Endoscopic Barrett’s eradication: myth or reality?

Le traitement par résection endoscopique d’une lésion néoplasique superficielle au sein d’un oesophage de Barrett est le nouveau standard de la prise en charge de cette pathologie. Elle permet d’orienter la stratégie thérapeutique ultérieure et en particulier d’éviter l’oesophagectomie en cas de lésion intramuqueuse de bon pronostic. Cependant, ce traitement local pose le problème de la métaplasie intestinale résiduelle porteuse d’un risque de développement de nouvelle lésion. La destruction endoscopique de l’ensemble de la métaplasie et son remplacement par un épithélium malpighien, permettraient une réduction du risque néoplasique et de la nécessité de suivi de ces patients. À ce jour, malgré de bons résultats immédiats, plusieurs techniques d’ablation ont été abandonnées après démonstration d’une importante fréquence de réapparition de la métaplasie et un taux élevé de complications. L’ablation de la métaplasie par radiofréquence est une technique endoscopique récente permettant la destruction de larges plages de Barrett. Les résultats de suivi à 1 ou 2 ans des patients traités par cette technique sont encourageants et nous permettent de croire à l’avenir d’un traitement endoscopique global du Barrett en dysplasie.Endoscopic mucosal resection is a new standard of work up and therapeutic procedure in Barrett’s superficial neoplastic lesion. It allows a better therapeutic strategy and avoids unnecessary oesophagectomy even in case of low risk intramucosal cancer. However this local treatment raises the problem of residual intestinal metaplasia and the associated risk of new neoplastic lesion. The total endoscopic Barrett’s eradication and the intestinal metaplasia replacement with neosquamous epithelium could theoretically reduce the risk of neoplasia and the necessity of patient follow-up. Up to now, despite excellent immediate results, several Barrett’s ablation techniques were abandoned because of high rate of intestinal metaplasia reappearance and complications. Radiofrequency ablation is a new endoscopic technique, which allows destruction of large Barrett segments. One or two years’ follow-up studies of this technique are encouraging. There is still a hope for a future of global endoscopic treatment of dysplastic Barrett

International multicenter expert survey on endoscopic treatment of upper gastrointestinal anastomotic leaks

Background and study aims: A variety of endoscopic techniques are currently available for treatment of upper gastrointestinal (UGI) anastomotic leaks; however, no definite consensus exists on the most appropriate therapeutic approach. Our aim was to explore current management of UGI anastomotic leaks. Methods: A survey questionnaire was distributed among international expert therapeutic endoscopists regarding management of UGI anastomotic leaks. Results: A total of 44 % of 163 surveys were returned; 69 % were from gastroenterologists and 56 % had > 10 years of experience. A third of respondents treat between 10 and 19 patients annually. Fifty-six percent use fully-covered self-expandable metal stents as their usual first option; 80% use techniques to minimize migration; 4 weeks was the most common reported stent dwell time. Sixty percent perform epithelial ablation prior to over-the-scope-clip placement or suturing. Regarding endoscopic vacuum therapy (EVT), 56 % perform balloon dilation and intracavitary EVT in patients with large cavities but small leak defects. Regarding endoscopic septotomy, 56 % consider a minimal interval of 4 weeks from surgery and 90 % consider the need to perform further sessions. Regarding endoscopic internal drainage (EID), placement of two stents and shorter stents is preferred. Persistent inflammation with clinical sepsis was the definition most commonly reported for endoscopic failure. EVT/stent placement and EVT/EID were the therapeutic options most often chosen in patients with previous oncologic surgery and previous bariatric surgery, respectively. Conclusions: There is a wide variation in the management of patients with UGI anastomotic leaks. Future prospective studies are needed to move from an expert- to evidence- and personalization-based care

Esophageal leaks: extending our toolbox?

CommentEditorialSCOPUS: ed.jinfo:eu-repo/semantics/publishe

Endoscopic Treatment of Post-Bariatric Leaks

The prevalence of post-bariatric complications and post-bariatric leaks has dramatically increased over the last two decades, in line with the pandemic of morbid obesity and the growing number of bariatric surgeries. For bariatric leaks, re-operation with drainage, and possibly an attempt at surgical closure, has, for a long time, been considered as the only possible treatment.In the early 2000s, our team started to be involved in post bariatric complications management and, with the experience we acquired in other diseases associated with upper gastrointestinal leakages, endotherapy became logically a good theoretical option to treat these leaks. It offers a potentially less invasive alternative to an unsatisfactory surgical management.Insertion of a self-expandable stent to cover the leak and facilitate its closure was our initial treatment strategy. Our retrospectives studies in this field, in addition to demonstrating good results, helped to identify major clinical factors associated with treatment success, such as early endoscopic management after leakage diagnosis. We promoted the use of partially covered stents which helps to reduce the risk of migration, probably increases watertightness, and can be efficiently extracted after the insertion of a fully covered stent.However, post bariatric leaks is a serious and difficult clinical situation and we experienced disappointing results with stent treatment alone in several patients. This led us to develop complementary techniques, such as fistula plug insertion or internal drainage with double pig tail stents, which provided additional positive results. Internal drainage even appears to be effective as an isolated strategy in selected patients.The present work illustrates the evolution of this new clinical modality and demonstrates, based on our published results, how endotherapy has become a first-line option that now plays a pivotal role in the multimodal approach to post-bariatric leakage. We show that, in the hands of an experienced team and with treatment tailored to the variety of clinical presentations, endotherapy can reach almost 90% success. Based on our results and on our current experience, we propose a treatment algorithm for management of post bariatric leaks and fistulas in which deployment of intraluminal self-expandable stents remains the cornerstone.As prospective and comparative study for management of this life-threatening complication are lacking, we also propose several direction for future clinical researches in this area which could help to standardize the multimodal treatment of post-bariatric leaks.Doctorat en Sciences médicales (Médecine)info:eu-repo/semantics/nonPublishe

Plastic stents in the treatment of benign esophageal conditions.

CommentLetterinfo:eu-repo/semantics/publishe

Expandable metal stents for benign pancreatic duct obstruction

SCOPUS: re.jinfo:eu-repo/semantics/publishe

"Red flag" techniques in Barrett's esophagus: minor additional benefit or a waste of time?

EditorialSCOPUS: ed.jinfo:eu-repo/semantics/publishe

Prise en charge endoscopique des complications de la chirurgie œsogastrique

Anastomotic stenosis and fistulas are the two main complications of oesogastric surgery that can be managed endoscopically, besides anastomotic bleeding. Balloon dilatation is a safe and efficient technique that is now acknowledged as one of the first therapeutic options for stenosis. With the availability of plastic stents, the technique can now be used for benign strictures, in particular those refractory to dilatation. Other solutions, such as steroid injection and incision of strictures, are only marginal techniques. Endoscopic management of anastomotic fistulas and leaks also relies on self-expanding stents. For openings wider than 1 cm and acute dehiscence, they are a better option than other available techniques such as endoscopic clipping. Besides fistula closing, management of these complications must include an efficient drainage of perianastomotic collections through either percutaneous or endoscopic techniques. Endoscopic management of these complications is in any case less invasive than a new surgical intervention. However, the success rate is dependent on endoscopic expertise and good knowledge of the underlying surgical situation obtained through interdisciplinary communication.SCOPUS: sh.jinfo:eu-repo/semantics/publishe

How good is fine needle aspiration? What results should you expect?

Tissue acquisition plays a key role before treatment decision in most of oncological pathologies but also in several benign diseases. By offering tissue sampling, endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has become an essential tool in the diagnostic processes. One of the reasons for the success of the technique is related to its excellent diagnostic performance. The diagnostic accuracy of EUS-FNA is above 80% for most of the usual indications. These performances are however dependent on some factors related to both the disease and patient's medical history but also related to medical staff expertise. Endoscopist needs to know how to reach a lesion but also how to efficiently acquire good tissue samples. This review aims to report general recommendations available in the literature for high quality EUS-FNA. Sample processing and sample interpretation also influence diagnostic accuracy of FNA. This paper includes a discussion on sample processing and benefits of the on-site pathology examination. It also provides the results reported in the literature of sample adequacy and diagnostic performance of EUS-FNA for most common indications: Pancreatic diseases, sub-mucosal lesion, mucosal thickenings, lymph nodes, cystic lesion and free fluids.SCOPUS: re.jinfo:eu-repo/semantics/publishe