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Validation d’un algorithme d’orientation en ligne qui classe les demandes de consultations en 3 catégories : trouble respiratoire (TR), insomnie (I), ou trouble complexe (TC) nécessitant une consultation par un spécialiste du sommeil.

La prévalence du SAS en population cardiologique est élevée mais les ressources polygraphiques insuffisantes. Un nouveau questionnaire (QS) est donc proposé pour dépister les SAS significatifs en cardiologie libérale.

Évaluer la non-infériorité de 3 biopsies ciblées (BC) par fusion d’image IRM-échographie par rapport à 10–12 biopsies systématisées (BS) pour diagnostiquer un cancer de la prostate chez les patients ayant une image prostatique suspecte isolée détectée en IRM multiparamétrique.

La polygraphie (PG) et la polysomnographie (PSG) sont utilisées pour le diagnostic du syndrome d’apnées obstructives (SAHOS) mais leur équivalence dans des cohortes cliniques non sélectionnées est inconnue Notre hypothèse est que la méthode diagnostique influence le diagnostic et la sévérité du SAHOS.

Aim : The diagnosis of early chronic pancreatitis (ECP) remains difficult and endoscopic ultrasonography (EUS) features are still controversial. The aim of this study was to evaluate the long term follow-up of patients with ECP diagnosed at EUS. Methods : Between 1994 and 1998, 37 patients were diagnosed to have ECP at EUS. All experienced at least one episode of non biliary acute pancreatitis. None had evidence of pancreatic stone on plain film of the abdomen or on CTscanner. The ECP were classified as group A (possible ECP with either parenchymal signs or ductal signs), as group B (probable ECP with both parenchymal and ductal signs) and as group C (certain ECP with pancreatic stones). Results : 11 patients were lost to follow-up, 26 men with median age of 46.5 (23-70) years and median alcohol consumption of 76 ( 0-150) g per day, have been followed for a median duration of 37 (1-94).months.

Aim: To assess endoscopic treatment in hyperalgic chronic pancreatitis (CP). Patients and methods: Between 2/95 and 3/99, 21 patients (M: 17,W: 4), mean age 42 years (range: 22-69) with painful CP requiring dialy analgesic treatmentwith: central analgesic (such as dextropropoxyphen or codeine) or opioöds,were admitted in our unit for endoscopic retrograde cholangio-pancreatography (ERCP). Endoscopic treatment consisted to pancreatic sphincterotomy +/- pancreatic stent insertion. Follow-up was performed including clinical (pain score, weight) and therapeutic evaluation (nature and dose of analgesic medication). Patients were classified into 3 groups according to follow-up: Group I (pain disappearance no analgesic treatment), Group II (pain and analgesic treatment decreased), Group III (no modification or increased pain and analgesic treatment). Results: All patients had ERCP with pancreatic sphincterotomy in each cases (morbidity 14.3%: acute pancreatitis (n=2), sepsis (n=1)). Sixteen patients underwent pancreatic stent (5 to 11.5 French; mean: 1.6 stent). Three patients with ductal pancreatic stones were totally healthed after pancreatic sphincterotomy and stones extraction. The median duration of treatment with pancreatic stent was 6.9 months (1-17). The median followup was 38 months (6-48). Distribution of patients after endoscopic treatment were: Group I (n=18), Group II (n=1), Group III (n=2).Weight variations were +5.3 Kgs, -3 Kgs and 4.5 kgs respectively for groups I, II and III. Patients in Group II and Group III had distal pancreatic duct stricture. Conclusion: After mean follow-up of 3 years, 86% of patients stopped analgesic treatment and a ponderal increase is observed in 3/4 of cases. Endoscopic treatment of painful PC with pancreatic stent insertion is a reliable, efficient and reproducible method.

A multicenter randomized study was conducted to compare the tolerance to and the efficacy of nasal (NG) and oral route (OG) for gastroscopy. Methods: 10 centers (5 private practice and 5 universitary hospitals) included each 50 patients (pts) with a first indication of gastroscopy (= no previous gastroscopy). Randomization between NG and OG was done as 10 equivalent blocks of 50 pts. A 5mm diameter fiberscope (Olympus N30) was used for NG (250 pts) and a standard videoendoscope (diameter>10mm) for OG (250 pts). Pts had no sedation but a local anesthesia (lidocaine; NG: nasopharynx; OG: pharynx). Main evaluation criterion was a score of intolerance previously validated and calculated from 8 items (global discomfort, unpleasantness at scope introduction , pain, nausea, cough, eructation, bloating, feeling of asphyxia) analyzed in a post-procedure pt questionnaire. Secondary criteria were different parameters on vision quality (10 anatomical sites) and progress of the procedure. Results: Age, sex, indications were not significantly different between the 2 groups. Procedure failed in 17 pts (6.8%) for NG and in 4 pts (1.8%) for OG (p<0.005). Reasons for failure were for OG, pt refusal (4 pts) and for NG, refusal (3 pts), technical problem (2), transnasal introduction impossible (3) or too painful (9). Patient questionnaire: Intolerance score was lower for NG (13.3 vs 18.4) (p<0.0001). Global discomfort, nausea, eructation, bloating, feeling of asphyxia were significantly lower for NG. Pain was located in the nostrils for 52% of the NG patients. 10.3% of the NG pts said they would not accept a second endoscopy, compared to 25.2% in the OG group (p<0.001). Operator questionnaire: Quality of vision was better with NG for the pharynx (p<0.001) and with OG for the cardia (p<0.05) and the other sites (NS). Second portion of the duodenum was not seen in 38 NG and in 11G (p<0.001). Lavage, insufflation and aspiration were stated better in the group OG (p<0.001 each). OG was quoted more effective (p<0.05) but not easier. Diagnosis: The number of normal procedures was higher with NG (38.8% vs 26.8%, p<0.01). Duodenal ulcer was less frequently seen with NG (5 cases vs 20 cases, p<0.05). Conclusion: NG was possible in 93% of cases. Tolerance to gastroscopy and acceptance of a repeated procedure were markedly improved with NG. But, quality and efficacy of NG were judged lower and could explain the higher rate of normal procedures. Technical improvement (video, specific air-water channels) could allow to use oral route for initial gastroscopy.

Aim: To assess the clinical benefit of gastrointestinal tract enteroscopy. Methods: Between august 98 and october 99, 28 patients (16 men, 12 women), mean age: 51.5 (20-81 years) were admitted for upper and lower enteroscopy. In these 28 patients, indications were the followings: Iron deficiency anemia (n=20, mean rate of hemoglobina: 6.6 g/dl (4-11)) with (n=8; hematemesis n=1, melena n=7) or without macroscopic haemorrhages (n=12), abdominal pain (n=8). Results: Upper enteroscopy was performed in 25/28 patients (89%) and considered as sufficient by operator in 23 cases (92%). Twenty patients underwent lower enteroscopy (71.4%): satisfactory progression in 13 patients (65%), incomplete in 4 (20%) and no progression beyond caecum due to an irreducible loop in 3 cases (15%). Enteroscopy was normal in 15 cases (53.6%). In the 13 remaining patients (46.4%), findings were: angiomatous lesions (n=5: jejunal (n=2), colonic (n=3)), malignant tumours (n=2: jejunal adenocarcinomas including a HNPCC syndrom), jejunal benign tumours (n=2: moderate dysplasiaadenomas including one patient with Gardner syndrom), ulcerative gastric lesion (n=3: fundus ulcer (n=2), antral erosion (n=1)) missed by gastrocopy, intestinal lipomatosis (n=1). Lesions were diagnosed in 4/8 (50%) and 9/12 (75%) patients who had respectively anemia with or without macroscopic haemorrhages. Enteroscopy showed lesion strictly limited to the small intestine only in 6 cases (21.4%). A treatment was performed in 9 cases (32.1%): jejunal carcinoma resection (n=1), polypectomy (n=2), endoscopic electrocoagulation (n=3), antisecretory treatment without bleeding recurrence (n=3). Conclusion: Enteroscopy is useful for exploration of occult gastrointestinal bleeding. A therapeutic management was performed in one third of patients.

Aim: Prospective evaluation of endoscopic ultrasonography (EUS) for diagnosis and staging of ampullary tumors surgically resected. Patients and methods: Between may 95 and september 99, 16 consecutive patients (mean age: 62,2 years (44-74), sex-ratio: 0,5) admitted in our unit for diagnosis and pre-therapeutic staging of ampullary underwent bilio-pancreatic EUS (radial probe EUM3 et EUM20 7,5-12 MHz and miniprobe 20 MHz Olympus®) and following curative surgical resection. Diagnosis of ampulloma was suspected according to following criterias: jaundice (n=6), abdominal pain (n=1), acute pancreatitis (n=5), biological cholestastic syndrom (n=4). Results: EUS was performed in all patiens without complications. Dilatation of main pancreatic duct and/or main biliary duct were visualized at abdominal ultrasonography (US) and/or CT-scan (n=6). Ampullary lesion in CT-scan (n=4) showed an ampullary tumoral lesion in 4 cases (25%), all visualized in EUS. An ampullary tumor was revealed by EUS in 14 patients (87,5%), hypoechogenic (n=10), isoechogenic (n=2) or heterogenous (n=2). Two patients had a dilatation of main bile duct (n=1) and Wirsung duct (n=1). No vascular invasion or peritoneal metastasis were detected. A curative surgery was performed in all patients (Whipple resection (n=15), ampullectomy n=1) which showed ampullary carcinoma without vascular involvement in 14 cases (87,5%) including two tumors that had been not visualized by EUS. In the two remaining patients, a cholangiocarcinoma and an odditis was diagnosed. Correlation between EUS staging and surgical/pathological findings were: 6/10, 0/1 and 3/4 for ampullomas respectively classified T1, T2 and T3 - 12/13 and 3/1 for N staging. Conclusion: EUS is useful for the diagnosis of ampullary tumours not showed by classical morphologic exams (71.4%). EUS represents the most accurate imaging technique for detecting ampulloma potentially resectable.