Search

BACKGROUND Pelvic collections may occur after surgery or in medical diseases. EUS transmural (TM) treatment has been shown as highly effective and safe, becoming an alternative to surgery or radiology. We aimed to assess the results of EUS management of pelvic collections. METHODS Retrospective, single-center observational study conducted between 2004 and 2018. Patients with symptomatic collections treated by EUS-TM approach were enrolled. The procedures were performed with a therapeutic EUS-scope, following two possible options: puncture-aspiration-injection of antibiotics PAIA (group 1) or EUS-drainage by plastic double pigtail stents (DPS) with an ano-cavitary drain (ACD) or lumen-apposing metal Stent (LAMS) (group 2). The main objective was to assess the clinical effectiveness based on symptoms and collection resolution. RESULTS Seventy-three patients were included. Mean age was 42.5 years [12-87]. 30 patients in group 1 (41%) underwent PAIA and 43 in group 2 (59%) underwent DPS ± ACD in 41 patients (95%) and LAMS in 2. The collection was postoperative in 58%. The mean size was 48.9 mm [8-120], 33 +/- 17 mm in group 1, compared to 67 ± 21 mm in group 2 (p

Background and study aims Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) for pancreatic neuroendocrine tumors (NETs) and intraductal pancreatic mucinous neoplasia (IPMN) with worrisome features or high-risk stigmata (WF/HRS) has been evaluated in few series with short-term outcomes. This studyʼs primary endpoint was to assess the long-term efficacy of EUS-RFA in patients with NETs or pancreatic cystic neoplasms (PCNs) over at least 3 years. Patients and methods Twelve patients had 14 NETs with a mean 13.4-mm size (10–20) and 17 patients had a cystic tumor (16 IPMN, 1 MCA) with a 29.1-mm mean size (9–60 were included. They were treated with EUS-guided RFA, evaluated prospectively at 1 year, and followed annually for at least 3 years. Results The mean duration of follow-up was 42.9 months (36–53). Four patients died during follow-up (17–42 months) from unrelated diseases.At 1-year follow-up, and 85.7 % complete disappearance was seen in 12 patients with 14 NETs. At the end of follow-up (45.6 months), complete disappearance of tumors was seen in 85.7 % of cases. One case of late liver metastasis occurred in a patient with initial failure of EUS-RFA. At 1-year follow-up, a significant response was seen in 70.5 % of 15 patients with PCNs. At the end of the follow-up, there was a significant response in 66.6 % with no mural nodules. Two cases of distant pancreatic adenocarcinoma unrelated to IPMN occurred. Conclusions EUS-RFA results for pancreatic NETs or PCNs appear to be stable during 42 months of follow-up.

ObjectiveDiagnostic tests, such as Immunoscore, predict prognosis in patients with colon cancer. However, additional prognostic markers could be detected on pathological slides using artificial intelligence tools.DesignWe have developed a software to detect colon tumour, healthy mucosa, stroma and immune cells on CD3 and CD8 stained slides. The lymphocyte density and surface area were quantified automatically in the tumour core (TC) and invasive margin (IM). Using a LASSO algorithm, DGMate (DiGital tuMor pArameTErs), we detected digital parameters within the tumour cells related to patient outcomes.ResultsWithin the dataset of 1018 patients, we observed that a poorer relapse-free survival (RFS) was associated with high IM stromal area (HR 5.65; 95% CI 2.34 to 13.67; pConclusionThese findings suggest that artificial intelligence can potentially improve patient care by assisting pathologists in better defining stage III colon cancer patients’ prognosis.

International audience; Background & aims: Pancreatic ductal adenocarcinoma (PDAC) is associated with the highest incidence of venous thromboembolism (VTE) of any cancer type. However, little is known about risk factors for VTE or its outcomes in patients with PDAC.Methods: We collected data from a prospective, observational study performed at multiple centers in France from May 2014 through November 2018 (the Base Clinico-Biologique de l'Adénocarcinome Pancréatique [BACAP] study) linked to a database of patients with a new diagnosis of PDAC of any stage. Data were collected from 731 patients at baseline and during clinical follow-up or in the event of symptoms. The primary endpoint was the onset of VTE during follow-up. The secondary endpoints were progression-free survival (PFS) and overall survival (OS) times.Results: During a median follow-up of 19.3 months, 152 patients (20.79%) developed a VTE. The median time from PDAC diagnosis to the onset of VTE was 4.49 months. Cumulative incidence values of VTE were 8.07% (95% confidence interval [CI], 6.31-10.29) at 3 months and 19.21% (95% CI, 16.27-22.62) at 12 months. In multivariate analysis, PDAC primary tumor location (isthmus vs head: hazard ratio [HR], 2.06; 95% CI, 1.09-3.91; P = .027) and stage (locally advanced vs resectable or borderline: HR, 1.66; 95% CI, 1.10-2.51, P = .016; metastatic vs resectable or borderline: HR, 2.50; 95% CI, 1.64-3.79; P < .001) were independent risk factors for the onset of VTE. Patients who developed VTE during follow-up had shorter times of PFS (HR, 1.74; 95% CI, 1.19-2.54; P = .004) and OS (HR, 2.02; 95% CI, 1.57-2.60; P < .001).Conclusion: In an analysis of data from the BACAP study, we found that frequent and early onsets of VTE after diagnoses of PDAC are associated with significant decreases in times of PFS and OS. Studies are needed to determine whether primary prophylaxis of VTE in patients with PDAC will improve morbidity and mortality related to VTE. (ClinicalTrials.gov, Number: clinicaltrials.gov as number NCT02818829).

Background Pancreatic neuroendocrine tumors (NETs) and intraductal pancreatic mucinous neoplasia (IPMN) with worrisome features are surgically managed. Endoscopic ultrasound (EUS)-guided radiofrequency ablation (RFA) has recently been developed. The safety of EUS-RFA was the primary end point of this study, its efficacy the secondary end point. Methods This was a prospective multicenter study that was planned to include 30 patients with a 1-year follow-up with either a NET Results 12 patients had 14 NETs (mean size 13.1 mm, range 10 – 20 mm); 17 patients had cystic tumors (16 IPMNs, 1 MCA; mean size 28 mm, range 9 – 60 mm). Overall three adverse events occurred (10 %), two of these in the first two patients (one pancreatitis, one small-bowel perforation). After these initial patients, modifications in the protocol resulted in a decrease in complications (3.5 %), with one patient having a pancreatic ductal stenosis. Among the 14 NETs, at 1-year follow-up 12 had completely disappeared (86 % tumor resolution), with three patients having a delayed response. Among the 17 PCNs, at 12 months, there were 11 complete disappearances and one diameter that decreased by > 50 % (significant response rate 71 %). All 12 mural nodules showed complete resolution. Conclusions EUS-RFA of pancreatic NETs or PCNs is safe with a 10 % complication rate, which can be decreased by improved prophylaxis for the procedure.

IF 7.191 (2017); International audience; BACKGROUND:Previous studies showed that high and low body mass index (BMI) was associated with worse prognosis in early-stage colorectal cancer (CRC), and low BMI was associated with worse prognosis in metastatic CRC (mCRC). We aimed to assess efficacy outcomes according to BMI.PATIENTS AND METHODS:A pooled analysis of individual data from 2085 patients enrolled in eight FFCD first-line mCRC trials from 1991 to 2013 was performed. Comparisons were made according to the BMI cut-off: Obese (BMI ≥30), overweight patients (BMI ≥ 25), normal BMI patients (BMI: 18.5-24) and thin patients (BMI

Purpose Gemcitabine is the standard chemotherapy for patients with metastatic pancreatic adenocarcinoma. Although the 5-fluorouracil (5FU), folinic acid and cisplatin combination (LV5FU2-CDDP) is an option, the optimal order of the regimens must be determined. The first strategic phase III trial comparing LV5FU2-CDDP followed by gemcitabine versus gemcitabine followed by LV5FU2-CDDP was conducted. Methods Patients with metastatic pancreatic adenocarcinoma, performance status (PS) 0–2, without prior chemotherapy were randomly assigned (1:1) to receive either LV5FU2-CDDP followed by gemcitabine at disease progression or toxicity (Arm A), or the opposite sequence (Arm B). 202 patients had to be included and 170 deaths had to be observed to detect an expected improvement in median overall survival (OS) from 6.5 to 10 months in Arm A (two-sided α = 5% and β = 20%). Results 202 patients were included (Arm A, 102; Arm B, 100). Median age, male/female ratio, PS 0–1 and previous surgery were similar in the two arms. After a median follow-up of 44 months, median OS in Arm A was 6.6 months versus 8.0 months in Arm B (p = 0.85). Median progression-free survival was similar between Arms A and B. More grade 3/4 toxicities were observed when LV5FU2-CDDP was administered as a first-line treatment compared with gemcitabine: 79% versus 64% (p = 0.018). Conclusion This trial did not show any strategic advantage to using LV5FU2-CDDP as a first-line treatment and suggests that gemcitabine remains the standard first-line treatment. Sixty-one per cent of patients were able to receive a second line of chemotherapy.

Summary Objective The aim of this study was to investigate the clinical progression of patients who had severe acute pancreatitis (AP) and a stay in hospital of more than a month. Methods A total of 24 patients (median age: 57 years) were included in this eight-year retrospective study. Cure was defined as the restoration of the pancreatic parenchyma, and the disappearance of all pseudocysts and pancreatic fistulae. Data including the duration of hospital stay, disease severity and pancreatic sequelae were also collected. Results The median total duration of the hospital stay was 67 days. The overall mortality rate was 20.8%, whereas the mortality rate due to AP was 12.5%. The average healing period was 7.7 months. On univariate analysis, patients who also had respiratory diseases, chronic alcoholism, necrotizing superinfection, pseudocyst, food intolerance and/or hospital-acquired infection took significantly longer to heal. After cure, we observed pancreatic and/or hepatic duct stenoses in 50% of cases, and the onset or aggravation of diabetes in 25%. Conclusion In patients hospitalized for more than one month because of necrotizing AP, the rate of mortality is around 20%, with a final hospital stay of two months and a healing period of more than seven months. In addition, half of the patients presented with pancreatic or biliary sequelae.

Resume Introduction Le traitement des collections apres chirurgie pancreatique releve d’une prise en charge multidisciplinaire. Il peut s’envisager de plusieurs manieres : abstention, drainage externe, traitement endoscopique ou reprise chirurgicale. Methodes Nous rapportons ici les cas de cinq patients traites avec succes par endoscopie interventionnelle apres chirurgie pancreatique compliquee de collections. Le bilan lesionnel etait apporte par un scanner abdominopelvien avec injection, associe ou non a une echoendoscopie haute. Resultats Le traitement des collections consistait en une kystogastrostomie dans tous les cas, realisee sous echoendoscopie dans quatre cas suivie par la mise en place de deux protheses double queue de cochon, parfois associee a un drain nasokystique pour rincage et associee a un drainage transpapillaire pancreatique dans deux cas. Tous les patients ont ete gueris sur un plan clinique et avec une disparition de l’image radiologique dans un delai de 33 jours a trois mois. Une seule complication par surinfection est survenue et a ete traitee par la mise en place d’un drain nasokystique entre les protheses kystogastriques pour lavage pendant huit jours. Conclusion L’endoscopie interventionnelle, lorsqu’elle s’inscrit dans une concertation multidisciplinaire, peut permettre de traiter des collections pancreatiques postoperatoires.

Introduction : la fistule anastomotique est l’une des principales complications de l’oesophagectomie pour cancer de l’oesophage ou de la jonction oeso‐cardiale. Elle serait responsable de 40% des deces en post‐operatoire de cette chirurgie. Depuis 10 ans, la prise en charge endoscopique de ces fistules est devenue une alternative face a la reprise chirurgicale ou au traitement conservateur. L’objectif de cette etude est d’evaluer l’efficacite et les caracteristiques du traitement endoscopique dans cette indication. Materiel et methodes : dans cette etude monocentrique, 35 patients inclus consecutivement ont ete traites endoscopiquement pour une fistule anastomotique apres oesophagectomie pour cancer de l’oesophage ou de la jonction oeso‐cardiale entre juin 2010 et juin 2014. Toutes les procedures endoscopiques ont ete realisees dans l’unite d’endoscopie de l’hopital Nord a Marseille, par des endoscopistes interventionnels, chez des patients intubes sous anesthesie generale, avec un endoscope a large canal operateur (3,8mm, Pentax, Japon) sous controle scopique. Un controle endoscopique etait systematiquement effectue 4 a 8 semaines apres afin de s’assurer de l’efficacite ou de la necessite d’un traitement additionnel. L’efficacite primaire et secondaire, le delai entre la chirurgie, le diagnostic et l’endoscopie, le nombre de reprises endoscopiques, le materiel utilise (prothese, clip, drain), les complications et le taux de mortalite ont ete evalues et une analyse uni et multivariee a ete realisee afin de mettre en evidence des facteurs predictifs de succes. Resultats : parmi les 35 patients, il y avait 4 femmes et 31 hommes avec un âge moyen de 61,7 ans ± 8,9 [43‐85]. Les principales techniques chirurgicales employees ont ete celles de Lewis‐Santy pour 48,6% des cas et de Akiyama pour 45,7%. 71,4% des patients avaient beneficie d’une radiochimiotherapie neoadjuvante et 77,1% etaient hospitalises en reanimation. Le delai median entre la chirurgie et le premier traitement endoscopique etait de 8,5 jours (IQR ; 6,00‐18,25). 88,6% des patients ont ete traites par une prothese metallique oesophagienne avec un taux final d’extirpabilite de 100% et un taux de migration de 18%. Le nombre moyen d’endoscopies realisees par patient a ete de 2,6 ± 1,57 [1‐10] avec un nombre moyen de protheses oesophagiennes de 1,6 ± 1,35 [0‐7] par patient. L’efficacite primaire du traitement endoscopique a ete de 48,6% et l’efficacite finale de 68,6%. Le taux de mortalite en cas de traitement endoscopique a ete de 17%, aucun deces n’etant lie au traitement endoscopique par lui‐meme. Le type de technique chirurgicale, la realisation d’une radiochimiotherapie pre‐operatoire et la taille de l’orifice fistuleux n’ont pas eu d’influence sur l’efficacite du traitement endoscopique que ce soit en analyse uni ou multivariee. Conclusion : La prise en charge endoscopique des fistules anastomotiques post‐oesophagectomie est efficace, en particulier avec les protheses oesophagiennes metalliques et n’entraine aucune complication liee au traitement. Elle est de plus associee a un taux de mortalite de 17% inferieur a celui de la reprise chirurgicale ou du traitement conservateur (40 a 100%).

International audience; BACKGROUND:Metastatic colorectal cancer (mCRC) frequently occurs in elderly patients. However, data from a geriatric tailored randomized trial about tolerance to and the efficacy of doublet chemotherapy (CT) with irinotecan in the elderly are lacking. The benefit of first-line CT intensification remains an issue in elderly patients.PATIENTS AND METHODS:Elderly patients (75+) with previously untreated mCRC were randomly assigned in a 2 × 2 factorial design (four arms) to receive 5-FU (5-fluorouracil)-based CT, either alone (FU: LV5FU2 or simplified LV5FU2) or in combination with irinotecan [IRI: LV5FU2-irinotecan or simplified LV5FU2-irinotecan (FOLFIRI)]. The CLASSIC arm was defined as LV5FU2 or LV5FU2-irinotecan and the SIMPLIFIED arm as simplified LV5FU2 or FOLFIRI. The primary end point was progression-free survival (PFS). Secondary end points were overall survival (OS), safety and objective response rate (ORR).RESULTS:From June 2003 to May 2010, 71 patients were randomly assigned to LV5FU2, 71 to simplified LV5FU2, 70 to LV5FU2-irinotecan and 70 to FOLFIRI. The median age was 80 years (range 75-92 years). No significant difference was observed for the median PFS: FU 5.2 months versus IRI 7.3 months, hazard ratio (HR) = 0.84 (0.66-1.07), P = 0.15 and CLASSIC 6.5 months versus SIMPLIFIED 6.0 months, HR = 0.85 (0.67-1.09), P = 0.19. The ORR was superior in IRI (P = 0.0003): FU 21.1% versus IRI 41.7% and in CLASSIC (P = 0.04): CLASSIC 37.1% versus SIMPLIFIED 25.6%. Median OS was 14.2 months in FU versus 13.3 months in IRI, HR = 0.96 (0.75-1.24) and 15.2 months in CLASSIC versus 11.4 months in SIMPLIFIED, HR = 0.71 (0.55-0.92). More patients presented grade 3-4 toxicities in IRI (52.2% versus 76.3%).CONCLUSION:In this elderly population, adding irinotecan to an infusional 5-FU-based CT did not significantly increase either PFS or OS. Classic LV5FU2 was associated with an improved OS compared with simplified LV5FU2.CLINICALTRIALSGOV:NCT00303771.

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.

BACKGROUND AND STUDY AIMS The rendezvous endoscopic approach, already described, might be an interesting technique in complete esophageal obstructions (CEO). PATIENTS AND METHODS This retrospective report on nine patients referred because of CEO classified patients into two groups based on length of their esophageal disruption: the long (> 5 cm) group were three patients (esophageal stripping at stent removal [n = 2] and caustic ingestion [n = 1]; two patients having superior esophageal sphincter [SES] destruction); the short (

BACKGROUND AND STUDY AIMS Rectovaginal septal endometriosis (RVSE) can pose serious therapeutic problems when there is infiltration of the rectal septum (which occurs in approximately half of the cases). The aim of this study was to assess the value of endoscopic ultrasonography in diagnosing rectal wall involvement by pelvic endometriosis. PATIENTS AND METHODS A prospective study was carried out from May 1998 to March 2003 at a single hospital center. The 30 patients included in the study presented with suspected RVSE and underwent systematic anorectal endoscopic ultrasonographic exploration prior to the surgical intervention. The endoscopic ultrasonography was carried out under general anesthesia with a 7.5-MHz miniprobe equipped with a distal balloon. RESULTS The anorectal endoscopic ultrasonographic examination (EUS) showed the presence of endometriosis in the rectovaginal septum in 26 patients (88 %), in the uterosacral ligaments in 10 patients (33 %), and in the ovaries in two patients (6 %). At EUS, the nodules were infiltrating the rectal wall in 17 patients (56 %). The surgical exploration demonstrated endometriosis in the rectovaginal septum in 26 cases, the uterosacral ligaments in 22 cases, and the ovaries in 16 cases. The rectal wall was completely infiltrated in 12 cases and only partly in four cases, and intestinal tract resection was required in 10 cases. The sensitivity, specificity, and positive and negative predictive value of anorectal endoscopic ultrasonography as a means of diagnosing endometriosis of the rectovaginal septum and infiltration of the rectal wall were found to be 96 %, 100 %, 100 % and 83 %, and 92 %, 66 %, 64 % and 92 %, respectively; and the diagnostic accuracy was at 96 % and 80 %, respectively. The sensitivity for detecting nodules in the uterosacral ligaments or in the ovaries was 42 % and 14 %, respectively, leading to diagnostic accuracy rates of 56 % and 53 %. CONCLUSIONS In terms of its sensitivity and its negative predictive value, anorectal endoscopic ultrasonography is a very effective means of detecting endometriosis of the rectovaginal septum and assessing possible infiltration of the rectal wall. However, this method is not as accurate for nodules located far from the EUS probe, as is the case with the uterosacral ligaments and ovaries.

Autoimmune pancreatitis is a clinical entity with many different clinical and biological characteristics that make diagnosis difficult. Sensitive and specific pancreatic antibodies are still lacking to assess the diagnosis as is the availability of interpretable pathological specimens. However, suggestive features consist mainly of radiological findings and clinical anomalies, particularly if there are associated autoimmune-related diseases. The immunological pathway is probably of cell-mediated origin, although various autoantibodies, insensitive and non-specific, may exist. Finally, many studies are needed to define more efficient diagnostic criteria and to discover the true prevalence of autoimmune pancreatitis.

Background Chemoradiotherapy (CHRT) is often advocated for locally-advanced biliary tract cancer (LABTC). However there was not comparative study with chemotherapy alone (CH). Patients and methods Patients with hilar or extrahepatic non-metastatic, LABTC could be included in this phase II trial. The inclusion criteria required World Health Organisation (WHO) performance status ⩽2, bilirubinemia ⩽50 μM/L after biliary drainage if necessary, and possibility of external radiotherapy. Fluorouracil (5 FU) infusion and cisplatin, were given in association to radiotherapy (50 Gy) in the CHRT arm. Gemcitabine + oxaliplatin (GEMOX) was planned for 6 months in the CH arm. End-points were progression-free survival (PFS), overall survival (OS), toxicity and rate of biliary complications. Results The trial was closed before completion due to slow recruitment. Eighteen and 16 patients were included in the CHRT and CH arms, respectively. Median follow up was 27.9 months (±2.8). Grade III–IV toxicities were mostly haematological (23% and 25%), and gastrointestinal (11% and 6%), in the CHRT and CH arm, respectively. Biliary complications occurred in 28% of patients in the CHRT arm and 44% of patients in the CH arm (risk ratio (RR): 1.60 [0.65–3.92]). Median PFS was 5.8 months in the CHRT group and 11.0 months in the CH group (hazard ratio (HR): 0.65 [0.32–1.33]). Median OS was 13.5 months in the CHRT group and 19.9 months in the CH group (HR: 0.69 [0.31–1.55]). Conclusions Combination of gemcitabine plus cisplatin seems to be at least as efficient as chemoradiotherapy (50 Gy plus 5 FU and cisplatin) in LABTC.

Background Chemotherapy combinations and addition of cetuximab or bevacizumab to chemotherapy have been shown to improve overall survival of metastatic colorectal cancer (CRC) patients. However, the efficacy of cetuximab when administered after bevacizumab failure is still unknown. Methods Fifty-eight consecutive patients diagnosed with advanced colorectal cancer between treated with cetuximab following irinotecan failure were included in our analysis. A multivariate Cox model analysis was performed to estimate the effect of previous bevacizumab regimen on survival. Results Thirteen (22.4%) were pre-treated with anti-VEGF agents. None of them responded to cetuximab, and this subgroup presented a significantly decreased disease-specific survival as compared to treatment-naive patients (9.1 months vs. 4.9 months; p = 0.026). This difference remained statistically significant in a multivariate Cox model after adjusting for age, sex, performance status (PS), and K-RAS status (RR = 2.2; 95% CI: 1.1–4.5, p = 0.03). Conclusion These study results suggest that a previous anti-VEGF therapy decrease cetuximab efficiency.

AIM: To report the results of a medical management of sphincter of oddi dysfunction (SOD) after an intermediate follow-up period. METHODS: A total of 59 patients with SOD (2 men and 57 women, mean age 51 years old) were included in this prospective study. After medical treatment for one year, the patients were clinically re-evaluated after an average period of 30 mo. RESULTS: The distribution of the patients according to the Milwaukee’s classification was the following: 11 patients were type 1, 34 were type 2 and 14 were type 3. Fourteen patients underwent an endoscopic sphincterotomy (ES) after one year of medical treatment. The median intermediate follow-up period was 29.8 ± 3 mo (3-72 mo). The initial effectiveness of the medical treatment was complete, partial and poor among 50.8%, 13.5% and 35%, respectively, of the patients. At the end of the follow-up period, 37 patients (62.7%) showed more than 50% improvement. The rate of improvement in patients who required ES was not significantly different compared with the patients treated conservatively (64.2% vs 62.2%, respectively). CONCLUSION: Our study confirms that conservative medical treatment could be an alternative to endoscopic sphincterotomy because, after an intermediate follow-up period, the two treatments show the same success rates.

International audience; AIM: Endoscopic sphincterotomy is an efficient means of treating sphincter of Oddi dysfunction (SOD), but it is associated with a morbidity rate of 20%. The aim of this study was to assess how frequently endoscopic sphincterotomy was performed to treat SOD in a group of patients with a 1-year history of medical management. METHODS: A total of 59 patients, who had been cholecystectomized 9.3 years previously on average, were included in this study and they all underwent biliary scintigraphy. Medical treatment was prescribed for 1 year. Endoscopic sphincterotomy was proposed for patients whose medical treatment had been unsuccessful. RESULTS: Eleven patients were rated group 1 on the Milwaukee classification scale, 34 group 2 and 14 group 3. The hile-duodenum transit time (HDTT) was lengthened in 32 patients. The medical treatment was efficient or fairly efficient in 45% of the group 1 patients, 67% of the group 2 patients, and 71.4% of the group 3 patients (P=0.29). Only 14 patients out of the 21 whose medical treatment was unsuccessful agreed to undergo endoscopic sphincterotomy. HDTT was lengthened in 11 of the 14 patients undergoing endoscopic sphincterotomy and in 21 of the 45 non-endoscopic sphincterotomy patients (P=0.03). Twelve of the 14 patients who underwent endoscopic sphincterotomy were cured. CONCLUSION: In this prospective series of patients with a 1-year history of medical management, only 23% of the patients with suspected SOD underwent endoscopic sphincterotomy although 54% had an abnormally long HDTT.

International audience; BACKGROUND: Endoscopic procedures have become a first-line approach to the treatment of pancreatic pseudocysts. OBJECTIVE: Our purpose was to determine the results of a therapeutic algorithm including EUS-assisted drainage, transpapillary drainage, and conventional endoscopic drainage in terms of (1) feasibility and efficacy of the endoscopic procedure and (2) morbidity. DESIGN: Prospective study with a treatment algorithm drawn up before the endoscopic procedure, including either conventional endoscopic transmural drainage (CTMD), conventional transpapillary drainage (CTPD), or EUS-guided transmural drainage (EUS-GTD). PATIENTS: A total of 50 patients, including 15 women and 35 men with a mean age of 51 years, were included in this prospective study. RESULTS: The mean size of the pseudocysts was 8.2 cm (range 3-12 cm). A total of 29 pseudocysts did not bulge into the digestive wall (58%); 24 (48%) neither bulged nor communicated with the pancreatic duct. EUS-GTD was performed on 28 patients (56%), CTMD on 13 patients (26%), and CTPD on 8 patients (16%), and endoscopic procedures failed in 1 patient. Technical feasibility was 98% (49/50), and clinical success was achieved in 90% of the cases and disappearance of the pseudocysts in 96% of the cases without significant differences among the 3 groups. The morbidity rate was 18% (9 cases). Five superinfections occurred in the EUS-GTD group and 1 in the CTMD group. One death occurred from late bleeding in the CTMD group. LIMITATION: Randomization of patients in this prospective study was not possible because of the different characteristics of the pseudocysts. CONCLUSION: With this algorithm, clinical success was achieved in 45 (90%) of the cases and disappearance of the pseudocysts in 48 (96%) of the cases with a reasonable morbidity rate. In half of the cases, EUS is required for treating pancreatic pseudocyst.

Clinical symptoms of inflammatory bowel disease (IBD)-associated pancreatitis are found in approximately 2% of patients, but the frequency of the disease could be much higher since IBD-associated pancreatitis could be mainly a silent disease. The aim of this study was to describe the radiological and biological features of IBD-associated pancreatitis and assess its frequency by comparing data from IBD patients with or without a history of pancreatitis.79 patients were prospectively enrolled (median age 36 years). Symptoms of pancreatitis had been previously recorded in 30 of them (group P; the other 49 patients (group C) had no history of pancreatitis. Pancreatic ductal changes were investigated by pancreato-MRI. Exocrine function was assessed by the fecal elastase test and by assaying serum amylase, lipase, C-reactive protein, PAP, IgG4 and pancreatic autoantibodies.Increased levels of amylase and lipase occurred in 11% of IBD patients, that frequency being significantly higher in group P (23%) than in group C (4%) (p = 0.01). Low fecal elastase reflecting impaired exocrine function was observed in 30% of patients and again significantly more in group P (50%) than in group C (17%) (p = 0.04). The frequency of elevated values varied from 12% for amylase and lipase to 18% for PAP, 20% for pancreatic autoantibodies and 45% for CRP, without a difference between groups P and C. Silent exocrinopathy was observed in both groups, pancreatic autoantibodies and pancreatic duct alterations being found in 20 and 11% of patients, respectively.Finding pancreatic insufficiency in about 30% of the included patients and in 50% of those with a previous history of pancreatitis suggests that IBD might be associated with chronic pancreatic alteration. Episodes of mild acute pancreatitis observed in some patients are not always due to adverse effects of treatments and can be acute manifestations of the chronic disease.

Diagnostic indications of endoscopic retrograde cholangio-pancreatography (ERCP) have not completely disappeared. But the substitution of this examination by endoscopic ultrasonography (EUS) in the work-up of biliary and pancreatic diseases is supported by EUS's reliability and cost-effectiveness. In the future EUS will be challenged by magnetic resonance cholangio-pancreatography (MRCP), when easily available. Therefore, the choice between EUS, MRCP and ERCP will become simplified: MRCP as the first option for diagnosis, EUS in doubtful cases needing sampling for pathology and ERCP as a therapeutic alternative to some surgical procedures.

BACKGROUND AND STUDY AIMS Complications of endoscopic sphincterotomy (ES) have been assessed in recent multicenter studies. The aim of this series was to report and identify risk factors for complications of ES at a single tertiary referral center. PATIENTS AND METHODS Between 1996 and 2000, 1159 consecutive endoscopic retrograde cholangiopancreatographies (ERCP) procedures were performed and their related complications were assessed. A total of 658 patients (57 %) underwent ES. All the clinical, radiological and biological data were carefully recorded within the 30 days following the procedure. Multivariate analysis was performed using a stepwise logistic model. RESULTS The morbidity rate for ES was 7.7 %, being moderate to severe in 5 %. Morbidity included acute pancreatitis (3.5 %), perforations (1.8 %), sepsis (1.2 %) and bleeding (1.2 %). The 30-day mortality was 0.9 %. In the 1159 ERCP procedures, 231 patients underwent precut papillotomy (20 %) followed by sphincterotomy in 174 cases. Using logistic regression analysis, the risk factors for ES were precut papillotomy (relative risk, RR 2.76), confidence interval, (CI 1.39 - 5.49) and the presence of sphincter of Oddi dysfunction (RR, 7.72, CI 3.2 - 18.4). CONCLUSIONS In this single-center series, we found a complication rate of ES in about 7 %, comparable to that in multicenter series. Precut papillotomy and sphincter of Oddi dysfunction were the main independent risk factors for ES.

But de l'Etude: Apres une sphincterotomie endoscopique (SE) les patients sont le plus souvent laisses arbitrairement a jeun jusqu'au lendemain de l'examen. Le but de cette etude etait de verifier l'interet de ce jeune systematique apres SE. Patients et Methodes: De Janvier 1999 a Septembre 2001, nous avons realise une etude prospective randomisee.146 patients qui avaient une alimentation normale prealable ont ete inclus et tires au sort immediatement apres sphincterotomie endoscopique, biliaire ou pancreatique. Deux groupes ont ete constitues: reprise alimentaire precoce 6 heures apres le cathetherisme (groupe RAP) ou reprise alimentaire retardee de 24 heures (groupe RAR). Les deux groupes de patients etaient comparables en ce qui concerne les caracteristiques epidemiologiques et la procedure endoscopique. Resultats: 8 patients du groupe RAP (11 %) ont eu recours a des antalgiques mineurs alors que 26 dans le groupe RAR (37%) en ont necessite (P=0.001). La consommation d'antalgiques majeurs de type morphinique etait semblable dans les 2 groupes (8 vs. 5 patients; NS). II y avait significativement moins de douleurs a la realimentation dans le groupe RAP (5 vs. 13 patients; P=0.04). L'amylasemie augmentait significativement apres sphincterotomie endoscopique dans les deux groupes alors que la lipasemie n'augmentait que dans le groupe RAP. Le taux de complications apres sphincterotomie endoscopique etait identique, en particulier en ce qui concerne la pancreatite aigue. La duree d'hospitalisation etait significativement reduite dans le groupe RAP (2.6 jours vs. 3.8 jours; P= 0.01). Conclusion: Le jeune systematique ne se justifie pas apres sphincterotomie endoscopique. Bien au contraire, il entraine une augmentation du recours aux antalgiques mineurs, du risque de douleur a la realimentation et de la duree de sejour.

Background No study is available to determine the best strategy for inoperable locally advanced biliary tract cancer. CHRT has shown its efficacy in small series to control the local evolution. However CHRT results were not compared to palliative CH. Methods This prospective multicentric phase II trial randomized patients with hilar or extrahepatic non metastatic and locally advanced biliary tract cancer between CHRT (50 Gy plus 5FU infusion 300 mg/m2/D, D1 to D33 and CDDP 20 mg/m2/D D1 to D4 and D29 to D32 or CDDP 80 mg/m2 D1 and D29) and CH (G 1000 mg/m2 D1 + O 100mg/m2 D1; D1 = D15, 6 months). Main inclusion criteria required WHO performance status Results The study was closed before completion of the planned number of patients due to slow accrual. Eighteen patients and 16 patients were included in CHRT and CH arms, respectively. All prognostic factors were well balanced between the two arms. A second line of chemotherapy was given after progression to 55.6% and 25% of the patients in the CHRT and CH. Most frequent grade 3-4 adverse events respectively for CHRT and CH arms were haematological (23.5% and 25.0%), gastrointestinal (11.8% and 6.2%) and neurological toxicities (0 and 18.7%). Treatment had to be stopped due to toxicity in 1 and 2 patients. Median PFS was 5.8 months in CHRT group and 11.0 months in CH group (HR: 0.65 [0.32-1.33]). Median OS was 13.5 months in CHRT group and 19.9 months in CT group (HR: 0.69 [0.31-1.55]) with a median follow-up of 22.8 months in the CTRT group and 22.5 months in the CT group. Biliary complications, occurred in 27.8% of the patients in CHRT arm and 43.7% of the patients in CH arm (RR: 1.6[0.65-3.9]). It was mainly obstruction (26.7% and 18.2%) or angiocholitis (20.0% and 36.4%). Conclusion Our results suggest that G and O chemotherapy is a valuable option in locally advanced biliary tract cancer. Efficacy outcomes seem to be better than CHRT without increase of clinically relevant adverse events. This study was supported by grant from Sanofi France Disclosure J.M. Phelip: Sanofi. All other authors have declared no conflicts of interest.