Volume 82 - 2019 - Fasc.3 - Original articles
Endoscopic submucosal multi-tunnel dissection for large early esophageal cancer lesions
Objective : To evaluate the safety and efficacy of endoscopic submucosal multi-tunnel dissection (ESMTD) for early esophageal cancer lesions larger than 3 cm in diameter or cumulatively greater than 1/2 lumen size.
Method : Early esophageal cancer lesions in 15 patients were detected by endoscopy and endoscopic ultrasonography in our endoscopy center from December 2012 to June 2015. All lesions were successfully resected by ESMTD and diagnosed by pathology, and therapeutic efficiency and safety were followed after surgery.
Results : All 15 of the early esophageal cancer lesions were resected by ESMTD. The pathological results showed 9 moderately differentiated and 6 highly differentiated squamous cell carcinomas. En bloc resection was achieved in 13 lesions, with negative lateral and basal margins on pathology, whereas the other 2 required additional surgery. The average diameter of the resected lesions was 4.2±0.9 cm. The mean procedure time was 94.7±52.9 min. Esophageal stenosis was observed in 7 patients for whom esophageal water balloon dilatation was performed. No residual or recurrent lesion was found during the 6-36-month follow-up period.
Conclusion : ESMTD is a safe and efficient technique for treating large early esophageal cancer lesions. Grasping the key techniques of this procedure can reduce operating difficulty and shorten the operating time. (Acta gastroenterol. belg., 2019, 82, 355-358).
Treatment of chronic hepatitis C in patients with human immunodeficiency virus (HIV) with weekly peginterferon alpha-2b plus ribavirin: a multi-centred Belgian study
Background and study aims : In Belgium, 10-15% of patients infected with the human immunodeficiency virus (HIV) are co- infected with hepatitis C virus (HCV). Because of increased inci- dence of antiretroviral drug-related hepatotoxicity and more rapid clinical evolution towards end-stage liver disease, treatment of chronic hepatitis C becomes a priority. We report the results of a multi-centred Belgian study evaluating efficacy and safety of peginterferon alpha-2b plus ribavirin in HIV-HCV co-infected patients without AIDS and without decompensated liver disease.
Patients and methods : Forty-one patients, all genotypes, were screened to participate. Eventually 37 received treatment with peginterferon alpha-2b (1.5 µg/kg/week) plus daily weight-based ribavirin for 52 weeks. About one third of the patients were geno- types 1, 2/3, and genotype 4, most of the latter being of Central African origin. About 56% of the patients had severe fibrosis (Metavir score ?? F3).
Results : Sustained viral response (SVR) at 24 weeks of follow-up was observed in 10/37 (27%) of patients. SVR was higher in geno- type 2/3 compared to genotype 1/4 (46.7% versus 13.6% ; p = 0.06) and in low (F0-F1) versus high (F2-F4) grade fibrosis (p = 0.06). Treatment was withdrawn for side effects in 11/37 patients (30%). One Child A cirrhosis patient at the start of therapy died 7 months after treatment withdrawal as a result of severe haemolytic anaemia.
Conclusions : It can be concluded that weight-based peginterfer- on alpha-2b plus ribavirin can be successful in selected HIV-HCV co-infected patients. Caution should be applied in patients with advanced liver disease. (Acta gastroenterol. belg., 2009, 72, 389-393).
Background and study aims : In Belgium, 10-15% of patients infected with the human immunodeficiency virus (HIV) are co- infected with hepatitis C virus (HCV). Because of increased inci- dence of antiretroviral drug-related hepatotoxicity and more rapid clinical evolution towards end-stage liver disease, treatment of chronic hepatitis C becomes a priority. We report the results of a multi-centred Belgian study evaluating efficacy and safety of peginterferon alpha-2b plus ribavirin in HIV-HCV co-infected patients without AIDS and without decompensated liver disease.
Patients and methods : Forty-one patients, all genotypes, were screened to participate. Eventually 37 received treatment with peginterferon alpha-2b (1.5 µg/kg/week) plus daily weight-based ribavirin for 52 weeks. About one third of the patients were geno- types 1, 2/3, and genotype 4, most of the latter being of Central African origin. About 56% of the patients had severe fibrosis (Metavir score ?? F3).
Results : Sustained viral response (SVR) at 24 weeks of follow-up was observed in 10/37 (27%) of patients. SVR was higher in geno- type 2/3 compared to genotype 1/4 (46.7% versus 13.6% ; p = 0.06) and in low (F0-F1) versus high (F2-F4) grade fibrosis (p = 0.06). Treatment was withdrawn for side effects in 11/37 patients (30%). One Child A cirrhosis patient at the start of therapy died 7 months after treatment withdrawal as a result of severe haemolytic anaemia.
Conclusions : It can be concluded that weight-based peginterfer- on alpha-2b plus ribavirin can be successful in selected HIV-HCV co-infected patients. Caution should be applied in patients with advanced liver disease. (Acta gastroenterol. belg., 2009, 72, 389-393).
EUS-guided tissue samples for the diagnosis of patients with a thickened gastric wall and prior negative endoscopic biopsies
Aim : Evaluate the diagnostic yield of biopsies obtained by EUS guidance in patients with gastric wall thickening and prior negative endoscopic biopsies.
Material and methods : Data collected from October 2008 to January 2016 were analyzed in a retrospective manner. All included patients had undergone at least one endoscopy with a negative biopsy and showed evidence of gastric wall thickening by tomography, confirmed by endoscopy. All patients gave their written informed consent before the procedure. Demographics and baseline characteristics, including age, sex, number of previous endoscopies, and histopathological diagnosis were recorded. Follow-up data were obtained from a review of the electronic medical records.
Result : In total, 22 patients with previous negative endoscopic biopsies and gastric wall thickening were included. Using EUS- FNA/FNB, the diagnosis was made in the first procedure in 19/22 (86.30%) cases, while in 1/22 (4.5%) patients the diagnosis was made in the second EUS-FNA. A total of 18 (81.82%) patients with EUS-FNA were assessed using a standard Echo-tip, while the remaining four (18.18%) patients underwent EUS-FNB and using a ProCore needle. All patients with a final diagnosis of malignancy had a thickened gastric wall with impaired gastric distension and a loss of wall structure determined by EUS. Of patients with a benign final diagnosis, all (n=8) showed a thickened gastric wall by EUS but with preservation of the deep layers
Conclusion : EUS-FNA/FNB is necessary in patients with a thickened gastric wall and prior negative biopsy on endoscopy. The procedure is safe and has a good diagnostic. (Acta gastroenterol. belg., 2019, 82, 359-362).
Ulcerative colitis treatment : an insight into daily clinical practice
Background : The natural history of ulcerative colitis (UC) is unpredictable. Factors associated with the need for different types of step-up therapy in UC patients failing on 5-aminosalicylic acid (5-ASA) or corticosteroids are understudied.
Aims : Describe step-up therapy in patients with UC the first year after failing on 5-ASA or corticosteroids.
Methods : A Belgian, multi-center, prospective, non-interven- tional observational study comprising adult UC patients failing on 5-ASA or corticosteroids and naïve to immunomodulators/ biologicals. During a 12 months follow-up, patient characteristics, demography, medical therapy, biomarkers, therapy adherence and quality of life (QoL) were assessed.
Results : After 1 year, 35% of the patients were on biological therapy. Use of anti-TNF differed depending on baseline treatment: corticosteroid-refractory patients (55.8%), 5-ASA refractory (20.0%), and corticosteroid-dependent (16.0%) patients (p<0.001). The decision to start a line of therapy was based on the Mayo combined severity but not on biomarkers like faecal calprotectin, haemoglobin, CRP, albumin, platelets, and number of extra- intestinal manifestations. At year 1, 84.2% of the patients had only mild UC or remission and a significant improvement of fatigue (p=0.004) and IBDQ scores (p<0.001) were observed implying an improved QoL.
Conclusion : Treatment step-up, based on clinical scores in immunomodulatory and anti-TNF naïve patients with UC, provides good clinical outcomes and QoL. (Acta gastroenterol. belg., 2019, 82, 365-372).
Feasibility of endoscopic submucosal dissection for recurrent colorectal tumors after endoscopic mucosal resection
Background : Colorectal recurrent lesions after endoscopic mucosal resection (EMR) often contain severe fibrosis. In such lesions, repeat EMR is often difficult and endoscopic piecemeal mucosal resection (EPMR) has a high risk of repeated recurrence, while surgery is considered overtreatment. Whether ESD can be used safely and reliably to treat such difficult lesions has not been adequately verified. We analyzed the treatment outcomes of ESD for recurrent lesions after EMR.
Methods : Among 653 colorectal ESD conducted in our institution between April 2012 and August 2017, 27 consecutive patients underwent the procedure for recurrent lesions after EMR. Treatment outcomes including en bloc resection rate, R0 resection rate, and curative resection rate; complications were analyzed.
Results : Treatment outcomes of the 27 patients were as follows: en bloc resection rate 81.5%, R0 resection rate 74.1%, curative resection rate 74.1%, median procedure time 47 min (range 10?210 min), perforation rate 0%, and delayed bleeding rate 3.7%. The corresponding rates for 626 patients who underwent colorectal ESD during the same period for lesions other than recurrence after EMR were 97.2%, 95.5%, 88.7%, 37 min (7-225 min), 0.5%, and 2.8%. There were no differences in complication rates. Treatment outcomes including en bloc resection rate were inferior in the recurrence group compared to non-recurrent group, but no local recurrence was found in all patients.
Conclusions : Colorectal ESD is feasible for recurrent colorectal lesions after EMR. The procedure is safe and achieves good treatment outcomes with no local recurrence. (Acta gastroenterol. belg., 2019, 82, 375-378).
Who to screen for hepatitis C? A cost-effectiveness study in Belgium of comprehensive hepatitis C screening in four target groups
Background and study aims : Hepatitis C virus (HCV) infection often causes asymptomatic disease and patients are frequently diagnosed at an advanced stage. Oral direct acting antivirals (DAAs) are successful in treating HCV with high sustained virologic response (SVR) and excellent tolerability. The aim of this study is to evaluate cost-effectiveness of a broad screening strategy proposing screening to all undiagnosed members of a population (comprehensive HCV screening), in the general adult population, emergency department (ED) attendees, men who have sex with men (MSM) and people who inject drugs (PWID).
Patients and methods : We populated a theoretical model with Belgian data. A decision tree model simulating HCV screening and diagnosis was combined with a Markov state transition model simulating treatment. There was one screening round per year during five years. In the ED population only one screening round was considered.
Preoperative biliary drainage in patients performing pancreaticoduodenectomy : guidelines and real-life practice
Background and aim : Preoperative biliary drainage (PBD) in patients with pancreatic cancer remains debatable. The aim of this study was to analyse the indications for PBD in patients performing pancreaticoduodenectomy (PD) and to evaluate the impact of this procedure on postoperative outcome.
Methods : Observational retrospective cohort study of patients undergoing PD for pancreatic cancer. Clinical data and postoperative outcome, namely complications and 90-day mortality, were prospectively collected and compared between patients performing PBD or direct surgery (DS).
Results : Eighty-two patients were included: 40 underwent PBD and 42 performed DS. Major complications (27.5% vs 33.3%, P=0.156) and 90-day mortality (10% vs 16.7%, P=0.376) were similar between the two groups. There was a trend for higher mean total bilirubin in patients with PBD (P=0.073). The indication for PBD was suspicion of cholangitis/choledocholithiasis or need to perform neoadjuvant chemotherapy in 24 (60%) patients. In the remaining, elevated bilirubin was probably the only reason to perform PBD. Length of hospital stay was longer in PBD group (P=0.003). On multiple logistic regression, 90-day mortality was not related with preoperative bilirubin levels, biliary drainage or its indication, but solely with age (OR 1.15, 95%CI 1.05-1.31, P=0.008).
A comparison of the BISAP score and Amylase and BMI (CAB) score versus for predicting severe acute pancreatitis
Background and aims : Early prediction of severe acute pancreatitis (SAP)would be helpful for triaging patients to the appropriate level of care and intervention. The aim of this study is to compare the performance of the Change in Amylase And Body mass index (CAB) score and BISAP score for predicting SAP.
Patients and methods : A total of 406 with AP were enrolled. The age, gender, body mass index(BMI), blood urea nitrogen determined at the time of admission and serum amylase determined on day 1 and day 2 after hospitalization were collected and analyzed statistically.
Results : Multivariable analysis confirmed that blood urea nitrogen (OR 1.06; 95%CI 1.03-1.09) and percentage change in amylase day 2 (OR 0.75; 95%CI 0.65-0.87) were independently associated with development of SAP. No statistically significant association was observed between BMI (OR 1.04; 95%CI 0.95- 1.13) and severity of acute pancreatitis. The area under the receiver operating characteristic curve for Body mass index (BMI), percentage change in amylase day 2, BISAP score and CAB score were 0.57±0.05, 0.68±0.04, 0.84±0.03 and0.53±0.05, respectively.
Conclusions : BISAP is more accurate for predicting the severity of acute pancreatitis than the CAB score. (Acta gastroenterol. belg., 2019, 82, 397-400).
