Prospective multicenter evaluation of colon capsule examination indicated by colonoscopy failure or anesthesia contraindication

BACKGROUND AND STUDY AIMS

In France, in about 5% of cases colonoscopies are incomplete or temporarily contraindicated.We tested the diagnostic yield of colon capsule endoscopy (CCE) in these patients.

PATIENTS AND METHODS

In a prospective study, in 17 French centers, inclusion criteria were colonoscopy failure or general disease that excluded colonoscopy with anesthesia. Patients underwent CCE using the first-generation PillCam Colon capsule. The main end point was CCE diagnostic yield, defined as identification of a colorectal lesion that directly explained symptoms or necessitated a diagnostic or therapeutic examination. A secondary objective was to test a simplified Movi-Prep colon cleansing. Follow-up to identify missed symptomatic cancer was scheduled.

RESULTS

CCE showed positive findings in 36 patients (diagnostic yield 33.6 %), among whom 23 subsequently underwent therapeutic intervention. Among 64 patients with negative capsule findings, 9 had a complementary procedure showing adenomas in only 1 case. CCE was incomplete in 7/107 patients. Colonoscopy was done in one patient to retrieve a capsule retained in the left colon, and sigmoidoscopy in 11 because the rectum was not reached. No colorectal cancer was diagnosed during the follow-up period. Colon cleansing with MoviPrep was rated good or excellent in 75.9% of cases.

CONCLUSION

This study shows the feasibility and the usefulness of CCE in the situation of colonoscopy failure or contraindication. The colon capsule modality should be tested against other available approaches, such as virtual colonoscopy or repeat colonoscopy by an expert.

Diagnostic accuracy of esophageal capsule endoscopy versus conventional upper digestive endoscopy for suspected esophageal squamous cell carcinoma

BACKGROUND AND STUDY AIM

A video capsule similar to that used in small-bowel capsule endoscopy is now available for esophageal exploration. The aim of our study was to compare the accuracy of upper endoscopy (esophageal gastroduodenoscopy [EGE]) with esophageal capsule endoscopy (ECE) in patients at risk of esophageal squamous cell cancer (SCC).

PATIENTS AND METHODS

68 patients at risk of SCC secondary to a history of head and neck neoplasia were included in this comparison of techniques for detecting SCC and dysplasia. ECE was done using the first generation Pillcam ESO and EGE was performed in accordance with the usual practice of each center, followed by examination with 2 % Lugol staining and biopsy of unstained areas (39 neoplasia comprising 5 low grade dysplasia, 8 high grade dysplasia and 26 SCC).

RESULTS

Compared with EGE with and without Lugol staining, the sensitivities of ECE for neoplasia diagnosis were 46 % and 54 %, respectively. On a per-patient basis, the sensitivity, specificity, and positive and negative predictive value of ECE were 63 %, 86 %, 77 % and 76 %, respectively, compared with EGE without staining, and 61 %, 86 %, 77 % and 73 % compared with EGE with iodine staining. Neither the ECE transit time nor the distance between the esopharyngeal line and the neoplastic lesion differed between the 21 false-negative and 18 true-positive cases diagnosed by ECE; the only difference was a smaller median diameter among false negatives ( P < 0.001).

CONCLUSION

In a cohort at high risk for esophageal SCC, ECE is not sensitive enough to diagnose neoplastic lesions.

Clinical impact of capsule endoscopy compared to push enteroscopy: 1-year follow-up study

BACKGROUND AND STUDY AIMS

The long-term outcome for patients with obscure bleeding after capsule endoscopy (CE) is still unclear. In this study, the clinical outcome was used as the gold standard to determine the sensitivity and specificity of CE and push enteroscopy (PE) in the diagnosis of small-bowel lesions in patients with obscure bleeding.

PATIENTS AND METHODS

Fifty-eight patients from a previous prospective study (comparing PE and CE) were included; the patients were contacted after 1 year. The final diagnosis, bleeding status, new gastrointestinal examinations, and treatments performed were recorded. On the basis of these data, each case was classified into true/false positive or true/false negative findings at PE and CE. The results were compared with the initial classification of lesions observed at CE: highly relevant (P2) and less relevant (P0, P1) lesions.

RESULTS

Follow-up data were available for 56 patients. According to the defined true/false positive and negative cases, the sensitivity and specificity values for CE and PE were 92 % and 48 %, and 80 % and 69 %, respectively ( P < 0.01 for the difference between CE and PE). Highly relevant (P2) lesions observed at CE were more frequently classified into true-positive cases (15 of 18 versus seven of 22; P < 0.01) and led more frequently to therapeutic decisions (11 of 18 versus five of 22; P = 0.02) in comparison with less relevant lesions (P0, P1).

CONCLUSIONS

CE is a highly sensitive examination for the detection of small-bowel lesions in patients with obscure gastrointestinal bleeding, with a specificity lower than that of PE when the clinical outcome is used as the gold standard.

Any Clinical Benefit From the Use of Oncofoetal Markers in the Management of Chemotherapy for Patients with Metastatic Colorectal Carcinomas?

AIMS

Computed tomography (CT) is the reference technique for evaluating response to chemotherapy. The potential helpfulness of tumour markers is debated.

MATERIALS AND METHODS

From March 1997 to January 1999, 91 consecutive patients receiving chemotherapy for metastatic colorectal carcinoma underwent whole-body spiral CT, estimates of anti-carcinoembryonic antigen (CEA) and CA19-9 every 8 weeks.

RESULTS

CEA and CA19-9 levels were above normal in 78 (85.7%) and 61 (67.5%) patients, respectively. Tumour response evaluation according to the RECIST criteria was obtained at 8-week evaluation in 83 (91%) patients. The positive predictive values (PPV) for response of a decrease of the marker levels were 53.8 for CEA and 41.7 for CA19-9 using a 30% decrease threshold, and 60/52.2, respectively, using a 50% decrease threshold. Meaningful PPV values (> 90%) for progression of an increase of the marker levels were only obtained using the 200% increase threshold for CEA alone or a combination of CEA and CA 19-9. A 100% CEA increase between baseline and the 8-week evaluation was correlated to overall survival (P = 0.0023). The need for a radiological confirmation of tumour progression could be avoided by the systematic dosage of tumour markers at baseline and after 8 weeks of treatment only in a sub-population of 13% of the patients with a 200% increase of CEA or CA 19-9 at 8 weeks.

CONCLUSIONS

CEA, CA 19-9, or both should be used with caution for tumour response evaluation to chemotherapy in addition to CT in metastatic colorectal carcinoma.

Assessment of tumour response to chemotherapy for metastatic colorectal cancer: accuracy of the RECIST criteria

Evaluation of tumour size modifications in response to treatment is a critical issue in the management of advanced malignancies. In 1981, the World Health Organization (WHO) established guidelines for tumour response assessment. These WHO1981 criteria were recently simplified in a revised version, named RECIST (Response Evaluation Criteria in Solid Tumours), which uses unidimensional instead of bidimensional measurements, a reduced number of measured lesions, withdrawal of the progression criteria based on isolated increase of a single lesion, and different shrinkage threshold for definitions of tumour response and progression. In order to validate these new guidelines, we have compared results obtained with both classifications in a prospective series of 91 patients receiving chemotherapy for metastatic colorectal cancer. Data from iterative tomographic measurements were fully recorded and reviewed by an expert panel. The overall response and progression rates according to the WHO1981 criteria were 19% and 58%, respectively. Using RECIST criteria, 16 patients were reclassified in a more favourable subgroup, the overall response rate being 28% and the progression rate 45% (non-weighted kappa concordance test 0.72). When isolated increase of a single measurable lesion is not taken into account for progression with the WHO1981 criteria, only 7 patients were reclassified and the kappa test was satisfying, i.e. > or =0.75, for the whole population as well as for each of the responding and progressive subgroups. Since it provides concordant results with a simplified method, the use of RECIST criteria is recommended for evaluation of treatment efficacy in clinical trials and routine practice.

[Intussusception of the small intestine due to Peutz-Jeghers syndrome: a case report and review of the literature]

One case of small bowel's intussuception has been found in one patient with abdominal pains. Since 13 years this patient has a Peutz-Jeghers syndrome. A resection of the small bowel has been performed followed by total intraoperative enteroscopy. Besides small bowel, Peutz-Jeghers syndrome can affect many organs with an increased risk for cancer for patients affected by this genetic disease.

Small nodule detection in cirrhotic livers: evaluation with US, spiral CT, and MRI and correlation with pathologic examination of explanted liver

PURPOSE

The purpose of this work was to evaluate the detection and characterization of nodules > or = 8 mm and small hepatocellular carcinomas (HCCs) in liver cirrhosis.

METHOD

Pathologic examination and results of US, helical CT, and dynamic MRI with gadolinium were compared after orthotopic liver transplantation (OLT) of 43 cirrhotic patients. Nodules were classified as macroregenerative nodules (MRNs), borderline nodules (BNs), and HCC.

RESULTS

Pathologic examination classified 69 nodules: 50 MRNs, 6 BNs, and 13 HCCs. Sensitivities of MRN, BN, and HCC detection were, respectively, for US imaging 2% (1/50), 33.3% (2/6), and 46.2% (6/13); for helical CT 2% (1/50), 50% (3/6), and 53.8% (7/13); and for MRI 42% (21/50), 50% (3/6), and 76.9% (10/13). MRI detected 21 MRNs. They presented on T1/T2-weighted images as hyperintense/hypointense (n = 8), hyperintense/isointense (n = 7), hypointense/hypointense (n = 4), hypointense/isointense (n = 1), and hypointense depicted only on echo planar imaging (n = 1). The three detected BNs were hyperintense/hypointense nodules. The 10 detected HCCs appeared hyperintense/isointense (n = 7), hyperintense/hypointense (n = 2), and hypointense/isointense (n = 1). None of the MRNs but eight HCCs and one BN were enhanced after gadolinium injection.

CONCLUSION

Contrast-enhanced MRI is the most sensitive technique for detecting liver nodules. No MR signal intensity pattern characteristic of small HCCs enables differentiation from benign nodules, however. Gadolinium enhancement is the most sensitive and specific characteristic of HCC.

[Prospective randomized single-blind trial comparing oral sodium phosphate with polyethylene glycol for colonoscopy preparation]

AIM AND METHODS

The aim of this prospective, randomized, study performed in 60 outpatients was to compare 2 precolonoscopy bowel preparations: oral sodium phosphate (NaP) versus standard polyethylene glycol-based lavage solution (PEG). None of the patients met any of NaP exclusion criteria. All patients were prepared on the day prior to colonoscopy. A patient-questionnaire and measure of serum electrolytes (calcium, phosphate, sodium, potassium), pulse and blood pressure were used to assess tolerance and acceptability of the preparation. The quality of colon cleansing was judged by blinded endoscopists.

RESULTS

Patient's tolerance to NaP was superior to PEG: NaP preparation was easier to drink and feelings of abdominal plenitude occurred in a smaller proportion of patients. A potassium decrease, a sodium increase and hyperphosphatemia were observed in the NaP group but without clinical events. PEG preparation seemed to allow a better cleansing ability compared with NaP but this difference was not statistically significant.

CONCLUSIONS

NaP solution was better tolerated and accepted by patients. Colonic preparation quality compared to PEG is still to be discussed depending on the intake schedule. A biochemical data check seems necessary on account of significant serum electrolytes changes induced by NaP preparation.

[Barrett's esophagus and antireflux surgery: a study of a series of 26 patients]

STUDY AIM

The aim of this study was to report the results of a retrospective series of 26 patients with Barrett's esophagus treated by antireflux surgery.

PATIENTS AND METHODS

From 1979 to 1998, 21 men and five women (mean age: 53 years) with histologically proven Barrett's esophagus underwent an antireflux procedure. The mean length of Barrett's epithelium was 5.9 cm for 19 patients (73.1%). Six patients (23.1%) had tongue lesions of Barrett's epithelium, and one (3.8%) had ectopic gastric mucosa. None of the patients had a preoperative esophageal biopsy that revealed high-grade dysplasia or carcinoma. Laparotomy was performed in 17 cases and laparoscopy in nine cases. Preoperative endoscopic local treatment with argon coagulation was performed in one patient.

RESULTS

Clinical mean follow-up was 78 months and endoscopic mean follow-up was 59.3 months. No increase in the length of the Barrett's epithelium was observed. Seven patients (27%) had complete or partial regression (among them three patients with tongue lesions and one patient preoperatively treated by argon). No patients developed high-grade dysplasia or carcinoma.

CONCLUSION

Regression of Barrett's esophagus is possible but not frequent and unpredictable after antireflux procedure. However, endoscopic and histological surveillance should be continued postoperatively.

[Abdominal tuberculosis of pseudotumor aspect]

BACKGROUND

Abdominal tuberculosis is rarely encountered in developed countries, representing less than 1% of all forms of tuberculosis. There has however been a revival over the last few years.

CASE REPORTS

The initial diagnoses suspected in two young multiparous patients who had immigrated to France were malignant lymphoma and ovarian carcinoma. After the final diagnosis of abdominal tuberculosis was made, the clinical course rapidly improved.

DISCUSSION

Any abdominal organ may be involved in this localization of tuberculosis, but symptoms are not specific and diagnosis can often be missed. Tumor-forming abdominal mass is an exceptional finding and often mimics malignancy. Clinicians should be aware of this localization, particularly in light of epidemiological features, and examine all modern diagnostic procedures.

[Portasystemic anastomosis by transjugular approach: treatment of active and refractory hemorrhage caused by rupture of esophageal varices. Results in 11 patients]

OBJECTIVE

The aim of this study was to assess the feasibility and efficacy of transjugular intrahepatic portosystemic shunts for refractory variceal bleeding, uncontrolled by sclerotherapy or endoscopic ligation.

METHODS

11 patients (mean age: 52 years) with cirrhosis admitted for refractory haemorrhage from ruptured oesophageal varices were included in this study. Eight patients were Child-Pugh class C. All patients were actively bleeding.

RESULTS

All the procedures were successful. Variceal haemorrhage stopped within 24 h. There was no mortality during the procedure. Early complications such as rebleeding (18%) and thrombosis (18%) occurred. Thirty days mortality was 27%. Follow-up in the 8 surviving patients was 19.5 +/- 8 months. Three patients developed recurrent bleeding, from non-variceal sources in 2. In 4 surviving patients, occlusion of the shunt was treated with dilatation or insertion of a second stent. The incidence of hepatic encephalopathy was 25%. Five patients subsequently underwent liver transplantation. Among the 3 patients ineligible for transplantation, one died of hepatocellular carcinoma after 10 months. The 2 others were alive after 19 and 25 months, respectively.

CONCLUSIONS

These results suggest that transjugular intrahepatic portosystemic shunt is a safe and effective procedure of portal decompression in patients with refractory variceal bleeding. Prospective trials comparing this percutaneous procedure and surgical treatment are required.

[Endoscopic ligation of esophageal varices: prevention of hemorrhagic recurrences caused by rupture of esophageal varices. Results in 45 patients]

OBJECTIVES

The aim of this study was to assess the morbidity and efficacy of endoscopic variceal ligation for the prophylaxis of rebleeding from oesophageal varices.

METHODS

Forty-five patients with cirrhosis (Child's class: A: 18, B: 16, C: 11) and recent (< 48 h) variceal bleeding were included. Eleven of the patients were included after failure of sclerotherapy. All patients were treated by endoscopic ligation until the complete eradication of oesophageal varices. The mean follow-up was 8.7 +/- 6.8 months.

RESULTS

Oesophageal varices were eradicated in 40 patients (89%) after an average of 2 sessions (range: 1-5). In a subset of 11 patients treated after failure of sclerotherapy, 8 (73%) had complete eradication of oesophageal varices. Six of the 45 patients (13%) had recurrence of haemorrhage, due to post-ligation ulcerations in 5 cases and to rupture of oesophageal varices in one case. The rate of complications was 7%. Of the 40 patients whose oesophageal varices were eradicated, 7 (17%) were lost for follow up, and another treatment was performed in 4 (10%): liver transplantation in 2, and transjugular intrahepatic portosystemic shunt in 2. Recurrence of oesophageal varices after eradication was observed in 3 (10%) of the remaining 29 patients after a follow-up of 8.9 +/- 12.9 months. Of these 3 patients, only one (3%) presented with recurrence of haemorrhage due to ruptured oesophageal varices. Three patients (7%) died before eradication of oesophageal varices from causes unrelated to the technique.

CONCLUSION

This study confirms that endoscopic ligation is effective for eradication of oesophageal varices, with a low morbidity. This technique appears to be a method of choice in the prophylaxis of rebleeding from oesophageal varices, especially when sclerotherapy is ineffective.

The French experience of treatment of chronic type D hepatitis with a 12-month course of interferon alpha-2B. Results of a randomized controlled trial

Hepatitis due to hepatitis delta virus (HDV) infection is generally associated with severe histological abnormalities and rapid progression of the disease. To assess the efficacy of recombinant interferon-a2b in treatment of chronic delta hepatitis, 22 patients were entered into a randomized controlled trial: 11 received interferon-a2b subcutaneously three times weekly for 12 months (5 MU/m2 for 4 months and then 3 MU/m2 for a further 8 months) and 11 were untreated. All patients were followed up for 6 months after the completion of therapy. Nine treated patients completed the trial: one was withdrawn with hyperthyroidism and one committed suicide. Serum ALT levels were normalized or significantly reduced, always within 3 months of initiating treatment, and remained so in 73% of treated patients at the 4th month and in 54.5% at the 12th month, compared with 18% and 18%, respectively, in the untreated group. Moreover, in seven of nine treated patients, interferon was associated with the clearance of serum HDV-RNA, associated with amelioration of the histological picture, whereas this occurred in only four of 11 untreated patients. On cessation of therapy, all patients but one experienced a biological and/or virological relapse over the 6-month follow up. In conclusion, our data confirm that HDV is sensitive to inhibition by interferon-a2b, although the schedule used did not achieve permanent control of the disease. The adverse effects of interferon require consideration; in particular, care will be needed to avoid serious psychiatric side effects.

Clinical relevance of the detection of hepatitis delta virus RNA in serum by RNA hybridization and polymerase chain reaction

Hepatitis delta virus nucleic acid was detected by dot-blot hybridization using RNA probe and reverse transcription/polymerase chain reaction amplification in 223 serum samples from 66 patients with hepatitis D virus infection. Seven cases with chronic hepatitis D virus infection were treated with interferon: six for 3 months and one for 7.5 years. By using the primers located in the putative conserved regions, the technique of reverse transcription/polymerase chain reaction amplification was 10(3) to 10(4) times more sensitive than that of dot-blot hybridization. The main findings of this study are: (i) HDV RNA could be detected in the absence of any other serological hepatitis D virus marker in serum from acute hepatitis patients with IgM anti-HBc; (ii) high titer anti-HD antibodies (IgM and total anti-HD) persisted in patients during short-term interferon treatment, and in one patient during long-term interferon treatment, despite clearance of serum HDV RNA even after 3 years; (iii) total anti-HD alone was detected in the absence of IgM anti-HD and serum HDV RNA. These observations indicate that the detection of HDV RNA by molecular techniques in serum is a useful, sensitive and non-invasive technique for the early diagnosis and follow up of hepatitis D virus infection, as well as for the monitoring of antiviral therapy. In addition, total anti-HD antibody in the absence of HDV RNA may be the only residual marker of past infection. Finally, the choice of the technique for hepatitis D virus detection is important for the optimal assessment of the clinical stage and monitoring of antiviral therapy in hepatitis D virus-infected patients.

Detection of small and large genomes of hepatitis D virus in serum of patients with hepatitis D

By combining the polymerase chain reaction (PCR) with restriction enzyme digestion technologies, we characterized the genomes for the small and large delta proteins of HDV in retrospective analysis of sera from 10 patients with varied clinical outcomes. Both small and large genomes of HDV were present in all 13 serum samples from the 6 acute and 4 chronic cases studied, while the specific HDV proteins (P24 and P27) could be detected by immunoblot analysis in only 4 of them. The relative amounts and ratios of the genomes for the large and the small proteins of HDV were different for each individual. The molecular ratio of large to small HDV genomes in serum correlated with viral replication. When the replication of HDV RNA increased, the ratio decreased and vice-versa. No specific correlation, however, was found between the ratio of both molecular forms and the clinical outcome.

[What is the potential number of indications for liver grafts in France per year?]

The progress recently made in liver transplantation requires an estimation of the potential number of cases per year in France. The study of French Death Rate per age group, compared with either formal, discutable or aleatory indications of transplantation, is a valuable basis for that calculation. It confirms the relative scarcity of the potential number of liver transplantations, which can be estimated at between 2 or 3 per year and per million inhabitants.

[Peroperative radiotherapy. Initial experience at the Red Cross Hospital]

Intra operative radiation therapy is a new look at an old idea (Rich). In relation with the first experience at the Croix-Rousse Hospital with orthovoltage, a review of technical choices, surgical problems, and biological questions is presented. The analysis of literature about accumulated clinical results suggest that local control in recurrence, residual, or inoperable tumor can be obtained by combined surgery IOR, and external beam irradiation. This short experience demonstrate the feasibility of the treatment as a routine and emphasizes the need for continued study.

[Which hiatal hernias require surgery?]

Several clinical situations may justify surgery for hiatal hernia. The approach varies depending on whether the problem is a mechanical complication or a gastro-oesophageal reflux responsible for oesophagitis, peptic stenosis, chest pain, respiratory disorders or Barrett's oesophagus. Recurrence of reflux after surgery raises even more complex problems. Evaluation by modern exploratory techniques helps in establishing precise indications for the operation which must, be reserved to selected cases.