Dissecting malpractice in pancreaticoduodenectomy cases.

BACKGROUND: Medical malpractice is a growing concern for physicians in all fields. Surgical fields have some of the highest malpractice premiums and litigation rates. Pancreaticoduodenectomy (PD) has become a popular procedure; however, it is still associated with significant morbidity and mortality. This study is the first to analyze factors involved in litigation regarding PD cases. METHODS: The Westlaw database was searched for jury verdicts and settlements using the terms "medical malpractice" and "pancreaticoduodenectomy". Twenty-nine cases from 1991 to 2012 were initially collected. Seven entries not involving PD and three duplicate cases were excluded. Nineteen cases were included for analysis. RESULTS: Of the 19 cases included in the analysis, three (15.8%) reached a settlement, three (15.8%) were ruled in favor of the plaintiff, and 13 (68.4%) were ruled in favor of the physician. The average settlement award was $398,333 (range, $195,000-500,000), and the average plaintiff award was $4,288,869 (range, $1,066,608-10,300,000). The most common factors raised in litigation included PD being allegedly unnecessary (47.4%), followed by postoperative negligence and misdiagnosis (36.8% each). CONCLUSIONS: The most common factors present in litigation included the allegation that PD was unnecessarily performed. The cases that are awarded large monetary sums are those that involve continued medical care. Ways to improve patient safety and limit litigation include increasing transparency and communication with a thorough discussion between surgeon and patient of the most common topics of litigation discussed.

Carbohydrate Antigen (CA 19-9) Surge: Unraveling the Enigma of Elevated Levels in the Setting of Benign Etiologies.

Carbohydrate antigen 19-9 (CA 19-9) is widely recognized as a tumor marker primarily associated with pancreatic cancer. However, its elevation in benign pancreaticobiliary conditions complicates its diagnostic utility. We present the case of a 39-year-old male with no significant medical history who presented with symptoms of abdominal pain, nausea, vomiting, and diarrhea. The initial diagnosis suggested viral enteritis, but the subsequent worsening of symptoms led to further investigation. Elevated white blood cell counts, bilirubin levels, and liver function tests prompted magnetic resonance cholangiopancreatography (MRCP), which revealed dilated bile ducts and acute cholecystitis. Following endoscopic retrograde cholangiopancreatography (ERCP), significant hemobilia was observed, raising suspicions of cholangiocarcinoma. Despite extensive investigations, including CT angiography, MRCP, and repeat ERCPs, no malignancy was detected. Remarkably, the CA 19-9 level was elevated to 904 U/mL after the initial ERCP and uptrended to 7380 U/mL. These levels, however, normalized to 13 U/mL within two weeks of discharge. While CA 19-9 is a valuable marker in the diagnosis of pancreatic cancer, its elevation in benign pancreaticobiliary conditions necessitates cautious interpretation. In our case, choledocolithasis, cholangitis, and biliary manipulation appeared to have contributed to a transiently elevated CA 19-9. Clinicians must consider the entire clinical context when evaluating elevated CA 19-9 levels to avoid misdiagnosis and ensure appropriate patient management.

Case report: a rare case of gastroduodenal intussusception caused by GIST in an elderly patient and literature review.

Gastroduodenal intussusception is a rare phenomenon in adults and is caused by gastrointestinal stromal tumors (GIST) in the majority of the documented cases. It commonly presents with abdominal pain, vomiting and melena. GIST is the most common gastrointestinal mesenchymal tumor in gastric and non-gastric locations. It is characterized classically by KIT or PGDFRA expression, and immunohistochemical analysis is the mainstay of diagnosis. Surgical resection provides definitive treatment in 70% of the cases. Here, we present a rare case of gastroduodenal intussusception caused by GIST in an elderly patient.

Gallstone ileus in a patient with amyotrophic lateral sclerosis: A case report.

INTRODUCTION AND IMPORTANCE: Gallstone ileus is a rare disease that most commonly occurs in elderly females with a history of cholelithiasis. It has not been previously associated with Amyotrophic Lateral Sclerosis (ALS); a neurodegenerative disease that primarily affects the motor neurons at the spinal and bulbar levels. Autonomic malfunction, in particular, gastrointestinal dysfunction has been documented in ALS patients which may predispose this population to the development of gallstones and gut dysmotility. CASE PRESENTATION: In this paper, we report a case of gallstone ileus in a patient with diagnosed ALS. We performed an exploratory laparotomy, enterolithotomy, and an open cholecystectomy with takedown/closure of a cholecystoduodenal fistula. The patient had a relatively uncomplicated postoperative course and was discharged from the hospital on postoperative day nine. CLINICAL DISCUSSION: Delays in gastric emptying and colonic transit times in ALS patients may pose a risk for the development of gallstones and the potential impaction of a gallstone ileus in patients who are left untreated. Multifactorial evaluation of this patient population is necessary when assessing a potential causal pattern of gallstone ileus in patients with significant comorbidities. CONCLUSION: We present an unusual pathology without an established incidence, which has pertinent multidisciplinary implications. The suspicion of ALS as a potential cause for the development of a gallstone ileus is relevant and essential in the diagnostic workup for an elderly patient who develops a small bowel obstruction with multi-comorbidities.

Debulking of Advanced Gastrointestinal Stromal Tumor With Peritoneal Carcinomatosis Refractory to Imatinib and Sunitinib: A Case Report.

Gastrointestinal stromal tumors (GISTs) are non-epithelial stromal tumors that arise in the gastrointestinal tract. Pharmacological treatments for GIST are tyrosine kinase inhibitors. For metastatic disease, debulking may be helpful in reducing the tumor burden, thus increasing the effectiveness of tyrosine kinase inhibitors. Debate on whether resection would benefit the patient is still present. Here is a case of a 52-year-old African American male presenting with metastatic malignant GIST with peritoneal carcinomatosis refractory to imatinib and sunitinib. Since this patient had stage IV metastasis it was ultimately decided to proceed with a therapeutic debulking procedure. For this patient, the procedure increased the effectiveness of the medication and reduced mass effect symptoms, improving quality of life.

Decreasing the burden: An unusual GIST presentation, a case report.

INTRODUCTION: Gastrointestinal stromal tumours (GIST) are notoriously one of the most common mesenchymal tumours of the alimentary canal. Most commonly originating from the gastric stroma, they are recognized by their mass effects on the abdominal cavity. Recurrence frequently occurs with GIST and these tumours may become refractory to tyrosine kinase inhibitors (TKIs). Therefore, resection may be indicated for improved outcomes. PRESENTATION OF CASE: We present a 52-year-old African American male with a surgical history of GIST resection with recurrence that came to the emergency room with worsening diffuse abdominal pain. The tumour was refractory to two TKIs, Imatinib and Sunitinib. Computed tomography (CT) of the abdomen and pelvis was done which showed severe metastatic disease with carcinomatosis, multiple dilated loops of small bowel in the left hemiabdomen without discrete transition point. After seventeen days on nasogastric tube, antiemetics, the patient worsened, and it was decided to go to surgery. In this report, attention is focused on the surgical approach of tumour debulking with subsequent Regorafenib therapy for decreased obstructive symptoms and improved quality of life. CONCLUSION: This case serves as an example of the importance of surgical debulking in addition to molecular therapy for patients with severely extensive GISTs. Tumour debulking is important to decrease tumour burden, improve chemotherapeutic response and improve quality of life especially in persons refractory to pharmacological therapy.

Current status of antireflux surgery.

This article summarizes the historical aspects of antireflux surgery,including the initial techniques and subsequent modifications. Appropriate patient selection is essential to the success of antireflux procedures. The authors review the diagnostic evaluation, the technical details of the procedure, and how to manage surgical failures.

Making liver transection even safer: a novel use of microwave technology.

Hepatic surgery has evolved significantly in the past decade. The current article describes the largest series of patients in United States undergoing liver resective therapy with the use of microwave technology for liver precoagulation. Glisson's capsule was incised after securing inflow and outflow control. Two antennae, 2 cm apart, connected to a 915-MHz generator, were inserted 5 cm into liver parenchyma at a 130° angle. Once the parenchyma was firm and changed its color to gray, the antennae were advanced along the line of transection. The parenchyma was divided with electrocautery. Intra- and postoperative data were analyzed. Thirty-five patients (24 men) underwent liver resections. Diseases treated were colorectal metastases (n = 9), hepatic adenoma (n = 3), gallbladder cancer (n = 3), hepatocellular carcinoma (n = 4), neuroendocrine tumor (n = 2), cholangiocarcinoma (n = 5), hemangioma (n = 2), focal nodular hyperplasia (n = 2), metastatic gastrointestinal stromal tumor (n = 1), hydatid cyst (n = 1), hepatoid carcinoma (n = 1), hepatolithiasis (n = 1), and suspected metastatic breast cancer (n = 1). Resections done were right hepatectomy (n = 19), segmental resection (n = 5), left hepatectomy (n = 4), extended right hepatectomy (n = 4), Segment IVb and Segment V resections during radical cholecystectomy (n = 2), and left lateral sectionectomy (n = 1). Median operative time for major resection was 188 and 251 minutes for minor resection. There was one postoperative mortality. Bile leak needing stenting occurred in one patient. Median blood loss for major resection was 500 mL and 265 mL for minor resection. Intraoperative transfusion was required in nine major and one minor resections. Other complications were ileus in four, deep vein thrombosis in two, intra-abdominal abscess in one, and cardiac events in two patients. Liver precoagulation with microwave technology is a novel and efficient technique with minimal morbidity and mortality for liver transection.

Feasibility of pancreaticoduodenectomy in a nonuniversity tertiary care center: what are the key elements of success?

It is advocated that a favorable outcome for pancreaticoduodenectomy (PD) is related to a high volume at university centers. This article examines the specific elements that allow an equivalent outcome from PD in a nonuniversity tertiary care center (NUTCC). The study was performed to: (1) evaluate the outcome of PDs done at a NUTCC; (2) study the components of the process that are required to attain success in a NUTCC; and (3) provide a new look at the volume-outcome relationships in complex surgeries in a novel nonuniversity setting. Medical records of patients who underwent PD by a single surgeon between September 2005 and August 2008 at a high-volume NUTCC were analyzed. The records were reviewed with respect to preoperative and postoperative data, 30-day mortality, morbidity, and histopathology data. A total of 122 patients underwent PD. The mean age was 68.2 years. Jaundice was the most common presenting symptom in 57 per cent (69 patients). Thirty-nine patients (32%) underwent a pylorus-preserving PD. The mean operative time was 237 minutes. The mean estimated blood loss was 480 mL. The mean length hospital stay was 13 days. Thirty-day mortality was 3.2 per cent (four patients) and overall morbidity was 49 per cent. The key factors in developing a team dedicated to the care of the patient undergoing PD are discussed. A center of excellence can be developed in a NUTCC resulting in outcomes that meet and indeed may exceed nationally reported benchmarks. The key elements to success include a team approach to the patient undergoing PD.

Surgical management of gastric varices and morbid obesity: a novel approach.

BACKGROUND: Morbid obesity is a growing pandemic. The greater prevalence of chronic conditions such as diabetes, hypertension, and heart and liver disease has made management of obesity challenging. Many surgical techniques are in practice, each with some elements of restrictive or malabsorptive components. Nonalcoholic steatohepatitis can lead to portal hypertension, which can further manifest as upper gastrointestinal bleeding. METHODS: We performed sleeve gastrectomy at a nonuniversity tertiary care center, as a novel approach for the management of isolated gastric varices, in a morbidly obese cirrhotic patient. RESULTS: The operating time was 142 minutes. The estimated blood loss was 150 mL. The patient did not receive intraoperative or postoperative transfusions. The length of stay was prolonged to 10 days because of an ischemic cardiac event that was managed by coronary angioplasty on postoperative day 7. The patient did not develop any other complications. During the next couple of months, the patient lost significant weight and had no complaints. CONCLUSION: Sleeve gastrectomy with devascularization is a durable approach that will address the problems of both portal hypertension and morbid obesity, with the desired effect of weight reduction and treatment of gastric varices using a single surgical approach.