Comparison between transpapillary versus transmural endoscopic ultrasound-guided decompression for biliary obstruction: a meta-analysis.

BACKGROUND: Recent advances have led to the development of transmural endoscopic ultrasound guided biliary drainage (EUS-BD) for cases where the duodenal papilla cannot be accessed. OBJECTIVES: We performed a meta-analysis comparing efficacy and complications of both approaches for biliary drainage. REVIEW METHODS: English articles were searched in PubMed. Primary outcomes included technical success and complications. Secondary outcomes were clinical success and subsequent stent malfunction. Patient demographics and etiology of obstruction were collected and relative risk ratios and 95% CIs were calculated. P-value <0.05 was considered as statistically significant. RESULTS: Initial database search yielded 245 studies from which 7 were chosen based upon inclusion criteria for final analysis. There was no statistically different relative risk for technical success when comparing primary EUS-BD to endoscopic retrograde cholangiopancreatography (ERCP) (RR: 1.04) or overall procedural complication rate (RR 1.39). EUS-BD did have increased specific risk of cholangitis (RR: 3.01). Likewise, primary EUS-BD and ERCP had similar RR for clinical success (RR: 1.02) and overall stent malfunction (RR: 1.55), but stent migration was higher in the primary EUS-BD group (RR: 5.06). CONCLUSIONS: Primary EUS-BD may be considered when the ampulla cannot be accessed, when there is gastric outlet obstruction, or presence of a duodenal stent.

Evaluating the Efficacy of Surgical Consent.

BACKGROUND: Patient autonomy is the most important of the core values of medical ethics, yet the process of obtaining surgical consent remains a lesser scrutinized area of modern surgical practice. Informed consent implies a patient's understanding of nature of the operation, indications, risks, benefits, and alternatives. Surgical consent has traditionally been obtained through verbal communication and formalized by signing a legal document. This process oftentimes leaves patients unequipped with adequate knowledge about the procedure they just consented to. In most cases, it is simply impossible for the non-medically trained layperson to fully understand the nuances of surgery in a conversation. Some may argue a degree of paternalism may be inevitable; we believe there is room for improvement. METHODS: We chose to examine English-speaking adult patients undergoing common procedures (laparoscopic cholecystectomy, open inguinal hernia repair, and skin mass/soft tissue excision). We asked 71 patients to complete a free response survey on the risks, benefits, and alternatives to the operation they had just consented to. The patients were administered the survey either in the outpatient clinic or in the preoperative area. RESULTS: Our analysis showed that most of our patients understand the inherent risks, benefits, and alternatives when being consented but that less than 50% of those consented were considered to have adequate understanding of the procedures they were consented for. DISCUSSION: This study highlights key deficits and potential areas of improvement in the informed consent process. Based on the results, we have significant room for improvement and the responsibility to do so.

Laparoscopic Graham Patch for Anterior Duodenal Perforation in a 6-Year-Old.

Peptic ulcer disease causing perforation is extremely rare in children and primarily affects teenagers. We present a case of a perforated peptic ulcer in a 6-year-old with abdominal pain and emesis with CT findings of moderate pneumoperitoneum and pelvic free fluid without a distinct cause. He was emergently transferred, found to be peritonitic, and taken to the operating room for diagnostic laparoscopy revealing an anterior duodenal ulcer, and underwent laparoscopic Graham patch repair. Postoperatively, the child had positive fecal antigen for H. pylori. He was treated with triple therapy and underwent subsequent testing to confirm eradication. Perforated peptic ulcer is an uncommon pediatric surgical problem, and imaging may not be diagnostic as in the case presented here. Thus, clinicians need to maintain a high index of suspicion when evaluating children with free air and a surgical abdomen in the setting of long-standing abdominal pain.

Colonic Trichobezoar Causing Acute Large Bowel Obstruction.

A trichobezoar is a solid mass of undigested hair that accumulates in the gastrointestinal tract that is typically associated with trichotillomania and trichophagia. Most documented cases are reported to be found in the stomach and small intestine. We report a case of a complete large bowel and small bowel obstruction secondary to a trichobezoar in an 81-year-old male with abdominal pain for one month. He presented to the emergency department with sudden onset nausea, vomiting, constipation, and severe abdominal pain, prompting him to come to the emergency department. CT demonstrated a mechanical obstruction with a transition point at the splenic flexure with pneumatosis. He was taken for urgent exploratory laparotomy, where a colotomy was made and the obstructive intraluminal mass in the transverse colon was identified and removed, and a transverse colostomy was matured. Subsequent pathology revealed the mass as hair and fecal material, confirming a diagnosis of colonic obstruction due to trichobezoar.