Pancreatic Stones and Extracorporeal Shockwave Lithotripsy: A Review of the Literature.

ABSTRACT: Pancreatic stones are sequelae of chronic pancreatitis, resulting in poor quality of life, frequent hospitalizations, and a significant economic burden. Extracorporeal shock wave lithotripsy (ESWL) can be used to treat pancreatic stones and is less invasive when compared to other modalities. In this review article, we have discussed the role of ESWL in the treatment of pancreatic stones and how it differs from other modalities. Databases were searched electronically for articles discussing the treatment of pancreatic ductal stones by ESWL or other modalities. Articles discussing or comparing treatment success rates were preferentially included. An inductive approach was used to identify articles related to the treatment of pancreatic stones with ESWL throughout the review process. Although laser lithotripsy and electrohydraulic lithotripsy appear to have higher success rates, the potential for ESWL to affect clinical outcomes is substantial, especially in individuals with a higher risk for invasive procedures. The decision to perform ESWL should be considered if the outcome will substantially alter the clinical management when performed by an experienced endoscopist. Further randomized controlled trials are needed to compare ESWL and peroral pancreatic lithotripsy methods.

Disseminated Coccidioidomycosis Following Insufficient Treatment at Initial Presentation: Case Report.

A 35-year-old male presented to our university hospital with night sweats, fevers, ulcerated skin lesions to the lower mouth and posterior neck, shortness of breath, and an enlarging cervical lymph node. The patient was evaluated 2 months prior for respiratory symptoms, cervical lymphadenopathy, and skin lesions resulting in a diagnosis of primary pulmonary coccidioidomycosis and was treated with a 4-week course of fluconazole. On presentation to our hospital, initial laboratory test results revealed leukocytosis, increased liver enzymes, elevated inflammatory markers, and hypercalcemia. Computed tomography scan of the chest revealed lung nodules in a miliary pattern and prominent mediastinal lymphadenopathy. Magnetic resonance imaging revealed multiple vertebral and iliac bone lesions, as well as bilateral psoas muscle lesions. Serum ELISA (enzyme linked immunosorbent assay) detected elevated serological markers against coccidioides, and sputum culture revealed coccidioides arthroconidia, confirming the presence of an acute coccidioides infection. Biopsy of the right iliac crest and cervical lymph node revealed spherules resembling coccidioides, escalating the diagnosis to disseminated coccidioidomycosis. The patient's hospital course was complicated by septic shock, acute respiratory distress syndrome requiring several days of mechanical ventilation, and acute kidney injury. He was ultimately treated with several weeks of voriconazole and liposomal amphotericin-B. He made a full recovery and was discharged on an extended course of oral voriconazole. Our case highlights the importance of recognition and appropriate treatment duration of disseminated coccidioidomycosis at initial presentation. Failure to do so may lead to increased morbidity and mortality.

Feasibility of holmium laser enucleation of the prostate as a 1-day surgery.

PURPOSE: To assess the safety and feasibility of HoLEP as a day-case procedure. METHODS: We reviewed all consecutive patients who underwent HoLEP at our institution between February 2017 and March 2018. During this time, we began a prospective trial aimed at same-day discharge of specific patients. Baseline and demographic variables, and past medical, past urological, intra-operative and post-operative variables in addition to disposition and readmission data were collected. Bivariate analysis was conducted to compare patients based on the day of discharge and readmission. A multivariable model using multiple-regression analysis was used to assess predictors for early discharge or readmission. RESULTS: There were 179 total HoLEP procedures that were performed during the study period. Forty-seven patients were suitable candidates for same-day discharge. Among this group, 28 (59.5%) patients were successfully discharged home on the same day. Nineteen patients (40.4%) could not be discharged. The most common cause of not to discharge patients was the degree of hematuria without continuous bladder irrigation. Pre-operative prostate volume was different between the two groups (88.4 ± 30.7 cc for discharged patients vs 69.0 ± 30.7 cc for admitted patients, p = 0.033). No other pre-operative differences were identified. There were five readmissions (17.8%) following same-day discharge. Readmitted patients had higher rates of history of urinary tract infection (80% vs 26.2%, p = 0.0304). On multivariable analysis, no statistically significant predictors were identified for early discharge or readmission. CONCLUSIONS: Same-day discharge following HoLEP is safe and feasible in well-selected patients.

Spontaneous perforation of Meckel's diverticulum in an adult female with literature review.

BACKGROUND: Perforated Meckel's diverticulum is a rare complication of an already rare disease process, which often mimics a perforated appendix on presentation and diagnosis. The majority of case reports for perforation involve either a foreign body or fecalith. CASE PRESENTATION: We report the case of a 54-year-old female who initially presented at another institution with signs and symptoms of acute appendicitis and underwent appendectomy with a drain left in place. Subsequently, she underwent exploratory laparotomy at our institution for a perceived stump leak or incidental perforation and was found to have a perforated Meckel's, with no evidence of foreign body or fecalith. CONCLUSION: The literature of Meckel's diverticulum is reviewed, and we discuss the difficulty in diagnosis as well as the quandary of incidental resection.