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Background: The optimal therapy for bleeding small bowel vascular lesions is controversial. This study investigated the efficacy and safety of endoscopic band ligation in this clinical condition. Methods: Fourteen patients bleeding from angiodysplasia and 4 bleeding from Dieulafoy's lesions located in the small bowel were included in this pilot study. Endoscopic band ligation was performed by using less than 200 mBar negative pressure in suctioning the target lesion into the ligation cap just before band release. Mean follow-up was 18 months (range 6–31 months). Observations : Endoscopic band ligation achieved hemostasis in a single session in all patients. No adverse events occurred except for mild abdominal pain in two patients. Mortality was null, and no patient required further blood transfusion during the 40 days after endoscopic band ligation. No patient with Dieulafoy's lesion had further bleeding, whereas bleeding recurred in 6 of 14 (43%) patients with angiodysplasia during long-term follow-up. Conclusions: Endoscopic band ligation is safe and effective for treatment of acutely bleeding small bowel vascular lesions. Although endoscopic band ligation is definitive therapy for Dieulafoy's lesion, long-term efficacy in the treatment of Gl bleeding from angiodysplasia is limited.

Pancreatic Endoscopic-Percutaneous Rendezvous Through Jejunostomy for Treating Complex Pancreatic Postsurgical Fistula Rafel Campo, Joan Falco, Enric Brullet, Felix Junquera, Valenti Puig-Divi, Mercedes Vergara, Mireia Miquel, Xavier Calvet Introduction: Management of complex pancreatic fistula can be challenging, especially in patients with gastrointestinal anatomy distorted by prior surgery. To our knowledge, this is the first time a combined endoscopic-percutaneous procedure has been used to treat pancreatic fistula. Case report: A 44-year-old male underwent subtotal esophagectomy and esophagogastric anastomosis for Boerhaave syndrome in 1994. Afterwards, he required surgical repair of a gastrocutaneous fistula on three occasions. Finally, in 2004 total gastrectomy, esophagostomy, and feeding jejunostomy were performed after a surgical attempt to repair a retroesternal gastrocutaneous fistula. A pancreato-cutaneous fistula appearing in the postoperative period did not respond to conservative management with octreotide and total parenteral nutrition. Due to the impossibility of standard ERCP, a radiological percutaneous puncture of the Wirsung duct in the pancreatic tail was performed in order to insert a drainage catheter to the duodenum. However, a Wirsung duct stenosis impeded this procedure, and it was only possible to position a guide-wire in the Wirsung duct and exit through the orifice of the cutaneous fistula. Therefore, a combined endoscopic-percutaneous procedure was performed. The jejunostomy was dilated with a 15-mm pneumatic balloon and a videogastroscope was introduced to the papilla. After cannulation of the Wirsung duct, it was only possible to place a guide-wire through the fistulous tract and exit through the cutaneous orifice, in parallel with the previously placed percutaneous guide-wire. The percutaneous guide-wire was replaced by a catheter and the endoscopic guide-wire was then introduced into the catheter until it exited through the tip of the catheter on the side of the percutaneous puncture. The catheter was withdrawn and the two extremes of the guide-wire were pulled so that it was aligned in the Wirsung duct. This made it possible to insert a 7 F plastic prosthesis through the pancreatic stenosis and resolved the fistula. Discussion: The interest of the present case is centered in three aspects not previously published: 1) The combined pancreatic endoscopic-percutaneous rendezvous to treat a pancreatic fistula, 2) the procedure to reach the papilla through a feeding jejunostomy, and 3) the technique of exchanging two guidewires that run in parallel through the cutaneous orifice of a pancreatic fistula.