Cristiano Giardiello

Single-step treatment of gallbladder and bile duct stones: A combined endoscopic-laparoscopic technique☆☆☆

BACKGROUND The introduction of laparoscopic cholecystectomy has given rise to a debate as to whether endoscopic retrograde cholangiopancreatography (ERCP) should be performed before or after cholecystectomy in patients with bile duct stones. METHODS This study evaluated the efficacy of treatment of cholecystocholedocholithiasis in a single step by performing ERCP during surgery in 52 patients (35 women, 17 men; mean age 57.0 years; age range 20 to 89 years). Laparoscopic intraoperative cholangiography via the cystic duct was carried out to confirm the presence of duct stones. A soft-tipped guidewire was passed through the cystic duct and papilla into the duodenum. A papillotome was inserted endoscopically over the guidewire. Endoscopic sphincterectomy was performed and the stones removed with balloon and basket catheters. RESULTS Endoscopic stone removal was successful in 94% of cases without complications related to ERCP or surgery. Although operative time was lengthened by about 20 minutes, the hospital stay was as short and equal to that for simple laparoscopic cholecystectomy (3 days on average). CONCLUSIONS The single-step combined endoscopic-laparoscopic technique is safe and effective for treatment of patients with gallbladder and bile duct stones.

Exhaled nitric oxide in severe obesity: Effect of weight loss

Exhaled nitric oxide (NO) is a recognized biomarker in the lower respiratory tract. The effect of large variation in body mass on exhaled NO in the same individuals is not well known. The aim of the study was to evaluate both the effect of severe obesity and the influence of weight reduction on exhaled NO. A consecutive series of 24 uncomplicated obese patients (OB), who had laparoscopic adjustable gastric banding (LAGB) and 15 healthy controls (HC) were studied. Body mass index (BMI), exhaled NO and respiratory function tests were assessed. Exhaled NO was lower in obese in comparison to HC (12.0+/-3.6ppb versus 15.8+/-4.0ppb, p=0.0035). A significant positive correlation was found between exhaled NO and BMI in HC, which was not evident in OB. Among the respiratory indexes, functional residual capacity was significantly associated to exhaled NO. After 1 year, 12 obese patients undergone to LAGB were re-evaluated. Mean BMI (kg/m(2)) decreased from 44.8 before surgery to 32.3 post-operatively. The exhaled NO increased from 11.8+/-3.2ppb before surgery to 14.9+/-3.1ppb 1 year post-operatively (p=0.0023, n=12). In conclusion exhaled NO is consistently reduced in severe obesity and it is restored after weight reduction. The relationship between exhaled NO, large body mass excess and decrease of resting lung volume in severe obesity deserves further studies.

Gastric Perforation in an Obese Patient with an Intragastric Balloon, following Previous Fundoplication

Background: The Bioenterics Intragastric Balloon (BIB) has been a safe and effective method used in treatment of moderate obesity. Gastric perforation is a rare complication, and its possible sequelae are dangerous. Methods: A 52-year-old women (BMI 37 kg/m2), with hiatal hernia, moderate hypertension and dyspnea, 1 year ago underwent laparoscopic fundoplication. She now underwent positioning of a BIB® filled with 500 cc of saline. After 8 days, 6 kg weight loss occurred and her clinical condition was satisfactory. On day 11, severe abdominal pain and vomiting occurred, which spontaneously regressed in the following 6-8 hours. Ultrasound confirmed the correct position of the BIB®, and showed widespread abdominal meteorism. On day 18, acute abdomen with paralytic ileus occurred. On admission, CT scan documented hydropneumoperitonitis. At operation, a large perforation of the lesser curvature was found, with undigested food in the abdomen. She underwent peritoneal lavage, removal of the BIB, and suture of the gastric laceration. Results: She was discharged in good condition after 11 days. Conclusion: According to our experience, fundoplication represents an absolute contraindication to positioning of a BIB®.

Endometriomas in the region of a scar from Cesarean section: Sonographic appearance and clinical presentation vary with the size of the lesion

To describe the sonographic (US) appearances of endometriomas developed in the vicinity of a scar from Cesarean section and compare sonographic and clinical characteristics of large (≥3 cm) scar endometriomas (LSEs) with small scar endometriomas (SSEs).

Giant mucocele of the appendix : Clinical and imaging findings in 3 cases

Objective. Clinical and imaging (sonographic and computed tomographic [CT]) findings in 3 cases of giant mucocele of the appendix are described. Methods. Clinical records of 3 cases of giant mucocele of the appendix were reviewed. All patients had a basal B‐mode sonographic examination and a contrast‐enhanced sonographic examination using a second‐generation low–mechanical index contrast medium. In all cases, a dual‐phase spiral CT examination was carried out. Results. In 2 cases, the abdominal masses were discovered in asymptomatic patients; 1 patient had vague abdominal discomfort. A pathologic diagnosis of benign cystoadenoma was found at pathologic examination in all cases, and malignant pseudomyxoma peritonei was disclosed in 1 patient 1 year later. Common sonographic findings were as follows: (1) a huge abdominal mass with a maximum diameter ranging between 20 and 25 cm; (2) a thin hyperechoic border without either solid vegetations or signs of infiltration of surrounding tissues; (3) a complex internal echo structure with anechoic lacunae interspersed between curvilinear, wavy bands of echogenic material (the so‐called sonographic onion skin sign); and (4) avascularity of the masses shown on contrast‐enhanced sonography with a low–mechanical index medium. At CT, a well‐circumscribed cysticlike mass of low attenuation was displayed in all cases. There was lack of enhancement during a dual‐phase examination in 2 cases; in the other, a small peripheral area of faint enhancement was appreciated. Only in the latter case could CT reliably assess the origin of the mass. Conclusions. It is suggested that a combination of sonographic (namely the onion skin sign) and CT findings may aid in the correct preoperative diagnosis of giant mucocele of the appendix.

Ultrasound as the imaging method of choice for monitoring the intragastric balloon in obese patients: Normal findings, pitfalls and diagnosis of complications

Background: The authors studied ultrasound (U/S) monitoring of the BioEnterics intragastric balloon (BIB) for treatment of moderate obesity by describing normal U/S aspects, diagnostic pitfalls and assessment of complications. Methods: Over the last 3 years, 151 BIB systems have been endoscopically placed and filled with 500-700 ml of saline plus 10 ml of methylene blue in 131 patients (mean age 38.4 years, range 18-72); males/females 46/85; mean BMI 43.8 kg/m2). In all patients abdominal U/S was carried out before and 12 days after endoscopy and thereafter at scheduled follow-up examinations, and/or whenever the subject complained of epigastric burning/ache, vomiting, and lack of sensation of a BIB with or without staining of urine and/or feces. Results: The BIB appeared as a round anechoic structure, with a thick hyperechoic wall and a hyperechoic band-like valve inside. Complications occurred in 18 patients: in 8, staining of urine and/or feces prompted immediate endoscopic removal. In 10 patients, U/S findings were: 1) decreased volume, loss of the spherical shape with the valve still visible (5 cases); 2) multiple hyperechoic streaks regularly spaced due to a completely collapsed BIB, not modified by decubitus changes (3 cases); 3) migration through the intestine (2 cases): in one patient the BIB was passed in the stools after 4 days, whereas in the other case large bowel obstruction required laparoscopic surgery. Conclusion: U/S affords a quick, safe and accurate method for assessing both BIB status after endoscopic deployment and the most frequently-occurring complications (partial/complete deflation, migration through the pylorus with intestinal obstruction) in obese patients.

Bleeding after stapled haemorhoidopexy using PPH 03 instrument.

Stapled haemorrhoidopexy (SH) is an effective treatment for symptomatic second-degree and third-degree haemorrhoids. Several trials have confirmed the effective symptom control of SH.1–3 SH has been carried out until 2004 using a PPH 01 (Ethicon Endosurgery, Cincinnati, OH, USA) device. In 2004, a modified device PPH 03 (Ethicon Endosurgery) was brought into the trade. Bleeding after SH is a complication, which may occur early and late (after 7–10 days); it may be major (>5Hb point loss) or minor (<5Hb point loss). The majority of authors have reported that the bleeding rate is from 1.5 to 13.3. CorreaRovelo et al. reported a rate of 4.7%3 and Gravié et al. reported a rate minor of 2%.2 Oughriss et al. reported an early bleeding rate of 1.8%.4 Sutherland et al. reported a trend toward a higher requirement for interventions for bleeding when a stapled procedure was used and a trend towards reduced risk of secondary haemorrhage requiring blood transfusion following SH.5 All these authors reported experience of SH using a PPH 01 device. 672 CORRESPONDENCE