Treatment of Leaks Following Sleeve Gastrectomy by Endoscopic Internal Drainage (EID).

BACKGROUND: Leaks are considered one of the major complications of laparoscopic sleeve gastrectomy (LSG) with a reported rate up to 7 %. Drainage of the collection coupled with SEMS deployment is the most frequent treatment. Its success is variable and burdened by high morbidity and not irrelevant mortality. The aim of this paper is to suggest and establish a new approach by endoscopic internal drainage (EID) for the management of leaks. METHODS: Since March 2013, 67 patients presenting leak following LSG were treated with deployment of double pigtail plastic stents across orifice leak, positioning one end inside the collection and the other end in remnant stomach. The aim of EID is to internally drain the collection and at the same time promote leak healing. RESULTS: Double pigtails stent were successfully delivered in 66 out of 67 patients (98.5 %). Fifty patients were cured by EID after a mean time of 57.5 days and an average of 3.14 endoscopic sessions. Two died for event not related to EID. Nine are still under treatment; five failure had been registered. Six patients developed late stenosis treated endoscopically. CONCLUSIONS: EID proved to be a valid, curative, and safe mini-invasive approach for treatment of leaks following SG. EID achieves complete drainage of perigastric collections and stimulates mucosal growth over the stent. EID is well tolerated, allows early re-alimentation, and it is burdened by fewer complications than others technique. Long-term follow-up confirms good outcomes with no motility or feeding alterations.

Nonsurgical treatment of staple line leaks after laparoscopic sleeve gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is gaining popularity as a "per se" bariatric procedure due to its effectiveness on weight loss and comorbidity resolution. The most feared and life-threatening complication after LSG is the staple line leak and its management is still a debated issue. Aim of this paper is to analyze the incidence of leak and the treatment solutions adopted in a consecutive series of 200 LSG. METHODS: From October 2002 to November 2008, 200 patients underwent LSG. Nineteen patients (9.5%) had a body mass index (BMI) of >60 kg/m(2). A 48-Fr bougie is used to obtain an 80-120-ml gastric pouch. An oversewing running suture to reinforce the staple line was performed in the last 100 cases. The technique adopted to reinforce the staple line is a running suture taken through and through the complete stomach wall. RESULTS: Staple line leaks occurred in six patients (mean BMI 52.5; mean age 41.6 years). Leak presentation was early in three cases (first, second, and third postoperative (PO) day), late in the remaining three cases (11th, 22nd, and 30th PO day). The most common leak location was at the esophagogastric junction (five cases). Mortality was nihil. Nonoperative management (total parenteral nutrition, proton pump inhibitor, and antibiotics) was adopted in all cases. Percutaneous abdominal drainage was placed in five patients. In one case, a small fistula was successfully treated by endoscopic injection of fibrin glue only. Self-expandable covered stent was used in three cases. Complete healing of leaks was obtained in all patients (mean healing time 71 days). CONCLUSION: Nonoperative treatment (percutaneous drainage, endoscopy, stent) is feasible, safe, and effective for staple line leaks in patients undergoing LSG; furthermore, it may avoid more mutilating procedures such as total gastrectomy.

Palliative treatment for malignant jaundice: endoscopic vs surgical approach.

In this retrospective, comparative study a total of 107 patients, presenting with malignant inoperable strictures of common bile duct, due to a pancreatico-biliary malignancy, underwent palliative treatments. In a group, consisting of 82 patients (76.64%), endoscopic stenting procedures were performed; polyethylene stents or self-expanding metal stents were applied in 37 and 45 patients, respectively. The prerequisites for a successful endoscopic stenting were a) accuracy of diagnosis and b) exclusion of patients presenting with tumors potentially treatable by a curative resection. In the other group, consisting of 25 patients (23.36%), biliary-enteric bypass procedures were performed. Endoscopic treatment was successful in 97.5% of the cases (80/82); complication rate was 7.3% (6 patients on 82), and mortality rate was 3.6% (3 patients on 82). Median hospital stay was 13.4 and 7.3 days in patients treated with plastic stents and metallic stents, respectively. Bypass surgery was successful in 99% of the cases (24/25); complication rate was 24% (6 patients on 25), and mortality rate was 16% (4 patients on 25). Median hospital stay was 26 days. For the patients in whom a curative resection could not be performed, both the above mentioned methods resulted in a high rate of immediate technical and therapeutic success. However, the surgical approach showed a significantly higher rate in procedure-related mortality and morbidity; in addition, the hospital stay lasted longer in surgically treated patients. The patients who are definitely unsuitable for curative resection are better managed by positioning a stent. The use of metal stents should be preferred in those less serious patients who may supposedly survive longer.

Conservative approach in the treatment of the biliary tract's iatrogenic lesions.

Iatrogenic lesions of the biliary tract have always represented a problem of real actuality in the abdominal surgery. The incidence of post-cholecystectomy complications is from 0.1% to 0.25% and it's increased to 0.3-0.6% for laparoscopic surgery. Potential predisposing factors to iatrogenic biliary lesions are anatomic anomalies, acute and chronic phlogosis and technical mistakes. Anatomic anomalies are present in 6-25% of all cases according to different statistics; an incomplete knowledge of the biliary tract can predispose to a mistake legating or dissecting a wrong branch. This paper present a caseload of 27 patients admitted to our Service of Digestive Endoscopy owing to post laparoscopic cholecystectomy complications. Patients have been recruited in a period from two days to six months to the intervention. Detected complicances have been divided in "major", which comprehended biliary lesions (7 cases) and biliary stenosis (8 cases), and in "minor" which included biliary leakages (12 cases). CPRE, PTC, Ultrasound, CT and cholangio-MR were used to diagnose the biliary damage. Conservative approach has been resolutive in all patients with minor biliary lesions and in three cases of major lesions; in seven cases of biliary stenosis endoscopic-radiologic combined treatment has been successfully performed, in the other patients surgical operation was obliged choice. Comparing our results with literature we can affirm that conservative treatment represents the first choice in case of minor lesions (100% of successes), whereas in case of major biliary lesions it constitutes a valid alternative to the reparative surgery; when surgical option results impossible to defer, it can help the surgeon identifying the damage and draining the biliary tract.

Improvement of intestinal metaplasia six month after misoprostol treatment.

PURPOSE: To establish whether misoprostol (a synthetic prostanoid) is effective in improving intestinal metaplasia of dyspeptic patients. PATIENTS: Of the 206 dyspeptic patients without Helicobacter pylori, 18 (7.1%) had histological evidence of intestinal metaplasia (2 presented mild metaplasia, 9 moderate and 7 severe). They were treated with misoprostol 200 mg twice daily for six months and, after stopping the treatment, they all underwent endoscopic control. RESULTS: There was a statistical significant improvement of intestinal metaplasia (p < 0.001) and of the activity of antral gastritis (p = 0.03). There were no significant changes in antral and body specimens during follow-up. DISCUSSION: Though the small number of the patients and the lack of control group, our results suggest that misoprostol allows regression and/or improvement of histological IM (p < 0.001). It has proved to be effective in prevention of both gastric and duodenal ulcers induced by NSAID therapy, probably related largely to replacement of endogenous prostaglandins inhibited by the use of NSAID and it may also exerts its protective effects through inhibition of gastric acid secretion. Moreover, misoprostol showed to increase the rate of gastric blood flow, inducing a mucosal protective effect against the factors damaging gastric mucosa. It has been also documented that misoprostol regulates inflammatory cytokines and prolonged the survival of transplants, reflecting both its immunosuppressive and anti-inflammatory effect. In conclusion, since intestinal metaplasia increases the risk of gastric cancer, the use of misoprostol, in this pathology, would be of some interest.

Magnetic resonance-cholangiopancreatography in the diagnosis of biliopancreatic diseases.

BACKGROUND: Magnetic resonance cholangiopancreatography (MRCP) is a new, noninvasive imaging technique for the visualization of the biliary ducts with cholangiographic images similar to those obtained with endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography. No contrast medium injection is used. The aim of this study was to assess the feasibility of MRCP versus ERCP in the diagnosis of biliary tract and pancreatic diseases. PATIENTS AND METHODS: One hundred and thirty-six patients were submitted to MRCP. They were referred to MR study according to four inclusion criteria: (1) evidence or suspicion of choledocholithiasis, (2) benign or malignant bile ducts stenosis, (3) follow-up of patients submitted to biliary-enteric anastomosis, and (4) chronic pancreatitis with Wirsung duct dilatation. The MRCP was performed with a 0.5T superconducting magnet (Philips Gyroscan T5). When neoplastic disease was detected, additional images on axial planes were acquired. MRCP allowed images of diagnostic value to be obtained in all the cases. RESULTS: In choledocholithiasis, MRCP showed 91.6% sensitivity, 100% specificity, and overall diagnostic accuracy 96.8%. Of 48 patients with stenotic lesions, 16 were correctly characterized as benign and 30 as malignant. Two cases of focal chronic pancreatitis were misdiagnosed as pancreatic head carcinoma. In the patients submitted to biliary-enteric anastomosis, MCRP was able to detect the dilatation of the intrahepatic ducts, the stenosis, and associated stones in all 8 positive cases. In the remaining 7 patients with mild signs of cholangitis, MCRP showed irregular aspects of the biliary tree in the main ducts. In the 11 patients with chronic pancreatitis, MCRP was able to depict the dilated Wirsung duct and the stenotic tract, although the fine details of the secondary ducts were not evaluated due to the low spatial resolution as compared with conventional films. CONCLUSIONS: MRCP can be considered a technique able to completely replace diagnostic ERCP. Further studies are necessary for a better evaluation of the potential advantages and disadvantages of this technique.

ESWL experience in the therapy of difficult bile duct stones.

In recent years, alternatives to surgery for difficult bile duct stones have been developed. Routine endoscopy fails in about 10% of patients. To verify the role of extracorporeal shock wave lithotripsy in residual CBD stones, we treated 32 patients by HM4 or MPL 9000 Dornier lithotripters. Ten (34.4%) patients needed two extracorporeal shock wave lithotripsy sessions, and 3 (10.3%) patients three. Complete clearance was achieved in 29 patients (90.6%) after one or more sessions either by endoscopic (20 pts) or percutaneous (9 pts) extraction of the debris; of the remaining 3 patients, in 2 a bilioduodenal stent was placed and in 1 electrohydraulic lithotripsy was performed. Eighteen and seven-tenths percent transient mild hemobilia, 12.5% microhematuria, and no mortality were observed. It is possible to state that in site- or size-related difficult biliary stones, extracorporeal shock wave lithotripsy is a rapid, safe, and highly effective treatment as an additional nonoperative option to resolve the failure of routine endoscopic measures.

Sequential endoscopic-laparoscopic treatment of cholecystocholedocholithiasis.

Preoperative common bile duct (CBD) clearance with endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) is routinely performed in many centers where laparoscopic cholecystectomy (LC) is the procedure of choice for the treatment of cholelithiasis. The purpose of this study was to evaluate prospectively the results of the sequential endoscopic-laparoscopic management in patients with gallstones and suspected CBD stones. From November 1990 to May 1993, 700 consecutive patients were evaluated for LC. Preoperative workup included clinical history and physical examination; serum levels of bilirubin, alkaline phosphatase, and amylase; and ultrasonography. Preoperative ERCP was indicated in cases with previous or present jaundice or acute pancreatitis, altered liver or pancreatic blood tests, dilated CBD (> 6 mm) and CBD stones at ultrasonography. If CDB pathology was confirmed, ES was performed and treatment attempted. All patients were assigned to undergo LC within 48 h. Morbidity, mortality, hospital stay, and disability were recorded. Of 700 patients, 49 (7%) underwent ERCP. In 26 patients (54.2%), CBD stones were identified; ES was performed and stone extraction succeeded in 22 patients (84.6%). Two patients with intrahepatic stones were successfully treated with a percutaneous transhepatic approach and then underwent surgery. Two patients with cholecystocholedochal fistula underwent open surgery. In two cases ERCP showed a papillary stenosis, which was treated with ES. Of 44 patients, 35 (79.5%) underwent LC within 48 h. The overall morbidity (ERCP/ES plus LC) was 10.4%. No mortality occurred. The mean hospital stay was 4.5 days. Return to normal activities occurred within 11 days after LC. This sequential approach resulted in a safe and effective treatment of cholecystocholedocholithiasis and a decrease in the overall costs.

Non-invasive evaluation of the biliary tree with magnetic resonance cholangiopancreatography: initial clinical experience.

Magnetic resonance cholangiopancreatography is a new, non-invasive imaging technique for visualization of the biliary ducts. Magnetic resonance cholangiopancreatography was performed on 136 patients (20-87 years old) with a superconductive magnet at 0.5T (Philips Gyroscan T5). Volumetric images on coronal planes were acquired; a T2 weighted turbo spin echo sequence (TR = 3000; TE = 700; number of excitations = 8; echo train length = 128; Acquisition time = 5'48") with respiratory compensation was performed. Images were reconstructed on coronal planes rotated at different angles using the MIP algorithm. When neoplastic disease was detected additional images on axial planes (SE Tlw: TR/TE 300/10 and turbo spin echo T2w: TR/TE 3000/120) were acquired. Magnetic resonance cholangiopancreatography allowed images of diagnostic value to be obtained in all cases. In choledocholithiasis, the technique had a sensitivity of 91.6%, specificity of 100% and overall diagnostic accuracy of 96.8%. Of the 48 patients with stenotic lesions, 16 cases were correctly characterized as benign and 30 as malignant. Two cases of focal chronic pancreatitis were misdiagnosed as pancreatic head carcinoma. In patients submitted to bilioenteric anastomosis, the technique was able to detect dilation of intrahepatic ducts, stenosis and associated stones in the 8 positive cases. In all 11 patients with chronic pancreatitis, dilated Wirsung duct and the stenotic tracts were revealed. In conclusion, magnetic resonance cholangiopancreatography can be considered as a technique able to completely replace diagnostic endoscopic retrograde cholangiopancreatography. However, further studies are necessary for a better evaluation of potential advantage and disadvantages.

Minimally invasive approach in Mirizzi's syndrome.

During a 4-year period (November 1990-September 1994), 1152 patients underwent laparoscopic cholecystectomy (LC). In five (0.4%) patients a cholecysto-choledochal fistula (Mirizzi's syndrome type II) was diagnosed and a minimally invasive treatment (endoscopy-laparoscopy-interventional radiology) was attempted. The first two cases were converted to open surgery probably because of severe anatomical distortion and inadequate confidence in performing a laparoscopic choledochal repair. The last three patients were successfully treated by minimally invasive procedures. These data indicate that a minimally invasive treatment can be safely attempted through a multi-disciplinary approach in Mirizzi's syndrome.

Complications after laparoscopic cholecystectomy. Coordinated radiologic, endoscopic, and surgical treatment.

The diagnostic and therapeutic approaches used for patients referred for bile duct injuries and other major complications after laparoscopic cholecystectomy (LC) were reviewed and the results of a coordinated radiologic, endoscopic, and surgical approach were assessed. From April 1991 to October 1993, 23 patients were observed. Seven patients had biliary strictures, five had biliary lesions, five presented with retained common bile duct (CBD) stones, and one had a minor cystic duct leak. Five patients had miscellaneous abdominal fluid collections; in addition, biloma or bile ascites were present in 10/23 cases. Correct definition of iatrogenic lesions was mainly made by endoscopic retrograde cholangiography (ERCP) (n = 15), associated in six cases also with percutaneous cholangiography (PTC). "Minimally invasive" treatment included the full range of endoscopic and interventional radiological procedures. Six patients with biliary strictures, one patient with a biliary lesion, all five patients with residual CBD stones, and four patients with abdominal collections were treated by "minimally invasive" techniques: Therefore, laparotomy was avoided in 70% of cases (16/23 patients). Open surgery was necessary in 7/23 patients (30%), because of ductal lesion (n = 4), ductal stricture by endoloop (n = 1), iliac artery injury (n = 1), and phlegmon of gallbladder bed (n = 1). It appears that careful assessment of complications after LC is mandatory and often requires the combined use of ERCP/PTC and cross-sectional imaging.(ABSTRACT TRUNCATED AT 250 WORDS)

[Intraoperative digital cholangiography during laparoscopic cholecystectomy interventions]. / Colangiografia intraoperatoria digitale in corso di interventi di colecistectomia laparoscopica.

In the last years, laparoscopic cholecystectomy has become the method of choice in the surgical treatment of gallbladder stones. Recently, the same laparoscopic approach has been used to remove choledochus stones. This surgical procedure needs the accurate intraoperative study of the biliary tree with diagnostic imaging modalities to better define the anatomy of the biliary ducts and the possible presence of choledochus stones. To this purpose, transcutaneous and endolaparoscopic US with dedicated probes and intraoperative cholangiography can be performed. In this study, we performed 30 laparoscopic cholecystectomies during which all the patients were submitted to intraoperative cholangiography with a digital fluoroscopic unit. The maneuvers for catheter insertion in the cystic duct and the examination as a whole took 3 to 5 minutes. Intraoperative cholangiography demonstrated choledochus stones in 3 patients, while preoperative US detected them in 2 patients only. In 8 cases the dynamic study, carried out with digital image acquisition, allowed to refer the biliary duct filling defects to artifacts caused by the presence of air bubbles. In conclusion, intraoperative cholangiography, also during endolaparoscopic cholecystectomy, plays a major role in the surgical assessment of the biliary tree. When the procedure was performed with a digital fluoroscopic unit, its diagnostic accuracy was higher and the images on the TV monitor were better visualized.

[Pharmacokinetics of the biliary excretion of some chemotherapeutic agents in patients with biliary disease]. / Farmacocinetica dell'escrezione biliare di alcuni chemioterapici in pazienti con patologia biliare.

The authors have assessed the concentration of 7 antibiotics in the bile of patients undergoing biliary surgery or carriers of a T tube in the common bile duct. 1 hour preoperatively, 122 patients were administered with the following chemotherapeutic agents: Cefoxitin 2 g i.v.; Cefamandole 2 g i.v.; Ceftriaxone 1 g i.v.; Clindamycin 600 mg i.v.; Amikacin 500 mg i.v.; Gentamycin 160 mg i.v.; Norfloxacin 400 mg by mouth; 30 patients showed obstructive jaundice or obstructed cystic duct. Samples of bile were withdrawn from gallbladder and common bile duct. The same antibiotics were administered to 81 patients carrying a T tube. Samples of bile and serum were collected at baseline and every 30 minutes for 4 hours and subsequently at 12 and 24 hours following administration. 18 patients showed altered liver function tests. The chemotherapeutic agents were tested by the microbiological assay as well as by HPLC. Mean concentration in the gallbladder bile was: Cefoxitin 209 +/- 86 micrograms/ml; Cefamandole 436 +/- 108 micrograms/ml; Ceftriaxone 482.7 +/- 214.84 micrograms/ml; Clindamycin 64 +/- 22 micrograms/ml; Amikacin 5 +/- 1.4 micrograms/ml; Gentamycin 4 +/- 2 micrograms/ml; Norfloxacin 22 +/- 14 micrograms/ml. In the bile of jaundiced patients or with non-visualized gallbladder no antibiotics were detected.(ABSTRACT TRUNCATED AT 250 WORDS)

Biliary pseudocyst. A rare consequence of an iatrogenic lesion of the bile ducts.

A patient with a biliary pseudocyst due to an iatrogenic lesion of the hepatic duct is reported. The pseudocyst caused compression of the bile duct with progressive jaundice. Diagnostic problems and the utility of ERCP and PTC in determining the exact site of the lesion for surgical treatment are reported.

Acute cholangitis: diagnostic and therapeutic problems.

A retrospective study was carried out, analyzing the diagnostic and therapeutic problems in 80 patients with acute cholangitis at the time of hospitalization. 23% of the 17 patients with pus in the bile duct showed Reynolds' pentad, which was observed in 10% of patients with nonsuppurative acute cholangitis. Common bile duct lithiasis was responsible in 80% of cases presenting with Reynolds' pentad and in 66% of postoperative mortality. In 75% of patients with tumors, the clinical picture showed a rapid development following PTC. 79% of patients responded positively to antibiotic therapy with subsequent elective surgery, while in 21% of patients who did not respond to antibiotic therapy, biliary drainage was the treatment of choice. Mortality in patients with shock or hypotension was 30% while it was 17% in those undergoing early (less than 72 hours) surgery. On the basis of the results, it is concluded that, since it is not possible to assess preoperatively whether a patient belongs to the group of suppurative acute cholangitis or to that of nonsuppurative acute cholangitis, the different severity of the clinical picture should be based on clinical and biochemical parameters. The most severe developments were observed in common bile duct lithiasis or in patients with tumors who underwent PTC. In case of failure to respond to antibiotic therapy, decompression was shown to be the most suitable treatment. The mortality rate is related to the severity of the clinical picture (presence or not of shock) as well as to a prompt surgical treatment.