Management of complex acute biliary disease for the general surgeon: A narrative review.

Acute gallbladder diseases are a common surgical emergency faced by General Surgeons that can sometimes be quite challenging. These complex biliary diseases require multifaceted and expeditious care, optimized based on hospital facility and operating room (OR) resources and the expertise of the surgical team. Effective management of biliary emergencies requires two foundational principles: achieving source control while mitigating the risk of injury to the biliary tree and its blood supply. This review article highlights salient literature on seven complex biliary diseases: acute cholecystitis, cholangitis, Mirizzi syndrome, gallstone ileus with cholecystoenteric fistula, gallstone pancreatitis, gall bladder cancer, and post-cholecystectomy bile leak.

A distinct case of an 8-year-old female with cyclic neutropenia presenting with C. septicum abdominal sepsis and myonecrosis requiring a bowel resection and leg fasciotomy.

Clostridium septicum is a very rare cause of severe spontaneous pediatric enterocolitis and is often associated with underlying malignancy or immunocompromise. Likewise, cyclic neutropenia is a rare congenital immunodeficiency that is characterized by cyclical periods of neutropenia, often with more severe symptoms in the pediatric population. Here, we present a unique case of spontaneous C. septicum enterocolitis, sepsis, and myonecrosis in a child with undiagnosed cyclic neutropenia. Early recognition of pediatric sepsis, frequent reevaluation and identification of rapidly progressive infection, and early surgical intervention are critical for the effective management of a rare and severe infection.

A rare case of a congenital pancreatic duplication cyst in an infant complicated by an upper GI bleed, pancreatitis, cyst infection and gastric outlet obstruction.

Enteric duplication cysts are rare congenital entities most commonly found in the esophagus, ileum or colon but can be in remote locations such as the biliary tree, liver or pancreas. Pancreatic duplication cysts are very uncommon and usually present in adulthood with pancreatitis or abdominal pain. Here, we present a unique and complex case of an infant with a pancreatic duplication cyst initially presenting with an upper gastrointestinal bleed followed by pancreatitis, cyst infection and gastric outlet obstruction.

Laparoscopic removal of massive pediatric gastric trichobezoars: A brief report.

BACKGROUND: Trichobezoars are foreign bodies in the gastrointestinal tract composed of ingested hair. These can develop into large, hard, obstructing objects that are often impossible to remove endoscopically. The size often leads surgeons to remove these via laparotomy or laparoscopic-assisted procedure (midline laparotomy for specimen removal), with few removed completely laparoscopically. BRIEF REPORT: We present a case of a 5-year-old female with pica who had symptoms of foul-smelling diarrhea and weight loss and was found to have a massive gastric trichobezoar. The bezoar was removed laparoscopically with pfannensteil incision facilitating specimen extraction. Further, technical aspects of the procedure are discussed. CONCLUSION: We conclude that there are benefits to using a laparoscopic approach to remove a massive gastric trichobezoar. This includes the use of a Pfannensteil incision rather than a midline laparotomy for specimen removal.

CHIVA - A prospective study of a vein sparing technique for the management of varicose vein disease.

BACKGROUND: Varicose vein disease (VVD) affects approximately one third of adults. Cure Conservatrice et Hémodynamique de l'Insuffisance Veineuse en Ambulatoire (CHIVA) is a minimally invasive, vein sparing technique that is emerging as an alternative to ablative techniques for treating VVD. METHODS: This prospective study assessed the rate of recurrence of venous reflux with CHIVA. We evaluated 150 primary procedures with clinical and duplex ultrasound examinations pre and post operatively. Patients were followed at <3 months and >1-year post-op. Recurrence was defined as reflux in the diseased vessel at the saphenofemoral junction on duplex examination. RESULTS: There was no documented recurrence at the early follow up. To date, 58 legs have completed the late follow up and reflux was found in 5 legs resulting in a recurrence rate of 8.6%; 95% CI (2.4%, 19%). CONCLUSION: Our results indicate that CHIVA appears to offer a promising alternative for the treatment of VVD.

Call to care: the impact of 24-hour postdischarge telephone follow-up in the treatment of surgical day care patients.

BACKGROUND: Patient satisfaction and effective management of postoperative complaints are important factors in determining the success of outpatient surgery programs. METHODS: In September 2013, a 24-hour postdischarge telephone follow-up (TFU) call was initiated by surgical day care nurses at the Royal Jubilee Hospital in Victoria, BC. The study group was contacted to evaluate the effectiveness of the TFU in identifying and addressing postoperative complaints and determining the level of satisfaction with discharge instructions and care. RESULTS: A total of 854 patients were contacted. Overall, 313 (36.7%) received TFU and 541 (63.3%) did not; these served as our control group. Independent sample t-tests revealed that patients who received TFU had significantly fewer postoperative complaints compared with the controls (.19 vs .28, respectively). CONCLUSIONS: Day surgery patients receiving TFU reported fewer postoperative concerns. Results of this study suggest that a TFU call results in increased patient satisfaction with discharge care and is an appropriate tool to address patients' postoperative complaints and improve patient-reported outcomes.

Detecting short-term change and variation in health-related quality of life: within- and between-person factor structure of the SF-36 health survey.

BACKGROUND: A major goal of much aging-related research and geriatric medicine is to identify early changes in health and functioning before serious limitations develop. To this end, regular collection of patient-reported outcome measure (PROMs) in a clinical setting may be useful to identify and monitor these changes. However, existing PROMs were not designed for repeated administration and are more commonly used as one-time screening tools; as such, their ability to detect variation and measurement properties when administered repeatedly remain unknown. In this study we evaluated the potential of the RAND SF-36 Health Survey as a repeated-use PROM by examining its measurement properties when modified for administration over multiple occasions. METHODS: To distinguish between-person (i.e., average) from within-person (i.e., occasion) levels, the SF-36 Health Survey was completed by a sample of older adults (N = 122, M age = 66.28 years) daily for seven consecutive days. Multilevel confirmatory factor analysis (CFA) was employed to investigate the factor structure at both levels for two- and eight-factor solutions. RESULTS: Multilevel CFA models revealed that the correlated eight-factor solution provided better model fit than the two-factor solution at both the between-person and within-person levels. Overall model fit for the SF-36 Health Survey administered daily was not substantially different from standard survey administration, though both were below optimal levels as reported in the literature. However, individual subscales did demonstrate good reliability. CONCLUSIONS: Many of the subscales of the modified SF-36 for repeated daily assessment were found to be sufficiently reliable for use in repeated measurement designs incorporating PROMs, though the overall scale may not be optimal. We encourage future work to investigate the utility of the subscales in specific contexts, as well as the measurement properties of other existing PROMs when administered in a repeated measures design. The development and integration of new measures for this purpose may ultimately be necessary.

Optimizing bowel preparation for colonoscopy: what are the predictors of an inadequate preparation?

BACKGROUND: This retrospective study evaluates factors that are associated with an inadequate bowel preparation. METHODS: A chart review was performed on 2,101 patients who underwent colonoscopy. The quality of preparation was classified as adequate or inadequate. Univariate and multivariate regression analyses identified factors associated with inadequate preparations. RESULTS: A total of 91.5% of preparations were adequate. Standard preparations using polyethylene glycol-electrolyte solution and sodium picosulfate alone were 91.1% adequate. Regimens with adjuncts were 91.9% adequate. Factors that predicted an inadequate preparation include the following: stroke/dementia (odds ratio [OR] 3.5, 95% confidence interval [CI] 1.6 to 7.7, P = .002), opioids (OR 2.3, 95% CI 1.1 to 4.6, P = .02), male sex (OR 2.0, 95% CI 1.4 to 2.9, P = .000), calcium channel blockers (OR 1.9, 95% CI 1.1 to 3.3, P = .03), and antidepressants (OR 1.7, 95% CI 1.1 to 2.7, P = .02). CONCLUSIONS: Several factors are associated with inadequate preparations. Adjuncts do not improve preparation quality. The effect of patient education on preparation quality is an area for further research.

Can general surgeons evaluate visceral slide with transabdominal ultrasound to predict safe sites for primary laparoscopic port placement? A prospective study of sonographically naïve operators at a tertiary center.

BACKGROUND: Port placement injuries are a potentially devastating complication of laparoscopic surgery. Ultrasound assessment for visceral slide has the ability to preoperatively determine adhesion-free areas. The utility of this technique has not been studied when performed by surgeons. METHODS: Surgeons without expertise in ultrasound were taught the visceral slide technique. Patients with a history of abdominal surgery were then assessed for adhesion-free areas on the abdominal wall. Ultrasound assessments were validated against intraoperative visualization. RESULTS: Nine surgeons using the visceral slide technique assessed 145 patients for the presence of adhesions immediately before surgery. Surgeon who performed ultrasound demonstrated a sensitivity of 69.6%, specificity of 98.7%, and positive predictive value of 99.5% for detection of areas free from critical adhesions. The median time to perform the examination was 2 minutes. CONCLUSION: The visceral slide technique was easily learned, was rapid to perform, and reliably identified adhesion-free areas of the abdominal wall.

Which prediction models best identify additional axillary disease after a positive sentinel node biopsy for breast cancer?

To determine which web-based model best identifies women at low risk of further axillary disease after a positive sentinel lymph node (SLN+) biopsy. 673 women with T1-2cN0M0 SNB+ breast cancer who underwent completion axillary dissection (AxD) were identified. A subgroup not eligible to avoid AxD as part of the Z0011 study was defined (Z0011 exclusion group). Predicted risk of further axillary disease was generated using seven web-based models. "Low risk" was defined as a ≤10% risk of further axillary disease. False negative ("low risk" prediction but AxD+) rates (FNRs), area under the receiver operating characteristic curve (AUC), and Brier score were determined for each model. 6 of 7 models identified "low risk" patients but FNRs ranged from 14 to 30%. The Stanford and Memorial Sloan-Kettering (MSKCC) models had the best FNRs. FNRs were lower with SLN micrometastasis (7-15%) and higher in the Z0011 exclusion group (21-41%). All models under-predicted further nodal disease in low risk patients and over-predicted in higher-risk patients. The Stanford and MSKCC models were able to identify women with SLN micrometastasis with a ≤10% FNR. Models were not able to accurately identify low risk women from a cohort that would have been excluded from Z0011.

Trauma association of Canada Pediatric Subcommittee National Pediatric Cervical Spine Evaluation Pathway: consensus guidelines.

BACKGROUND: The Institute of Medicine calls for the use of clinical guidelines and practice parameters to promote "best practices" and improve patient outcomes. In 2006, The Trauma Association of Canada Pediatric Committee set out to create an evidence-based, national pediatric cervical spine (c-spine) clearance guideline based on the literature, existing algorithms from each pediatric trauma center and from expert opinion from across Canada. METHODS: A review of the literature took place in September 2006 using the PubMed database. Search criteria were "cervical spine," "c-spine," "clearance," and "trauma." Limits that were applied were "Languages: English," "Humans," "Type of Article: Meta-Analysis, Practice Guidelines, Randomized Control Trial, Review," and "Ages: all child 0-18 years." These search criteria were repeated in December 2007, April 2009, and October 2009. A total of 248 articles were identified. Existing guidelines were identified and their practices examined as models of care. Two draft guidelines were created for discussion: one for the pediatric patient with a reliable clinical examination and the other for the pediatric patient with an unreliable clinical examination. Via email, telephone, and two national videoconferences, the content of the guidelines was reviewed, discussed, and amended. The final article was prepared and circulated for author input until consensus was reached. RESULTS: A consensus was reached on two pathways to evaluate the pediatric cervical spine: a patient with a reliable clinical examination and a patient with an unreliable examination. CONCLUSION: Presented herein are the consensus Trauma Association of Canada, National Pediatric Cervical Spine Evaluation Pathways for the patient with a reliable clinical examination, and the patient with and unreliable clinical examination.

Rituximab for management of refractory pregnancy-associated immune thrombocytopenic purpura.

BACKGROUND: Rituximab is a novel therapy for immune thrombocytopenic purpura (ITP); however, information about its safety in pregnancy is limited. This case illustrates the successful use of rituximab to treat pregnancy-associated ITP. CASE: A 34-year-old woman presented with severe ITP at 23 weeks' gestation. Standard treatment with corticosteroids, intravenous immune globulin, and splenectomy failed to raise the platelet count. Due to ongoing bleeding, rituximab was given in the 26th week of pregnancy. The platelet count rose to over 100 × 10(9)/L after four weeks. The neonatal B-lymphocyte count normalized at four months after delivery. There were no neonatal complications of rituximab therapy. CONCLUSION: Rituximab may be safe for use in treating pregnancy-associated ITP. This case highlights the need to investigate further the safety and efficacy of rituximab in pregnancy.

The benefits of computed tomographic colonography in reducing a long colonoscopy waiting list.

PURPOSE: The Radiology Department, Royal Jubilee Hospital, Victoria, BC, with the support of gastroenterologists and surgeons, was awarded a BC Innovation fund to run a pilot project of computed tomographic colonography to reduce an unacceptably long 2-year colonoscopy waiting list. Funds were approved in April 2007 for a 1-year project, which was completed on March 31, 2008. METHODS: This article describes the challenges of delivering a high-volume computed tomographic colonography program at a busy community hospital, with discussion of the results for the 2,005 patients who were examined. RESULTS: Colonoscopy was avoided in 1,462 patients whose computed tomographic studies showed no significant lesions. In the remainder of patients, only lesions larger than 5 mm were reported, with a total of 508 lesions identified in 433 patients. There were 57 cancers of which 52 were reported as either definite or possible cancers, whereas 5 were not seen on initial scans. Some of the patients with cancer had been on the colonoscopy waiting list for 2 years. In addition, there were 461 patients with significant extracolonic findings, including 84 who required urgent or semi-urgent further management for previously unsuspected conditions, such as pneumonia, aneurysms larger than 5 cm, and a range of solid renal, hepatic, and pancreatic masses. There were no procedural complications from the computed tomographic colon studies. CONCLUSIONS: We have shown that it is feasible to run a high volume CTC service in a general hospital given hospital support and funding. The benefits in this group of over 2000 patients included avoidance of colonoscopy in over 70% of patients, detection of significant polyps or cancer in approximately 20% of patients, and identification of clinically important conditions in 7%-18% depending on the definition used. The estimated costs including capital, operating, and professional fees were in the range of $400.

Early "sham" feeding of neonates promotes oral feeding after delayed primary repair of major congenital esophageal anomalies.

BACKGROUND: To promote the appropriate and early development of the suck and swallow mechanism, we instituted a "sham" feeding protocol in infants undergoing delayed primary repair of an esophageal atresia anomaly. METHODS: Four patients who were born with esophageal atresia required delayed repair and were sham fed before surgical correction. Each infant started with a small volume of oral feeds by using a bottle/nipple with a continuous Replogle suction system placed nasally into the esophageal pouch. They were carefully monitored. The volume of feeds was slowly increased as tolerated. RESULTS: All infants successfully completed the sham feeding protocol before undergoing delayed primary esophageal repair. After repair, they had a shortened time to full oral feeding. CONCLUSION: Our "sham" feeding protocol is safe and very effective in early development of oral feeding mechanisms and shortens time to complete oral feeding after delayed esophageal repair.

Current management of appendicitis at a community center--how can we improve?

BACKGROUND: Controversies regarding the diagnosis and treatment of appendicitis remain. Practices and outcomes at a community center including imaging, timing of surgery, and surgical technique are reported. METHODS: From January to July 2006, 134 patients undergoing appendectomy in Victoria, British Columbia, were reviewed. Accuracy of preoperative imaging, time from the emergency room to the operating room, length of stay, and early complications were analyzed. Patients with and without perforation were compared using sample t tests. RESULTS: Preoperative computed tomography was obtained for 101 patients (75%) with a negative appendectomy rate of 3% versus 10% for patients without imaging. Imaging did not prolong the time to surgery (11.8 vs 10.9 h, P = .48). Patients with perforation stayed in the hospital significantly longer and had more complications. CONCLUSIONS: The liberal use of computed tomography resulted in fewer negative appendectomies without a significant delay to surgery. Patients with perforation had increased complications and longer hospitalizations. Efforts should be made to identify and treat early appendicitis.

Measuring surgeon performance of sentinel lymph node biopsy in breast cancer treatment by cumulative sum analysis.

BACKGROUND: This study was performed to determine if surgeons' performance of sentinel lymph node biopsy (SLNB) for breast cancer varied with time and to devise a method to continuously evaluate that performance. METHODS: We retrospectively examined the SLNB experience of 13 community surgeons performing 765 SLNBs and 579 concomitant axillary dissections. False-negative rates (FNRs) were assessed for individuals and cohorts defined by caseload. Performance with time was assessed using cumulative sum (CUSUM) analysis. RESULTS: Overall, the SLN identification rate was 94.3%, and FNR was 5.3%. Each surgeon demonstrated variation in identification rate and/or FNR with time. CUSUM analysis provided an effective means to demonstrate when surgeon variation breached performance standards. CONCLUSIONS: Surgeon performance of SLNB varied with time, independent of case load. CUSUM may prove to be a useful statistical tool to evaluate performance before adopting stand-alone SLNB.