Remy Dumas

EMR of large sessile colorectal polyps

BACKGROUND EMR optimizes histopathologic assessment of resected lesions. This study evaluated the outcome of EMR of large sessile colorectal polyps in terms of complications and recurrence. METHODS An uncontrolled prospective study was conducted of a cohort of 136 patients with sessile colorectal polyps referred for EMR. After submucosal injection, EMR was performed piecemeal by either snare polypectomy alone or with cap aspiration. RESULTS In 136 patients, a total of 139 sessile polyps were resected, 86 of which were in the right colon. Median polyps diameter was 20 mm in the right colon and 30 mm in the other colonic segments. Intraprocedure bleeding occurred after 15 polypectomies (10.8%) and was controlled endoscopically in all cases; there was no delayed bleeding. Post-polypectomy syndrome occurred in 5 patients (3.7%). There was no perforation. Invasive carcinoma was found in 17 sessile colorectal polyps, and surgery was performed in 10 of 17 cases. Follow-up colonoscopy in 93 patients without invasive carcinoma (96 polyps), over a median of 12.3 months, disclosed local recurrence of 21 adenomatous polyps (21.9%). Colonoscopic follow-up in 5 of the 7 patients, who had sessile colorectal polyps with invasive carcinoma and did not undergo surgery, disclosed no local recurrence. CONCLUSIONS EMR, including EMR with cap aspiration, is effective and safe for removal of sessile colorectal polyps throughout the colon.

A prospective study of pancreatic disease in patients with alcoholic cirrhosis: comparative diagnostic value of ERCP and EUS and long-term significance of isolated parenchymal abnormalities

BACKGROUND The prevalence of pancreatic disease in patients with alcohol-related liver cirrhosis is uncertain. We assessed the prevalence of pancreatic abnormalities in patients with alcoholic cirrhosis, and we compared endoscopic ultrasonography (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) for the detection of chronic pancreatitis and other pancreatic lesions. In addition, we assessed the long-term significance of isolated pancreatic parenchymal abnormalities detected at EUS. METHODS EUS and ERCP were performed in each patient. Subjects with minimal parenchymal changes at initial EUS underwent clinical follow-up and subsequent EUS and/or ERCP to document the occurrence, absence, or progression of these changes. RESULTS Seventy-two patients with alcoholic cirrhosis were recruited. Chronic pancreatitis was diagnosed in 14 patients (19%) by both methods independently. Isolated parenchymal lesions were observed in 18 patients by EUS alone. After a mean follow-up of 22 months the EUS appearance was unchanged. Ten of the 18 patients underwent follow-up ERCP and this was normal in all cases. CONCLUSIONS This study demonstrated that (1) 19% of patients with alcoholic cirrhosis have chronic pancreatitis, (2) an additional 25% have isolated pancreatic parenchymal changes at EUS, and (3) these parenchymal abnormalities do not progress during follow-up.

Endoscopic management of GI fistulae with the over-the-scope clip system (with video).

1. Brugge WR, Lewandrowski K, Lee-Lewandrowski E, et al. Diagnosis of pancreatic cystic neoplasms: a report of the cooperative pancreatic cyst study. Gastroenterology 2004;126:1330-6. 2. Raval JS, Zeh HJ, Moser AJ, et al. Pancreatic lymphoepithelial cysts express CEA and can contain mucous cells: potential pitfalls in the preoperative diagnosis. Mod Pathol 2010;23:1467-76. 3. Morris-Stiff G, Lentz G, Chalikonda S, et al. Pancreatic cyst aspiration analysis for cystic neoplasms: mucin or carcinoembryonic antigen--which is

A new source of drug-induced acute pancreatitis: codeine

A variety of drugs have been reported to cause acute pancreatitis during the past 40 years. We report the first series of four cases of acute pancreatitis related to codeine ingestion. Four patients (three female, mean age 50.2 yr) presented with clinical, biochemical, and radiological evidence of acute pancreatitis. All four had ingested a therapeutic dose of codeine 1–3 h before the onset of abdominal symptoms. Unintentional rechallenge occurred in three cases and was followed by recurrence of acute pancreatitis in all three. All patients made a full recovery. All four patients had had a previous cholecystectomy. The likely underlying pathophysiological mechanism is codeine-induced spasm of the sphincter of Oddi combined with sphincter of Oddi dysfunction related to a previous cholecystectomy. Codeine ingestion leads to acute pancreatitis in some individuals. Previous cholecystectomy seems to predispose to codeine-induced pancreatitis.

A study of the effect of age on pancreatic duct morphology

BACKGROUND Interpretation of endoscopic pancreatograms is difficult in elderly patients. Age-related parenchymal changes and associated ductographic changes are ill-defined, and it is sometimes difficult to distinguish these from pathologic processes. METHODS To define age-related pancreatogram changes, all endoscopic retrograde pancreatograms performed in patients older than 70 years of age over a 6-year period were analyzed and compared with those of a control group (younger than 50 years of age). RESULTS Of the 136 elderly subjects included in the study, 31 (22.8%) were found to have definite pathology. Comparing the remaining 105 subjects with the control group, the mean main pancreatic duct diameter (in millimeters) was larger in the head (5.3 vs. 3.3), body (3.7 vs. 2.3), and tail (2.6 vs. 1.6) (p < 0.05). The duct diameter also increased significantly in each of the age cohorts (70 to 79, 80 to 89, and 90 to 99 years). Only 33 of 105 (31.4%) of the elderly patients had duct diameters within defined normal limits. In the majority (63.3%), dilatation was global but in a minority it was confined to the head and/or body. In 21 subjects the ductal diameter was greater than 2 standard deviations above normal, and in 5 subjects it was greater than 3 standard deviations above normal. Dilatation of secondary ducts was also observed. CONCLUSION The majority of elderly patients who do not have pancreatic pathology have a dilated pancreatic duct by comparison with younger patients. Patient age must be considered when interpreting endoscopic pancreatograms.

Endoscopic insertion of biliary stents in 18 patients with metallic duodenal stents who developed secondary malignant obstructive jaundice

AIM The aim of this work was to evaluate the feasibility of endoscopic insertion of biliary stents in patients with duodenal stents who develop secondary malignant obstructive jaundice. PATIENTS AND METHODS The study population included 133 patients with unresectable malignant duodenal obstruction. In 106 patients a biliary stent was inserted before or at the same time as the duodenal stent. Malignant biliary obstruction appeared secondarily in 18 patients; fifteen of these patients already had a biliary stent. We present our experience of biliary stent insertion in these 18 patients with metallic duodenal stents. RESULTS Biliary obstruction was successfully alleviated in 17 out of 18 patients (94%) without complication. Insertion of a new biliary stent failed in one patient because the mesh of the duodenal stent passed over the metallic biliary stent already in place. Mean duration of endoscopic insertion was 95 minutes (range: 60 - 180). All patients remained free of biliary complications to death (57 days, range: 30 - 120). CONCLUSION Our report shows that endoscopic insertion of a biliary stent is feasible in patients who have metallic duodenal stents. Technical difficulties exist especially if the mesh of the duodenal stent passes over the papilla.

Endoscopic treatment of pancreatico-biliary malignancies

Biliary obstructions, due to pancreatic cancer and cholangiocarcinoma, have an ominous prognosis. At the time of diagnosis, most patients are beyond any curative treatment. Palliative therapies, such as transhepatic biliary drainage, bypass surgery, and endoscopy, have an established role in the management of such patients. Endoscopic retrograde cholangio-pancreatography (ERCP) plays a key role, allowing diagnosis, collection of cytologic and bioptic specimens, and insertion of large-bore biliary stents. The major drawback of plastic stents is the high rate of clogging, requiring frequent stent exchange. In the 1990s, self-expanding metal stents (SEMS) were developed and randomized studies have shown their superiority over plastic stents. SEMS can be successfully used in patients with hilar tumors. Duodenal obstruction due to biliopancreatic neoplasms can also be managed endoscopically. ERCP can be performed on an outpatient basis in selected patients, reducing costs related to hospitalization. A team approach is mandatory to obtain the best results.

Endoscopic treatment of wirsungo-cysto-pleural fistula

A case is reported of a female with chronic alcoholic calcifying pancreatitis who presented with a wirsungo-cysto-pleural fistula. Endoscopic retrograde pancreatography demonstrated the fistulous tract and a naso-pancreatic drain was inserted. Subsequently, this drain was replaced by a pancreatic endoprosthesis. This endoscopic therapy led to full resolution of the fistula. We suggest that endoscopic intervention is the first-line treatment for this condition and that surgical intervention should be reserved as a second-line treatment

Endoscopic Nd:YAG laser therapy for villous adenomas of the right colon.

BACKGROUND Endoscopic laser therapy is considered an acceptable treatment of benign colorectal adenomas. The aim of our study was to evaluate the efficacy of Nd:YAG laser to ablate right-sided colonic sessile adenomas. METHODS Between January 1990 and February 1996, 56 patients underwent laser therapy because of high operative risk or refusal of surgery. Lesions were located as follows: cecum (23), ascending, (15), and hepatic flexure (18). Six patients (10.7%) had multiple polyps in the ascending colon. Histologic examination showed a tubulovillous pattern in 20 (35.7%) and a villous pattern in 36 (64.3%). Low-grade dysplasia was detected in 44 patients (78. 5%) and high-grade dysplasia in 12 (21.4%). RESULTS The number of laser sessions ranged between 1 and 6 (median 3) and complete ablation, histologically confirmed, was achieved in 49 cases (87.5%). Seven patients (12.5%) underwent surgery: 2 for incomplete tumor destruction, 3 because of invasive carcinoma on repeated biopsies. Two patients (3.6%) had complications (one perforation of the cecum and one hemorrhage). Follow-up ranged from 6 to 60 months and no recurrences were observed. CONCLUSION Laser therapy is an effective method for the destruction of sessile adenomas of the right colon in selected patients.

Long term treatment of biliary stricture due to chronic pancreatitis with a metallic stent

The exact role of endoprostheses in the management of chronic pancreatitis-associated biliary strictures has not yet been clearly established. We report an unusual case of a patient with this condition who was treated for an unexpectedly long term with a self-expanding metallic endoprosthesis. There has only been one previous report of the use of metallic stents in this situation. It appears that metallic endoprostheses may have a role to play in the management of selected patients who have chronic pancreatitis-associated bile duct stricture.