Enrico Arnone

Endoscopic Resection of a Large Colonic Lipoma: Case Report and Review of Literature

Colonic lipomas are uncommon, benign, submucosal adipose tumors that are usually asymptomatic. Large lipomas can cause symptoms such as constipation, abdominal pain, rectal bleeding and intussusception. We report the case of a 60-year-old man with a history of lower abdominal pain and pseudoobstructive symptoms. Colonoscopy revealed a large polypoid sessile lesion in the sigma. We used a standardized technique of polypectomy, preceded by submucosal injection of dilute 5 ml polygelin with epinephrine 1:10,000 solution, to fully resect large colonic lipomas. The lipoma size was 3.5 cm. No bleeding or perforation developed. Histology showed the polyp to be a submucosul lipoma. On follow-up, there was no residual lesion. Colonic lipomas larger than 2 cm can be safely and efficaciously removed using electrosurgical snare polypectomy technique. The technique of submucosal injection before resection and using an electrocautery snare appears to be safe and reduces the risk of perforation reported in the literature.

Surgical treatment of coledochal cyst associated with an aberrant posterior hepatic duct: report of a case and brief literature review.

Choledochal cysts (CCs) are rare congenital cystic or fusiform dilatations of the biliary tree that can involve the extrahepatic and/or intrahepatic biliary tree. We report a case of huge type I CC associated with an aberrant posterior hepatic duct. A 52-year-old man presented with a 3-week history of upper right abdominal pain and jaundice and serologic sign of obstructive jaundice. Ultrasonography (US), magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography were performed with the diagnosis of CC type I according to the classification of Alonso-Lej and Todani-Watanabe. The indication for surgical resection was posed. The cyst was completely resected and the biliary tract was reconstructed with a double hepatico-jejunostomy using the same Roux limb, since during the surgical dissection a before unrecognized anatomical variation of the right biliary tree (aberrant posterior hepatic duct at VI–VII segment) was identified. The diagnosis of CC is often difficult and US and magnetic resonance cholangiopancreatography are necessary to definite biliary dilatation. Endoscopic retrograde cholangiopancreatography should be the most definitive and reliable procedure for the diagnosis and treatment of bilio-pancreatic disorders. Gold standard treatment is surgery (bilio-jejunostomy) and frozen-section histology should be performed to rule out the presence of cancer. In conclusion, surgery is the gold standard for the treatment of CC type I and does not depend on the age of patients, based on a substantial lifetime risk of developing cholangiocarcinoma. Preoperative study is mandatory to assess the biliary tree morphology and to research any anatomical variation.

Is nasobiliary tube really safe? A case report.

A case of esophageal ulcer caused by nasobiliary tube is described. This tool is not routinely considered to be a cause of major complications in the literature and to our knowledge, this is the first report of this kind of complication in nasobiliary tube placement. A 72-year-old patient presented with Charcot’s triad and was demonstrated to have cholangitis with multiple biliary stones in the common bile duct. Biliary drainage was achieved through endoscopic retrograde cholangiography, endoscopic sphincterotomy, biliary tree drainage and nasobiliary tube with double pigtail. The patient presented odynophagia, dysphagia and retrosternal pain 12 h after the procedure and upper endoscopy revealed a long esophageal ulcer, which was treated conservatively. This report provides corroboration of evidence that nasobiliary tubeplacement has potential complications related to pressure sores. In our opinion this is a possibility to consider in informed consent forms.