Over-the-catheter precut to gain access to the biliary duct during ERCP rendezvous.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) rendezvous during laparoscopic cholecystectomy is an efficient and safe method to treat cholecystocholedocholithiasis. Advancing a guidewire through the cystic duct into the duodenum and withdrawing it in the accessory channel of duodenoscope may be, however, laborious. Moreover, rendezvous performed in the typical manner needs the use of several costly accessories. We herein describe a simpler and cheaper method to gain access to the biliary duct at rendezvous. METHODS: Twenty-four consecutive patients undergoing ERCP rendezvous during laparoscopic cholecystectomy were considered. A catheter was introduced in the cystic duct and advanced into the duodenum. Access to the bile duct was than achieved by means of a precut sphincterotomy performed over the catheter emerging from the papilla. RESULTS: Cannulation was successful in all but two patients, in whom ERCP was performed in the conventional manner. The only complication was a case of mild post-sphincterotomy bleeding. In comparison with the typical rendezvous technique our procedure allowed savings of about 250, since its performance only requires a catheter and a knife sphincterotome. CONCLUSIONS: Over-the-catheter precut during ERCP rendezvous is a feasible and safe method which avoids the need for the manipulation of several accessories and guidewires, and thus results in money and time savings.

[Successful management of severe unremitting chylothorax after thoraci trauma]. / Trattamento efficace di chilotorace grave e persistente dopo trauma toracico.

Post-traumatic chylothorax needs surgical approach when conservative treatment is not successful to reduce chyle leakage. Thoracic duct ligation requires thoracoscopic or thoracotomic access. The authors report on a surgical thoracotomic approach to a severe and unremitting thoracic duct lesion after IX and X ribs and vertebral fractures.

[Inflammatory colitis: classification and surgical treatment]. / Le coliti infiammatorie. Classificazione e trattamento chirurgico.

The development of clinical and histopathological criteria for the diagnosis of Crohn's disease (CD) and ulcerative colitis (UC), pushed the scientists to identify a new category: the indeterminate colitis (CI). This term is used when definitive diagnosis of UC or CD has not been made by colonoscopy, colonic biopsy or colectomy. The distinction between these forms has major implications including the choice of medical treatment, timing of surgery, prognosis and disease course. The role of surgery in inflammatory bowel disease differs between the three main forms: in CD is primarily to treat complications of the disease process; in UC surgery is curative for intestinal manifestations and nearly eliminates the risk of future malignancy; in IC is actually discussed: the current guidelines identify in surgery the best treatment for fulminate disease, intractability of disease symptoms or failure of medical therapy. Although there is a few number of studies in the literature, selective criteria for the diagnosis and successful treatment must be revisited. The term CI should be used as a pending tray diagnosis, representing diagnostic inadequacy and not as specific nosological entity. Evidence emerging from the studies of serological markers (ASCA and P-ANCA) suggests that a subgroup of patients initially diagnosed as IC maybe identified as a separate group, and so they need a specific treatment for their disease.

Outcome of non-variceal acute upper gastrointestinal bleeding in relation to the time of endoscopy and the experience of the endoscopist: a two-year survey.

AIM: To prospectively assess the impact of time of endoscopy and endoscopist's experience on the outcome of non-variceal acute upper gastrointestinal (GI) bleeding patients in a large teaching hospital. METHODS: All patients admitted for non-variceal acute upper GI bleeding for over a 2-year period were potentially eligible for this study. They were managed by a team of seven endoscopists on 24-h call whose experience was categorized into two levels (high and low) according to the number of endoscopic hemostatic procedures undertaken before the study. Endoscopic treatment was standardized according to Forrest classification of lesions as well as the subsequent medical therapy. Time of endoscopy was subdivided into two time periods: routine (8 a.m.-5 p.m.) and on-call (5 p.m.-8 a.m.). For each category of experience and time periods rebleeding rate, transfusion requirement, need for surgery, length of hospital stay and mortality we compared. Multivariate analysis was used to discriminate the impact of different variables on the outcomes that were considered. RESULTS: Study population consisted of 272 patients (mean age 67.3 years) with endoscopic stigmata of hemorrhage. The patients were equally distributed among the endoscopists, whereas only 19% of procedures were done out of working hours. Rockall score and Forrest classification at admission did not differ between time periods and degree of experience. Univariate analysis showed that higher endoscopist's experience was associated with significant reduction in rebleeding rate (14% vs 37%), transfusion requirements (1.8+/-0.6 vs 3.0+/-1.7 units) as well as surgery (4% vs 10%), but not associated with the length of hospital stay nor mortality. By contrast, outcomes did not significantly differ between the two time periods of endoscopy. On multivariate analysis, endoscopist's experience was independently associated with rebleeding rate and transfusion requirements. Odds ratios for low experienced endoscopist were 4.47 for rebleeding and 6.90 for need of transfusion after the endoscopy. CONCLUSION: Endoscopist's experience is an important independent prognostic factor for non-variceal acute upper GI bleeding. Urgent endoscopy should be undertaken preferentially by a skilled endoscopist as less expert staff tends to underestimate some risk lesions with a negative influence on hemostasis.