Daniele Bernardi

Giant leiomyoma of the gastroesophageal junction: technique and results of endoscopic full-thickness resection.

Four consecutive patients with a giant leiomyoma originating from the posterior aspect of the gastroesophageal junction were treated with full-thickness endoscopic retroflex dissection. A complete removal of the lesion was obtained in all cases. No complications were observed except for some degree of air filtration causing symptomatic pneumoperitoneum in one patient. Retroflex endoscopic full-thickness resection of giant leiomyoma at the gastroesophageal junction is feasible and safe.

Atypical presentation and transabdominal treatment of chylothorax complicating esophagectomy for cancer

Chylotorax is a relatively uncommon and difficult to treat complication after esophagectomy for cancer. We report a case of a young adult male who underwent neoadjuvant chemoradiationtherapy followed by Ivor-Lewis esophagectomy for a squamous-cell carcinoma of the distal esophagus. During the postoperative course the patient presented recurrent episodes of hemodynamic instability mimicking cardiac tamponade, secondary to compression of the left pulmonary vein and the left atrium by a mediastinal chylocele. Mediastinal drainage and ligation of the cisterna chyli and the thoracic duct was successfully performed through a transhiatal approach.

Hybrid and total minimally invasive esophagectomy: how I do it

Esophagectomy is a major surgical procedure associated with a significant risk of morbidity and mortality. Minimally invasive esophagectomy is becoming the preferred approach because of the potential to limit surgical trauma, reduce respiratory complications, and promote earlier functional recovery. Various hybrid and total minimally invasive surgical techniques have been introduced in clinical practice over the past 20 years, and minimally invasive esophagectomy has been shown equivalent to open surgery concerning the short-term outcomes. Implementation of a minimally invasive esophagectomy program is technically demanding and requires a significant learning curve and the infrastructure of a dedicated multidisciplinary center where optimal staging, individualized therapy, and perioperative care can be provided to the patient. Both hybrid and total minimally invasive techniques of esophagectomy have proven safe and effective in expert centers. The choice of the surgical approach should be driven by preoperative staging, tumor site and histology, comorbidity, patients anatomy and physiological status, and surgeons experience.

Trans-Gastric ERCP After Roux-en-Y Gastric Bypass: Systematic Review and Meta-Analysis

BackgroundTrans-oral endoscopic access to the pancreaticobiliary system is challenging after Roux-en-Y gastric bypass (RYGB). Trans-gastric ERCP (TG-ERCP) has emerged as a viable option to manage patients with symptomatic post-RYBG choledocolithiasis. The aim of this systematic review and meta-analysis was to examine the outcomes of TG-ERCP to better define the risk-benefit ratio of this procedure and to guide clinical decision-making.MethodsA literature search was conducted to identify all reports on ERCP after RYGB. Pubmed, MEDLINE, Embase, and Cochrane databases were thoroughly consulted matching the terms “ERCP” AND “gastric bypass.” Pooled prevalence of ERCP success rate, ERCP-related morbidity, post-procedural infectious complications, and overall morbidity were calculated using Freeman-Tukey double arcsine transformation and DerSimonian-Laird estimator in random effect meta-analysis. Heterogeneity among studies was evaluated using I2-index and Cochrane Q test. Meta-regression was used to address the effect of potential confounders.ResultsThirteen papers published between 2009 and 2017 matched the inclusion criteria. Eight hundred fifty patients undergoing 931 procedures were included. The most common clinical indications for TG-ERCP were biliary (90%) and pancreatic (10%). The majority of patients underwent an initial laparoscopic approach (90%). Same-day ERCP was successfully achieved in 703 cases (75.5%). Pooled prevalence of ERCP success rate, ERCP-related morbidity, post-procedural infectious complications, and overall morbidity were 99% (95% CI = 98–100%), 3.1% (95% CI = 1.0–5.8%), 3.4% (95% CI = 1.7–5.5%), and 14.2% (95% CI = 8.5–20.8%), respectively.ConclusionTG-ERCP is a safe and effective therapeutic option in patients with symptomatic post-RYGB choledocolithiasis.

Adult ileocolic intussusception caused by Burkitt lymphoma

Ileocolic intussusception due to Burkitt lymphoma is extremely rare in adults. A man aged 17 years presented with a history of recurrent abdominal pain over the past 3 weeks. The abdomen was distended with diffuse tenderness, and bowel sounds were present. Abdominal ultrasound and CT scans showed evidence of small bowel obstruction with marked wall thickening in the ileocecal region and ‘target’ signs suggestive for intussusception. At laparoscopy, a mass involving the caecum and the terminal ileum was found, along with multiple locoregional nodes, which was highly suggestive of malignancy. A typical en bloc right colectomy with intracorporeal ileocolic anastomosis was performed. Histopathological examination showed a high-grade B-cell Burkitt lymphoma that was confirmed by immunohistochemistry. The patient was subsequently treated with adjuvant combination chemotherapy and is alive and disease-free at the 3-year follow-up.

Minimally invasive esophagectomy for Barrett’s adenocarcinoma

Minimally invasive esophagectomy has become the preferred approach for invasive Barretts adenocarcinoma because it can speed recovery and enhance patients quality of life. Multiple minimally invasive surgical techniques have been described during the last two decades. Preoperative staging, anatomy and physiological patients status, comorbidity, and experience of the surgical team should drive the choice of the surgical approach. The trans-thoracic Ivor Lewis esophagectomy, either hybrid or totally minimal invasive, remains the preferred approach in these patients. Lymph node yield and short-term clinical outcomes have proven similar to open surgery, while quality of life appears improved. To establish a minimally invasive esophagectomy program, a steep learning curve and a multidisciplinary approach are required in order to provide optimal staging, personalized therapy, and adequate perioperative care. The role of minimally invasive surgery in the treatment of invasive Barretts adenocarcinoma will continue to expand in synergy with enhanced recovery after surgery pathways.