Impact of bile acids on the severity of laryngo-pharyngeal reflux.

OBJECTIVES: The primary end point of this study was to evaluate the impact of bile acids on severity of laryngo-pharyngeal reflux (LPR) and the possible correlation with esophagitis and upper airway malignancies. The second end point was to evaluate if salivary bile acids and molecules other than pepsin might serve as diagnostic biomarkers of LPR. DESIGN: Observational prospective comparative study. SETTING: Otorhinolaryngology unit of a tertiary hospital. PARTICIPANTS: Sixty-two consecutive adult outpatients suspected of LPR. MAIN OUTCOME MEASURES: Bile acids, bilirubin and pepsinogen I-II were measured in saliva. Patients underwent pH metry and based on the results of bile acids were subdivided as acid, mixed and alkaline LPR. RESULTS: Significantly higher Reflux Findings Score (RFS) and Reflux Symptoms Index (RSI) were seen in patients with alkaline and mixed LPR compared to acid LPR. Salivary bile acids >1 µmol/L seem to be a reliable indicator of the severity of LPR. Compared to those without, patients with esophagitis or a history of upper airway malignancy have high concentrations of bile acids in saliva. Among the molecules studied, bile acids were the most suitable for diagnosis of LPR, with a sensitivity of 86% and a positive predictive value of 80.7%. CONCLUSIONS: Our data suggest that high concentrations of bile acids are associated with higher values of RSI and RFS in LPR as well as a higher risk of esophagitis and history of upper airway malignancies. We finally observed that bile acids provided the best biometric parameters for diagnosis of LPR among the molecules tested.

Endoscopic Double-Pigtail Catheter (EDPC) Internal Drainage as First-Line Treatment of Gastric Leak: A Case Series during Laparoscopic Sleeve Gastrectomy Learning Curve for Morbid Obesity.

OBJECTIVES: The prevalence of morbid obesity has dramatically increased over the last several decades worldwide, currently reaching epidemic proportions. Gastric leak (GL) remains the potentially fatal main complication after sleeve gastrectomy (SG) for morbid obesity. To our knowledge, there are no standardized guidelines for GL treatment after laparoscopic sleeve gastrectomy (LSG) yet. The aim of this study was to represent our institutional preliminary experience using the endoscopic double-pigtail catheter (EDPC) as the method of internal drainage and propose it as first-line treatment in case of GL after LSG. METHODS: One hundred and seventeen patients were admitted to our surgical department and underwent laparoscopic sleeve gastrectomy (LSG) for morbid obesity from March 2014 to June 2019. In 5 patients (4.3%) of our series, GL occurred as a complication of LSG. EPDC was the stand-alone procedure of internal drainage and GL first-line treatment. The internal pig tail was endoscopically removed from 30th to 40th POD in all cases. RESULTS: Present data (clinical, biochemical, and instrumental tests) showed a complete resolution of GL, with promotion of a pseudodiverticula and complete re-epithelialization of leak. Follow-up was more strict than usual (clinical visit and biochemical test on 7th, 14th, and 21st day after discharge; a CT scan with gastrografin on 30th day from discharge if clinical visit and exams were normal). CONCLUSION: This was a preliminary retrospective observational study, conducted on 5 patients affected by GL as a complication of LSG for morbid obesity. EDPC maintains the safety, efficacy, and nonexpensive characteristic and may be proposed as better first-line treatment in case of GL after bariatric surgery.

Hypovolemic shock after pelvic radiotherapy. A rare combination leading to a devastating complication.

BACKGROUND: Radiotherapy currently plays a key role in pelvic malignancies' management. Excellent outcomes have been reported on its association with chemotherapy for the treatment of the anal carcinoma. Despite that, the combined use of chemo- and radiotherapy and the high doses administered seem to be strongly associated with early and late onset side effects. METHODS: We reported a case of a 72 years old woman, affected by anal squamous cell carcinoma. She underwent chemotherapy, and then radiotherapy, with good results. RESULTS: During a regular MR control, the patient developed anaphylactic reaction to Gadolinium, and after that a rectosigmoid ischemia with total necrosis of the posterior rectal wall was diagnosed and surgically treated with Hartmann procedure. CONCLUSION: In our case we faced with the rapid and severe degeneration of pelvic anatomy determined by the sum of vascular alterations following hypovolemic shock and pelvic tissues alteration after radiotherapy. It seems essential not to underestimate the exponential outcome of a similar unusual combination of events. KEY WORDS: Anal carcinoma, Hypovolemic shock, Pelvic radiotherapy, Rectal necrosis.

Gastric leak after laparoscopic sleeve gastrectomy: management with endoscopic double pigtail drainage. A systematic review.

Gastric leak remains the main complication after sleeve gastrectomy, but there are no standardized guidelines for its treatment. Good results have been reported using endoscopic double-pigtail stent. To estimate its effectiveness, we carried out this systematic review. Eleven eligible articles were identified by searching PubMed, Embase, and Cochrane Library databases. A total of 385 patients met the inclusion criteria. The pooled proportion of successful leak closures by using double pigtail drainage was 83.41%. The proportion of successful leak closures by using double pigtail drainage by experienced operators as first-line treatment was 84.71%. Our review suggested that double-pigtail stent could be a valid approach to manage the postbariatric gastric leak, with low rate of complications and a good tolerance by patients. More high-quality studies with large samples sizes should be undertaken to better evaluate and compare the variety of techniques available.

A case of intrasplenic displacement of an endoscopic double-pigtail stent as a treatment for laparoscopic sleeve gastrectomy leak.

INTRODUCTION: The most frequent and severe complication after laparoscopic sleeve gastrectomy is gastric leak. Nowadays, there is no specific standard recommendation for its management, but the endoscopic placement of a double-pigtail drain across the leak has been proven to be effective and minimally invasive. Stent displacement into the abdominal cavity is not common and intrasplenic migration is even more rare. CASE PRESENTATION: We report a case of a 49-year-old woman with intrasplenic displacement of an endoscopic double-pigtail stent as a treatment for laparoscopic sleeve gastrectomy leak. DISCUSSION: Pigtail drain migration involving the spleen is rare but may potentially expose the patient to the risk of parenchymal abscess or haemorrhage. Often the clinic does not indicate early this complication. CONCLUSION: We underline the need for a close radiologic follow-up, regardless of clinical conditions, in all patients treated with double-pigtail drain and its early removal in case of migration.

Phytobezoar and duodenal ulcer as complication of Duodopa therapy in a patient affected by Parkinson's disease.

Continuous duodenal infusion of levodopa/carbidopa intestinal gel (LCIG) is an established treatment to control motor fluctuations in Parkinson's disease. Duodenal infusion allows a steady absorption of the drug in the small bowel, reducing plasmatic fluctuations of levodopa. Some complications may occur during the treatment, often related to intrajejunal percutaneous endoscopic gastrostomy (PEG-J). We report a case of duodenal ulcer associated with a phytobezoar involving the end of jejunal probe, in a patient who underwent PEG-J for LCIG infusion. In the last 2 weeks, the patient suffered from abdominal pain and dyspepsia. Oesophagogastroduodenoscopy showed an ulcerative lesion of the duodenum due to traction of the jejunal tube; the end of the jejunal tube was wrapped in a phytobezoar. This case is interesting because of the extension of the ulcerative lesion due to PEG-J dislocation and because of the subtle symptoms associated with it.

Peroral Endoscopic Myotomy for Esophageal Achalasia: Outcomes of the First 100 Patients With Short-term Follow-up.

OBJECTIVE: Aim of this study is to report the mid-term outcomes of a large series of patients treated with peroral endoscopic myotomy (POEM) in a single European center. BACKGROUND: POEM is a recently developed treatment of achalasia, which combines the efficacy of surgical myotomy, with the benefits of an endoscopic procedure. Previous studies, including few patients with a short-term follow-up, showed excellent results on dysphagia relief. METHODS: The first 100 adult patients treated in a single tertiary referral center were retrospectively identified and included in this study (41 men, mean age 48.4 years). Patients were treated according to a standard technique. Follow-up data, including clinical evaluation, and results of esophagogastroduodenoscopy (EGD), manometry, and pH monitoring were collected and analyzed. RESULTS: POEM was completed in 94% of patients. Mean operative time was 83 minutes (49-140  minutes). No complications occurred. Patients were fed after a median of 2 days (1-4 days). A mean follow-up of 11 months (3-24 months) was available for 92 patients. Clinical success was documented in 94.5% of patients. Twenty-four-hour pH monitoring documented Gastro-Esophageal Reflux Disease (GERD) in 53.4% of patients. However, only a minority of patients had heartburn (24.3%) or esophagitis (27.4%), and these patients were successfully treated with proton-pump inhibitors. CONCLUSIONS: Our results confirm the efficacy of POEM in a large series of patients, with a mean follow-up of 11 months. Should our results be confirmed by long-term follow-up studies, POEM may become one of the first-line therapies of achalasia in the next future.

Treatment of esophageal achalasia in children: Today and tomorrow.

BACKGROUND: Esophageal achalasia (EA) is a rare esophageal motility disorder in children. Laparoscopic Heller myotomy (LHM) represents the treatment of choice in young patients. Peroral endoscopic myotomy (POEM) is becoming an alternative to LHM. The aim of this study is to evaluate the effectiveness, safety, and outcomes of POEM vs LHM in treatment of children with EA. METHODS: Data of pediatric patients with EA, who underwent LHM and POEM from February 2009 to December 2013 in two centers, were collected. RESULTS: Eighteen patients (9 male, mean age: 11.6 years; range: 2-17 years) were included. Nine patients (6 male, mean age: 10.7 years; range: 2-16 years) underwent LHM, and the other 9 (3 males, mean age: 12.2 years; range: 6-17 years) underwent POEM procedure. Mean operation time was shorter in POEM group compared with LHM group (62/149 minutes). Myotomy was longer in POEM group than in LHM group (11/7 cm). One major complication occurred after LHM (esophageal perforation). No clinical and manometric differences were observed between LHM and POEM in follow-up. The incidence of iatrogenic gastroesophageal reflux disease was low (1 patient in both groups). CONCLUSIONS: Results of a midterm follow-up show that LHM and POEM are safe and effective treatments also in children. Besides, POEM is a mini-invasive technique with an inferior execution timing compared to LHM. A skilled endoscopic team is mandatory to perform this procedure.

EndoFLIP system for the intraoperative evaluation of peroral endoscopic myotomy.

BACKGROUND: Peroral endoscopic myotomy (POEM) has been recently introduced in clinical practice for the treatment of achalasia. The endoluminal functional lumen imaging probe (EndoFLIP) system) uses impedance planimetry for the real-time measurement of the diameter of the oesophago-gastric junction. OBJECTIVE: The aim of this study is to prospectively evaluate the effect of POEM on the oesophago-gastric junction using EndoFLIP. METHODS: All the patients who underwent POEM in a single centre between April and July 2013 were enrolled in the study. EndoFLIP was used intraoperatively, immediately before and after POEM. During follow-up patients underwent oesophagogastroduodenoscopy, oesophageal pH monitoring and manometry. Clinical outcomes were compared with the diameter of the oesophago-gastric junction after POEM. RESULTS: In total, 23 patients (12 males, mean age 51.7 years) were enrolled, and 21 underwent POEM successfully. Preoperative mean basal lower oesophageal sphincter pressure was 42.1 mmHg (±17.6). Before POEM, the mean oesophago-gastric junction diameter and cross-sectional area were 6.3 mm (±1.8) and 32.9 mm(2) (±23.1), respectively. After treatment, the mean diameter and cross-sectional area of the oesophago-gastric junction were 11.3 mm (±1.7 SD) and 102.38 mm(2) (±28.2 SD), respectively. No complications occurred during a mean follow-up of 5 months. Median post-operative Eckardt score was 1. Three patients (14.3%) referred heartburn. Follow-up studies revealed gastro-oesophageal reflux disease (GORD) in 57.1% of patients and oesophagitis in 33.3%. No correlations were observed between the diameter of oesophago-gastric junction after POEM and symptoms relief, GORD incidence and lower oesophageal sphincter pressure. CONCLUSIONS: The diameter of oesophago-gastric junction substantially increases after POEM. EndoFLIP is a reliable method for the intraoperative evaluation of oesophago-gastric junction diameter. However, the real usefulness of this technology after POEM remains controversial.

Defining esophageal landmarks, gastroesophageal reflux disease, and Barrett's esophagus.

The following paper on gastroesophageal reflux disease (GERD) and Barrett's esophagus (BE) includes commentaries on defining esophageal landmarks; new techniques for evaluating upper esophageal sphincter (UES) tone; differential diagnosis of GERD, BE, and hiatal hernia (HH); the use of high-resolution manometry for evaluation of reflux; the role of fundic relaxation in reflux; the use of 24-h esophageal pH-impedance testing in differentiating acid from nonacid reflux and its potential inclusion in future Rome criteria; classification of endoscopic findings in GERD; the search for the cell origin that generates BE; and the relationship between BE, Barrett's carcinoma, and obesity.

Peroral endoscopic myotomy for the treatment of achalasia in children.

Peroral endoscopic myotomy (POEM) is a new endoscopic technique for the treatment of esophageal achalasia, with excellent results in adults. Three children with classic-type achalasia (mean age 9.6 years) underwent POEM in a single center. Mean basal lower esophageal sphincter pressure and Eckard score were 34.6 mmHg and 5.3, respectively. Mean length of myotomy was 10 cm. On average, POEM was completed in 60.6 minutes. No patients experienced postoperative complications or gastroesophageal reflux disease. In the 2 patients who completed a 12-month follow-up, complete symptoms relief was documented (Eckard score 0), as well as a significant drop of the basal lower esophageal sphincter pressure.

Three-year results of a multicenter prospective study of transoral incisionless fundoplication.

BACKGROUND: To date, there are no long-term data on the use of transoral incisionless fundoplication (TIF) for the treatment of chronic gastroesophageal reflux disease (GERD). We sought to prospectively evaluate the long-term safety and durability of TIF in a multi-center setting. METHODS: A longitudinal per protocol (PP) and a modified intention-to-treat (mITT) analysis at 1 and 3 years consisted of symptom evaluation using the GERD health-related quality of life (GERD-HRQL) questionnaire, medication use, upper gastrointestinal endoscopy, and pH-metry. RESULTS: Of 79 patients previously reported at 1 year, 12 were lost to follow-up, and 1 died from an unrelated cause. The remaining 66 patients were followed up and analyzed (mITT). Of 66 patients, 12 underwent revisional procedures, leaving 54 patients for PP analysis at a median of 3.1 years (range = 2.9-3.6). No adverse events related to TIF were reported at 2- or 3-year follow-up. On PP analysis, median GERD-HRQL score off proton pump inhibitors (PPIs) improved significantly to 4 (range 0-32) from both off (25 [13-38], P < .0001) and on (9 [0-22], P < .0001) PPIs. Discontinuation of daily PPIs was sustained in 61% (mITT) and 74% (PP) of patients. Of 11 patients with pH data at 3 years (PP), 9 (82%) remained normal. Based on mITT analysis, 9/23 (39%) remained normal at 3 years. CONCLUSIONS: The clinical outcomes at 3 years following TIF, patient satisfaction, healing of erosive esophagitis, and cessation of PPI medication support long-term safety and durability of the TIF procedure for those with initial treatment success. Although complete normalization of pH studies occurred in a minority of patients, successful cases showed long-term durability.

Prospective evaluation of the partially covered nitinol "ComVi" stent for malignant non hilar biliary obstruction.

BACKGROUND: Biliary partially covered self-expandable metal stents (PC-SEMS) offer prolonged relief of symptoms of biliary obstruction but may induce complications including pancreatitis, cholecystitis and migration. AIMS: To assess efficacy and safety of the ComVi partially covered self-expandable metal stents as primary palliative treatment of distal malignant biliary obstruction. METHODS: Seventy patients (mean age 69.2 years) with distal malignant biliary strictures were prospectively included and underwent endoscopic retrograde cholangio-pancreatography and partially covered self-expandable metal stents placement. Follow-up was done for 12 months. self-expandable metal stents patency, survival and complication-rate after partially covered self-expandable metal stents placement were evaluated. RESULTS: Overall median survival time was 190 days (30-856). Forty-four patients (62.8%) died after median 175.5 days (30-614) without signs of stent dysfunction; 37 patients (52.8%) were alive after 6 months without signs of self-expandable metal stents occlusion. Survival rapidly dropped between 8 and 12 months after treatment. Survival was not influenced by sex (P = 0.1) or type of neoplasia (P = 0.178). Median survival was longer (254 days [44-836]) in patients who underwent chemotherapy (P < 0.0001). Partially covered self-expandable metal stents occlusion had 24 (35.7%) patients 154 days (35-485) after treatment. Median survival after re-treatment was 66 days (13-597). Cholecystitis occurred in one patient (1.7%). CONCLUSIONS: The ComVi partially covered self-expandable metal stents is effective for palliation of biliary obstruction secondary to distal malignant biliary strictures. Self-expandable metal stents patency during follow-up is satisfactory without significant complications.

Peroral endoscopic myotomy (POEM) for oesophageal achalasia: preliminary results in humans.

BACKGROUND: Peroral endoscopic myotomy has been developed to provide a less invasive treatment for oesophageal achalasia compared to surgical cardiomyotomy. AIMS: To report our initial experience on feasibility, safety and clinical efficacy of peroral endoscopic myotomy. METHODS: Eleven patients (eight women, mean age 32, range 24-58) underwent an attempt at peroral endoscopic myotomy under general anaesthesia. After submucosal injection, a mucosal entry into the oesophageal submucosa, and a tunnel extending to the oesophagogastric junction and beyond into the stomach were created (total mean length: 15 ± 1.7 cm). Myotomy of the circular oesophageal and gastric muscle bundles was then achieved under direct vision (total mean length: 10.2 ± 2.8 cm). Haemostatic clips were used to close the mucosal entry. The Eckardt Score and manometry were used to evaluate the results. RESULTS: Peroral endoscopic myotomy could be completed in 10 out of 11 patients (91%). Mean procedure time was 100.7 min (range 75-140 min). No major complication occurred. Clinical success was achieved in all patients at 1-month follow-up (Eckardt Score 7.1 vs. 1.1, p=0). Lower oesophageal sphincter pressure decreased from 45.1 to 16.9 mm Hg (p=0). CONCLUSIONS: This initial experience with peroral endoscopic myotomy shows its safety and efficacy in the treatment of achalasia. Further studies are warranted to assess the long-term efficacy and to compare peroral endoscopic myotomy with other treatment modalities.

Endoscopic treatment of obesity.

Obesity is a worldwide epidemic, complex metabolic disease associated with a variety of severe comorbidities. Bariatric surgery provides the patients with the benefits of sustained weight loss and improves obesity-related comorbidities, but can result in potentially life-threatening complications. Gastrointestinal endoscopy has recently been proposed as a scarless and noninvasive approach to obesity. Most of the current endoluminal devices and techniques are comparable to restrictive surgery. A variety of medical devices and procedures have been evaluated in recent years; however, with the exception of the intragastric balloon, evaluation of all the other endoluminal procedures is limited by the numbers of patients treated, the short follow-up and especially by the study design. Today, only a few devices have been evaluated in randomized controlled trials. The preliminary results of the first studies are extremely promising, but definitive statements cannot be drawn yet.

Acute pancreatitis associated with primary hyperparathyroidism.

Coexistence of primary hyperparathyroidism and acute pancreatitis has widely been reported in literature, but a causal relationship remains controversial. A case of acute pancreatitis as a first symptom of primary hyperparathyroidism with severe hypercalcemia is reported. In this patient a reduction of serum calcium level was obtained with medical therapy and resulted in the resolution of acute pancreatitis symptoms within 10 days. At the same time a parathyroid adenoma was clinically identified and elective parathyroidectomy was performed with complete normalization of intact parathyroid hormone and serum calcium level. At three-year follow-up, no recurrence or complications of pancreatitis were documented. The presented case suggests a cause and effect relationship between acute pancreatitis and severe hypercalcemia which should be kept in mind in the differential diagnosis of non-biliary, non-alcoholic acute pancreatitis. Reduction of hypercalcemia with medical treatment can represent a good chance for elective surgical neck exploration.