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La coagulation par plasma d’Argon (APC) est le traitement de reference des telangiectasies rectales post-radiques symptomatiques. L’application locale de formaline peut representer une alternative a choisir au cas par cas. Les complications potentielles de ces traitements rendent necessaires une technique adaptee.

BACKGROUND AND STUDY AIM: Polyp miss rates during colonoscopy have been calculated in a few tandem or back-to-back colonoscopy studies. Our objective was to assess the adenoma miss rate while limiting technique or operator expertise biases, i. e. by performing a large multicenter study, with same-day back-to-back video colonoscopy, done by two different operators in randomized order and blinded to the other examination. PATIENTS AND METHODS: 294 patients at 11 centers were included. Among the 286 analyzable tandem colonoscopies, miss rates were calculated in both a lesion- and patient-based analysis. Each of these rates was determined for polyps overall, for adenomas, and then for lesions larger than 5 mm, and for advanced adenomas. Univariate and logistic regression analysis were performed to define independent variables associated with missed polyps or adenomas. RESULTS: The miss rates for polyps, adenomas, polyps ≥ 5 mm, adenomas ≥ 5 mm, and advanced adenomas were, respectively, 28, 20, 1, 9 and 11 %. None of the masses with a carcinomatous (n = 3) or carcinoid component (n = 1) was missed. The specific lesion miss rates for patients with polyps and adenomas were respectively 36 and 26 % but the corresponding rates were 23 and 9.4 % when calculated for all 286 patients. The diameter (1-mm increments) and number of polyps (≥ 3) were independently associated with a lower polyp miss rate, whereas sessile or flat shape and left location were significantly associated with a higher miss rate. Adequacy of cleansing, presence of diverticula, and duration of withdrawal for the first procedure were not associated with adenoma miss rate. CONCLUSIONS: We confirm a significant miss rate for polyps or adenoma during colonoscopy. Detection of flat polyps is an issue that must be focused on to improve the quality of colonoscopy.

BACKGROUND AND STUDY AIM: The learning curve for endoscopic ultrasonography (EUS) is known to be difficult, especially in the field of pancreatic and biliary diseases. The aim of this study was to assess the impact of a live pig model developed for EUS credentialing in France. METHODS: A total of 17 trainees obtained hands-on EUS experience using a live pig model. Trainees were asked to visualize anatomical structures, to carry out fine-needle aspiration (FNA) on lymph nodes in the liver hilum, and to perform celiac neurolysis. Assessment of the FNA procedure or celiac neurolysis included measurement of time (seconds), evaluation of the precision of the puncture (mm), and existence of technical errors. RESULTS: A significant improvement between a pre-test and post-test was observed for diagnostic procedures in the following anatomical areas: splenic mesenteric vein, vena cava, splenic mesenteric artery, celiac tree, pancreatic gland, and bile duct. For lymph node FNA, a significant improvement was observed in the duration of the procedure (84 seconds vs. 60 seconds; P = 0.01), and precision (4.2 mm vs. 1.8 mm; P = 0.009), but not for the rate of technical error (29 % vs. 6 %; not significant [n. s.]). For celiac neurolysis, a significant improvement was observed in procedure time (150 seconds vs. 84 seconds; P = 0.003), but not in the rate of technical error (6 % vs. 6 %; n. s.) or precision (4.2 mm vs. 2.8 mm; n. s.). CONCLUSION: Teaching EUS with a live pig model significantly increased competence in diagnostic procedures with regard to visualizing anatomical structures, performance of FNA and, to a lesser extent, EUS-guided celiac neurolysis.

Biliary bipolar radiofrequency ablation (RFA) is a new treatment for extrahepatic cholangiocarcinoma (CCA) currently under evaluation. The purpose of this study was to evaluate the safety, particularly biliary fistula occurrence, and the feasibility of biliary RFA in a homogeneous group of patients treated using the same RFA protocol. Twelve patients with inoperable or unresectable CCA were included in a bicentric case series study. After removal of biliary plastic stents, a radiofrequency treatment with a new bipolar probe (Habib™ EndoHBP®) was applied. The energy was delivered by a RFA generator (VIO® 200 D), supplying electrical energy at 350 kHz and 10 W for 90 s. At the end of the procedure, one or more biliary stents were left in place. Adverse events were assessed per-procedure and during follow-up visits. CCA was confirmed in all patients by histology (66 %), locoregional evolution or metastatic evolution. The types of CCA were Bismuth I stage (N = 4), Bismuth II stage (N = 3), Bismuth III stage (N = 2) and Bismuth IV stage (N = 3). No serious adverse events occurred within 30 days following endoscopic treatment: One patient had a sepsis due to bacterial translocation on day 1 and another had an acute cholangitis on day 12 due to early stent migration. No immediate or delayed biliary fistula was reported. The ergonomics of the probe made treatment easy in 100 % of cases. Mean survival was 12.3 months. Endoscopic radiofrequency treatment of inoperable CCA appears without major risks and is feasible. No major adverse events or biliary fistula were identified.

L’exploration de l’intestin grele par videocapsule (VCE) se generalise et son rendement diagnostique est bien etabli. Son impact dans le traitement ou la prise en charge des patients suspects d’etre atteints d’une pathologie intestinale est peu connu et doit etre precise pour determiner sa cotation et prise en charge dans la nouvelle CCAM. Notre objectif a ete de definir l’impact diagnostique et therapeutique immediat et a long terme de la VCE.

One side effect of the immunomodulatory effect of interferon is the possible triggering or exacerbation of systemic or cutaneous sarcoidosis. We report two new cases and offer an exhaustive review of the literature. A 39-year-old man with type C chronic active hepatitis developed new respiratory symptoms and pulmonary infiltrates with hilar and mediastinal adenopathy after 7 months of treatment with pegylated interferon. The evolution was favourable after stopping treatment. The second patient developed cutaneous lesions after 6 months of treatment. Resolution occurred after the discontinuation of the treatment. In these two cases ribavirin was stopped before the first signs of sarcoidosis.

Background: Gastrointestinal angiodysplasias (GIADs) could be responsible for recurrent bleeding and severe anemia. Somatostatin analogs could reduce transfusion requirements in these patients but no randomized controlled study is available. The main objective of the ANGIOPAS phase II double-blinded randomized, noncomparative study was to assess the effectiveness of pasireotide-LAR in reducing transfusion requirements in patients with refractory GIADs bleeding. Methods: A total of 22 patients with transfusion requirements ⩾6 units of packed red blood cells (pRBCs) during the 6 months prior to inclusion were randomized to receive pasireotide-LAR 60 mg ( n = 10) or placebo ( n = 12) every 28 days for 6 months. Patients were then followed for an additional 6 months after stopping treatment. Results: The pasireotide-LAR and placebo groups were equivalent for age, sex, comorbidities and transfusion requirement during the reference period (median 13 and 9.5 pRBCs). A 50 and 83% success rate (success defined as a decrease of at least 30% of transfused pRBCs) was observed in the pasireotide-LAR arm in the Intent to Treat (ITT) and per protocol (PP) analysis respectively. The need for transfusion during the intervention period was 3 pRBC units in the pasireotide-LAR group (range 0–26) and 11.5 pRBC units in the placebo group (range 0–23). Overall, three cases with glycemic control impairment were observed in the pasireotide-LAR group including one de novo diabetes. Conclusion: This double-blinded noncomparative randomized phase II study suggests, for the first time, the effectiveness of pasireotide-LAR 60 mg every 28 days to decrease the transfusion requirement in patients with recurrent bleeding due to GIADs.

Dual-Knife(®) (Olympus) and Hydride-Knife(®) are new needle knives frequently used for submucosal dissection because of their safety and precision. In this study we aimed to evaluate the efficacy and safety of such devices in the diverticulopexy by flexible endoscopy.From February 2009 to March 2013, 42 patients (25 men), mean age 74.5, with symptomatic Zenker's diverticulum, were included in a non-randomized prospective multicenter study. The symptoms described by all patients include dysphagia, regurgitation and/or swallowing disorders. The diverticulopexy was performed with the Dual-Knife(®) or Hydrid-Knife(®), after septum exposure with the diverticuloscope, and terminated with distal tip clips positioning. All complications were noted. Patients' symptoms were regularly assessed during follow-up visits or telephone interviews.The first endoscopy treatment was successful for all patients. Thirty-seven patients (88%) had symptoms improvement after the first treatment. The recurrence rate was 14% (6 patients); a second endoscopic treatment was required 12 months on average after the first treatment, with 100% efficiency. Mid-term (16 months) efficiency was 91.67% after 1 to 3 endoscopic treatments. A total of 55 procedures were performed without perforation or significant bleeding and 3 patients underwent surgery. In multivariate analysis, the diverticulum size and the type of dissection knife were not risks factors for recurrence.Endoscopic diverticuloscope-assisted diverticulotomy with submucosal dissection knives is a safe and effective alternative treatment for patients with a symptomatic Zenker's diverticulum measuring between 2 and 10 cm.

Si la ponction-aspiration sous echoendoscopie de la surrenale gauche est une methode sure et rentable, seulement deux etudes ont ete publiees sur la faisabilite de la ponction-aspiration sous echoendoscopie de la surrenale droite. Un patient de 45 ans a subi une ponction- aspiration sous controle echoendoscopique, par voie transduodenale, d’une volumineuse lesion de la surrenale droite. Il presentait un cancer endocrine peu differencie du poumon; lors de la surveillance, le TDM a trouve une lesion de 40 mm de la surrenale droite. La ponction sous echoendoscopie a montre qu’il s’agissait d’une metastase de son cancer pulmonaire, ce diagnostic a ete confirme par une resection chirurgicale. La ponction-aspiration sous echoendoscopie par voie transduodenale de la surrenale droite semble possible et sure.

BACKGROUND The existence of endosonographic abnormalities of the oesophagus in achalasia is discussed. The place of endoscopic ultrasonography (EUS) needs to be clarified. PATIENTS Thirty five untreated patients suffering from achalasia and 28 controls without oesophageal disease were prospectively enrolled since 1993. Pseudoachalasia was diagnosed in two patients. METHODS EUS measurements were performed at two opposite sites at the level of the cardia, and 5 cm and 10 cm proximally, avoiding compression by the water filled balloon. RESULTS The oesophageal wall and the fourth hypoechoic layer were significantly thicker at the level of the cardia and 5 cm above, with mean differences between patients and controls of 0.37/0.42 mm and 0.16/0.23 mm respectively. No statistically significant correlation could be demonstrated between the thickness of the oesophageal wall or of the fourth hypoechoic layer and weight loss, or the average pressure of the lower oesophageal sphincter. However, a significant inverse relationship was demonstrated between the duration of symptoms and the thickness of the fourth hypoechoic layer. The thickness of the fourth hypoechoic layer was also increased in patients who required only one pneumatic dilatation (P < 0.01). CONCLUSION The thickness of the oesophageal wall and of the fourth hypoechoic layer appeared to be significantly increased in achalasia patients. However, the slight increase of the mean size (< 0.5 mm) of the muscularis propria suggests that EUS is not helpful in the diagnosis of achalasia. The physiopathological basis of advanced achalasia has to be reconsidered as we demonstrated an inverse relationship between the duration of symptoms and the thickness of the muscularis propria.

Adequate bowel preparation prior to colonic diagnostic procedures is essential to ensure adequate visualisation. This consensus aims to provide guidance as to the appropriate use of bowel preparation for a range of defined clinical circumstances. A consensus group from across Europe was convened and met to discuss appropriate bowel preparation. The use of polyethylene glycol (PEG), sodium picosulphate and sodium phosphate (NaP), together with other agents, prokinetics and simethicone, in colonoscopy and small bowel video capsule endoscopy were considered. A systematic review of the literature was carried out and additional unpublished data was obtained from the members of the consensus group where required. Recommendations were graded according to the level of evidence. PEG-based regimens are recommended first line for both procedures, since their use is supported by good efficacy and safety data. Sodium-picosulphate-based regimens are recommended second line as their cleansing efficacy appears less than PEG-based regimens. NaP is not recommended for bowel cleansing due to the potential for renal damage and other adverse events. However, the use of NaP is acceptable in patients in whom PEG or sodium picosulphate is ineffective or not tolerated. NaP should not be used in patients with chronic kidney disease, pre-existing electrolyte disturbances, congestive heart failure, cirrhosis or a history of hypertension. The timing of the dose, dietary restrictions, use in special patient groups and recording of the quality of bowel preparation are also considered for patients undergoing colonoscopy. During the development of the guidelines the European Society of Gastrointestinal Endoscopy (ESGE) issued guidance on bowel preparation for colonoscopy. The ESGE guidelines and these consensus guidelines share many recommendations; differences between the guidelines are reviewed. The use of bowel preparation should be tailored to the individual patient and their specific clinical circumstances

This article is the second of a two-part publication that expresses the current view of the European Society of Gastrointestinal Endoscopy (ESGE) about endoscopic ultrasound (EUS)-guided sampling, including EUS-guided fine needle aspiration (EUS-FNA) and EUS-guided Trucut biopsy. The first part (the Clinical Guideline) focused on the results obtained with EUS-guided sampling, and the role of this technique in patient management, and made recommendations on circumstances that warrant its use. The current Technical Guideline discusses issues related to learning, techniques, and complications of EUS-guided sampling, and to processing of specimens. Technical issues related to maximizing the diagnostic yield (e.g., rapid on-site cytopathological evaluation, needle diameter, microcore isolation for histopathological examination, and adequate number of needle passes) are discussed and recommendations are made for various settings, including solid and cystic pancreatic lesions, submucosal tumors, and lymph nodes. The target readership for the Clinical Guideline mostly includes gastroenterologists, oncologists, internists, and surgeons while the Technical Guideline should be most useful to endoscopists who perform EUS-guided sampling. A two-page executive summary of evidence statements and recommendations is provided.

Background and study aims: Endoscopic stenting is a recognized treatment of postcholecystectomy biliary strictures. Large multicenter reports of its long-term efficacy are lacking. Our aim was to analyze the long-term outcomes after stenting in this patient population, based on a large experience from several centers in France. Methods: Members of the French Society of Digestive Endoscopy were asked to identify patients treated for a common bile duct postcholecystectomy stricture. Patients with successful stenting and follow-up after removal of stent(s) were subsequently included and analyzed. Main outcome measures were long-term success of endoscopic stenting and related predictors for recurrence (after one stenting period) or failure (at the end of follow-up). Results: A total of 96 patients were eligible for inclusion. The mean number of stents inserted at the same time was 1.9 ±0.89 (rangel―4). Stent-related morbidity was 22.9% (n = 22). The median duration of stenting was 12 months (range 2-96 months). After a mean follow-up of 6.4 ± 3.8 years (range 0-20.3 years) the overall success rate was 66.7% (n=64) after one period of stenting and 82.3% (n=79) after additional treatments. The mean time to recurrence was 19.7 ±36.6 months. The most significant independent predictor of both recurrence and failure was a pathological cholangiography at the time of stent removal. Conclusion: Endoscopic stenting helps to avoid surgery in more than 80% of patients bearing postcholecystectomy common bile duct strictures. However, a persistent anomaly on cholangiography at the time of stent removal is a strong predictor of recurrence and may lead to consideration of surgery.

Chronic pancreatitis associated with inflammatory bowel disease is now considered as extraintestinal manifestation of that disease. The clinical and radiological features of the new entity are markedly different from those of chronic calcifying pancreatitis. We report the case of a 68-year-old man presenting with a pseudotumorous chronic pancreatitis associated with ulcerative colitis. Diagnosis was made after endoscopic retrograde cholangiopancreatography (ERCP) and cytological analysis of stenosis brushings and was confirmed by the clinical evolution. Existence of IBD-associated pancreatitis with pseudotumorous features has to be taken into account in order to avoid inappropriate pancreatic resection.

International audience; A number of guidelines on the management of gastro-intestinal stromal tumours (GISTs) have been published, mostly based on expert consensus. However, these guidelines have generally failed to address the specific problem of GISTs of limited size (i.e. those measuring a few centimetres in diameter) with which gastroenterologists are increasingly confronted. The aim of the present work was to draw up proposals for the diagnosis and treatment of GISTs measuring less than 5 cm in diameter. For this purpose, a number of practical questions were put to a panel of French experts.

Introduction Le but de ce travail a ete de decrire et quantifier prospectivement l'ensemble des coloscopies realisees en France et son evolution depuis 1998. Materiels et Methodes une enquete prospective a ete realisee du 15 au 27 novembre 2004 aupres de l'ensemble des gastro-enterologues francais (n=2963). Le recueil des donnees concernait les endoscopies effectuees sur deux jours ouvrables, fixes prealablement. 1101 reponses ont ete adressees soit 7205 endoscopies realisees. L'echantillon etait representatif sur le sexe, l'âge, la region et le type d'exercice. Des extrapolations ont ete realisees sur la base des 2963 gastroenterologues. Resultats 1.049.348 coloscopies totales ont ete realisees en 2004 soit une augmentation de 11,4% depuis 2003. La coloscopie etait totale dans 96% des cas. Les echecs de coloscopie sont en diminution –30,2% par rapport a 2003. Les echecs etaient dus a des difficultes techniques dans 24,9%, une insuffisance de preparation dans 32,7%, un obstacle colique dans 35,5%. L'anesthesie generale est delivree dans 95,2% des cas. Une polypectomie etait associee a 29,2% des coloscopies, chiffre en augmentation, un autre geste therapeutique etait associe dans 2,7%. Les indications principales de la coloscopie etaient: coloscopie de depistage (25,1%), rectorragies (19,8%), troubles fonctionnels intestinaux (12,9%), surveillance apres polypectomie (15,5%), surveillance d'un cancer du colon (6,3%). Les indications de la coloscopie de depistage etaient: antecedents familiaux (74,9%), Hemoccult® positif (11,8%), souhait du patient (13,2%). La coloscopie etait pathologique dans 59,6% des cas. Les principaux diagnostics etaient le polype rectocolique (372.802), diverticulose simple (226.051), tumeurs malignes rectocoliques en excluant les surveillances et les diagnostiques prealables par une R.S.S. (40.000), MICI (35.966). Le nombre total de polypes enleves est de 694.527 (en 2003: 637.628, en 2000: 492.892). En cas de coloscopie de depistage (troubles fonctionnels intestinaux, souhait du patient, antecedents familiaux du premier degre), le pourcentage de polype trouve varie de 35,6% a 25,8% et le pourcentage de cancer trouve varie de 2,97% a 1,3%. Le pourcentage de complications est stable avec moins de perforations 0,03% en 2004 pour 0,07% en 2003. Conclusion le nombre de coloscopies pratiquees en France a augmente. 700.000 polypes coliques ont ete enleves et 40.000 cancers ont ete diagnostiques. Malgre l'augmentation des polypectomies (700.000), le nombre de cancers rectocoliques continue a augmenter (40.000) ce qui signifie que le depistage du cancer du colon n'est pas encore efficace. Structure: Endoscopie et Imagerie digestives

Worldwide diagnoses of bowel cancer approximate an estimated one million new cases per year, comprising 9% of all cancer cases, and this has continued to increase over the last 25 years. With the association between cancer risk and increasing age, together with the suggestion that by 2015 there will be a 22% increase in the proportion of the population aged over 65 years and a 50% increase in the proportion of people aged over 80 years, there is likely to be a significant increase in the demand on cancer services throughout Europe and the rest of the world. This article discusses the current state of bowel cancer screening within Europe.

When pancreatography shows a stenosis of the main pancreatic duct in patients with normal or inconclusive ultrasound and computed tomography, the exact nature of such stenosis is sometimes difficult to precise before surgical exploration. In such cases, the authors systematically performed a percutaneous fine-needle aspiration cytologic study of the stenosis under pancreatographic guidance. Fifteen patients were referred because of suspected pancreatic malignancy. The tumor markers, carcinoembryonic antigen (CEA) and CA 19-9 were normal in 11 patients and elevated in one patient, whereas only CA 19-9 was elevated in three others. In 14 cases, both the ultrasound and computed tomography did not show any obvious pancreatic mass. The pancreatography was done through endoscopic retrograde cholangiopancreatography (ERCP) (12 patients) or percutaneously in case of failure at ERCP3 and showed a main pancreatic duct stenosis that underwent aspiration by percutaneous fine needle precisely positioned using biplane fluoroscopy. The aspirated material was then smeared on glass slides, air-dried, and stained by Giemsa. In nine of the 15 patients, cytologic study revealed adenocarcinoma. This was confirmed by surgery in five and by progressive deterioration followed by death in four. In six patients, cytologic study gave a nonmalignant result. Chronic pancreatitis was found in five of them, confirmed at surgery in three and based on uneventful follow-up of at least 12 months in two others. In one case, a pancreatic adenocarcinoma not detected by cytologic study was found at surgery. Thus, the sensitivity and specificity of this diagnostic approach were 90% and 100%, respectively. No serious complication was noticed. The authors conclude that when ultrasound and computed tomography are inconclusive, percutaneous fine-needle aspiration cytologic study of main pancreatic duct stenosis under pancreatographic guidance is a safe, simple, and helpful procedure in the investigation of patients with suspected pancreatic malignancy.

The complications of gastrointestinal (GI) endoscopy have become very rare, due to technical advances but also the use of good practices by all gastroenterologists. The overall rate of complications is 1 percent per year for more than 2 millions of lower and upper GI endoscopies, all indications included. The most common complication, though with a frequency inferior to 1/1,000 per year, is still perforation during colonoscopy, most often induced by a fragile intestine or a healing abdomen. Other complications are often the consequence of diathesis or comorbidities, especially if this procedure is performed under anesthesia. Thus in patients with severe cardiovascular or respiratory diseases, or simply depending on the age of patients, risks should be carefully assessed so that the endoscopic procedure can be adapted or even postponed. Being aware of and especially taking into account any risk factor before performing a diagnostic endoscopic examination should thus allow gastroenterologists to avoid complications.

ERMA; International audience; BACKGROUND AND STUDY AIM: Polyp miss rates during colonoscopy have been calculated in a few tandem or back-to-back colonoscopy studies. Our objective was to assess the adenoma miss rate while limiting technique or operator expertise biases, i. e. by performing a large multicenter study, with same-day back-to-back video colonoscopy, done by two different operators in randomized order and blinded to the other examination. PATIENTS AND METHODS: 294 patients at 11 centers were included. Among the 286 analyzable tandem colonoscopies, miss rates were calculated in both a lesion- and patient-based analysis. Each of these rates was determined for polyps overall, for adenomas, and then for lesions larger than 5 mm, and for advanced adenomas. Univariate and logistic regression analysis were performed to define independent variables associated with missed polyps or adenomas. RESULTS: The miss rates for polyps, adenomas, polyps > or = 5 mm, adenomas > or = 5 mm, and advanced adenomas were, respectively, 28 %, 20 %, 12 %, 9 % and 11 %. None of the masses with a carcinomatous (n = 3) or carcinoid component (n = 1) was missed. The specific lesion miss rates for patients with polyps and adenomas were respectively 36 % and 26 % but the corresponding rates were 23 % and 9.4 % when calculated for all 286 patients. The diameter (1-mm increments) and number of polyps (> or = 3) were independently associated with a lower polyp miss rate, whereas sessile or flat shape and left location were significantly associated with a higher miss rate. Adequacy of cleansing, presence of diverticula, and duration of withdrawal for the first procedure were not associated with adenoma miss rate. CONCLUSIONS: We confirm a significant miss rate for polyps or adenoma during colonoscopy. Detection of flat polyps is an issue that must be focused on to improve the quality of colonoscopy.

Introduction: L'approche endoscopique est souvent favorisee dans le traitement des stenoses biliaires postoperatoires en raison de resultats favorables a court terme. L'objectif de cette etude retrospective etait d'evaluer a l'echelon national les resultats a long terme du calibrage des stenoses biliaires post-cholecystectomie par prothese endoscopique. Afin d'affiner les resultats, nous avons introduit un element prospectif en actualisant les donnees cliniques, biologiques et morphologiques au moment de l'analyse. Patients et Methodes: Nous avons inclus dans notre etude les patients ayant eu une intubation biliaire pour stenose biliaire benigne post-cholecystectomie dans l'un des 14 centres participants entre 1984 et septembre 2003. Seuls les patients ayant beneficie d'un suivi superieur a trois ans ont ensuite ete retenus. Les donnees du suivi ont ete obtenues aupres des correspondants, des medecins traitants et des patients. La realisation d'une echographie abdominale et de tests hepatiques a ete proposee a tous les patients. Des facteurs predictifs du succes a long terme du traitement endoscopique ont ete recherches a l'aide d'une analyse univariee puis multivariee par regression logistique. Resultats: Nous avons identifie 218 patients ayant eu une stenose biliaire post-operatoire. Cent trente-neuf ne correspondaient pas aux criteres d'inclusion (autres stenoses post-operatoires) dont 28 par defaut de suivi. Soixante-dix neuf patients ont donc ete analyses. Le nombre moyen de protheses par seance etait de 1,9. La duree moyenne du traitement endoscopique etait de douze mois (extremes: 1,5 a 96 mois). La morbidite au cours du traitement etait de 25.3% (20 patients). Le calibrage etait juge satisfaisant a la fin du traitement endoscopique (i.e. Absence de stenose residuelle ou anomalie residuelle minime) chez soixante-dix patients (88,6%). Dix-huit patients ont ete perdus de vue. Cinquante-deux patients (65,8%) sont restes asymptomatiques pour un suivi de 84 mois apres un seul traitement endoscopique (extremes: 36 a 159 mois). En septembre 2006, cinquante des 61 patients encore suivis (82%) etaient asymptomatiques et avaient des tests hepatiques et une echographie abdominale normaux apres 1,3 traitements endoscopiques pour un suivi de 68 mois. Seulement 3 des 21 patients (14%) ayant une voie biliaire principale normale a la fin du traitement endoscopique ont recidive. Neuf patients ont ete operes pour stenose persistante ou recidive de la stenose. Nous avons identifie deux facteurs predictifs d'absence de recidive apres un traitement endoscopique: premierement l'obtention d'une cholangiographie normale ou subnormale en fin de traitement, deuxiemement une duree d'intubation superieure a un an. Seule la normalite de la cholangiographie en fin de procedure etait predictive du succes final. Nous n'avons pas retrouve d'effet centre. Conclusion: Un succes a long terme defini sur des bases clinique, biologique et morphologique pouvait etre obtenu apres un calibrage de plusieurs mois chez plus de 80% des patients ayant une stenose biliaire post-cholecystectomie. References: Giovanni D. De Palma, M.D. et al. Surgery or endoscopy for treatment of postcholecystectomy bile duct strictures? The American Journal of Surgery 185 (2003) 532–535. Bismuth H. Postoperative strictures of the bile ducts. In Blumgart LH (ed.) The Biliary Tract V. New York, NY: Churchill-Livingstone, 1982, pp. 209–218.(97, 161)

In 19 patients, extraction of bile duct stones through the papilla using a Dormia basket or a mechanical lithotripter was not possible following endoscopic sphincterotomy. After the insertion of a nasobiliary drain, extracorporeal lithotripsy was performed with intravenous sedation using an ultrasonographic stone localization system. The number and location of stones were first determined by retrograde cholangiography. At the time of lithotripsy, saline was injected in the bile ducts to modify the acoustic impedance of tissues surrounding the stones, and subsequent ultrasonography was effective in localizing all stones present in 4 of 5 (80%) patients with intrahepatic stones, and 13 of 14 (93%) with common bile duct stones. In 10 patients (53%), fragmentation was satisfactory and the bile ducts were cleared completely. The mean single stone diameter was significantly smaller in successful cases of fragmentation compared with failures (22.8 ± 6.6 mm vs. 40 ± 10 mm). The results in patients with multiple stones were significantly worse than those in patients with single stones of similar size (25% vs. 100% successful fragmentation). Reasons for this difference in results included the small size of the focal area and the reduced ability of ultrasonography (1) to adequately visualize multiple calculi individually and (2) to assess the degree of stone destruction. Care was taken to first await the resolution of infection or the correction of coagulation abnormalities when present; no morbidity following extracorporeal lithotripsy was observed. Despite its 3-step approach (endoscopic sphincterotomy, lithotripsy, and endoscopic extraction), the need for only intravenous sedation and the absence of patient immersion in water render this technique attractive for elderly and frail patients.

One side effect of the immunomodulatory effect of interferon is the possible triggering or exacerbation of systemic or cutaneous sarcoidosis. We report two new cases and offer an exhaustive review of the literature. A 39-year-old man with type C chronic active hepatitis developed new respiratory symptoms and pulmonary infiltrates with hilar and mediastinal adenopathy after 7 months of treatment with pegylated interferon. The evolution was favourable after stopping treatment. The second patient developed cutaneous lesions after 6 months of treatment. Resolution occurred after the discontinuation of the treatment. In these two cases ribavirin was stopped before the first signs of sarcoidosis.

Hepatitis C virus (HCV) is transmitted primarily through direct percutaneous exposure to infected blood. Sporadic HCV cases exist and may represent more than 10% of HCV transmission. We report the first case of documented transmission of HCV during a fight from a person who unknowingly had chronic HCV infection to a person who subsequently contracted acute hepatitis C. Patient-to-patient transmission was ascertained by sequence analysis of part of the NS5B genome and phylogenetic analysis. This case report suggests that sporadic HCV infection may be a result of blood exposure. This example of transmission could have a major impact in sports such as boxing or rugby. We suggest that in any fight, single use or nondisposable material should be used to dry blood to avoid such contamination.

La recherche clinique en milieu liberal est possible mais requiert une disponibilite, une implication, une tenacite de tous les instants. Elle necessite la constitution d’une equipe associant au depart, des praticiens liberaux et ensuite, du personnel dedie a la recherche clinique ou chacun des intervenants doit etre anime de la meme determination et du meme engagement. C’est cet esprit d’equipe qui nous a permis d’obtenir la reconnaissance des promoteurs et la perennisation de la structure malgre les difficultes rencontrees.