Technique for Salvage Reconstruction of Shredded Left Main Coronary Artery After Rotablator Injury.

We report the technique needed to effectively repair a left main coronary artery shredding after rotational atherectomy and destruction of the left main coronary artery. The patient had been deemed inoperable at another center because of diffuse distal coronary disease. The complication led to cardiac tamponade and hemodynamic collapse, necessitating cardiopulmonary resuscitation and salvage surgery. This is perhaps the first case in the literature to show a successful repair of such a complex and significant left main, left anterior descending, and left circumflex coronary artery rupture in a patient in extremis.

Trends and Outcomes of Early Versus Late Percutaneous Endoscopic Gastrostomy Placement in Patients With Traumatic Brain Injury: Nationwide Population-based Study.

BACKGROUND: Oral intake for traumatic brain injury (TBI) patients is often not an option because of facial trauma, swallowing dysfunctions, altered consciousness, etc. These patients often require percutaneous endoscopic gastrostomy (PEG) placement for nutrition support. To date, there is lack of studies examining the relationship between the timing of PEG placement and patient outcome in the TBI group. METHODS: We conducted a population-based study in a retrospective cohort of TBI patients undergoing PEG, using the national inpatient sample for years 2011 to 2013. RESULTS: A total of 96,625 patients were identified for TBI and 3343 of those patients received PEG. TBI patients who undergo an early or late PEG placement had a higher rate of in-hospital mortality, when compared with patients with a standard timing of PEG placement. Late PEG was preferably placed in patients with higher Charlson index and trauma-related comorbidities, and these patients had a higher incidence of complications, that is, sepsis, urinary tract infection, acute respiratory distress syndrome/pneumonia, and deep vein thrombosis/pulmonary embolism. When stratified by mortality-risk groups, early PEG was associated with higher rates of in-hospital mortality while standard PEG was associated with best mortality outcomes in low-mortality-risk group and moderate-mortality-risk group. CONCLUSIONS: The results of this study suggest that if a PEG placement is indicated for a TBI patient, a standard (7 to 14 d) timing may be associated with better patient outcomes. However, secondary to limitations associated with the use of administrative databases, further prospective studies are needed to establish clear guidelines regarding the optimal timing of placing PEG in TBI patients.

Agreement in interpreting villous elements and dysplasia in adenomas less than one centimetre in size.

BACKGROUND: Villous elements and dysplasia grade in small adenomas are used in many countries to guide post-polypectomy colonoscopy intervals. AIMS: Measure agreement in interpretation of villous elements and dysplasia in small adenomas. METHODS: Consecutive endoscopically resected adenomas <10mm in size (203 adenomas less than 6mm and 149 adenomas 6-9 mm in size) were reviewed by 3 expert gastrointestinal pathologists. Interpretations were compared to routine clinical pathology readings at our institution and to each other. RESULTS: All pathologists used the same definitions for villous and tubular histology. The overall kappas for villous elements in <6mm and 6-9 mm adenomas were 0.29 and 0.26, respectively. Interpretation of dysplasia grade had kappas of 0.02 and 0.09 for adenomas <6mm and 6-9 mm, respectively. Two expert pathologists who used cytologic criteria had much higher fractions of high grade dysplasia compared to the third expert and the pathologists at our centre, who relied on architectural criteria. CONCLUSIONS: Villous elements and dysplasia grade in small adenomas are problematic as determinants of post-polypectomy surveillance intervals. Uniform pathologic criteria for dysplasia grade are needed.

Intraoperative near-infrared imaging of surgical wounds after tumor resections can detect residual disease.

PURPOSE: Surgical resection remains the most effective therapy for solid tumors worldwide. The most important prognostic indicator for cure following cancer surgery is a complete resection with no residual disease. However, intraoperative detection of retained cancer cells after surgery is challenging, and residual disease continues to be the most common cause of local failure. We hypothesized that visual enhancement of tumors using near-infrared imaging could potentially identify tumor deposits in the wound after resection. EXPERIMENTAL DESIGN: A small animal model of surgery and retained disease was developed. Residual tumor deposits in the wound were targeted using an U.S. Food and Drug Administration-approved imaging agent, indocyanine green, by the enhanced permeability and retention effect. A novel handheld spectrometer was used to optically visualize retained disease after surgery. RESULTS: We found residual disease using near-infrared imaging during surgery that was not visible to the naked eye or micro-CT. Furthermore, examination of tumor nodules was remarkably precise in delineating margins from normal surrounding tissues. This approach was most successful for tumors with increased neovasculature. CONCLUSIONS: The results suggest that near-infrared examination of the surgical wound after curative resection can potentially enable the surgeon to locate residual disease. The data in this study is the basis of an ongoing Phase I/II clinical trial in patients who undergo resection for lung and breast cancer.

Clinical characteristics and prevalence of early repolarization associated with ventricular arrhythmias following acute ST-elevation myocardial infarction.

Early repolarization (ER) on a 12-lead electrocardiogram has recently been associated with ventricular tachyarrhythmias (VTAs) in patients without structural heart disease and in patients with healed myocardial infarction (MI). An association between ER and VTAs in the setting of acute ST-segment elevation MI (STEMI) has not been explored. In a single-center retrospective case-control design, 50 patients with STEMI complicated by VTAs (cases), defined as ventricular fibrillation, sustained ventricular tachycardia, or nonsustained ventricular tachycardia within 72 hours of the index hospitalization, were matched for age and gender with 50 subjects with STEMI without VTAs (controls). Electrocardiograms obtained an average of 1 year before STEMI were analyzed for ER pattern, defined as notching or slurring of the terminal QRS complex or J-point elevation >0.1 mV above baseline in ≥ 2 contiguous leads. A higher prevalence of ER was associated with VTAs overall in cases compared to controls (26% vs 4%, p = 0.01) and localized to anterior (16% vs 0%) and inferior (14% vs 2%, p = 0.07) leads but not lateral limb leads. Notching (10% vs 2%, p = 0.1) and J-point elevation (16% vs 0%) were more common in cases. Slurring was uncommon. ER was associated with VTAs (odds ratio [OR] 6.5, 95% confidence interval [CI] 1.5 to 28.8, p = 0.01), even after adjustment for creatine kinase-MB (OR 9.2, 95% CI 1.6 to 53.4, p = 0.01) and ejection fraction (OR 5.7, 95% CI 1.2 to 27.1, p = 0.03). In conclusion, ER is associated with VTAs in patients with STEMI even after adjustment for left ventricular ejection fraction or creatine kinas-MB levels. Larger prospective studies exploring potential associations and mechanisms of ventricular arrhythmogenesis with ER pattern are needed.

Primary Submucosal Squamous Cell Carcinoma of the Rectum Diagnosed by Endoscopic Ultrasound: Case Report and Literature Review.

Primary colorectal squamous cell carcinoma (SCC) is one of the very rare malignancies of the gastrointestinal tract. The diagnosis cannot be made before ruling out other common primary sites. Using the endoscopic ultrasound (EUS) technique to get a tissue biopsy for submucosal tumors has not been demonstrated as the best diagnostic approach in the literature. Surgery is the gold standard treatment with arising evidence of good efficacy following conventional chemoradiation therapy. A 49-year-old male presented with rectal discomfort. Sigmoidoscopy revealed multiple submucosal masses in the rectosigmoid colon. Mucosal biopsies showed nonspecific inflammation. Subsequently, an EUS with fine needle biopsy was done and established the diagnosis of rectal SCC. There were no other primary sites noticed in the extensive evaluation. The patient chose to be treated only with chemoradiation without surgery. At the time of writing this report he had no evidence of recurrence achieving 2.5 years of survival. EUS is an emerging excellent approach to diagnose submucosal colorectal SCC. This case will add supportive evidence of having a complete response following combining treatment with squamous cell directed chemotherapy and external beam radiotherapy without preceded surgery.