INTRODUCTION:Bleeding esophageal varices is the most serious complication of the portal hypertension, and the greater cause of dead (25% of the patients). The survival after esophageal varices bleeding depends in wide part from the swiftness and effectiveness of hemostasis and from the degree of functional liver reserve. Aim of our manuscript is to report our experience about hemostasis bleeding esophageal varices with endoscopic rubber band ligation.PATIENTS AND METHODS:From January 1999 to January 2008 we performed 302 esofagogastroduodenoscopy (EGDS) for esophageal varices bleeding (M: F ratio = 1.4:1, mean age 56.4 years, 62% of cases with HCV-related cirrhosis, 29% alcoholic cirrhosis and 9% cryptogenic cirrhosis; 20% suffered from chronic renal failure, 15% diabetes mellitus, 10% hepatocellular carcinoma on cirrhosis, 5% systemic encephalopathy and 1% AIDS). RESULTS; All patients were treated within 6 hours after the first reported episode of haematemesis and all received beta-blocker therapy after the episode. In the first phase of our experience were used rechargeable elastic ligator and then multibyte, even in combination with polidocanol sclerotherapy (8%) or injection of cyanoacrylate (5%). The best results were achieved with band ligation, in terms of primitive haemostasis, rebleeding, (3%), intraoperative mortality (1%) and 6 weeks mortality (1%).CONCLUSION:To date, no single method applicable to all patients with bleeding esophageal varices, but endoscopic rubber band ligation is currently considered the first-line treatment of proper multidisciplinary approach to the patient, both during the acute event than prevention of rebleeding, because it is an effective, safe and repeatable, in experienced hands.

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 tube placement has potential complications related to pressure sores. In our opinion this is a possibility to consider in informed consent forms.

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.

Introduzione. Il sanguinamento da varici esofagee e la piu grave complicanza della ipertensione portale, e ne costituisce la maggiore causa di morte (25% dei soggetti). La sopravvivenza dopo ematemesi da rottura di varici esofagee dipende infatti in larga parte dalla rapidita e dall’efficacia dell’emostasi primaria e dal grado di riserva funzionale epatica. Riportiamo di seguito la nostra esperienza dell’emostasi endoscopica di varici esofagee sanguinanti con legatura elastica. Pazienti e metodi. Da gennaio 1999 a gennaio 2008 sono state eseguite 302 esofagogastroduodenoscopie (EGDS) per rottura di varici esofagee (M:F=1.4:1, eta media 56.4 anni, 62% dei casi affetti da cirrosi epatica HCV-correlata, 29% da cirrosi epatica alcolica e 9% da cirrosi criptogenetica; 20% affetto da insufficienza renale, 15% da diabete mellito, 10% da epatocarcinoma su cirrosi, 5% da encefalopatia porto-sistemica di vario grado e 1% da AIDS conclamato). Risultati. Tutti i pazienti sono stati trattati entro 6 ore dal primo riferito episodio di ematemesi ed in tutti era stata intrapresa terapia con betabloccante al presentarsi dell’episodio stesso. Nella prima fase della nostra esperienza sono stati utilizzati legatori elastici ricaricabili e successivamente multibyte, anche in associazione alla scleroterapia con polidocanolo (8%) o iniezione di cianoacrilato (5%). I migliori risultati sono stati raggiunti con la legatura elastica, in termini di emostasi primitiva, di risanguinamento (3%), mortalita intraoperatoria (1%) e mortalita a 6 settimane (1%). Conclusioni. Non esiste un metodo unico applicabile a tutti i pazienti con emorragia da rottura di varici esofagee, ma la legatura elastica va oggi considerata il trattamento di prima linea di un corretto approccio multidisciplinare al paziente, sia durante l’evento acuto che nella prevenzione del risanguinamento, poiche e un metodo efficace, sicuro e ripetibile, in mani esperte.

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.

INTRODUCTION:Obesity leads to serious health consequences, therefore many strategies are recommended for preventing or curing this emerging problem. Treatments are various: diet, physical activity, psychotherapy, drugs and bariatric surgery. In order to try to improve the tolerance of intragastric balloons, a new device inflated with air to improve weight loss was developed in 2004 (Heliosphere BAG). We report our personal experience about this tool.MATERIAL AND METHODS:Between January 2005 and December 2007, in our unit, 50 intragastric air filled insertion were performed under analgosedation and endoscopic control. The balloon was removed (24 hours) in two patients (4%) for acute intolerance. In other 2 patients (4%) the balloon was easily removed after 5 months because of premature desuflation, radiologically confirmed. The remnant 46 balloons were removed after six months. We evaluated efficacy, tolerance and the safety of this procedure.RESULTS:Forty one women and 9 men, with a mean age of 38.1 years (range 18-62), mean basal BMI of 39.8 (range 28-64) were included, after providing informed consent. Weight and BMI loss were evaluated on all patients. BMI decreased 5.9%, weight loss was 16.8 kg. Tolerance was very good, limited only to some dispeptic symptoms during the first 2 days after insertion. No serious technical problems were noted at balloon insertion. Balloon removal was very simple after correct desuflation after the conclusion of learning curve (10 procedures).DISCUSSION:The aim to treat obesity before bariatric surgery is based on reduction of bariatric surgical risks, general surgical risks and the prevalence of cardiovascular diseases, diabetes, musculoskeletal disorders and some cancers.CONCLUSIONS:The intragastric air filled balloon showed an acceptable profile of efficacy, good tolerance and improvement of comorbidities after 6 months.

INTRODUCTION Esophageal duplication (ED) cyst is unusual congenital disorder of the foregut, accounting for 10% to 15% of duplications of all foregut cysts. We report a case of esophageal duplication with acute clinical presentation, treated successfully with surgical resection. CASE REPORT 46-year-old man with acute dysphagia and gastroesophageal reflux of 2 weeks duration, showed submucosal bulging mass in the posterior wall of the middle third of oesophagus, fluid-filled cystic structure, dyshomogeneous, low-attenuation mass with smooth borders compatible with an hemorrhagic esophageal duplication cyst. With the suspect of acute presentation of a complicated esophageal cyst, the patient underwent surgery by right posterolateral thoracotomy. A gastrografin esophagogram was performed on third postoperative day and showed no leaks. DISCUSSION Up to 80% of the esophageal duplication cysts are diagnosed in childhood and the majority of young patients develop symptoms, while symptomatic cyst into adult life is very rare (<7%). Acute onset is generally due to complications, i.e. intracystic hemorrhage, perforation, and infection, especially of the cyst with esophageal communication. Complete surgical excision by thoracotomy or thoracoscopy is the therapy of choice even if the patient is asymptomatic because of the risk of complications such as aspiration and bleeding. CONCLUSIONS The diagnosis and treatment of esophageal cysts is still evolving. The pathological diagnosis of oesophageal duplication requires the presence of the Ladd and Gross criteria. The infrequent acute onset doesn't modify the management and the surgical resection is the procedure of choice. The future of the treatment of esophageal cysts lies in the advancement of minimally invasive operative techniques.

Introduction. Although upper gastrointestinal (GI) endoscopy is reasonably safe, it is not perfectly so. The complication rate is about 0.1% for EGDS. Aim of this study is to schedule and evaluate all possible complications, starting from personal experience in Operative Unit of Surgical Endoscopy.Patients and methods. We evaluated all EGDS performed at the Operative Unit of Surgical Endoscopy of Policlinico in Palermo between January 2000 and January 2008. A single staff of endoscopists performed diagnostic and therapeutic exam. All complications were tabulated and scheduled to identify possible risk factors or indicators procedure- or patient-related.Results. 5.258 patients (43.6 %) experienced temporary and self-limiting hypoxia (SaO(2) < 85%); we report totally 18 complications (0.15%), according to literature data: 2 hypopharinx perforations (0.016%), 2 middle esophagus perforation (either with death of patients = 0.016%), 3 post-biopsy hematomas of the gastric wall (0.02%) and 2 duodenal wall (0.016%) 6 (0.04%) post-polypectomy bleeding, 1 abscess post-percutaneous endoscopic gastrostomy (PEG) (0.008%) and 1 accidentally PEG remove (0.008%).Discussion. EGDS-related complications may occur and cannot be prevented completely even in expert hands however, early recognition and proper management will lead to better outcome. Because of the complexity of endoscopic procedures has increased, endoscopists need to be aware of all possible procedure-related complications and should use strategies to minimize it.Conclusions. Endoscopic complications will inevitably occur if an endoscopist does many procedures. The knowledge of potential complications and their expected frequency can lead to improved risk-benefit analysis by physicians and patients as well as true informed consent by patients. Early recognition of complications and prompt intervention may minimize patient morbidity.

Background & aims. Colonoscopic surveillance is an established method of colorectal cancer (CRC) screening that reduces death rates, but has an adenoma miss rate of 10-20%. Narrow band imaging (NBI), a novel endoscopic technology, highlights superficial mucosal capillaries and improves contrast for small adenomas. This study evaluated the role of NBI in the improving colon adenoma detection.Patients and methods. White light colonoscope was compared with NBI for adenoma detection during colonoscopy. 120 patients presenting for diagnostic colonoscopy were randomly assigned to undergo colonoscopy using either conventional white light or NBI colonscope during instrument withdrawal. The outcome parameter was the difference in the adenoma detection rate between the two techniques. All polyps detected were removed for histopathological analysis.Results. Adenomas were detected more frequently in the NBI group (51) than in the control group (49); however, the difference was not statistically significant (p = 0.128). The extubation time was significatively longer in the NBI group (p = 0.003).Conclusions. In our experience, the NBI did not increased the adenomas detection rate compared to white light by an endoscopist with a known high detection rate using white light.

Introduction. The differential diagnosis between malignant and benign biliary strictures is the cornerstone of the management of jaundiced patients. The aim of our study is to define the role of cytology of the bile withdrawn during endoscopic retrograde cholangiopancreatography (ERCP), to reach a diagnosis of the nature of biliary stricture.Patients and methods. This retrospective study was conducted on 67 consecutive patients affected of ingravescent obstructive jaundice who underwent ERCP +/- PTE (percutaneous transhepatic endoscopic) + bile withdrawn + stenting. We founded hilar stricture in 21 patients (31.3%), middle third the common duct stricture in 17 (25.3%), and lower third stricture in 28 patients (41.4%). In one patient (2%) the cholangiography did not show any stricture, but we continued with the withdrawn of bile after positioning a naso-biliary drainage.Results. Diagnosis was made in only 40 of 65 patients (61.5%) and no epithelial lining cells of the biliary tree was found in the remaining 25 patients (38.5%). The presence of neoplasm in the pancreato-biliary tract was excluded (absence of malignant cells) in 25 of 40 diagnostic exams (62.5%). During follow-up only 7 of these 25 patients resulted in having a benign disease (true negatives 28%) while the remaining 18 cases were diagnosed with malignant neoplasm of the pancreato-biliary tract (false negatives 72%). Nine of 14 with positive cytology for carcinoma were diagnosed with cholangiocarcinoma (65%), 4 with pancreatic (28%) and 1 with ampullary carcinoma. Of 25 non-diagnostic samples, 5 (20%) resulted as benign, 20 (80%) as malignant. The statistical analysis by chi-square test allowed us to conclude that bile cytology, if diagnostic, is significantly valid in identifying carcinoma of the pancreato-biliary tract (p < 0.05) instead, considering the high rate of non diagnostic samples, its meaning is limited (p = 0.09).Discussion. Exfoliative cytology of bile samples obtained during ERCP is easier and less invasive method to determine the diagnosis of biliary strictures, but due to its low sensibility, varying from 6 to 63%, it doesn't appear accurate to establish a definite diagnosis; the stricture dilatation before the withdrawal increases the diagnostic sensibility and accuracy of the cytological exam.Conclusion. Bile withdrawn for cytology during ERCP is a safe method with no increasing in patient's morbidity. It allows a diagnostic orientation in 75% of the patients. Bile withdrawn after dilatation of stricture allows improves sensibility and accuracy. Negative results does not exclude malignant disease, however, if positive, it is considered diagnostic (positive predictive value 100%).

BACKGROUND:The diffusion in the years '80 of the stapler has modified the habits of the surgeons, determining the reduction of the operative time in colorectal surgery and the possibility to operate cancer of lower rectum, but leaving unchanged the rates of postoperative complications and bringing to the footlights some new complications. Aim of paper is to report our experience about of mechanical sutures in the colorectal anastomoses, with particular attention to the risk factors and complications procedure-related.PATIENTS AND METHOD:From January 2000 to January 2006 in the Section of General and Thoracic Surgery of the University in Palermo, 26 stapled colorectal anastomosis and 11 mechanical terminal colostomies after Miles' amputation have been performed; 12 patients have been submitted to low colorectal termino-terminal anastomosis, 6 to termino-terminal ultralow anastomosis, 1 to coloanal anastomosis and 7 to Knight-Griffen technique.RESULTS:We registered 2 anastomotic dehiscences (8%), 3 (12%) anastomotic bleeding and one anastomotic stenosis (4%) 12 months after surgery. No mortality procedure-related took place.DISCUSSION:From the literature review emerges the absence of statistically differences between manual and mechanical suture in the colorectal anastomosis in terms of mortality, morbidity (clinical and radiological incidence of the anastomotic gaps, anastomotic stenosis, redo, bleeding, infection of the wound) of employed time to make the anastomosis and of staying in hospital. These data are from American Schools, while greater incidence of radiological leakage is recorded in the European schools is for the manual suture.CONCLUSIONS:At present does not exist clinical trial that shows the superiority of mechanical stapling versus manual suture in the colorectal anastomosis. Stapler makes possible the lower colo-rectal anastomosis often avoiding abdomino-perineal amputation of the rectum, with better quality of life and oncological radicality, but increasing however the incidence of complications as anastomotic dehiscence and stenosis, even if not statistically significant.

Introduction: we describe the first case in literature of biliary stent obstruction by bezoar impaction in a iuxtapapillary duodenal diverticulum.Case report: this case illustrates an juxtapapillary duodenal diverticulum and bezoar in it causing obstructive jaundice in subject with two biliary stents for cholangiocarcinoma (Klatskin's tumor) in the absence of bile duct stones. Result: successful treatment with endoscopic stent removal and diverticulum toilette. Obstructive jaundice was cured after endoscopic removal of the bezoar and stent substitution.Discussion: the presence of a bezoar and its possible contribution to the pathogenesis of pancreatitis in the presence of periampullary extraluminal duodenal diverticula makes endoscopic intervention for removal of the bezoar necessary and effective.Conclusions: biliary bezoar is a very rare but treatable cause of stents obstruction in patients with juxtapapillary duodenal diverticula. Endoscopic retrograde cholangiopancreatografhy is helpful in making diagnosis and for resolutive treatment.

OBJECTIVE The Authors report their experience in diagnosis and treatment of one case of mesenteric cystic lymphangioma; recent international literature review. EXPERIMENTAL DESIGN Complete clinical report. Diagnostic, clinical and prognostic indication, evaluation of effectiveness of radical surgical treatment and follow-up. SETTING Operative Unit of General and Thoracic Surgery. University Paolo Giaccone of Palermo. INTERVENTION Radical surgical treatment, according to international guide-lines. RESULTS Complete recovery with restitutio ad integrum. No relapse were recorded at short follow up. CONCLUSIONS Even when asymptomatic and discovered incidentally, LCM must be treated surgically because of the potential to grow, invade vital structures, and develop life-threatening complications. The best and only radical treatment is the total removal of the lesions with microscopically clear borders, when it is available.