C. Caparello

A pneumatic dilation strategy in achalasia: prospective outcome and effects on oesophageal motor function in the long term

Aliment Pharmacol Theru200231, 658–665

Subcardial 24-h Wireless pH Monitoring in Gastroesophageal Reflux Disease Patients With and Without Hiatal Hernia Compared With Healthy Subjects

OBJECTIVES:After meals, highly acidic gastric juice is present in the subcardial region, the so-called acid pocket. Patients with gastroesophageal reflux disease (GERD) have a higher frequency of acidic reflux. Our aim was to investigate the possible differences in subcardial pH in GERD over 24u2009h and the role of hiatal hernia (HH), using a wireless capsule.METHODS:A total of 14 healthy volunteers (4 men, 24–60 years), 10 GERD patients without HH (4 men, 25–68 years), and 11 GERD patients with HH ≥3u2009cm (2 men, 46–74 years) underwent 24-h wireless pH monitoring 2u2009cm below the squamocolumnar junction. All patients had increased 24-h acid reflux. A standardized lunch was given to all study subjects.RESULTS:No capsule detached during the 24-h recording. Median 24-h pH was similar in healthy subjects, and in patients without and with HH, median: 1.4 (interquartile range: 1.2u2009–1.9), 1.5 (1.3u2009–1.7), and 1.4 (1.3u2009–1.7), respectively. Similar results were seen in the supine period. Median pH after the standardized meal was often highly acidic, 2.7 (1.5u2009–u20093.2), 1.9 (1.6u2009–u20092.3), and 2.5 (1.6u2009–u20093.2), respectively. The first minute with a median pH <2 occurred 14u2009min (4u2009–u200949), 14u2009min (6u2009–u200925), and 20u2009min (4u2009–u200943), respectively, P=NS, after the end of the meal. Similar data were observed on pooling all meals together.CONCLUSIONS:Subcardial pH is confirmed to be highly acidic early after meals, but it is similar over 24u2009h in healthy subjects and GERD patients independent of the presence of HH.

Computer simulator among experts involved in screening colonoscopy

Background In the era of screening colonoscopy, assessment of operator competence is warranted. Aim To evaluate feasibility of a computer simulator (CS) use for assessment of competence in colonoscopy by investigating performance of expert endoscopists at CS. Subjects Twenty expert endoscopists involved in screening colonoscopy. Methods Experts returned a questionnaire regarding personal practice (duration of activity, number of colonoscopies in the last year and assistance by a nurse) and performances (percentage of caecal intubation and polyp detection rate). One easy and one difficult colonoscopy were proposed at CS in randomized order. Results Participation rate was 75%. Caecal intubation rate in clinical practice was more than 90% for all experts. At CS, time to caecal intubation and number of attempts for ileal intubation were significantly lower during easy versus difficult colonoscopy (P<0.01 for both items); interestingly, percentage of mucosa explored was higher (P<0.05) during the difficult simulation. Withdrawal time ≥6u2009min was achieved by 40 and 33% of experts during the easy and difficult simulation, respectively. Independent of simulation difficulty, time with loop was lower (P<0.05) for experts using hands-free insertion (nu2009=u20098) compared with those using nurse assistance in their clinical practice (nu2009=u20097). No correlation was found between scores at CS and performance in clinical practice. Conclusion Scores at CS are sensitive to the rate of technical difficulty and nurse assistance during daily practice. Withdrawal time is often shorter than required for high accuracy in polyp detection. CS could be a well-accepted tool for assessment of competence.

Traditional vs wireless intragastric pH monitoring: are the two techniques comparable?

Backgroundu2002 Few data are available comparing intragastric pH measured with the traditional catheter‐based and the more recent wireless system (Bravo), and also comparing intraesophageal and intragastric pH during reflux events. Aims of our study were to elucidate these points.

Role of Symptoms, Trend of Liver Tests, and Endotherapy in Management of Post-Cholecystectomy Biliary Leak

AimBiliary leaks are widely reported complications of cholecystectomy, but standard management remains undecided. The objective of our study was to report the role of symptoms, biochemical tests, and ERCP in patients with a leak.Materials and MethodsTwenty-one patients (8xa0M, 26–77xa0years) with suspected post-cholecystectomy biliary leak were retrospectively studied. Symptoms and liver tests (LTs) after surgery were monitored. Trends of LTs were considered positive if increases at >48xa0h were seen. ERCP was performed in all patients. Findings at endoscopy and treatments were reported. Outcome results were obtained for all patients.ResultsSeventeen of 21 patients had persistent biliary leak at ERCP, because of direct injury (nxa0=xa010), accessory duct (nxa0=xa04), or cystic duct stump (nxa0=xa03). Eleven of 17 patients (six without symptoms), had distal obstruction because of surgical injury (nxa0=xa08), stone (nxa0=xa02), or cholangiocarcinoma (nxa0=xa01) and underwent stenting (nxa0=xa04), naso-biliary drainage, NBD (nxa0=xa03), or surgery (nxa0=xa04). Among the six patients without obstruction (four without symptoms), stenting was performed in two and NBD in four. The four patients without apparent leak underwent NBD. Impairment of LTs was present in ten out of eleven (91%) patients with obstruction versus six of ten (60%) without obstruction. No complications occurred after ERCP. During a median follow-up of 33 months (cholangiocarcinoma excluded) all but one remained asymptomatic.ConclusionsSymptoms and trend of LTs were not predictive of biliary obstruction in patients with a leak after cholecystectomy. Both endotherapy and surgery had favorable outcomes.

Double balloon extraction in choledocholitiasis

We present here the case of multiple biliary stones in a very large (max 30-mm wide) CBD. After an extended biliary sphincterotomy, removal of two 15-mm stones was performed with a balloon catheter (Fig. 1). A few weeks later symptomatic residual stones were seen at abdominal ultrasound. A new attempt at clearing the CBD with an 18-mm balloon (maximal diameter commercialized in Italy at the time of the procedure) and baskets was unsuccessful. In such a condition it could be helpful to use two balloon catheters together, but it is not possible to insert them into the therapeutic channel of the duodenoscope. We have overcome this limitation with a new and simple technique that uses two large diameter balloons side-by-side. We have fixed the tip of a stiff 0.035-inch guidewire externally to the duodenoscope with a polipectomy snare previously inserted into the therapeutic channel of the scope by closing the snare around it (Fig. 2). We have inserted the scope and the guidewire close to it and cannulated the sphincterotomized papilla with the snare, which was placed into the CBD below the hilum together with the guidewire. A 15-mm balloon catheter was inserted over the guidewire to the hilum. The snare was opened and removed leaving the guidewire free into the CBD. A second 15-mm balloon catheter was inserted into the therapeutic channel over a second guidewire previously impacted Fig. 1