Searching the best approach for third-generation cholecystectomy

[Excerpt] We carefully read the study from Pai el al1 that demonstrates the technical feasibility of transcolonic cholecystectomy. Recently, we also investigated an endoscopic approach to perform scarless cholecystectomy through a transgastric and transvesical combined approach.[2] In our study, we also confirmed that an abdominal inferior port provides an en face orientation to the upper abdominal organs and allows better visualization and the ability to work straightforwardly. However, for these purposes, we used a transvesical instead of a transcolonic port. In fact, the transvesical access to the peritoneal cavity was feasible, easy to install, and safe in a survival porcine model study. Moreover, it should be emphasized that we did not experience any complications, such as adhesions or peritonitis, even when we left the vesicotomy point unclosed.[3] However, previous studies that tried to perform cholecystectomy by natural orifice transluminal endoscopic surgery (NOTES) performed it by using a single port, either transgastric or transcolonic.[1,4,5] These approaches share common limitations, such as difficulties in performing effective retraction and dissection with triangulation. In fact, we should not forget that cholecystectomy is a moderately complex procedure, usually needing 4 to 5 trocars in the laparoscopic technique. To deal with these limitations, we combined 2 diametrically opposed ports (transgastric and transvesical), which was particularly useful.[2] [...](undefined

Estenoses benignas faringo-esofágicas: um achado crescente ainda desafiante

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Eosinophilic esophagitis-endoscopic distinguishing findings

Eosinophilic esophagitis (EE) is the most frequent condition found in a group of gastrointestinal disorders called eosinophilic gastrointestinal diseases. The hypothetical pathophysiological mechanism is related to a hypersensitivity reaction. Gastroesophageal reflux disease- like complaints not ameliorated by acid blockade or occasional symptoms of dysphagia or food impaction are likely presentations of EE. Due to its unclear pathogenesis and unspecific symptoms, it is difficult to diagnose EE without a strong suspicion. Although histological criteria are necessary to diagnosis EE, there are some characteristic endoscopic features. We present the case of a healthy 55-year-old woman with dysphagia and several episodes of esophageal food impaction over the last six months. This case report stresses the most distinguishing endoscopic findings-mucosa rings, white exudative plaques and linear furrows-that can help in the prompt recognition of this condition

N.O.T.E.S peroral transluminal endoscopic surgery

Tese de doutoramento em Ciências da Saúde (ramo do conhecimento em Medicina Clínica

Endoscopic removal of multiple sharp gastro-duodenal foreign bodies

A 45 years old female,with bipolar disorder,was brought to the Emergency Department with abdominal pain. The patient was hemodynamically stable,with no signs of respiratory distress. On abdominal examination she had pain in the upper quadrants,without peritoneal irritation. The successful endoscopic removal decreases if delayed approach, beyond 12 h, and sharp objects. Moreover in case of sharp objects, even if already into the stomach or duodenum, they should be retrieved endoscopically if it can be accomplished safely, because the risk of a complication during its natural exteriorization is as high as 35%. Extreme caution is required as it is easy to injure the wall of the gastrointestinal tract, in order to that one method involves using an overtube to protect the esophagus and another technique fashioning a protective hood. Instead we were able to remove all the needles without complication using the method described above. Lately we found in literature a similar description although using a sheath - a good option to obviate any risk for the endoscope.info:eu-repo/semantics/publishedVersio

Gaining competence in needle - knife fistulotomy - can I begin on my own?

BACKGROUND: While there are guidelines for appropriate training in ERCP, these are non-existent for needle-knife precut. The aim of this study was: (1) evaluate the experience curve of three endoscopists in needle-knife fistulotomy (NKF); (2) propose a minimum number of NKF procedures to attest proficiency. METHODS: Between November 1997 and March 2011, the first 120 consecutive NKF performed by three endoscopists (A, B, and C) were selected (360 patients) from three centers. Each group of 120 patients was chronologically ordered into three subgroups of 40.?The main outcomes were: NKF use, NKF success, and post-ERCP adverse events. RESULTS: The need for NKF did not decrease over time. The NKF success rate in the first attempt for endoscopist A and C in each of the three subgroups was 85?%/85?%, 87.5?%/87.5?%, and 87.5 %/90?%, respectively. Furthermore, both demonstrated a high NKF success in their initial 20 NKFs (85?% and 80?%, respectively). Endoscopist B however presented a different pattern as the success rate initiated at 60?%, then rose to 82.5?% and 85?% for the last group (P?=?0.03). Adverse events were mild (28 of the 32 occurrences) with no clear reduction with increased experience. CONCLUSIONS: A skillful endoscopist may expect to master NKF easily with few adverse events. While some endoscopists could begin on their own because of their innate skills, a minimal training is needed for all, as we cannot predict skills in advance. We propose a minimum of 20 NKF precuts to attest a trainee's competence in this procedure.info:eu-repo/semantics/publishedVersio

Digital rectal examination and balloon expulsion test in the study of defecatory disorders: are they suitable as screening or excluding tests?

Background. Rome III criteria add physiological criteria to symptom-based criteria of chronic constipation (CC) for the diagnosis of defecatory disorders (DD). However, a gold-standard test is still lacking and physiological examination is expensive and timeconsuming. Aim. Evaluate the usefulness of two low-cost tests-digital rectal examination (DRE) and balloon expulsion test (BET)-as screening or excluding tests ofDD. Methods. Weperformeda systematic search inPUBMEDandMEDLINE. We selected studies where constipated patients were evaluated by DRE or BET. Heterogeneity was assessed and random effect models were used to calculate the sensitivity, specificity, and negative predictive value (NPV) of the DRE and the BET. Results. Thirteen studies evaluating BET and four studies evaluating DRE (2329 patients) were selected. High heterogeneity (.. 2 > 80%) among studies was demonstrated. The studies evaluating the BET showed a sensitivity and specificity of 67% and 80%, respectively. Regarding the DRE, a sensitivity of 80% and specificity of 84% were calculated. NPV of 72% for the BET and NPV of 64% for the DRE were estimated. The sensitivity and specificity were similar when we restrict the analysis to studies using Rome criteria to define CC. The BET seems to performbetter when a cut-off time of 2minutes is used and when it is compared with a combination of physiological tests. Considering the DRE, strict criteria seem to improve the sensitivity but not the specificity of the test. Conclusion. Neither of the low-cost tests seems suitable for screening or excluding DD.info:eu-repo/semantics/publishedVersio

Transvesical route for NOTES urological applications: advances & controversies

Natural Orifice Transluminal Endoscopic Surgery (NOTES) has emerged recently in the experimental surgical field, innovating for the passage of luminal barrier, the absence of scars and reduction of post-operative pain. Among the various ports of access (transvaginal, transgastric, transvesical and transcolonic), this paper is an update on advances & controversies of transvesical port for NOTES Urological applications

Isolated gastric Kaposi's sarcoma

[Excerpt] A 47-year-old male patient presented with a 6-month A B history of epigastric pain, anorexia, weight loss of 10 kg, and night sweats. He confirmed engaging in high-risk sexual behavior. Physical examination was unremarkable, except for mild epigastric tenderness on abdominal palpation.[...