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Roux-en-Y gastric by-pass (RYGB) is one of the most effective bariatric procedures, but the rate of weight regain (WR) can reach 63% after the second year. Enlargement of the gastrojejunal anastomosis is one of the reported causes. A newly CE-marked flexible endoscopic system, Bariatric Anastomotic Reduction System (BARS) (Ovesco Endoscopy, Tuebingen, Germany), derivative of the well-established endoscopic over-the-scope-clip (OTSC) clipping system, has been recently developed. It was tested in pre-clinical and preliminary clinical use for feasibility and effectiveness in bariatric anastomotic reduction.Using a single-channel endoscope with external supplemental working channel, the BARS device captures the two limbs of the anastomosis, reducing its size, thus slowing food passage. After preclinical assessment, six patients with at least a 15% WR and the presence of an enlarged gastrojejunostomy20 mm were enrolled. The mean patient age was 49 years (range 24-67). Average interval between gastric bypass and BARS procedure: 8 years (4-13).All procedures were safely performed without complications. Mean procedure time: 52 min (37 - 75). Preliminary results: mean weight loss 6 kg (4-9) at a 3-month FU.BARS could be a promising endoscopic system in case of WR after gastric bypass due to enlargement of the anastomosis.

The laparoscopic Roux-en-Y gastric bypass (LRYGB) is the gold standard treatment for morbid obesity. After LRYGB, the endoscopic access to the gastric remnant and pancreaticobiliary system is challenging. The laparoscopic gastric bypass with fundectomy and exploration of the gastric remnant (LRYGBfse) was introduced in an attempt to overcome this limitation. The purpose of this study was to analyze the medium-term outcomes and safety of LRYGBfse. Observational prospective single-arm multicenter cohort study. Patients with BMI > 35 kg/m2 were included. Previous open abdominal surgery was an exclusion criterion. Postoperative 1, 2, 3, and 5-year weight loss, BMI decrease, and percentage of excess weight loss (%EWL) were recorded. Wilcoxon signed rank sum test was used for paired data. Among 653 enrolled patients, 229 completed the 5-year follow-up. Preoperative median body weight (kg) and BMI (kg/m2) were 133.4 kg (interquartile range (IQR) = 12.0) and 48.2 kg/m2 (IQR = 10.1), respectively. Median 5-year body weight, BMI, and %EWL were 83.7 (IQR = 17.3), 31.2 (IQR = 7.7), and 74.8 (IQR = 23.4), respectively, all significantly improved compared to baseline (p = 0.002, p = 0.001, and p = 0.012, respectively). Comorbid improvement or resolution was observed in 88% of the patients. No major intraoperative complications were reported. Postoperative overall morbidity and mortality rates were 1 and 0%, respectively. Banding removal was necessary in one patient 62 months after the index operation. The LRYGBfse seems safe and effective with durable results at 5-year follow-up. Endoscopic exploration of the gastric remnant is an additional valuable tool.

OBJECTIVE Evaluate if bariatric surgery can improve hypertension (HPT) control leading to both reduction of blood pressure values and antihypertensive therapy withdrawal. METHODS Eight-hundred and sixty-four consecutive patients who referred to our hospital, from March 2001 to February 2011, because of morbid obesity were initially enrolled in this retrospective study. To obtain two comparable groups, propensity-matching was applied. Finally, the study included 444 (51% out of initial 864 patients), 222 on diet (group D) and 222 patients undergoing surgery (group S). RESULTS In group D, sistolic blook pressure (SBP) showed a significant increase (135 ± 14 vs 138 ± 11 mmHg; P = 0.006); conversely in group S, SBP decreased (130 ± 14 vs 124 ± 9 mmHg; P = 0.001). In group D, diastolic blood pressure (DBP) showed a significant increase (80 ± 6 vs 82 ± 6 mmHg; P = 0.004); conversely in group S, DBP decreased (81 ± 9 vs 79 ± 8 mmHg; P = 0.015). Among 136 patients with HPT, 73 (53%) withdrew antihypertensive therapy: significantly more in group S (55/63, 87%) than in group D (17/56, 23%), P

Gastric cancer is the world's second most common malignancy. In the U.S., patients present with advanced disease, and surgery with curative intent accounts for only 30% of gastric malignancies. Palliative surgery has significant morbidity and mortality. Recently, there have been encouraging reports of self-expanding endoprostheses in obstructing gastrointestinal neoplasms. We report a case of a 70-yr-old woman with inoperable outlet stenosis secondary to a mucinous infiltrating adenocarcinoma involving nearly the entire stomach, except the anterior wall, which provided a percutaneous access site for gastrostomy and subsequently successful management of outlet obstruction with metallic stents.

Transjugular liver biopsy is the method of choice for evaluating the cause of diffuse hepatic disease when a percutaneous biopsy route is contraindicated. This route has also been used for renal biopsies in patients with clotting disorders when the percutaneous route would be similarly precluded. Masses in the vena cava present a problem for obtaining biopsy specimens. We describe the transjugular approach using the Quick Core Biopsy System* as an alternative to obtaining biopsies of tumors in the vena cava.

Gastrointestinal perforations are conservatively managed at endoscopy by through-the-scope endoclips and covered self expandable stents, according to the size and tissue features of the perforation. This is believed to be the first report of successful closure of two gastro-cutaneous fistulas with over-the-scope clips (OTSCs). After laparoscopic gastric banding, a 45-year old woman presented with band erosion and penetration. Despite surgical band removal and gastric wall suturing, external drainage of enteric material persisted for 2 wk, and esophagogastroduodenoscopy demonstrated two adjacent 10-mm and 15-mm fistulous orifices at the esophagogastric junction. After cauterization of the margins, the 10-mm fistulous tract was grasped by the OTSC anchor, invaginated into the applicator cap, and closed by a traumatic OTSC. The other 15-mm fistula was too large to be firmly grasped, and a fully-covered metal stent was temporarily placed. No leak occurred during the following 6 wk. At stent removal: the OTSC was completely embedded in hyperplastic overgrowth; the 15-mm fistula significantly reduced in diameter, and it was closed by another traumatic OTSC. After the procedure, no external fistula recurred and both OTSCs were lost spontaneously after 4 wk. The use of the anchor and the OTSC seem highly effective for successful closure of small chronic perforations.

To investigate the postoperative pulmonary and abdominal findings following uncomplicated percutaneous laparoscopic cholecystectomy, 27 patients were studied by upper abdominal CT within 24 h of the surgical procedure. Both pneumoperitoneum (70%) and subcutaneous emphysema (56%) were commonly observed. Postoperative atelectasis and pleural effusions were observed in 44 and 33% of the patients, respectively. Forty-eight percent of the patients had a postoperative ileus demonstrated by CT. Approximately 22% of the patients had fluid in the abdomen as either edema in the gallbladder fossa or small amounts of ascites. In our patients the amount of ascitic fluid was small and no clinical significance could be attributed to the intraabdominal fluid collections.

Our case of a parastomal hernia is rare because the stomach became incarcerated in the hernial sac. The diagnosis of parastomal hernia is not a difficult one, but one must be aware of the possible complications of the colostomy and the rare occurrence of the parastomal hernia containing the stomach.

Intramural diverticulosis of the esophagus is a rare disease of unknown etiology with a characteristic esophagogram consisting of small flask-like diverticula. This paper presents the ninth patient with this disease. There has been confusion about the etiology of the disease and its relation to monilial esophagitis, and this differential diagnosis is discussed. Although the etiology remains speculative, we conclude that intramural diverticulosis of the esophagus may develop in a normal esophagus and that it is not caused byMonilia.

A case of a mucus-secreting carcinoma of the stomach with calcification has been presented. Calcification in gastric carcinoma is rare, with only 13 previously reported cases found in the English literature. The fine, sand-like calcification found in gastric carcinomas appears to be characteristic of a mucus-secreting tumor.

Although chemodectomas of the mediastinum are uncommon lesions, they have very characteristic arteriographic findings. When a vascular tumor mass is found in the region of the aortic bodies, mediastinal chemodectoma should be considered. Angiography is valuable in defining the vascular supply and determining the resectability of mediastinal chemodectomas.

Water soluble contrast myelography has been associated with a variety of complications. The inadvertant injection of air into the thecal sac may produce an apparent extramedullary, intradural defect on myelography. Post myelography CT examination should be used to confirm the presence of such a pseudolesion.

An upside-down configuration of the spleen can be mistaken for a left suprarenal mass. A radioisotopic liver-spleen scan will demonstrate a characteristic appearance of the spleen with its hilus superiorly and its convex border medially and adjacent to the kidney. When a left suprarenal mass is identified, we advocate the liver-spleen scan as the first step in the diagnostic workup. If the typical configuration is found, no further studies are necessary.

A case of renal liposarcoma is described. The clinical presentation, angiographic findings and treatment are discussed.

A CT examination of a woman with an intraocular melanoma revealed a high density mass lesion with an adjacent retinal detachment of slightly lower density. The “double density” identified in this case can serve as a useful sign in distinguishing melanomatous lesions with accompanying retinal tears.

• We report three cases of ureteral obstruction producing hydronephrosis following aortofemoral bypass graft. In each case, the obstruction occurred in the area where the ureter crossed over the limb of a Dacron graft. Ureterolysis relieved the obstruction. Most of the previously reported cases of this complication of bypass surgery occurred when the ureter was situated between the limb of a graft and the patient's own iliac artery. Various methods of surgical approach are listed. In some cases, ureterolysis is a suitable alternative to division and reanastomosis of the ureter to relieve obstruction. (Arch Surg114:853-856, 1979)