common but life-threatening complication of aortic reconstructive surgery [1]. Here we report on the diagnosis of an aortoduodenal fistula using an atypical endoscopic method. A 82-year-old man was admitted to our hospital with melena. He had undergone implantation of a prosthetic graft for a celiac trunk aneurysm 3 years ago. A contrast-enhanced computed tomography scan was nondiagnostic (●" Fig. 1). Therefore, we carried out upper gastrointestinal endoscopy using an operating gastroscope (ES-250WE5, Fujinon Inc., Saitama, Japan), which did not reveal any potentially bleeding lesions, however, a small amount of red blood was found over the pylorus. The endoscopic examination was continued into the third and the fourth portions of the duodenum, where a smaller amount of red blood was visualized in the duodenal bulb, but without any sign of a bleeding source. Substitution of the operating gastroscope with a side-viewing duodenoscope (ED200XU, Fujinon Inc., Saitama, Japan) allowed identification of 1-mm diameter, deep ulcer in the posterior wall of the duodenal bulb, with oozing bleeding (●" Fig. 2). The patient was then promptly referred to a vascular surgeon, and during surgery a fistula was found between the graft and duodenal bulb. The graft was removed and the small defect in the posterior wall of the bulb closed. Aortoduodenal fistulas are the most common aortoenteric fistulas (80%), and the third and fourth duodenal segments are the most frequently involved sites. However, communication with other parts of the gut, such as the small bowel, the colon, and the rectum has also been reported [2,3]. The present case is unusual for an aortoduodenal fistula because of the atypical surgical history (previous aortoceliac bypass for an aneurysm of the celiac trunk). To the best of our knowledge, this is the first report of an aortoduodenal fistula involving the duodenal bulb; in this rare condition, use of sideviewing endoscopy aided direct visualization of the site of bleeding, thus permitting early diagnosis.

Endoscopic ultrasound-guided transmural drainage (EUS-GTD) has become the standard procedure for treating symptomatic pancreatic fluid collections. The aim of this series was to evaluate the efficacy and safety of covered self-expanding metal stent (CSEMS) placement for treating infected pancreatic fluid collections. From January 2007 to May 2010, 22 patients (18 M/4F; mean age 56.9) with infected pancreatic fluid collections (mean size, 13.2 cm) at two Italian centers were evaluated for EUS-GTD. In 20 of the 22 patients, EUS-GTD with CSEMS placement was indicated. Early complications occurred in two patients: one patient developed a superinfection, which was managed conservatively, and one experienced stent migration and superinfection, and was managed surgically. The CSEMSs were removed without difficulty in 18 patients after a median of 26 days, while stent removal failed in one patient due to inflammatory tissue ingrowth; instead it was removed during surgery performed for renal cancer. Clinical success was achieved without additional intervention in 17 patients during a mean follow-up of 610 days; only one symptomatic recurrence was observed. In our experience, EUS-GTD with CSEMS placement appears safe for the treatment of infected pancreatic fluid collections.

The Gastro-Laryngeal Tube (G-LT) is a modification of the laryngeal tube which provides a dedicated channel for the insertion of an endoscope while acting as a supraglottic airway for ventilation. The aim of this study was to assess the safety and effectiveness of this device in patients undergoing anesthesia for interventional endoscopic biliopancreatic procedures (IEBPPs).A total of 22 patients were included in the study. The G-LT was inserted successfully in all patients. Arterial oxygen saturation was stable; the mean value was 97.9%. The IEBPPs were performed successfully in all patients through the endoscopic channel, with a mean duration of 99 minutes. The maneuverability of the endoscope was considered good in all patients. There were two cases of sore throat after the procedures, two cases of asymptomatic erosion of the upper esophageal mucosa, one case of Mallory-Weiss syndrome, and one case of pancreatitis after endoscopic retrograde cholangiopancreatography.Our results suggest that the G-LT is an effective and secure device for airway management and for use during IEBPPs.

Context Endoscopic ultrasonography (EUS) can show pancreatic tumors of few millimeters; nowadays, in the years of laparoscopic approach, the most difficult and time-consuming issue can be how to identify a tumor throughout the pancreatic parenchyma in order to select the site where to transect the pancreas. Preoperative EUS-tattooing could be of help in locating small pancreatic tumors during pancreatic resections. Case report Because of the onset of recurrent mild abdominal pain and diarrhea lasting for 4 months, a 70-year-old woman performed a trans-abdominal US that showed a hypoecogenic area of about 7 mm in the body of the pancreas. She had no other significant medical history or laboratory index. A CT-scan did not reveal any lesion throughout the pancreas. EUS examination (using a linear echoendoscope Fujinon) confirmed a hypoecogenic, solid, irregular mass of the body of the pancreas of about 7x4 mm. An EUS-guided fine-needle aspiration biopsy of the lesion was performed with a 22-gauge ProCore needle (Cook) and then, EUS-guided tattoo was performed using a 22 gauge EchoTip needle: the needle was inserted 3-5 mm proximal to the lesion and 2 mL of sterile purified carbon particles were injected under direct visualization. The patient received pre-procedural i.v. ciprofloxacin and no complications were observed. Cytological examination reported cells suspicious for adenocarcinoma. Nineteen days later, the patient underwent a laparoscopic left pancreatectomy. Ink was clearly visible on the anterior surface of the pancreas. Operative time was 110 minutes. Postoperative outcome was uneventful. Pathologic evaluation revealed a ductal adenocarcinoma of 5 mm in diameter with 17 negative nodes. Distance between pancreatic resection margin and cancer was 15 mm. Conclusions Preoperative EUS-tattooing could facilitate laparoscopic localization of small lesions. Further studies to assess safety, indications and limits are needed.

AIM:The aim of this paper was to evaluate the effect of carbon dioxide (CO2) vs. air insufflation on post-endoscopic retrograde cholangiopancreatography (ERCP) abdominal pain and distension. In addition, we investigated the changes in the partial pressure of end-tidal CO2 (PetCO2) and the partial pressure of arterial CO2 (PaCO2).METHODS:From October 2009 to January 2010, all patients admitted to our centre for ERCP were screened for enrollment; the patients recruited were randomised to CO2 or air insufflation. The patients were asked to rate their abdominal pain intensity and distension using a 100-mm Visual Analogue Scale (VAS) before, in the recovery room and at 1, 3, 6 and 24 hours after the ERCP. All anesthesiological and endoscopic details and complications were evaluated.RESULTS:We included 76 patients, 39 in the Air group and 37 in the CO2 group. The groups were similar for age, gender, indications and duration of the procedure. Post-procedure mean values of pain (in the recovery room and at 1, 3 and 6 hours) and distension (at recovery room, and at 1 and 3 hours) according to the VAS were significantly reduced in the CO2 group as compared to the Air group. At baseline, the PetCO2 values were similar between the two groups while, during the ERCP, they increased significantly in CO2 group as compared to the Air group; these values were reduced by simply increasing the ventilation.CONCLUSION:CO2 insufflation during ERCP significantly reduces post-procedural abdominal pain and distension. Increased PetCO2 and PaCO2 values remained within acceptable or readily controllable ranges.

Recently, the use of partially or fully covered self-expandable metal stents (FCSEMSs) has been described for the treatment of complex bile leaks after laparoscopic or open cholecystectomy [1] [2].

AIM:The aim of this study was to evaluate the short- and long-term outcomes of self-expanding metal stent (SEMS) insertion as a bridge to surgery (BTS) in patients presenting with acute left-sided colorectal cancer obstruction (LCCO).METHODS:All patients with acute LCCO who underwent endoscopic SEMS placement as a BTS between January 2005 and December 2010 were reviewed and included in the study.RESULTS:Thirty-six patients (19M and 17F; mean age 68.5) were included. The most frequent location was the sigmoid colon (47.2%). Technical success was achieved in 91.6% and clinical success in 88.9%. Technical failure was related to the location of the stricture at the rectosigmoid junction (P=0.03). There were four SEMS-related complications: one fecal obstruction, one haemorrhage treated with APC and two silent perforations which were noted during surgical resection. The mean time between SEMS insertion and surgical treatment was 19 days (range 6-80 days) and the most frequent intervention was a left hemicolectomy (46.9%). No intraoperative mortality and morbidity, or postoperative mortality were observed. The postoperative morbidity rate was 18.8% (two wound infections, one deep venous thrombosis, one case of pneumonia and one anastomotic dehiscence). Finally, after discharge from hospital, a total of 29 patients (90%) were stoma free. At the end of the follow-up period, 24 patients are still alive and the mean survival rate was 37.3±18 months (range 9-72).CONCLUSION:In our experience, SEMS placement as a BTS is a safe and effective strategy for the treatment of patients with acute LCCO.

Since its development in the 1980s, endoscopic ultrasonography (EUS) has undergone a great deal of technological modifications. EUS has become an important tool in the evaluation of patients with various clinical disorders and is increasingly being utilized in many centers. EUS has been evolving over the years; EUS-guided fine needle aspiration (FNA) for cytological and/or histological diagnosis has become standard practice and a wide array of interventional and therapeutic procedures are performed under EUS guidance for diseases which otherwise would have needed surgery, with its associated morbidities. EUS shares the risks and complications of other endoscopic procedures. This article addresses the specific adverse effects and risks associated with EUS, EUS-FNA and interventional EUS, namely perforation, bleeding, pancreatitis and infection. Measures to help minimizing these risks will also be discussed.

In 145 CRCs, by multivariate correspondence analysis, we found an association between Vangl2 methylation and BRAF mutation (p=0.0001), functional p53 (p<0.0001), and low IHC expression of hMLH1 (p=0.0141), Cox-2 (p=0.002), E-cadherin (p=0.0019) and cytoplasmic β-catenin (p=0.0019). No association was found with KRAS mutation. Conclusions: Epigenetic loss of Vangl2 occurs in MSI CRC and is associated with other molecular features of this subset of tumors. The association with BRAF mutation suggests that Vangl2 methylation might contribute to Wnt derangement in sporadic MSI CRC.

Endoscopic ultrasonography-guided biliary drainage (EUS-BD) has been developed as an alternative drainage technique in patients with obstructive jaundice where endoscopic retrograde cholangiopancreatography (ERCP) has failed. Between July 2008 and December 2009, 16 patients (9 men; median age 79 years) with biliopancreatic malignancy, who were candidates for alternative techniques of biliary decompression because ERCP had been unsuccessful, underwent EUS-BD with placement of a transmural or transpapillary partially covered nitinol self-expandable metal stent (SEMS). EUS-assisted cholangiography was successful in all patients, with definition of the relevant anatomy, but biliary drainage was successfully performed in only 12 (75 %) of the 16 patients (9 choledochoduodenostomies with SEMS placement and 3 biliary rendezvous procedures with papillary SEMS placement), with regression of the cholestasis. No major complications and no procedure-related deaths occurred. There was one case of pneumoperitoneum which was managed conservatively. The median follow-up was 170 days. During the follow-up, eight patients of the 12 patients in whom biliary draining was successful died; four are currently alive. None of the patients required endoscopic reintervention. This series demonstrated that EUS-BD with a partially covered SEMS has a high rate of clinical success and low complication rates, and could represent an alternative choice for biliary decompression.

A COLONIC SELF-EXPANDINGMETAL STENT PLACEMENT AS “BRIDGE TO SURGERY” IS THE SAFEST STRATEGY IN THE MANAGEMENT OF PATIENTS WITH LEFT-SIDED COLON CANCER OBSTRUCTION C. Vincenzo ∗ ,6, C. Luigiano7, L. Ansaloni8, F. Coccolini 8 , L. Fuccio6, C. Fabbri 7 , A. Mussetto 9, L. Ceroni 6, G. Manes 10, T. Casetti 9 , A.D. Pinna8, N. D’Imperio7, R.M. Zagari 6, F. Bazzoli 6 6Department of Internal Medicine and Gastroenterology, Bologna, Italy; 7Unit of Gastroenterology, Ausl Bologna Bellaria-Maggiore Hospital, Bologna, Italy; 8Department of General Surgery and Transplant, University of Bologna, Bologna, Italy; 9Unit of Gastroenterology, Ravenna Hospital, Ravenna, Italy; 10Unit of Gastroenterology, L. Sacco Hospital, Milano, Italy