Rare Diagnostic and Clinical Manifestations in an Acute Hepatitis A Infection: A Case Report.

The hepatitis A virus (HAV) is a common cause of infectious hepatitis worldwide. In adults, clinical manifestations typically involve fever, nausea/vomiting, fatigue, abdominal pain, and jaundice, although rarer manifestations may be observed. Acute hepatitis A infection is detected via anti-HAV IgM antibodies, which are present in almost all patients at symptom onset. In this case, we present a patient who not only tested negative for acute HAV infection at symptom onset, but also presented with uncommon, extrahepatic manifestations including maculopapular skin rash and polyarthralgia. Wariness of such a presentation can facilitate the timely diagnosis of atypical cases of HAV infection. We report the case of a 51-year-old man who presented with fever, abdominal pain, headaches, and diarrhea for one week with elevated liver enzymes and leukocytosis. Workup consisting of viral hepatitis panels, various infectious studies, and rheumatologic antibody titers did not initially reveal an etiology for the patient's presentation. Computed tomography (CT) abdomen and pelvis, abdominal ultrasound, magnetic resonance cholangiopancreatography (MRCP), and hepatobiliary iminodiacetic acid (HIDA) scan did not reveal acute pathology. The patient's symptoms worsened over the following days, and he additionally developed bilateral wrist pain, digital arthralgias, paraspinal back pain, diffuse muscular weakness, and a pruritic maculopapular rash affecting the flanks and extremities. Eventually, viral hepatitis studies were repeated which revealed elevated levels of anti-HAV IgM antibodies, indicating acute hepatitis A infection. The patient was treated supportively while hospitalized with subsequent improvement of symptoms and lab abnormalities. Since discharge, the patient had not experienced persistent sequelae of the disease. This case of acute viral hepatitis A infection is notable for two reasons: (1) the patient experienced uncommon, delayed, extrahepatic manifestations of disease, and (2) the initial viral hepatitis studies revealed undetectable anti-HAV IgM levels despite having experienced symptoms of illness for several days. This case suggests that repeat viral hepatitis testing may be warranted in patients who continue to experience manifestations of the infection after initially testing negative. It also emphasizes the importance of recognizing potential atypical manifestations of acute hepatitis A infection.

Severe Post-prandial Pain: A Case Report.

Median arcuate ligament syndrome (MALS) is a rare cause of post-prandial abdominal pain due to compression of the celiac artery and celiac plexus. Associated symptoms include nausea, vomiting, diarrhea, and weight loss. The incidence of radiologic compression of the celiac axis is reported to be between 10% and 24%; however, symptomatic compression is noted to be found in about half of the population. MALS is considered a diagnosis of exclusion due to its tendency to present with nonspecific symptoms that mimic other common causes of abdominal pain. Radiologic evidence from angiography with breathing maneuvers is the gold standard for diagnosis. Surgical division of the median arcuate ligament to decompress the celiac artery is an effective treatment proving to provide up to 60-70% of symptomatic relief.

Evolution and literature review of robotic general surgery resident training 2002-2018.

The University of Illinois purchased their first da Vinci System in September of 2002. Within the first calendar year, their program began orienting trainees to the da Vinci Standard System to make its inclusion in their clinical training run more smoothly. During the ensuring 16 years, their program has evolved into more frequent resident orientations, lectures, and courses. The program has grown over the course of different versions of the da Vinci System. Currently, their program houses three Xi and two Si systems. Led by Dr. Crawford and Mr. Dwyer they have formalized their curriculum using a systematic progression of skill acquisition. The lecture will detail the program's organic development over the last 16 years. It will also explain the scientific measurement tools recently applied to the curriculum.

One hundred and two consecutive robotic-assisted minimally invasive colectomies--an outcome and technical update.

BACKGROUND: The objective of this study was to review 102 consecutive robotic colectomies at our institution. We evaluated the 8-year experience of one surgeon (DLC) in Peoria, IL using the da Vinci system. METHODS: An IRB-approved retrospective review was performed. Results were compared with the literature. Changes in technique over the years were evaluated. RESULTS: One hundred and two robotic colectomies, right (59) and sigmoid (43), were performed. Mean age is 63.5 years and mean BMI 27.4 kg/m². Preoperative indications are polyps (53), diverticular disease (27), cancer (19), and carcinoid (3). Mean total case time (TCT) for all cases is 219.6 ± 45.1 (50-380) min, and mean robot operating time (ROT) is 126.6 ± 41.6 (12-306) min. Operative times for Right: Port setup time (PST) 32.4 ± 10.5 (20-64) min, ROT 145.2 ± 39.6 (53-306) min, TCT 212.3 ± 46.4 (50-380) min; times for sigmoid: PST 31.2 ± 9.6 (10-57) min, ROT 101.2 ± 29.2 (12-165) min, TCT 229.7 ± 41.6 (147-323) min. Median length of stay for all patients is 3 (2-27) days. The overall complication rate is 18.6%, the overall conversion rate 8.8%, and the anastomotic leak rate is 0.98%. Residents PGY 1-5 participated in 61 cases (59.8%). CONCLUSION: We report our updated procedural sequence and technical alterations. Experience has allowed residents to evolve to be primary surgeons. We add our results to the current robotic literature.

Robotic-assisted minimally invasive surgery; a useful tool in resident training--the Peoria experience, 2002-2009.

BACKGROUND: The purpose of this study was to review the use of robotic-assisted general surgery at our institution. We evaluated the 8 year experience of one minimally invasive surgery (MIS) fellowship-trained surgeon in Peoria, IL, performing 240 cases of foregut, colon, solid organ and biliary surgery using the da Vinci system, with resident assistance. Foregut and colon procedures are the fifth and sixth most commonly performed procedures of the senior author annually. METHODS: An IRB-approved retrospective review of prospectively collected data representing 124 foregut and 102 colon operations was performed. Data analysed were procedure performed and indications for surgery, gender, age, body mass index (BMI), estimated blood loss (EBL), port set-up time (PST), robot operating time (ROT), total case time (TCT), length of stay (LOS), complications, conversions and resident involvement were recorded. Fourteen cases were excluded from the data review. Statistical analysis using the ANOVA test was applied. A specific review of resident participation was performed. RESULTS: Times for 226 foregut and colon cases were: PST 31.2 ± 9.4 (range 10-64) min, ROT 119.3 ± 41.5 (range 12-306) min, and TCT 194.8 ± 50.3 (range 50-380) min. The EBL was 48.6 ± 55.0 (range 5-500) ml, BMI 28.5 ± 4.7 (range 15.4-46.8) kg/m(2) , and median LOS 2.0 (range 0-27) days. The overall complication rate was 13.3%. No deaths occurred. Over the 8 year study period the number of cases participated in by residents was 0, 16, 22, 15, 29, 26, 28 and 10 (as of June 2009), respectively. CONCLUSION: This series demonstrates the technical feasibility and safety of robotic surgery for the foregut and colon in a clinical setting where the surgeon does far more of other types of MIS. This series compares favorably with the literature. Incorporation of robotic training in the curriculum has allowed residents to learn robotic techniques in an effective manner.

Delayed presentation of colonic impalement injury by picture frame glass fragment treated using hand-assisted laparoscopic colectomy.

This is a case of impalement injury with delayed presentation. A 60-year-old man experienced a traumatic injury after a fall on top of a broken picture frame, which caused a small laceration to his left upper abdominal wall. Sixteen months after the injury, he developed a tender left abdominal wall and lower abdominal cramping pain. Colonoscopy identified a shard of glass in the left colon. The glass presumably impaled his abdominal wall as a result of his previous traumatic injury and migrated to the left colon. Laparoscopic surgery was used to safely and efficiently remove the impaled glass shard and affected portion of colon. Such a case has never been reported.

Robot-assisted laparoscopic colectomy: 70 cases-one surgeon.

This study reviewed the use of robot-assisted laparoscopic surgery for colon resection. We described the six-year experience of one minimally invasive fellowship-trained surgeon performing 70 consecutive colectomies using the da Vinci system. Between September 2002 and 2007, data on 70 patients undergoing robotic colectomy for diverticular disease, polyps, cancer, or carcinoid tumor were collected. Operations were right colectomy and sigmoid colectomy. A total of 38 right and 32 sigmoid colectomies were performed in 32 males and 38 females. The postoperative diagnoses were diverticular disease (19), polyps (36), cancer (13), and carcinoid (2). Times for the right colectomies were: port setup time 33.6 ± 12.1 (20-64) min, robotic time 147.2 ± 44.4 (53-306) min, and total case time 221.3 ± 43.7 (150-380) min. The estimated blood loss (EBL) was 53.9 ± 78.2 (15-500) ml, the body mass index (BMI) 27.2 ± 4.2 (17-36.8) kg/m(2), and the median length of stay (LOS) 3 (2-27) days. The robotic portion represented 66.5 % of the total case time. Times for the sigmoid colectomies were: port setup time 30.0 ± 9.8 (10-57) min, robotic time 101.8 ± 25.3 (67-165) min, and total case time 228.4 ± 40.5 (147-323) min. The EBL was 71.2 ± 47.9 (15-200) ml, the BMI 27.1 ± 4.9 (17.0-40.5) kg/m(2), and the median LOS 4 (2-27) days. The robotic portion represented 44.6% of the total case time. Eight different types of complication occurred. Eight cases were converted-five to open and three to laparoscopic. Two resulted from robot malfunction. Residents participated in 40 cases (57.1%). In the years 2002-2006, respectively, 5, 12, 10, 11, and 19 robotic colectomies were performed. In the first nine months of 2007, 13 robotic colectomies were performed. These 70 consecutive cases have demonstrated robotic colectomy to be a safe and technically feasible approach. The number of robotic colectomies performed each year has steadily increased over the last six years. This series compared favorably with other robotic series in length of hospital stay, conversion rates, and total case time.

Postcholecystectomy biliary symptoms.

Patients with postcholecystectomy biliary symptoms beyond their original surgery present a diagnostic challenge for the practicing surgeon. The diagnostic algorithm is the same as in an initial episode and should rule out nonbiliary causes of right upper quadrant pain. If biliary causes are suspected, the most common diagnosis is retained common bile duct stones.(1) Among the less common diagnoses, congenital anomalies of the biliary system must also be considered. Anatomical variants are well described in medical literature and must be anticipated by the general surgeon. Here the course and imaging of 2 different patients with postcholecystectomy biliary symptoms are presented followed by a discussion of several etiologies that could cause these symptoms. These cases are presented to remind the general surgeon of the wide variety of presentations possible with biliary disease. In these situations, knowledge of a patient's surgical history can lead to confusion when attempting to make an accurate diagnosis. A prepared surgeon can help shed light on a case complicated by inconsistencies between imaging studies and patient history.

Metastatic breast cancer presenting as linitis plastica of the stomach.

Early detection and treatment of breast cancer, leading to longer survival, has revealed the natural history of this disease process. Linitis plastica of the stomach is a potential long-term sequela of metastatic breast cancer. Here we present a case of metastatic breast cancer presenting as linitis plastica, as well as the treatment algorithm for this rare clinical entity. The world literature describes a clear pattern of linitis plastica for metastatic infiltrating lobular breast cancer and a discrete nodular pattern for infiltrating ductal cancer, in regard to metastasis to the stomach. To our knowledge, this is the first case of infiltrating ductal cancer presenting as linitis plastica of the stomach.

Symptoms before and after laparoscopic cholecystectomy for gallstones.

Between 1989 and 1995, 1380 patients underwent laparoscopic cholecystectomy for symptomatic cholelithiasis by a single surgical group at a large private teaching hospital. Thirteen hundred surveys were mailed, and 573 (44.3%) were completed at least 6 months postoperatively. Pain and nonpain symptoms were present preoperatively in 432 (75%) and 457 (80%) patients, respectively. Postoperatively, pain and nonpain symptoms were present in 141 (25%) and 247 (43%) patients, respectively (P < 0.05). All nonpain symptoms were significantly reduced postoperatively except for diarrhea (P < 0.05). Longer duration of pain, age < 40, frequent episodes of pain, postprandial pain, and increased sites of pain preoperatively were all predictive of a higher incidence of persistent postoperative pain (P < 0.05). Persistent nonpain symptoms were more likely if diarrhea, fatty food intolerance, age < 40, or both pain and nonpain symptoms were present preoperatively (P = 0.05) and less likely if only pain symptoms were present preoperatively (P = 0.0001). This series quantifies symptom-specific outcomes for the surgeon. While most symptoms improve, a significant number of pain and nonpain symptoms persist after laparoscopic cholecystectomy. With these data, surgeons can modulate postoperative expectations and advise on the possible persistence of symptoms.