The transduodenal rendezvous: a new approach to deeply cannulate the main pancreatic duct.
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Cholangiopancreatography, Endoscopic Retrograde↗
Biomedical subjects
J Devière
Publications and source records attributed to J Devière.
The impact of magnetic resonance cholangiopancreatography on ERCP.
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Bile Ducts↗
Esophageal fistula sealing: choice of stent, practical management, and cost.
BACKGROUND: Three models of covered metal stents are available to seal esophageal fistulas. METHODS: Stainless steel covered stents were inserted in 5 patients (group I); nitinol covered stents were inserted in 12 patients (group II) with malignant (n = 14) or benign (n = 3) esophageal fistulas. RESULTS: Stent positioning was satisfactory in all cases. Fistula sealing was complete in 1 of 5 (20%) and 12 of 12 (100%) patients of groups I and II, respectively (p < 0.005). Continued esophageal leakage was initially related to the passage of fluids alongside the stent covering (n = 3) and to early stent migration (n = 1). Complications related to stent placement were observed in 2 of 17 (12%) patients and were fatal. During follow-up (mean 153 +/- 143 days), esophageal fistulas relapsed after initial sealing in 5 of 13 (38%) patients. Further treatment (glue or fibrin sealant injection, additional stent insertion) was attempted in 7 cases of persistent or relapsing esophageal fistula, with sealing obtained in 5 of them. The costs per patient and per day free from symptoms due to the esophageal fistula were $106 and $57 in groups I and II, respectively. CONCLUSION: Nitinol covered stents more frequently provided complete esophageal fistula sealing, as compared with stainless steel covered stents. Further treatments tailored to the mechanisms of fistula persistence or relapse often provided sealing.
Adolescent↗
Blunted anti-inflammatory response to adenosine in alcoholic cirrhosis.
BACKGROUND/AIM: Adenosine is an endogenous nucleoside that is released under metabolically unfavourable circumstances such as ischaemia or infection. It exerts potent anti-inflammatory effects by decreasing tumour necrosis factor release and costimulating interleukin-10 production by human monocytes. The aim of this study was to assess the cytokine response to adenosine in whole blood cultures from alcoholic cirrhotic patients. METHODS: Whole blood from 17 patients and 17 healthy controls stimulated with lipopolysaccharide was cultured in the presence of adenosine at different concentrations and, in some experiments, with the adenosine deaminase inhibitor deoxycoformycin. Peripheral blood mononuclear cell response was compared to whole blood, and plasma adenosine deaminase activity was measured. RESULTS: Adenosine (100 microM) significantly inhibited TNF release and increased IL-10 production in whole blood cultures from controls stimulated with lipopolysaccharide, but not from cirrhotic patients. However, the response to adenosine was restored in peripheral mononuclear cells of patients in the absence of autologous plasma. To test the hypothesis that plasma adenosine deaminase, which was increased in the patients' plasma, was actually involved in this blunted response to adenosine in alcoholic cirrhosis, we performed adenosine dose-response experiments and pharmacologically blocked adenosine deaminase activity with deoxycoformycin. In both kinds of experiment, adenosine-induced inhibition of TNF release could be restored in alcoholic cirrhotic patients. CONCLUSIONS: These data indicate that increased circulating adenosine deaminase activity blunts the anti-inflammatory properties of adenosine in alcoholic cirrhotic patients.
Adenosine↗
Hepatocyte proliferative activity in human liver cirrhosis.
BACKGROUND/AIMS: The objective of this study was to validate, with an independent prospective cohort of patients, our previous data indicating that the proliferating cell nuclear antigen-labeling index (PCNA-LI) reflects the liver functional reserve in human cirrhosis and might have prognostic significance for patient survival. We also examined how this proliferative index is related to the expression of transforming growth factor beta1 (TGFbeta1) as a possible correlate of hepatocyte proliferative activity. METHODS: The present group (n=70 patients) was similar in composition to our previous group regarding age, sex and severity of liver cirrhosis. PCNA and TGFbeta1 immunostaining were analyzed on methanol-fixed, paraffin-embedded liver biopsies. RESULTS: Our data show that PCNA-LI declined significantly with worsening Child class and was negatively correlated with the Pugh score. Twenty-five patients died and 10 underwent liver transplantation during the observation period. Liver function, hepatic venous pressure gradient and hepatocyte PCNA-LI were significantly different in survivors and non-survivors. At a mean follow-up of 356 days, the patients with a PCNA-LI higher than 4.4% (the previously determined best cut-off value) had a significantly higher probability of survival than those with a PCNA-LI < or = 4.4% (0.87 vs 0.48, p=0.0009). TGFbeta1 expression in liver parenchyma correlated negatively with PCNA-LI, suggesting that this cytokine could be involved in the impaired regeneration observed in worsened liver cirrhosis. CONCLUSIONS: This prospective study strengthens our previous observation that, in cirrhosis, hepatocyte proliferative activity, as evaluated by the PCNA-LI, provides information on liver functional reserve as well as on the patient's prognosis.
Biopsy↗
[Interpretation and role of endoscopy in gastroesophageal reflux].
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Diagnosis, Differential↗
The ultraflex diamond stent for malignant biliary obstruction.
The Ultraflex Diamond stent presents three features that might be of interest when treating biliary strictures: ease of insertion, high flexibility, and presentation of relatively large meshes. Limited clinical studies have shown its efficacy in relieving duct obstruction (in contrast with some other stent models, correct positioning of the Ultraflex Diamond stent provides adequate biliary drainage in almost all cases), and satisfactory long-term patency rates. The main improvement awaited is an efficient means to prevent late stent obstruction. The addition of coverage to this stent is feasible and could be the first step toward this goal.
Alloys↗
The ultraflex diamond stent for benign biliary obstruction.
The most frequent type of benign bile duct stricture (BBDS) that complicates surgery, is not an indication for placement of any current model of metal stent because of poor long-term results. This statement could not apply to less frequent types of BBDSs, in particular those complicating chronic pancreatitis (CP) and radiotherapy. The authors report their preliminary results observed in 10 patients whose CP-related BBDS was treated with an Ultraflex Diamond stent. No stent dysfunction was detected in the observed patients during a mean follow-up of 17 months. Studies involving larger numbers of patients followed for longer periods of time are necessary to know whether endoscopy using this material may replace surgery in this indication.
Bile Duct Diseases↗
Expandable metal stents for benign pancreatic duct obstruction.
Among patients with advanced chronic pancreatitis and morphologically demonstrable main pancreatic duct (MPD) abnormalities who are candidates for endotherapy, about two-thirds have a MPD stricture and require stenting to achieve appropriate ductal decompression. The standard stent used in this indication is the plastic stent, which provides a median patency rate of 6 to 12 months. The requirement for stent exchange represents a limitation for the treatment of this relatively young patient population. By analogy with the biliary tract, the authors hypothesize that self-expandable metal stents might offer a long-lasting drainage of the MPD. Several years ago the authors used such stents on an experimental basis to treat patients with MPD strictures. Although routine use of self-expandable metal stents should be discouraged, the authors propose some guidelines for further technical improvement.
Adolescent↗
Interleukin-10 controls neutrophilic infiltration, hepatocyte proliferation, and liver fibrosis induced by carbon tetrachloride in mice.
The role of the anti-inflammatory cytokine interleukin-10 (IL-10) was investigated in the mouse model of liver injury induced by carbon tetrachloride (CCl4). To address the role of endogenous IL-10 production, acute hepatitis was induced by CCl4 in C57Bl/6 IL-10 gene knock out (KO) and wild-type (WT) mice. After CCl4 challenge, serum and liver levels of tumor necrosis factor-alpha (TNF-) and serum levels of transforming growth factor-beta 1 (TGF-beta1) increased and were significantly higher in IL-10 KO mice, whereas IL-6 serum levels were only slightly increased compared with WT mice. At histological examination, the livers disclosed a significantly more prominent neutrophilic infiltration in IL-10 KO mice 12 and 24 hours after CCl4 injection. In contrast, hepatocyte necrosis, evaluated by histological examination and serum alanine aminotransferase levels, was only marginally affected. The proliferative response of hepatocytes, assessed by the proliferating cell nuclear-antigen labeling index, was significantly increased in IL-10 KO mice, compared with WT mice 48 hours after CCl4 injection. Finally, repeated CCl4 injections led to more liver fibrosis in IL-10 KO mice after 7 weeks. In conclusion, endogenous IL-10 marginally affects the hepatocyte necrosis although it controls the acute inflammatory burst induced by CCl4. During liver repair, it limits the proliferative response of hepatocytes and the development of fibrosis.
Animals↗
Magnetic resonance cholangiopancreatography: interest of IV secretin administration in the evaluation of pancreatic ducts.
The aim of this study was to investigate whether IV secretin administration is useful to enhance the delineation of the main pancreatic duct (MPD) and its side branches, and if it provides additional information concerning signal voids and strictures. Twenty-seven patients referred for abdominal pain or laboratory abnormalities (group 1, n = 13) or for the follow-up of chronic pancreatitis (CP; group 2, n = 14) were studied. Magnetic resonance cholangiopancreatography was acquired at 1.5 T before and after IV secretin by a coronal 3D TSE T2-weighted sequence with maximum intensity projection postprocessing. In group 1 secretin provided a better visualization of MPD in 9 patients. In a patient with pancreas divisum, it allowed suggestion of stenosis of the accessory papilla, confirmed at endoscopic retrograde cholangiopancreatography (ERCP). In group 2 secretin provided a better visualization of MPD only in the 3 patients with mild disease. A mild dilation upstream a stricture occurred in 2 cases and a marked dilation appeared upstream a wallstent which was non-patent at ERCP. Few changes were noticed concerning side branches. These preliminary results indicate that in patients without CP, secretin improves MPD delineation avoiding invasive diagnostic ERCP. In patients with mild CP secretin does not improve the characterization of signal voids, but it may be useful to appreciate their significance and to follow-up stenosis.
Adult↗
Relevant radiological anatomy of the pig as a training model in interventional radiology.
The use of swine for teaching purposes in medicine and surgery has largely increased in recent years. Detailed knowledge of the porcine anatomy and physiology is a prerequisite for proper use of pigs as a teaching or an experimental model in interventional radiology. A systematic study of the radiological anatomy was undertaken in more than 100 female pigs aged 6-8 weeks. All studies were performed under general anesthesia in a single session. Animals were sacrificed at the end of the study. Selective angiographies were systematically obtained in all anatomical territories. In other animals CT and MRI examinations were performed and were correlated to anatomical sections and acrylic casts of the vascular structures. Endoscopical examinations of the upper gastrointestinal tract, including retrograde opacification of the biliary and pancreatic ducts, were added in selected animals. The main angiographic aspects of the brain, head and neck, thorax, abdomen, and pelvis were recorded. Similarities and differences in comparison with human anatomy are stressed. Potential applications in interventional radiology are indicated.
Animals↗
A guiding catheter to facilitate accurate stent length determination.
BACKGROUND: Endoscopic stenting is widely used for drainage in benign and malignant strictures of the bile and pancreatic ducts. Accurate fitting of the stent to the anatomic ductal features is essential, although this is often done by visual assessment alone. METHODS: A new guiding catheter, the measuring-mounting catheter, with radiopaque bands at 1 cm intervals from its distal end, was used in 10 patients. Visual estimates, based on fluoroscopic images, of the length of the duct segments considered for stenting were compared with measurements obtained with the catheter. RESULTS: There was a significant difference between duct length estimations based on visual assessment and lengths determined objectively using the catheter (mean +/- SD, 17 +/- 11 mm; p < 0.0005). In one half of the cases, the operator rejected the stent he chose before using the catheter. CONCLUSIONS: The measuring-mounting catheter improves the precision of plastic stent implantation without loss of time during the procedure. It is particularly useful in technically difficult situations such as hilar or main pancreatic duct strictures.
Bile Ducts↗
Relative contribution of Ki-ras gene analysis and brush cytology during ERCP for the diagnosis of biliary and pancreatic diseases.
BACKGROUND: Ki-ras mutation analysis from material collected during ERCP has been claimed to improve the diagnosis of pancreatic and bile duct carcinomas as compared with conventional cytology. Our aim was to study the relative contribution of both Ki-ras analysis and brush cytology in patients with a significant stricture at ERCP. METHODS: Brushings were collected in duplicate for both analyses in 142 patients in whom a definitive diagnosis was obtained by histology or a minimal follow-up of 6 months. RESULTS: For pancreatic strictures, sensitivity, specificity, and accuracy of Ki-ras analysis vs. cytology in detecting malignancy were 81% vs. 66%, 72% vs. 100%, and 70% vs. 74%, respectively. For biliary strictures, they were 25% vs. 42%, 100% vs. 100%, and 35% vs. 43%, respectively. The combination of the two methods only marginally increased their sensitivity and accuracy in both types of strictures. CONCLUSION: Ki-ras analysis is a sensitive method for diagnosing pancreatic but not biliary carcinoma. However, its specificity is lowered by a high frequency of Ki-ras mutations in patients with chronic pancreatitis (25%) who did not manifest cancer development within a 6-month follow-up period. In pancreatic duct strictures, brush cytology appears to be more specific in detecting malignancy; specificity for Ki-ras and cytology are equivalent for the diagnosis of malignant bile duct strictures. Therefore, making a clinical decision on the sole basis of Ki-ras analysis is probably not justified in the majority of the cases.
Adult↗
Plastic and metal stents for postoperative benign bile duct strictures: the best and the worst.
BACKGROUND: Endoscopic treatment of postoperative benign bile duct strictures (BBDS) is technically challenging, and the long-term outcome after stricture dilation remains poorly defined. METHODS: Forty-eight cases of postoperative BBDS with attempted endoscopic treatment (either transient plastic stenting or definitive metal stent insertion) were reviewed. RESULTS: Endoscopic stricture dilation succeeded in 47 of 48 cases (98%). No procedure-related mortality was observed; 16 (33%) procedure-related or stent-associated complications were observed during treatment. Endoscopic treatment was interrupted in five patients. Stricture relapse occurred in 6 of 6 (100%) and 7 of 36 (19%) patients after metal stent insertion and plastic stent removal, respectively (p < 0.001) (mean follow-up periods 50+/-12 and 44+/-34 months, respectively). After plastic stent removal, stricture relapses were more frequent among patients with strictures related to liver transplantation as opposed to other surgical procedures (p < 0.05); these recurrent strictures were successfully treated by repeated insertion of plastic stents on a temporary basis. At the end of follow-up, all but one patient treated with plastic stents had normal serum alkaline phosphatase values. CONCLUSION: Metal stents proved to be inadequate for treating postoperative BBDS. Temporary insertion of a plastic stent (possibly repeated) provided long-term results equal or superior to those reported for surgical biliary drainage. Repeated insertion of plastic stents was more frequently indicated for strictures related to liver transplantation compared with other surgical procedures.
Adult↗
Intraductal papillary and mucinous tumors of the pancreas: accuracy of preoperative computed tomography, endoscopic retrograde pancreatography and endoscopic ultrasonography, and long-term outcome in a large surgical series.
BACKGROUND: Few data are available on the accuracy of preoperative imaging or on long-term outcome after surgery for intraductal papillary and mucinous tumors of the pancreas. The aims of this study were to assess the following: (1) the accuracy of preoperative computed tomography, endoscopic retrograde pancreatography, and endoscopic ultrasonography for determination of tumor invasion and pancreatic extension as compared with surgical findings; (2) the long-term outcome after surgery. METHODS: Forty-seven patients who underwent surgery between 1980 and 1995 for pathologically diagnosed intraductal papillary and mucinous tumors were included in this study. The findings of available computed tomography (n = 25), endoscopic retrograde pancreatography (n = 29), and endoscopic ultrasonography (n = 21) were reviewed by experienced clinicians blinded to pathologic diagnosis to assess tumor invasion and pancreatic extension. Pathologic specimens were reviewed by experienced pathologists. Postoperative follow-up data were analyzed. RESULTS: Histologic features of invasive carcinoma were found in 43% of patients, severe dysplasia in 21%, and mild or moderate dysplasia in 36%. The overall accuracy of computed tomography, endoscopic retrograde pancreatography, and endoscopic ultrasonography in distinguishing between invasive and noninvasive tumors were, respectively, 76%, 79%, and 76%. The overall 3-year disease-free survival rate was 63%, but it was 21% among patients with invasive carcinoma at surgery (p < 0.001). CONCLUSIONS: This study emphasizes the need for early surgical resection in patients with suspected intraductal papillary and mucinous tumors of the pancreas because of the high frequency of invasive carcinoma and the inadequacy of preoperative imaging for assessing malignancy.
Adenocarcinoma, Mucinous↗
Rupture of pseudoaneurysm: a cause of delayed hemorrhage after endoscopic cystoenterostomy; angiographic diagnosis and treatment.
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Adult↗
The wirsungorrhagies: causes and management in 14 patients.
BACKGROUND AND STUDY AIMS: Wirsungorrhagy is an extremely rare cause of upper gastrointestinal bleeding. The present study describes 14 cases observed over a seven-year period. MATERIAL AND METHODS: Among 10,000 endoscopic retrograde cholangiopancreatographies performed between 1989 and 1996 we have identified 14 wirsungorrhagies, which were reviewed retrospectively. They occurred in patients with chronic and acute pancreatitis, and primary and metastatic pancreatic cancer. RESULTS: Clinical signs of bleeding were present in six patients; three other patients had occult blood loss, and in five patients wirsungorrhagy was caused by endoscopic manipulation (n=3) or extracorporeal shock-wave lithotripsy (n=2) without clinical or hemodynamic effects. In six patients, wirsungorrhagy was managed by endoscopic methods. Five patients in unstable clinical conditions had an arteriography which allowed identification and treatment of the source of bleeding in three cases. Two patients with bleeding from a communicating cyst in chronic pancreatitis underwent surgery. CONCLUSIONS: Wirsungorrhagy can be responsible for massive bleeding in certain patients, especially those with chronic pancreatitis and pseudoaneurysm. In these cases, arteriography is most useful for identification and treatment of the bleeding. When it occurs during endoscopic manipulations, it can usually be managed endoscopically and/or stops spontaneously with appropriate main pancreatic duct drainage. When it occurs in patients with pancreatic tumors, optimal treatment is surgical resection; this is, unfortunately, usually not feasible.
Acute Disease↗