BACKGROUND Endoscopic bilateral biliary drainage is a first line palliative treatment for unresectable malignant hilar biliary obstruction(MHBO)but remains technically challenging.The emergence of self-expandable meta...BACKGROUND Endoscopic bilateral biliary drainage is a first line palliative treatment for unresectable malignant hilar biliary obstruction(MHBO)but remains technically challenging.The emergence of self-expandable metallic stents carried by an ultrathin(6 Fr or smaller)delivery system now permits simultaneous bilateral stent placement.To date,only a few studies have compared this new method with conventional sequential bilateral stenting.AIM To evaluate a possible superiority of simultaneous“side by side”(SBS)biliary drainage in unresectable MHBO.METHODS We identified 135 patients who benefited from bilateral drainage using uncovered self-expandable metallic stents between 2010 and 2023.Among them,62 benefited from simultaneous SBS bilateral drainage between 2017 and 2023,and 73 benefited from sequential bilateral drainage[38 using“stent in stent”(SIS)technique and 35 using SBS technique between 2010 and 2017].RESULTS Technical success was significantly increased in simultaneous drainage compared with sequential drainage(94%vs 75%,P=0.008).However,simultaneous SBS drainage and sequential SIS drainage had a similar technical success(94%vs 95%).We observed no differences regarding clinical success,procedure duration and recurrent biliary obstruction rate.Stent patency was shorter in the SIS group compared with the simultaneous group(103 days vs 144 days).Early adverse events were more frequent in the sequential group(31%vs 21%,P=0.205),with no differences regarding SIS or SBS technique.Technical failure was associated with a higher rate of infectious fatal adverse events(9.5%vs 1.7%,P=0.02).Reintervention after recurrent biliary obstruction seems to be more successful after using SBS rather than SIS techniques(83%vs 75%,P=0.53).CONCLUSION Simultaneous SBS metallic stent placement using an ultra-thin delivery system was technically easier and as efficient as sequential bilateral stenting in unresectable MHBO to achieve bilateral drainage.The SIS procedure remains a good option in unresectable MHBO.展开更多
AIM: To investigate whether an endoscopy-based management could prevent the long-term risk of postoperative recurrence.METHODS: From the pathology department database, we retrospectively retrieved the data of all the ...AIM: To investigate whether an endoscopy-based management could prevent the long-term risk of postoperative recurrence.METHODS: From the pathology department database, we retrospectively retrieved the data of all the patients operated on for Crohn’s disease (CD) in our center (1986-2015). Endoscopy-based management was defined as systematic postoperative colonoscopy (median time after surgery = 9.5 mo) in patients with no clinical postoperative recurrence at the time of endoscopy.RESULTS: From 205 patients who underwent surgery, 161 patients (follow-up > 6 mo) were included. Endoscopic postoperative recurrence occurred in 67.6%, 79.7%, and 95.5% of the patients, respectively 5, 10 and 20 years after surgery. The rate of clinical postoperative recurrence was 61.4%, 75.9%, and 92.5% at 5, 10 and 20 years, respectively. The rate of surgical postoperative recurrence was 19.0%, 38.9% and 64.7%, respectively, 5, 10 and 20 years after surgery. In multivariate analysis, previous intestinal resection, prior exposure to anti-TNF therapy before surgery, and fistulizing phenotype (B3) were postoperative risk factors. Previous perianal abscess/fistula (other perianal lesions excluded), were predictive of only symptomatic recurrence. In multivariate analysis, an endoscopy-based management (n = 49/161) prevented clinical (HR = 0.4, 95%CI: 0.25-0.66, P < 0.001) and surgical postoperative recurrence (HR = 0.30, 95%CI: 0.13-0.70, P = 0.006).CONCLUSION: Endoscopy-based management should be recommended in all CD patients within the first year after surgery as it highly decreases the long-term risk of clinical recurrence and reoperation.展开更多
BACKGROUND The individual performances and the complementarity of Crohn’s disease(CD)activity index(CDAI),C-reactive protein(CRP)and faecal calprotectin(Fcal)to monitor patients with CD remain poorly inves-tigated in...BACKGROUND The individual performances and the complementarity of Crohn’s disease(CD)activity index(CDAI),C-reactive protein(CRP)and faecal calprotectin(Fcal)to monitor patients with CD remain poorly inves-tigated in the era of“tight control”and“treat to target”strategies.AIM To assess CDAI,CRP and Fcal variation,alone or combined,after 12 wk(W12)of anti-tumor necrosis factor(TNF)therapy to predict corticosteroids-free remission(CFREM=CDAI<150,CRP<2.9 mg/L and Fcal<250μg/g with no therapeutic intensification and no surgery)at W52.METHODS CD adult patients needing anti-TNF therapy with CDAI>150 and either CRP>2.9 mg/L or Fcal>250μg/g were prospectively enrolled.RESULTS Among the 40 included patients,13 patients(32.5%)achieved CFREM at W52.In univariable analysis,CDAI<150 at W12(P=0.012),CRP level<2.9 mg/L at W12(P=0.001)and Fcal improvement at W12(Fcal<300μg/g)or,for patients with initial Fcal<300μg/g,at least 50%decrease of Fcal or normalization of Fcal(<100μg/g)(P=0.001)were predictive of CFREM at W52.Combined endpoint(CDAI<150 and CRP≤2.9 mg/L and FCal improvement)at W12 was the best predictor of CFREM at W52 with positive predictive value=100.0%(100.0-100.0)and negative predictive value=87.1%(75.3-98.9).In multivariable analysis,Fcal improvement at W12[odd ratio(OR)=45.1(2.96-687.9);P=0.03]was a better predictor of CFREM at W52 than CDAI<150[OR=9.3(0.36-237.1);P=0.145]and CRP<2.9 mg/L(0.77-278.0;P=0.073).CONCLUSION The combined monitoring of CDAI,CRP and Fcal after anti-TNF induction therapy is able to predict favorable outcome within one year in patients with CD.展开更多
AIM To assess magnetic resonance imaging(MRI)and faecal calprotectin to detect endoscopic postoperative recurrence in patients with Crohn's disease(CD).METHODS From two tertiary centers,all patients with CD who un...AIM To assess magnetic resonance imaging(MRI)and faecal calprotectin to detect endoscopic postoperative recurrence in patients with Crohn's disease(CD).METHODS From two tertiary centers,all patients with CD who underwent ileocolonic resection were consecutively and prospectively included.All the patients underwent MRI and endoscopy within the first year after surgery or after the restoration of intestinal continuity[median=6 mo(5.0-9.3)].The stools were collected the day before the colonoscopy to evaluate faecal calprotectin level.Endoscopic postoperative recurrence(POR)was defined as Rutgeerts'index≥i2b.The MRI was analyzed independently by two radiologists blinded from clinical data.RESULTS Apparent diffusion coefficient(ADC)was lower in patients with endoscopic POR compared to those with no recurrence(2.03±0.32 vs 2.27±0.38×10^(-3)mm^2/s,P=0.032).Clermont score(10.4±5.8 vs 7.4±4.5,P=0.038)and relative contrast enhancement(RCE)(129.4%±62.8%vs 76.4%±32.6%,P=0.007)were significantly associated with endoscopic POR contrary to the magnetic resonance index of activity(Ma RIA)(7.3±4.5 vs 4.8±3.7;P=0.15)and MR scoring system(P=0.056).ADC<2.35×10^(-3)mm^2/s[sensitivity=0.85,specificity=0.65,positive predictive value(PPV)=0.85,negative predictive value(NPV)=0.65]and RCE>100%(sensitivity=0.75,specificity=0.81,PPV=0.75,NPV=0.81)were the best cutoff values to identify endoscopic POR.Clermont score>6.4(sensitivity=0.61,specificity=0.82,PPV=0.73,NPV=0.74),Ma RIA>3.76(sensitivity=0.61,specificity=0.82,PPV=0.73,NPV=0.74)and a MR scoring system≥MR1(sensitivity=0.54,specificity=0.82,PPV=0.70,and NPV=0.70)demonstrated interesting performances to detect endoscopic POR.Faecal calprotectin values were significantly higher in patients with endoscopic POR(114±54.5μg/g vs 354.8±432.5μg/g;P=0.0075).Faecal calprotectin>100μg/g demonstrated high performances to detect endoscopic POR(sensitivity=0.67,specificity=0.93,PPV=0.89 and NPV=0.77).CONCLUSION Faecal calprotectin and MRI are two reliable tools to detect endoscopic POR in patients with CD.展开更多
文摘BACKGROUND Endoscopic bilateral biliary drainage is a first line palliative treatment for unresectable malignant hilar biliary obstruction(MHBO)but remains technically challenging.The emergence of self-expandable metallic stents carried by an ultrathin(6 Fr or smaller)delivery system now permits simultaneous bilateral stent placement.To date,only a few studies have compared this new method with conventional sequential bilateral stenting.AIM To evaluate a possible superiority of simultaneous“side by side”(SBS)biliary drainage in unresectable MHBO.METHODS We identified 135 patients who benefited from bilateral drainage using uncovered self-expandable metallic stents between 2010 and 2023.Among them,62 benefited from simultaneous SBS bilateral drainage between 2017 and 2023,and 73 benefited from sequential bilateral drainage[38 using“stent in stent”(SIS)technique and 35 using SBS technique between 2010 and 2017].RESULTS Technical success was significantly increased in simultaneous drainage compared with sequential drainage(94%vs 75%,P=0.008).However,simultaneous SBS drainage and sequential SIS drainage had a similar technical success(94%vs 95%).We observed no differences regarding clinical success,procedure duration and recurrent biliary obstruction rate.Stent patency was shorter in the SIS group compared with the simultaneous group(103 days vs 144 days).Early adverse events were more frequent in the sequential group(31%vs 21%,P=0.205),with no differences regarding SIS or SBS technique.Technical failure was associated with a higher rate of infectious fatal adverse events(9.5%vs 1.7%,P=0.02).Reintervention after recurrent biliary obstruction seems to be more successful after using SBS rather than SIS techniques(83%vs 75%,P=0.53).CONCLUSION Simultaneous SBS metallic stent placement using an ultra-thin delivery system was technically easier and as efficient as sequential bilateral stenting in unresectable MHBO to achieve bilateral drainage.The SIS procedure remains a good option in unresectable MHBO.
文摘AIM: To investigate whether an endoscopy-based management could prevent the long-term risk of postoperative recurrence.METHODS: From the pathology department database, we retrospectively retrieved the data of all the patients operated on for Crohn’s disease (CD) in our center (1986-2015). Endoscopy-based management was defined as systematic postoperative colonoscopy (median time after surgery = 9.5 mo) in patients with no clinical postoperative recurrence at the time of endoscopy.RESULTS: From 205 patients who underwent surgery, 161 patients (follow-up > 6 mo) were included. Endoscopic postoperative recurrence occurred in 67.6%, 79.7%, and 95.5% of the patients, respectively 5, 10 and 20 years after surgery. The rate of clinical postoperative recurrence was 61.4%, 75.9%, and 92.5% at 5, 10 and 20 years, respectively. The rate of surgical postoperative recurrence was 19.0%, 38.9% and 64.7%, respectively, 5, 10 and 20 years after surgery. In multivariate analysis, previous intestinal resection, prior exposure to anti-TNF therapy before surgery, and fistulizing phenotype (B3) were postoperative risk factors. Previous perianal abscess/fistula (other perianal lesions excluded), were predictive of only symptomatic recurrence. In multivariate analysis, an endoscopy-based management (n = 49/161) prevented clinical (HR = 0.4, 95%CI: 0.25-0.66, P < 0.001) and surgical postoperative recurrence (HR = 0.30, 95%CI: 0.13-0.70, P = 0.006).CONCLUSION: Endoscopy-based management should be recommended in all CD patients within the first year after surgery as it highly decreases the long-term risk of clinical recurrence and reoperation.
文摘BACKGROUND The individual performances and the complementarity of Crohn’s disease(CD)activity index(CDAI),C-reactive protein(CRP)and faecal calprotectin(Fcal)to monitor patients with CD remain poorly inves-tigated in the era of“tight control”and“treat to target”strategies.AIM To assess CDAI,CRP and Fcal variation,alone or combined,after 12 wk(W12)of anti-tumor necrosis factor(TNF)therapy to predict corticosteroids-free remission(CFREM=CDAI<150,CRP<2.9 mg/L and Fcal<250μg/g with no therapeutic intensification and no surgery)at W52.METHODS CD adult patients needing anti-TNF therapy with CDAI>150 and either CRP>2.9 mg/L or Fcal>250μg/g were prospectively enrolled.RESULTS Among the 40 included patients,13 patients(32.5%)achieved CFREM at W52.In univariable analysis,CDAI<150 at W12(P=0.012),CRP level<2.9 mg/L at W12(P=0.001)and Fcal improvement at W12(Fcal<300μg/g)or,for patients with initial Fcal<300μg/g,at least 50%decrease of Fcal or normalization of Fcal(<100μg/g)(P=0.001)were predictive of CFREM at W52.Combined endpoint(CDAI<150 and CRP≤2.9 mg/L and FCal improvement)at W12 was the best predictor of CFREM at W52 with positive predictive value=100.0%(100.0-100.0)and negative predictive value=87.1%(75.3-98.9).In multivariable analysis,Fcal improvement at W12[odd ratio(OR)=45.1(2.96-687.9);P=0.03]was a better predictor of CFREM at W52 than CDAI<150[OR=9.3(0.36-237.1);P=0.145]and CRP<2.9 mg/L(0.77-278.0;P=0.073).CONCLUSION The combined monitoring of CDAI,CRP and Fcal after anti-TNF induction therapy is able to predict favorable outcome within one year in patients with CD.
文摘AIM To assess magnetic resonance imaging(MRI)and faecal calprotectin to detect endoscopic postoperative recurrence in patients with Crohn's disease(CD).METHODS From two tertiary centers,all patients with CD who underwent ileocolonic resection were consecutively and prospectively included.All the patients underwent MRI and endoscopy within the first year after surgery or after the restoration of intestinal continuity[median=6 mo(5.0-9.3)].The stools were collected the day before the colonoscopy to evaluate faecal calprotectin level.Endoscopic postoperative recurrence(POR)was defined as Rutgeerts'index≥i2b.The MRI was analyzed independently by two radiologists blinded from clinical data.RESULTS Apparent diffusion coefficient(ADC)was lower in patients with endoscopic POR compared to those with no recurrence(2.03±0.32 vs 2.27±0.38×10^(-3)mm^2/s,P=0.032).Clermont score(10.4±5.8 vs 7.4±4.5,P=0.038)and relative contrast enhancement(RCE)(129.4%±62.8%vs 76.4%±32.6%,P=0.007)were significantly associated with endoscopic POR contrary to the magnetic resonance index of activity(Ma RIA)(7.3±4.5 vs 4.8±3.7;P=0.15)and MR scoring system(P=0.056).ADC<2.35×10^(-3)mm^2/s[sensitivity=0.85,specificity=0.65,positive predictive value(PPV)=0.85,negative predictive value(NPV)=0.65]and RCE>100%(sensitivity=0.75,specificity=0.81,PPV=0.75,NPV=0.81)were the best cutoff values to identify endoscopic POR.Clermont score>6.4(sensitivity=0.61,specificity=0.82,PPV=0.73,NPV=0.74),Ma RIA>3.76(sensitivity=0.61,specificity=0.82,PPV=0.73,NPV=0.74)and a MR scoring system≥MR1(sensitivity=0.54,specificity=0.82,PPV=0.70,and NPV=0.70)demonstrated interesting performances to detect endoscopic POR.Faecal calprotectin values were significantly higher in patients with endoscopic POR(114±54.5μg/g vs 354.8±432.5μg/g;P=0.0075).Faecal calprotectin>100μg/g demonstrated high performances to detect endoscopic POR(sensitivity=0.67,specificity=0.93,PPV=0.89 and NPV=0.77).CONCLUSION Faecal calprotectin and MRI are two reliable tools to detect endoscopic POR in patients with CD.
