The influence of VKORC1 and CYP2C9 mutations on warfarin response after total hip and knee arthroplasty.

AIMS: This study characterizes the influence of genotype at two loci on warfarin response after arthroplasty. METHODS: 121 postarthroplasty patients given warfarin thromboprophylaxis were reviewed for international normalized ratio (INR) values on the first three days postoperatively. Significant differences among genotypes in INR values on each of the first three postoperative days were assessed. RESULTS: Wild-type patients at both loci (∼23% of patients) had yet to reach therapeutic INR (1.5-2.0) by postoperative day three more frequently than those with a mutation conferring hyper-responsiveness (61% vs. 30%; P ≤ .01). CONCLUSIONS: Wild-type patients are not anticoagulated in a sufficiently prompt manner after arthroplasty.

Ex vivo renal repair: technical tips, when, and why.

Ex vivo renal artery repair combined with cold perfusion protection is an operative technique for managing complex renal artery lesions. Most diseases of the renal artery are proximal, and typically treated either medically, by endovascular means, or surgically. When surgery of the main renal artery is required, it can typically be performed with warm renal ischemia times of <30 minutes. However, in more distal disease, which can involve the segmental branches, a much more complicated surgical reconstruction can be anticipated. This often will necessitate warm ischemia times of >45 minutes, and can lead to direct renal nephron damage. In this setting, the ex vivo technique with cold perfusion can allow for lengthy reconstructive times of several hours without any measurable harm to renal function. The technique can be performed with low morbidity and mortality, an excellent rate of renal salvage, and preservation of renal function.

Cutaneous surgery in patients on warfarin therapy.

Warfarin is a commonly used anticoagulant for patients with prosthetic heart valves, atrial fibrillation, stroke, deep vein thrombosis, or pulmonary emboli to prevent thromboembolic events. There is no clear consensus regarding the perioperative management of warfarin therapy for plastic surgery procedures. Our objective is to evaluate the safety and quantify any increased morbidity in patients on warfarin therapy, undergoing soft tissue surgery. In a retrospective chart review of prospectively collected data, patients undergoing cutaneous surgery on warfarin therapy from 2000 to 2006 were identified. Perioperative complications were evaluated, including major hemorrhage, incisional bleeding, hematoma, wound or flap complications, graft success, and cosmetic surgical outcome. A total of 26 anticoagulated patients who underwent 56 procedures were included. Intraoperative bleeding was controlled in all cases without difficulty. Minor postoperative bleeding was noted in 1 patient, and this was easily controlled with gentle pressure. All wounds healed without complication, including 2 split thickness skin grafts. The cosmesis of all scars was acceptable. Anticoagulation with warfarin can be safely continued in patients undergoing minor soft tissue procedures, thereby avoiding the risk of potentially devastating thromboembolic events.

Pregnancy outcomes after laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Early reports described adverse perinatal outcomes of pregnancies after weight loss surgery (WLS), which subsequently raised concerns regarding safety. Our objective was to investigate, in a community-based, academic, tertiary care center, the safety of pregnancies after laparoscopic Roux-en-Y gastric bypass (LRYGB) and its potential effect on obesity-related perinatal complications. METHODS: The pregnancy outcomes of patients delivering infants after LRYGB at our institution were compared with those of control subjects (stratified by body mass index) who had not undergone WLS. The charts were retrospectively reviewed for demographics, delivery route, and perinatal complications. RESULTS: A total of 26 patients who delivered after LRYGB and 254 controls were identified. The mean interval from LRYGB to conception was 25.4 +/- 13.0 months. In general, the perinatal complications in the LRYGB patients were similar to those in the nonobese controls and lower than in the obese and severe obese controls, although statistical significance was not noted for all complications. No spontaneous abortions or stillbirths occurred in the LRYGB patients. No LRYGB patients required intravenous nutrition or hydration. The overall incidence of cesarean section in the LRYGB patients was similar to that in the obese and severely obese controls but significantly greater than that in the nonobese controls. The complication rates were similar in pregnancies occurring "early" (<12 mo) versus "late" (>18 mo) after LRYGB. CONCLUSION: The results of our study have shown that pregnancy after LRYGB is safe, with an incidence of perinatal complications similar to that of nonobese patients, and lower than that of obese and severely obese patients, who had not undergone WLS. Larger studies are required to demonstrate statistically significant improvements in outcome in patients treated with WLS.

Metastatic malignant melanoma of the gallbladder presenting as biliary colic: a case report and review of literature.

Malignant melanoma (MM) is the most common cancer to metastasize to the gastrointestinal tract. Autopsy reports estimate that up to 15 per cent of these patients also have gallbladder metastases, and MM accounts for up to 60 per cent of metastatic lesions to the gallbladder. However, despite its prevalence, MM to the gallbladder is reported only sparingly in the literature. This discordance may be explained by the fact that these lesions are seldom symptomatic. Abdominal ultrasound remains the modality of choice in studying gallbladder pathology and has the ability to define metastatic lesions. The effect of screening for gallbladder metastases on improving survival is not well defined, and thus its role remains controversial. Cholecystectomy for melanoma metastases to the gallbladder seems to be mostly palliative, although there have been isolated reports of excellent long-term survival outcomes. The role for immunotherapy and chemotherapy in this population is not well defined, and overall prognosis is poor. Recent reports have advocated laparoscopic cholecystectomy as the treatment of choice, though there remains a concern for peritoneal port site seeding. We present the case of a 48-year-old man with MM metastatic to the gallbladder and a brief review of the literature.

Retroperitoneal ganglioneuroma encasing the celiac and superior mesenteric arteries.

Ganglioneuroma is a rare neoplasm arising from the sympathoadrenal neuroendocrine system and has anatomic distribution paralleling the sympathetic chain ganglia and the adrenal medulla. In some cases, ganglioneuroma is the end stage maturation of less-differentiated neoplasms such as neuroblastoma or ganglioneuroblastoma, but based on age at diagnosis (over 10 years of age) and anatomic location, many of these tumors appear to arise de novo. It must be included in the differential diagnosis of posterior mediastinal and retroperitoneal mass. We report a case of retroperitoneal ganglioneuroma involving the celiac axis and superior mesenteric arteries in a 40-year-old female.