A case report of necrotizing fasciitis caused by Haemophilus influenzae co-infection in the setting of COVID-19 pneumonia.

INTRODUCTION AND IMPORTANCE: Necrotizing fasciitis is an aggressive skin and soft tissue infection that is a surgical emergency, and Haemophilus influenzae (H. flu) is a rare cause. We present a case of H. flu co-infection causing necrotizing fasciitis in the setting of COVID-19 pneumonia. CASE PRESENTATION: A 56-year-old male presented with 2 weeks of upper respiratory symptoms. He was unvaccinated against COVID-19 and tested positive for COVID-19 five days prior. He developed respiratory failure requiring intubation, and was treated with dexamethasone, remdesivir, and tocilizumab for COVID-19 pneumonia. On hospital day 2, he was hypotensive with new rapidly evolving erythematous lesions with crepitus of his lower extremities suspicious for necrotizing fasciitis. He underwent wide excision and debridement with significant hemodynamic improvements. H. flu co-infection was identified from blood cultures. Aberrant cells with 94 % lymphocytes were noted and suggested chronic lymphocytic leukemia (CLL) that was not previously known. He developed progressive lesions globally, concerning for purpura fulminans with clinical disseminated intravascular coagulation and neurological decline ultimately leading to withdrawal of care. CLINICAL DISCUSSION: COVID-19 infection is often associated with concomitant opportunistic infections. Our patient was also immunocompromised by CLL, diabetes, chronic steroids, and initial appropriate COVID-19 treatments. Despite appropriate treatments, he could not overcome his medical comorbidities and multiple infections. CONCLUSION: Necrotizing fasciitis caused by H. flu is rare, and we present the first case as a co-infection in the setting of COVID-19 pneumonia. Due to the patient's immunocompromised state with underlying CLL, this proved to be fatal.

Triclosan elicited biochemical and transcriptomic alterations in Labeo rohita larvae.

In the current study, Triclosan (TCS, a commonly used antimicrobial agent) induced alterations in biochemical parameters and gene expression were recorded in the larvae of Labeo rohita after 96 h exposure and 10 days recovery period to find out health status biomarkers. 96 h exposure to 0.06, 0.067 and 0.097 mg/L TCS significantly declined the levels of glucose, triglycerides, urea and uric acid and activity of alkaline phosphatase (ALP), glutamic oxaloacetic transaminase (GOT) and glutamic pyruvic transaminase (GPT). There was a non-significant decline in the levels of cholesterol and total protein but albumin and total bilirubin showed no change. After 10 days of recovery period, trend was opposite for glucose, urea and ALP only. Decline in the expression of trypsin and pancreatic amylase and elevation in creatine kinase during exposure to TCS showed a reverse trend after recovery period. However, concentration dependent elevation of chymotrypsin persisted till the end of recovery period. Principal Component Analysis (PCA) showed association of total protein, ALP, GOT, creatine kinase and pancreatic amylase with PC1 after exposure as well as recovery period. Therefore, these can be considered as important biomolecules for identification of health status of TCS stressed fish.

Genomic markers for the biological responses of Triclosan stressed hatchlings of Labeo rohita.

Triclosan (TCS) used commonly in pharmaceuticals and personal care products has become the most common pollutant in water. Three-day-old hatchlings of an indigenous fish, Labeo rohita, were given 96h exposure to a nonlethal (60 µg L-1) and two moderately lethal concentrations (67 and 97 µg L-1) of TCS and kept for 10 days of recovery for recording transcriptomic alterations in antioxidant/detoxification (SOD, GST, CAT, GPx, GR, CYP1a and CYP3a), metabolic (LDH, ALT and AST) and neurological (AchE) genes and DNA damage. The data were subjected to principal component analysis (PCA) for obtaining biomarkers for the toxicity of TCS. Hatchlings were highly sensitive to TCS (96h LC50 = 126 µg L-1 and risk quotient = 40.95), 96h exposure caused significant induction of CYP3a, AChE and ALT but suppression of all other genes. However, expression of all the genes increased significantly (except for a significant decline in ALT) after recovery. Concentration-dependent increase was also observed in DNA damage [Tail Length (TL), Tail Moment (TM), Olive Tail Moment (OTM) and Percent Tail DNA (TDNA)] after 96 h. The damage declined significantly over 96h values at 60 and 67 µg L-1 after recovery, but was still several times more than control. TCS elicited genomic alterations resulted in 5-11% mortality of exposed hatchlings during the recovery period. It is evident that hatchlings of L. rohita are a potential model and PCA shows that OTM, TL, TM, TDNA, SOD and GR (association with PC1 during exposure and recovery) are the biomarkers for the toxicity of TCS. Graphical abstract.

Biliary hyperkinesia: an indication for cholecystectomy?

BACKGROUND: The main indications for laparoscopic cholecystectomy are stone-related diseases in adults. With a normal abdominal ultrasound (US), a hepatobiliary iminodiacetic acid (HIDA) scan with ejection fraction (EF) is recommended to evaluate gallbladder function. Biliary dyskinesia or low gallbladder EF (EF < 35%) is a recognized indication for cholecystectomy. Recent articles report long-term resolution of symptoms in children with high EFs on the HIDA scan. The purpose of this study is to evaluate the response of patients with biliary colic and hyperkinetic gallbladder to cholecystectomy. We suggest that laparoscopic cholecystectomy might be a considerable surgical option in a subset of the adult population whose workup for food-related biliary abdominal pain is negative except for the high-value EF on HIDA scan. METHODS: Data were consecutively collected from all patients who underwent laparoscopic cholecystectomy between June 2012 and June 2019 at a single institution. Cases were identified using Current Procedural Terminology codes. Patients older than 17 years of age with the negative US (no stone, no sludge, no gallbladder wall thickening) and EF greater than 80% on cholecystokinin (CCK)-HIDA scan were included in this study. All patients were seen at 2 weeks and 10-16 months after surgeries. RESULTS: Over 7 years from June 2012 until June 2019, of 2116 patients who underwent laparoscopic cholecystectomy, 59 patients (2.78%) met study criteria. Postprandial abdominal pain was the most common symptom (43, 72.90%) followed by nausea/vomiting. Forty-seven patients (74.6%) had a reproduction of symptoms with CCK infusion. The average EF was 88.51%. Final pathology showed chronic cholecystitis in 41 (69.5%) patients, cholesterolosis in 13 (22%), polyp in 2 (3.4%). Thirty-six (61%) patients had complete resolution of symptoms, 9 (15%) patients had partial resolution, and 14 (24%) patients had no change. There was a complete resolution rate of 61% and an improvement rate of 76%. CONCLUSIONS: In patients with biliary symptoms, negative ultrasound, and elevated EF on HIDA scan (EF > 80%), laparoscopic cholecystectomy led to a significant rate of symptomatic relief. Interestingly, 94% also had unexpected pathologic findings. This disease process requires further analysis, but this could represent a new indication for laparoscopic cholecystectomy in the adult population.

Biomarkers for the toxicity of sublethal concentrations of triclosan to the early life stages of carps.

Accumulation, contents of protein, non-enzymatic antioxidant glutathione (GSH and GSSG), lipid peroxidation product (melondialdehyde-MDA) and organic acids (fumarate, succinate, malate and citrate), and activities of neurological (acetylcholinesterase-AChE), detoxification (glutathione S-transferase-GST) and metabolic (lactate dehydrogenase-LDH, aspartate transaminase-AST and alanine transaminase-ALT) enzymes were recorded in the hatchlings of Cyprinus carpio, Ctenopharyngodon idella, Labeo rohita and Cirrhinus mrigala after 7 and 14 days exposure and 10 days post exposure (recovery period) to sublethal concentrations (0.005, 0.01, 0.02 and 0.05 mg/L) of triclosan, a highly toxic and persistent biocide used in personal care products. Accumulation was maximum between 7-14 days at 0.01 mg/L for C. carpio and L. rohita but at 0.005 mg/L for C. idella and C. mrigala. No triclosan was observed at 0.005 mg/L in C. carpio and C. mrigala after recovery. Significant decline in protein, glutathione and acetylcholinesterase but increase in glutathione S-transferase, lactate dehydrogenase, aspartate transaminase, alanine transaminase, melondialdehyde and organic acids over control during exposure continued till the end of recovery period. Integrated biomarker response (IBR) analysis depicted higher star plot area for glutathione and glutathione S-transferase during initial 7 days of exposure, thereafter, during 7-14 days of exposure and the recovery period, higher star plot area was observed for acetylcholinesterase, aspartate transaminase, alanine transaminase and organic acids. Higher star plot area was observed for protein in all the species throughout the study. The study shows that L. rohita is most sensitive and glutathione, acetylcholinesterase, aspartate transaminase and alanine transaminase are the biomarkers for the toxicity of sublethal concentrations of TCS.

Biochemical markers for prolongation of the acute stress of triclosan in the early life stages of four food fishes.

In the present study, embryos of four food fishes viz. Cyprinus carpio, Ctenopharyngodon idella, Labeo rohita and Cirrhinus mrigala were given acute (96 h) exposure to their respective LC0, LC10 and LC30 (causing 0, 10 and 30% mortality, respectively) concentrations of triclosan [TCS, 5-chloro-2-(2,4-dichlorophenoxy) phenol], a broad spectrum biocide. Bioaccumulation, contents of protein, non-enzymatic antioxidants (GSH and GSSG), MDA (lipid peroxidation product) and organic acids (fumarate, succinate, malate and citrate) along with the activities of AChE (neurological enzyme), GST (detoxification enzyme) and three metabolic enzymes (LDH, AST and ALT) were estimated after 48 and 96 h exposure and 10 days post exposure. Around 1/10 of the TCS in water got accumulated in the hatchlings after 96 h, increase over 48 h values was maximum at LC0 (+195.30, +143.23 and + 140.75%) but minimum at LC30 (+89.62, +84.26 and + 126.72%) for C. idella, L. rohita and C. mrigala, respectively. In C. carpio, TCS got accumulated only at LC30 after 48 h but at all the concentrations after 96 h exposure. Contents of protein, GSH, GSSG and activity of AChE decreased but activities of GSH, LDH, AST and ALT and contents of MDA and organic acids increased concentration dependently in all the fishes. TCS declined by 85-90% but its toxic effects on biomolecules prolonged till the end of the recovery period. Such acute exposures are accidental but there is a need to evaluate biomarkers for prolongation of the stress of small concentrations especially LC0 and LC10 (causing negligible mortality) of lipophilic pollutants like TCS.

Teratogenicity and accumulation of triclosan in the early life stages of four food fish during the bioassay.

TCS [5-chloro-2-(2,4-dichlorophenoxy)phenol] caused a concentration dependent delay in embryonic development, delay and decline in hatching and reduction in length and weight of hatchlings along with an increase in abnormal/deformed embryos and larvae and percent mortality. These parameters varied in a species specific manner and increased with TCS residue in body. The 96 h LC50 values of TCS for Cyprinus carpio, Ctenopharyngodon idella, Labeo rohita and Cirrhinus mrigala were estimated at 0.315, 0.116, 0.096 and 0.131 mg/L, respectively. Hatching got delayed by 16.33 h for C. carpio (0.47 and 0.50 mg/L TCS) and C. idella (0.20 mg/L TCS) but by 18.07 h for L. rohita (0.15 mg/L TCS) and by 19.33 h for C. mrigala (0.18 mg/L TCS). Spine malformations, oedema (yolk sac and cardiac) and deflated swim bladder were present in 100% larvae of C. carpio, C. idella, L. rohita and C. mrigala at 0.30, 0.08, 0.13 and 0.14 mg/L TCS, respectively. TCS also caused hemorrhage (all but C. idella, only 3.33%), albinism and deformed caudal fin (C. idella), hypopigmentation and rupturing of yolk sac (C. mrigala), gas bubble disease (C. mrigala and L. rohita), fusion of eyes (C. carpio) and degeneration of digestive tract (L. rohita) in 10-40% hatchlings. Exposed hatchlings were very weak and paralyzed, could not swim and remained settled at the bottom of jars. Embryonic development was observed to be an early indicator of the toxicity of TCS as oedema and bubbles in yolk were observed in 40-100% embryos/hatchlings at 0.08 mg/L TCS while 100% mortality was observed between 0.15 and 0.50 mg/L TCS. L. rohita was most sensitive and C. carpio was least sensitive to the stress of TCS. Accumulation of TCS in the hatchlings (1/10 of TCS in water) after 96 h exposure hints that even small quantities of TCS may change species diversity in natural waters.

Large Sized Left Inferior Phrenic Artery and Parahiatal Type of Diaphragmatic Hernia Generating Confusion During Robotic Surgical Repair.

INTRODUCTION: As an advanced minimally invasive surgical procedure, the repair of the diaphragmatic hernia may sometimes be very challenging especially when the anatomy is unclear. MATERIALS AND METHODS: We are presenting a rare case of a parahiatal hernia defect repair where the understanding of the anatomy was complicated by the presence of an unusual large sized left inferior phrenic artery. The Da Vinci surgical platform was used to perform the entire procedure. Hernia sac dissection, identification of the crura, primary closure of the defect, and use of biologic mesh reinforcement were the main steps performed in the usual manner for hernia repair. In addition, the use of intraoperative ultrasound was of great utility to clarify the vascular anatomy. RESULTS: The additional time required for the intraoperative ultrasound and identification of the vascular anatomy has increased the duration of the procedure that otherwise was uneventful. The accurate identification of the anatomy allowed for a safe surgical outcome. The postoperative course was favorable and patient was free of symptoms at 1-month follow-up. CONCLUSION: The challenge of the repair of this rare, parahiatal type of diaphragmatic hernia where a large sized left inferior phrenic artery was also encountered was successfully mitigated by the use of the intraoperative Doppler ultrasound and by compliance with the basic steps of the procedure.

Repair of Morgagni Hernia in Adults with Primary Closure and Mesh Placement: First Robotic Experience.

INTRODUCTION: Morgagni hernia (MH) is an uncommon type of diaphragmatic hernia, especially in adults. Laparoscopic or thorascopic approaches have been described in adults. There are few reported cases using the Da Vinci robot in children and no previously described cases in adults. We report our early experience and technique using the robotic approach for MH repair in adults and its potential advantages. METHOD: Robotic repair of MH was performed in 3 female patients. Four trocars were used to gain access to the abdomen. The hernia contents were reduced, the sac excised, and the defect closed primarily. A 4 × 6 inch bioabsorbable coating mesh was used in 2 patients and a biologic mesh in 1 for reinforcement. RESULTS: Robotic repair of MH was technically successful in all 3 patients. The average operative time was 199.3 minutes, and difficult hernia exposure in one case caused prolonged surgical time. There were no intraoperative complications. Additional interventions, including a repair of a transverse colon serosal tear during the reduction of hernia contents, occurred in 1 patient. Two of the 3 female patients were discharged on postoperative day 1, whereas the other patient was discharged on postoperative day 3. There were no postoperative complications. CONCLUSION: Robotic MH repair is an alternative minimally invasive approach for adults that allows for precise sac excision and primary tension-free repair with mesh reinforcement.

The First Case Report of Robotic Multivisceral Resection for Synchronous Liver Metastasis from Pancreatic Neuroendocrine Tumor: A Case Report and Literature Review.

INTRODUCTION: Surgery for liver metastases in pancreatic neuroendocrine tumor (PNET) improves overall survival rate. We present the first case report for robotic multivisceral resection of distal pancreas, spleen, and left liver for metastatic PNET. MATERIALS AND METHODS: We present a case of 52-year-old female diagnosed with PNET in the pancreatic neck metastatic to the liver, responding to somatostatin and bland embolization, who underwent surgical debulking using da Vinci robotic platform. Intraoperative Doppler ultrasound was used to define the vascular distribution and tumor extension. The parenchymal liver transection was performed with vessel sealer. The distal pancreas and the spleen were approached medial to lateral and resected in an en-bloc fashion. The left liver inflow, outflow, and splenic artery and vein were transected with vascular stapler device. RESULTS: Da Vinci robot-assisted multivisceral resection has been performed with good postoperative outcome. Operative time was 369 minutes and the estimated blood loss was 100 mL. The patient had a short hospital stay with quick recovery and good outcome at 5 months follow-up after the surgery. DISCUSSION: Liver metastases in PNETs are considered an adverse factor. Aggressive surgical management is a mainstay. The laparoscopic approach to pancreatic or hepatic surgery is difficult in inexperienced hands with steep learning curve. The recent robotic system seems to overcome many limitations. This is the first case of robotic multivisceral resection for synchronous liver metastasis from PNET. Concurrent primary tumor resection with hepatectomy offers potential curative intention.

Complications of laparoscopic transgastric ERCP in patients with Roux-en-Y gastric bypass.

BACKGROUND: The altered anatomy of Roux-en-Y gastric bypass presents a challenge when duodenal access is required for ERCP. One technique, laparoscopic transgastric ERCP, was first described in 2002. Since that time, a total of 77 laparoscopic or percutaneous transgastric ERCPs have been reported. The largest case series includes 26 ERCPs, and no reports specifically address complications. We reviewed our experience with 85 transgastric ERCPs and report the limitations and complications associated with access and ERCP. METHODS: Retrospective review was conducted of gastric bypass patients who underwent transgastric ERCP in our practice from 2004-2014. RESULTS: Forty-one patients underwent 85 transgastric ERCPs during the study period. Conversion from laparoscopic to open procedure occurred in 4.8%, and selective cannulation rate was 93%. Forty-seven percent of cases were repeat ERCPs performed through a gastrostomy tube tract. During 15-month median follow-up, the overall complication rate was 19%, with 88% of complications related to access rather than ERCP. Most complications were minor; there were no deaths or cases of severe pancreatitis. Additional intervention, including repair of a posterior stomach laceration or transfusion for bleeding, occurred in 4.7% of cases. Operative intervention occurred in two cases: repair of a duodenal perforation, and debridement of an abdominal wall abscess. Post-ERCP hyperamylasemia was common but did not result in increased length of stay or significant clinical pancreatitis. CONCLUSIONS: Roux-en-Y gastric bypass eliminates the normal approach to the duodenum for ERCP. Transgastric access has a high rate of successful cannulation but is associated with complications. Conversion to open procedure occurred in 4.8%, and 16% developed a complication related to the access site, though the rate of operative intervention was low (2.4%). Our study is limited by its retrospective design, which may underestimate the complication rate, and by our homogenous patient population (94% female, 68% sphincter of Oddi dysfunction).

Chemicals: friends and foes.

There are many chemicals used in and around homes and workplaces that can result in accidents. Can it be said that the insecticides, drugs, polychlorinated biphenyls, DDT, asbestos, cleansers, cosmetics, and other chemicals are worth the price paid in terms of accidental poisonings? That is for the consumer to decide. Generally, it is the misuse of these chemicals that often leads to tragedy. Chemicals can be dangerous, but they can be advantageous when used with care.

Safe techniques for endoscopic resection of gastrointestinal lipomas.

PURPOSE: Gastrointestinal (GI) lipomas are rare, benign, slowly growing, submucosal tumors, which can either be incidentally found as silent tumors of the GI tract or be the cause for GI bleeding, anemia, intussusception, and bowel obstruction. Endoscopic removal is a valid alternative to surgical resection of these tumors. In the recent past, many submucosal lipomas were for the most part resected surgically due to the risk of perforation using endoscopy. There are newer techniques available to allow safe endoscopic removal of these lesions. We present 3 successful techniques tailored to the location of the lipoma and size. METHODS: In our unit, 3 symptomatic GI lipomas were referred to us for surgical resection, 2 originating from the duodenum and 1 from the cecum were diagnosed and resected under endoscopic ultrasound and endoscopy. We performed 3 different techniques to remove these lipomas. One of the lipomas in the duodenum was in the duodenal bulb. It was mobile and 3 cm in size. We attempted to remove this broad-based lipoma by snare and cut technique after its borders were elevated with injection of saline and epinephrine. The second duodenal lipoma was 1.5 cm. This pedunculated lipoma was located in the second portion, on the pancreatic side of the duodenum proximal to ampulla. This lipoma was lifted up with a snare and its base was cauterized resulting in successful removal. The third GI lipoma was 3.5 cm in size pedunculated and located in the cecum. The base of this pedunculated lipoma was ligated with poly loop device and endoclip resulting in ischemia and spontaneous separation of the lipoma from the colonic wall. All cases were revisited with follow-up endoscopy. All 3 methods, when used selectively, were found to be very safe and effective. RESULTS: All 3 lesions were successfully removed and histopathologically confirmed to be lipomas. After endoscopic removal, no complications were observed. CONCLUSIONS: Carefully selected GI lipomas, which in the past have required surgical resection due to high risk for perforation can be endoscopically removed with great success.

Laparoscopic transgastric endoscopic retrograde cholangiopancreatography (ERCP) after gastric bypass: case series and a description of technique.

BACKGROUND: Roux-en-Y gastric bypass excludes the biliary and pancreatic tree from traditional endoscopic evaluation and treatment. As the number of former bypass patients accrues, the need to assess and treat this subset of patients for biliary and pancreatic disease will increase. The authors describe their technique, indications, and outcomes for this group of patients. METHODS: Data were collected by a retrospective chart review of the experience two surgeons had with laparoscopically assisted transgastric endoscopic retrograde cholangiopancreatography (ERCP) from July 2004 to October 2008 at a single institution. This review identified 22 cases. The operating surgeon performed the entire procedure. The indications were suspected sphincter of Oddi dysfunction in 18 patients and recurrent pancreatitis in four patients. Adhesions were lysed, and a purse-string suture was placed on the anterior portion of the stomach. A gastrotomy was made with monopolar electrocautery, and a 12 mm trocar was inserted. It was secured with a purse-string suture. A side-viewing duodenoscope was inserted through this port. An intestinal clamp was placed on the biliopancreatic limb. The intended interventions were sphincter of Oddi manometry, sphincterotomy, placement of a pancreatic duct stent, and injection of botulinum toxin if indicated. RESULTS: Laparoscopic access to the remnant stomach was sufficient for ERCP in 21 cases. One patient required conversion to an open procedure. A total of 12 patients had undergone prior open upper abdominal surgery. One retroperitoneal perforation was noted, with precut sphincterotomy and cannulation of the minor duodenal papilla and no clinical repercussions. Manometry was performed for 18 patients. The pancreatic duct cannulation rate for manometry was 89%, and the rate of bile duct cannulation for manometry was 94%. The manometry studies for 12 patients yielded abnormal results. Eight patients had transient improvement, and three patients had long-term improvement or resolution of symptoms after the index procedure. With additional treatment, two of the transient responders had long-term resolution of symptoms. CONCLUSIONS: The findings demonstrate that gastric bypass patients with biliary pain can be successfully evaluated endoscopically by laparoscopic transgastric ERCP for sphincter of Oddi dysfunction. The rate for technical success and complications does not appear to be significantly greater than for standard ERCP. A few helpful techniques were noted during this experience. Comparison of efficacy with that of a prior study was limited.

Management of postgastric bypass noninsulinoma pancreatogenous hypoglycemia.

INTRODUCTION: Postgastric bypass noninsulinoma hyperinsulinemic pancreatogenous hypoglycemia defines a group of patients with postprandial neuroglycopenic symptoms similar to insulinoma but in many cases more severe. There are few reports of patients with this condition. We describe our surgical experience for the management of this rare condition. METHODS: A retrospective study was performed at St. Vincent Hospital, Indianapolis. Fifteen patients were identified with symptomatic postgastric bypass hypoglycemia for the period 2004-2008. All patients were initially treated with medical therapy for hypoglycemia. Nine patients eventually underwent surgical treatment. The preoperative workup included triple-phase contrast CT scan of the abdomen, endoscopic ultrasound of the pancreas, a 72-h fast followed by a mixed meal test, and calcium-stimulated selective arteriography. Intraoperative pancreatic ultrasound also was performed in all patients. Patients then underwent thorough abdominal exploration, exploration of the entire pancreas, and extended distal pancreatectomy. RESULTS: Nine patients underwent surgery. The mean duration of symptoms was 14 months. The 72-h fast was negative in eight patients (as expected). Triple-phase contrast CT scan of the abdomen was negative in eight patients and showed a cyst in the head of pancreas in one patient. Extended distal (80%) pancreatectomy was performed in all nine patients. The procedure was attempted laparoscopically in eight patients but was converted to open in three. One patient had an open procedure from start to finish. Pathology showed changes compatible with nesidioblastosis with varying degrees of hyperplasia of islets and islet cells. Follow-up ranged from 8-54 (median, 22) months. All patients initially reported marked relief of symptoms. Over time, two patients had complete resolution of symptoms; three patients developed occasional symptoms (once or twice per month), which did not require any medication; two patients developed more frequent symptoms (more than twice per month), which were controlled with medications; and two patients had severe symptoms refractory to medical therapy (calcium channel blockers, diazoxide, octreotide). DISCUSSION: Postprandial hypoglycemia after gastric bypass surgery with endogenous hyperinsulinemia is being increasingly recognized and reported in the literature. Our experience with nine patients is one of the largest. The etiology of this condition is not entirely understood. There may be yet unknown factors involved but increased secretion of glucagon-like peptide 1 and decreased grehlin are being implicated in islet cell hypertrophy. There is no "gold standard" treatment-medical or surgical-but distal pancreatectomy to debulk the hypertrophic islets and islet cells is the main surgical modality in patients with severe symptoms refractory to medical management.

The routine use of laparoscopic ultrasound decreases bile duct injury: a multicenter study.

OBJECTIVE: Laparoscopic ultrasound (LUS) has been used for over 15 years to screen the bile duct (BD) for stones and to delineate anatomy during laparoscopic cholecystectomy (LC). LUS as a modality to prevent BD injury has not been investigated in a large series. This study evaluated the routine use of LUS to determine its effect on preventing BD injury. METHODS: A multicenter retrospective study was performed by reviewing clinical outcome of LC in which LUS was used routinely. RESULTS: In five centers, 1,381 patients underwent LC with LUS. LUS was successful to delineate and evaluate the BD in 1,352 patients (98.0%), although it was unsuccessful or incomplete in 29 patients (2.0%). LUS was considered remarkably valuable to safely complete LC, avoiding conversion to open, in 81 patients (5.9%). The use of intraoperative cholangiography (IOC) varied depending on centers; IOC was performed in 504 patients (36.5%). For screening of BD stones (which was positive in 151 patients, 10.9%), LUS had a false-positive result in two patients (0.1%) and a false-negative result in five patients (0.4%). There were retained BD stones in three patients (0.2%). There were minor bile leaks from the liver bed in three patients (0.2%). However, there were no other BD injuries including BD transection (0%). Retrospectively, IOC was deemed necessary in 25 patients (1.8%) to complete LC in spite of routine LUS. CONCLUSION: LUS can be performed successfully to delineate BD anatomy in the majority of patients. The routine use of LUS during LC has obviated major BD injury, compared to the reported rate (1 out of 200-400 LCs). LUS improves the safety of LC by clarifying anatomy and decreasing BD injury.

Meeting report: threats to human health and environmental sustainability in the pacific basin.

The coastal zone of the Pacific Rim is home for about one-third of the world's population. Disproportionate growth of Far Eastern economies has produced a disproportionate share of related environmental difficulties. As the region searches for acceptable compromises between growth and environmental quality, its influence on global environmental health is certain to increase. Consequences of global environmental change such as habitat alteration, storms, and sea level rise will be particularly acute among Pacific Rim nations. Adverse health effects from arsenic exposure in Pacific Rim nations have been used to justify drinking water standards in the United States and elsewhere. As global manufacturing in the Pacific Rim increases, the centroid of global air quality and waste management issues will shift further toward Far Eastern nations. The Eleventh International Conference of the Pacific Basin Consortium (PBC) was held in September 2005 in Honolulu, Hawaii. The purpose of the conference was to bring together individuals to discuss regional challenges to sustainable growth. The historic emphasis of the conference on hazardous wastes in relation to human health makes the PBC an ideal forum for discussing technical aspects of sustainable economic growth in the Pacific region. That role is reflected in the 2005 PBC conference themes, which included management of arsenic in potable waters, air quality, climate change, pesticides, mercury, and electronics industry waste-each with emphasis on relationships to human health. Arsenic management exemplifies the manner in which the PBC can focus interdisciplinary discussion in a single technical area. The conference program provided talks on arsenic toxicology, treatment technologies, management of arsenic-bearing residuals from water treatment, and the probable societal costs and benefits of arsenic management.