Self-Expanding Metal Stenting in the Management of a Benign Colonic Stricture.

Colonic postanastomotic strictures occur in 1.5-8% of patients following colorectal surgery. Traditionally, colonic strictures were treated by multiple modalities including endoscopic dilatation. Self-expanding metal stents (SEMS) have been indicated in the management of benign colonic strictures; however, there are limited available data with regard to their efficacy. We present the case of a 68-year-old male who had perforated sigmoid diverticulitis followed by Hartmann's procedure with eventual reanastomosis 6 months later. He subsequently developed benign colonic stricture, which was treated with a metal stent. SEMS are associated with a low mortality rate and are appropriate in treating acute colonic obstruction as a result of benign stricture in the setting of postanastomosis.

Wedge and needle liver biopsies show discordant histopathology in morbidly obese patients undergoing Roux-en-Y gastric bypass surgery.

BACKGROUND: Controversy exists over whether or not single-needle liver biopsies are sufficient to compare histological parameters in patients with non-alcoholic fatty liver disease. AIMS: To identify sampling variability, we biopsied four liver specimens per patient, based on biopsy size (needle vs wedge) and location (left vs right lobe), immediately prior to bariatric Roux-en-Y gastric bypass surgery. METHODS: Ten prospectively enrolled, morbidly obese patients underwent 40 laparoscopy-guided biopsies; two needle and two wedge from each of 16 left and 16 right liver lobes. The Kappa coefficient for concordance compared histological parameters from left and right lobe needle- and wedge biopsies. Wedge biopsies were considered our 'Gold Standard'. RESULTS: Each patient had two wedge- and two needle liver biopsies. Kappa concordance between all needle and wedge biopsies from right and left lobes showed variability. Wedge- and needle liver biopsies from contralateral lobes had higher concordance with each other, compared to ipsilateral needle/wedge biopsy pairs. Contralateral wedge pairs had higher concordance than contralateral needle/needle pairs. There were no biopsy complications. CONCLUSIONS: Wedge biopsy pairs had the best Kappa concordance but contralateral needle/needle biopsy pairs had good Kappa concordance. There were no complications from the 40 needle- and wedge liver biopsies, confirming the safety of laporoscopic multi-biopsy in both liver lobes.

Severity of injury is underestimated in the absence of autopsy verification.

BACKGROUND: Trauma disproportionately affects young, productive citizens. To decrease the preventable death rate and morbidity, and to save society some of the estimated 230 million dollars per day revenue loss attributable to these injuries, trauma systems were developed. New York State instituted a population-based regional trauma registry to enter all patients meeting appropriate International Classification of Diseases, Ninth Revision diagnostic codes. METHODS: We evaluated the registry records deaths in a single New York State trauma region. We compared the medical records used for registry entry to the autopsy records from the County Medical Examiner's Office to determine accuracy of diagnostic coding. On the basis of autopsy data, the records were then recoded and the extent of the trauma rescored. RESULTS: One hundred thirty-four deaths from 1993 to 1998 were recorded. Twelve records (9%) were accurately entered. One hundred twenty-two records had 452 errors. The mean Injury Severity Score (ISS), based on the medical record face sheet, was 29.93. The revised ISS, based on autopsy review, was 34.44 (p = 0.0108, two-tailed t test). The 95% confidence interval of the difference was 1.05 to 7.96. Z scores were -14.36 before autopsy review and -13.21 after autopsy review (p = 0.4395, not significant). We demonstrated a significantly higher ISS in the patients who died when the autopsy findings were included for coding. This information was not available from the medical record. CONCLUSION: To accurately compare trauma center performance and injury severity, the inclusion of autopsy data is critically important. Present state law does not permit sharing of this information with the trauma centers. When comparing mortality rates of New York State trauma centers, data must be carefully interpreted.