Stanislas Chaussade

Outcomes of Treatment for Achalasia Depend on Manometric Subtype

BACKGROUND & AIMSnPatients with achalasia are treated with either pneumatic dilation (PD) or laparoscopic Heller myotomy (LHM), which have comparable rates of success. We evaluated whether manometric subtype was associated with response to treatment in a large population of patients treated with either PD or LHM (the European achalasia trial).nnnMETHODSnEsophageal pretreatment manometry data were collected from 176 patients who participated in the European achalasia trial. Symptoms (weight loss, dysphagia, retrosternal pain, and regurgitation) were assessed using the Eckardt score; treatment was considered successful if the Eckardt score was 3 or less. Manometric tracings were classified according to the 3 Chicago subtypes.nnnRESULTSnForty-four patients had achalasia type I (25%), 114 patients had achalasia type II (65%), and 18 patients had achalasia type III (10%). After a minimum follow-up period of 2 years, success rates were significantly higher among patients with type II achalasia (96%) than type I achalasia (81%; P < .01, log-rank test) or type III achalasia (66%; P < .001, log-rank test). The success rate of PD was significantly higher than that of LHM for patients with type II achalasia (100% vs 93%; P < .05), but LHM had a higher success rate than PD for patients with type III achalasia (86% vs 40%; P = .12, difference was not statistically significant because of the small number of patients). For type I achalasia, LHM and PD had similar rates of success (81% vs 85%; P = .84).nnnCONCLUSIONSnA higher percentage of patients with type II achalasia (based on manometric tracings) are treated successfully with PD or LHM than patients with types I and III achalasia. Success rates in type II are high for both treatment groups but significantly higher in the PD group. Patients with type III can probably best be treated by LHM. Trialregister.nl number NTR37; ISRCTN56304564.

Functional results after extended myotomy for diffuse oesophageal spasm

The role of surgery in the management of patients with diffuse oesophageal spasm (DOS) remains controversial. The aim of this study was to assess functional results after extended myotomy for DOS.

Deep Learning and Radiomics predict complete response after neo-adjuvant chemoradiation for locally advanced rectal cancer

Treatment of locally advanced rectal cancer involves chemoradiation, followed by total mesorectum excision. Complete response after chemoradiation is an accurate surrogate for long-term local control. Predicting complete response from pre-treatment features could represent a major step towards conservative treatment. Patients with a T2-4 N0-1 rectal adenocarcinoma treated between June 2010 and October 2016 with neo-adjuvant chemoradiation from three academic institutions were included. All clinical and treatment data was integrated in our clinical data warehouse, from which we extracted the features. Radiomics features were extracted from the tumor volume from the treatment planning CT Scan. A Deep Neural Network (DNN) was created to predict complete response, as a methodological proof-of-principle. The results were compared to a baseline Linear Regression model using only the TNM stage as a predictor and a second model created with Support Vector Machine on the same features used in the DNN. Ninety-five patients were included in the final analysis. There were 49 males (52%) and 46 females (48%). Median tumour size was 48u2009mm (15–130). Twenty-two patients (23%) had pathologic complete response after chemoradiation. One thousand six hundred eighty-three radiomics features were extracted. The DNN predicted complete response with an 80% accuracy, which was better than the Linear Regression model (69.5%) and the SVM model (71.58%). Our model correctly predicted complete response after neo-adjuvant rectal chemoradiotherapy in 80% of the patients of this multicenter cohort. Our results may help to identify patients who would benefit from a conservative treatment, rather than a radical resection.

Quality Indicators for Colonoscopy Procedures

Colonoscopy remains the gold standard for morphologic colon. Despite the development of new methods of morphologic bowel, colonoscopy is still considered the « gold standard » because of its ability at detecting small neoplasic lesions as well as adenomas. Unlike other methods, colonoscopy has the great advantage of carrying out the same time the removal of polyps. Colonoscopy also has a number of limitations. Studies have confirmed that the colonoscopy examination was an improvement over the performance review that fluctuates depending on the quality of it. Thus Pickardt et al showed that colonoscopy could miss up to 10% of polyps greater than 10mm (1). Also, it should be noted that interval cancers after colonoscopy is not uncommon (2). These results underpin the idea that colonoscopy is an examination of improvement and it is necessary to define quality criteria. The most famous of all is the detection rate of adenoma. This simple criterion was used to compare the performance of endoscopists (3). To reduce variation between endoscopists and to generalize the practice of colonoscopy quality, we must have reliable and easily measurable criteria for assessing the quality of examinations. These criteria should ensure that consideration is medically justified. It is carried out by using standard validated, that lesions are diagnosed correctly and appropriate treatments are made. All of it should be done with minimal risk to patients. Moreover, these criteria must evaluate the entire examination and not just the technical act. Those criteria must also take into account: the information provided to the patient, risk assessment, and conditions of the act. Indications for colonoscopy and appropriate intervals have been established by the taskforce in 2006 between the American College of Gastroenterology and the American Society of Digestive Endoscopy (4).

Place de la chimiothérapie adjuvante dans le cancer du côlon chez les patients âgés

Le cancer colorectal (CCR) represente un vrai enjeu de sante publique. Son incidence elevee associee au vieillissement de la population rend de plus en plus frequent le diagnostic de CCR chez les patients de plus de 74 ans. Il n’est donc plus rare d’avoir a discuter en reunion de concertation pluridisciplinaire de l’interet d’une chimiotherapie adjuvante chez un patient de plus de 74 ans. Si le traitement de reference du CCR opere est le schema FOLFOX 4 depuis l’etude MOSAIC en 2004, le benefice d’une intensification de la chimiotherapie par de l’oxaliplatine dans les CCR operes apres 74 ans est discute. Par ailleurs, l’incidence des tumeurs microsatellite instable (MSI+) est de l’ordre de 15 a 20 % dans la population generale. Ces tumeurs MSI+ ont une sensibilite reduite a la chimiotherapie a base de 5FU ce qui rend la connaissance du statut MSI indispensable lors du choix du traitement. Ce choix doit egalement prendre en compte la toxicite de la chimiotherapie et les facteurs de vulnerabilite des patients âges. L’âge chronologique n’est pas un bon element d’orientation therapeutique ; en revanche, l’esperance de vie sans maladie a l’âge de la chirurgie represente une aide a la decision. Elle est a 75, 85 et 95 ans de dix, cinq et deux ans chez l’homme. Une evaluation pluridisciplinaire des risques geriatriques permet de guider au mieux le traitement. La Comprehensive Geriatric Assessment ou evaluation gerontologique multidimensionnelle est un processus d’evaluation globale qui permet d’identifier trois sous-groupes parmi les patients âges : robustes, fragiles, vulnerables. Ce score permet de predire la mortalite a deux ans sans traitement qui est respectivement de 10, 19 et 40 %. L’objectif de cette mini-revue est de faire le point sur la chimiotherapie adjuvante des cancers colorectaux apres 74 ans et de souligner les elements qui guident le choix du traitement chez les sujets âges en prenant en compte leur fragilite.

Alternatives à la coloscopie, état des lieux en 2009

La coloscopie optique standard est l’examen de reference pour l’exploration du colon. Sa morbidite et son acceptabilite mediocre ont entraine le developpement de techniques alternatives. L’imagerie du colon, en particulier le coloscanner, a beneficie d’un nombre considerable de travaux. La sensibilite et la specificite pour la detection de polypes superieurs a 9 mm sont respectivement de 85 et de 97 % selon la meta-analyse de Mulhall et al. Le caractere irradiant de cette technique ferait preferer la colo-IRM, technique apparue plus recemment, pour laquelle les travaux sont moins nombreux. Par ailleurs, la technologie de la videocapsule du grele a ete adaptee a l’etude du colon. Les resultats de la videocapsule colique sont prometteurs : une etude multicentrique europeenne portant sur 320 patients retrouvait des valeurs de sensibilite, specificite, VPP et VPN respectivement de 64, 84, 60 et 86 % pour la detection de polypes superieurs a 6 mm. Aucune complication severe n’avait ete observee. Enfin, des ameliorations du coloscope classique ont ete recherchees : Aer-O-Scope™, Invendoscope™, coloscope CathCam™, systeme endoscopique NeoGuide™, etc. Ces coloscopes « alternatifs » n’en sont qu’a leurs balbutiements. Les caracteristiques de ces methodes d’exploration du colon sont tres differentes d’une technique a l’autre, et leur place et leurs indications respectives restent a definir.

Prévention des complications hémorragiques de la polypectomie colique

La polypectomie est de fait un geste a fort risque hemorragique, le plus souvent immediat, parfois plus tardif. La prevention de cette complication potentiellement grave est indispensable. Celle-ci prend place tant avant l’endoscopie (identification des patients a risque hemorragique) que pendant le geste (technique adaptee). Le probleme des patients sous antithrombotiques (AT) est complexe. Le relais medicamenteux est souhaitable et la plupart du temps realisable, permettant un geste regle, fait dans des conditions de securite optimales. Ce relais et ses conditions, notamment la question du moment de reprise des AT, doivent se discuter au cas par cas, de preference avec le medecin a l’origine de la prescription. Ces donnees font dorenavant l’objet de recommandations redigees par la Societe francaise d’endoscopie digestive*. L’aspirine et les anti-inflammatoires non steroidiens ne sont plus un obstacle a la realisation de polypectomies. Il est recommande d’utiliser un lasso (Endoloop ®) pour les lesions pediculees, surtout quand le pied est large. Elle est a proscrire pour les pieds de moins 4 mm. Il n’est recommande de mettre en place des clips hemostatiques qu’apres la resection, sur les eventuels vaisseaux apparents et les suintements hemorragiques. Les methodes combinees (adrenaline + Endoloop ®), lorsqu’elles sont possibles, sont les plus efficaces.