Splenic rupture is a rare but serious complication after colonoscopy, with high global mortality (5%). Diagnosis requires a high index of suspicion because presentation can be subtle, nonspecific, and delayed from hours to days and then not easily attributed to a recent endoscopy. Urgent splenectomy is the most common treatment option. A 73-year-old woman was admitted to the emergency department 8 h following a diagnostic colonoscopy. She presented abdominal pain and syncope. The diagnosis of splenic rupture was made and a splenectomy was urgently performed. The patient's postoperative recovery was uneventful. Splenic rupture is a rare complication of colonoscopy which cannot be underestimated in the differential diagnosis of abdominal pain after this procedure. Splenic injuries may occur in apparently uncomplicated, easy colonoscopies performed by experienced endoscopists, with no risk factors identified, as in this case.

Stroke after cardiac surgery remains a devastating complication and its treatment options are limited. Systemic fibrinolysis is a relative contraindication, because it raises the risk of systemic hemorrhage. Endovascular therapy, mechanical thrombectomy, and intra-arterial fibrinolysis have emerged as safer options. We present three patients who developed strokes following cardiac surgery who underwent successful mechanical thrombectomy and review the literature on this subject. doi: 10.1111/jocs.12776 (J Card Surg 2016;31:517-520).

Dextrose was not deleterious to the tendinous tissue, as it did not change the mechanical and histological properties of Achilles tendons in rats. The data obtained in this study may help clinicians in their daily work as they suggest that injections of 12.5% dextrose caused no harm to the tendons, although the clinical importance in humans still needs to be defined.

Background: Chronic anal fissure is a frequent and disabling disease, often affecting young adults. Botulinum toxin and lateral internal sphincterotomy are the main therapeutic options for refractory cases. Botulinum toxin is minimally invasive and safer compared with surgery, which carries a difficult post-operative recovery and fecal incontinence risk. The long-term efficacy of Botulinum toxin is not well known. Objective: The aim of this study was to evaluate the long-term efficacy and safety of Botulinum toxin in the treatment of chronic anal fissure. Methods: This was a retrospective study at a single center, including patients treated with Botulinum toxin from 2005 to 2010, followed over at least a period of 5 years. All patients were treated with injection of 25U of Botulinum toxin in the intersphincteric groove. The response was registered as complete, partial, refractory and relapse. Results: Botulinum toxin was administered to 126 patients, 69.8% (n ¼ 88) were followed over a period of 5 years. After 3 months, 46.6% (n ¼ 41) had complete response, 23.9% (n ¼ 21) had partial response and 29.5% (n ¼ 26) were refractory. Relapse was observed in 1.2% (n ¼ 1) at 6 months, 11.4% (n ¼ 10) at 1 year, 2.3% (n ¼ 2) at 3 years; no relapse at 5 years. The overall success rate was 64.8% at 5 years of follow-up. Botulinum toxin was well tolerated by all patients and there were no complications. Conclusion: The use of Botulinum toxin to treat patients with chronic anal fissure was safe and effective in long-term follow-up.

Chronic anal fissure is a linear ulcer in the anal canal that has not cicatrized for more than 8-12 weeks of treatment. Most anal fissures are idiopathic and are located in the posterior midline. Squamous cell carcinoma of the anus commonly presents as bleeding and anal pain. It may also present as a mass, nonhealing ulcer, itching, discharge, fecal incontinence and fistulae. Not uncommonly, small and early cancers are misdiagnosed as benign anorectal disorders like anal fissures or hemorrhoids. The clinical suspicion of squamous cell carcinoma of the anus is of paramount importance in patients with nonhealing anal fissures, fissures in atypical positions or with indurated or ulcerated anal tags and in patients with risk factors for the development of anal squamous intraepithelial lesions that are precursors of invasive anal squamous cell carcinoma. The authors present 3 cases of squamous cell carcinoma of the anus initially misdiagnosed as benign chronic anal fissure.

Common variable immunodeficiency (CVID) is an immunodeficiency disorder with a high incidence of gastrointestinal (GI) manifestations and an increased risk of gastric malignancy. We report a case of a CVID with mild anemia presenting with multiple GI manifestations: gastric low-grade dysplasia (LGD), enteropathy with villous atrophy, refractory Giardia infection, nodular lymphoid hyperplasia, and inflammatory bowel-like disease. The differential diagnosis with celiac sprue could be challenging because of CVID enteropathy with villous flattening. Gastric LGD in a patient with an increased risk for gastric malignancy makes the appropriate surveillance of gastric cancer in CVID challenging.

Background and Aims: Accurate determination of colonic polyp size is vital to an appropriate surveillance. The main aim of this study was to evaluate variation between the polyp size reported by the endoscopist and its pathological measurement. Methods: A retrospective analysis of all colonic adenomatous polyps resected in a 12-month period was performed at our center. Endoscopic and pathological size for each polyp were compared, and overestimation rates, underestimation rates, and endoscopic-pathological variation (EPV) were calculated. Results: Among the 573 polyps that were included, the mean endoscopic and pathological sizes were 8.00 and 6.66 mm, respectively. The most frequent error, in 62.1%, was overestimation by the colonoscopist. Overestimation and EPV were associated with resection technique (higher in endoscopic mucosal resection and smaller with biopsy forceps) and colonoscopist. They were not associated with years of experience in colonoscopy. Overestimation was more frequent in larger polyps. Conclusions: Our study shows significant discordance between endoscopic and pathological size of colonic polyps with a clear tendency for endoscopic overestimation. Larger polyps are more difficult to accurately assess than smaller ones. This propensity for error was not related to colonoscopist’s years of experience and seems to be an individual tendency.

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