Background: Lumen apposing metal stents (LAMS) were originally developed for pancreatic fluid collections drainage (EUS-PFCD). Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) and endoscopic ultrasound-guided biliary drainage (EUS-BD) have been increasingly used as an alternative to percutaneous transhepatic biliary drainage after failed endoscopic retrograde cholangiopancreatography (ERCP) or in patients unfit for surgery. Recently, a novel dedicated fully-covered and electrocautery-enhanced LAMS (Hot Axios^TM; Boston Scientific) has been developed.

Aim & Methods: This study aimed to evaluate the safety and feasibility of EUS-GBD, EUS-BD and EUS-PFCD with Hot Axios^TM system. Twenty five patients (56% women, median age 77.6 ± 12.3 years) presenting pancreatic fluid collections, inoperable acute gallstone cholecystitis (with or without bile duct lithiasis) or malignant bile duct obstruction (after failed ERCP), were consecutively enrolled. All the patients underwent EUS-guided drainage using Hot Axios^TM system over a one-year period. Primary outcomes were technical and clinical success. We also recorded the occurrence of adverse events, procedure time, and stent patency.

Results: Fifteen patients unfit for surgery presented acute gallstone cholecystitis (four with associated common bile duct lithiasis). Four patients showed pancreatic fluid collections (three with walled-off necrosis). Six patients failed ERCP because of malignant bile duct obstruction (five presenting advanced pancreatic head cancer and one advanced hilar cholangiocarcinoma). The procedure was technically successful in 24/25 patients (96%). The clinical success was obtained in all patients. Adverse events occurred in 1 patient (4%) (gastric bleeding). Stent patency was good in all the cases. The median procedure time was 20 min (range 14-26). LAMS was removed four weeks after placement, in patients with good life expectancy, otherwise it was left indefinitely. No complications as “buried stent” were observed at the moment of removal. Starting from LAMS’ placement, median follow-up time was 181.2 days (range 30–365) assessed by abdomen computer tomography (CT-scan).

Conclusion: EUS-guided drainage by Hot Axios^TM system has high technical and long-term success rates, shows very low complications and reintervention rates, being able to be left indefinitely or easily removed. Patients unfit for surgery because of comorbidity and/or end-stage disease are best candidates.

Introduction: EUS guided sampling for biochemical and cytological analysis is recommended for managing cystic lesions of the pancreas when they are bigger than 10 mm. We report a case of a patient with cystic lesion of adrenal origin, which was mimicking pancreatic cystic tumor.

Case: We present a 31 years old woman with pain in the left part of the abdomen, severe anemia, which has led to two hemotransfusions, no data for acute pancreatitis in the past. All these symptoms started a few months after giving birth. During the hospital stay we diagnosed severe iron deficiency anemia and a palpable tumor mass in the left upper abdomen. CT-scan showed a 160 mm cystic tumor most probably originating from the pancreatic tail. The performed EUS revealed large cystic tumor, engaging the body and tail of the pancreas with thick wall (20mm). Cystic fluid was aspirated, the "strip sign" was negative and there were very low levels of amylase, lipase and CEA in the aspirate. Cytology from the capsule was inconclusive. We referred the patient for surgery with the suspicion of solid pseudopapillary neoplasm of the pancreas.Laparotomy was performed. Large cystic mass was found, most probably originating from the pancreas, engaging surrounding structures. Multivisceral resection was performed. The pathology report changed the diagnosis to adrenal pseudocyst.

Pseudocysts of the adrenal gland are rare and are usually discovered incidentally. Large adrenal pseudocysts can however present with severe abdominal pain and can be comlicated by hemorrhage, rupture or infection. There are few reports which show a connection between high levels of hormones during pregnancy and growth of the pseudocyst. Epidemiologically, adrenal pseudocysts are more common in women and typically are found between ages of 30 and 60.

Conclusion: Adrenal pseudocysts are quite rare.Most of the times the diagnosis can be challenging and a comlex approach is always needed. Radiological and clinical features of the tumor are nonspecific, thus, histopathological examination is essential in order to establish a definitive diagnosis.

Introduction: Pancratic pseudocysts are a common complication of acite and chronic pancreatitis. In rare cases, an ascending involvement of the mediastinum is observed. The condition has diverse insidious manifestations. Patients could be asymptomaticor they cen present with dysphagia, chest pain, dyspnea, cardiac rhythm disorders or congestive heart failure. The clinical course is unpredictable and could rapidly turn into a life-threatening condition due to airway or cardiac compression. The literature reports different treatment approaches: conservative therapy with observation, endoscopic treatment or surgical drainage. We present a case of a pancreatic pseudocyst with mediastinal and cervical involvement, manifested with respiratory insufficiency.

Case: A 47-year-old woman was admitted for abdominal pain and ascites. The diagnostic workout established chronic calcifying pancreatitis, peripancreatic fluid collection, ascites, partial thrombosis of the portal vein and v. cava inferior. Despite the optimal medication treatment the patient developed severe dyspnea. Progressive pleural effusions were established, which led to the performance for bilateral thoracic drainage. However, the general condition of the patient and the respiratory function deteriorated and a symmetric cervical oedema occured. We performed EUS, which revealed an increase of fluid collections with involvement of the posterior mediastinum and the parapharyngeal space.

We opted for a combination of therapeutic interventions, including surgical mediastinal drainage, followed by EUS-guided transgastric drainage of the pancreatic pseudocyst and ERCP with stenting of the main pancreatic duct and common bile duct. After the procedures we registered fast improvement in the respiratory function and the general condition of the patient. The mediastinal drainages were removed on the fourth post-procedural day due to lack of secretion and the patient was discharged on the seventf day in good general condition.

Discussion: The thoracic and cervical extension of the pancreatic pseudocyst is quite uncommon. It is a diagnostic and therapeutic challenge due to its diverse clinical manifestations and lack of experience with such cases. EUS could be extremely in detection and dynamic follow-up of not only intraabdominal but also mediastinal complication of pancreatitis. It offers safe and precise options for drainage, which makes it first-line treatment.

Endoscopic ultrasound guided interventions could be feasible with adult endoscopes and accessories in pediatrics. We report a large pancreatic pseudocyst in a 3-year old child, which developed following chemotherapy for acute lymphoblastic leukemia. After multiple trials of percutaneous drainage and infection, the patient was referred for EUS guided drainage. Successfully, 10 Fr 5 cm silicon double pigtail stent was inserted into the cyst using a Fujifilm linear echoendoscope with good drainage. 

AIM: Endoscopic drainage forms the basis of symptomatic pancreatic pseudocyst treatment and we investigated the vascular pathologies of our cases with pseudocyst drainage.

METHOD: We evaluated the drainage process of 12 patients (F/M= 5/7) who were indicated for cystgastrostomy. Pigtail stents were placed and cystogastrostomy was performed on the patients. The endoscopic, EUS, CT, portal doppler findings of the patients were evaluated with drainage process data. Follow-up of the patients was performed by USG and CT. The diagnosis time of the pseudocyst, the drainage time, the localization of the cyst, the diameter, the number of stents applied or NBD were assessed by evaluating the coexistence of concomitant vascular pathologies. FINDINGS: The mean age of the patients was (F/M=56.6/46.28). Duration of diagnosis of acute pancreatitis with pseudocyst was done at the end of the first month in 6 patients, at the third month in 4 patients, and after the 5th month in 2 patients. All cases had symptoms such as abdominal pain, loss of appetite, weight loss and nausea.  The localization of the cysts in the pancreas was 4 in body, 8 in head + body. The mean diameter of the cysts was 13.3 cm. Time between diagnosis of pseudocyst and drainage time; in 5 cases, drainage was performed in the normally recommended period (6-8 wk) and in 7 cases with an average delay of 4.35 months. In the cystogastrostomy procedure in one case hemorrhage into a cyst that was stopped with medical treatment took place and mild acute pancreatitis developed in one case. Full drainage time of the cyst was 8.4 weeks in patients who underwent drainage at normal recommended time, and over 9 weeks in patients with delayed drainage. Five patients underwent double stents and the others underwent a single stent. One patient underwent intense cyst fluid and the other underwent NBD due to abscess development. In cases which had a cyst diameter of over 10cm, in the head + body location there were splenic vein thrombosis, superior mesenteric vein thrombosis and collaterals. Six of these cases were accompanied by fundus varices. RESULTS: In our cases, in the development of vascular complications, the pseudocyst; the size of its diameter, its being located in head + body, late application of drainage process seems to be related. In such cases, it may be advised to follow more closely and to keep this possibility in mind in order to diagnose thrombosis and varicose development which may accompany thrombosis.

Introduction: Colorectal polyps are common in the general population. Endoscopy is used to detect and characterize the type of polyp. This is fundamental to determining the technique to be used to perform the resection. The objective of our study is to determine the prevalence of colcolic polyps within our department and their management

Materials and Methods: This is a descriptive and analytical retrospective study, spanning a period of 19 years, from January 2000 to April 2019, collected in the service of Hepao-Gastroenterology II of the Mohammed V Military Training Hospital in Rabat, Morocco. The Inclusion Criteria was patients aged 18 with less than 4 colorectal polyps over 3 mm and having undergone endoscopic resection. Resection techniques have been studied as well as complication management. The statistical analysis was done using SPSS 24.0 software.

Result : 3.23% (n -214) of patients who received total colonoscopy during the study period ( n-6607) had one or more polypectomies. The average number of polyps in each patient was 1.32 -0.66. The history of cto-colic cancer operated on was 13.2% (n-27). The indication of total colonoscopy was dominated by rectorrhies in 22.9% (n-47). During colonoscopy, the majority of polyps were located in the left colon in 45.1% (n-93) with a predominance of sessile polyps (Is) which accounted for 73.83% (n-158). The most commonly used resection technique was exeresis clamp biopsy and polypectomy. The rate of early complication was 2% (no.2), and the rate of late complication after endoscopic hemostasis was zero.

Conclusion : Endoscopic resection of rectocolic polyps is currently an alternative to radical surgery, decreasing incidence and mortality from colcolic cancer. In our department the prevalence was 3.23%, the most commonly used resection technique was exeresis clamp biopsy and polypectomy.

Introduction: Bile lithiasis is the main cause of acute pancreatitis (AP). The objective of our work is to evaluate the therapeutic interest of  endoscopic sphincterotomy (SE) in the management of acute bile pancreatitis through the analysis of results obtained in a Moroccan department and a review of literature.

Materials and Methods: This is a retrospective study, in a period of 8 years, from September 2010 to December 2018, collected in the Department of Hepatology and Gastroenterology II of the Military Training Mohammed V of Rabat in Morocco, including patients carriers of acute pancreatitis of bile origin and having benefited from an endoscopic retrograde Cholangio-pancreatography (ERCP) for diagnostic and therapeutic purposes.

Results: 96 patients with acute pancreatitis received an ERCP with the intention of endoscopic sphincterotomy. The diagnosis of the bile origin of the AP was made on clinical, biological and morphological arguments. The success rate of the SE was 89%. ERCP has allowed the extraction of one or more gallstones in 73 patients. The progression of acute pancreatitis after ERCP was favourable in the majority of cases, cure was raised in 91 patients with a success rate of 89%.

Discussion: Emergency decompression of the bile ducts is a priority therapeutic objective in the management of bile-based AP. SE has shown efficacy on the evolution of PA in series of four randomized prospective studies subject to compliance with its summary indications as follows; AP with angiocholitis and or obstructive jaundice, severe acute pancreatitis, SE can be achieved at 72 degrees hour.

Conclusion: Through this study we can conclude that endoscopic sphincterotomy is an effective method in the management of acute bile pancreatitis.

Introduction: Angiodysplasia is currently considered one of the most common causes of occult digestive bleeding in the elderly and hemodialysis. The treatment of endoscopic hemostasis is usually offered first-line most often by clotting with argon plasma or bipolar electrocoagulation. In the event of frequent recurrences despite appropriate endoscopic treatment, systemic thalidomide medical therapy may be offered as a complementary treatment. The objective of our case is to report the efficacy of Thalidomide in refractory digestive bleeding due to gastrointestinal angiodysplasia in the cas of a chronic hemodialysis patient.

Clinical case: This is a 74-year-old woman, chronically hemodialysis, admitted for management of a melena. A high gastrointestinal endoscopy and colonoscopy showed diffuse angiodysplasia involving the entire digestive tract. The small intestine was explored by high and low double balloon enteroscopy. Despite several sessions of argon clotting, the digestive hemorrhage is persistent and requires several transfusions. Treatment with thalidomide at 100 mg/day was initiated after the patient's informed consent and elimination of contraindications of this medication. After 4 months of treatment, gastrointestinal bleeding was controlled and the patient remained stable over the past 12 months during follow-up.

Conclusion: Bleeding due to angiodysplastic lesions of the digestive tract is commonly observed in hemodialysis patients and is responsible of a significant morbidity and mortality. This clinical case illustrates the possible use of Thalidomide as an effective therapeutic option in hemodialysis patients to control recurrent gastrointestinal bleeding by angiodysplies.

Introduction:

Papillary and mucinous intrachannel tumors of the pancreas (IPMNs)) are cystic lesions of the pancreas developing at the expense of the main and secondary ducts. Recent studies have indicated that patients with IPMNs often develop extra-pancreatic malignancies synchronously. We report a clinical case of IPMNs discovered incidentally during the extension of a rectal adenocarcinoma.

Clinical case: 

A 49-year-old patient admitted for management of rectorragies that has been evolving for 1 year associated with abdominal pain, non-fat glairo-bloody diarrhea, tenesms and weight loss. The colonoscopy objective the presence of a rectal adenocarcinoma locally associated with a cystic pancreatic lesion. The radiological aspect was typical of intrapapillary and mucinous tumors of the body of the pancreas. Bilio-pancreatic echoendoscopy has shown the appearance of a IPMNs with malignancy criteria. The patient was referred for pre-operative radio-chemotherapy for rectal adenocarcinoma. The patient was operated on from an exeresis of the rectum with postoperative chemotherapy. A pancreatic scan at 16 months of follow-up showed the same results with more or less stable lesions. A cephalic duodeno-pancreatectomy was considered remotely from chemotherapy.

Conclusion:

The presence of IPMNs is associated with a significantly higher risk of developing extra-pancreatic cancer, including colorectal cancer. In most cases, IPMNs are discovered by chance, especially in the balance of another tumour. This discovery may change the therapeutic strategy depending on whether it is disturbing or not.

Background and aims:

Primary linitis plastica (PLP) of the rectum is an uncommon entity (0.1% of colorectal cancer) that is difficult to diagnose due to the lack of mucosal lesions on endoscopy, the low diagnostic yield of biopsy and non-specific findings of barium radiology and computerized tomography. We present an unusual case of PLP associated with krukenburg tumor in a young patient, diagnosed at the department of Hepatology and Gastroenterology I of the Military Training Hospital of Rabat in Morocco

Clinical case:

31 years old woman, presented with 1 year history of dysenteric syndrome and severe loss of weight. The rectal examination showed a circumferential tumor at 3 cm from the anal margin. The biopsy revealed an adenocarcinoma with independent cell out of signet ring. Gastric endoscopic ultrasonographically was normal. Pelvic CT scan and MRI showed stenotic rectal tumor extending to the rectosigmoid junction with perirectal fat infiltration, a right ovarian mass of 5 cm in diameter with multiple cysts and peritoneal carcinomatosis. The patient underwent an exploratory laparotomy. The histopathological finding of ovarian mass was consistent with metastatic adenocarcinoma of the rectum. The patient received palliative treatment.

Conclusion:

The delay of diagnosis darkens the prognosis and complicates the therapeutic attitude.

Introduction: Achalasia is defined by a deficit, complete or not, of the relaxation of the lower esophageal sphincter in response to swallowing and the disappearance of esophageal peristalsis. The various treatments proposed so far are only symptomatic attempts to minimize the motor abnormalities observed on the esophageal body and, more particularly for endoscopic treatments, to remove the sphincteric obstacle.

The purpose of our study is to evaluate the effectiveness of the endoscopic dilation in patients with achalasia supported in our department.

Materials and methods: This is a retrospective study, spread over a period of 9 years, from January 2010 until January 2019, gathered in the Department of Hepatology and Gastroenterology I of the Military Training Hospital Mohammed V of Rabat in Morocco, including 84 patients with achalasia, whose diagnosis was retained on a set of clinical arguments, endoscopic, manometric; The effectiveness of the treatment was judged by the Eckart Score. Failure was defined by the lack of improvement after a number of dilations> 3.

Results: The average age of our patients is 44 years [18-70 years] with a sex ratio of 0.75. Dysphagia was the main symptom present in all our patients, followed by weight loss present in 46.42% of patients. The average Eckart score before dilation was 5.5. Oesogastroduodenal fibroscopy was performed in all patients and showed a positive jump in 82.14%. Manometry was performed in all our patients and confirmed the diagnosis of achalasia in all cases. We performed a total of 174 balloon dilation sessions. With average 2, 07 sessions per patient (1-5). 72 patients (85.71%) presented a remission after less than 4 sessions. Only 12 patients (14.28%) presented refractory stenosis, 6 of which were operated while the other six continued dilation. The average time to recidivism was 2.3 months. The average Eckart score after dilation was 1.5 (range 0 to 6).

Conclusion: The results of our study are in line with those in the literature which emphasize the effectiveness of esophageal dilation in case of achalasia, which can limit as much as possible the role of surgery and metal endoscopic prostheses for such a benign pathology.