Endoscopic Management of a Complex Gastrojejunal and Pancreatic Leak Following Pancreaticoduodenectomy.

BACKGROUND: Pancreaticoduodenectomy remains the mainstay of surgical treatment of malignant periampullary disorders. Postoperative morbidity rates are driven by postoperative pancreatic fistula. Although most can be managed conservatively or with percutaneous techniques, complex fistulas including gastroenteric leakage frequently require operative reexploration. Endoscopic therapies in this setting offer an opportunity to avoid invasive reoperation. CASE REPORT: We present the case of a 67-year-old male individual who developed a complex intra-abdominal abscess after pancreaticoduodenectomy with confirmed pancreaticojejunal disruption, gastric staple line dehiscence, and enterocutaneous fistula. Five endoscopic sessions utilizing advanced techniques over a period of 60 days led to complete healing of the patient's external fistula, resolution of complex abdominal abscess, creation of functional communication between the gastric staple line disruption and the afferent jejunum, and return of normal gastrointestinal function. Baseline functional and dietary status was restored without gastrointestinal symptoms or necessity for supplemental tube feedings.

Effects of intraoperative leak testing on postoperative leak-related outcomes after primary bariatric surgery: an analysis of the MBSAQIP database.

BACKGROUND: Intraoperative leak test (IOLT) is commonly performed to evaluate the integrity of an anastomosis or staple line during bariatric surgery. However, the utility of IOLT is controversial. OBJECTIVE: To evaluate the effect of IOLT on postoperative leak-related outcomes after primary bariatric surgery. SETTING: Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program-accredited centers. METHODS: The 2015 and 2016 Metabolic and Bariatric Surgery Accreditation and Quality Improvement databases were analyzed for sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and biliopancreatic diversion with duodenal switch (BPDDS) to determine the postoperative anastomotic/staple line leak (A/SL) and leak-related outcomes. RESULTS: Data for a total of 265,309 patients who underwent SG (69.6%), RYGB (29.7%), or BPDDS (.8%) were analyzed. IOLT was performed in 81.9% of all patients. Overall A/SL, mortality rate in patients with leakage, and 30-day leak-related mortality were .28%, .1%, and .003%, respectively. There were no significant differences between the IOLT and non-IOLT groups in terms of A/SL, 30-day mortality in patients with leakage, 30-day leak-related mortality, readmission, reoperation, intervention, or organ/space surgical site infection. However, the rate of 30-day leak-related intervention in BPDDS was significantly lower in the IOLT group compared to the non-IOLT group (.18% versus 1.15%, P = .01). Whether IOLT was performed endoscopically or nonendoscopically had no effect on the rate of postoperative leaks. Overall mean operative time increased by 19.1 minutes (9.5, 11.9, and 21.2 min for SG, RYGB, and BPDDS, respectively) when IOLT was performed. CONCLUSION: The overall rate of postoperative A/SL and leak-related morbidity was low. This study provided no evidence of either benefit or harm from IOLT in patients who underwent SG, RYGB, or BPDDS.

Effectiveness, Compliance, and Acceptability of Preoperative Weight Loss with a Liquid Very Low-Calorie Diet Before Bariatric Surgery in Real Practice.

OBJECTIVE: A preoperative very low-calorie diet (VLCD) is a common method to reduce weight before bariatric surgery. However, patient compliance and acceptability are not always known. The aim of this study is to evaluate the effectiveness, compliance, and acceptability of our regimen in a metropolitan academic quaternary care center. METHODS: Patients with a BMI < 50 kg/m2 and a BMI ≥ 50 kg/m2 were instructed to be on a liquid VLCD for 1 week and 2 weeks, respectively. The primary outcome was the amount of weight loss. Secondary outcomes were patient compliance and acceptability of either regimen using a questionnaire for hunger, satisfaction, desire, and deviation for solids. RESULTS: The study included 128 patients. Ninety-four patients were in the BMI < 50 kg/m2 group, and 34 patients were in the BMI ≥ 50 kg/m2 group. The BMI ≥ 50 kg/m2 group had a greater percentage of total weight loss (mean ± SD) than that of the BMI < 50 kg/m2 group without statistical differences (4.4 ± 1.3% vs. 3.8 ± 1.6%, p = 0.072). There were no statistical differences between the groups in terms of hunger, satisfaction with a liquid diet, or satisfaction of eating over drinking. However, hunger sensation (median [IQR]) tended to be higher in the BMI < 50 kg/m2 group than that in the BMI ≥ 50 kg/m2 group (2 [2] vs. 2 [2, 3]; p = 0.06). There was no statistical difference in the percentage of patient compliance between the groups (75.5% [n = 71] vs. 61.8% [n = 21], p = 0.18). CONCLUSIONS: Preoperative liquid VLCD provided a modest amount of weight loss and showed a high rate of patient compliance and acceptability.

Impact of vagus nerve integrity testing on surgical management in patients with previous operations with potential risk of vagal injury.

BACKGROUND: Thoracic and foregut operations can cause vagal nerve injury resulting in delayed gastric emptying or gastroparesis. However, the cause of gastroparesis in these patients is not always from a vagal injury. We hypothesize that vagal nerve integrity (VNI) testing may better define who has vagal nerve dysfunction. This information may change subsequent operations. The aim of this study was to evaluate the impact of VNI testing in patients with prior thoracic or gastric surgery. METHODS: From January 2014 to December 2017, patients who had previous operations with the potential risk of vagal injury and had VNI testing were reviewed. Excluded patients were those with no plan for a second operation or the second operation was only for gastroparesis. The main outcome was the percentage of operations altered due to the results of VNI testing. RESULTS: Twelve patients (eight females) were included. Ages ranged from 37 to 77 years. VNI results were compatible with vagal injury in eight patients (67%). VNI test results altered subsequent operative plans in 41.7% (5/12). Pyloroplasty was done in addition to fundoplication in two patients. Plans for hiatal hernia repair with or without redo-fundoplication in three patients were changed by an additional pyloroplasty in one patient and partial gastrectomy with Roux-en-Y reconstruction in two patients. All patients who had secondary surgery had resolution of symptoms and improvement in objective testing. CONCLUSION: The addition of VNI testing in patients with a previous potential risk of vagal nerve injury may help the surgeon select the appropriate secondary operation.

Management and Prevention of Surgical and Nutritional Complications After Bariatric Surgery.

Bariatric surgery is well-recognized for its effects on health, beyond weight-loss. It underwent a revolution recently with the growing performance of laparoscopic procedures, leading to enhanced recovery and a reduction in procedural risk. However, surgical complications, although rare, do develop. It is important to recognize the complications, and ideally prevent them from happening. This article reviews the risks of the four most commonly performed bariatric procedures, with an emphasis on technique and management in the intraoperative and postoperative period. The nutritional aspect of bariatric surgery is of the utmost importance, because catastrophic consequences have been linked to malnutrition and vitamin deficiencies.

Hyperthermic intraperitoneal chemotherapy with oxaliplatin as treatment for peritoneal carcinomatosis arising from the appendix and pseudomyxoma peritonei: a survival analysis.

BACKGROUND: Appendiceal peritoneal carcinomatosis (PC) is rare and its long-term prognosis is poor. The aim of this study was to evaluate the results of an aggressive treatment approach used in our institution for the last eight years. METHODS: Data from all patients with PC arising from the appendix were prospectively collected and analyzed. Treatment consisted of complete surgical cytoreduction (CRS), followed by hyperthermic intraperitoneal chemotherapy (HIPEC) with oxaliplatin (460 mg/m2) at 43°C over 30 minutes. Ronnett's histologic classification was used for tumor grading. RESULTS: Between February 2003 and April 2011, 78 patients underwent laparotomy with curative intent. The mean follow-up period was 33.7 months. A total of 58 patients received HIPEC, but 11 patients could not have CRS and received no HIPEC. Nine patients with a negative second-look surgery also received no HIPEC. The five-year overall survival for the entire cohort was 66.2%; 100% for the negative second-look patients, 77% for the HIPEC patients and 9% for the unresectable patients (P<0.0001). A total of 15 patients (25.9%) had isolated peritoneal recurrence, no patient had visceral recurrence only, and five patients (8.6%) had both. In regards to the five-year disease-free survival for the HIPEC patients, histologic grade (disseminated peritoneal adenomucinosis 100%, peritoneal mucinous carcinomatosis with intermediate features 40%, peritoneal mucinous carcinomatosis 20%; p=0.0016) and completeness of cytoreduction (CCR-0 56%, CCR-1 24%; P=0.0172) were prognostic factors. There was one postoperative mortality. The major complication rate for patients treated with HIPEC was 40%, including intra-abdominal abcess (17%), hemorrhage (12%) and anastomotic leak (10%). One patient in the HIPEC group experienced temporary grade II neuropathy and grade III thrombocytopenia. CONCLUSIONS: This therapeutic approach seems both feasible and safe in selected patients. Recurrence is, however, frequent and represents a challenge.

Relationship between genome and epigenome--challenges and requirements for future research.

Understanding the links between genetic, epigenetic and non-genetic factors throughout the lifespan and across generations and their role in disease susceptibility and disease progression offer entirely new avenues and solutions to major problems in our society. To overcome the numerous challenges, we have come up with nine major conclusions to set the vision for future policies and research agendas at the European level.

Early migration of fully covered double-layered metallic stents for post-gastric bypass anastomotic strictures.

INTRODUCTION: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is well recognized for its efficiency in morbidly obese patients. Anastomotic strictures present in 5-15% of cases and have a significant impact on the patient's quality of life. Endoscopic balloon dilation is the recommended treatment but management of refractory cases is challenging. PRESENTATION OF CASE: Two patients with anastomotic stenoses refractory to dilations were treated with fully covered esophageal stents. Both cases presented early stent migration. The first patient finally underwent surgical revision of the anastomosis. For the second patient, a double-layered stent was installed after the first incident. After the migration of this second stent, three sessions of intralesional injection of triamcinolone acetonide were performed. Both patients were free of obstructive symptoms at a follow-up of 9 months. DISCUSSION: Treatment of post-gastric bypass strictures with stents is based on years of successful experience with endoscopic stenting of malignant esophageal strictures, gastric outlet obstruction in addition to anastomotic stenoses after esophageal cancer surgery. The actual prosthesis are however inadequate for the particularities of the LRYGB anastomosis with a high migration rate. Intralesional corticosteroid injection therapy has been reported to be beneficial in the management of refractory benign esophageal strictures and seems to have prevented recurrence of the stenosis in this post-LRYGB. CONCLUSION: Stents are aimed at preventing a complex surgical reintervention but are not yet specifically designed for that indication. Local infiltration of corticosteroids at the time of dilation may prevent recurrence of the anastomotic stricture.

Risk factors for mortality following emergency colectomy for fulminant Clostridium difficile infection.

PURPOSE: This study evaluated risk factors for mortality after emergency colectomy for fulminant Clostridium difficile infection. METHODS: Retrospective study of 130 cases of Clostridium difficile infection that required a colectomy between 1994 and 2007 in four hospitals of Quebec, Canada. Primary outcome was 30-day mortality. RESULTS: Twenty-five cases underwent colectomy in 1994 to 2002, 41 in 2003, 40 in 2004, and 24 in 2005 to 2007. Common indications were septic shock (41 percent) and nonresponse to medical treatment (39 percent). Overall, 30-day mortality was 37 percent. Mortality increased with age but was not influenced by comorbidities burden. Mortality correlated with preoperative lactate (< or =2.1 mmol/L: 26 percent; 2.2-4.9 mmol/L: 52 percent; > or =5.0 mmol/L: 75 percent, P < 0.001), leukocytosis (<20.0 x 10(9)/L: 32 percent; 20.0-49.9 x 10(9)/L: 33 percent; > or =50.0 x 10(9)/L: 73 percent, P = 0.008), albumin (> or =25 g/L: 19 percent; 15-24 g/L: 38 percent; <15 g/L: 52 percent, P = 0.04) and renal failure. In multivariate analysis, risk factors for mortality were age (per year, adjusted odds ratio: 1.03, 95 percent confidence interval: 1.00-1.06), preoperative lactate greater than or equal to 5.0 mmol/L (adjusted odds ratio: 10.32, 95 percent confidence interval: 2.59-41.1), leukocytosis greater than or equal to 50.0 x10(9)/L (adjusted odds ratio: 3.68, 95 percent confidence interval: 0.92-14.8) and albumin less than 15 g/L (adjusted odds ratio, 6.57, 95 percent confidence interval: 1.31-33.1). CONCLUSIONS: Incidence of Clostridium difficile infection-related emergency colectomies increased 20-fold during the epidemic. Postoperative mortality can be predicted by simple laboratory parameters. Three-fourths of patients with leukocytosis greater or equal to 50.0 x10(9)/L or lactate greater or equal to 5.0 mmol/L died. When possible, emergency colectomy should be performed earlier.

Hyperthermic intraperitoneal chemotherapy with oxaliplatin for peritoneal carcinomatosis arising from appendix: preliminary results of a survival analysis.

BACKGROUND: Peritoneal carcinomatosis (PC) arising from the appendix is a rare disease for which the long-term prognosis is poor. The aim of this study was to evaluate the results of an aggressive approach used in our institution over the last 5 years. METHODS: Data from all patients with PC arising from the appendix were prospectively collected and analyzed. Treatment consisted in complete surgical cytoreduction followed by hyperthermic intraperitoneal chemotherapy (HIPEC) with oxaliplatin (460 mg/m(2)) in 2 L/m(2) of D5W at 43 degrees C during 30 min. Ronnett's histologic classification was used for tumor grading. RESULTS: From February 2003 to March 2007, 38 patients with PC arising from the appendix underwent laparotomy with curative intent. Mean follow-up was 23 months. Twenty-three patients received HIPEC but ten patients could not have complete cytoreductive surgery and received no HIPEC. Five patients with a negative second-look surgery also received no HIPEC. Three-year overall survival (OS) was 100% for the negative second-look patients, 86% for the HIPEC patients, and 29% for the unresectable patients (P = 0.0098). Three-year disease-free survival (DFS) was 49% for the HIPEC patients. Histologic grade was a prognostic factor with regard to DFS for the HIPEC patients (P = 0.011). There was one postoperative mortality. The overall major (grade III-V/V) complication rate for treated patients was 39%, including intra-abdominal abscess (22%), hemorrhage (18%), and anastomotic leak (9%). CONCLUSION: Although these results are preliminary, this therapeutic approach seems both feasible and safe in selected patients.

Evolutionary function of dreams: A test of the threat simulation theory in recurrent dreams.

proposed an intriguing and detailed evolutionary theory of dreams which stipulates that the biological function of dreaming is to simulate threatening events and to rehearse threat avoidance behaviors. The goal of the present study was to test this theory using a sample of 212 recurrent dreams that was scored using a slightly expanded version of the DreamThreat rating scale. Six of the eight hypotheses tested were supported. Among the positive findings, 66% of the recurrent dream reports contained one or more threats, the threats tended to be dangerous and aimed at the dreamer, and when facing a threat, the dreamer tended to take defensive or evasive actions that were possible and reasonable. However, less than 15% of the recurrent dreams depicted realistic and probable situations critical for one's physical survival or reproductive success and the dreamer rarely succeeded in fleeing the threat despite important and appropriate efforts. The findings thus provide mixed support for the threat simulation theory.

cDNA microarray and proteomic approaches in the study of brain diseases: focus on schizophrenia and Alzheimer's disease.

Recent advances in experimental genomics and proteomics, coupled with the wealth of sequence information available for a variety of organisms, have tremendous implications for how biomedical research is performed. Genomic techniques, such as complementary DNA (cDNA) microarrays, currently allow researchers to quickly and accurately quantify vast numbers of potential gene expression changes simultaneously. Modern proteomic techniques allow for the detection and elucidation of protein-protein interactions on a scale and at a speed never before possible. Although hurdles remain, together, these tools open the possibility of enormous change in our ability to analyze and interpret complex biological processes. The field of neuroscience is particularly well suited to analysis with these new techniques, given the complexity of neuronal signaling and the diversity of cellular responses. This review summarizes the major cDNA microarray and proteomic findings of relevance to schizophrenia and Alzheimer's disease (AD) as 2 representative areas of neuroscience research. The potential for these techniques to help unravel the underlying pathology of complex neurological and neuropsychiatric conditions is considerable and warrants continued investigation.

A Blue Luminescent Star-Shaped ZnII Complex that Can Detect Benzene.

Binding benzene: A novel blue luminescent star-shaped ZnII complex has been found to be able to detect benzene selectively by fluorescent quenching. This is attributed to the compoundapos;s high affinity to benzene, as demonstrated in the crystal structure (see picture; yellow: benzene, red: zinc).