were detected in 74 patients. No adverse event was observed after either EGD or ECE. Seven (6%) patients were unable to swallow the capsule. The mean recording time was 204 s (range 1–876). Sensitivity, specificity, negative predictive value, and positive predictive value of ECE for the detection of esophageal varices were 77%, 86%, 69%, and 90%, respectively. Sensitivity, specificity, negative and positive predictive values of ECE for the indication of primary prophylaxis (esophageal varices ⩾grade 2 and/or red signs) were 77, 88, 90, and 75%, respectively, and 85% of the patients were adequately classified for the indication (or not) of prophylaxis. Interobserver concordance for ECE readings was 79.4% for the diagnosis of varices, 66.4% for the grading of varices, and 89.7% for the indication of prophylaxis.CONCLUSIONS:This large multicenter study confirms the safety and acceptable accuracy of ECE for the evaluation of esophageal varices. ECE might be proposed as an alternative to EGD for the screening of portal hypertension, especially in patients unable or unwilling to undergo EGD.

RBC 6-TGN and hematological parameters in patients with Crohn's disease treated by azathioprine.

OBJECTIVE The immunosuppressive properties of azathioprine (AZA) are mediated by intracellular metabolism of 6-MP into its active metabolites 6-thiguanine nucleotide (6-TGN) and 6-methylmercaptopurine (6-MMP). The aims of this study were to correlate red blood cell (RBC) 6-TGN and hematological parameters and their change in adult patients with Crohns disease (CD) treated by AZA and to determine independent factors enabling determination of RBC 6-TGN. METHODS RBC 6-TGN concentration was determined with high performance liquid chromography (HLPC) performed on 74 hepa-rinized blood samples from 32 patients. Changes of hematological parameters were measured for each RBC 6-TGN concentration. RBC 6-TGN concentration above 235 pmol/8x108 RBC was proposed as the therapeutic level in patients treated by AZA. Correlations between the various parameters were assessed as appropriate. Logistic regression analysis was used to determinate independent variables. P<0.05 was considered significant. RESULTS There was a positive correlation between RBC 6-TGN and decreased red cell count (DeltaRBC) (r=0.314; P=0.006), platelet count (DeltaPlatelets) (r=0.314; P=0.007), White cell count (DeltaWC) (r=0.241; P=0.04) and neutrophil count (DeltaPMN) (r=0.292; P=0.02). RBC 6-TGN in the therapeutic zone was positively correlated with mean corpuscular volume (MCV) (r=0.527; P=0.01), mean corpuscular hemoglobin concentration (MCHC) (r=0.437; P=0.04), increase in MCV (DeltaMCV) (r=0.512; P=0.012), decrease in White cell count (DeltaWC) (r=0451; P=003) and in neutrophil count (DeltaPMN) (r=0.463; P=0.03). Multivariate analysis showed that low activity of CD (P<0.02), young age at onset of treatment by AZA (P<0.03) and a low red cell distribution width (RDW) (P=0.003) were independent factors for RBC 6-TGN situated in therapeutic zone. RBC 6-TGN could be determined by logistic regression from AZA dose (mg/kg/d) and MCV increase. CONCLUSION This study confirms that hematological parameters or their change can be used to determine whether RBC 6-TGN concentration has reached the therapeutic level. Logistic regression analysis showed that decreased RDW and increased MCV were independent factors for RBC 6-TGN level.

Massive hemobilia during extraction of a covered self-expandable metal stent in a patient with portal hypertensive biliopathy.

Ralph Waldo Emerson advised, ‘‘Do not go where the path may lead, go instead where there is no path and leave a trail’’; unfortunately, this metal stent took his advice: it exited the left intrahepatic duct, penetrated the liver, and sought refuge in the peritoneal cavity. I am not sure there is any technical lesson to be learned here; perhaps one can question whether the plain film immediately after the procedure showed the stent to be in optimal position, but to paraphrase Catherine of Siena, to a skilled endoscopist, good and bad luck are his right and left hands; he uses both. I am sure these authors will have better luck next time. Lawrence J. Brandt, MD Associate Editor for Focal Points At the Focal Point

Removal of transanastomotic pancreatic stent tubes after pancreaticoduodenectomy: a new role for double-balloon enteroscopy.

BACKGROUND Endoscopic interventions are usually very challenging in patients with anatomic changes caused by earlier GI surgery. The recent development of the double-balloon enteroscopy (DBE) system creates an opportunity to reach the biliary tract and the pancreatic duct in postsurgical conditions. OBJECTIVE To report a further application of DBE in surgical patients; namely, extraction of pancreatic stents placed in pancreaticojejunal anastomosis during pancreaticoduodenectomy. DESIGN Two case reports. SETTING A single-center experience in a tertiary-care unit. PATIENTS AND INTERVENTIONS Two patients who underwent Whipple resection with Roux-en-Y reconstruction presented with migration of pancreatic stent tubes inserted in pancreaticojejunal anastomoses. Stents had migrated to the end of the afferent limb and were causing abdominal pain. Because extraction failed by using conventional endoscopy, we used the DBE system. MAIN OUTCOME MEASURES Successful extraction of the stents. RESULTS Stents were successfully removed in both patients with no complications. After 1 year of follow-up, the patients remained free of painful symptoms. LIMITATIONS Small volume case series. CONCLUSIONS Double-balloon enteroscopy is a reliable way to investigate and treat patients with postsurgical altered anatomy. Here, we report the successful removal of pancreatic stents migrating into the jejunal loop through pancreaticojejunal anastomosis.