Five-Year Experience with Transcystic Laparoscopic Common Bile Duct Exploration.

Background: Common bile duct (CBD) stones associated with cholecystitis can be treated by single-stage CBD exploration at the time of cholecystectomy or a two-stage approach with endoscopic stone extraction before or after cholecystectomy. The ideal management remains a matter of debate. The aim of this study is to analyze our outcomes with transcystic laparoscopic common bile duct exploration (LCBDE). Material and Methods: A retrospective review of patients who underwent transcystic LCBDE between 2015 and 2019 was performed. Results: A total of 106 patients underwent transcystic LCBDE over 5 years. We performed 1192 laparoscopic cholecystectomies with cholangiograms from March 2015 to December 2019. Fifteen patients had a preoperative endoscopic retrograde cholangiopancreatography (ERCP) for CBD stones seen on magnetic resonance cholangiopancreatography that during laparoscopic cholecystectomy with intraoperative cholangiogram (IOC), there were stones and/or sludge found in the CBD, which required clearance through a transcystic approach. Of the 91 patients who did not have a preoperative ERCP, clearance of the CBD was successful through a transcystic approach in 78 patients (86%). In the 13 patients that intraoperative clearance was not achieved (n = 13, 14%), a postoperative ERCP was performed. A total of 28 patients underwent either pre- or postoperative ERCP (n = 28, 26%). Choledochotomy was not performed in any of the patients. The mean operative time was 127 minutes (127 ± 48). The mean hospital length of stay (LOS) was 4 days (3.9 ± 2.8) with a median LOS of 3 days. Complications observed include wound infection (n = 2, 2%), pancreatitis after ERCP (n = 1, 1%), pneumonia (n = 1, 1%), and right hepatic duct injury (n = 1, 1%). Conclusion: Transcystic LCBDE is an effective and safe option for treatment of CBD stones. While a transcystic approach does not guarantee clearance of the CBD, it avoids the morbidity associated with a choledochotomy and can often prevent patients from having to undergo an additional procedure.

Secondary autogenous arteriovenous fistulas in the "fistula first" era: results of a longterm prospective study.

BACKGROUND: The outflow vein of a dysfunctional arteriovenous dialysis access can be used to create a secondary autogenous arteriovenous fistula (SAVF) (type I). In the absence of an outflow vein, an SAVF can still be created elsewhere in the ipsilateral or contralateral extremity by identifying vessels suitable for SAVF creation (type II). But their patency rates and the use of tunneled dialysis catheters during the postoperative period have not been reported in a prospective fashion. STUDY DESIGN: Patients undergoing SAVF creation were included in this analysis. Data were collected prospectively. The primary, secondary, and cumulative patency rates, along with the number of procedures required to maintain patency, were investigated. The need for tunneled dialysis catheters in patients with SAVF before the fistula was ready to support dialysis was also evaluated. RESULTS: Sixty-two (type I, n=35; type II, n=27) SAVFs were created over a period of 5 years. The primary patency rates for types I and II SAVF at 6 and 12 months were 87% and 14% (type I) and 71% and 11% (type II), respectively. The secondary patency rates for type I at 12, 24, and 36 months were 100%, 100%, 83%, respectively, and for type II were 92%, 88%, 83%, respectively. The primary and secondary patency rates between the groups were not statistically significant. The cumulative patency rates for type I at 12, 24, and 36 months were 100%, 100%, 94%, respectively, and for type II were 96%, 96%, and 91%, respectively. Type I required 1.4 procedures/year, and type II needed 1.5 procedures/year (p=nonsignificant). Tunneled dialysis catheters were required in 21 patients with type I and 27 patients with type II SAVF. CONCLUSIONS: Although the primary patency rates were not colossal, excellent secondary and cumulative patency rates were observed for SAVF in this study.

Role of surgical intervention for cephalic arch stenosis in the "fistula first" era.

Cephalic arch stenosis (CAS) is a frequent cause of vascular access dysfunction in patients with brachiocephalic fistulae. While percutaneous balloon angioplasty has been used to treat CAS, the results of this approach have been poor due to multiple factors including resistant nature of the stenosis, development of early restenosis, as well as poor patency and high vein rupture rates. In this analysis, we report the results of an alternative approach to manage this problem. Thirteen patients with frequently recurring CAS were referred for surgical intervention. Angiographic images recorded during the prior percutaneous procedures were made available to the surgeons. The surgical procedure entailed transecting the healthy portion of the cephalic vein distal to the stenotic segment in the arch, transposing and anastomosing it to the upper basilic/axillary vein. Following surgical revision, development of access dysfunction was treated with percutaneous balloon angioplasty. Patency rates for angioplasty before and after the surgical revision were evaluated. Primary patency rates for angioplasty before the surgical revision were 23%, 8% and 0% at 3, 6, and 12 months, respectively. Following surgical revision, all patients needed angioplasty procedure. However, primary patency increased to 92%, 69%, and 39% at 3, 6, and 12 months, respectively (p = 0.0001). Secondary patency before the surgical revision at 3, 6, and 12 months was 100%, 39%, and 8%, respectively, compared with 92% at 3, 6, and 12 months postsurgical revision (p = 0.0003). The results of this study demonstrate that surgical transposition of the cephalic vein in frequently recurring CAS is a viable option and yields better patency rates for future angioplasty procedures.

Creation of secondary arteriovenous fistulas: maximizing fistulas in prevalent hemodialysis patients.

National Kidney Foundation Dialysis Outcomes Quality Initiative (NKF-DOQI) guideline 29 suggests that a patient should be evaluated for a secondary arteriovenous fistula (AVF) following each episode of dialysis access failure. Regretfully, it does not appear that this approach is used, even though recent data have emphasized that veins suitable for the creation of a secondary AVF can be identified in dialysis patients who are receiving dialysis via a synthetic arteriovenous graft (AVG) or other type of potentially dysfunctional vascular access. In this study nine patients (five with an AVG and four with an AVF) with vascular access dysfunction undergoing percutaneous interventions were evaluated for secondary AVF creation. All were found to have suitable vascular anatomy and had the AVF created. The secondary fistula was successful in all nine patients with a mean follow-up of 4.8 +/- 1.4 months in post-AVG cases and 5.6 +/- 1.7 months in the post-AVF patients. In addition, it was possible to continue uninterrupted dialysis without the use of a tunneled dialysis catheter in three of the patients with AVGs. This experience demonstrates the validity and success of this approach to the management of dialysis access dysfunction. In the ongoing effort to optimize vascular health status, we suggest that during percutaneous interventions, patients should routinely have identification of vessels suitable for creation of a secondary AVF.

Phlegmonous gastritis associated with Kaposi sarcoma: a case report and review of the literature.

We report a case of phlegmonous gastritis associated with Kaposi sarcoma in a 37-year-old, human immunodeficiency virus (HIV)-positive man who presented with an acute abdomen. Computed tomographic scan revealed free fluid in the abdominal cavity and a thickened gastric wall. A partial gastrectomy was performed. The resected portion of stomach had a hemorrhagic, necrotic thickened wall and showed extensive, acute suppurative inflammation, especially in the submucosa, with focal transmural involvement. Beneath an area of healing ulceration, a focus of Kaposi sarcoma was present. Group A beta-hemolytic streptococcus was grown from peritoneal fluid, and treatment with numerous antibiotics was initiated. After a difficult postoperative course that responded to 8 weeks of antibiotic therapy, the patient was medically stable and discharged from the hospital on antiretroviral therapy for HIV. Phlegmonous gastritis is a rare and rapidly progressive bacterial infection of the gastric wall. Kaposi sarcoma is one of the most common malignancies in HIV-positive patients, and gastric involvement is relatively common in those patients with systemic Kaposi sarcoma. To our knowledge, this is the first reported case of phlegmonous gastritis associated with Kaposi sarcoma, and it represents a rare survival following surgical and antibiotic therapy.

Automated evaluation of chemical shift perturbation spectra: New approaches to quantitative analysis of receptor-ligand interaction NMR spectra.

This paper presents new methods designed for quantitative analysis of chemical shift perturbation NMR spectra. The methods automatically trace the displacements of cross peaks between a perturbed test spectrum and the reference spectrum (or among a series of titration spectra), and measure the changes of chemical shifts, heights, and widths of the altered peaks. The methods are primary aimed at the (1)H-(15)N HSQC spectra of relatively small proteins (<15 kDa) assuming fast exchange between free and ligand-bound states on the chemical shift time scale, or for comparing spectra of free and fully bound states in the slow exchange situation. Using the (1)H-(15)N HSQC spectra from a titration experiment of the 74-residue Pex13p SH3 domain with a Pex14p peptide ligand (14 residues, K (d)= approximately 40 microM), we demonstrate the scope and limits of our automatic peak tracing (APET) algorithm for efficient scoring of high-throughput SAR by NMR type HSQC spectra, and progressive peak tracing (PROPET) algorithm for detailed analysis of ligand titration spectra. Simulated spectra with low signal-to-noise ratios (S/N ranged from 20 to 1) were used to demonstrate the reliability and reproducibility of the results when dealing with poor quality spectra. These algorithms have been implemented in a new software module, FELIX-Autoscreen, for streamlined processing, analysis and visualization of SAR by NMR and other high-throughput receptor/ligand interaction experiments.