Surgery for lesions of the proximal part of the pancreatic body or neck can be challenging, and when enucleation is not possible, central pancreatectomy is an option. Laparoscopic central pancreatic resection is rarely described worldwide; it is considered a difficult procedure mainly because of the risk of double pancreatic fistula developing at two sites of resection. However, it seems to be an excellent alternative to distal pancreatectomy or pancreaticoduodenectomy, with the advantages of preserving functioning parenchyma and reducing endocrine and exocrine failure. Nevertheless, patients with pancreatic lesions requiring central resection are often managed with the open approach in many hospitals due to the complexity of total laparoscopic central pancreatectomy, which requires advanced laparoscopic skills, expertise and experience. Here, we report a case of a 29-year-old female who underwent total laparoscopic central pancreatic resection with gastro-pancreatic anastomosis for symptomatic serous cystadenoma. We discuss the details of case management and review the relevant literature.

A 72-year-old woman presented with a 2-month history of jaundice and abdom-inal pain. A computed tomography scan revealed a large mass in the pancreatic head with dilated bile ducts. Endoscopic ultrasound (EUS)-guided fine-needle biopsy (FNB) and endoscopic retrograde cholangiopancreatography were sched-uled for tissue acquisition and jaundice resolution.

A 66-year-old man with cerebrovascular disease underwent placement of a percutaneous endoscopic gastrostomy (PEG) using a 20-Fr dome-bolstered tube. After 1-month, the patient was admitted to our institute for investigation of infusion resistance and leakage around the tube. On physical examination, the internal bumper was not rotatable or moveable, and was subcutaneously palpable. A computed tomography scan confirmed dislocation of the peritoneal bumper ([Fig. 1 a]). Endoscopically, just a small dimple was visible in the mucosa of the anterior wall of the stomach ([Fig. 1 b]), confirming the diagnosis of complete buried bumper syndrome. The PEG was removed with gentle external traction.

A 39-year-old man underwent a distal spleno-pancreatectomy and colonic resection for a tail pancreatic cancer infiltrating the colonic splenic flexure. Five days after surgery, the patient experienced fever and abdominal pain. A computed tomography (CT) scan showed a 10-cm intra-abdominal collection with free air bubbles inside; oral contrast-medium intake revealed a passage from the colon to the abdominal collection, highly suspicious of an anastomotic leak ([Fig. 1]).

EUS-guided biliary drainage (EUS-BD) with Lumen Apposing Metal Stent (LAMS) is a mini-invasive approach for jaundice palliation in distal malignant biliary obstruction (D-MBO) not amenable to ERCP, with good efficacy and not exiguous adverse events. From January 2015 to December 2019, we retrospectively enrolled all the EUS-BD with electrocautery-enhanced LAMS for biliary decompression in unresectable D-MBO and failed ERCP. Primary study aims were to evaluate technical/clinical success and AEs rate. In case of maldeployment, we estimated the efficacy of an intra-operative rescue therapy. Secondary aims were to assess the jaundice recurrence and gastric outlet obstruction symptoms. Thirty-six EUS-BD were enrolled over a cohort of 738 patients (ERCP cannulation failure rate was 2.6%): 31 choledocho-duodenostomy and 5 cholecystogastrostomy. A pre-loaded guidewire through the LAMS was systematically used in case of common bile duct ≤ 15 mm or scope instability for a safe/preventive biliary entryway in case of intra-procedural complications. Technical success was 80.6% (29/36 patients). Seven cases of LAMS maldeployment during EUS-guided choledocho-duodenostomy were successfully treated with RT by an over-the-wire fully-covered Self-Expandable Metal Stent (FC-SEMS). The FC-SEMS was released through the novel fistula tract in endoscopic fashion in 5/7 cases and transpapillary in percutaneous-transhepatic-endoscopic rendezvous (1/7) and laparoscopic-endoscopic rendezvous (1/7) in the two remaining cases. The total efficacy of rescue therapy was 100%. Same-session duodenal SEMS was placed in 17 patients with optimal gastric outlet obstruction management. Final clinical success was 100% and no other late adverse events or FC-SEMS migration were observed. EUS-BD with LAMS is effective for jaundice palliation after ERCP failure but with considerable adverse events. Maldeployment remains a serious complication with fatal evolution if not correctly recognized/managed. Rescue therapy must be promptly applied especially in tertiary-care centers with highly skilled endoscopists, interventional radiologist and dedicated surgeon.

Gastric Outlet Obstruction (GOO) due to advanced gastro-duodenal and bilio-pancreatic cancer is frequently associated to Malignant Biliary Obstruction (MBO). In this setting, double biliary and duodenal stenting is needed. This endoscopic approach is a valid alternative to surgical by-pass.

A 56-year-old man was admitted to our hospital with severe acute necrotizing gallstone pancreatitis. Computed tomography showed a 15-cm infected walled-off pancreatic necrosis (WOPN) extending to the anterior pararenal space with free air bubbles inside. After multidisciplinary evaluation and according to septic status, endoscopic ultrasound-guided drainage was planned.

Objective: To report a case of gastric epithelioid haemangioendothelioma, given its low incidence. Introduction: Epithelioid haemangioendothelioma is a vascular neoplasm composed of epithelioid or histiocytoid cells with endothelial characteristics. They have a very low incidence of approximately one per one million and are usually asymptomatic with a difficult preoperative diagnosis. Case Report: This study reports the case of a 58-year-old woman with a history of chronic anaemia. She underwent an elective upper endoscopy with evidence of an ulcerated submucosal lesion in the gastric antrum. The histological examination performed over the endoscopic biopsies showed the vascular characteristic of the tumor and endosonography confirmed the submucosal origin of the lesion. After resective surgery, the tumor showed the histological and immunohistochemical features of the epithelioid haemangioendothelioma. Conclusion: Surgery in the form of wide excision seems to be the treatment of choice for this rare neoplasm in the absence of histological markers of malignant potential.

Mirizzi’s syndrome is a possible complication of chronic gallstone disease and surgery remains the preferred approach for treatment in symptomatic patients [1]. An endoscopic approach is usually considered only a “bridge-to-surgery” treatment for decompressing the common bile duct (CBD) by papillotomy and stent (or nasal bile drainage) placement [2]. Here we describe the potential role of holmium laser lithotripsy under direct peroral cholangioscopy in a singular case of Mirizzi’s syndrome (▶Video 1). An 82-year-old man was admitted due to abdominal pain and jaundice. Biochemistry showed high transaminases and bilirubin levels. Computed tomography was suspicious for Mirizzi’s syndrome with a large stone between the CBD and a badly recognizable gallbladder (▶Fig. 1a). Considering the patient’s severe comorbidity (chronic obstructive pulmonary disease and heart failure) and the high risks related to surgery and anesthesiology, according to the surgeon, we performed endoscopic retrograde cholangiopancreatography (ERCP). ERCP showed Mirizzi’s syndrome type III with cholecystobiliary fistula involving up to two-thirds of the CBD diameter with an impacted large stone (▶Fig. 1b). Stone extraction using both the retrieval balloon and the Dormia basket failed. We decided to use the SpyGlass System (Boston Scientific, Massachusetts, United States) to fragment the impacted stone with holmium laser lithotripsy (Storz 25750220, 365-μm-diameter fiber, 15Hz/20W). The green aiming beam allowed the stone to be targeted (▶Fig. 2a), with the laser fiber in contact with the stone until it was fragmented (▶Fig. 2b); all fragments were finally removed with the retrieval balloon (▶Fig. 2c) being able to obtain complete CBD toilette, as confirmed at cholangioscopy and cholangiography (▶Fig. 2d). VidEIO

LINKED CONTENTThis article is linked to Iannone et al paper. To view this article, visit https://doi.org/10.1111/apt.15493.

We read with great interest the paper by Mancini et al. which shows as a well organised regional faecal immunochemical test (FIT) screening programme, with many centres networked together, allowed to invite all patients with positive results to attend a complete screening colonoscopy [ [1] Mancini S Bucchi L Giuliani O Ravaioli A Vattiato R Baldacchini F et al. Proportional incidence of interval colorectal cancer in a large population-based faecal immunochemical test screening programme. Dig Liver Dis. 2020 Mar 9; ([Epub ahead of print]) Abstract Full Text Full Text PDF Scopus (4) Google Scholar ]. Unfortunately “a chain is only as strong as its weakest link” and one of the most significant problems that must be faced every day is the progressive lengthening of waiting list for a colonoscopy depending on the region of residence. In 2019 the annual report on waiting lists in Italy [ [2] www.quotidianosanita.it/allegati/allegato2112108.pdf Google Scholar ] highlighted significant differences through the country, with a mean waiting time for a colonoscopy of 33.4 days in Emilia Romagna compared to 157.9 days for the same procedure in Sicily. However, the overall mean waiting time of 111.7 days in Italy represents a disheartening picture. Obviously endoscopic centres have to meet with multiple needs for population and not only with screening colonoscopies. Countries renowned for having an efficient National Health Service (NHS) also have to face up to similar problems. Recently the NHS of England published data about diagnostic waiting times [ [3] www.england.nhs.uk/statistics/statistical-work-areas/diagnostics-waiting-times-and-activity/monthly-diagnostics-waiting-times-and-activity/monthly-diagnostics-data-2019-20/ Google Scholar ] showing a progressive increase in the number of patients waiting six weeks or more to undergo a colonoscopy. Up to now all scientific societies and their guidelines, included a recent ESGE position statement [ [4] Săftoiu A Hassan C Areia M Bhutani MS Bisschops R Bories E et al. Role of gastrointestinal endoscopy in the screening of digestive tract cancers in Europe: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement. Endoscopy. 2020 Feb 12; ([Epub ahead of print]) PubMed Google Scholar ], recommend the implementation of organized population-based screening programs for average-risk populations based on FIT, although some authors reported as the increased volume of FIT screening results in a longer waiting time [ [5] Jen HH Hsu CY Chen SL Yen AM Chiu SY Fann JC et al. Rolling-out Screening Volume Affecting Compliance Rate and Waiting Time of FIT-based Colonoscopy. J Clin Gastroenterol. 2018; 52: 821-827 Crossref PubMed Scopus (5) Google Scholar ]. Considering the obvious concerns of the patients and the long waiting lists, it is easy to understand the significant increase in the demand for private colonoscopies [ [2] www.quotidianosanita.it/allegati/allegato2112108.pdf Google Scholar ], and this is not acceptable in a country with a forefront public NHS. Therefore, making the waiting list adequate, by testing the right people at the right time, could represent the key issue for the correct management of patients needing for a colonoscopy. In this regard, we would like to report our experience about the possible “handicaps” influencing the waiting list for colonoscopies. We decided to collect data from all the consecutive outpatient colonoscopies scheduled by the local outpatient booking office within thirty days. Using an anonymous survey, we recorded data on: 1) demographic characteristics of patients; 2) clinical reasons for colonoscopy; 3) adherence to the pre-procedure advices provided by the outpatient booking office; 4) bowel cleansing score at the end of colonoscopy. All the data were reported in an electronic database for the analysis. Finally we collected data on 170 patients. Eighty-seven patients (51%) were male and the overall mean age was 58.3 ± 15.1 years; 115 patients (67%) were affected by one or more comorbidities and 90 patients (54%) had a lower-middle education level (up to middle school). Twenty-nine patients (17%) did not read the pre-procedure advices and in only 52% of patients the general practitioner (GP), who had recommended the colonoscopy, read the medical informative booklet provided to the patients. Moreover, at the time of endoscopy, 16% of patients referred symptoms different to those reported on the GP's prescription. The majority of patients (63%) took high volume bowel preparations and none of the patients chose the split-dose bowel preparation. In 62% of patients the final decision on type and regimen of bowel preparation was made without involving the GP. At the final analysis, 10% of patients did not complete the bowel preparation with an overall rate of poor (Boston Scale [BS] < 5) bowel cleansing of 26% (44 patients). Among patients with a BS ≥5 (126 patients [74%]) less than half (46% [58 out of 126]) reached a very good bowel cleansing (BS ≥7). Variables related to a low BS were: age ≥50 years (p=0.009), comorbidities (p=0.05), diabetes (p=0.02), lack of the GP's involvement (p=0.05), lower education level (p=0.04). Proportional incidence of interval colorectal cancer in a large population-based faecal immunochemical test screening programmeDigestive and Liver DiseaseVol. 52Issue 4PreviewThe European guidelines for quality assurance in colorectal cancer (CRC) screening recommend that interval cancer rate be expressed as a proportion of background incidence rate. Full-Text PDF

An 88 year-old male was admitted for fever, leukocytosis and abnormal cholestasis. Abdominal ultrasound showed dilation of biliary intra-hepatic ducts and common bile duct (CBD) with 2 cm stone inside. The patient was scheduled for ERCP.

Background: Standard suction and slow-pull techniques have been utilized during endoscopic ultrasound-guided fine needle aspiration of pancreatic solid lesions, but the correct sampling technique remains unclear. New needles designed to obtain samples suitable for histological evaluation have become available. We performed a study comparing the two sampling methods during endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) in patients with pancreatic solid lesions. Methods: We performed EUS-FNB with a 20 Gauge FNB needle using slow-pull or standard suction techniques in a prospective, randomized, multicenter study. The primary aim was bloodiness of the collected specimens. Secondary aims were technical success and performance of the two techniques. Results: 110 patients were included (55 per group). No difference in blood contamination was observed (slow-pull 80% vs. suction 74%, p = 0.917). Technical success was 95% (96% vs. 94%, p = 0315). Sensitivity (96% vs. 93%), specificity (100% vs. 100%), positive likelihood ratio (NA), negative likelihood ratio (0.04 vs. 0.07), diagnostic accuracy (96 vs. 93%) did not differ between the two groups. Conclusion: EUS-FNB with slow-pull and standard suction techniques are comparable in terms of blood contamination providing similar high diagnostic sensitivity and accuracy in pancreatic solid lesions. The use of the new generation FNB needle allows to reach such high level of diagnostic adequacy regardless of the technique utilized. (C) 2019 Published by Elsevier Ltd on behalf of Editrice Gastroenterologica Italiana S.r.l.

A 66-year-old woman was admitted because of a sensation of a foreign body in the proximal part of the esophagus after she had eaten lamb meat. The chest radiograph showed a radiopaque image in the upper esophagus (A). Endoscopy, performed with anesthesiologic assistance and after tracheal intubation to protect the airway, showed a flat bone impacted immediately below the upper esophageal sphincter (B). Each attempt to mobilize it upward was ineffective, whether by use of foreign body retrieval forceps or a snare (C). We were able to gently move the flat bone into the stomach (D) with the aim of trying to fragment the bone with a dormia basket (E). Unfortunately, the attempt failed, and we decided to split the bone using forced argon plasma coagulation (F, G). The argon plasma coagulation created a groove along the bone surface, allowing it to easily break into 2 fragments with use of the dormia basket (H, I). The cutting procedure lasted 20 minutes. Through an esophageal overtube, each fragment was safely removed with a retrieval net. Both fragments were recovered; the flat bone was 3 cm wide and 3.5 cm long (J). No adverse events were observed, and the patient was discharged a few hours later.

Two female patients, aged 71 and 70 years respectively, were admitted due to impacted foreign bodies of the common bile duct (CBD). The first one presented a fractured distal end of a Dormia basket previously used for a mechanical lithotripsy of a large stone; the second patient presented an impacted biliary plastic stent previously placed for a stricture of the CBD. All attempts to remove the foreign bodies were ineffective so we decided to use the SpyGlass System (Boston Scientific, Massachusetts, USA) as a rescue approach. The Dormia basket and the plastic stent were clearly identified as shown in Figs. 1A and 2A . In the patient with the impacted Dormia basket we first fragmented the large stone through holmium laser lithotripsy (Storz 25750220, 365-μm-diameter fiber, 15 Hz/20 W) and subsequently we moved the basket out from the CBD with the aid of a SpyBite forceps (Boston Scientific, Massachusetts, USA [Fig. 1B]). Then a successful balloon sweep of the CBD with the Fogarty balloon catheter was performed. No complications were recorded and it was not necessary to place a biliary plastic stent. In the patient with the impacted plastic stent we were able to move out the stent grasping its wall with the SpyBite forceps (Fig. 2B). After the plastic stent was removed, the suspected malignant tissue involving the CBD and the hepatic common duct was evidenced, and a biopsy sample was performed. At cholangiography there were dilated intrahepatic bile ducts, and for this reason a metallic stent was placed. The histological exam confirmed the diagnosis of cholangiocarcinoma. No complications were recorded. In conclusion choledocoscopy trough the SpyGlass System, with the aid of the SpyBite forceps, can help to remove difficult foreign bodies impacted in the CBD. Fig. 2(A) Impacted bilary plastic stent (SpyGlass and fluoroscopic view); (B) grasping of the plastic stent wall and its removal. View Large Image Figure Viewer Download Hi-res image