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Paraganglioma is an exceedingly rare tumour of the duodenum that arises in close proximity to the ampulla of Vater. To date a total of 133 cases of duodenal paraganglioma have been reported in the literature; of these, 27 (20%) were histologically gangliocytic paragangliomas. This neoplasm generally behaves in a benign fashion, although instances of recurrence and/or lymph node metastasis have been described. The treatment consists in endoscopic polypectomy or surgical resection in relation to the histological features and the macroscopic extent of the neoplasm. We present a case of a benign duodenal gangliocytic paraganglioma treated by a laparo-endoscopic approach. We report a case of gangliocytic paraganglioma in a 75-year-old woman admitted to the General Surgery Division of Aosta Regional Hospital (Aosta-Italy), complaining of melaena and anaemia. Upper gastrointestinal endoscopy followed by enteroscopy with a video-capsula, revealed a pedunculated neoplasm in the second portion of the duodenum, with ulceration of the overlying mucosa. Multiple biopsies were performed during the endoscopic examination and showed the cellular pattern of benign paraganglioma. After stabilisation of the patient's clinical status, we performed a resection of the neoplasm via a laparoscopic transduodenal approach and a concomitant intraoperative duodenoscopy. The histological features showed a gangliocytic paraganglioma without a malignant cell pattern. The size of the neoplasm was 4 cm. The resection margins were free of neoplastic infiltration. The postoperative stay was 9 days and there were no intraoperative or postoperative complications. The patient is currently in good health without any tumour recurrence. Transduodenal laparoscopic resection with intraoperative duodenoscopy is a valuable treatment for benign gangliocytic paraganglioma of the duodenum which is unresectable by upper gastrointestinal endoscopy. This approach affords the advantages of the minimally invasive technique and fulfils the surgical tenets of the open transduodenal approach, if en bloc resection of the neoplasm with the adjacent duodenal wall is performed.

Gastroesophageal reflux disease (GERD) is a frequent illness, sometimes causing disabling symptoms and/or permanent oesophageal lesions. Etiology is multifactorial and not completely defined. Therapy is medical at first step, surgical indication is reserved to those patients with less compliance for medical therapy, unsuccessful medical therapy or reflux related complications. Different surgical techniques have been suggested for treatment of GERD, like Nissen, Rossetti or Toupet fundoplication. During the last decade laparoscopy has been proposed as a less invasive approach when surgery is indicated. From 1995 to the first months of 1999, 42 pts (28 females, 14 males, mean age 53.7 years), were operated on. Diagnosis and surgical indication were confirmed preoperatively by barium X-rays, endoscopy and 24 hrs-Ph-manometry. Hiatal hernia was demonstrated in 37 cases (88%), I or II grade esophagitis in 16 and III grade in 2; 1 patient had Barrett oesophagus. 37 pts were operated on by laparoscopic Nissen fundoplication, 5 patients had a Toupet operation. Mortality and conversion rate were 0. Complications occurred in 3 patients: 1 intraoperative pneumothorax, 1 acute cardiac ischemia in a patient with known hypertension, 1 permanent dysphagia successfully treated by endoscopic dilatation. Mean postoperative hospital stay was 6.1 days. Mean follow up was 9 months (3-48) in 100% of cases. Despite the fact that few patients were operated on by using this new less invasive approach, results are encouraging with no mortality, less morbidity and great advantages for patients.