Reduction of an incarcerated, prolapsed ileostomy with the assistance of sugar as a desiccant.

Prolapse is a well-described complication after ileostomy or colostomy, and is typically asymptomatic and easily reduced. Acute incarceration of a prolapsed stoma is a rare event, however. A patient presented with an incarcerated, prolapsed ileostomy causing small bowel obstruction and stomal ischemia. Successful reduction was performed with the assistance of sugar as a desiccant. Incarceration of a prolapsed ileostomy is highly atypical, but can be approached in a similar manner to an incarcerated rectal prolapse. Successful reduction can prevent an emergent operation, allowing for medical optimization and elective surgical treatment if necessary.

Minimally invasive surgery for splenic malignancies.

While minimally invasive surgery, i.e. laparoscopy, has become well-accepted in the treatment algorithm for malignancies of the gastrointestinal tract and gynecologic tumors, the role of laparoscopy for malignancies involving the spleen is less clear. Initially described in 1992 for benign hematologic disease, laparoscopic splenectomy (LS) for splenic malignancy was avoided secondary to the severe hematologic disease, profound cytopenia, and massive splenomegaly frequently seen in these patients. As experience with LS grew and larger data were generated, it became clear that hematologic malignancy and splenomegaly could be safely managed laparoscopically. In experienced hands, LS can be used for the diagnosis and treatment of both lymphoproliferative and myeloproliferative disorders affecting spleen, in addition to splenic tumors of both primary and metastatic origin. LS can be performed from a lateral or anterior approach, and hand-assisted laparoscopic splenectomy can provide significant benefit in cases of massive splenomegaly. Preoperative imaging for accurate splenic measurement is invaluable to guide surgical planning. Triple vaccination should be given to all patients prior to surgery, and splenic artery embolization before surgery should be considered in patients with massive splenomegaly to reduce intraoperative bleeding. LS can be performed safely for nearly all cases of malignancy involving the spleen, and potentially offers significant advantages of decreased pain and recovery time while maintaining equivalent complications and survival compared to open splenectomy.

Multimedia article. Laparoscopic repair of a perforated marginal ulcer 2 years after gastric bypass.

The authors present the case of a 43-year-old women who underwent a laparoscopic gastric bypass in 2003 for morbid obesity. They report that 2 years later, she had maintained significant weight loss, but had developed acute abdominal pain, followed by nausea and emesis. In the emergency room, she had diffuse tenderness, tachycardia, and leukocytosis. After initial resuscitation, a computed tomography was performed, which showed free air above the liver and thickened small bowel loops. She was brought emergently to the operating room for laparoscopy. At surgery, turbid fluid and inflamed small bowel loops were seen. A perforated marginal ulcer was discovered in the Roux limb, approximately 2 cm distal to the gastrojejunal anastomosis. The perforation was oversewn primarily and patched with omentum. The repair was tested by intraoperative endoscopy. A gastrostomy tube also was placed within the gastric remnant for enteral access. The patient did extremely well postoperatively, and had an uneventful postoperative course. She was discharged on postoperative day 4. The gastrostomy tube was removed at 1 month, and at this writing, she remains well since surgery. An upper endoscopy at 2 months was completely normal, and the Helicobacter pylori test results were negative. The gastric pouch had not significantly enlarged since initial surgery, as indicated by both endoscopy and barium study. Marginal ulcer is reported to be 0.6% to 16% after laparoscopic gastric bypass. Etiologies include gastrogastric fistula, excessively large gastric pouch containing antral mucosa, H. pylori infection, nonsteroidal antiinflammatory use, and smoking. Unfortunately, none of these applied to the reported patient. Because her exact etiology remains unknown, she at this writing continues to receive proton pump inhibitor therapy.

Diaphragmatic eventration presenting as a recurrent diaphragmatic hernia.

Diaphragmatic eventration is an uncommon condition, usually discovered incidentally in asymptomatic patients. Even in symptomatic patients, the diagnosis can be challenging and should be considered among the differential diagnoses of diaphragmatic hernia. The correct diagnosis can often only be made in surgery. We describe the case of a 31-year-old patient with diaphragmatic eventration that was misdiagnosed as a recurrent congenital diaphragmatic hernia and review the corresponding literature.

When are sex-specific effects really sex-specific?

We examined developmental programming studies that reported sex-specific effects published between 2012 and 2014, and examined whether the authors reported a statistical approach to explicitly test whether the effect of treatment differed between the sexes, for example, a sex by treatment interaction term. Less than half of the studies that reported sex-specific effects described explicitly testing whether effects were indeed sex-specific; in most cases, an effect was considered 'sex-specific' if it was significant in one sex but not the other. This is not a robust approach, since significance in one sex and lack of significance in the other sex does not imply a significant difference between the sexes. However, sample size often limits statistical power to detect interactions. We suggest that if the effect is significant in only one sex, but the interaction term is not significant, alternative solutions would be to present the confidence intervals for the effect size for each sex, or using Bayesian approaches to calculate the probability that the effect sizes differ between the sexes. We present a simple example of a Bayesian analysis to illustrate that this approach is reasonably easy to implement and interpret.

Analysis of steroids in songbird plasma and brain by coupling solid phase extraction to radioimmunoassay.

It is a common practice to extract steroids from plasma, serum, or tissue samples prior to steroid measurement by radioimmunoassay (RIA) or enzyme immunoassay (EIA). Steroid extraction is critical because it can remove substances that interfere with the RIA or EIA. Steroid extraction is commonly achieved using organic solvents, such as diethyl ether or dichloromethane. However, organic solvent extractions can suffer from low recovery, imprecise recovery, or incomplete removal of assay interference. Here, we describe validations of a simple protocol to extract steroids (e.g., dehydroepiandrosterone, corticosterone, and estradiol) from avian plasma, serum, and brain tissue using solid phase extraction (SPE) with commercially available C18 columns. We compare various methods for (1) eluting steroids from columns, (2) drying eluates, and (3) resuspending dried eluates prior to RIA. The SPE method yields high and consistent recoveries. The SPE method also effectively separates steroids from interfering substances, even when extracting steroids from lipid-rich plasma and brain tissue. These data indicate that SPE is superior to organic solvent extraction on several measures. SPE should be broadly useful for extracting steroids from plasma or tissue samples.