An endoscopic approach to the management of surgical bile duct injuries: nine years' experience.

BACKGROUND: The evaluation of the endoscopic treatment of surgical bile duct injuries, especially in the management of post-operative strictures, remains controversial. AIM: The aim of this study was to evaluate the feasibility of using endoscopic management from a study of the clinical reports of two of the main endoscopy units in Sicily. PATIENTS AND METHODS: A total of 137 consecutive patients were selected. There were 85 simple biliary fistulas: 64 from the cystic duct stump; 19 from the gall bladder bed; and two from intra-hepatic bile ducts. There were 52 biliary lesions: 15 complete transections; 12 incomplete lesions of the common bile duct with six associated strictures; five complete or incomplete sections of the right antero-medial duct; and 20 incomplete strictures (without leak). RESULTS: The success rate was 96.3% for simple biliary fistulas. Endoscopic therapy was feasible only in 40.6% of lesions of the common bile duct or the right antero-medial duct (13/32), but with 100% success. In the case of strictures (with or without associated leak), there was a good outcome in 88.2% of patients who completed the therapeutic procedure. CONCLUSIONS: Endoscopic management of simple biliary fistulas and incomplete lesions of the common bile duct is the preferred approach. If continued for 12-24 months, with the placement of three or more 10F stents, the management of stenoses is guaranteed to yield good results.

How to predict a high rate of inappropriateness for upper endoscopy in an endoscopic centre?

BACKGROUND: Inappropriateness of upper endoscopy (EGD) indication causes decreased diagnostic yield. Our aim of was to identify predictors of appropriateness rate for EGD among endoscopic centres. METHODS: A post-hoc analysis of two multicentre cross-sectional studies, including 6270 and 8252 patients consecutively referred to EGD in 44 (group A) and 55 (group B) endoscopic Italian centres in 2003 and 2007, respectively, was performed. A multiple forward stepwise regression was applied to group A, and independently validated in group B. A <70% threshold was adopted to define inadequate appropriateness rate clustered by centre. RESULTS: discrete variability of clustered appropriateness rates among the 44 group A centres was observed (median: 77%; range: 41-97%), and a <70% appropriateness rate was detected in 11 (25%). Independent predictors of centre appropriateness rate were: percentage of patients referred by general practitioners (GP), rate of urgent examinations, prevalence of relevant diseases, and academic status. For group B, sensitivity, specificity and area under receiver operating characteristic curve of the model in detecting centres with a <70% appropriateness rate were 54%, 93% and 0.72, respectively. CONCLUSIONS: A simple predictive rule, based on rate of patients referred by GPs, rate of urgent examinations, prevalence of relevant diseases and academic status, identified a small subset of centres characterised by a high rate of inappropriateness. These centres may be presumed to obtain the largest benefit from targeted educational programs.

A temporary endoscopic solution that significantly improves the prognosis of Bouveret's syndrome.

We report the case of a 73-year-old woman who was hospitalized for mild abdominal pain after her referral following a diagnostic assessment of acute lithiasic cholecystitis. After the spontaneus regression of her painful symptoms and fever and several days of well-being, her clinically acute abdominal features suddenly showed an obstruction of the upper gastrointestinal tract. An emergency esophagogastroduodenoscopy (EGDS) confirmed that a large gallstone completely obstructed the pylorus as previously demonstrated by an ultrasound examination of the gallbladder. During the course of endoscopy, removal of the gallstone from the duodenum was achieved by pulling it into the stomach; the patient underwent an operation, the gallstone was removed, and the cholecystoduodenal fistula resolved. Postoperative procedures and recovery were rapid and favorable.

Chronic pancreatitis in Sicily. Preliminary reports.

The aetiology and clinical characteristics of 42 patients affected with chronic calcifying pancreatitis in a Sicilian population were investigated and compared with a series of other Italian and foreign reports. It was found that the aetiology was 62% alcoholics and 38% idiopathic in origin and that the M/F ratio was 2.5:1. Clinical features as pain, weight loss, pancreatic calcifications, steatorrhea, pseudocysts and associated cirrhosis are significantly more frequent in the group of alcoholics, while cholelithiasis was more frequent in the non-alcoholic group. Two aspects are worth noting in comparison to the north of Italy: a) the lesser frequency of alcoholic forms and b) the high incidence of women.