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

Endoscopic internal drainage for the management of leak, fistula, and collection after sleeve gastrectomy: our experience in 617 consecutive patients

Background: Endoscopy plays a pivotal role in the management of adverse events (AE) following bariatric surgery. Leaks, fistulae, and post-operative collection after sleeve gastrectomy (SG) may occur in up to 10% of cases. Objectives: To evaluate the efficacy and safety of endoscopic internal drainage (EID) for the management of leak, fistula, and collection following SG. Setting: Retrospective, observational, single center study on patients referred from several bariatric surgery departments to an endoscopic referral center. Methods: EID was used as first-line treatment for the management of leaks, fistulae, and collections. Leaks and fistulae were treated with double pigtail stent (DPS) deployment in order to guarantee internal drainage and second intention cavity obliteration. Collections were treated with endoscropic ultrasound (EUS)–guided deployment of DPS or lumen apposing metal stents. Results: A total of 617 patients (83.3% female; mean age, 43.1 yr) were enrolled in the study for leak (n = 300, 48.6%), fistula (n = 285, 46.2%), and collection (n = 32, 5.2%). Median follow-up was 19.5 months. Overall clinical success was 84.7% whereas 15.3% of cases required revisional surgery after EID failure. Clinical success according to type of AE was 89.5%, 78.5%, and 90% for leak, fistula, and collection, respectively. A total of 10 of 547 (1.8%) presented a recurrence during follow-up. A total of 28 (4.5%) AE related to the endoscopic treatment occurred. At univariate logistic regression predictors of failure were: fistula (OR 2.012), combined endoscopic approach (OR 2.319), need for emergency surgery (OR 1.755), and previous endoscopic treatment (OR 4.818). Conclusion: Early EID for the management of leak, fistula, and post-operative collection after SG seems a safe and effective first-line approach with good long-term results

Valutazioni multicriterio e GIS: analisi del mercato immobiliare ed indirizzi progettuali per le Zone a Traffico Limitato nel centro storico di Napoli

A partire dal luglio 2011 il centro storico di Napoli è stato interessato dall’istituzione di Zone a Traffico Limitato (ZTL). Sulla base di criteri di omogeneità storico-urbanistica, è stata perimetrata un’area di studio più ampia di quella strettamente interessata dalle ZTL, ma che comprende parte del territorio comunale presumibilmente influenzato dagli effetti dei dispositivi di traffico introdotti; per tale area, relativamente al periodo 2007-2013, è stata esaminata la variazione dei valori di mercato e di locazione, con riferimento agli immobili residenziali e commerciale. In particolare, i valori immobiliari disponibili sono stati inseriti in un GIS ed è stata condotta un’analisi multivariata, individuando le correlazioni tra detti valori. Successivamente sono state dedotte delle “regole decisionali”, che sono state utilizzate all’interno di una analisi multicriterio, i cui risultati hanno consentito di proporre alcuni indirizzi progettuali di modifica degli attuali dispositivi del traffico

Multidimensional Potential Energy Surfaces Resolved at the RASPT2 Level for Accurate Photoinduced Isomerization Dynamics of Azobenzene

We have used state-of-the-art ab initio restricted active RASPT2 computations using a 16 orbitals, 18 electrons active space to produce an extended three-dimensional map of the potential energy surfaces (PESs) of the ground and first n\u3c0 17 excited states of azobenzene along CNNC torsion and the two CNN bending angles, which are the most relevant coordinates for the trans-cis photoisomerization process. Through comparison with fully unconstrained optimizations performed at the same level of theory, we show that the three selected coordinates suffice to correctly describe the photoisomerization mechanism and the S1-S0 crossing seam. We also provide a map of the nonadiabatic coupling between the two states in the region where they get closer in energy. Eventually, we show that treating the two CNN bending angles as independent coordinates is fundamental to break the symmetry and couple the two electronic states. The accuracy of the S0 and S1 PESs and couplings was validated with semiclassical dynamics simulations in the reduced space of the scanned coordinates, showing results in good agreement with published full-coordinate dynamics