EUS-guided Anastomosis Complication in a Patient with Roux-en-Y Gastric Bypass: Dehiscence of the Surgical Anastomosis During Endoscopic Mucosal Resection Across EUS-guided Jejunum-gastric Anastomosis with Lumen Apposing Metal Stent

Introduction: Roux-en-Y gastric bypass (RYGB) is one of the most common surgical procedures for the management of morbid obesity. However, RYGB poses technical difficulties in exploring the gastric remnant and in performing endoscopic biliary interventions due to altered anatomy. Recently, EUS guided gastro-gastric anastomosis to access the excluded stomach has been introduced in order to allow direct trans-gastric interventions. Method and Material: We report the case of a 38-year-old female referred to our unit to undergo EUS direct trans-gastric intervention (EDGI) for the management of a small stone in the biliary tract. Pre-procedural CT scan highlighted an abnormal distension of the gastric remnant. EUS guided jejuno-gastric anastomosis was carried out with the deployment of a 15 x 10 mm lumen apposing metal stent (LAMS). Results: After 3 days, an upper GI endoscopy was performed, highlighting a mobile 25 mm polyp near the pylorus. Therefore endoscopic resection was planned before the performance of the ERCP. Piecemeal endoscopic mucosectomy was carried out with no evidence of any adverse event. However, endoscopic evaluation after specimen retrieval detected an almost complete dehiscence of the anastomosis. Emergency surgery was decided with restoration of the continuity of the gastric cavity to allow future endoscopic examinations/procedures. Discussion: Here, we report the first case of dehiscence of the surgical gastro-jejunal anastomosis during EDGI procedure. Performing an ERCP during EDGI is probably safer than performing gastric interventions. When performing EDGI, it is paramount to carefully evaluate the type of planned gastric procedure and to adopt a tailored approach according the several variables involved

Per Oral Endoscopic Myotomy for the Management of Achalasia in a Patient with Prior Lap Band, Sleeve Gastrectomy, and Roux-en-Y Gastric Bypass

Introduction: Achalasia after bariatric surgery is a rare pathological entity. Nonetheless, several cases have been described in literature. Per oral endoscopic myotomy has recently emerged as the preferred approach for the management of esophageal motility disorders. Material and Methods: We report a video case of POEM performed in a female patient with prior multiple bariatric surgical procedures. In her past medical history, she underwent to laparoscopic lap band, sleeve gastrectomy, and Roux-Y-gastric bypass. Results: POEM was carried out without complication. Myotomy was performed only for 1 cm below the cardias due to the presence of the gastro-jejunal anastomosis. Post-operative course was uneventful and oral diet was restarted after one day. At 2 months follow-up, the patient is asymptomatic with no weight regain. Conclusion: We report the first case of POEM after three different bariatric surgical procedure. Fibrosis due to prior interventions did not hampered POEM procedure, and the shorter myotomy due to the presence of small gastric pouch did not reduced its efficacy

Body center of mass trajectory and mechanical energy using inertial sensors: a feasible stride?

Background: The description of the three-dimensional (3D) trajectory of the body center of mass (BCoM) provides useful insights on the mechanics of locomotion. The BCoM trajectory can be estimated from ground reaction forces, recorded by force platforms (GRF, gold standard), or from marker trajectories recorded by stereophotogrammetric systems (MKR). However, both instruments do not allow for monitoring locomotion in the real-life environment. In this perspective, magneto-inertial measurement units (MIMUs) are particularly attractive being wearable, thus enabling to collect movement data out of the laboratory. Research questions: To investigate the feasibility and accuracy of a recent marketed full-body MIMU-based method for the estimation of the 3D BCoM trajectory and energetics during walking. Methods: Twelve subjects walked at self-selected and slow speed along a 12 m long walkway. GRF and MKR were acquired using three force platforms and a stereophotogrammetric system. MIMU data were collected using a full-body MIMU-based motion capture system (Xsens MTw Awinda). The 3D BCoM trajectory, external mechanical work and energy recovery were extracted from the data acquired by the three measurement systems, using state-of-the-art methods. The accuracy of both MKR- and MIMU-based estimates compared with GRF was assessed for the BCoM trajectory (maximum, minimum, range, and RMSD), as well as for mechanical work and energy recovery. Results: A total number of 108 strides were analyzed. MIMU-based BCoM trajectory displayed larger errors in comparison with GRF (and MKR) for the trajectory ranges: 89 ± 47(93 ± 44)% in antero-posterior, 46 ± 25(40 ± 79)% medio-lateral and -13 ± 23(-5 ± 25)% vertical directions, leading to a 3D RMSD of 17 ± 5(12 ± 5) mm (mean ± SD). These discrepancies largely affected the estimation of both mechanical work and energy recovery (+115 ± 85% and -28 ± 21%, respectively). Significance: Preliminary findings highlighted that the tested MIMU-based method for BCoM trajectory estimation still lacks accuracy and that the quantification of energetics in real-life situations remains an open challenge

Endoscopic management of gastrointestinal leaks and fistulae: What option do we have?

Gastrointestinal leaks and fistulae are serious, potentially life threatening conditions that may occur with a wide variety of clinical presentations. Leaks are mostly related to post-operative anastomotic defects and are responsible for an important share of surgical morbidity and mortality. Chronic leaks and long standing post-operative collections may evolve in a fistula between two epithelialized structures. Endoscopy has earned a pivotal role in the management of gastrointestinal defects both as first line and as rescue treatment. Endotherapy is a minimally invasive, effective approach with lower morbidity and mortality compared to revisional surgery. Clips and luminal stents are the pioneer of gastrointestinal (GI) defect endotherapy, whereas innovative endoscopic closure devices and techniques, such as endoscopic internal drainage, suturing system and vacuum therapy, has broadened the indications of endoscopy for the management of GI wall defect. Although several endoscopic options are currently used, a standardized evidence-based algorithm for management of GI defect is not available. Successful management of gastrointestinal leaks and fistulae requires a tailored and multidisciplinary approach based on clinical presentation, defect features (size, location and onset time), local expertise and the availability of devices. In this review, we analyze different endoscopic approaches, which we selected on the basis of the available literature and our own experience. Then, we evaluate the overall efficacy and procedural-specific strengths and weaknesses of each approach

An optimal procedure for stride length estimation using foot-mounted magneto-inertial measurement units

Stride length is often used to quantitatively evaluate human locomotion performance. Stride by stride estimation can be conveniently obtained from the signals recorded using miniaturized inertial sensors attached to the feet and appropriate algorithms for data fusion and integration. To reduce the detrimental drift effect, different algorithmic solutions can be implemented. However, the overall method accuracy is supposed to depend on the optimal selection of the parameters which are required to be set. This study aimed at evaluating the influence of the main parameters involved in well-established methods for stride length estimation. An optimization process was conducted to improve methods' performance and preferable values for the considered parameters according to different walking speed ranges are suggested. A parametric solution is also proposed to target the methods on specific subjects' gait characteristics. The stride length estimates were obtained from straight walking trials of five healthy volunteers and were compared with those obtained from a stereo-photogrammetric system. After parameters tuning, percentage errors for stride length were 1.9%, 2.5% and 2.6% for comfortable, slow, and fast walking conditions, respectively

A method for gait events detection based on low spatial resolution pressure insoles data

The accurate identification of initial and final foot contacts is a crucial prerequisite for obtaining a reliable estimation of spatio-temporal parameters of gait. Well-accepted gold standard techniques in this field are force platforms and instrumented walkways, which provide a direct measure of the foot–ground reaction forces. Nonetheless, these tools are expensive, non-portable and restrict the analysis to laboratory settings. Instrumented insoles with a reduced number of pressure sensing elements might overcome these limitations, but a suitable method for gait events identification has not been adopted yet. The aim of this paper was to present and validate a method aiming at filling such void, as applied to a system including two insoles with 16 pressure sensing elements (element area = 310 mm2), sampling at 100 Hz. Gait events were identified exploiting the sensor redundancy and a cluster-based strategy. The method was tested in the laboratory against force platforms on nine healthy subjects for a total of 801 initial and final contacts. Initial and final contacts were detected with low average errors of (about 20 ms and 10 ms, respectively). Similarly, the errors in estimating stance duration and step duration averaged 20 ms and <10 ms, respectively. By selecting appropriate thresholds, the method may be easily applied to other pressure insoles featuring similar requirements

Temporary Trans-gastric Stent Deployment Over a 20 French Gastrostomy for Single-Stage Endoscopic Retrograde Cholangiopancreatography After Gastric Bypass

Introduction: Treatment of pancreato-biliary disorders after gastric bypass is challenging due to altered anatomy. Several techniques have been proposed to overcome this condition; however, none has emerged as the gold standard treatment. Furthermore, a decision-making algorithm evaluating when and why apply one technique over another is still lacking. Objectives: To describe a novel trans-gastric approach to allow endoscopic retrograde cholangiopancreatography (ERCP) in Roux-en-Y gastric bypass (RYGB) anatomy soon after prior laparoscopic cholecystectomy (LC) and to propose a decision-making algorithm for selection of the most suitable technique according a tailored approach. Setting: Private hospital. Methods: Between January and March 2020, patients with Roux-en-Y gastric bypass anatomy referred to our tertiary center to undergo ERCP after recent laparoscopic cholecystectomy were retrospectively evaluated. A 20 french (Fr) gastrostomy was performed during cholecystectomy. A single-stage ERCP was carried out by means of temporary trans-gastric stent deployment over a 20 Fr gastrostomy. Results: A total of 5 patients (mean age 41; mean body mass index 48.3) were enrolled. ERCP was performed after an average of 2 days from surgery. Technical and clinical success was achieved in 100%. No adverse events occurred. Spontaneous closure of the gastrostomy after its bedside removal was observed in all cases. Conclusions: Our approach allows to perform a single-stage ERCP in RYGB patients, early after LC, with no need of any other re-interventions. Any surgeon facing unexpected biliary disorders, during LC, can easily perform a 20 Fr gastrostomy thus allowing the patient to undergo early ERCP without any delay

ERCP in Total Situs Viscerum Inversus

A 69-year-old cholecystectomized female with known total situs viscerum inversus presented recurrent colicky pain in the left upper abdominal quadrant and jaundice. Laboratory parameters showed increased neutrophils and coniugated bilirubin of 5.53 mg/dl. US and MRCP confirmed total situs viscerum inversus and a dilatation of the intra- and extrahepatic ducts with a peripapillary 13 mm stone. ERCP, sphincterotomy and successful common bile duct stone extraction were performed in the conventional way. ERCP was carried out successfully despite situs inversus maintaining the patient in the prone position with the endoscopist on the right side of the table. Some authors have reported similar cases in whom ERCP was performed in other positions, while this report shows that an experienced endoscopist can achieve the same results in the conventional way as it is possible when anatomical changes, Billroth II or Roux-en-Y, or different positions of the patient, supine or on the left side, are present

Inter-leg distance measurement as a tool for accurate step counting in patients with multiple sclerosis

Step detection is commonly performed using wearable inertial devices. However, methods based on the extraction of signals features may deteriorate their accuracy when applied to very slow walkers with abnormal gait patterns. The aim of this study is to test and validate an innovative step counter method (DiSC) based on the direct measurement of inter-leg distance. Data were recorded using an innovative wearable system which integrates a magneto-inertial unit and multiple distance sensors (DSs) attached to the shank. The method allowed for the detection of both left and right steps using a single device and was validated on thirteen people affected by multiple sclerosis (0 < EDSS < 6.5) while performing a six-minute walking test. Two different measurement ranges for the distance sensor were tested (DS 200 : 0–200 mm; DS 400 : 0–400 mm). Accuracy was evaluated by comparing the estimates of the DiSC method against video recordings used as gold standard. Preliminary results showed a good accuracy in detecting steps with half the errors in detecting the step of the instrumented side compared to the non-instrumented (mean absolute percentage error 2.4% vs 4.8% for DS 200 ; mean absolute percentage error 2% vs 5.4% for DS 400 ). When averaging errors across patients, over and under estimation errors were compensated, and very high accuracy was achieved (E % <1.2% for DS 200 ; E % <0.7% for DS 400 ). DS 400 is the suggested configuration for patients walking with a large base of support

Visuomotor Integration for Coupled Hand Movements in Healthy Subjects and Patients With Stroke

Many studies have investigated the bilateral upper limb coordination during movements under different motor and visual conditions. Bilateral training has also been proposed as an effective rehabilitative protocol for patients with stroke. However, the factors influencing in-phase vs. anti-phase coupling have not yet been fully explored. In this study, we used a motion capture device based on two infrared distance sensors to assess whether the up and down oscillation of the less functional hand (the non-dominant one in healthy younger and older subjects and the paretic one in patients with stroke) could be influenced by in-phase or anti-phase coupling of the more functional hand and by visual feedback. Similar patterns were found between single hand movements and in-phase coupled movements, whereas anti-phase coupled movements were less ample, less sinusoidal, but more frequent. These features were particularly evident for patients with stroke who showed a reduced waveform similarity of bilateral movements in all conditions but especially for anti-phase movements under visual control. These results indicate that visuomotor integration in patients with stroke could be less effective than in healthy subjects, probably because of the attentional overload required when moving the two limbs in an alternating fashion