Endotherapy including temporary stenting of fistulas of the upper gastrointestinal tract after laparoscopic bariatric surgery.

BACKGROUND: Reoperations for complications of bariatric surgery are associated with high morbidity and mortality. It is not known whether endoscopic treatment may reduce reoperation rates. METHODS: Twenty-one patients underwent endoscopic treatment for persisting large anastomotic leaks before considering redo surgery. Eight patients had a gastric bypass, eight had a sleeve gastrectomy combined with a duodenal switch (SDS), four had a sleeve gastrectomy alone, and one had a Scopinaro procedure (biliopancreatic diversion). Fistulas were gastrocutaneous in 15 patients, duodenocutaneous in 2, gastroperitoneal in 3, and gastrobronchial in 1. Partially covered self-expanding metal stents (SEMSs) were used, followed by additional endoscopic procedures if the SEMS failed. SEMSs were removed by traction alone or by insertion of a self-expanding plastic stent (SEPS) followed by extraction of both stents together. RESULTS: SEMS insertion led to 62 % (13/21) primary closures. Complementary endoscopic treatment led to 4 secondary closures. Total success rate was 81 % (17/21). Three patients in whom SEMSs failed underwent reoperation but died during postoperative follow-up; one patient died from pulmonary embolism before SEMS extraction. The success rates of endotherapy were 100 % (8/8) in the gastric bypass group, 62.5 % (5/8) in the SDS group, 75 % (3/4) in the sleeve gastrectomy group, and 100 % (1/1) for the Scopinaro procedure. Gastrocutaneous fistulas on sleeve sutures were successfully treated in 60 % of cases (6/10), while other anastomotic fistulas were successfully treated in 100 % of cases (11/11) ( P = 0.0351). CONCLUSIONS: Endoscopic treatment using SEMSs for complications of bariatric surgery is feasible. Healing of severe leaks was obtained in 81 % (17/21) of patients, avoiding high-risk reintervention. Gastrocutaneous fistulas on a sleeve suture are the most difficult condition to treat.

Esophageal fistula sealing: choice of stent, practical management, and cost.

BACKGROUND: Three models of covered metal stents are available to seal esophageal fistulas. METHODS: Stainless steel covered stents were inserted in 5 patients (group I); nitinol covered stents were inserted in 12 patients (group II) with malignant (n = 14) or benign (n = 3) esophageal fistulas. RESULTS: Stent positioning was satisfactory in all cases. Fistula sealing was complete in 1 of 5 (20%) and 12 of 12 (100%) patients of groups I and II, respectively (p < 0.005). Continued esophageal leakage was initially related to the passage of fluids alongside the stent covering (n = 3) and to early stent migration (n = 1). Complications related to stent placement were observed in 2 of 17 (12%) patients and were fatal. During follow-up (mean 153 +/- 143 days), esophageal fistulas relapsed after initial sealing in 5 of 13 (38%) patients. Further treatment (glue or fibrin sealant injection, additional stent insertion) was attempted in 7 cases of persistent or relapsing esophageal fistula, with sealing obtained in 5 of them. The costs per patient and per day free from symptoms due to the esophageal fistula were $106 and $57 in groups I and II, respectively. CONCLUSION: Nitinol covered stents more frequently provided complete esophageal fistula sealing, as compared with stainless steel covered stents. Further treatments tailored to the mechanisms of fistula persistence or relapse often provided sealing.

[Radiation monitoring in the area of metallic dental replacement during cobalt 60 gamma radiation and in electron radiation of oral tumors]. / Dosismessungen im Bereich von metallischem Zahnersatz bei Kobalt-60-Gammabestrahlung und bei Elektronenbestrahlung von Mundhöhlentumoren

In the radiotherapy of malignant tumors of the oral cavity, the exact distribution of radiation dosage in the neighborhood of metallic dental replacement has been uncertain so far. Many authors therefore asked that crowns and bridges be removed before radiotherapy. By means of lithium fluoride thermo-luminescence dosimetry, punctate measurements of doses are possible for the first time. In view of the dose values obtained, removal of metallic dental replacement before the beginning of radiotherapy as a prophylactic measure to prevent radioosteomyelitis appears not to be necessary.

Plastic and metal stents for postoperative benign bile duct strictures: the best and the worst.

BACKGROUND: Endoscopic treatment of postoperative benign bile duct strictures (BBDS) is technically challenging, and the long-term outcome after stricture dilation remains poorly defined. METHODS: Forty-eight cases of postoperative BBDS with attempted endoscopic treatment (either transient plastic stenting or definitive metal stent insertion) were reviewed. RESULTS: Endoscopic stricture dilation succeeded in 47 of 48 cases (98%). No procedure-related mortality was observed; 16 (33%) procedure-related or stent-associated complications were observed during treatment. Endoscopic treatment was interrupted in five patients. Stricture relapse occurred in 6 of 6 (100%) and 7 of 36 (19%) patients after metal stent insertion and plastic stent removal, respectively (p < 0.001) (mean follow-up periods 50+/-12 and 44+/-34 months, respectively). After plastic stent removal, stricture relapses were more frequent among patients with strictures related to liver transplantation as opposed to other surgical procedures (p < 0.05); these recurrent strictures were successfully treated by repeated insertion of plastic stents on a temporary basis. At the end of follow-up, all but one patient treated with plastic stents had normal serum alkaline phosphatase values. CONCLUSION: Metal stents proved to be inadequate for treating postoperative BBDS. Temporary insertion of a plastic stent (possibly repeated) provided long-term results equal or superior to those reported for surgical biliary drainage. Repeated insertion of plastic stents was more frequently indicated for strictures related to liver transplantation compared with other surgical procedures.

Acinar filling during secretin-stimulated MR pancreatography.

OBJECTIVE: The purpose of this study is to report a new sign, "acinar filling," observed on dynamic MR pancreatography after secretin stimulation in patients with suspected early chronic pancreatitis. CONCLUSION: Acinar filling might reflect tissue hypertension or loss of pancreatic parenchyma compliance or both. This finding is probably an insensitive but specific sign of early chronic pancreatitis.

Whole gut lavage for colonoscopy--a comparison between two solutions.

The clinical efficacy and patient acceptability of a new solution containing mainly sodium sulfate and polyethylene glycol (solution II) compared with a balanced standard electrolyte solution (solution I) for whole gut lavage prior to colonoscopy were evaluated in 240 ambulatory and hospital patients randomly allocated to receive either of the two solutions. On the basis of the quality and rapidity of the bowel preparation and the good results obtained by clinical and biological parameters, we found that the newly designed solution was superior.