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Ludovica GUERRIERO

Ospedale Monaldi
Naples, Italy
MD
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Endoscopic sleeve gastroplasty (ESG): live educational procedure with resolution of device-related complication
Endoscopic sleeve gastroplasty (ESG) is a novel endobariatric procedure with a mechanism of action totally different from the one used for a standard sleeve gastrectomy. An over-the-scope suturing system (OverStitch™, Apollo Endosurgery, Austin, TX) mounted on a dual-channel gastroscope (GIF- 2TH180, Olympus, Center Valley, PA) allowed to place full-thickness sutures in order to obtain gastric volume reduction and shrinking. The number of applied sutures relies on the gastric volume. Sutures are placed starting from the incisura to the fundus that is spared in a U-shaped fashion. A tissue-retracting helix device is used to grab the gastric wall. In this live educational video, Professor Silvana Perretta presented the case of a morbidly obese 38-year-old female patient with a BMI of 36.72kg/m2.
The procedure was performed with the patient under general anesthesia and carbon dioxide insufflation. An Overtube™ (Apollo Endosurgery, Austin, TX) was placed at the beginning of the procedure to protect the airways, the esophagus, and the hypopharynx. Each purse-string suture consisted of 6 to 8 full-thickness bites starting first on the anterior gastric wall, then on the greater curvature, and the posterior wall and moving backward in the opposite direction. Once completed, the suture was tied and knotted using a cinching device (EndoCinch™). During the live procedure, a complication occurred due to an excessive pressure placed on the EndoCinch™ handle which caused a break of the collar part of the cinch. The management of this complication was achieved by cutting the suture, so that the collar part of the cinch which grasped the mucosa could be detached with a grasper to allow for suture replacement. A total of 4 sutures were applied in order to obtain gastric tubulization.
Surgical intervention
26 days ago
185 views
5 likes
2 comments
52:53
Endoscopic sleeve gastroplasty (ESG): live educational procedure with resolution of device-related complication
Endoscopic sleeve gastroplasty (ESG) is a novel endobariatric procedure with a mechanism of action totally different from the one used for a standard sleeve gastrectomy. An over-the-scope suturing system (OverStitch™, Apollo Endosurgery, Austin, TX) mounted on a dual-channel gastroscope (GIF- 2TH180, Olympus, Center Valley, PA) allowed to place full-thickness sutures in order to obtain gastric volume reduction and shrinking. The number of applied sutures relies on the gastric volume. Sutures are placed starting from the incisura to the fundus that is spared in a U-shaped fashion. A tissue-retracting helix device is used to grab the gastric wall. In this live educational video, Professor Silvana Perretta presented the case of a morbidly obese 38-year-old female patient with a BMI of 36.72kg/m2.
The procedure was performed with the patient under general anesthesia and carbon dioxide insufflation. An Overtube™ (Apollo Endosurgery, Austin, TX) was placed at the beginning of the procedure to protect the airways, the esophagus, and the hypopharynx. Each purse-string suture consisted of 6 to 8 full-thickness bites starting first on the anterior gastric wall, then on the greater curvature, and the posterior wall and moving backward in the opposite direction. Once completed, the suture was tied and knotted using a cinching device (EndoCinch™). During the live procedure, a complication occurred due to an excessive pressure placed on the EndoCinch™ handle which caused a break of the collar part of the cinch. The management of this complication was achieved by cutting the suture, so that the collar part of the cinch which grasped the mucosa could be detached with a grasper to allow for suture replacement. A total of 4 sutures were applied in order to obtain gastric tubulization.
Anastomotic biliary stricture after liver transplantation
Biliary stricture is the most frequent complication after liver transplantation, and ranges from 5 to 32%. Biliary strictures in transplanted patients can be anastomotic and non-anastomotic. Endoscopic Retrograde Cholangiopancreatography (ERCP) is the first-line treatment modality for anastomotic biliary strictures and in selected cases of non-anastomotic biliary strictures. Anastomotic biliary strictures arise at the site of the choledocho-choledochostomy. ERCP with multiple plastic stent placements is the first-line treatment of anastomotic biliary strictures, with long-term success rates ranging from 90 to 100%. Also covered self-expandable metal stents can be used for dilation of these strictures, but not routinely.
Surgical intervention
2 years ago
1585 views
68 likes
0 comments
09:31
Anastomotic biliary stricture after liver transplantation
Biliary stricture is the most frequent complication after liver transplantation, and ranges from 5 to 32%. Biliary strictures in transplanted patients can be anastomotic and non-anastomotic. Endoscopic Retrograde Cholangiopancreatography (ERCP) is the first-line treatment modality for anastomotic biliary strictures and in selected cases of non-anastomotic biliary strictures. Anastomotic biliary strictures arise at the site of the choledocho-choledochostomy. ERCP with multiple plastic stent placements is the first-line treatment of anastomotic biliary strictures, with long-term success rates ranging from 90 to 100%. Also covered self-expandable metal stents can be used for dilation of these strictures, but not routinely.
Postoperative CBD stenosis
Benign biliary strictures are often a consequence of iatrogenic injury during laparoscopic cholecystectomy or they may arise after liver transplantation or hepatic resection with duct-to-duct biliary anastomosis. Other etiologies of benign biliary strictures are primary sclerosing cholangitis, chronic pancreatitis, and autoimmune cholangitis. In the past, surgical repair was the treatment of choice. Today, ERCP has a pivotal role in the treatment of the vast majority of these lesions. Up to 80% of postoperative benign biliary strictures develop within 6 to 12 months after surgery with symptoms as pruritus, jaundice, abdominal pain, alterations of liver function tests and recurrent cholangitis. Prompt identification of these lesions is essential because long-standing cholestasis can lead to secondary biliary cirrhosis. MRCP with cholangiographic sequences is the preferred non-invasive method for diagnostic cholangiography. In particular, this imaging method can be useful in hilar strictures and in patients with suspected anastomotic biliary stricture after liver transplantation.
Surgical intervention
2 years ago
1111 views
66 likes
0 comments
11:04
Postoperative CBD stenosis
Benign biliary strictures are often a consequence of iatrogenic injury during laparoscopic cholecystectomy or they may arise after liver transplantation or hepatic resection with duct-to-duct biliary anastomosis. Other etiologies of benign biliary strictures are primary sclerosing cholangitis, chronic pancreatitis, and autoimmune cholangitis. In the past, surgical repair was the treatment of choice. Today, ERCP has a pivotal role in the treatment of the vast majority of these lesions. Up to 80% of postoperative benign biliary strictures develop within 6 to 12 months after surgery with symptoms as pruritus, jaundice, abdominal pain, alterations of liver function tests and recurrent cholangitis. Prompt identification of these lesions is essential because long-standing cholestasis can lead to secondary biliary cirrhosis. MRCP with cholangiographic sequences is the preferred non-invasive method for diagnostic cholangiography. In particular, this imaging method can be useful in hilar strictures and in patients with suspected anastomotic biliary stricture after liver transplantation.
Common bile duct stricture due to an inoperable pancreatic head cancer: metal stent placement
There are several major indications for the endoscopic drainage of malignant common bile duct obstruction. There are several types of drainage: a preoperative biliary drainage, which is performed in selected cases (delayed surgery, high bilirubin levels, itching, cholangitis), a biliary drainage before neo-adjuvant therapies, and a biliary drainage for palliation. According to the ESGE guidelines, palliative biliary drainage should be performed according to life expectancy. If less than 4 months, plastic stent placement is recommended; if longer than 4 months, a self-expandable metal stent should be placed. In any case, every single patient should be evaluated for the best treatment. In particular, since uncovered self-expandable metal stents are impossible to remove, malignancy must be evidenced before placement of these stents.
Surgical intervention
2 years ago
925 views
83 likes
0 comments
18:14
Common bile duct stricture due to an inoperable pancreatic head cancer: metal stent placement
There are several major indications for the endoscopic drainage of malignant common bile duct obstruction. There are several types of drainage: a preoperative biliary drainage, which is performed in selected cases (delayed surgery, high bilirubin levels, itching, cholangitis), a biliary drainage before neo-adjuvant therapies, and a biliary drainage for palliation. According to the ESGE guidelines, palliative biliary drainage should be performed according to life expectancy. If less than 4 months, plastic stent placement is recommended; if longer than 4 months, a self-expandable metal stent should be placed. In any case, every single patient should be evaluated for the best treatment. In particular, since uncovered self-expandable metal stents are impossible to remove, malignancy must be evidenced before placement of these stents.
ERCP: acute cholangitis in a patient with antiplatelet (clopidogrel) therapy
Acute cholangitis is a clinical emergency. Urgent biliary drainage and bile ducts disobstruction represent the only effective therapy. Acute cholangitis is a result of bile flow obstruction and bile infection. Both ERCP and percutaneous biliary drainage are valid therapeutic options associated with antibiotics. ERCP with biliary sphincterotomy and stones clearance is less invasive and generates less discomfort as compared to percutaneous biliary drainage. Percutaneous biliary drainage is reserved for patients in poor or bad clinical conditions and co-morbidities, unavailability of ERCP or surgically altered anatomy unsuitable for ERCP. We present a case of an 81-year-old female patient with antiplatelet therapy (Plavix®/clopidogrel) and cholangitis. During ERCP, there was evidence of previously unreported small biliary sphincterotomy. Consequently, biliary balloon dilation followed by stones extraction were performed. A nasobiliary drainage was also placed to flush the bile ducts with saline over 24 hours.
Surgical intervention
2 years ago
563 views
93 likes
1 comment
09:17
ERCP: acute cholangitis in a patient with antiplatelet (clopidogrel) therapy
Acute cholangitis is a clinical emergency. Urgent biliary drainage and bile ducts disobstruction represent the only effective therapy. Acute cholangitis is a result of bile flow obstruction and bile infection. Both ERCP and percutaneous biliary drainage are valid therapeutic options associated with antibiotics. ERCP with biliary sphincterotomy and stones clearance is less invasive and generates less discomfort as compared to percutaneous biliary drainage. Percutaneous biliary drainage is reserved for patients in poor or bad clinical conditions and co-morbidities, unavailability of ERCP or surgically altered anatomy unsuitable for ERCP. We present a case of an 81-year-old female patient with antiplatelet therapy (Plavix®/clopidogrel) and cholangitis. During ERCP, there was evidence of previously unreported small biliary sphincterotomy. Consequently, biliary balloon dilation followed by stones extraction were performed. A nasobiliary drainage was also placed to flush the bile ducts with saline over 24 hours.