Background
Gastro-bronchial and gastro-colic fistulas (GB-GC) represent a rare, but serious complication after laparoscopic sleeve gastrectomy (LSG). The aim of this study is to evaluate the efficacy ...of endoscopic first-line approach with endoscopic internal drainage (EID) by inserting double pigtail stents (DPS)
Methods
We retrospectively analyzed data from 40 consecutive patients referred at two tertiary centers for gastro-bronchial (
N
=30) and gastrocolic (
N
=10) fistulas following LSG. Nineteen patients previously experienced emergency surgical drainage. The mean interval between the index surgery and endoscopic fistula treatment was 265.6±521 days.
Results
Healing of the fistulous tract was achieved in 19 patients (47.5%), with complete resolution at an average follow-up of 16 months. Mean time of treatment duration was 157.8±141 days with 5.0±2.9 endoscopic sessions. No major adverse events were registered.
Conclusions
Despite complete fistula healing was achieved in less than 50% of our population, EID for GB/GC fistula after LSG still represents the most conservative approach with low complications rate. Previous surgical drainage seems to be a positive prognostic factor for endoscopic healing. While the longer the interval between the index surgery and endoscopic treatment, the lower was the rate of treatment success.
Graphical abstract
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background and Aims
Endoscopy is effective in management of bariatric surgery (BS) adverse events (AEs) but a comprehensive evaluation of long-term results is lacking. Our aim is to assess the ...effectiveness of a standardized algorithm for the treatment of BS-AE.
Patients and Methods
We retrospectively analyzed 1020 consecutive patients treated in our center from 2012 to 2020, collecting data on demographics, type of BS, complications, and endoscopic treatment. Clinical success (CS) was evaluated considering referral delay, healing time, surgery, and complications type. Logistic regression was performed to identify variables of CS.
Results
In the study period, we treated 339 fistulae (33.2%), 324 leaks (31.8%), 198 post-sleeve gastrectomy twist/stenosis (19.4%), 95 post-RYGB stenosis (9.3 %), 37 collections (3.6%), 15 LAGB migrations (1.5%), 7 weight regains (0.7%), and 2 hemorrhages (0.2%). Main endoscopic treatments were as follows: pigtail-stent positioning under endoscopic view for both leaks (CS 86.1%) and fistulas (CS 77.2%), or under EUS-guidance for collections (CS 88.2%); dilations and/or stent positioning for sleeve twist/stenosis (CS 80.6%) and bypass stenosis (CS 81.5%). After a median (IQR) follow-up of 18.5 months (4.29–38.68), complications rate was 1.9%. We found a 1% increased risk of redo-surgery every 10 days of delay to the first endoscopic treatment. Endoscopically treated patients had a more frequent regular diet compared to re-operated patients.
Conclusions
Endoscopic treatment of BS-AEs following a standardized algorithm is safe and effective. Early endoscopic treatment is associated with an increased CS rate.
Graphical abstract
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
Submucosal tumors (SMTs) of the gastrointestinal tract are a rare pathological entity comprising a wide variety of neoplastic and non-neoplastic lesions. Even if most SMTs are benign ...tumors (e.g., leiomyomas), a smaller portion may have a malignant potential (e.g., gastrointestinal stromal tumor (GIST)). Preoperative diagnosis of SMT in bariatric patients may arise challenging clinical dilemmas. Long-term surveillance may be difficult after bariatric surgery. Moreover, according to SMT location, its presence may interfere with planned surgery. Submucosal tunneling endoscopic resection (STER) has emerged as an effective approach for minimally invasive en bloc excision of SMTs. This is the first case series of STER for SMTs before bariatric surgery.
Methods
Seven female patients underwent STER for removal of SMTs before bariatric surgery. All lesions were incidentally diagnosed at preoperative endoscopy. STER procedural steps comprised mucosal incision, submucosal tunneling, lesion enucleation, and closure of mucosal defect.
Results
En bloc removal of SMT was achieved in all cases. Mean procedural time was of 45 min (SD 18.6). No adverse event occurred. Mean size of the lesions was 20.6 mm (SD 5.8). Histological diagnoses were 5 leyomiomas, 1 lipoma, and 1 low grade GIST. Bariatric procedure was performed after a mean period of 4.1 months (SD 1.6) from endoscopic resection.
Conclusion
STER is a safe and effective treatment for the management of SMT even in bariatric patients awaiting surgery. Preoperative endoscopic resection of SMTs has the advantages of reducing the need for surveillance and removing lesions that could interfere with planned surgery. STER did not altered accomplishment of bariatric procedures.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
Laparoscopic sleeve gastrectomy (LSG) is widely adopted but exposes serious complications.
Methods
A retrospective database analysis was done to study LSG staple line complications in a ...tertiary referral university center with surgical ICU experienced in treatment of morbid obesity and complications. Twenty-two consecutive patients were referred between January 2004 and February 2012 with postoperative gastric leak or stenosis after LSG. Interventions consisted in the control of intra-abdominal and general sepsis; restoration of staple line continuity or revision of LSG; nutritional support; treatment of associated complications. Main outcome measures concerned success rates of therapeutic strategies, morbidity and mortality rates, LOS, and time to cure.
Results
Thirteen patients (59 %) were referred after failure of reoperation (seven fistula repairs were attempted). Three patients received emergency surgery in our center with transorificial intubation and jejunostomy formation. An endoscopic stent was tried in nine patients but failed in 84.6 % of cases within 20 days (1–161). Seven patients (32 %) necessitated total gastrectomy within 217 days (0–1,915 days) for conservative treatment failure. Procedures under general anesthesia were required in 41 % of cases, organ failure was found in 55 % of cases, and central venous device infection in 40 %. Mortality rate was 4.5 % (
n
= 1). Patients with unfavorable evolution of LSG complications (death or additional gastrectomy) had more previous bariatric procedure (82 % vs. 18 %,
p
= 0.003). Median time to cure was 310 days (9–546 days).
Conclusions
LSG exposes severe complications occurring in patients with benign condition. Endoscopic stents entail high failure rate. Total gastrectomy is required in one third of the cases.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
The research presented was mostly carried out between 2010 and 2015 in the laboratory GERPHAU (UMR CNRS 7218 LAVUE) during the preparation of a doctoral thesis in architecture, co-led by Paris 8 ...university in France and Federico II in Italy. A study is proposed of the historical evolution
of Naples in connection with the topic of the management of different kinds of remains. The analysed period, the transition between the nineteenth and twentieth centuries, seems crucial from this point of view: an action of urban metamorphosis, both technical and ideological, was being
implemented, aiming at the transformation of the existing city into a modern metropolis, and we recognise the subject of recycling the leftovers - not only waste, used materials and organic excreta, but also abandoned buildings, vacant parcels and derelict structures - as a real issue. The
strategies analysed seem to suggest a sort of forma mentis peculiar to preindustrial Naples, based on a principle of persistence and on an enhancement of what already exists. We will thus address optimisation strategies of different urban and architectural fallouts generated
by the control of metabolic functioning and by the government of the built city and its territory. Our hypothesis is that this comparative reading will allow us to highlight the general paradigm linking men to resources, urban systems to natural environments, and stress the importance of looking
at these from a new point of view: a multidisciplinary historical perspective.
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BFBNIB, NUK, PNG, UL, UM, UPUK
Endoscopy plays a pivotal role in the management of adverse events (AE) following bariatric surgery. Leaks, fistulae, and post-operative collection after sleeve gastrectomy (SG) may occur in up to ...10% of cases.
To evaluate the efficacy and safety of endoscopic internal drainage (EID) for the management of leak, fistula, and collection following SG.
Retrospective, observational, single center study on patients referred from several bariatric surgery departments to an endoscopic referral center.
EID was used as first-line treatment for the management of leaks, fistulae, and collections. Leaks and fistulae were treated with double pigtail stent (DPS) deployment in order to guarantee internal drainage and second intention cavity obliteration. Collections were treated with endoscropic ultrasound (EUS)-guided deployment of DPS or lumen apposing metal stents.
A total of 617 patients (83.3% female; mean age, 43.1 yr) were enrolled in the study for leak (n = 300, 48.6%), fistula (n = 285, 46.2%), and collection (n = 32, 5.2%). Median follow-up was 19.5 months. Overall clinical success was 84.7% whereas 15.3% of cases required revisional surgery after EID failure. Clinical success according to type of AE was 89.5%, 78.5%, and 90% for leak, fistula, and collection, respectively. A total of 10 of 547 (1.8%) presented a recurrence during follow-up. A total of 28 (4.5%) AE related to the endoscopic treatment occurred. At univariate logistic regression predictors of failure were: fistula (OR 2.012), combined endoscopic approach (OR 2.319), need for emergency surgery (OR 1.755), and previous endoscopic treatment (OR 4.818).
Early EID for the management of leak, fistula, and post-operative collection after SG seems a safe and effective first-line approach with good long-term results.
Gastric sleeve stenosis (GSS) is described in 1%-4% of patients.
To evaluate the role of endoscopy in the management of stenosis after laparoscopic sleeve gastrectomy using a standardized approach ...according to the characteristic of stenosis.
Retrospective, observational, single-center study on patients referred from several bariatric surgery departments to an endoscopic referral center.
We enrolled 202 patients. All patients underwent endoscopy in a fluoroscopy setting, and a systematic classification of the type, site, and length of the GSS was performed. According to the characteristics of the stenosis, patients underwent pneumatic dilatation or placement of a self-expandable metal stent or a lumen-apposed metal stent. Failure of endoscopic treatment was considered an indication for redo surgery, whereas patients with partial or complete response were followed up for 2 years. In the event of a recurrence, a different endoscopic approach was used.
We found inflammatory strictures in 4.5% of patients, pure narrowing in 11%, and functional stenosis in 84.5%. Stenosis was in the upper tract of the stomach in 53 patients, whereas medium and distal stenosis was detected in 138 and 11 patients, respectively, and short stenosis in 194 patients. A total of 126 patients underwent pneumatic dilatation, 8 self-expandable metal stent placement, 64 lumen-apposed metal stent positioning, and 36 combined therapy. The overall rate of endoscopy success was 69%.
GSS should be considered to be a chronic disease, and the endoscopic approach seems to be the most successful treatment, with a prolonged positive outcome of 69%. Characteristics of the stenosis should guide the most suitable endoscopic approach.
The late Pleistocene trachytic Campanian Ignimbrite (>300 km3 DRE, ca. 39 ka) covers the Campanian Plain (Italy) around Naples. It is found behind ridges >1000 m high at 80 km from the source in the ...Campi Flegrei caldera. This points towards very dilute currents, that together with the huge amount of discharged magmatic material, suggest a magma reservoir highly enriched in volatiles. The huge volume of magma that extruded during the Campanian Ignimbrite eruption differentiated and mixed at shallow depth (6–3 km), as shown by modelling of the petrologic and geochemical features of the erupted products together with melt inclusion-based studies of gas-melt saturation. With respect to compositionally similar but lower magnitude Phlegraean eruptions (e.g., Agnano-Monte Spina, >1 km3 DRE, ca. 4.6 ka), the large amount of volatiles discharged by Campanian Ignimbrite was likely due to fractional crystallization of the lowermost portion of its magmatic reservoir. Because of the long residence time of the Campanian Ignimbrite magmatic system within the crust, an efficient decoupling took place during the upward migration of volatile elements in response to a chromatographic fractionation between H2O and CO2. This caused early pulses of nearly pure CO2 (CO2-fluxing), followed by a long-lasting H2O enrichment which yielded dissolved H2O contents up to 6–7 wt%. An overpressurized CO2-dominated gas cap was consequently produced, uniformly distributed at the top of the magma chamber. The onset of the eruption tapped this cap and generated Plinian columns, causing depressurization and fast volume decrease that facilitated, or even drove, the caldera collapse. H2O-rich magma was discharged during the following phase, characterised by pyroclastic density currents. The uniform distribution of the high values of void fraction (>70%) and the high degree of vesicle connectivity throughout the magma body testify to the huge abundance of volatiles. These percolate from the crystallizing basal layers and determine the volatile-melt fining process yielding an efficient separation between H2O and CO2. The gas saturation-based estimates of the tapped foamy magma are compatible with the extent of magma chamber roof collapse, the strong expansion revealed by textural data, and the transport and deposition mechanisms, reflecting depressurization and inflation of the volatile-rich magma within the collapsed and laterally confined caldera.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
