Laparo-endoscopic management of chole-choledocholithiasis: Rendezvous or intraoperative ERCP? A single tertiary care center experience.

Introduction: The management of chole-choledocholithiasis remains a matter of debate to preserve minimal invasive management and different options have been proposed, with single- or two-stage approaches. Two techniques of single-stage approach are intraoperative ERCP and laparoscopic rendezvous, which have the great advantage of reducing the length of hospital stay with increased patient compliance. This retrospective study aims to evaluate and compare the efficacy and safety of intraoperative ERCP and rendezvous technique for more than 15 years. Materials and methods: Clinical records of 113 patients who underwent single-stage management for chole-choledocholithiasis between January 2003 and December 2020 were retrospectively reviewed using a prospectively maintained database. Patients were separated into two groups: those managed with intraoperative ERCP and those with rendezvous, and their intraoperative and postoperative parameters were compared. All patients were followed up for 6 months in an outpatient setting. Results: A total of 68 (60%) patients were treated with intraoperative ERCP, while the remaining 45 (40%) were treated with rendezvous. There were no significant differences in terms of comorbidities. ERCP was performed with a median operative time of 145 min (104-168) and an endoscopic time of 27 min (15-36). Meanwhile, rendezvous was performed with a significantly lower operative [120 min (94-147)] and endoscopic time [15 min (12-22)]. No intraoperative complications were recorded. Patients treated with rendezvous had a significantly shorter median hospitality stay [4 (3-5) vs. 3 (2-4) days, p < 0.05]. No hospital readmissions or mortalities were observed in either group after 30 days. Ten mild pancreatitis cases were observed, mainly in the intraoperative ERCP group (9 vs. 1, p < 0.05), and all were treated conservatively. Only two patients treated with intraoperative ERCP developed biliary complications later on. Conclusion: Laparoscopic rendezvous should be considered a preferable alternative to intraoperative ERCP for the treatment of patients with concomitant CBD stones and gallstones.

Necrotizing Fasciitis of the Thigh as Unusual Colonoscopic Polypectomy Complication: Review of the Literature with Case Presentation.

Necrotizing fasciitis (NF) is an infection characterized by necrosis of the superficial muscle fascia and surrounding soft tissues. It usually occurs following skin breaches from penetrating traumas or high-degree burns. Less frequently, it could be related to major abdominal surgery. However, no cases of thigh NF after minor abdominal procedures have ever been reported. A previously healthy 59-year-old male patient underwent a colonoscopic polypectomy. After the procedure, the patient developed an increasing right groin pain. The CT scan showed a gas collection in the right retroperitoneum space and in the right thigh soft tissues. Thus, a right colon perforation was hypothesized, and the patient was moved to the nearest surgery department and underwent a right hemicolectomy procedure. During surgery, the right thigh was also incised and drained, with gas and pus leakage. Nevertheless, the right lower limb continued to swell, and signs of systemic infection appeared. Afterward, clinical conditions continued to worsen despite the drainage of the thigh and antibiotic therapy, and the patient died of septic shock after just two days. This case shows that, although rare, lower limb NF should be considered among the causes of early post-operative local painful symptoms.

Successful endoscopic treatment of gastric phytobezoar: A case report.

INTRODUCTION: Gastric bezoars are a rare condition associated with situations of gastric dysmotility and prior gastric surgery, though sometimes they can present without any risk factor. We describe the first successful treatment in medical literature of a large gastric bezoar in the outpatient setting through endoscopic fragmentation. CASE PRESENTATION: A 76-year-old man was referred to our outpatient endoscopy clinic because of dyspepsia and epigastric pain. Upper GI endoscopy with a standard endoscope revealed a 10-cm-diameter gastric phytobezoar with necrotic pressure ulcer of the angulus. We fragmentized the bezoar into smaller pieces, with complete dissolution and without any complication. The patient was then promptly discharged home with a medical therapy. Follow-up endoscopy at 6 months showed the total disappearance of any residual fibers. DISCUSSION: Different types of bezoars are described in literature, of which phyto- and trychobezoars are the most frequent. They can be absolutely asymptomatic or can arise with epigastric pain, pressure ulcer bleeding, gastrointestinal perforation or small bowel obstruction. The treatment is debated though endoscopic removal or fragmentation with the help of Coca-Cola lavages has showed the best success rate. The main experiences in literature concern hospitalized patients or describe treatment techniques which require overnight stays. An effective and rapid treatment in the outpatient setting is described in our experience, without short- or long-term complications. CONCLUSION: The endoscopic fragmentation of large gastric bezoars in the outpatient setting is safe with a good clinical course.

Endoscopic management of large colorectal polyps.

OBJECTIVES: The optimal treatment for large colorectal polyps (LCPs) is still a controversial issue. The aim of this study was to evaluate the safety and effectiveness of endoscopic polypectomy (EP) of colorectal polyps >or=2 cm in size. PATIENTS AND METHODS: One hundred fifty-one EP LCPs were performed over a period of 7 years. Diathermal snare was used for pedunculated and pseudopedunculated polyps and endoscopic mucosal resection (EMR) or biopsy forceps polypectomy for sessile and flat polyps. The resected polyps were recovered and collected for histology. At scheduled follow-up visits 1, 3, 6, and 12 months after polypectomy, complications and recurrences were recorded in all patients. RESULTS: Fifteen polyps were located in the rectum, 84 in the sigmoid colon, 11 in the descending colon, four in the splenic flexure, 11 in the transverse colon, 11 in the hepatic flexure, seven in the ascending colon and eight in the cecum. Fifty-six polyps were sessile, 54 pedunculated, 25 pseudopedunculated, and 16 flat. At histology, most of polyps (131) were adenomas (nine with adenocarcinoma in situ). Five were invasive polypoid carcinomas and required colonic resection. Immediate bleeding occurred in ten patients (7.6%) and it was stopped by endoscopic hemoclips (7), epinephrine injection (1), or surgery (2). There were three perforations (2.3%; all polypoid carcinomas), managed endoscopically (1) or surgically (2). Delayed bleeding occurred in two patients (1.5%) and was treated by endoscopic diathermy and hemoclips (1) or surgery (1). During follow-up, six (4.6%) incompletely excised polyps and three (2.3%) relapses in the site of previous EP were detected and endoscopically removed. CONCLUSION: EP is relatively safe and effective for benign-appearing LCPs.