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Obesity, insulin resistance, and metabolic syndrome continue to increase in prevalence. Hypertriglyceridemia is commonly associated and represents a valuable marker of metabolic syndrome. An increase in subcutaneous fat deposition places patients at risk for visceral adipose deposition in sites such as the liver, heart, and pancreas. Pancreatic steatosis in the setting of metabolic syndrome is a rapidly emerging entity whose clinical spectrum remains to be defined. Hypertriglyceridemia is an accepted cause of acute pancreatitis but its role in chronic pancreatic injury remains to be explored. We present 3 patients with chronic abdominal pain and pancreatic steatosis in the setting of underlying metabolic syndrome with hypertriglyceridemia. These cases were identified in one endoscopic ultrasonographer’s practice over a 12-month period. Each patient had documented hypertriglyceridemia but no history of acute hypertriglyceride-induced pancreatitis. A history of significant alcohol exposure was carefully excluded. Each patient underwent endoscopic ultrasonography (EUS) which proved critical in delineating the spectrum of chronic pancreatic injury. Each of our patients had EUS documentation of pancreatic steatosis and sufficient criteria to establish a diagnosis of chronic pancreatitis. Intraductal pancreatic calculi were identified in all 3 patients. Our series suggests that in the setting of metabolic syndrome, chronic hypertriglyceridemia and pancreatic steatosis may be associated with chronic pancreatitis. We hypothesize that hypertriglyceridemia may provide a pathogenic role in the development of chronic pancreatic microinjury. In addition, each of our patients had EUS-documented pancreatic ductal lithiasis. To our review, these are novel findings which have yet to be reported. We believe that with an enhanced awareness, it is likely that the entity of metabolic syndrome with features of pancreatic steatosis and hypertriglyceridemia with their associated manifestations of chronic pancreatitis, including ductal lithiasis, will be widely appreciated.

The aim of this study was to evaluate the mechanisms of failure after laparoscopic fundoplication and the results of revision laparoscopic fundoplication.Laparoscopic Nissen fundoplication has become the most commonly performed antireflux procedure for the treatment of gastroesophageal reflux disease, with success rates from 90 to 95%. Persistent or new symptoms often warrant endoscopic and radiographic studies to find the cause of surgical failure. In experienced hands, reoperative antireflux surgery can be done laparoscopically. We performed a retrospective analysis of all laparoscopic revision of failed fundoplications done by the principle author and the respective fellow within the laparoscopic fellowship from 1992 to 2006.A review was performed on patients who underwent laparoscopic revision of a failed primary laparoscopic fundoplication.Laparoscopic revision of failed fundoplication was performed on 68 patients between 1992 and 2006. The success rate of the laparoscopic redo Nissen fundoplication was 86%. Symptoms prior to the revision procedure included heartburn (69%), dysphagia (8.8%), or both (11.7%). Preoperative evaluation revealed esophagitis in 41%, hiatal hernia with esophagitis in 36%, hiatal hernia without esophagitis in 7.3%, stenosis in 11.74%, and dysmotility in 2.4%. The main laparoscopic revisions included fundoplication alone (41%) or fundoplication with hiatal hernia repair (50%). Four gastric perforations occurred; these were repaired primarily without further incident. An open conversion was performed in 1 patient. Length of stay was 2.5 +/- 1.0 days. Mean follow-up was 22 months (range, 6-42), during which failure of the redo procedure was noted in 9 patients (13.23%).Laparoscopic redo antireflux surgery, performed in a laparoscopic fellowship program, produces excellent results that approach the success rates of primary operations.

Background: Preoperative evaluation of patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGBP) has included esophagogastroduodenoscopy (EGD) with little data to substantiate its use. Methods: A retrospective analysis was conducted of patients from Feb 04 to Mar 05 who underwent preoperative EGD and subsequently LRYGBP. Results: 169 patients underwent EGD prior to surgery. Their mean age was 41.1 years (range 14-66), mean BMI 49.7 (range 35-78), and 82% were females. There were no complications from EGD. Significant findings in patients at EGD included gastric ulceration in 3 (2%), duodenal ulcer in 1 (0.7%), Barrett's esophagus in 2 (1.3%), and a GI stromal tumor (GIST) in 1 (0.7%). EGD revealed hiatal hernias in 56 (35.2%), esophagitis in 28 (17%), Schatzki's ring in 5 (3%), gastritis in 43 (27%), gastric polyps in 8 (5%), and duodenitis in 9 (6%). 53 patients (33.3%) had a negative EGD. Ulcer and severe gastritis, esophagitis, and duodenitis diagnosed preoperatively were treated medically before surgery. 9 hiatal hernias were repaired intraoperatively. The patient with the GIST underwent laparoscopic near-total gastrectomy and gastric bypass, while 1 patient with an antral polyp underwent laparoscopic partial gastrectomy in addition to the LRYGBP. Conclusion: EGD is essential for diagnosis of GI diseases including tumors, ulcers, and hiatal hernias that alter the medical and surgical management of patients undergoing gastric bypass.

Background: The initial use of verapamil for the symptomatic treatment of microscopic colitis is reported. Study: Four patients diagnosed with microscopic colitis who failed to respond to conventional therapy are presented. Results: Verapamil was instituted, resulting in prompt and sustained resolution of symptoms. Conclusions: This therapy was convenient and well tolerated.

Excerpt Foreign bodies are commonly encountered in the gastrointestinal tract. Most produce no symptoms, and only 10% to 20% fail to traverse the entire gut (1). Considerable morbidity and mortalit...

The Impact of Colonscopic Electrocautery on Pacemaker Function Navin Kumar, Hemant Roy, Alan Zunamon, Eva Gliwa, Mick Meiselman, Michael Goldberg, Tat-Kin Tsang, Randall Brand Background: While some guidelines advocate inactivation of pacemakers prior to use of electrocautery for colonoscopic polypectomy, this is not done by most endoscopists. These recommendations are based upon expert opinion, small non-blinded studies and anecdotal case reports. In order to provide evidencebased insight into this issue, we performed a pilot study analyzing the risk of electrocardiographic abnormalities during cautery. Methods: A total of 19 patients were enrolled in this study. Each patient had rhythm strips run preand post-colonoscopy, when the cecum was reached and during all episodes of cautery use. Continuous ECG rhythm monitoring was also performed during the colonoscopy. The technique (continuous vs. brief, short bursts) of cautery was dependent on the endoscopist preference. The grounding electrode was placed on the patient’’s buttock or thigh. Identified preand post-procedure strips along with either an unidentified cecal (control) or cautery strip were grouped together and evaluated by a cardiologist blinded to the cautery status of the third strip. Results: Eight of the 19 patients underwent a total of 18 polypectomies using electrocautery. No incidence of pacemaker dysfunction or change in cardiac rhythm occurred in the control or cautery groups. All 19 patients tolerated each colonoscopy without any other adverse cardiac events or complications. Conclusion: This study suggests that electrocautery use is safe in patients with pacemakers as along as the electrocautery pad is positioned on the lower part of the body away from the pacemaker. To our knowledge this is the first blinded, prospective trial demonstrating the safety of performing electrocautery during colonoscopy in patients with a pacemaker. If confirmed with larger patient numbers, this would strongly argue for new practice recommendations.

We report a case of pancreatic duodenal fistula as a complication of peptic ulcer disease. Complete healing of the ulcer and fistula was achieved with intensive medical therapy. No surgical intervention was required. The unique radiographic and endoscopic features of the case are presented and pertinent literature is reviewed.

Campylobacter pylori has been associated with gastritis, duodenitis, and duodenal ulceration in the immunocompetent individual. It has been described within the superficial mucus layer, in interepithelial junctions, and occasionally in the microcanaliculi of epithelial cells, but never in the lamina propria. We describe a case of invasive C. pylori in a patient with the acquired immunodeficiency syndrome and discuss its clinical presentation and histopathological findings.

We report 2 homosexual patients with the acquired immune deficiency syndrome and histopathologic evidence for cytomegalovirus colitis. In each case, the initial endoscopic impression was Kaposi's sarcoma but the appropriate diagnosis was made by histologic demonstration of a cytomegalovirus vasculitis. Clinical manifestations may include diarrhea, abdominal pain, and hematochezia. Fulminant progression to gangrenous bowel was documented in 1 patient and was associated with histologic evidence of severe cytomegalovirus vasculitis. The pertinent clinical, endoscopic, and pathologic findings are reviewed.

Patients with Crohn's disease of the small bowel or the colon are at risk for development of cancer within their chronically inflamed intestinal loops. We present here the first reported case of malignant degeneration of duodenal mucosa involved by Crohn's disease. The clinical observations as well as radiographic and endoscopic features of this unusual complication are described.

Some authors believe the endoscopic placement of large biliary prostheses has become the preferred palliative treatment for unresectable malignant obstruction of the biliary ducts.4 The success rate for inserting these stents endoscopically has approached 90%.3.5.6 In a collected series the mean survival of stented patients has ranged from 13 months for those with ampullary cancers to 5 months for patients with lesions above the midcommon bile duct. However, the presence of prior Billroth II partial gastrectomy with its attendant difficulty in ampullary access has been cited for causing failures of endoscopic approach to prosthetic placement.• Other methods of combined percutaneous-endoscopic biliary stenting (PEBS) that achieve placement of 10-11.5 F internal biliary stents with relative ease have recently been described.4.8·9 Our recently described techniqueS appears to be particularly suited to patients with prior gastric resection. We present two examples, one patient having had prior Billroth II and another with prior total gastrectomy and Roux-en-Y enteroenterostomy.

Seven men and five women with nonresectable esophageal carcinoma were treated endoscopically with the neodymium-YAG (yttrium-aluminum-garnet) infrared laser. Before laser fulguration, tumors were dilated directly with metal olive dilators. Before treatment, mean tumor length was 5 cm with luminal occlusion averaging more than 80%. After a mean of 3.3 treatment sessions spanning 18.5 days, all patients had substantial immediate palliation. Continued symptomatic relief was noted during follow-up (mean, 83 days; range, 8 to 206 days).