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The most frequent causes of acute upper digestive tract hemorrhage are gastroduodenal ulcers, esophageal varices and gastric erosions. Esogastric cancers, angiodysplasias and Mallory-Weiss syndromes can also become complicated by significant digestive bleedings. Much rarer is the intragastric rupture of a splenic artery aneurysm that induces a cataclysmic upper gastrointestinal hemorrhage. We present such an entity, whose exceptional peculiarity is to be associated with a pancreatic adenocarcinoma.

The world’s epidemic of obesity is responsible for the development of bariatric surgery in recent decades. The number of gastrointestinal surgeries performed annually for severe obesity (BMI > 40 kg/m2) in the United States has increased from about 16,000 in the early 1990s to about 103,000 in 2003. The surgical techniques can be classified as restrictive, malabsorptive, or mixed procedures. This article presents the results for 2 years of bariatric surgery in the authors’ minimally invasive center and analyzes the results of the most used surgical techniques with regard to eating habits. Between January 2002 and January 2004, the authors attempted operations for morbid obesity in 110 consecutive patients adequately selected by a multidisciplinary obesity unit. This represented 43% of all consultations for morbidly obese patients. The patients were classified as sweet eaters or non–sweet eaters. All sweet eaters underwent gastric bypass. The procedures included 70 Roux-en-Y gastric bypasses, 39 Mason’s vertical banded gastroplasties, and 1 combination of vertical gastroplasty with an antireflux procedure. Revision procedures were excluded. The mean age of the patients was 41.36 years (range, 23–67 years), and 72.3% were female. The mean preoperative body mass index was 44.78 kg/m2 (range, 34.75–70.16 kg/m2). The mean operating time was longer for gastric bypass than for the Mason procedure. Three patients required conversion to an open procedure (2.7%). The two operative techniques had the same efficacy in weight reduction. Early complications developed in 11 patients (10%), and late complications occurred in 9 patients (8.1%). The postoperative length of hospital stay averaged 4.4 days (range, 1–47 days; median, 4 days), and was longer in the gastric bypass group. The mortality rate was zero. Data were available 2 years after surgery for 101 of the 110 patients (91%). Most comorbid conditions resolved by 1 year after surgery regardless of the type of operation used. With zero mortality and low morbidity, bariatric surgery performed for adequately selected patients is the most effective therapeutic intervention for weight loss and subsequent amelioration or resolution of comorbidities. The patient’s eating habits before surgery play an important role in the choice of the operative technique used.

Purpose Postoperative esophagojejunal fistula induces morbidity and mortality after total gastrectomy and affects the long-term survival rate. Methods Between 2003 and 2011, 38 patients underwent laparoscopic total gastrectomy and 2 developed an esophagojejunal fistula. Results The diagnosis was established by a computed tomography scan with contrast ingestion. The absence of complete dehiscence and the vitality of the alimentary loop were checked during laparoscopic exploration, associated with effective drainage. During the endoscopy, dehiscence was assessed and a covered stent and nasojejunal tube were inserted for enteral feeding. The leaks healed progressively, oral feeding was resumed and the drains removed within 3 weeks. The stent was removed 6 weeks. Three months later, the patients were able to eat without dysphagia. Conclusions Early diagnosis allows successful conservative management. The objectives are effective drainage, covering by an endoscopic stent and renutrition. Management by a multidisciplinary team is essential.

Primary aortic thrombosis remains a rare entity that can be defined as clotting of the vessel without any obvious atheromatous lesion. Cancer chemotherapy, cocaine intake, essential thrombocythemia, some hypercoagulable states, heparin-induced thrombocytopenia, inflammatory disease of the digestive tract and acute pancreatitis are, beside some cases of rather unknown etiology, the causes of primary aortic thrombosis. Intravenous contrast-enhanced multislice CT, which is widely available, noninvasive and affordable in terms of cost, is the imaging modality of choice for the investigation of primary aortic thrombosis and the assessment of potential complications. Three cases due to chemotherapy, antiphospholipid syndrome and acute pancreatitis are reported.

The most optimal treatment for acute cholecystitis in high risk patients and severe acute cholecystitis remains still controversial. We review the outcomes of a two step treatment with percutaneous cholecystostomy and delayed laparoscopic cholecystectomy (DLC).We collected data prospectively from January 2004 to April 2010 from 26 patients that underwent percutaneous transhepatic CT-guided cholecystostomy and DLC.Percutaneous transhepatic CT-guided cholecystostomy was achieved in all cases with no complications. There was just one catheter dislodgement. Most of patients, 92%, improved after drainage. There was one case of mortality. Laparoscopic cholecystectomy was achieved in 88% of patients with no mortality, and a low rate of morbidity (7.6%) and of conversion to open surgery. Pre-operative percutaneous cholangiogram showed additional and useful information in 55.5% of patients.Two-step minimally invasive treatment combining percutaneous transhepatic CT-guided cholecystostomy and DLC is safe and feasible and report low morbi-mortality rates.

[Figure][1] ![Figure][1] [Video 1][2] Coronary Angiography The left coronary artery connected to the right coronary artery. ![Figure][1] [Video 2][3] Abnormal Flow in the Left Ventricular Outflow Tract Transthoracic echocardiography, parasternal long-axis view. In blue

The superior vena cava syndrome in malignancy is most often secondary to lung cancer where up to 10% of patients with small cell lung cancer and 2% with non-small cell lung cancer will have this syndrome. Classically, steroids, chemotherapy, and radiotherapy have been the standards of therapy. However, over the past few years, stenting has mostly replaced these standards as its advantages are rapid efficacy and giving at least equal results for the clinical syndrome in addition to allowing the securing of a biopsy tissue for diagnosis, and the clinical relief of symptoms is almost immediate.

After reading the interesting article ‘‘Predictive value of upper gastrointestinal studies versus clinical signs for gastrointestinal leaks after laparoscopic gastric bypass’’ by Madan [1] et al., we want to contribute our opinion about the use of routine imaging tests (RIT) after laparoscopic Roux-en-Y gastric bypass (LRYGB). The efficiency of upper gastrointestinal (UGI) studies relies mainly on radiologist experience; besides, it is well known that computed tomography (CT) scanning has a better sensitivity and specificity [2] than UGI studies for detection of leaks. Therefore we consider that in the case of clinical suspicions of any complications after LRYGB, a CT scan with isotonic oral contrast must be requested and UGI studies should be limited only to patients with a weight over the CT scanner limit (most frequently 180 kg). In the last few years, surgeons have acquired great experience in bariatric surgery, which has been translated into a significant decrease in leak rates [3], such that the most experienced bariatric surgeons show leak rates under 1%. For this reason, we do not support the routine use of any RIT after LRYGB, but to perform them when patient’s clinical signs and symptoms require us to do so.