Evaluation of four mesh fixation methods in an experimental model of ventral hernia repair.

BACKGROUND: The present animal study was conducted to comparably investigate the performance of four different fixation techniques of intraperitoneally implanted meshes. MATERIALS AND METHODS: Fifteen New Zealand white rabbits were used. In each animal, four abdominal wall defects were created and repaired with four pieces of intraperitoneal mesh (Parietex Composite), fixed with nonabsorbable (titanium) spiral tacks (group A), absorbable (lactic and glycolic acid co-polymer) screw-type tacks (group B), transfascial polypropylene sutures (group C), or fibrin glue (group D). Adhesion formation, mesh shrinkage, tensile strength, and host tissue response were evaluated at 90 d. RESULTS: Adhesions were observed in all groups, and differences were not significant. The percentage of shrinkage was higher in group C (26.91%), lower in group D (12%), whereas in groups A and B, the mean shrinkage was 20.17% and 23.33%, respectively (P = 0.032). The incorporation of mesh fixation element to the abdominal wall was 9.18 ± 3.91 N, 6.96 ± 3.0 N, 13.68 ± 5.38 N, and 2.57 ± 1.29 N, in groups A, B, C, and D, respectively (P < 0.001). Regarding local inflammatory response and foreign body reaction, no difference was observed between groups. However, with respect to fibrous tissue presence, its quantity was clearly less in group D compared with the other groups (P < 0.001). CONCLUSIONS: None of the examined fixation techniques proved to be ideal. Probably, the best way to fixate an intraperitoneally implanted mesh may be achieved using a combination of the studied materials. Prospective randomized trials are needed to confirm the superiority of the combined use of different fixation devices in clinical practice.

A comparative study of 10-Fr vs. 7-Fr straight plastic stents in the treatment of postcholecystectomy bile leak.

BACKGROUND: Biliary decompression is a key factor in the treatment of postcholecystectomy bile leak. However, the optimal size of the stent introduced by therapeutic endoscopic retrograde cholangiopancreatography (ERCP) is yet to be determined. The aim of the study was to compare the effectiveness of two straight plastic stents with different sizes (10-Fr and 7-Fr) in the treatment of postcholecystectomy bile leak. METHODS: Between January 2003 and August 2006, 63 patients underwent therapeutic ERCP for postcholecystectomy bile leak. After visualization of the bile duct injury, endoscopic sphincterotomy was performed and the patients were randomized to receive either a 7-Fr (31 subjects, group A) or a 10-Fr (32 subjects, group B) straight plastic stent for four weeks. The success of the endoscopic treatment was determined by the elimination of the symptoms and the removal of the drain without any adverse outcomes. RESULTS: The endoscopic intervention was successful in 29 patients of group A (93.54%) and in 31 patients of group B (96.87%). In the remaining two patients of group A, the 7-Fr stent was substituted by a 10-Fr stent after 7 days because the leak remained unaffected, resulting in healing of the leaks. Surgery was required in the remaining one patient of group B. Eight patients developed post-ERCP pancreatitis (5 mild, 2 moderate, 1 severe), which was treated conservatively. CONCLUSIONS: This trial suggests that the stent size does not affect the outcome of the endoscopic intervention in postcholecystectomy bile leaks due to minor biliary tract injury; however, larger cohorts are required to confirm the optimal stent size in bile leaks due to major bile duct injury.

Endoclipping-assisted resection of large colorectal polyps.

BACKGROUND: The use of endoclipping may minimize the risk of bleeding after endoscopic polypectomy of large pedunculated polyps. The aim of this study was to assess the safety and efficacy of endoclipping of the stalk before resection of large pedunculated colorectal polyps, drawing particular attention to the cases in which the use of this method could be very useful. PATIENTS AND METHODS: This retrospective study included 17 patients [10 men, 7 women; median age: 62 y (range 38 to 79)] with 18 large pedunculated colorectal polyps, who underwent endoclipping-assisted endoscopic polypectomy between March 2003 and May 2006. The outcome of the technique and the technique-related complications were evaluated. RESULTS: Application of the clips was possible in all patients. In 4 patients (23.5%), the endoclipping was performed via the more flexible gastroscope. En bloc resection of colon polyps was achieved in all patients. No immediate or late bleeding or perforation occurred. One patient (5.9%) developed postcoagulation syndrome and was successfully treated conservatively. Histologic examination showed in situ carcinoma in 6 polyps (33.3%). Follow-up colonoscopy demonstrated no recurrence of polyps or cancer development. CONCLUSIONS: Endoclipping, followed by snare transection, may be safer than conventional polypectomy in large pedunculated colorectal polyps. Special attention is needed not to cut very close to clips to avoid thermal injury of colonic wall.

Cecal lipoma with pseudomalignant features: a case report and review of the literature.

Colonic lipoma is a well-documented benign neoplasia, endoscopically appearing as a smooth round yellowish polyp with a thick stalk or broad-based attachment. We describe a 63-year old woman with persistent abdominal pain, in whom colonoscopy revealed a cecal mass with malignant features. Based on the colonoscopy findings, right hemicolectomy was laparoscopically performed for a presumptive diagnosis of a cecal adenocarcinoma, but histological examination revealed a colonic lipoma with overlying mucosal ulceration.

A novel technique for the treatment of a symptomatic giant colonic lipoma.

Submucosal lipomas are usually harmless neoplasms arising from submucosal adipocytes. They are found most commonly in the colon, but may develop in any part of the gastrointestinal tract. Most colonic lipomas are asymptomatic and need no treatment, whereas larger ones (>2 cm) may present with abdominal pain, changes in bowel habits, rectal bleeding, and intussusception or prolapse. The literature on the endoscopic resection of colonic lipomas is limited owing to the increased risk of colonic perforation. In this paper, we describe a novel technique for the treatment of colonic obstruction resulting from a giant lipoma by placing two large clips at the narrow base of the lipoma and performing multiple cuttings on the mucosa covering the fatty tissue by using a needle-knife to facilitate the fat's discharge into the colon's lumen. Our case showed that the endoclipping of semi- or pedunculated large colonic lipomas not amenable for endoloop ligation and associated with cuttings of the mucosa covering the fat is a promising new technique, which avoids the risk of perforation or bleeding of the snare cautery, especially in high-risk patients.

Successful treatment of intractable bronchobiliary fistula using long-term biliary stenting.

A bronchobiliary fistula (BBF) is an uncommon entity with bilioptysis being a pathognomonic sign. We describe the case of a 41-year-old man who had recurrent BBF, 6 months after resection of the anterior segment of the right lower pulmonary lobe and repair of a BBF due to hepatic hydatid disease. Magnetic resonance cholangiography revealed a communication between the biliary tree and the lower lobe of the right lung. Endoscopic biliary sphincterotomy and repeated insertion of large size biliary plastic stents led to a successful resolution of the symptoms and closure of the fistula.

A case of early depressed-type ampullary carcinoma treated by wire-guided endoscopic resection.

A 72-year-old man, with known prostate cancer, was admitted to our endoscopic unit for further evaluation of an obstruction at major papilla level. Endoscopic cholangiopancreatography revealed a depressed-type carcinoma at the ampulla of Vater and dilation of both the common bile and pancreatic ducts without intraductal filling defects. Intraductal ultrasonography showed a hypoechoic mass limited to the ampulla of Vater. Endoscopic wire-guided ampullectomy was performed after informed consent was obtained. Histologic examination of the resected specimen showed a completely excised well-differentiated adenocarcinoma limited to the ampulla of Vater. Both accurate preoperative staging and proper histologic evaluation of the resected specimen seem to justify endoscopic treatment of early ampullary cancer by an experienced endoscopist.

Aggressive treatment of acute anal fissure with 0.5% nifedipine ointment prevents its evolution to chronicity.

AIM: To investigate the efficacy of topical application of 0.5% nifedipine ointment in healing acute anal fissue and preventing its progress to chronicity. METHODS: Thirty-one patients (10 males, 21 females) with acute anal fissure from September 1999 to January 2005 were treated topically with 0.5% nifedipine ointment (t.i.d.) for 8 wk. The patients were encouraged to follow a high-fiber diet and assessed at 2, 4 and 8 wk post-treatment. The healing of fissure and any side effects were recorded. The patients were subsequently followed up in the outpatient clinic for one year and contacted by phone every three months thereafter, while they were encouraged to come back if symptoms recurred. RESULTS: Twenty-seven of the 31 patients completed the 8-wk treatment course, of them 23 (85.2%) achieved a complete remission indicated by resolution of symptoms and healing of fissure. Of the remaining four unhealed patients (14.8%), 2 opted to undergo lateral sphincterotomy and the other 2 to continue therapy for four additional weeks, resulting in healing of fissure. All the 25 patients with complete remission had a mean follow-up of 22.9 +/- 14 (range 6-52) mo. Recurrence of symptoms occurred in four of these 25 patients (16%) who were successfully treated with an additional 4-wk course of 0.5% nifedipine ointment. Two of the 27 (7.4%) patients who completed the 8-wk treatment presented with moderate headache as a side effect of nifedipine. CONCLUSION: Topical 0.5% nifedipine ointment, used as an agent in chemical sphincterotomy, appears to offer a significant healing rate for acute anal fissure and might prevent its evolution to chronicity.

The role of endoscopic treatment in postoperative bile leaks.

BACKGROUND/AIMS: Bile leak is among the most common and serious complications of biliary tract surgery. The aim of this non-randomized study was to evaluate the role of endoscopic intervention as an accepted treatment for this complication. METHODOLOGY: An endoscopic retrograde cholangiopancreatography (ERCP) database was reviewed retrospectively to identify all cases of bile leak related to cholecystectomy (laparoscopic or open). Patients' records and endoscopy reports were reviewed. Moreover, structured telephone interviews were conducted to collect data. RESULTS: Twenty-four patients, 4 males and 20 females, with a median age of 54 (range 28-76 years) with suspected postcholecystectomy bile leaks were referred for ERCP performed 3-73 days after operation (mean 9.5 days). All but one case had high-grade bile-like liquid outflowing from the original drainage tubes or the fistulous tract of T-tube. One patient presented with bilious ascites, 17 patients had sudden or gradual abdominal pain, 3 jaundice, 2 abdominal pain with fever, and 1 nausea and vomiting. ERCP was successful in all cases, and revealed leakage from the cystic stump in 10 cases, from a common bile duct (CBD) defect in 6, from a common hepatic duct defect in 3, from the gallbladder bed in 2, from a T-tube track in 1, and complete CBD transection in 2 patients. Seventeen patients were successfully treated by endoscopic sphincterotomy (ES) plus endoprosthesis, 3 by stent placement without sphincterotomy, 2 with complete transection by proximal hepaticojejunostomy, and 2 patients with leakage from the cystic stump and a CBD defect were operated after unsuccessful endoscopic intervention. CONCLUSIONS: ERCP is recommended as a safe and efficacious intervention to detect and treat postoperative bile leaks. ES plus endoprosthesis is effective for the treatment of bile leakage. Endoscopic stenting without sphincterotomy may be offered as a primary option in young patients with postoperative bile leaks.

Endoscopic mucosal resection of lateral spreading tumors of the colon using a novel solution.

Lateral spreading tumors (LSTs) of the colon are lesions over 10 mm in diameter that are low in height and grow superficially. They are increasingly being diagnosed in Western cohorts. The aim of this study was to investigate the safety and efficacy of dextrose 50% solution in the endoscopic mucosal resection (EMR) of LSTs. The study population consisted of 21 patients with LSTs of the colorectum. The mean size of the LSTs was 23.52+/-13.60 mm. Dextrose 50% solution was injected, via a variceal needle, into the submucosa to lift up the LST sufficiently from the proper muscle layer. Subsequently, a snare was positioned around the lesion and then closed while being pressed against the mucosa, with suction being applied to draw the lesion into the snare. Blended current was used for resection. If necessary, a piecemeal technique was used to achieve complete resection. Immediate and delayed complications were recorded. After the EMR, patients were followed up at 3, 6, and 12 months or later, using total colonoscopy. Endoscopic resection was completed in all LSTs. Of the 21 LSTs, 15 (71.4%) were resected en bloc and 6 (28.6%) piecemeal. The mean amount of injected dextrose 50% solution was 14.86+/-9.13 mL. One patient (4.78%) had immediate bleeding after EMR, which was stopped endoscopically. Histologic examination of resected LSTs showed adenoma with high-grade dysplasia 9 (42.9%), adenoma with low-grade dysplasia 10 (47.6%), and invasive carcinoma 2 (9.5%). Twenty patients were followed up for 37.9+/-24.03 months. Local recurrent disease was detected in 4 patients (20%), all within 6 months of the index EMR. These recurrent lesions were completely resected endoscopically. The contribution of submucosal injection of dextrose 50% is significant for a safe and efficient EMR of LSTs of the colorectum.

Endoscopic hemoclip placement for postsphincterotomy bleeding refractory to injection therapy: report of two cases.

Bleeding is a serious complication of patients undergoing endoscopic sphincterotomy and is the most common sphincterotomy-associated cause of death. Two patients presented bleeding after endoscopic sphincterotomy. Despite injection treatment with large amounts of epinephrine (1:10,000), the bleeding was uncontrolled. Hemostasis was achieved by placing 2 and 3 hemoclips, respectively at the bleeding site. Our cases suggest that postsphincterotomy bleeding refractory to injection treatment can be safely and effectively controlled by endoscopic hemoclipping, thereby avoiding surgery.

Endoscopic hemoclip application in the treatment of nonvariceal gastrointestinal bleeding: short-term and long-term benefits.

We conducted an uncontrolled retrospective study to evaluate endoscopic hemoclip application as the first-choice hemostatic treatment of gastrointestinal bleeding lesions from a wide variety of sources. Clinical data, endoscopic findings, complications, and short- and long-term outcomes were also investigated. A total of 52 patients (men/women, 36/16; age, 65 +/- 11.5 years) were included in the study. Hemoclipping was technically successful in 51 cases (98%). The average number of therapeutic endoscopic sessions needed to achieve permanent hemostasis was 1.42 +/- 1.2 (range, 1-4). The number of hemoclips required for hemostasis depended on the nature of bleeding with the average number of hemoclips used being 3.11 +/- 1.12 (range, 2-8). No complications occurred, although 1 patient presented recurrent bleeding and was operated on. No further hemorrhage occurred during a median follow-up period of 17.32 +/- 5.4 months (range, 2-53). Endoscopic hemoclipping provided an effective and safe modality for achieving hemostasis in gastrointestinal bleeding from a wide variety of sources, with long-term benefits.

Recurrent cholangitis as the first manifestation of an intraductal papillary mucinous tumor of the pancreas.

Intraductal papillary mucinous tumor is a rare pancreatic tumor originating from the epithelium of the pancreatic duct and exhibiting papillary proliferation of tall columnar epithelial cells. The usual clinical presentation is recurrent episodes of pancreatitis due to hypersecretion of mucin and obstruction of a markedly dilated pancreatic duct. We describe a 74-year-old man who presented recurrent attacks of cholangitis, due to a common bile duct obstruction from thick pancreatic mucus reflux, as the first manifestation of intraductal papillary mucinous tumor.

Endoclipping for gastric perforation after endoscopic polypectomy: an alternative treatment to avoid surgery.

A 47-year-old woman underwent endoscopic polypectomy of a villous adenoma in the lesser curvature of the gastric antrum. Shortly after the procedure, she complained of severe abdominal pain. An abdominal x-ray showed air under the diaphragm, suggestive of gastric perforation. On re-endoscopy, the cavity at the site of polypectomy was closed using endoscopically applied metallic clips. She was treated with intravenous hyperalimentation, omeprazole, and antibiotics for 10 days. Ingestion of food was started 10 days after admission, and she was discharged without any complaints. She is free of symptoms on follow-up after 8 months, and endoscopy showed complete healing of the perforation. The procedure is the third described for the stomach in the English literature and emphasizes the use of endoclipping in selected cases of small and well-defined perforations.

Hematemesis as a presenting symptom of lung cancer with synchronous metastases to the esophagus and stomach. A case report.

A rare case of upper gastrointestinal hemorrhage due to synchronous metastases to the esophagus and stomach from an asymptomatic lung cancer is reported. A 51-year-old white man presented with hematemesis and an emergency endoscopy revealed submucosal tumorous lesions with central ulcerations in the esophagus and stomach. A needle aspiration biopsy revealed the presence of cellular proliferation of adenocarcinoma, which led to the diagnosis of lung cancer, along with a chest radiograph revealing a tumor in the right middle lung field. The importance of conducting an upper gastrointestinal endoscopic examination for staging of patients with lung cancer is stressed.

Pedunculated cecal lipoma causing colo-colonic intussusception: a rare case report.

Colonic lipomas are uncommon nonepithelial neoplasms that are typically sessile, asymptomatic and incidentally found during endoscopy, surgery, or autopsy. We present a very rare case of a 34-year-old female patient with symptomatic pedunculated cecal lipoma causing intermittent colo-colonic intussusception. Despite adequate imaging studies, definite preoperative diagnosis was not established and the patient underwent exploratory laparotomy. Intraoperatively, intussusception of the cecum into the ascending colon was found and right hemicolectomy was performed. Macroscopic assessment of the resected specimen showed the presence of a giant cecal pedunculated polypoid tumor with features of lipoma, causing intussusception. Histopathological examination confirmed the diagnosis of pedunculated cecal lipoma.

Retroperitoneal Abscess Formation as a Result of Spilled Gallstones during Laparoscopic Cholecystectomy: An Unusual Case Report.

One of the complications of laparoscopic cholecystectomy for gallstone disease that seems to exceed that of the traditional open method is the gallbladder perforation and gallstone spillage. Its incidence can occur in up to 40% of patients, and in most cases its course is uneventful. However in few cases an abdominal abscess can develop, which may lead to significant morbidity. Rarely an abscess formation due to spilled and lost gallstones may occur in the retroperitoneal space. We herein report the case of a female patient who presented with clinical symptoms of sepsis six months following laparoscopic cholecystectomy. Imaging investigations revealed the presence of a retroperitoneal abscess due to retained gallstones. Due to patient's decision to refuse abscess's surgical drainage, she underwent CT-guided drainage. The 24-month followup of the patient has been uneventful, and the patient remains in good general condition.

Secondary rectal linitis plastica as first manifestation of urinary bladder carcinoma.

Secondary rectal linitis plastica is a very rare malignancy with poor prognosis. Diagnosis is difficult because of nonspecific clinical and endoscopic findings and negative biopsies in most cases owing to the fact that the mucosa is frequently unaffected. We herein describe a 68-year-old man who presented with a six-month history of tenesmus and constipation. Endoscopy revealed a narrow distal rectum with an indurated, cobblestone appearance of mucosa. Multiple biopsies and fine-needle aspiration were negative for malignancy. Abdominal MRI and transrectal ultrasonography showed findings compatible with rectal linitis plastica. He underwent rectal extirpation with total cystectomy and lymph nodes dissection. Histology demonstrated secondary rectal linitis plastica due to a poorly differentiated urinary bladder carcinoma. We emphasize the endoscopic and endosonographic features and the difficulty to establish a preoperative diagnosis of secondary rectal linitis plastica.