Diagnosing celiac disease by video capsule endoscopy (VCE) when esophagogastroduodenoscopy (EGD) and biopsy is unable to provide a diagnosis: a case series.

BACKGROUND: Video capsule endoscopy (VCE) is mainly used to evaluate patients with celiac disease in whom their course after diagnosis has been unfavorable and the diagnosis of adenocarcinoma, lymphoma or refractory celiac disease is entertained, but it has been suggested that VCE could replace esophagogastroduodenoscopy (EGD) and biopsy under certain circumstances. METHODS: We report a single center case series of 8 patients with suspected celiac disease who were diagnosed by VCE. RESULTS: EGD and biopsy had been performed in 4 patients resulting in a negative biopsy, declined by 2, and contraindicated in 2 due to hemophilia and von Willebrand disease. In all patients, mucosal changes of scalloping, mucosal mosaicism and reduced folds were seen in either the duodenum or jejunum on VCE. Follow-up in 7 patients demonstrated improvement in either their serological abnormalities or their presenting clinical features on a gluten-free diet. CONCLUSIONS: Our case series demonstrates that VCE and the visualization of the characteristic mucosal changes of villous atrophy may replace biopsy as the mode of diagnosis when EGD is either declined or contraindicated, or when duodenal biopsies are negative and there remains a high index of suspicion. Further study is needed to clarify the role and cost of diagnosing celiac disease with VCE.

Antiplatelet agents do not impact the hospital course in patients with gastrointestinal bleeding.

BACKGROUND: Use of antiplatelet agents (APAs) have been shown to increase the risk of gastrointestinal (GI) bleeding despite their cardiovascular benefits. AIM: To understand the impact of APAs, we assessed the outcomes in patients admitted with acute GI bleeding to our hospital. We hypothesized there is no difference among GI bleeders admitted to the hospital while bleeding on or off APAs. METHODS: In an observational prospective cohort study, 104 sequential patients admitted with a diagnosis of GI bleeding were followed. Patients were classified as either on APA or not. RESULTS: Thirty of 104 (29%) patients were on long-term aspirin and/or clopidogrel on admission and 5 were taking nonaspirin nonsteroidal anti-inflammatory drugs, total of 35 (34%). There was no difference between patients using APA and those not using APA with regard to admission hemoglobin, age, presentation, source of bleed, total number of units transfused, intensive care unit admission rates, and overall length of stay. There was, however, a significant difference in the presence of hemodynamic compromise on initial presentation, with a higher proportion of APA users being orthostatic (51.4% vs 26% in nonusers, with P=0.02, by Fisher exact test). Clopidogrel was safely restarted in high-risk patients with significant cardiac history. CONCLUSIONS: This study demonstrated that APA use did not significantly alter the course or outcome in GI bleeders admitted to our institution during their hospital stay.

Live view video capsule endoscopy enables risk stratification of patients with acute upper GI bleeding in the emergency room: a pilot study.

BACKGROUND: Risk stratification of patients with acute upper GI bleeding (UGIB) in the emergency room (ER) enables appropriate triage to urgent endoscopy and therapeutic intervention. AIM: The aim of this study was to evaluate the ability of Live View Video Capsule Endoscopy (VCE) with Pillcam Eso(®) to accurately identify high and low risk patients with UGIB. METHODS: Twenty-four patients with a history of UGIB within 48 h of admission to the ER were randomized to VCE versus standard clinical assessment. VCE was read real-time at the bedside and later reviewed after download. Positive VCE findings included coffee grounds, blood clot, red blood, or a bleeding lesion. VCE positive patients underwent EGD within 6 h. Control patients and VCE negative patients underwent EGD within 24 h. RESULTS: Seven of 12 patients were VCE positive. All seven had confirmatory stigmata at EGD. Of the five VCE negative patients, four had no stigmata at EGD and one was not endoscoped due to comorbidities. The actual lesion was visualized at VCE in four of 12 patients during live view and in an additional two patients after download (6/12). Time to endoscopy in the VCE positive group was significantly shorter than control patients (2.5 vs. 8.9 h, P = 0.029). There was no mortality. Blood transfusion requirement and length of stay were not significantly different in the two groups. CONCLUSIONS: Live view VCE accurately identifies high and low risk ER patients with UGIB. Use of VCE to risk stratify these patients significantly reduced time to emergent EGD and therapeutic intervention.

Sleeve Gastrectomy Is Associated with a Greater Reduction in Plasma Liver Enzymes Than Bypass Surgeries-A Registry-Based Two-Year Follow-Up Analysis.

Bariatric surgeries may lead to an improvement in metabolic fatty liver disease, and a reduction in the levels of the hepatic enzyme Alanine Aminotransferase (ALT). We compared the effects of Sleeve Gastrectomy (SG), Roux en Y Gastric Bypass (RYGB) and One Anastomosis Gastric Bypass (OAGB) on the levels of ALT by analysis of two-year follow-up data from 4980 patients in the Israeli Bariatric Registry that included laboratory tests and demographic information. Pre-operative characteristics of patients, and particularly levels of liver enzymes, were similar across surgery types. Regression modeling and retrospective matching showed that SG was superior to RYGB and OAGB in reducing ALT levels, and in reducing the fraction of patients with abnormally high ALT levels. Two-year post-surgery, an increase in ALT levels from normal to abnormal levels was observed in 5% of SG patients, and in 18% and 23% of RYGB and OAGB patients. In conclusion, SG leads to a greater reduction in ALT levels compared with bypass surgeries and a lower incidence of post-surgical elevation of ALT levels. Further studies are required to identify the cause for the rise in liver enzymes, and to determine whether ALT levels correlate with liver pathology especially following bariatric surgery.

Bariatric Surgery Affects Plasma Levels of Alanine Aminotransferase Independent of Weight Loss: A Registry-Based Study.

Patients that undergo bariatric surgery experience weight loss and a reduction in the plasma levels of the hepatic enzymes alanine aminotransferase (ALT) and aspartate aminotransferase (AST). We used the Israeli national bariatric registry, which includes demographic, clinical, and biochemical data on 19,403 patients, of which 1335 patients had two-year follow-up data on ALT, AST, A1C, and BMI, to test the dependence of the reduction in the levels of ALT and AST on weight loss. The data were analyzed using regression models, retrospective matching, and time course analyses. Changes in liver enzymes did not correlate with change in BMI, and linear regression models did not demonstrate that the change in ALT and AST values were dependent on pre-operative levels of BMI or the extent of weight loss. ALT and AST levels were reduced two years after surgery compared with a cohort of retrospectively matched patients for ethnicity, sex, age, BMI, and A1C. Finally, patients who regained weight displayed a reduction in levels of liver enzymes. Our results suggest that bariatric surgery affects AST and ALT levels via weight loss dependent and independent mechanisms. Mechanistic studies that will identify the nature of this effect and the clinical relevance of ALT and AST levels to the post-bariatric liver function are warranted.

The impact of bariatric surgery on nonalcoholic fatty liver disease as measured using non-invasive tests.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is common in bariatric surgery candidates. We evaluated the effect of sleeve gastrectomy (SG) on NAFLD using validated non-invasive measures. METHODS: Patients with morbid obesity and NAFLD, planned for SG, were evaluated before and after surgery. Data collected included anthropometrics, biochemistry, adiponectin, SteatoTest™, NashTest™, FibroTest™, OWLiver® test and real-time ShearWave™ elastography (SWE). RESULTS: Twenty-six subjects were included in the study, mean age 44.1 ± 4.8 years, 69.2% males. One year following SG, body mass index decreased significantly from 41.7 ± 4.8 kg/m2 to 29.6 ± 4.5 kg/m2. Concomitantly, significant improvements in triglycerides, ALT, diabetes markers and adiponectin were observed. Mean steatosis, as measured by SteatoTest™, was significantly improved. Steatohepatitis score measured by NashTest™ and OWLiver® significantly decreased. Mean fibrosis, as measured by SWE liver stiffness and FibroTest™, did not change over time. CONCLUSION: Steatosis and steatohepatitis are significantly improved by SG as measured by non-invasive measures.

Association of intussusception and celiac disease in adults.

INTRODUCTION: Intussusception (IS) is rare in adults. However, the more frequent use of cross-sectional imaging has resulted in an increase in its detection. Because of the reported association with celiac disease, we determined the prevalence of IS among a cohort with celiac disease. METHODS: An anonymized prospectively maintained celiac disease database and radiological database were reviewed. RESULTS: Of a total of 880 patients, 14 (age 47 ± 17.5 years; 50% female) had IS that was detected by CT in 10, capsule endoscopy in three, and barium studies in two. The reason for evaluation was abdominal pain in 78% (11/14), whereas in the remainder (3/14) were incidental. IS was the initial manifestation of celiac disease in 57% (8/14). Two patients were found to have lead-point intussusceptions and both had small-bowel adenocarcinoma, and 10/14 had severe villous atrophy (subtotal or total). Among those with established celiac disease, IS was detected early, within 3 years of diagnosis. Follow-up was available for 11 patients, 9 of who adhered strictly to a gluten-free diet, and six had no recurrence. Among all the patients diagnosed with IS on radiologic studies at our institution, 45 were considered to have idiopathic IS. Only two of these patients had evaluation for celiac disease. CONCLUSION: IS occurs in celiac disease. It may be the initial presentation and is associated with abdominal pain. Adenocarcinoma needs to be excluded. The majority of patients do not have recurrent symptoms after adherence to a gluten-free diet. Celiac disease should be considered more frequently when IS is encountered.

Gastric emptying is not affected by sleeve gastrectomy--scintigraphic evaluation of gastric emptying after sleeve gastrectomy without removal of the gastric antrum.

BACKGROUND: The aim of this study is to clarify whether laparoscopic sleeve gastrectomy (LSG) to treat morbid obesity causes changes in gastric emptying. METHODS: Gastric emptying scintigraphy was performed before and 3 months after LSG, in 21 consecutive morbidly obese patients. After an overnight fast, subjects consumed a standard semi-solid meal, to which 0.5 mCi Tc99-labeled sulfur colloid had been added. The meal was consumed within 10 min. Scintigraphic imaging was performed with a gamma camera immediately after the completion of the meal as well as after 30, 60, 120, 180, and 240 min. Quantitative and qualitative analysis was performed by drawing a region of interest (ROI) enclosing the stomach on the anterior and the posterior images. Time 0 was considered the time of meal completion (all the ingested activity) and was defined as 100% retention. The same ROI was used on all consecutive images of the same projection for the same patient. The geometric mean of the anterior and the posterior counts for each time point is calculated and corrected for Tc(99m) decay. Gastric emptying curves were constructed. T 1/2 is the time interval between completion of the meal and the point at which half of the meal (by radioactivity counts) has left the stomach. Retention is expressed as the percent remaining in the stomach at each time point (half, 1, 2, 3, 4 h). RESULTS: The mean T 1/2 raw data was 62.39+/-19.83 and 56.79+/-18.72 min (p=0.36, t=-0.92, NS) before and 3 months after LSG, respectively. The T 1/2 linear was 103.64+/-9.82 and 106.92+/-14.55, (p=0.43, t=-0.43, NS), and the linear fit slope 0.48+/-0.04 and 0.47+/-0.05 (p=0.48, t=0.7, NS). CONCLUSIONS: LSG with antrum preservation as performed in this series has no effect on gastric emptying.

Bacterial Endocarditis Following Deep Enteroscopy: Is Prophylaxis Warranted?

The development of bacterial endocarditis as a result of endoscopic interventions within the gastrointestinal tract is exceedingly rare. Antibiotic prophylaxis for endoscopic procedures is generally not warranted, except for certain high-risk patients. Double-balloon enteroscopy (DBE) is a common endoscopic procedure for evaluation of the small bowel. Bacterial endocarditis secondary to DBE has not been previously described. We describe the first case of enterococcal endocarditis attributed to DBE in a patient with a history of stage 1 primary biliary cholangitis.

A comparative study of microstructural development in paired human hepatic and gallbladder biles.

Cholesterol gallstones usually develop in the gallbladder and rarely form in bile ducts even in patients with highly lithogenic bile. Bile concentration and proteins (e.g. mucin) may affect crystallization, but the exact nature of this effect, especially in relation to crystallization pathways and microstructural evolution remains unclear. We examined lipid microstructures in paired hepatic and gallbladder biles to reveal ones that are essential for crystallization. Combining digital light microscopy with cryogenic-temperature transmission electron microscopy we are able to directly visualize and compare the time evolution of lipid microstructures in paired hepatic, gallbladder and diluted gallbladder biles of gallstone patients and controls, without drying or separating. Gallbladder bile exhibited several multilamellar vesicles and spheroidal micelles preceding and throughout crystallization. Vesicle morphology changed before crystallization was observed. In contrast, hepatic bile revealed almost no crystallization and while a variety of unilamellar vesicles and spheroidal micelles existed throughout the examination, multilamellar vesicles were rare. Diluted gallbladder bile was different from native gallbladder bile, as well as the paired hepatic bile, yielding occasional crystallization. Our findings suggest that maturing multilamellar vesicles precede (and at least partially initiate) crystallization in gallbladder bile. Although microstructural development seems to be concentration dependent, dilution of gallbladder bile to hepatic bile concentrations neither makes it identical to hepatic bile, nor prevents crystallization.

Laparoscopic sleeve gastrectomy with minimal morbidity. Early results in 120 morbidly obese patients.

BACKGROUND: In recent years, laparoscopic sleeve gastrectomy (LSG) as a single-stage procedure for the treatment of morbid obesity is becoming increasingly popular. Of continuing concern are the rate of postoperative complications and the lack of consensus as to surgical technique. METHODS: A prospective study assessment was made of 120 consecutive morbidly obese patients with body mass index (BMI) of 43+/-5 (30 to 63), who underwent LSG using the following technique: (1) division of the vascular supply of the greater gastric curvature and application of the linear stapler-cutter device beginning at 6-7 cm from the pylorus so that part of the antrum remains; (2) inversion of the staple line by placement of a seroserosal continuous suture close to the staple line; (3) use of a 48 Fr bougie so as to avoid possible stricture; (4) firing of the stapler parallel to the bougie to make the sleeve as narrow as possible and prevent segmental dilatation. RESULTS: Intraoperative difficulties were encountered in four patients. There were no postoperative complications-no hemorrhage from the staple line, no anastomotic leakage or stricture, and no mortality. In 20 patients prior to the sleeve procedure, a gastric band was removed. During a median follow-up of 11.7 months (range 2-31 months), percent of excess BMI lost reached 53+/-24% and the BMI decreased from 43+/-5 to 34+/-5 kg/m(2). Patient satisfaction scoring (1-4) at least 1 year after surgery was 3.6+/-0.8. CONCLUSIONS: The good early results obtained with the above-outlined surgical technique in 120 consecutive patients undergoing LSG indicate that it is a safe and effective procedure for morbid obesity. However, long-term results are still pending.

Laparoscopic sleeve gastrectomy--volume and pressure assessment.

BACKGROUND: Aiming to clarify the mechanism of weight loss after the restrictive bariatric procedure of sleeve gastrectomy (LSG), the volumes and pressures of the stomach, of the removed part, and of the remaining sleeve were measured in 20 morbidly obese patients. METHODS: The technique used consisted of occlusion of the pylorus with a laparoscopic clamp and of the gastroesophageal junction with a special orogastric tube connected to a manometer. Instillation of methylene-blue-colored saline via the tube was continued until the intraluminal pressure increased sharply, or the inflated stomach reached 2,000 cc. After recording of measurements, LSG was performed. RESULTS: Mean volume of the entire stomach was 1,553 cc (600-2,000 cc) and that of the sleeve 129 cc (90-220 cc), i.e., 10% (4-17%) and that of the removed stomach was 795 cc (400-1,500 cc). The mean basal intragastric pressure of the whole stomach after insufflations of the abdominal cavity with CO(2) to 15 mmHg was 19 mmHg (11-26 mmHg); after occlusion and filling with saline it was 34 mmHg (21-45 mmHg). In the sleeved stomach, mean basal pressure was similar 18 mmHg (6-28 mmHg); when filled with saline, pressure rose to 43 mmHg (32-58 mmHg). The removed stomach had a mean pressure of 26 mmHg (12-47 mmHg). There were no postoperative complications and no mortality. CONCLUSIONS: The notably higher pressure in the sleeve, reflecting its markedly lesser distensibility compared to that of the whole stomach and of the removed fundus, indicates that this may be an important element in the mechanism of weight loss.

Omega-loop gastric bypass is more effective for weight loss but negatively impacts liver enzymes: a registry-based comprehensive first-year analysis.

BACKGROUND: The impact of omega-loop gastric bypass (OLGB) on weight loss and liver enzymes remains inconclusive. OBJECTIVE: The aim of this study was to compare the impact of sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and OLGB on weight loss and liver enzyme levels. SETTING: National Bariatric Surgery Registry. METHODS: The study included 10,675 cases of SG, 1590 cases of RYGB, and 469 cases of OLGB that had available baseline and 1-year (12 ± 2 mo) follow-up data. RESULTS: The highest percentage of excess weight loss was achieved by the OLGB group (84.5% ± 26.7%), followed by the SG (78.5% ± 26.0%) and RYGB (72.0% ± 26.5%) groups (P<.05). The data show that 10% of OLGB cases, 5.2% of RYGB cases, and 1.9% of SG cases (P<.001) had increases in alanine aminotransferase levels, from a normal baseline mean of 23.9 ± 7.5 U/L to an abnormal mean of 64.8.7 ± 66.0 U/L, at follow-up. Similar trends were observed for aspartate aminotransferase and alkaline phosphatase. A regression analysis showed that OLGB was a predictive risk factor for normal baseline alanine aminotransferase levels becoming abnormal postoperatively compared with SG (odds ratio [OR] = 5.65) or RYGB (OR = 2.08) (P<.001). Similarly, OLGB was a predictive risk factor for baseline aspartate aminotransferase and alkaline phosphatase levels becoming abnormal postoperatively. Female sex was the only other meaningful predictive risk of alanine aminotransferase (OR = 2.45) and aspartate aminotransferase (OR = 1.82) becoming abnormal postoperatively. CONCLUSION: This study confirmed the strengths of OLGB weight loss outcomes but also demonstrated its negative impact on liver enzymes. Thus, patients and caregivers should be informed of the risks, and close follow-up is warranted.

Primary Endoscopic Closure of Duodenal Perforation Secondary to Biliary Stent Migration: A Case Report and Review of the Literature.

Duodenal perforation due to biliary stent migration is rare, and it often requires surgical repair; however, endoscopic closure has recently become a viable option in the appropriate patients. We present the case of a 79-year-old female who underwent biliary stent placement for a common bile duct stricture, who subsequently was found to have a duodenal wall perforation secondary to stent migration. The stent was extracted endoscopically with successful defect closure using a ConMed® repositional DuraClip™. We aim to contribute to the limited body of literature that describes endoscopic repair of duodenal perforation secondary to biliary stent migration using through-the-scope endoclips.

Technical aspects of laparoscopic sleeve gastrectomy in 25 morbidly obese patients.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has recently come to be performed as a sole bariatric operation. The postoperative morbidity and mortality are cause for concern, and possibly are related to non-standardized surgical technique. METHODS: The following is the surgical LSG technique used in 25 morbidly obese patients. Five trocars are used. Division of the vascular supply of the greater gastric curvature is begun at 6-7 cm proximal to the pylorus, proceeding to the angle of His. A 50-Fr calibrating bougie is positioned against the lesser curvature. The LSG is created using a linear stapler-cutter device with one 4.1-mm green load for the antrum, followed by five to seven sequential 3.5-mm blue loads for the remaining gastric corpus and fundus. The staple-line is inverted by placing a sero-serosal continuous absorbable suture over the bougie from the angle of His. The resected stomach is removed through the 12-mm trocar, and a Jackson-Pratt drain is left along the suture-line. RESULTS: The mean operative time was 120 minutes, and length of hospital stay was 4 +/- 2 days. There were no conversions to open procedures. There were no postoperative complications (no hemorrhage from the staple-line, no anastomotic leakage, no stricture) and no mortality. In 1 patient, cholecystectomy was also done, and in 4, a gastric band was removed. During a median follow-up of 4 months, BMI decreased from 43 +/- 5 kg/m2 to 34 +/- 6 kg/m2, and the % excess BMI loss was 49 +/- 25%. CONCLUSIONS: The proposed surgical technique appears to be a safe and effective procedure for morbid obesity.

A Case of Sub-Diaphragmatic Abscess after Injection of Botulinum Toxin to Treat Achalasia.

Achalasia is a disorder of the esophagus characterized by decreased lower esophageal sphincter (LES) relaxation and absence of esophageal peristalsis. Botulinum toxin (BT) injection targeting the LES has been used in the treatment of achalasia and other esophageal motility disorders, and it is considered to be safe and effective for short-term symptomatic relief. Serious adverse events of this procedure are rare. We report the case of an 83-year-old woman treated with BT injection for achalasia who subsequently developed a subdiaphragmatic abscess.

Different effects of bariatric surgical procedures on dyslipidemia: a registry-based analysis.

BACKGROUND: The scale and variables linked to bariatric surgery's effect on dyslipidemia have not been conclusive. OBJECTIVE: To compare the effect of Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), and adjustable gastric banding (LAGB) on dyslipidemia SETTING: National bariatric surgery registry. METHODS: Plasma lipids and associated variables were compared at baseline and 1 year (12±4 mo) after surgery for registry patients with dyslipidemia enrolled from June 2013 to August 2014. RESULTS: The greatest mean total-cholesterol (TC) reduction was observed post-RYGB, 226.7±26.4 to 181.3±30.9 mg/dL (19.9%, n = 208), followed by post-SG, 227.9±24.4 to 206.7±34.2 mg/dL (8.9%, n = 1515; P<.001). Normal TC levels of below 200 mg/dL were achieved by 76% post-RYGB patients compared with 43.5% post-SG patients (odds ratio [OR] = 6.24, 95% confidence interval [CI]: 3.69-10.53) and 25.6% post-LABG patients (OR = 9.66, 95% CI: 4.11-22.67; P<.01). Although equivalent patterns were observed for low-density-lipoprotein cholesterol (LDL), the levels of high-density-lipoprotein cholesterol (HDL) were most improved post-SG, reaching normal levels in 58.1% of SG male patients versus 39.5% of RYGB male patients (OR = 1.56, 95% CI: 1.04-2.35), (P = .02). The lowering of triglyceride levels by approximately 75% was comparable after SG and RYGB procedures. The type of surgery was the strongest independent predictor for all lipid level improvements or remissions. Male sex was an independent predictor for LDL normalization only (OR = 1.88, 95% CI: 1.24-2.85). Excess weight loss offered no meaningful prediction for lipid improvement (OR = 1.01-1.03). CONCLUSION: Particular types of bariatric surgeries had different effects on dyslipidemia, independent of weight loss. Overall, the RYGB achieved the biggest reduction in plasma lipids (TC and LDL), although SG did affect HDL. Our results could aid in the decision-making process regarding the most appropriate procedure for patients with dyslipidemia.

Gastric Wall Thickness and the Choice of Linear Staples in Laparoscopic Sleeve Gastrectomy: Challenging Conventional Concepts.

BACKGROUND: Little evidence is available on the choice of linear staple reloads in laparoscopic sleeve gastrectomy (LSG). Previous literature recommends matching closed staple height (CSH) to tissue-thickness (TT) to avoid ischemia. Our objective was to examine feasibility and safety of "tight" hemostatic (CSH/TT <1) stapling and map the entire gastric wall TT in LSG patients. METHODS: Prospectively collected outcomes on 202 consecutive patients who underwent LSG with tight order of staples (Ethicon Endosurgery) in this order: pre-pylorus-black (CSH = 2.3 mm), antrum-green (CSH = 2.0 mm), antrum/body-blue (CSH = 1.5 mm), and white (CSH = 1.0 mm) on the body and fundus. Measurements of entire gastric wall TT were made on the first 100 patients' gastric specimens with an electronic-dogmatic indicator. RESULTS: Study included 147 females and 55 males with a mean age of 41.5 ± 11.9 years and body mass index of 41.5 ± 3.8 kg/m2. Gastric wall measurements revealed mean CSH/TT ratio <1, decreasing from 0.7 ± 0.1 at pre-pylorus to 0.5 ± 0.1 at the fundus. There were 3.1% mechanical failures, mainly (68%) at pre-pylorus-black reloads. Post-operative bleeding occurred in 5 (2.5%) patients. There were no leaks or clinical evidence of sleeve ischemia. Stepwise regression analysis revealed that body mass index (P < 0.001), hypertension (P < 0.01), and male gender (P < 0.001) were associated with increased gastric TT. CONCLUSIONS: Our study suggests that reloads with CSH/TT <1 in LSG including staples with CSH of 1 mm on body and fundus are safe. The results challenge the concept that tight stapling cause's ischemia. Since tight reloads are designed to improve hemostasis, their application could have clinical benefit.

Capsule endoscopy in celiac disease: diagnosis and management.

Celiac disease occurs in about 1% of the population. Although diarrhea is the classical presentation, the diagnosis of celiac disease is frequently not considered as part of the differential diagnosis of a variety of different symptoms. It is,therefore, imperative that physicians who perform capsule endoscopy, and those who review the images, are aware of the variety of mucosa appearances inpatients who have celiac disease. In addition, studies are needed to determine the role of capsule endoscopy in the diagnosis and management of celiac disease.