Laparoscopic-Assisted Transgastric Endoscopic Retrograde Cholangiopancreatography With Placement of a Biliary Stent to Treat Traumatic Intrahepatic Bile Duct Disruption in a Patient With Roux-en-Y Gastric Bypass.

Hepatic injuries are common following blunt trauma and while frequently managed expectantly, biliary injury as a result of the trauma requires a high index of suspicion, a focused workup, and likely interventional treatment. A 44-year-old female with a history of Roux-en-Y gastric bypass presented after a ground level fall and was initially discharged home but represented with worsening abdominal pain and elevated liver enzymes. She was found to have a segment 5/6 biliary injury requiring laparoscopic-assisted transgastric endoscopic retrograde cholangiopancreatography with common bile duct stent placement. This case represents the difficulty of diagnosing biliary injuries following blunt trauma, and the need for advanced endoscopic interventions for treatment in patients with atypical anatomy.

Outcomes of ileocolic resection and right hemicolectomies for Crohn's patients in comparison with non-Crohn's patients and the impact of perioperative immunosuppressive therapy with biologics and steroids on inpatient complications.

BACKGROUND: The purpose of this study was to compare medication use and complication rates between Crohn's disease (CD) and non-CD patients undergoing ileocolic resections and right hemicolectomies. METHODS: A review of patients who underwent ileocolic resections and right hemicolectomies from January 1, 2003, through December 31, 2010, was performed. Data collected included demographics and clinical information, biologics use (eg, infliximab, adalimumab), other medication use (eg, steroids), complications, and mortality. RESULTS: There were 791 records reviewed, with 93 CD patients. There was no significant difference in major or minor complications, anastomotic leaks, operating room time, or postoperative ileus occurrence between the CD and non-CD groups (P > .05). Use of biologics and steroids were significantly higher among the CD patients. Mortality, age, and American Society of Anesthesiologists score were significantly higher in the non-CD group. CONCLUSIONS: Ileocolic resections and right hemicolectomies in CD patients are not associated with an increase in complication rates even when the patients use steroids and biologics in the preoperative period.

Citrulline: a potential immunomodulator in sepsis.

BACKGROUND: Sepsis leads to a complex systemic response of cytokines (both pro- and anti-inflammatory) and more recently recognized adipokine mediators. Endothelial nitric oxide (NO) may be a key component in regulating this response, but the pharmacologic manipulation of endothelial NO via L-arginine supplementation or inhibitors has provided inconsistent clinical data related to outcomes. These failures are related to the metabolism of L-arginine in the liver, toxicity of L-arginine, and asymmetric dimethylarginine inhibition, all of which may explain the "arginine paradox." L-citrulline (CIT) offers a potentially valuable means of supplementing arginine and therefore impacting favorably NO availability. The goal of this study was to determine whether CIT supplementation altered the systemic response of mediators and cytokines in a rat model of sepsis with varying degrees of severity. METHODS: Sepsis was induced with 2 models of cecal ligation and puncture (CLP) of varying severity in Wistar rats. CIT supplementation was provided to half the animals as 8% CIT-supplemented feed for 3 weeks. Baseline mediator levels were assessed in the Wistar rats followed by comparison of the following groups at days 0, 1, and 3: sham-operated; CLP 8-mm (localized); and CLP 12-mm (extensive). The following analyses were performed in the groups: interleukin-6 (IL-6), IL-8, IL-10, resistin, and adiponectin levels (enzyme-linked immunosorbent assay performed in duplicate). L-arginine and CIT were measured with high-performance liquid chromatography combined with mass spectrometry. RESULTS: Ninety-eight Wistar rats were evaluated, and survival was similar in both sepsis models with and without CIT. Serum IL-6 levels were lower in the CIT/CLP 8-mm group compared to the standard rat chow (STD)/CLP 8-mm group (41 vs 117 pg/mL; P = .011) on postoperative day 3. Serum IL-8 and IL-10 responses were similar across all groups. Serum resistin levels were lower in the CIT/CLP 12-mm group compared to the STD/CLP 12-mm group in the more severe sepsis model on day 3 (19 vs 38 ng/mL; P < .0001). The levels of serum L-arginine were greater in the CIT-supplemented animals compared to STD rodent diet animals before surgical insult (86.3 vs 294.0 µM; P = .004). Adiponectin was not affected by CIT supplementation. CONCLUSION: CIT may decrease the proinflammatory mediator response (IL-6 and resistin) without impairing the secretion of anti-inflammatory mediators (IL-10 and adiponectin) and thereby provide a safe means of immunomodulation that preserves the anti-inflammatory mediator response.

Hidradenitis suppurativa and pruritus ani.

Hidradenitis suppurativa (HS) is a chronic debilitating disorder that can affect any areas bearing apocrine glands. Perineal HS is associated with high morbidity compared with other anatomic regions. Early-stage disease may mimic various other forms of cutaneous disorders, but as HS progresses pathognomonic skin changes occur. Clinical stage can guide the therapeutic approach, but the lowest recurrence rate is obtained by removing all involved skin and subcutaneous fat. Pruritus ani is a complex disease with a multitude of etiologies. Its management can be frustrating and disappointing for the patient and doctor alike. The key is to start with simple treatment options focusing on perianal hygiene and avoidance of the most common offending foods and beverages. If these measures fail, topical medications should be attempted before graduating to perianal injections of methylene blue as a last resort.