Retrieval of the gastric specimen following laparoscopic sleeve gastrectomy. Experience on 275 cases.

Severe obesity leads to a high incidence of complications and a decrease in life expectancy, especially among younger adults. Laparoscopic sleeve gastrectomy (LSG) first intended as the first step of biliopancreatic diversion with duodenal switch is gaining a per-se procedure role because of its effectiveness on weight loss and comorbidity resolution. Different techniques have been described for specimen extraction in LSG. In this article we report the technique adopted in 275 LSGs performed in our department. In the first 120 LSGs performed from 2007, the specimen was extracted through a mini laparotomy. In the following 155 cases the technique has been simplified: the grasped specimen has been withdrawn through the 15 mm trocar site. We registered in the fist group six cases of wound infection (5%), ten cases of hematoma (8.3%) and four cases of port site hernia (3.3%). In the second group only one case of hematoma (0.6%, p = 0.01) but no cases of wound infection (p = 0.01) or port site hernia, (p = 0.03) although we registered a specimen perforation during retrieval in 16 patients, were reported. The technique described in the 155 cases of the control group has shown to be more effective than the technique we used in the case group, allowing significantly lower operative time (112.9 ± 1.0 vs 74.9 ± 9.1 p < 0.001) and complications, and providing unchanged costs.

Complications during colonoscopy: prevention, diagnosis, and management.

Colonoscopy is largely performed in daily clinical practice for both diagnostic and therapeutic purposes. Although infrequent, different complications may occur during the examination, mostly related to the operative procedures. These complications range from asymptomatic and self-limiting to serious, requiring a prompt medical, endoscopic or surgical intervention. In this review, the complications that may occur during colonoscopy are discussed, with a particular focus on prevention, diagnosis, and therapeutic approaches.

A decade of bariatric surgery. What have we learned? Outcome in 520 patients from a single institution.

BACKGROUND: Today a variety of bariatric surgical procedures is available and, currently, it is difficult to identify the most effective option based on patient characteristics and comorbidities. Aim of this retrospective study is to evaluate the efficacy of four different techniques; Intragastric Balloon (IB), Laparoscopic Adjustable Gastric Banding (LAGB), Laparoscopic Sleeve Gastrectomy (LSG) and Laparoscopic Mini Gastric Bypass (LMGB), performed in our unit along ten years. PATIENTS AND METHODS: Starting from January 2005, 520 patients, 206 men (39.6%) and 314 women (60.4%) were treated at our institution. Among patients candidate to bariatric surgery 145 underwent IB, 120 underwent LAGB, 175 underwent LSG and 80 underwent LMGB. Follow up rate was 93.1% for IB at 6 months; 74.1% and 48% for LAGB at 36 and 60 months respectively; 72.8% and 58.1% for LSG at 36 and 60 months respectively; and 84.2% for LMGB at 36 months. RESULTS: The period 2005-2014 has been considered. Mortality was 1/520 patients (0.19%). The excess weight loss rate (EWL%) has been 32.8 for IB at six months, 53.7 for LAGB and 68.1 for LSG, at 60 months respectively and 79.5 for LMGB at 36 months. Early major postoperative complications requiring surgery were 0.6% for IB and 1.1% for LSG whereas late major postoperative complications were 1.2% for IB, 4.1% for LAGB and 0.5% for LSG. Diabetes resolution rate was 0 for LAGB, 76.9% for LSG and 80% for LMGB at 36 months. CONCLUSIONS: If more invasive procedures as LSG or LMGB may entail higher operative and peroperative risks, conversely, in skilled hands their efficacy remains undisputed, especially in the long term, presenting a very low rate of major complications. In general, the efficacy of a bariatric surgery unit seems improved by the capability to offer both different primary procedures and re-do surgery.

Multiple lymphomatous polyposis with diffuse involvement of the gastrointestinal tract. Case report.

The gastrointestinal tract is the predominant site of extranodal non-Hodgkin lymphomas. Multiple lynphomatous polyposis is a type of appearance of mantle cell lymphoma. It is characterized by multiple polypoid lesions involving long gastrointestinal tracts and it accounts for only approximately 1-2% of non-Hodgkin lymphomas. A 78 years old patient was admitted to our Department of General Surgery with rectal bleeding, abdominal pain and weight loss. Multiple lymphomatous polyposis was detected by endoscopy. Endoscopic biopsies confirmed the diagnosis of mantle cell lymphoma. The patient was transferred to the Department of Hematology for cycles of chemotherapy.

Biliary duct injuries in the laparoscopic era: our experience.

AIM: The main aim of our study is to evaluate the incidence, the type, the causes and the therapy of biliary duct injuries which occurred after the video laparoscopic cholecystectomies performed in our Department during the period from 1990 to 2012. PATIENTS AND METHODS: A retrospective analysis of 1186 VLC has been made in our Department from March 1990 to June 2012. Before the cholecystectomy all patient were evaluated with trans abdominal echography. Beyond the incidence of BDI was evaluated damaging mechanism, etiology, therapy and time of diagnosis. RESULTS: From 1990 to 2012 a total of 9 BDIs occurred, with an incidence of 0,75%. Out of 9 patients 4 had major lesions and 5 had minor lesions; the most common BDI was Strasberg A (45%), the most common etiology was the presence of anatomical variations. In four cases the diagnosis has been intraoperative, in five cases has been postoperative. CONCLUSIONS: Our clinical experience shows that the main cause of BDI are the surgeon experience and the bile ducts anatomical variation.

Comparison between tungsten and steel polypectomy snares: evaluation of depth of colonic thermal wall injury in a pig model.

BACKGROUND AND STUDY AIMS: Thermal injury of the colonic wall during polypectomy may induce complications such as bleeding and perforation. To date, the role of the snare material in these injuries has not been examined. The aim of this study was to evaluate the depth of colonic post-polypectomy thermal wall injury induced by tungsten and steel endoscopic snares, in an effort to reduce electrosurgery-related complications. MATERIALS AND METHODS: This was a single tertiary center experimental study in a porcine model. A total of 90 polypectomies where performed in three live pigs under general anesthesia, using both steel and tungsten snares by cut, coagulation, and blend current modes. The pigs were then euthanized and their colons examined histologically. RESULTS: Steel snares induced significantly deeper tissue injury than tungsten snares in the pure cut mode (Pearson χ2 = 6.136, P = 0.013). The ordinal logistic regression analysis showed that the current mode and snare material were significantly associated with the ordinal score for the depth of injury. Thus, cut mode was positively associated with a lower score and coagulation mode with a higher score. In addition, tungsten was significantly associated with a lower depth of tissue injury. CONCLUSIONS: Due to its inherent electrical properties, tungsten is very well suited for manufacture into electrosurgical endoscopic devices. Thus, tungsten snares may be advantageous for routine use in endoscopic polypectomy, although further studies are needed to confirm these promising findings in human patients.

Technical aspects in endoscopic biopsy of lesions in esophageal pemphigus vulgaris.

BACKGROUND AND AIMS: Aim of this study is to compare a specific kind of biopsy forceps to a traditional one in providing an adequate specimen of esophageal pemphigus vulgaris lesions that includes the basement membrane for definitive diagnosis. PATIENTS AND METHODS: Prospective, randomized, blind, single-center study. We performed upper endoscopy with biopsy in 32 patients divided into two groups of 16 each: in group A with a commercially available standard biopsy forceps while in group B with a commercially available rocking biopsy forceps. Hundred-ninety-six biopsy specimens from both groups were blindly evaluated by the same pathologist. RESULTS: In group A 18.8% of biopsy specimens were adequate (basement membrane included). In group B 87.5% of biopsy specimens were adequate. The presence of the entire thickness of the mucosa was significantly higher in group B compared to group A. All parameters typically taken into account by pathologist for diagnosis of esophageal pemphigus vulgaris were significantly improved in group B. CONCLUSIONS: The biopsy forceps used in group B permits a rocking motion of the tip on contact with the mucosa, produces a deeper full-thickness mucosal sample up to the basement membrane and assists in the evaluation of histologic features of esophageal pemphigus vulgaris.

Proximal stomach function in obesity with normal or abnormal oesophageal acid exposure.

There is an increased prevalence of gastro-oesophageal reflux and symptoms in obese patients. Information about the proximal stomach in obese patients with reflux is lacking. Gastric volume and compliance are similar between obese and lean subjects. To study the proximal stomach function and perception in obese patients with normal or abnormal oesophageal acid exposure, thirty-one obese patients, with normal or abnormal oesophageal acid exposure, underwent medical evaluation of oesophageal and gastrointestinal symptoms by a questionnaire and measurement of proximal stomach function and perception by an electronic barostat and a standardized questionnaire. Nineteen obese patients had abnormal oesophageal acid exposure. The percentage of total time with pH <4 is significantly related to the presence of hiatal hernia, the oesophageal intensity-frequency symptom score and gender, i.e. higher percentage in men. The perception cumulative score was significantly different between patients with normal and abnormal oesophageal acid exposure after adjusting for covariates (gender, body mass index, age, minimal distending pressure, gastric tone and gastric compliance). Gastric tone and compliance were significantly related to the perception cumulative score. In conclusion, patients with abnormal oesophageal acid exposure have increased gastric perception. A significant relation among gastric tone, gastric compliance and upper gastrointestinal sensations was shown.

Laparoscopic antireflux surgery: indications, preoperative evaluation, techniques, and outcomes.

BACKGROUND/AIMS: During the past decade, the development of mini-invasive surgery has determined a resurgence in popularity of the antireflux surgery. The purpose of this study is to examine indications, preoperative evaluation, surgical techniques, and outcomes after mini-invasive surgery. METHODOLOGY: From 1996 to 2000, 25 patients with gastroesophageal reflux disease associated to hiatal hernia underwent laparoscopic surgery. The indication for surgery was failure of long-term medical therapy. All patients had severe acid reflux on 24h-pH monitoring, endoscopic evidence of esophagitis, and defective lower esophageal sphincter. Nissen fundoplication was performed in 16 patients with normal esophageal body motility, and 270 degrees posterior fundoplication in 9 patients with low esophageal motility. RESULTS: Mortality and conversion rate were 0. Mean operative time was 130 minutes and mean postoperative hospital stay 5 days. Twenty-four (96%) patients were completely cured of reflux symptoms off all medications. Transient, mild postoperative dysphagia occurred in 3 patients (12%). There was a significant improvement of the results in postoperative esophageal manometry and 24h-pH monitoring. CONCLUSIONS: Despite the fact that few patients were treated by using laparoscopic approach, results are encouraging with less morbidity and great advantages for patients. Precise selection of patients and surgical techniques are essential.

The role of upper endoscopy in identifying oesophageal involvement in patients with oral pemphigus vulgaris.

BACKGROUND AND AIMS: The involvement of oesophagus in pemphigus vulgaris is still debated. The aims of this study were to evaluate the prevalence of oesophageal involvement and the gastro-duodenal mucosa appearance before and after high-dose corticosteroid therapy in a group of patients with oral pemphigus vulgaris. METHODS: We prospectively studied 28 consecutive patients with oral pemphigus by oesophageal symptom standardised questionnaire, upper gastro-intestinal endoscopy, exfoliative cytology and histological biopsy. After clinical remission, all patients underwent new endoscopy. RESULTS: The prevalence of oesophageal symptoms was 57.1%. Endoscopic examination revealed oesophageal involvement with different degrees of severity in 67.8% of patients. After corticosteroid therapy, endoscopy showed normal oesophageal-gastro-duodenal mucosa. No examination-related exacerbations of the oesophageal lesions were seen. CONCLUSIONS: The upper gastro-intestinal endoscopic examination, in oral pemphigus vulgaris patients with oesophageal symptoms, is safe in skilled hands technique and a useful diagnostic tool prior to starting therapy.

Added value of CT colonography after a positive conventional colonoscopy: impact on treatment strategy.

BACKGROUND: Conventional colonoscopy (CC) requires an experienced operator to avoid technical or interpretative errors, and an endoscopic error rate of 14% for tumor localization has been reported. We evaluated the impact of computed tomographic colonography (CTC) on surgical treatment strategy in patients with CC reported as having colorectal neoplasm. METHODS: Fifty-three patients testing positive for colorectal neoplasm on CC underwent CTC: 32 patients had CC in our hospital (group A) and 21 had CC in area hospitals (group B). All CTC procedures were performed with a multidetector CT system. The results of CTC and CC were compared with that of surgery. The preoperative surgical planning evaluated on the basis of CC and CTC was compared with the actual surgical approach, and the percentage of patients in whom CTC modified the treatment strategy suggested by CC was calculated. RESULTS: CTC changed the treatment strategy in four of 53 patients (7.5%) in whom CC showed technical or interpretative errors. Group analysis showed that CTC did not influence the surgical management in any patient in group A but did affect treatment strategy in four of 21 patients (19%) in group B. The effect of CTC on treatment strategy between groups was statistically significant (p < 0.05). CTC identified five adenomas and three adenocarcinomas localized proximally to an impassable stenosis. CONCLUSION: CTC can be used to reevaluate the findings of a positive CC and can indicate a more correct therapeutic approach in patients with colorectal neoplasms who are candidates for surgery.

[Personal experience with the endoscopic treatment of pancreatic pseudocysts. Long-term results and analysis of prognostic factors]. / Esperienza personale nel trattamento per via endoscopica delle pseudocisti pancreatiche. Risultati a lungo termine ed analisi dei fattori prognostici.

BACKGROUND: The aim of this study was to assess the safety and utility of endoscopic treatment of pancreatic pseudocysts. Prognostic factors for the outcome of endoscopic drainage were assessed in a prospective analysis. METHODS: Forty-nine consecutive symptomatic patients were included in the study. Transmural drainage was used in 30 patients and transpapillary drainage in 19 patients. RESULTS: Successful drainage was achieved in 27/30 (90%) of patients after transmural drainage and in 16/19 (84.2%) patients after transpapillary drainage. Twelve (24.5%) patients had complications; 2 patients had bleeding, 2 had mild pancreatitis, 8 had cyst infection, in relation to the presence of necrosis (5 patients) or stent clogging (3 patients). Nine patients (20.9%) had recurrence of pseudocyst. Endoscopic drainage was a definitive treatment in 37 out of 49 (75.5%) patients (median follow-up: 25.9 months). Presence of necrosis was the only significant prognostic factor for infectious complication. CONCLUSIONS: Endoscopic drainage provides a successful and safe minimally invasive approach to the management of pancreatic pseudocysts.

Three years experience with the new intragastric balloon, and a preoperative test for success with restrictive surgery.

BACKGROUND: The BioEnterics Intragastric Balloon (BIB) is a smooth, spherical, saline-filled, silicone elastomer with a black radiopaque filling valve, intended to induce weight loss by limiting food consumption. This can be considered a "restrictive" procedure, and by using this balloon, we can assess the patient's eligibility for a restrictive surgical procedure (the BIB-Test). METHODS: From May 1997 to May 2000, 87 BIB were inserted in 77 moderately to severely obese patients (4 BIB in 1 patient, 2 BIB in 7 patients). 64 patients completed the treatment. Out of these, 18 (16 female, 2 male) underwent laparoscopic gastric banding after BIB removal. RESULTS: After the treatment (3-6 months), weight loss results were as follows: WL 14.3 kg, %EWL 23.5 and loss in BMI 5.3. 12 patients after the preliminary BIB, have been followed > or = 6 months after gastric banding, and have significant further weight loss. CONCLUSIONS: BIB appears to have good results. A supervised nutritional and behavioral regimen is mandatory. The balloon may be indicated to: 1) induce weight loss in patients whose obesity is not severe enough to warrant surgery; 2) reduce the surgical risk in those who are massively obese; 3) select patients for gastric restrictive surgery if they lose weight with the balloon. The data showed that patients who had good results with the BIB (positive BIB-Test) are still losing weight after subsequent gastric banding.

Unilateral versus bilateral endoscopic hepatic duct drainage in patients with malignant hilar biliary obstruction: results of a prospective, randomized, and controlled study.

BACKGROUND: The necessity for drainage of both liver lobes in tumors arising at the biliary bifurcation is controversial. The aim of this study was to compare the outcome of unilateral versus bilateral drainage in patients with biliary obstruction at the hilum. METHODS: One hundred fifty-seven consecutive patients with primary cholangiocarcinoma, gallbladder cancer, or periportal lymph node metastases were randomly allocated to unilateral (group A) or bilateral (group B) hepatic duct drainage. RESULTS: In intention-to treat analysis, group A had a significantly higher rate of successful endoscopic stent insertion than group B (88.6% vs. 76.9%, p = 0.041). Group B had a significantly higher rate of complications than group A (26.9% vs. 18.9%, p = 0.026) because of the higher rate of early cholangitis (16.6% vs. 8.8%, p = 0.013). In per-protocol analysis the rate of successful drainage, complications, and mortality did not differ between the two groups. Median survival did not differ between the two groups but was significantly different for patients with cholangiocarcinoma and those with gallbladder cancer versus patients with metastatic tumors (p = 0.0247). CONCLUSION: The insertion of more than one stent would not appear justified as a routine procedure in patients with biliary bifurcation tumors.

Endoscopic stenting for definitive treatment of irretrievable common bile duct calculi. A long-term follow-up study of 49 patients.

BACKGROUND/AIMS: The value of endoprostheses for long-term management of bile duct stones has not been formally established. A prospective evaluation of results and complications of the insertion of biliary endoprostheses was performed in patients with endoscopic irretrievable bile duct stones. METHODOLOGY: From January 1990 to September 1998, 49 patients (18 men and 31 women; average age 75.5 years), underwent endoscopic biliary stenting for endoscopically irretrievable bile duct stones. RESULTS: Successful biliary drainage was achieved in all patients. Early complications occurred in 12.2% of cases. Over the long-term follow-up (median follow = 39 months) late complications occurred in 40.8% of cases, with 3 cases of biliary-related death. CONCLUSIONS: For immediate bile duct drainage, endoprostheses proved a safe and effective alternative for treatment of patients with endoscopically irretrievable bile duct stones. Because of the risk of subsequent complications, its use as a definitive treatment should be confirmed to highly selected cases.

Secondary aortoduodenal fistula. Rare endoscopic finding in the course of digestive hemorrhage.

Secondary aortoduodenal fistula is a rare and life-threatening long-term complication of abdominal aortic surgery. Pathogenesis is often not clear; both mechanical trauma and septic procedures are involved as principal factors. The interval between first intervention and development of the fistula can vary from months to years. The presentation is often subtle with a herald bleeding followed by a period of grace, followed or not by an exsanguinating hemorrhage. The right diagnosis of aortoduodenal fistula hemorrhage can be difficult. We emphasize the need to have an early and correct diagnosis in one with differential diagnosis of patients with gastrointestinal bleeding after previous abdominal aortic replacement surgery. The esophagogastroduodenoscopy (until the Treitz) is the main diagnostic procedure, able to demonstrate the fistula and rule out other possible causes of bleeding.

[Results of the use of endoprostheses in the treatment of retained common bile duct stones]. / Risultati dell'utilizzo di protesi per via endoscopica nel trattamento della litiasi difficile della via biliare principale.

BACKGROUND: The value of endoprostheses for long term management of bile duct stones has not been formally established. A retrospective evaluation of results and complications of the insertion of biliary endoprostheses was performed in patients with endoscopic irretrievable bile duct stones. METHODS: From January 1990 to September 1999, 52 patients (19 men and 33 women; average age 76 years), underwent endoscopic biliary stenting for endoscopically irretrievable bile duct stones. RESULTS: Successful biliary drainage was achieved in 50/52 (96.1%) patients. Early complications occurred in 11.5% of cases. Over the long term follow-up (average follow-up = 39.5 months) late complications occurred in 40.8% of cases, with 3 cases of biliary-related death. CONCLUSIONS: For immediate bile duct drainage, endoprostheses proved a safe and effective alternative for treatment of patients with endoscopically irretrievable bile duct stones. Because of the risk of subsequent complications, its use as a definitive treatment should be confirmed to highly selected cases.

[The palliation of dysphagia secondary to esophageal-cardial carcinoma with self-expandable metal prostheses. The authors' personal experience with 92 patients]. / La palliazione della disfagia secondaria a carcinoma esofago-cardiale con protesi metalliche autoespandibili. Esperienza personale su 92 pazienti.

BACKGROUND: Endoscopic insertion of a stent is an important option in the palliative management of esophageal obstruction and esophagorespiratory fistula. Plastic stents have been available for over 20 years. A new class of self-expanding metal stents for palliation of esophageal and cardial cancer is now available. METHODS: Between September 1992 and October 1997, 92 patients underwent implantation of self-expanding metal stents for palliation of dysphagia due to inoperable esophageal or cardial cancer (65 patients) or for locally recurrent carcinoma after surgery (12 patients), laser-therapy (11 patients) or radiotherapy (4 patients). RESULTS: Successful stent implantation was achieved in 89/92 patients (96.7%). After stent implantation the dysphagia score improved from 3.0, on average, to 0.5, on average. Early complications were observed in 4.5% and peroperative mortality was 2.1%. Late complications were observed in 25.6%, with a mortality rate of 1.1%. The mean survival time was 6.9 months. CONCLUSIONS: Self-expanding metal stents are a new effective alternative for palliation of dysphagia due to esophageal and cardial cancers.