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Background: Management of biliary disorders in patients with altered anatomy may be challenging. EUS-guided gastrointestinal anastomosis using lumen apposing metal stent (LAMS) have been introduced to allow endoscopic retrograde cholangiography (ERC) in such cases. However the appropriate stent indwelling time is still uncertain. We report long-term LAMS deployment after duodeno-jejunal or jejuno-jejunal anastomosis (EUS-DJA) to allow endoscopic re-interventions in case of recurrences. Methods: 11 consecutive patients underwent to EUS-DJA with long standing LAMS between January 2017 and December 2018. ERC treatment was carried out over a 12 months period with multiple endoscopic sessions across DJA. Results: Technical success was 91% (10/11 pts) for EUS-DJA and 100% for ERC. Four patients presented stricture recurrence after an average of 489±31.7 days from the end of ERC treatment. A novel ERC across LAMS anastomosis was feasible in all cases. At average of 781 days±253 all LAMS are still in place with no evidence of any adverse event. Conclusion: Long-term LAMS placement after EUSDJA may be feasible and safe in order to maintain a direct access to the excluded limb.

Introduction: Surgery is the gold standard treatment of morbid obesity and its related co-morbidities. However early or late surgical related adverse events(AE) occurs in 4 to 25% of patients requiring, in most cases, re- interventions. Endoscopy is an effective treatment especially if it is per- formed soon after occurrence of AE. However a comprehensive evalua- tion of long-term results and need for revisional surgery after endoscopic management is lacking. aims & Methods: The aim of this study is to report overall results and long- term outcomes of patients underwent to endoscopic management for AE following bariatric surgery in a tertiary interventional endoscopic center. From January2013 to April2019, 830 consecutive patients(640F), average age 44(17 - 72), underwent upper GI endoscopy for suspected AE following obesity surgery. 651 patients underwent Sleeve Gastrectomy, 167 gastric-by-pass(98 Roux- en-Y and 69 Omega)(GBP)and 12 had lap-band. 168 patients presented an AE after revisional bariatric surgery. 358 patients were addressed for sepsis due to supposed leak(extravasation of medium contrast). 226 patients presented dysphagia due to GI stenosis. 201 subjects presented fistula(abnormal communication between two re- epithelized structures or skin due to previous placement of surgical drain- age). 28 patients had a perigastric intra-abdominal collection. 12 patients had partial intragastric migration of gastric band. 5 presented weight regain following GBP for enlargement of G-J anas- tomosis. Endoscopic management according to the different type of AE were one or an association of the following: endoscopic internal drain- age, septotomy, stenting with Lumen apposed metal stent, Argon plasma coagulation(APC) anastomotic remodeling and trans-oral lap band abla- tion. Clinical success was defined as follows: leak and fistula: no medium con- trast extravasation, no chemistry tests alterations no need for prolonged antibiotics therapy. Stricture: adequate passage of medium contrast at swallow study or easy crossing of the stricture with a standard gastro- scope. Lap band migration:uneventful removal. Loss of excess weight after G-J anastomotic remodeling with APC. Long term clinical success was con- sidered after a minimum follow up of more than 18 months. results: 89 patients underwent endoscopy after one week from index surgery(5,13 ± 1,92days), 451 between 8 and 42days(19,63 ± 9,17), 93 patients between 43 and 91days(60,34 ± 13,07) and 197 after more than 91days(854,93 ± 1170,37). Overall mean period was of 223days(0-2100) from index surgery. 70 patients(8.4%) presented normal findings at upper endoscopy. An average of 6 endoscopic sessions(1-31) were needed to achieve AE reso- lution in 72%(598) of patients. At long follow up (more than 18 months) 16%(96 out 598) of patients healed were lost whereas. 8%(66) are still under treatment. Overall mortality was of 0,6%(5 out 830) whereas overall AE related to en- doscopic treatment was of 2%(15)namely bleeding, stent migration with/ or perforation. 3 patients with perforation required emergency surgery. 11.%(91 patients) underwent revisional surgery either for endoscopic treat- ment failure or poor quality of life after an average of 331days(15 - 1400). conclusion: According to this large case series endoscopy plays a pivotal role in the management of AE following bariatric surgery guaranteeing good results with low morbidity and mortality rates avoiding emergency surgery in 65% of cases. However several endoscopic sessions are needed. Long-term follow up showed that 11% of patients require, revisional sur- gery, either in case of endoscopic clinical success.

Introduction: Complete transection of the common bile duct is a dramatic complication after biliary surgery especially after laparoscopic cholecystectomy. Since 1995 we have proposed an endoscopic – radiologic rendez-vous that successfully obtains the reconstruction of the biliary tree in a minimal invasive way. After treatment with 4 or 5 biliary plastic stents left in place for at least one year1 patients were followed up for at least five years. Aims and Methods: Since 1995, 91 patients were treated for complete transection of the common bile duct: 3 patients had traumatic biliary section, 88 iatrogenic, (73 after lap.chole. 15 after open surgery). All patients were successfully treated with endoscopic-radiologic rendez-vous and after right and left transhepatic approach 4 or 5 plastic 10 F stents were radiologically put in place. After 12 months, the stents were endoscopically removed and a control cholangiography with an ERCP was performed. If stones and sludge were found they were removed. In case of duct stenosis a new transhepatic approach was made and several plastic stents put in place again for 12 months. The patients were followed up for 5 years with blood analysis, ultrasounds and MR cholangiography. Results: 60 patients were evaluated as 21 were lost at follow-up and 10 are under treatment, 44 patients (73%) are well after 5 years without any symptoms of cholestasis and biliary dilatation at MR cholangiography. 2 patients died for sepsis after 6 and 12 months of treatment. 4 patients had cholangitis after 6 and 8 months: the stents were removed and replaced after recovery, 16 patients had stenosis of the main bile duct after stent removal: they were treated again with 4 plastic stents for 1 year, 8 patients had stenosis recurrence during follow up after 2 or 3 years: they were treated endoscopically and a fully covered selfexpanding metallic stent left in place for one year. All patients, also those retreated, are well after 5 years of follow up. Conclusion: The radiologic-endoscopic rendez-vous is a safe and efficient technic for minimal invasive treatment of the common bile duct complete section. It is challenging for the radiologist as the intrahepatic biliary ducts are thin and for the endoscopist that has to puncture the duct often clipped. It requires many sessions for complete treatment and in a few cases treatment for stenosis recurrence but in this way we can avoid surgical treatment on the biliary tree that requires difficult intervention which has a high morbidity and mortality. Disclosure: Nothing to disclose

Alcohol use disorder (AUD) is one of the most common psychiatric disease in the general population, characterized by having a pattern of excessive drinking despite the negative effects of alcohol on the individual's work, medical, legal, educational, and/or social life. Currently, the bio-psycho-social model describes properly AUD as a multidimensional phenomenon including biological, psychological, and socio-cultural variables affecting the nature, maintenance, and expression of the disorder. The AUD diagnostic process is crucial since the treatment success depends heavily on the accuracy and the adequacy of the diagnosis. The diagnosis is based on a comprehensive assessment of the patient's characteristics and uses interviews and psychometric instruments for collecting information. This paper will provide insights into the most important psychological dimensions of AUD and on the best psychometric instruments for proposing AUD diagnosis.

The phenomenon of homeless people is eliciting a devastating social impact with an estimated prevalence in the USA and in Europe between 5.6% and 13.9%. These persons have a poor quality of life, a limited or no social life. They are often unemployed or work only occasionally. They are at risk for problems with the law and often suffering from addiction to other drugs, psychiatric and other medical diseases. Alcohol is often not the cause of their social status, but only the result of other discomforts thus contributing to their bio-psycho-social degradation. In 2009 the US Department of Housing and Urban Development’s Homelessness Assistance Programs and in 2010 the European Consensus Conference on Homelessness discussed about the social rehabilitation of these people, using the concept of case management. In particular, the Standard Case Management was able to improve the housing stability, to reduce the use of drugs and to remove the working barriers. The Assertive Community Treatment was able to improve the housing stability and had a better efficacy for patients suffering from double diagnosis.

Alcohol withdrawal syndrome (AWS) is a medical emergency, rare in the general population, but very common among alcoholic individuals, which can lead to severe complications when unrecognized or late treated. It represents a clinical condition which can evolve in few hours or days following an abrupt cessation or reduction of alcohol intake and is characterized by hyperactivity of the autonomic nervous system resulting in the development of typical symptoms. According to DSM-5 criteria, the alcohol withdrawal syndrome is defined as such: if patients present at least two of typical signs and symptoms. The Clinical Institute Withdrawal Assessment of Alcohol Scale, revised version (CIWA-Ar), is the tool for assessing the severity of AWS. The support to patient with AWS includes pharmacological intervention as well as general support, restoration of biochemical imbalances and specific therapy. Regarding the pharmacological treatment, benzodiazepines represent the gold standard, in particular long-acting benzodiazepines, administered with a gradual reduction up to cessation.

Background: Gastro-bronchial and gastro-colic fistulas (GB-GC) represent a rare, but serious complication after laparoscopic sleeve gastrectomy (LSG). The aim of this study is to evaluate the efficacy of endoscopic first-line approach with endoscopic internal drainage (EID) by inserting double pigtail stents (DPS) Methods: We retrospectively analyzed data from 40 consecutive patients referred at two tertiary centers for gastro-bronchial (N=30) and gastrocolic (N=10) fistulas following LSG. Nineteen patients previously experienced emergency surgical drainage. The mean interval between the index surgery and endoscopic fistula treatment was 265.6±521 days. Results: Healing of the fistulous tract was achieved in 19 patients (47.5%), with complete resolution at an average follow-up of 16 months. Mean time of treatment duration was 157.8±141 days with 5.0±2.9 endoscopic sessions. No major adverse events were registered. Conclusions: Despite complete fistula healing was achieved in less than 50% of our population, EID for GB/GC fistula after LSG still represents the most conservative approach with low complications rate. Previous surgical drainage seems to be a positive prognostic factor for endoscopic healing. While the longer the interval between the index surgery and endoscopic treatment, the lower was the rate of treatment success. Graphical abstract: [Figure not available: see fulltext.]

Gastrointestinal leaks and fistulae are serious, potentially life threatening conditions that may occur with a wide variety of clinical presentations. Leaks are mostly related to post-operative anastomotic defects and are responsible for an important share of surgical morbidity and mortality. Chronic leaks and long standing post-operative collections may evolve in a fistula between two epithelialized structures. Endoscopy has earned a pivotal role in the management of gastrointestinal defects both as first line and as rescue treatment. Endotherapy is a minimally invasive, effective approach with lower morbidity and mortality compared to revisional surgery. Clips and luminal stents are the pioneer of gastrointestinal (GI) defect endotherapy, whereas innovative endoscopic closure devices and techniques, such as endoscopic internal drainage, suturing system and vacuum therapy, has broadened the indications of endoscopy for the management of GI wall defect. Although several endoscopic options are currently used, a standardized evidence-based algorithm for management of GI defect is not available. Successful management of gastrointestinal leaks and fistulae requires a tailored and multidisciplinary approach based on clinical presentation, defect features (size, location and onset time), local expertise and the availability of devices. In this review, we analyze different endoscopic approaches, which we selected on the basis of the available literature and our own experience. Then, we evaluate the overall efficacy and procedural-specific strengths and weaknesses of each approach.

Introduction: Treatment of pancreato-biliary disorders after gastric bypass is challenging due to altered anatomy. Several techniques have been proposed to overcome this condition; however, none has emerged as the gold standard treatment. Furthermore, a decision-making algorithm evaluating when and why apply one technique over another is still lacking. Objectives: To describe a novel trans-gastric approach to allow endoscopic retrograde cholangiopancreatography (ERCP) in Roux-en-Y gastric bypass (RYGB) anatomy soon after prior laparoscopic cholecystectomy (LC) and to propose a decision-making algorithm for selection of the most suitable technique according a tailored approach. Setting: Private hospital. Methods: Between January and March 2020, patients with Roux-en-Y gastric bypass anatomy referred to our tertiary center to undergo ERCP after recent laparoscopic cholecystectomy were retrospectively evaluated. A 20 french (Fr) gastrostomy was performed during cholecystectomy. A single-stage ERCP was carried out by means of temporary trans-gastric stent deployment over a 20 Fr gastrostomy. Results: A total of 5 patients (mean age 41; mean body mass index 48.3) were enrolled. ERCP was performed after an average of 2 days from surgery. Technical and clinical success was achieved in 100%. No adverse events occurred. Spontaneous closure of the gastrostomy after its bedside removal was observed in all cases. Conclusions: Our approach allows to perform a single-stage ERCP in RYGB patients, early after LC, with no need of any other re-interventions. Any surgeon facing unexpected biliary disorders, during LC, can easily perform a 20 Fr gastrostomy thus allowing the patient to undergo early ERCP without any delay.

Aim Diverticular disease is widespread worldwide. Mainstay approach is non-operative treatment with bowel rest and broad-spectrum intravenous antibiotics. However, extra-colic abscess larger than 4 cm may require percutaneous trans-abdominal drainage. We report a single centre case series of patients underwent to trans-luminal endoscopic ultrasound (EUS)-guided drainage of pelvic abscess in diverticular disease with temporary placement of lumen apposing metal stent (LAMS). Methods All patients referred to our tertiary centre from January 2019 to July 2020 were enrolled in a prospective data base that was retrospectively analysed. Procedural steps were as follows: pre-operative computed tomography scan, broad-spectrum antibiotic therapy, EUS-guided deployment of LAMS for 15 days, LAMS removal and deployment of pigtail stent in case of pseudo-cavity persistence. Results Ten patients (6F) with an average of 59.6 years were enrolled with deployment of 10 LAMS. One patient was excluded after EUS evaluation and 1 patient had 2 LAMS for 2 separate abscesses. Technical and clinical success was achieved in 88.8% (8/9). Conclusions Management of diverticulitis has shifted from primary surgical intervention towards a non-operative approach of bowel rest and broad-spectrum intravenous antibiotics in conjunction with interventional procedures to drain abscesses whenever necessary. EUS-guided drainage with LAMS for the management of diverticular abscesses seems an efficient treatment modality for encapsulated abscesses more than 4 cm in size and close to colonic wall. In expert centres, it may avoid radiologic intervention and/or surgery in a relevant percentage of cases.