Search

Background Gastric leak is the most feared surgical postoperative complication after sleeve gastrectomy. An endoscopic procedure is usually required to treat the leak. No data are available on the cost-effectiveness of different stent types in this procedure. Methods Between April 2005 and July 2016, patients with a confirmed gastric leak undergoing endoscopic treatment using a covered stent (CS) or double-pigtail stent (DPS) were included. The primary objective of the study was to assess overall costs of the stent types after primary sleeve gastrectomy. Secondary objectives were the cost-effectiveness of each stent type expressed as an incremental cost-effectiveness ratio (ICER); the incremental net benefit; the probability of efficiency, defined as the probability of being cost-effective at a threshold of €30 000, and identification of the key drivers of ICER derived from a multivariable analysis. Results One hundred and twelve patients were enrolled. The overall mean costs of gastric leak were €22 470; the mean(s.d.) cost was €24 916(12 212) in the CS arm and €20 024(3352) in the DPS arm (P = 0·018). DPS was more cost-effective than CS (ICER €4743 per endoscopic procedure avoided), with an incremental net benefit of €25 257 and a 27 per cent probability of efficiency. Key drivers of the ICER were the inpatient ward after diagnosis of gastric leak (surgery versus internal medicine), type of institution (private versus public) and duration of hospital stay per endoscopic procedure. Conclusion DPS for the treatment of gastric leak is more cost-effective than CS and should be proposed as the standard regimen whenever possible.

Few data are available to describe the changes in incidence of pediatric-onset inflammatory bowel disease (IBD). The aim of this study was to describe changes in incidence and phenotypic presentation of pediatric-onset IBD in northern France during a 24-year period.Pediatric-onset IBD (17 years) was issued from a population-based IBD study in France between 1988 and 2011. Age groups and digestive location were defined according to the Paris classification.1,350 incident cases were recorded (8.3% of all IBD) including 990 Crohn's disease (CD), 326 ulcerative colitis (UC) and 34 IBD unclassified (IBDU). Median age at diagnosis was similar in CD (14.4 years (Q1=11.8-Q3=16.0)) and UC (14.0 years (11.0-16.0)) and did not change over time. There were significantly more males with CD (females/males=0.82) than UC (females/males=1.25) (P=0.0042). Median time between onset of symptoms and IBD diagnosis was consistently 3 months (1-6). Mean incidence was 4.4/10In this population-based study, CD and UC incidences increased dramatically in adolescents across a 24-year span, suggesting that one or more strong environmental factors may predispose this population to IBD.

Acinar cell carcinoma of the pancreas is a rare tumour with specific clinical and paraclinical presentation. Its management is not well codified resulting from its low frequency.

Hilar cholangiocarcinoma is a cancer with a poor long-term survival rate (20% at five years), even after curative resection (R0: surgical margins free of tumour). Recent advances have been made in the preoperative management of these patients: clinical imaging, such as magnetic resonance cholangiography, biliary drainage according to the type of hilar obstruction or laparoscopic assessment before portal vein embolization. Extended hemihepatectomy has recently been recognized as the standard curative treatment for hilar bile-duct cancer with concomitant resection of the portal-vein bifurcation as a radical resective procedure. Neoadjuvant-photodynamic therapy could be a new approach to treating hilar cholangiocarcinoma decreasing tumour margins, which is a major prognostic factor.

We report a case of calcifying fibrous pseudotumor fortuitously discovered on abdominal CT-scan in a 50 year-old woman presenting with metrorragia. CT-scan showed a 2 cm hypodense nodular tumor of the gastric wall with granular calcifications. Upper endoscopy showed a nodular tumor along the lesser curvature of the gastric body, covered by normal gastric mucosa and biopsies were negative. A diagnosis of gastric stromal tumor was suspected and a partial gastrectomy was performed. On gross examination surgical specimen showed a firm, whitish nodular tumor measuring 2 cm in diameter. On microscopic examination the tumor was composed of whorls of dense hyalinized collagen bundles with a few fibroblasts. There were psammomatous calcifications and nodular aggregates of mononuclear inflammatory cells. Immunohistochemically, spindle cells stained for vimentin. They did not stain for smooth muscle actin, desmin, CD34, CD117, S100 protein, Ki-67 and ALK-1. Surgical resection of the tumor was complete. Patient has no evidence of disease with a follow-up of 12 months. Only seven cases of gastric calcifiying fibrous pseudotumors have been reported in the literature. These benign tumors are usually incidentally discovered. They have characteristic imaging and microscopic features and appear as a distinct clinicopathologic entity different from stromal tumors.

A patient presented with a cholangiocarcinoma of the common bile duct; it was initially considered unresectable leading to the placement of the metallic stent whose upper end extended beyond the convergence of the hepatic ducts. The metallic biliary stent became obstructed and so encrusted as to be unremovable; the patient required a left hepatectomy with resection of the stent and the biliary convergence in addition to a pancreatoduodenectomy in order to resect his primary lesion This difficult situation emphasizes that, whenever there is doubt as to the resectability of a biliary lesion, the decision to place a metallic stent should be the fruit of a thorough medico-surgical discussion; where there is any doubt, a plastic stent which is more easily removable should be placed.

Pancreas divisum, the most frequent congenital malformation of the pancreas, results from the absence of embryologic fusion of the dorsal and ventral pancreatic ducts which keep an autonomy of drainage. The dorsal pancreatic duct is dominant and drains the major part of the pancreatic fluid through a non adapted accessory papilla. The high prevalence of pancreas divisum in patients presenting recurrent acute pancreatitis, the presence of obstructive pancreatitis electively located on the dorsal pancreatic duct and the results of the treatments targeted on the accessory papilla are the arguments pleading for the pathogenic character of the pancreas divisum. Currently, the diagnosis of pancreas divisum is based on magnetic resonance imaging. For symptomatic patients (after exclusion of patients with intestinal functional disorders), results of endoscopic sphincterotomy or surgical sphincteroplasty are favourable in 75% of patients with recurrent acute pancreatitis. They are worse in patients with chronic pain. Surgical sphincteroplasty must be discussed in the same manner as the endoscopic treatment for sometimes avoiding multiplication of the procedures.

Fifteen to thirty percent of colonic cancers are diagnosed at acute colic obstruction stage. In this situation surgery is associated with a high morbi-mortality. The self-expandable metallic stents (SEM) have two objectives: (a) resolution of the obstructive to allow secondary planified radical surgical procedure; (b) palliative in the event of advanced disease.From May 2001 to December 2002, 11 patients, mean age 75 +/- 8 years, presenting with acute colic obstruction were initially treated by SEM placed by endoscopy. Four patients were classified score ASA 4. Ten patients had a colonic cancer, and a patient presented a peritoneal carcinomatosis from an ovarian carcinoma. Overall five patients had a carcinomatosis. Stenosis, mean length 4 +/- 3 cm, were located on the left colon. In five patients the SEM was proposed as a palliative treatment.Successfully placement of SEM was obtained in 10 (91%) patient without perforation. Three complications (bleeding, reobstruction, migration) were observed. Clinical success (colonic decompression within 96 h without endoscopic or surgical reintervention) was observed in nine out of ten (90%) patients. Six patients had a SEM with curative attempt allowing (i) colonic resection (9 +/- 2 days) without stomy (one postoperative death) in five patients; (ii) a colo-colic derivation for diffuse carcinomatosis discovered peroperatively. A diverting colostomy was carried out in two of the four patients (j6, j30) (reobstruction, migration) for whom the SEM had been proposed as palliative treatment.This study confirms that SEM and surgery are not competitive but complementary techniques. When the SEM is placed with curative attempt, it allows resolution of the obstructive syndrome and secondary planified radical surgical procedure under better conditions. The results observed in the palliative SEM group suggested to reconsider this indication.

Hydrolysis of dietary constituents is necessary to allow nutrients absorption by the small intestinal enterocytes. The digestion process takes place in the intestinal lumen, in the brush border membrane, in the enterocyte, and is mediated by a large number of hydrolases secreted in the gastrointestinal tract or produced by the epithelial cells and localized in the brush border. Nutrients are essentially absorbed via a transcellular route across enterocyte cell membranes to enter bloodstream or lymphatic circulation. Transport of nutrients across apical or basolateral membranes occur by active or facilitated mechanisms involving specific transporters. Water, electrolytes and small molecules can be partly absorbed via paracellular pathway. Tight junction permeability is regulated by osmolarity of intercellular space, definite nutrient concentrations in lumen, and activity of brush border membrane transporters.

We report two cases of Lyme disease, revealed by hepatic damage in a 71- and a 59-year old man. In the first case, the disease was revealed by febrile jaundice whereas, in the second case, results of liver tests showed cytolytic and cholestatic abnormalities with fever. Lyme disease is a zoonosis due to infection by Borrelia burdorferi transmitted by ticks. The multiple phases of the disease explain the polymorphism of the clinical manifestations. Usually, extrahepatic symptoms are first observed, including neurological tropisms of Borrelia burdorferi. On the contrary, hepatic impairment due to Lyme disease is rare, often asymptomatic and with biological manifestations only.

The pancreatic toxicity of oral 5-aminosalicylic acid (5ASA) derivatives used for the treatment of inflammatory bowel diseases remains controversial. A new case of mesalazine-induced acute pancreatitis (AP), with positive rechallenge, and an analysis of the previous published cases are presented. Twenty-nine patients (17 women, 12 men), aged 26.4 +/- 9.9 (12-43) years, were involved, receiving sulfasalazine (n = 11), mesalazine (n = 16), olsalazine (n = 1) or 5ASA without further informations (n = 1), for ulcerative colitis (n = 15), Crohn's disease (n = 13) or another indication (n = 1). The AP occurred in the first month of treatment in 71.4 per cent of the cases (n = 28). The clinical course was essentially benign in most of the cases. Recurrence of AP after rechallenge was observed in 17 of the 19 cases, even if the molecule, the dose or the form were modified. These results show that all 5ASA derivatives are potentially pancreatotoxic. An AP must be considered when an occurrence or increase of abdominal pain occurs during such therapy and warrants serum amylase assay and discontinuation of the drug.

The treatment of acute cholecystitis or angiocholitis is often difficult in elderly or very ill patients. The aim of this retrospective study was to assess the efficacy and the results of ultrasound guided percutaneous cholecystostomy in patients with acute cholecystitis or biliary tract obstruction and anesthetic or surgical contraindications.Thirty patients (25-93 years, 16 men and 14 women) were included in this study. Ultrasound guided percutaneous cholecystostomy was successful on the septic syndrome in 27 patients; endoscopic sphincterotomy was performed in 6 patients after clinical improvement. A failure of the procedure on sepsis was observed in 3 patients: cholecystectomy was performed after cardiac improvement in one patient, and 2 patients died. Two other patients died of extradigestive diseases. No serious complication related to cholecystostomy was observed.Ultrasound guided percutaneous cholecystostomy is a safe and simple procedure. It can be done at bedside and has low morbidity and mortality. It can be considered as a definitive treatment, or a temporary one with secondary surgical or endoscopic management.

BACKGROUND/AIMS: The period of refeeding in patients with acute pancreatitis is critical because they may have pain relapse. A multicentre, multidimensional, prospective study was performed to assess the frequency and the risk factors of pain relapse in these patients. METHODS: Patients were included if they had acute pancreatitis severe enough to stop oral feeding for more than 48 hours. Clinical, biochemical, radiological, and therapeutic data were prospectively recorded and analysed by unidimensional and multidimensional analysis. The moment to refeed patients was chosen by the clinician but the diet was the same in all centres. RESULTS: A total of 116 patients were included with a Ranson's bioclinical score > or = 3 in 35% and a Balthazar's CT score > or = D in 42%. The cause of acute pancreatitis was biliary in 47% and alcohol misuse in 31%. During the oral refeeding period, 21% of the patients had pain relapse. This occurred on days 1 and 2 in 50% of patients. The duration of the painful period was longer in patients who relapsed than in others (p < 0.002). Pain relapse occurred in 39% of patients with a serum lipase concentration > 3x the upper limit of the normal range the day before refeeding and in 16% of other patients (p < 0.03). Patients with higher Balthazar's CT scores had pain relapse more often than the others (p < 0.002). None of the therapeutic procedures significantly modified the frequency of pain relapse. Using multidimensional analysis, Balathazar's CT score, period of pain, and serum lipase concentration the day before refeeding were independently associated with an increased risk of pain relapse. At a threshold of 0.5, a logistic score had a 37% sensitivity, 95% specificity, and 83% accuracy to predict pain relapse. Pain relapse nearly doubled total hospital stay and hospital stay after the first attempt at oral refeeding. CONCLUSION: Pain relapse occurred in one fifth of the patients with acute pancreatitis during oral refeeding and was more common in patients with necrotic pancreatitis and with longer periods of pain. The results of this study can be used to predict high risk patients and are a first step in the prevention of pain relapse.

Infectious complications currently account for 80% of deaths from acute pancreatitis. The aim of this study was to evaluate the necessity for prophylactic antibiotics in patients with severe acute pancreatitis. Twenty-three consecutive patients suffering from acute alcoholic pancreatitis with computed tomography demonstrating two or more fluid collections were randomly assigned to one of two groups receiving either nonantibiotic treatment or prophylactic antibiotics (ceftazidime, amikacine, and metronidazole for 10 days). Sepsis was always diagnosed by positive cultures. Seven episodes of severe sepsis occurred (pancreatic infection and septic shock) in the nonantibiotic group, and no infection occurred in the prophylactic antibiotic group (p0.03). In conclusion, the use of prophylactic antibiotics in severe alcoholic acute pancreatitis significantly reduces the incidence of severe infection.

The epidemiology of viral hepatitis A has been evolved in the past few years, resulting in an increasing number of people without immunity to this virus. Health care workers are usually considered to be a group at risk of contamination by hepatitis A. A sero-epidemiologic study was performed in 525 members of the Pediatry, Gastroenterology, Internal medicine, Digestive radiology, kitchen and maintenance department staffs in the Amiens University Hospital. The aim of this study was to describe the epidemiology of hepatitis A and to estimate the level of occupational hazard it represents in the hospital.Age, low education level, country of origin in an endemic region and more than 2 siblings or children were significantly associated with the presence of anti-HAV antibodies. The prevalence of 50% was similar to that observed in other hospitals, but lower than that found in the general population. Seroprevalence was not higher in departments exposed to stools (Pediatry, Digestive endoscopy and laboratories) than in others. A higher rate of seroprevalence was observed in kitchen and maintenance staffs than in medical, laboratory and Radiology staffs, in Internal medicine than in the Gastroenterology Department, and in the laboratory than in Radiology Department. These differences disappeared after adjustment for extraprofessional parameters which appeared to be most important for hepatitis A epidemiology.The hospital occupational hazard for hepatitis A virus did not seem higher than that observed in the general population.

Pancreaticopleural fistula is a rare complication of pancreatic diseases. It results from communication between a pancreatic duct and the pleural space, either directly, or through a pseudocyst. The treatment is medical or surgical. We report a case of pancreaticopleural fistula occurring in a man suffering from chronic pancreatitis, and treated by endoscopy.

The authors report two cases of leiomyosarcoma of the small intestine revealed by lower and isolated digestive bleeding. In both cases, only the pelvic examinations by means of ultrasonography and/or CT scan have shown a mass which corresponded to the small intestine tumor. The authors underlined the necessity of US and/or CT scan pelvic when faced with a lower digestive bleeding whose etiology cannot be determined by the endoscopic or radiologic intestinal examinations.

Toutes ces donnees confirment un certain nombre d’elements evolutifs connus de la PCC. Elle evolue en 2 stades : un stade non calcifie puis un stade calcifie. L’incidence des douleurs a tendance a diminuer avec le temps ainsi que les poussees de pancreatite aigue, et, a l’inverse, la survenue de troubles de la glycoregulation a augmenter avec le temps. L’hyperamylasemie liee au sexe, plus frequente chez les hommes, n’a pas jusqu’a present ete signalee. Quant aux disparites regionales dans la realisation des examens paracliniques, elles traduisent une approche diagnostique differente de la PCC. La place de la wirsungographie retrograde dans les suites d’une poussee de pancreatite aigue alcoolique est discutee.

Many studies have established that nosocomial infection rates are more important in intensive care units (ICU). The objective of the study was to evaluate frequency and severity of imported and acquired nosocomial bacteremia in the different ICU of a teaching hospital in relation to bacteremia occurring in the entire hospital.

We report two cases of rare complication of acute pancreatitis: colonic stenosis and ureteral stenosis.

Idiopatic hereditary pancreatitis is a rare form of primary chronic pancreatitis transmitted as an autosomal dominant trait with a variable clinical penetration. We report an additionnal case.

The effects of dopamine and domperidone, a dopamine antagonist, have been studied on the exocrine secretion of the dog pancreas. The purpose of this study was to see if dopamine acted on enzyme secretion and if its action was merely 'pharmacological' or had a physiological role. Conscious Beagle dogs, fitted with Thomas cannulae were studied following infusions of dopamine 125-1000 micrograms kg-1 h-1. During dopamine infusion, a secretory peak lasting 10 min was observed. This was followed by a stable plateau which was approximately 1/3 of the peak. The pattern of water, bicarbonate and protein secretion was similar. The maximum effect was obtained with 500 micrograms kg-1 h-1 dopamine. The stimulatory action of dopamine was blocked by domperidone, without any detected effect on the central nervous system, but not by propranolol or phenoxybenzamine. Domperidone 10 micrograms kg-1 almost completely suppressed the secretory response to the maximally effective dose of dopamine. This inhibition was not competitive. Atropine decreased the secretory response to dopamine. The protein response was not observed when dopamine was infused against a background infusion of secretin. This suggests that the effect of dopamine on protein secretion could be due to a wash-out phenomenon. The maximally effective dose of domperidone, 10 micrograms kg-1, did not modify the pancreatic response to a solid meal. Thus, in the non-anaesthetized dog, the effect of dopamine on water and bicarbonate secretion has been confirmed. It is concluded that dopamine had no detectable action on protein secretion and that the physiological role of dopamine with respect to pancreatic secretion is still questionable.

During the 22nd week of her first pregnancy, a 28-year-old woman developed an attack of acute pancreatitis 10 months after pancreatoduodenectomy for chronic pancreatitis of alcoholic origin. She received total parenteral nutrition without complications for 83 days until the cesarean delivery of a child weighing 2,120 g. During that time, clinical, biological, and echographic signs of pancreatitis progressively disappeared. The favorable outcome for both mother and fetus suggests that prolonged TPN may be a useful measure in the management of severe digestive disease occurring during pregnancy.

The occurrence of solitary liver abscess is described in a young farmer with subacute terminal ileitis mimicking Crohn's disease. Serologic tests showed high titers of antibodies for Yersinia pseudotuberculosis. Treatment with troleandomycin was successful. This case report suggests that: (a) Yersinia infection must be systematically searched for in all forms of subacute ileitis; (b) a classically benign Yersinia ileitis may be complicated by liver abscess; (c) antibiotic therapy must be undertaken in Yersinia pseudotuberculosis subacute ileitis to avoid severe infectious complications.

Development of an intraabdominal bile collection (biloma) usually occurs secondary to traumatic or iatrogenic injury including abdominal surgery, percutaneous catheter drainage, and transhepatic cholangiogram. We present a case of hepatic subcapsular biloma following endoscopic retrograde cholangiography and identified by ultrasound and computed tomodensitometry examinations. A percutaneous drainage procedure allowed a subsequent endoscopic retrograde cholangiopancreatography to be performed that documented the location and extent of the bile leak and led to resolution of the biloma.

We report the case of a 66 year-old man who developed acute necrotizing pancreatitis. The usual etiologies of acute pancreatitis were easily excluded. Endoscopic retrograde cholangiopancreatography demonstrated a 10 mm diameter filling defect in the distal common bile duct. After endoscopic sphincterotomy, a polypoid tumour which appeared to arise from the common bile duct was delivered through the wound. Diathermic resection of the tumor was performed. Microscopic examination disclosed papillary adenoma, without histologic signs of malignancy. Follow-up was favorable.

The authors report the cases of 4 patients with jaundice following the administration of ajmaline. The disease had a pseudo- angiocholitic onset with fever, chills and pruritus in the 4 patients and abdominal pains in 2 patients. Serum transaminase activity and serum alkaline phosphatase activity were increased in the 4 patients. Blood eosinophilia was found in 3 patients. Liver lesions included predominantly centrilobular cholestasis, mild hepatocytic lesions, and portal inflammation. After the interruption of the drug administration, recovery occurred in the 4 patients. Two patients resumed the intake of ajmaline; transient hepatitis recurred in these 2 patients.