Gastrointestinal perforations and post-surgical fistulas are dreaded complications that dramatically increase morbidity and mortality. A new endoscopic over-the-scope clip (OTSC) system may be potentially useful for sealing visceral perforations in several clinical settings. We evaluated the advantages and clinical impact of the placement of OTSCs on the management of non-malignant gut leaks in 12 consecutive patients. OTSCs of 9.5 or 10.5 mm were used, according to the diameter of the defect within the wall. The indications for treatment were mainly related to post-surgical fistulas. Healing of the fistula was assessed by endoscopic or radiological means, and failed only once. No OTSC-related complications occurred. Endoscopic closure of perforations and post-surgical fistulas with the OTSC system is a simple and minimally invasive technique. This approach, when feasible, may be less expensive and more advantageous than a surgical approach.

Laparoscopy is a safe and effective tool for management of complications following laparoscopic colorectal surgery. In this setting, RL represents the first step of re-exploration and treatment, with no delay to conversion to open procedure even in skilled laparoscopic hands.

The surveys showed an increasing use of laparoscopy for patients with abdominal emergencies. The 2012 national guidelines profoundly influenced the Italian surgical practice in the laparoscopic approach to the acute abdomen.

Safety of single-balloon enteroscopy: our experience of 72 proceduresWe read with great interest the article by Aktas et al. [1] on the complications of single-balloon enteroscopy (SBE). The authors performed 166 SBE procedures (105 by the oral approach and 61 by the anal approach) in 105 patients. No complications were reported in the 145 diagnostic SBE procedures. There was only one perforation in the 21 therapeutic SBE procedures, which occurred during dilation of a stricture in the distal ileum and was not related to the SBE technique. Moreover, although 13 patients had post-SBE hyperamylasemia, none had clinical acute pancreatitis.Here we report our experience with the SBE system (Olympus Co., Ltd., Tokyo, Japan). Between March 2008 and April 2010, we performed a total of 72 procedures in 67 patients (57 by the oral approach and 15 by the anal approach). The mean procedure times were 62.5 ± 23.4 minutes for the oral approach and 67.5 ± 16.9 minutes for the anal approach. The mean insertion depths were 229.0 ± 59.5 cm beyond the ligament of Treitz and 125.0 ± 69.4 cm beyond the ileocecal valve. A total of 60 procedures (56 oral and 4 anal) were performed under general anesthesia, and the remaining 12 (1 oral and 11 anal) were done under conscious sedation. Therapeutic interventions were included in 22 procedures (30.6 %): argon plasma coagulation in 19 (86.4 % of interventions), balloon dilation in 1 (4.5 %), positioning of clip in 1 (4.5 %), and injection therapy in 1 (4.5 %). Within 30 days after SBE, no complications had occurred following either the 50 diagnostic SBE procedures or the 22 therapeutic SBE procedures.Among the 412 SBE procedures published to date [1 -4], only one perforation (0.24 %) was related to the SBE technique, which occurred in a postoperative case of ulcerative colitis where the sliding tube may have caught on an anastomotic region when it was inserted. In the remaining two perforations published, one was a mucosal tear (no free air was seen on abdominal computed tomography) [3], and the other one was related to balloon dilation and not to the SBE technique. Moreover, the overall risk of perforation decreases if we include our data in the analysis (one perforation in 484 SBE procedures, i. e. 0.21 %). Finally, the incidence of perforation during SBE is comparable to that reported during double-balloon enteroscopy (DBE) (0.30 %) [5]. However, scrupulous care is required when passing a small-intestinal lesion or in patients with known adhesions or strictures. In contrast to per oral DBE, no acute pancreatitis has been reported following SBE. We agree with the hypothesized mechanisms of onset of acute pancreatitis according to Aktas et al.: inflation of two balloons in the duodenum results in an increase of intraluminal pressure, leading to reflux of duodenal fluids into the pancreatic duct, and the repeated 'push-andpull' with stretching of the small intestine. However, we think that the lowered incidence of this complication after SBE is mainly due to the differences in SBE and DBE t...

Inflammatory bowel disease (IBD) is a chronic affection, in which the two main phenotypical components are Crohn's disease and ulcerative colitis. In both diseases, medical treatment has the main role; in some phases of the natural history of IBD, surgery becomes an important therapeutic tool. The IBD represents a model of multidisciplinary management. Timing represents the key issue for proper management of IBD patients. For acute and severe IBD, the surgery can be a salvage procedure. Today, the laparoscopic approach plays an important role in armamentarium of the surgeon. Several articles compared the short- and long-term results between laparoscopic and open approaches in IBD. The aim of this review is to focus the role of surgery in IBD as well as the role of laparoscopic approach, and principally, the "state of the art" for surgical treatment, sometimes very challenging for surgeon, in all clinical features of IBD by a review of literature highlighted by the most recent international guidelines.