Volume 80 - 2017 - Fasc.4 - Original articles
A single center experience in resectable pancreatic ductal adenocarcinoma : the limitations of the surgery-first approach. Critical review of the literature and proposals for practice update
Background and study aims : The current standard of care for resectable pancreatic ductal adenocarcinoma (PDAC) is surgery- first followed by adjuvant chemotherapy. We review our single center experience in a PDAC cohort managed by the surgery- first strategy. We then compare our data to those of Belgian and international literature.
Patients and methods : We reviewed a series of 83 consecutive resectable patients with PDAC, treated by the surgery- first approach in a Belgian Academic Hospital between 2007 and 2013. The outcomes were assessed with univariate and multivariate Cox regression analysis. Kaplan-Meier curves were drawn according to patient groups.
Results : For the entire population, the median survival (MS) was 18.4 months; the 1-year relapse-free survival was 56%, and the 5-year overall survival (OS) was 13%.
The size of the primary tumor larger than 3 cm (OS, HR = 1.76, p = 0.033) and vascular resection (DFS, HR = 2.1, p = 0.024) were the single independent prognostic factors in the multivariate analysis of this cohort.
Manometric and ultrasonographic characteristics of patients with coexisting fecal incontinence and constipation
Background : The treatment of fecal incontinence (FI) depends upon the dominant pathophysiology: impaired sphincter contractility or overflow due to pelvic floor dyssynergia and insufficient rectal emptying. In this study, we aimed to define the manometric and anorectal ultrasound characteristics in FI patients with and without constipation.
Methods : We did a retrospective study of 365 anal manometries, performed between October 2012 and July 2015, in patients with FI. Clinical information was obtained from questionnaires. In 220 of these patients an anorectal ultrasound was also available.
Key results : A high prevalence of self-reported constipation was seen in the total population of FI patients (66%). This number was lower (31%) when Rome IV criteria were applied. A very high percentage of manometric pelvic floor dyssynergia was seen in the total population with FI (81%). However, patients with FI and constipation did not show pelvic floor dyssynergia more often than patients without constipation. Anal resting pressure, squeeze pressure and anorectal pressure sensitivity were not different when comparing patients without and with constipation. The prevalence of a functional defecation disorder (FDD) in our study population of FI patients was 20%. Wexner score in this subgroup was lower compared with patients without FDD. Anal sphincter defects were more prevalent in women than men, and were associated with diminished sphincter contractility.
Conclusion and inferences : A very high percentage of FI patients showed manometric pelvic floor dyssynergia. The coexistence of fecal incontinence and constipation did not increase this percentage.
The association between gastroesophageal flap valve function and gastroeso- phageal reflux symptoms
Background and study aims : Upper gastrointestinal endoscopic examination is usually the first step in the evaluation of patients with suspected gastroesopageal reflux disease. The primary aim of this study was to investigate the association between gastroesophageal flap valve function (GEFV) and gastroesophapgeal reflux symptoms in patients undergoing routine upper endoscopy. Patients and methods: 1507 patients were included into the study and the GEFV graded I to IV as follows: Hill I-II: normal GEFV, and Hill III-IV: abnormal GEFV.
Results : Patients in abnormal GEFV group had a higher incidence of reflux symptoms compared to normal GEFV group (53.4% vs 47.4% for heartburn p = 0.03 and 53.2% vs 42.4% for regurgitation, p<0.01). In abnormal GEFV patients, esophagitis was more common compared to those with normal GEFV (32.6% vs 11.1%, p<0.01). Presence of heartburn and regurgitation (n = 556) correlated with Hill III-IV grades (n = 184/556), (sensitivity: 33%, p = 0.003). In contrast, 24.6% (157/638) of patients without reflux symptoms were in abnormal GEFV group. In patients undergoing endoscopy because of reflux symptoms, Grade III- IV valve was detected more commonly in patients with reflux symptoms compared to patients without reflux symptoms (p = 0.01).
Conclusions : Patients with abnormal valves (Hill grades III & IV) but without reflux symptoms, esophagitis and hiatal hernia should be evaluated individually by means of the presence of gastroesophageal reflux disease which means that GEFV is not a good indicator of reflux disease. (Acta gastroenterol belg., 2017, 80, 471-475).
Minimally-invasive treatment of hepatic hydatid disease with Perforator- Grinder-Aspirator Apparatus and follow-up of 42 patients
Introduction : The gold standard treatment for hydatid cyst (HC) is surgery. In surgical practice, open procedures still remain as the first option but in this minimally-invasive era, the frequency of laparoscopic procedures is increasing. The aim of this study is to evaluate the results of 42 patients with HC who underwent surgery with Perforator-Grinder-Aspirator-Apparatus (PGAA) and demonstrate the success and reliability of this technique.
Methods : The datas of 42 patients, who underwent laparoscopic surgery with PGAA between Jan 2010 and Feb 2016 were evaluated retrospectively. All patients diagnosed with ultrasonography and underwent computed tomography to identify the surgical anatomy, accessibility of the cyst and the relation with the other cysts. All patients had 10 mg/kg/day albendazole treatment at least 10 days before surgery and preoperative antibiotic prophylaxis was made by 1 gr ampicillin/sulbactam.
Results : Thirty-two patients had single cysts, 9 patients had 2 cysts and 1 patient had 3 cysts. Of the 53 cysts ; unroofing and drainage was performed to 38 cysts, unroofing-drainage and omentopexy were performed to 7 cysts and simple drainage was performed to 8 cysts. Four complications occurred after the procedure. The average duration of hospital stay was 4.73 ± 2.6 days.
Discussion and Conclusion : There are several treatment options in hydatid cyst and the most appropriate must be selected depending on the patient. We believe that the use of PGAA can increase the use of laparoscopy in cystic hydatidosis of liver and will achieve better results. (Acta gastroenterol. belg., 2017, 80, 477- 480).
Patients with primary localized high-grade sarcomas of the digestive tract excluding GIST : a retrospective study from the French sarcoma group
Introduction : The natural history of localized high-grade sarcomas of the digestive tract (SDT) excluding GIST has been rarely considered owing to their low incidence and heterogeneity. We describe the histoclinical characteristics of SDT and correlate them with patients' outcomes.
Methods : We retrospectively collected medical files from a European database covering connective tissue tumors listed in Europe for about twenty years. Only untreated localized primary high-grade SDT were included. A central histological review was performed for each case. Patients' characteristics were compared and correlated with clinical outcomes.
Results : A total of 45 patients were identified. Leiomyosarcomas (LMS) and undifferentiated sarcomas (UDS) were predominant, the former having better overall survival (OS) and progression- free survival (PFS) while the latter having a worse outcome than the other histological types. Complete remission was obtained in 34 patients (75%) and was associated with male sex, age over 40 years and monofocal tumor. Complete surgery and LMS histology were associated with a better prognosis without any significant difference in baseline characteristics or in treatment modalities.
Conclusion : Complete surgery and histological type seem to be prognostic indicators of SDT. These results suggest the importance of treating these patients in a reference center. (Acta gastroenterol. belg., 2017, 80, 481-486).
Efficacy and safety assessment of ERCP in patients with malignant biliary obstruction
Background : To assess the efficacy and safety of Endoscopic retrograde cholangiopancreatography (ERCP) for malignant biliary obstruction (MBO).
Material and Methods : A review of all ERCP-procedures performed at Akershus University Hospital during the six year period between 2009-2014 was analysed. Data for the period 2009- 2013 were obtained retrospectively and prospectively for 2014. Patients with jaundice due to MBO were selected for the present study.
Results : A total of 210 patients (51% females), median age of 70 years (range 33-96) were included. The total number of procedures were 314, whereof 218 (69%) were successful and 96 (31%) were failures. 292 procedures were palliative and 22 procedures were intended as 'bridge to surgery' whereof 15 patients underwent surgery. Pancreatic carcinoma occurred in 105 (50%) patients and was the most common reason for MBO. Straight plastic stents (I-stents) were applied in 145 (74%), double-pigtail stents (JJ-stents) in 29 (15%), self-expanding metal stent (SEMS) in 18 (9%) procedures and in 3 procedures (1.5%) an I-stent was inserted through an indwelling SEMS. Median duration of stent- patency in months was 2 (range 0-74) for I-stent, 1 (range 0-29) for JJ-stent and 4 (range 0-29) for SEMS. The rates of complication and mortality due to complication were 8.9% and 1.3% per procedure.
Conclusion : Adequate drainage of MBO by ERCP was obtained in 69%. The rates of complication and procedure related mortality were at acceptable levels. (Acta gastroenterol. belg. 2017, 80, 487-491).
Comparison of side-viewing duodenoscope and single-balloon enteroscope to perform ERCP in patients with Billroth II gastrectomy.
Endoscopic retrograde cholangiopancreatography (ERCP) in Billroth II patients is challenging and different endoscopes can be used. We retrospectively analysed 67 ERCP procedures in 38 Billroth II patients focussing on endoscope type and respective technical success and adverse event rate. 33 (49.2 %) ERCPs were performed using a duodenoscope, 87.9 % were successful and 3 were completed with the single-balloon enteroscope. 28 (41.8 %) ERCPs were performed with the single-balloon enteroscope, 82.1 % were successful and 2 were completed with a paediatric colonoscope. For 6 (9.0 %) ERCPs a paediatric colonoscope was used but only 3 (50.0 %) were successful. Overall technical success rate was 82.1 % without difference between the success rate of the duodenoscope and the single-balloon enteroscope. Overall adverse event rate was 10.5 %: 6.1 % duodenoscope,10.7 % single-balloon enteroscope, 33.3 % paediatric colonoscope. The duodenoscope allowed all conventional ERCP procedures, whereas the single- balloon enteroscope required dedicated ERCP catheters and did not allow metallic stent placement. However, the single-balloon enteroscope facilitated access to the papilla and sphincteroplasty allowed direct cholangioscopy. ERCP indications were bile duct stones (53.7 %), cholangitis (20.9 %), chronic pancreatitis (20.9 %), pancreatic cancer (1.5 %) and liver transplantation (3%).
Therapeutic ERCP success rate is high in patients with Billroth II gastrectomy using either a conventional duodenoscope or the single-balloon enteroscope, with an acceptable and comparable adverse event rate. The choice of endoscope may depend on local experience, post-operative anatomy and therapeutic indication. (Acta gastroenterol. belg., 2017, 80, 493-497).
Esophageal lesions detected during small bowel capsule endoscopy : incidence, diagnostic and therapeutic impact
Background : Nowadays, capsule endoscopy is the first-line procedure for the visualization of the small bowel. Although it was primarily designed with this goal, it may also identify other segments of the gastrointestinal tract. The aim of the current study is to evaluate the incidence of esophageal abnormalities detected in patients undergoing small bowel capsule endoscopy and its impact on patient management.
Patients and Methods : This study is a retrospective analysis of data from 2217 consecutive capsule endoscopy procedures performed at a single tertiary-care centre between January 2008 and February 2016. Patient baseline characteristics, esophageal lesions, diagnosis and management before and after capsule endo- scopy were recorded and a descriptive analysis was then performed.
Results : 2217 patients were finally included in the analysis. 1070 were male (48.2%) and the mean age was 56.1 ± 19.5 years (12-93). Obscure gastrointestinal bleeding (52.3%) and inflammatory bowel disease (18.3%) were the main procedure indications. Esophageal abnormalities were detected in 105 out of 2217 patients (4.7%). The most common lesions detected were peptic esophagitis (58.1%) and esophageal varices (17.1%). This information had a clinical/ diagnostic impact of 3.3% anda therapeutic impact of 3.2%.
Conclusion : Capsule endoscopy detects not only small bowel lesions, but also significant esophageal lesions that may be overlooked during initial gastroscopy. Therefore, all images of the esophagus should be read during small bowel capsule endoscopy, since it could provide relevant information that may result in changes on patient 's management. (Acta gastroenterol. belg., 2017, 80, 499-504).