Over-the-scope clips in the treatment of gastrointestinal tract iatrogenic perforation: A multicenter retrospective study and a classification of gastrointestinal tract perforations

AIM: To determine the outcome of the management of iatrogenic gastrointestinal tract perforations treated by over-the-scope clip(OTSC) placement.METHODS: We retrospectively enrolled 20 patients(13 female and 7 male; mean age: 70.6 ± 9.8 years) in eight high-volume tertiary referral centers with upper or lower iatrogenic gastrointestinal tract perforation treated by OTSC placement. Gastrointestinal tract perforation could be with oval-shape or with round-shape. Ovalshape perforations were closed by OTSC only by suction and the round-shape by the "twin-grasper" plus suction. RESULTS: Main perforation diameter was 10.1 ± 4.3 mm(range 3-18 mm). The technical success rate was 100%(20/20 patients) and the clinical success rate was 90%(18/20 patients). Two patients(10%) who did not have complete sealing of the defect underwent surgery. Based upon our observations we propose two types of perforation: Round-shape "type-1 perforation" and oval-shape "type-2 perforation". Eight(40%) out of the 20 patients had a type-1 perforation and 12 patients a type-2(60%). CONCLUSION: OTSC placement should be attempted after perforation occurring during diagnostic or therapeutic endoscopy. A failed closure attempt does not impair subsequent surgical treatment.

Modern approach to cholecysto-choledocholithiasis

Gallstones and common bile duct calculi are found to be associated in 8%-20% of patients, leading to possible life-threatening complications, such as acute biliary pancreatitis, jaundice and cholangitis. The gold standard of care for gallbladder calculi and isolated common bile duct stones is represented by laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography, respectively, while a debate still exists regarding how to treat the two diseases at the same time. Many therapeutic options are also available when the two conditions are associated, including many different types of treatment, which local professionals often administer. The need to limit maximum discomfort and risks for the patients, combined with the economic pressure of reducing costs and utilizing resources, favors single-step procedures. However, a multitude of data fail to strongly demonstrate the superiority of any technique(including a two or multi-step approach), while rigorous clinical trials that include so many different types of treatment are still lacking, and it is most likely unrealistic to conduct them in the future. Therefore, the choice of the best management is often led by the local presence of professional expertise and resources, rather than by a real superiority of one strategy over another.

在消化内视镜检查法的高技术成像

A thorough endoscopic visualization of the digestive mucosa is essential for reaching an accurate diagnosis and to treat the different lesions. Standard white light endoscopes permit a good mucosa examination but, nowadays, the introduction of powerful endoscopic instrumentations increased ability to analyze the fi nest details. By applying dyes and zoom-magnifi cation endoscopy further architectural detail of the mucosa can be elucidated. New computed virtual chromoendoscopy have further enhanced optical capabilities for the evaluation of submucosal vascolar pattern. Recently, confocal endomicroscopy and endocytoscopy were proposed for the study of ultrastructural mucosa details. Because of the technological contents of powerful instrumentation, a good knowledge of implemented technologies is mandatory for the endoscopist, nowadays. Nevertheless, there is a big confusion about this topic. We will try to explain these technologies and to clarify this terminology.

Secondary aortoduodenal fistula

Aorto-duodenal fistulae (ADF) are the most frequent aorto-enteric fistulae (80%), presenting with upper gastrointestinal bleeding. We report the first case of a man with a secondary aorto-duodenal fistula presenting with a history of persistent occlusive syndrome. A 59-year old man who underwent an aortic-bi-femoral bypass 5 years ago, presented with dyspepsia and biliary vomiting. Computed tomography scan showed in the third duodenal segment the presence of inflammatory tissue with air bubbles between the duodenum and prosthesis, adherent to the duodenum. The patient was submitted to surgery, during which the prosthesis was detached from the duodenum, the intestine failed to close and a gastro-jejunal anastomosis was performed. The post-operative course was simple, secondary ADF was a complication (0.3%-2%) of aortic surgery. Mechanical erosion of the prosthetic material into the bowel was due to the lack of interposed retroperitoneal tissue or the excessive pulsation of redundantly placed grafts or septic procedures. The third or fourth duodenal segment was most frequently involved. Diagnosis of ADF was difficult. Surgical treatment is always recommended by explorative laparotomy. ADF must be suspected whenever a patient with aortic prosthesis has digestive bleeding or unexplained obstructive syndrome. Rarely the clinical picture of ADF is subtle presenting as an obstructive syndrome and in these cases the principal goal is to effectively relieve the mechanical bowel obstruction.