A Change in Scope: Endoscopic Retrograde Cholangiopancreatography via a Gastroscope in Billroth II Gastrojejunostomy.

Previous gastric procedures often make endoscopic interventions challenging. Our case study focuses specifically on performing an endoscopic retrograde cholangiopancreatography (ERCP) through a gastroscope (EVIS EXERA III GIF-HQ190, Olympus, Center Valley, USA) in a patient with a history of Billroth II gastrojejunostomy. Successful ERCP in Billroth II using a gastroscope with traditional ERCP instrumentation has been very rarely reported in case reports in the literature review. This case study provides an alternative method of access to the common bile duct (CBD) and treatment of obstruction to prevent the risk of morbidities from an open CBD exploration. The primary diagnosis for this patient was choledocholithiasis. He initially underwent a standard ERCP with a side-viewing duodenoscope (EVIS EXERA II, TJF-Q190V, Olympus, Center Valley, USA); however, due to the difficult anatomy from his previous Billroth II reconstruction, the CBD was very difficult to access. A gastroscope was then used instead to perform the ERCP, providing an innovative endoscopic therapy. Given the patient's multiple comorbidities, he was at high risk for morbidity and mortality with an open CBD exploration. Hence, this case report provides insight into an innovative endoscopic approach to CBD exploration with difficult anatomy.

Colonic Intussusception Due to a Cecal Tumor: A Representative Case.

We present a case of ileo-colic intussusception in a 58-year-old female, with representative clinical features and useful intraoperative images. These cases are relatively rare in adults and should always be concerning for underlying malignancy, as was seen in our patient's case. In recent years, there has been a slight shift in the management of this pathology, and we present our arguments in agreement with these changes.

Intraoperative discovery of melanosis coli during emergent bowel resection for perforation.

A patient was taken to the operating room with a presumptive diagnosis of necrotic small bowel and colon. During the procedure, it was noted that she had black mucosa throughout the colon. Several factors suggested viable colonic tissue, and the decision was made to not resect the colon as originally planned. Final pathology of the specimen would later reveal melanosis coli, an ultimately benign diagnosis. Further questioning of the patient found that she had taken a herbal laxative supplement containing several components which are known to cause melanosis coli. We hope that this case report will serve as a reminder to surgeons and clinicians to remember melanosis coli as a clinical entity when confronted with blackened or darkened colonic mucosa. On review of available literature, we identified other cases in which melanosis coli was discovered intraoperatively, and we propose a number of factors to support intraoperative decision making.

In-situ bypass is associated with superior infection-free survival compared with extra-anatomic bypass for the management of secondary aortic graft infections without enteric involvement.

OBJECTIVE: The optimal revascularization modality following complete resection of aortic graft infection (AGI) without enteric involvement remains unclear. The purpose of this investigation is to determine the revascularization approach associated with the lowest morbidity and mortality using real-world data in patients undergoing complete excision of AGI. METHODS: A retrospective, multi-institutional study of AGI from 2002 to 2014 was performed using a standardized database. Baseline demographics, comorbidities, and perioperative variables were recorded. The primary outcome was infection-free survival. Descriptive statistics, Kaplan-Meier survival analysis, and univariate and multivariable analyses were performed. RESULTS: A total of 241 patients at 34 institutions from seven countries presented with AGI during the study period (median age, 68 years; 75% male). The initial aortic procedures that resulted in AGI were 172 surgical grafts (71%), 66 endografts (27%), and three unknown (2%). Of the patients, 172 (71%) underwent complete excision of infected aortic graft material followed by in situ (in-line) bypass (ISB), including antibiotic-treated prosthetic graft (35%), autogenous femoral vein (neo-aortoiliac surgery) (24%), and cryopreserved allograft (41%). Sixty-nine patients (29%) underwent extra-anatomic bypass (EAB). Overall median Kaplan-Meier estimated survival was 5.8 years. Perioperative mortality was 16%. When stratified by ISB vs EAB, there was a significant difference in Kaplan-Meier estimated infection-free survival (2910 days; interquartile range, 391-3771 days vs 180 days; interquartile range, 27-3750 days; P < .001). There were otherwise no significant differences in presentation, comorbidities, or perioperative variables. Multivariable Cox regression showed lower infection-free survival among patients with EAB (hazard ratio [HR], 2.4; 95% confidence interval [CI], 1.6-3.6; P < .001), polymicrobial infection (HR, 2.2; 95% CI, 1.4-3.5; P = .001), methicillin-resistant Staphylococcus aureus infection (HR, 1.7; 95% CI, 1.1-2.7; P = .02), as well as the protective effect of omental/muscle flap coverage (HR, 0.59; 95% CI, 0.37-0.92; P = .02). CONCLUSIONS: After complete resection of AGI, perioperative mortality is 16% and median overall survival is 5.8 years. EAB is associated with nearly a two and one-half-fold higher reinfection/mortality compared with ISB. Omental and/or muscle flap coverage of the repair appear protective.

Contemporary Outcomes After Partial Resection of Infected Aortic Grafts.

INTRODUCTION: Aortic graft infection remains a considerable clinical challenge, and it is unclear which variables are associated with adverse outcomes among patients undergoing partial resection. METHODS: A retrospective, multi-institutional study of patients who underwent partial resection of infected aortic grafts from 2002 to 2014 was performed using a standard database. Baseline demographics, comorbidities, operative, and postoperative variables were recorded. The primary outcome was mortality. Descriptive statistics, Kaplan-Meier (KM) survival analysis, and Cox regression analysis were performed. RESULTS: One hundred fourteen patients at 22 medical centers in 6 countries underwent partial resection of an infected aortic graft. Seventy percent were men with median age 70 years. Ninety-seven percent had a history of open aortic bypass graft: 88 (77%) patients had infected aortobifemoral bypass, 18 (16%) had infected aortobiiliac bypass, and 1 (0.8%) had an infected thoracic graft. Infection was diagnosed at a median 4.3 years post-implant. All patients underwent partial resection followed by either extra-anatomic (47%) or in situ (53%) vascular reconstruction. Median follow-up period was 17 months (IQR 1, 50 months). Thirty-day mortality was 17.5%. The KM-estimated median survival from time of partial resection was 3.6 years. There was no significant survival difference between those undergoing in situ reconstruction or extra-anatomic bypass (P = 0.6). During follow up, 72% of repairs remained patent and 11% of patients underwent major amputation. On univariate Cox regression analysis, Candida infection was associated with increased risk of mortality (HR 2.4; P = 0.01) as well as aortoenteric fistula (HR 1.9, P = 0.03). Resection of a single graft limb only to resection of abdominal (graft main body) infection was associated with decreased risk of mortality (HR 0.57, P = 0.04), as well as those with American Society of Anesthesiologists classification less than 3 (HR 0.35, P = 0.04). Multivariate analysis did not reveal any factors significantly associated with mortality. Persistent early infection was noted in 26% of patients within 30 days postoperatively, and 39% of patients were found to have any post-repair infection during the follow-up period. Two patients (1.8%) were found to have a late reinfection without early persistent postoperative infection. Patients with any post-repair infection were older (67 vs. 60 years, P = 0.01) and less likely to have patent repairs during follow up (59% vs. 32%, P = 0.01). Patients with aortoenteric fistula had a higher rate of any post-repair infection (63% vs. 29%, P < 0.01) CONCLUSION: This large multi-center study suggests that patients who have undergone partial resection of infected aortic grafts may be at high risk of death or post-repair infection, especially older patients with abdominal infection not isolated to a single graft limb, or with Candida infection or aortoenteric fistula. Late reinfection correlated strongly with early persistent postoperative infection, raising concern for occult retained infected graft material.

Hypermagnesaemia causing mesenteric ischaemia and small bowel infarction.

We present a case of mesenteric ischaemia caused by hypermagnesaemia after ingestion of a large oral dose of magnesium citrate, which resulted in smooth muscle relaxation, hypotension and bowel infarction. The patient had a history of chronic bowel dysmotility and renal impairment. On operative exploration, the bowel was noted to have a distinct pattern of ischaemia along its antimesenteric border. Small bowel resection was performed, and the patient was left in discontinuity, with definitive repair and anastomosis performed 24 hours later. The patient's magnesium level was 8.39 mg/dL, which was treated with intermittent haemodialysis and eventually normalised over several sessions. Our patient recovered and was discharged after a month-long hospitalisation. She returned shortly after with respiratory failure and died. On review of the literature, we identified similar cases and present a pathophysiological mechanism of hypermagnesaemia causing mesenteric ischaemia, consistent between our cases and those already reported.

Tuberculous appendicitis: A review of reported cases over the past 10 years.

BACKGROUND: Tuberculous appendicitis is a rare extrapulmonary manifestation of tuberculosis without clear summarization or consensus on its management. DATA SOURCES: Case reports were gathered from several online literature databases by searching terms "tuberculosis", "tuberculous", and "appendicitis".Report eligibility criteria: Cases of appendicitis due to M. tuberculosis identified on operative histology. Exclusion criteria: appendicitis caused by a mycobacterium other than M. tuberculosis, and appendiceal tuberculosis identified incidentally during procedures for other reasons. RESULTS: Thirty four patients were identified. Twenty five patients presented with acute right lower quadrant abdominal pain. Eleven patients described chronic symptoms of tuberculosis (cough, night sweats, or weakness/fatigue). Four patients had a known diagnosis of TB. Seven of 24 cases reported peri-operative chest imaging which demonstrated pulmonary lesions. AFB were present in tissue or fluid samples of 6 patients, and negative in 15 patients. All patients underwent pharmacotherapy on a WHO-recommended anti-tuberculous treatment (ATT) with RIPE or an alternative. The average duration of treatment was 7.2 ± 1.7 months. LIMITATIONS: Data was gathered from case reports without complete uniformity in diagnostic work-up. The potential for larger scale study is limited due to disease rarity. CONCLUSIONS: Tuberculous appendicitis cannot be diagnosed prior to histologic evaluation. Several data points may suggest the disease on a clinician's differential diagnosis if they present with a combination of the following: born in a country with endemic tuberculosis; chronic cough, weakness/fatigue, or nausea prior to onset of abdominal pain; pulmonary lesions on chest X-ray; white studding of the mesentery or peritoneum in a young patient; positive AFB stain of abdominal fluid or peritoneal tissue.