Management of Malignant Large-Bowel Obstruction.

CASE SUMMARY: An otherwise healthy 59-year-old man presented to the emergency department with 2 weeks of narrowed stools, 5 days of obstipation, and 1 day of abdominal pain, nausea, and vomiting. Computed tomography revealed an obstructing sigmoid mass without evidence of metastatic disease, and the CEA was 1.2 ng/mL. Flexible sigmoidoscopy confirmed a circumferentially obstructing distal sigmoid neoplasm. Endoscopic stent placement was immediately followed by a firm distended abdomen. An upright radiograph obtained following the procedure demonstrated free intraperitoneal air. An emergent Hartmann procedure was performed for iatrogenic colon perforation in a patient with malignant obstruction and chronic dilation of the proximal colon.

How can we utilize local excision to help, not harm, geriatric patients with rectal cancer?

A majority of the morbidity and mortality burden of rectal cancer is distributed within the geriatric age group. Current surgical and medical treatment modalities pose significant challenges in treating complications specifically in the already pre-disposed senior population with baseline dysfunction. This chapter reviews the work-up, management, current data and oncologic outcomes of treating rectal cancer in the senior adult.

Alexis St. Martin Gastropexy: A Novel Technique for Gastropexy During Percutaneous Endoscopic Gastrostomy Tube Placement.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is a preferred method of long-term enteral nutritional support. Despite its ease of placement, it has a 4% major complication rate, requiring surgical intervention or hospitalization. Early PEG tube dislodgment can cause peritonitis, requiring emergent laparotomy at significant morbidity and cost. T-fasteners have been used as an adjunct gastropexy, but nearly one third migrate into the abdominal wall within the first 2 weeks. We describe a low-cost, minimally invasive technique using widely available surgical instruments to appose the gastric and abdominal walls. METHODS: All PEG procedures were performed in our 60-bed surgical intensive care unit. Institutional IRB approval was obtained along with procedure specific consent for all patients. The adjunctive gastropexy procedure was performed on four patients at high risk for early PEG tube dislodgment. Following routine PEG tube placement, both ends of four 2-0 polyglactin ties were brought through the gastric and abdominal walls through separate stab incisions adjacent to the PEG tube exit site in the 3, 6, 9, and 12 o'clock positions. These were tied in the subcutaneous tissue, securing the gastric wall to the abdominal wall. RESULTS: No PEG tube complications occurred. All patients were discharged to long-term care facilities with PEG tubes intact or electively removed. CONCLUSIONS: We describe the results of a pilot study for a cost-effective, easily implementable, adjunct technique, named after the namesake of our institution, to decrease the incidence and severity of complications associated with PEG tube dislodgment. It was used in 4 patients at high risk for PEG tube dislodgment with satisfactory early results in all 4. Further recruitment of larger numbers of patients using this technique is ongoing to determine if this technique is truly effective at reducing PEG tube complications.

Outcomes in patients with renal hyperparathyroidism requiring cinacalcet pre-operatively followed by parathyroidectomy.

BACKGROUND: Cinacalcet is an effective treatment for renal hyperthyroidism when traditional medical therapy has failed. We studied the impact of pre-operative cinacalcet administration on post-surgical outcomes. METHODS: A retrospective analysis was performed of patients from 2002 to 2017 diagnosed with renal hyperparathyroidism requiring parathyroidectomy to evaluate the need for post-operative supplementation and outcomes. RESULTS: 102 patients were identified; 34 patients were treated with cinacalcet prior to undergoing parathyroidectomy. The cinacalcet treatment cohort (CT) demonstrated a greater duration of renal replacement therapy (p = 0.03) relative to the untreated cohort (NC). NC had greater proportion receiving peritoneal dialysis (p=<0.0001) compared to other forms of renal replacement, greater pre-operative PTH levels (p = 0.001) and greater decrease in PTH after resection (p = 0.0086). Post-operative vitamin D supplementation was more frequent in the CT group (p = 0.02). After propensity matching for pre-operative PTH and duration of renal replacement therapy, there were no differences in post-operative supplementation or outcomes. CONCLUSIONS: Cinacalcet patients may have advanced disease. These patients have longer duration of renal failure and higher PTH levels. After propensity matching, no significant differences were noted in terms of need for supplementation or outcomes.

Gelatin Thoracic Paravertebral Teaching Model for Placement of a Continuous Infusion Catheter in the Extrathoracic Paravertebral Space.

OBJECTIVE: Our aim was to develop an ultrasound-guided training curriculum for continuous infusion catheter placement in the paravertebral space and to create a gelatin thoracic spine-rib model for use in this training. We sought to create a model that was inexpensive and reusable such that multiple participants could use one model during training. DESIGN: The model was prepared by embedding a firm foam thoracic spine replica with bilateral attached ribs into an opaque gelatin mixture. Once solidified, a preselected area was excised on each side, such that the model could be easily refilled with new gelatin blocks for use by each participant. This allowed for multiple participants to use the same model while eliminating confusion with prior tract marks. SETTING: The Marcia and Eugene Applebaum Simulation Learning Institute, Beaumont Hospital, Royal Oak, MI; a private nonprofit tertiary care hospital associated with the OUWB School of Medicine, Rochester, MI. PARTICIPANTS: Fifty-two medical students and general surgery residents underwent a 30-minute didactic session on ultrasound technique for catheter placement followed by practice on the gelatin model. RESULTS: The texture and echogenicity of the model were subjectively comparable to those of tissue in vivo and the osseous elements of the spine in the model were clearly identified using ultrasound. The exchangeable catheter placement area provided an efficient and effective method to test accurate performance in catheter placement by multiple users. Participants increased their confidence in the use of ultrasound for this procedure. CONCLUSIONS: To date, this is the first gelatin thoracic spine-rib model that has been used to teach ultrasound-guided catheter insertion into the paravertebral space, with removable testing areas that can be used by multiple users. This model can provide an inexpensive training tool that can be used in a surgical simulation setting.

Solid, Cystic, and Tubular: Novice Ultrasound Skills Training Using a Versatile, Affordable Practice Model.

OBJECTIVE: In spite of the recognized benefits of ultrasound, many physicians have little experience with using ultrasound to perform procedures. Many medical schools and residency programs lack a formal ultrasound training curriculum. We describe an affordable ultrasound training curriculum and versatile, inexpensive practice model. DESIGN: Participants underwent a didactic session to teach the theory required to perform ultrasound-guided procedures. Motor skills were taught using a practice model incorporating analogs of common anatomic and pathologic structures into an opacified gelatin substrate. SETTING: The Marcia and Eugene Applebaum Simulation Learning Institute, Beaumont Hospital, Royal Oak, MI; a private nonprofit tertiary care hospital associated with the OUWB School of Medicine, Rochester, MI. PARTICIPANTS: The model was tested in a cohort of 50 medical students and general surgery residents. RESULTS: The gelatin model can be constructed for $1.03 per learner. The solid, cystic, and vascular structural analogs were readily identifiable on ultrasound and easily differentiated based on their echotextures. Eighty-four percent of participants successfully aspirated the cystic structure, 88% successfully biopsied a portion of the solid structure, and 76% successfully cannulated the tubular structure. Overall, 82% of participants achieved a passing score for the exercise based on a validated Objective Structured Assessment of Technical Skill instrument. There were no significant differences between the medical students and residents. CONCLUSION: This model can be used to teach basic ultrasound skills such as aspiration, biopsy, and vessel cannulation, providing a foundation for the use of ultrasound in a broad range of clinical procedures, as well as providing practice opportunities for medical students and residents to gain increased ultrasound competency and confidence.

Effects of repealing the motorcycle helmet law in Michigan.

BACKGROUND: In 2012, Michigan repealed its universal helmet law. Our study assessed the clinical impact of this repeal. METHODS: Our trauma database was queried retrospectively for 2 motorcycle riding seasons before and 3 seasons after repeal. On-scene death data was obtained from the Medical Examiner. RESULTS: Helmet use in hospitalized patients decreased after the helmet law repeal. Non-helmeted patients had a significant increased rate of head injury. Non-helmeted patients were more likely to die during hospitalization. While, helmet use and drugs/alcohol status significantly affected the risk for head injury, only drug/alcohol had a significant effect on overall mortality. CONCLUSIONS: Following helmet law repeal, helmet use has decreased. Helmet status and drug/alcohol use was found to significantly increase risk of head injury. Although overall mortality was only affected by drug/alcohol use, non-helmeted patients did have a higher inpatient mortality. These findings deserve furthermore study and may provide a basis for reinstating the universal helmet law.

Fibromatosis of the cervical region following laminectomy: a case report and literature review.

STUDY DESIGN: A case report and a discussion of recently published data. OBJECTIVE: To highlight the occurrence of postoperative fibromatosis arising in the cervical spine. SUMMARY OF BACKGROUND DATA: Fibromatosis is a benign, locally invasive fibroblastic proliferation that can cause compressive effects on adjacent structures. Although the precise etiology of fibromatosis remains unclear, numerous studies have investigated the role of pluripotent mesenchymal stem cells in ß-catenin-regulated tumorigenesis. At present, aggressive fibromatosis is managed with wide local excision. Postoperative radiation therapy is indicated for incomplete excision. METHODS: A 48-year-old woman presented with a 2-year history of enlarging paracervical fibromatosis after undergoing extensive cervicothoracic instrumentation for excision of an extradural schwannoma. The patient underwent wide local excision of the neck mass, with right trapezius myocutaneous flap reconstruction of the subsequent defect. RESULTS: Histologically, the lesion was shown to be fibromatosis. Six months postoperatively, the patient was doing well with no recurrence. CONCLUSION: Fibromatosis is an important diagnosis to consider when evaluating locally aggressive spinal lesions at sites of prior operative repair. Molecular and genetic studies pertaining to the role of mesenchymal stem cells and ß-catenin in the pathogenesis of aggressive fibromatosis tumors could lead to possible worthwhile treatment strategies in the future.

Outcomes of cytoreduction with hyperthermic intraperitoneal chemotherapy: our experience at a midwest community hospital.

BACKGROUND: Most cytoreduction with hyperthermic intraperitoneal chemotherapy procedures are performed at academic tertiary referral centers with numerous surgical oncology faculty. The objective of this study was to review the postoperative morbidity and mortality data of our institution, a large community hospital. METHODS: This was a retrospective cohort study of patients who underwent cytoreduction with hyperthermic intraperitoneal chemotherapy at a single institution. Two surgical oncologists performed all the procedures between May 2005 and June 2011. RESULTS: We retrospectively analyzed 57 patients. The most common pathology being treated was pseudomyxoma peritonei (34 of 57; 59.6%), followed by colorectal cancer (9 of 57; 15.8%). Other types of cancer included peritoneal mesothelioma and gastric adenocarcinoma. The average surgery time was 6.9 hours. Approximately 51% of patients suffered grade 3 or 4 morbidity and there were no perioperative mortalities. CONCLUSIONS: Cytoreduction with hyperthermic intraperitoneal chemotherapy can be performed at our institution with comparable outcomes as academic referral centers.