Sporadic pedunculated duodenal adenomas. Clinical presentations and endoscopic management: a case series.

The prevalence of sporadic duodenal polyps is estimated to be 0.3%-4.6% in patients referred for an upper endoscopy. Most of patients are asymptomatic (66-80%) at the time of diagnosis though bleeding, anemia and abdominal pain are the most commonly reported symptoms. These are related to the polyp's size, location and histological characteristics. We describe three cases of big, pedunculated nonampullary sporadic duodenal polyps (tubulovillous low-grade dysplasia adenomas) located in the second part of the duodenum and characterized by different clinical presentations, managed in our Endoscopic Unit within one year (between 2016 and 2017). Polypectomies were performed, either piece-meal or en-bloc using various endoscopic instruments. In one of our patients (case 1), a delayed bleeding (36 hours after the procedure) occurred eventually managed conservatively with two units of blood transfusion. In the same patient, in the following months after polypectomy, the pre-procedural state of anemia misclassified as Mediterranean anemia has improved with a significant rise of hemoglobin value (14.1g/dl). In a patient who previously underwent a renal transplant (case 2), endoscopy was indicated, based on the positive fecal occult blood test. In another patient (case 3), a big polyp induced pancreatitis since it exerted a strong traction on the duodenal wall during peristaltic movements. The removal of the polyp has led to the resolution of pancreatitis and associated symptoms.

Endoscopic sphincterotomy of the major duodenal papilla in acute relapsing pancreatitis associated with pancreas divisum: a case report.

We report a case of acute relapsing pancreatitis associated with pancreas divisum, who underwent major papilla sphincterotomy after failed minor papilla cannulation. Long-term results were satisfactory. The possible explanations of the efficacy of major papilla endoscopic resection in this particular case are discussed.

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.

Laparoscopic treatment of gastric stromal tumors.

BACKGROUND: The laparoscopic resection of gastric stromal tumors (GST) is being performed with increased frequency. METHODS: Between November 1993 and October 1998, nine consecutive patients with benign and low-grade gastric stromal tumors underwent laparoscopic resection using intraoperative endoscopy. For lesions located on the anterior wall (three cases), a direct approach was utilized. Lesions located on the posterior wall were resected via a transgastric approach (four cases) or through a small opening on the omentum or on the gastrocolic ligament (two cases). Excision of the lesions was performed manually by means of electrocautery and scissors in eight cases; the gastric incisions were closed by manual running suture. An endoscopic stapler device was used in one case only. RESULTS: All patients were successfully treated laparoscopically; there were no conversions to open surgery. Operative time ranged from 75 to 120 min. There was one bleeding from the suture line of the gastric wall postoperatively that was treated conservatively. The average postoperative hospital stay was 4 days (range, 2-6). CONCLUSIONS: In light of the results reported in the literature and on the basis of the present work, it seems that laparoscopic resection of GST should be considered as the treatment of choice. Wedge resection of anterior wall lesions is generally performed. The treatment of posterior wall lesions is still controversial. In our opinion the direct approach should be reserved for lesions located on the posterior wall of the body, which can be easily reached through the greater omentum, while the transgastric approach should be preferred for lesions located on the fundus and antrum. Manual excision allows a tailored operation; hand-sewn sutures are always feasible, and they are cheaper than stapled ones.

Laparoscopic cholecystectomy and intraoperative endoscopic sphincterotomy in the treatment of cholecysto-choledocholithiasis.

BACKGROUND: A single-stage minimally invasive procedure would be optimal for management of cholecysto-choledocholithiasis. Two alternative strategies are available: management by laparoscopy alone or a combined laparoscopic-endoscopic approach. This study evaluates the results of the latter procedure. METHODS: From June 1993 to September 1997, 1400 patients with symptomatic biliary stone disease were evaluated for laparoscopic cholecystectomy. Intraoperative cholangiography was performed on the basis of a preoperative suspicion of bile duct stones; bile duct stone treatment was by intraoperative endoscopic retrograde sphincterotomy. RESULTS: Intraoperative cholangiography was performed because of a preoperative suspicion of a bile duct abnormality in 141 of 1400 patients (10%) undergoing laparoscopic cholecystectomy because of biliary stone disease. Of those 141 patients, 54 (38.3%) presented with pathologic findings (bile duct stone [52] and papillary stenosis [2]); all 54 underwent intraoperative endoscopic sphincterotomy. Complete clearance of the ductal stones was achieved in 43 patients (82.7%) by intraoperative sphincterotomy, and in 9 patients by an additional postoperative endoscopic procedure. Laparoscopic cholecystectomy was carried out in all cases. There were no conversions to an open operation. Postoperative course in the uncomplicated cases was comparable to that for laparoscopic cholecystectomy alone. The postoperative complication rate was 5.6% and mortality 1.8%. Mean hospital stay was 3.3 days (range 2 to 16). At a mean 38 months follow-up, no complications related to the laparoscopic-endoscopic procedure were observed. CONCLUSION: The intraoperative combined laparoscopic-endoscopic approach seems to be a feasible and effective management of cholecysto-choledocholithiasis, saving patients a subsequent invasive procedure.

[Acute biliary pancreatitis. Role of laparoscopy after 30 years of traditional surgery experience]. / Pancreatite acuta biliare. Ruolo della laparoscopia dopo un'esperienza di chirurgia tradizionale di oltre trenta anni.

The authors herein show their own experience in the treatment of acute biliary pancreatitis. Aim of this study is to evaluate the effectiveness and the safety of the "early" laparoscopic approach to the mild to moderate acute biliary pancreatitis. The authors studied sixty cases of laparoscopic cholecystectomy with intraoperative colangiography for acute biliary pancreatitis (M/F 1:1.2; mean age 59.6 yrs, range 29.79). The patients were divided in two groups on the basis of the severity of the pancreatitis, defined through Ranson's score and Balthazar classification. The mortality rate was nil. Intraoperative morbidity rate was 6.6% in the group I (3/45), and 13.3% in the group II (2/15). Postoperative morbidity rate was 6.7% (3/45) in the group I and 40% in the group II (6/15). The authors show an original diagnostic and therapeutic algorithm for the treatment of acute biliary pancreatitis. Early laparoscopic cholecystectomy with I.O.C. is proposed as the gold standard treatment for mild to moderate acute biliary pancreatitis. This approach appears to be effective and safe in their experience. In case of severe acute biliary pancreatitis, further investigations are mandatory to evaluate the role of laparoscopic approach.

Esophageal metastasis from clear cell carcinoma of the kidney.

Esophageal metastasis from distant primary malignancies is an uncommon occurrence. The first case of a clear cell carcinoma of the kidney metastatic to the esophagus 5 yr after nephrectomy is reported.

Laparoscopic resection of solitary gastric schwannoma.

We report a case of successful laparoscopic resection of a solitary schwannoma of the gastric fundus performed on emergency. The patient was a 52-year-old man who presented with an upper gastrointestinal hemorrhage. At admission, the endoscopy and hydro-CT scan showed a submucosal tumor, 2.5 cm in maximum diameter, with an area of central ulceration arising from the anterior wall of the gastric fundus. A wedge laparoscopic resection of the gastric wall was performed under endoscopic guidance. The defect in the anterior wall was repaired in part by linear stapler and in part using a continuous suture. The postoperative recovery was uneventful and the patient was discharged on the 4th postoperative day. Laparoscopic approach represents a safe and efficient approach for the treatment of benign tumors of the stomach, also on emergency basis.

Giant leiomyoma of the oesophagus and cardia. Diagnostic and therapeutic considerations: case report and literature review.

A case of giant leiomyoma of the oesophagus and cardia is presented. Magnetic resonance imaging was particularly useful for assessing the relationship of the tumour to the neighbouring structures. Radical resection was performed by partial oesophagogastrectomy with intrathoracic oesophagogastrostomy. Giant oesophageal leiomyomas present a diagnostic and therapeutic challenge because of their size and the possibility of malignant behaviour.

Predictive value of early postoperative esophagoscopy for occurrence of benign stenosis after cervical esophagogastrostomy.

BACKGROUND AND STUDY AIMS: Benign anastomotic stenosis (BAS) represents a frequent complication following esophagectomy and cervical esophagogastrostomy for cancer. This study was undertaken to evaluate through early postoperative esophagoscopy the morphologic change of the anastomosis which could be related to BAS development. PATIENTS AND METHODS: Thirty-nine patients who underwent subtotal esophagectomy and cervical esophagogastrostomy were prospectively evaluated. The analyzed factors were: age; sex; the anastomotic size; the presence and number of endoscopically visible stitches; the presence and percentage of mucosal ulcerations involving the anastomotic suture line; the presence of anastomotic leak or dehiscence; the vascularization of the gastric tube; the patency of pylorus. RESULTS: No complications related to the early esophagoscopy were observed. Twelve patients (30.7 %) developed a stenosis postoperatively. The univariate analysis demonstrated anastomotic leak (p < 0.006), more than one endoscopically visible stitch (p < 0.0003), and mucosal ulceration involving more than 50% of the anastomosis (p<0.00009) as factors significantly correlated with BAS development. However stepwise logistic regression extracted the presence of ulcerations involving more than 50% of the anastomosis as the most important independent factor in predicting BAS development (Odds Ratio = 9.03+/-5.5, p = 0.009). All patients who developed a BAS were treated with early pneumatic dilatations, with an 83.3% success rate after a mean of 3.6 sessions. CONCLUSIONS: Early postoperative esophagoscopy seems a safe and effective tool for the monitoring of the anastomosis healing after cervical esophagogastrostomy. The presence of extended mucosal ulcerations appeared as the most important factor in predicting BAS formation.

Conservative approach to granular cell tumour of the oesophagus. Three case reports.

Granular cell tumour is an uncommon and generally benign lesion. In oesophageal location it is often asymptomatic and incidentally diagnosed at endoscopy. Three cases of granular cell oesophageal tumour are reported, with multiple location in one. In two cases the tumour was removed endoscopically by multiple biopsies.

[Esophageal manometry and pH-monitoring for surgical indications]. / La manometria e la pH-metria esofagea nell'indicazione chirurgica.

The Authors report a review of the data gathered by manometry and pH-metry in the functional esophageal diseases. Manometric and pH-metric patterns of gastro-esophageal reflux, Barrett esophagus, diverticula, achalasia, aspecific motility disorders and non-cardiac chest pain, are analyzed. Data conditioning the choice of surgical treatment in the literature and in the authors' experience are reported in detail.

[Partial splenectomy using a stapler and the role of regeneration of the residual splenic stump]. / Splenectomie parziali con stapler e ruolo della rigenerazione del moncone splenico residuo.

Current evidence indicates that only complete or partial intact spleen can protect the organism against pneumococcal sepsis. What is not clear is the amount of minimal splenic tissue needed to protect the organism against such infection. This study has been carried out on 20 dogs which underwent partial or total splenectomy with stapler. Animals were divided into 8 groups according to the quantity of the remnant splenic tissue: 0% (4 dogs); 5% (4); 15% (1); 25% (1); 35% (2); 50% (2); 75% (2); 100% (4), and were followed up for 6 and 12 months. No mortality or bleeding was registered. Results showed a splenic regeneration, histologically demonstrated as an increased number of germinal follicles, in 12 out of 16 dogs, more evident in the animals sacrificed at one year. In conclusion, even a small amount (5%) of splenic tissue preserved with its blood supply can regenerate and acquire with time enough immunological function to protect the organism against post-splenectomy sepsis.

The original Bassini technique in the surgical treatment of inguinal hernia.

Bassini's technique represents a fundamental step in the treatment of inguinal hernia. It can be asserted that a new era in its surgical therapy started with Bassini. As many difficulties exist in comprehending the archaic language used a century ago by the Italian surgeon, the principles of his technique are analysed. It is to Bassini's credit that he invented a simple and easily performed technique to be applied in each case, respecting all the anatomic structures without using any foreign material. Accordingly, it is believed that by using this technique correctly, good results can still be obtained today.

Surgical treatment of parotid gland tumors.

Fifty patients (27 females, 23 males) operated on for parotid neoplasms are reported. Eleven patients (22%) had benign tumors, 31 (62%) mixed tumors and 8 (16%) malignant tumors. Among patients with benign neoplasms, 10 (90,9%) were treated by enucleation (En.) and 1 (9,1%) by superficial parotidectomy (S.P.). Twenty-five patients (80,6%) with mixed neoplasms were operated on by total conservative parotidectomy (T.C.P.), 3 (9,7%) by S.P. and 3 (9,7%) by En. Three cases (37,5%) of malignant neoplasms were treated by T.C.P., and 5 (62,5%) by total demolitive parotidectomy (T.D.P.), associated to lateral lymphadenectomy in 3 patients. On the basis of a follow-up concerning 41 patients and of data from the literature, the authors report their present surgical approach for mixed tumors, underlining their preference for T.C.P., and limiting S.P. only to some selected cases.

Intracolonic by-pass: a new technique to prevent anastomotic complications in colon and rectal surgery.

A new technique, the "intracolonic bypass" designed to prevent anastomotic complications after colonic and rectal resections is reported. It consists of a latex tube fixed to the intestinal wall above the anastomosis, which prevents the fecal stream from reaching the anastomotic site. The tube is retained until complete healing of the anastomosis and then excreted spontaneously through the anus. This new and simple technique avoids the disadvantages of a temporary diverting ileostomy or colostomy.

Follow-up results of a new colomyotomy in the treatment of diverticulosis.

In the present study, we report upon the preliminary results of our technique of myotomy--combined colon-myotomy at L shaped or transversal T shaped--which includes a simultaneous incision of both longitudinal and circular muscle fibers, avoiding a large bloody area. Ten patients have been operated upon by this method, the results of follow-up examination of seven patients who were given roentgenologic and motility studies for a maximum of 24 months being reported upon. It appears that the technique is quite safe, with no mortality or morbidity being observed in the first ten patients operated upon. Even functional results are most satisfactory. On the basis of this preliminary study, the technique seems to offer better results than do other types of colomyotomies currently being used.