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Position du probleme La radiofrequence de l’œsophage (RFO) est un traitement endoscopique disponible dans la palette des methodes de traitement endoscopique de l’œsophage de Barrett (OB). Son efficacite et faible morbidite de gravite moderee ont ete demontrees dans des etudes prospectives et/ou randomisees.

Les buts de cette etude etaient d’evaluer la faisabilite et l’efficacite a long terme de la mise en place d’endoprotheses metalliques ou plastiques pour des stenoses recto-coliques malignes ou benignes dans la ≪vraie vie≫. De septembre 1994 a septembre 2006, 204 patients consecutifs (118 femmes, 86 hommes, âge moyen : 73,2 ans, extremes : 49–97 ans) presentant une obstruction rectocolique partielle ou complete, etaient traites par une ou plusieurs endoprotheses metalliques ou plastiques. Une pose d’endoprothese etait tentee pour 168 patients porteurs d’une stenose colique maligne en situation palliative, pour 17 malades porteurs ’egalement d’un cancer avant un geste chirurgical curatif, pour 19 patients presentant une stenose benigne, mais contreindiques pour la chirurgie en raison d’un etat general trop altere. La pose des protheses etait realisee par voie endoscopique et radioscopique. Differents modeles de protheses etaient utilises, incluant les Enteral Wallstent, Wallflex, Colonic Z stent, Ultraflex precision, Choo Stent, Hanarostent et Polyflex. Les donnees sur l’efficacite de la procedure, les complications et le devenir des patients etaient collectees retrospectivement a partir des medecins traitants qui ont suivi leurs patients jusqu’a leur deces. La pose d’une endoprothese etait effectuee avec succes chez 154 patients en situation palliative (91,6%), chez les 17 patients avant la chirurgie curative (100%) et chez 15 malades porteurs d’une stenose benigne (78%). Une complication survenait pour 28 patients : perforation colique (n=8); inefficacite (n=8); re-obstruction par matieres fecales ou progression tumorale (n=6); migration (n=4); douleur abdominale severe (n=1). Une patiente decedait. Une deuxieme endoprothese etait rendue necessaire ulterieurement chez 6 malades. La pose d’une prothese rectocolique par voie endoscopique est un traitement palliatif efficace en cas d’obstruction maligne. Ce traitement est egalement efficace avant un geste chirurgical curatif et pour certaines stenoses benignes en l’absence d’alternatives therapeutiques moins agressives.

La colostomie de decharge est la prise en charge therapeutique admise de l’occlusion rectocolique d’origine tumorale. Le but de cette etude etait d’evaluer la faisabilite et l’efficacite du traitement endoscopique des stenoses malignes colo-rectales par protheses metalliques expansives chez des patients non operables. Entre septembre 1994 et septembre 2002, 41 patients consecutifs (21 femmes, âge moyen de 69,5 ans, extreme 41–92 ans) presentant une occlusion colo-rectale d’origine neoplasique non operable ont ete traites de maniere palliative par pose d’endoprothese metallique auto-expansive. L’occlusion avait pour etiologie une atteinte tumorale colo-rectale primitive dans 32 cas et une atteinte carcinomateuse peritoneale compressive pour les 9 autres patients. Le niveau de l’occlusion etait rectal dans 11 cas, sigmoidien dans 26 cas, transverse colique dans 2 cas, a l’angle colique gauche dans un cas et a l’angle colique droit pour le dernier. Les protheses utilisees etaient de type Enterai Wallstent®, Colonic Z stent®, Ultraflex precision® ou encore de type Choo stent®. L’insertion prothetique etait possible chez 37 patients (90,2 %) et permettait de maniere constante la levee de l’occlusion. Huit de ces 37 patients presentaient un stent permeable apres un suivi moyen de 23,5 semaines. L’evolution fut la suivante pour les 29 autres patients: 22 patients avaient une prothese permeable au moment de leur deces, 2 protheses etaient envahies par la tumeur necessitant un second traitement endoscopique (insertion d’un second stent), 5 protheses (14,7 %) avaient migre de maniere spontanee sans recidive de l’occlusion et un stent avait ete retire pour un tenesme rectal a la suite de sa pose. L’insertion endoscopique de protheses metalliques auto-expansives est un traitement efficace et bien tolere des stenoses malignes colo-rectales. La complication la plus frequente est la migration survenant quel que soit le modele de prothese utilise. Diverting colostomy is the classical approach in malignant colorectal obstruction. The aim of our study was to assess the feasibility and the effectiveness of endoscopic treatment of malignant occluding colorectal cancers using selfexpanding metallic stents in nonsurgically treated patients. Between September 1994 and September 2002, 41 consecutive patients (21 females, mean age 69.5 years, range 41 –92) with malignant colorectal occlusion or subocclusion and without any curative surgery possibility, had palliative treatment with one or several endoscopic metallic stents. Colorectal cancer was the cause of occlusion in 32 patients, and in 9, peritoneal carcinomatosis with colonie invasion was present. The level of occlusion was rectal in 11 cases, sigmoid in 26 cases, transverse colon in 2 cases, splenic flexure in one case and right angle in another case. Prostheses were either Enterai Wallstent, colonie Z stent, Ultraflex stent precision or Choo stent. Placement of expandable stents was possible in 37 cases (90.2 %) and always relieved the bowel occlusion. Eight out of these 37 patients were still alive with a permeable stent after a mean follow up of 23.5 weeks. The evolution was as follows for the remaining 29 patients: 22 had a permeable stent at their death, two stents were invaded by tumor and were treated with a second stent, 5 stents had a spontaneous migration without reocclusion and one prosthesis was removed because of rectal tenesmus. Endoscopically inserted selfexpandable metal stents are an efficient palliative treatment of malignant colorectal obstruction. The most frequent complication is spontaneous migration occurring with various stent models.

Perforation of the colon during colonoscopy is still one of the most severe complications of this technique and occurs with a frequency of between 0.12 % and 0.2 % of cases after diagnostic colonoscopy and in up to 3 % of patients after therapeutic colonoscopy. The site of perforation is usually the sigmoid colon. The gold standard for treatment of this complication is surgery to be performed as rapidly as possible: a simple suture and peritoneal cleaning, with limited resection and anastomosis or colostomy only in case of confirmed fecal peritonitis. However, interventional endoscopy has made progress, in particular endoscopic suturing and Natural Orifice Transluminal Endocopic Surgery (NOTES) has been developed. There are several reports of endoscopically sutured perforated colons, most less than 10mm. We report our experience of two colonic perforations which were at least 10mm treated by endoscopic suturing with hemoclips: a perforated sigmoid diverticulum during simple colonoscopy in the first case and a large polypectomy by endoscopic mucosal resection of the ascending colon in the second.

Fibrate derivatives and HMG-CoA reductase inhibitors modify homeostasis of cholesterol. The aim of this study was to assess in an unselected population whether these hypolipidemic drugs are risk factors for cholelithiasis or, conversely, are protective agents. Both sexes, all socioeconomic categories, pregnant women, and cholecystectomized subjects were included. Clinical data collection and gallbladder ultrasonography were both carried out in a double-blind fashion. Fibrate derivatives were predominantly fenofibrate, HMG-CoA reductase inhibitors were simvastatin and pravastatin. On univariate analysis, age (50 years), sex, and use of fibrates were found to be significantly related to the presence of cholelithiasis. Age, sex, and fibrate treatment remained independently correlated with the presence of gallstones on multivariate analysis. With fibrates, the relative risk for lithiasis was 1.7 (P = 0.04). The HMG-CoA reductase inhibitors were not associated with a protective effect on univariate analysis. Of the lipid-lowering drugs, only fibrate derivatives were found to increase the risk of gallstone formation.

Cholelithiasis leads to 80,000 cholecystectomies being performed every year in France, but its prevalence is still unknown. The aim of this study was to assess the prevalence and risk factors of cholelithiasis in a random population of 1027 women and 727 men over the age of 30 in a small town in the southeast of France. Detailed clinical history, dietary investigation, and gallbladder ultrasound were collected for each subject and assessed by univariate analysis. A regression model was used in the multivariate analysis to detect the relative risk of cholelithiasis. Cholelithiasis was found in 130 individuals (global prevalence 13.9%). The relative risk for lithiasis was higher in women compared to men (1.89). Age (P0.0001) and body mass index (BMI)25 (P = 0.013) were also significant risk factors. Neither pregnancy nor oral contraceptive use proved to be risk factors. Typical biliary colic pain was the only symptom significantly associated with cholelithiasis (P0.0001). These results show that the prevalence of gallstones in France is similar to that in Denmark and Italy.

The role of a large gallbladder volume with regard to a predisposition for gallstones is unknown. It is possible that an increase in gallbladder volume could result in impaired gallbladder motility and bile stasis. We looked for factors affecting gallbladder volume in a random population in the southeast of France.To assess the relationship between gallbladder volume and gallstones, 528 subjects over the age of 30 were studied (72 with lithiasis). Age, sex, body mass index, body surface area and gallbladder volume were collected for each subject. A linear regression analysis was performed to look for significant variables.The overall adjusted prevalence of cholelithiasis was 13.9% in our population. On linear regression analysis, two variables (age and surface area) were found to be independently correlated with gallbladder volume. Gallbladder volume was significantly increased in subjects over 50 years (p0.001). There was a positive correlation between gallbladder volume and body surface area (r = 0. 33, p0.001). In this study, the presence or absence of gallstones did not significantly affect the gallbladder volume.We report that there is dilatation of the gallbladder with age and with an increase in body surface area. Whether this could represent risk factors for the occurrence of gallstone remains uncertain.

The gallbladder seems to play an important role in lithogenesis. Moreover, the morphology and the implantation of the cystic duct may also influence this process. Our purpose was to evaluate if the length and the implantation of the cystic duct may affect the formation of gallstones. Between April 1992 and March 1994, 270 patients who underwent endoscopic retrograde cholangiopancreatography were included in the study, and the radiological length of the cystic duct was carefully recorded. Patients were divided into two groups: I, absence of lithiasis: 113 patients (65 men, 48 women); and II, gallbladder lithiasis or lithiasis in the common bile duct with or without gallbladder lithiasis: 157 patients (73 men, 84 women). A statistically significant difference was observed among the two groups regarding the insertion of the cystic duct: implantation on the left side of the common bile duct represented a risk factor of lithiasis. The length of the cystic duct was not directly implicated. Hypokinesis of the gallbladder is currently recognized as being a major factor in the initial steps of lithogenesis, but the implantation of the cystic duct can play an important role by increasing cystic duct resistance and causing a reduced washout effect of the gallbladder contents, including cholesterol crystals.

La pose de protheses metalliques par voie endoscopique au niveau du duodenum represente une alternative therapeutique efficace et bien toleree au traitement chirurgical palliatif des obstructions duodenales d’origine neoplasique. Les dispositifs recents permettant une pose au travers du canal operateur d’un endoscope facilitent et securisent l’insertion. Cette alternative interesse particulierement les patients deja porteurs d’endoprothese biliaire palliative qui developpent secondairement une stenose duodenale.