Amir A. Rahnemai-Azar

Percutaneous endoscopic gastrostomy: Indications, technique, complications and management

Percutaneous endoscopic gastrostomy (PEG) is the preferred route of feeding and nutritional support in patients with a functional gastrointestinal system who require long-term enteral nutrition. Besides its well-known advantages over parenteral nutrition, PEG offers superior access to the gastrointestinal system over surgical methods. Considering that nowadays PEG tube placement is one of the most common endoscopic procedures performed worldwide, knowing its indications and contraindications is of paramount importance in current medicine. PEG tubes are sometimes placed inappropriately in patients unable to tolerate adequate oral intake because of incorrect and unrealistic understanding of their indications and what they can accomplish. Broadly, the two main indications of PEG tube placement are enteral feeding and stomach decompression. On the other hand, distal enteral obstruction, severe uncorrectable coagulopathy and hemodynamic instability constitute the main absolute contraindications for PEG tube placement in hospitalized patients. Although generally considered to be a safe procedure, there is the potential for both minor and major complications. Awareness of these potential complications, as well as understanding routine aftercare of the catheter, can improve the quality of care for patients with a PEG tube. These complications can generally be classified into three major categories: endoscopic technical difficulties, PEG procedure-related complications and late complications associated with PEG tube use and wound care. In this review we describe a variety of minor and major tube-related complications as well as strategies for their management and avoidance. Different methods of percutaneous PEG tube placement into the stomach have been described in the literature with the pull technique being the most common method. In the last section of this review, the reader is presented with a brief discussion of these procedures, techniques and related issues. Despite the mentioned PEG tube placement complications, this procedure has gained worldwide popularity as a safe enteral access for nutrition in patients with a functional gastrointestinal system.

Single-Site Robotic Cholecystectomy: The Timeline of Progress.

AimTo investigate the learning curve and perioperative outcomes of single-site robotic cholecystectomy during the first 102 cases by a single surgeon.Materials and methodsA retrospective review of a prospectively maintained database was performed on the first 102 cases of single-site robotic cholecystectomy. Patients were divided into five chronological groups based on the date of surgery, with 20 patients in each group except the 5th group which had 22 patients. The groups were compared by docking time, robotic dissection time, and overall surgery time. A P value of 0.05 was used as statistically significant.ResultsThe female to male ratio was 2:1. The mean age was 51xa0years (18–87) and the mean BMI was 28.26 (18–41). Overall, 69xa0% of the patients underwent elective cholecystectomy and 31xa0% required urgent surgery. In all, 17xa0% of patients had previous abdominal surgeries. In total, 45xa0% of procedures were regarded as same day surgery. The total mean length of stay was 1.97xa0days (0–8). The mean operative time was 110xa0min (36–265), mean robotic console time 70xa0min (26–179), and mean docking time 9xa0min (1–26). The overall conversion rate was 3.9xa0% and the complication rate was 4xa0%. The docking time, robotic time, and average operative time were significantly different in the first group as compared to the remaining the five groups (Pxa0=xa00.001).ConclusionSingle-site robotic cholecystectomy is safe in both elective and urgent conditions, and in patients with previous abdominal surgeries. It has a short learning curve.

Independent risk factors for early urologic complications after kidney transplantation

Urologic complications are the most frequent technical adverse events following kidney transplantation (KTX). We evaluated traditional and novel potential risk factors for urologic complications following KTX. Consecutive KTX recipients between December 1, 2006 and December 31, 2010 with at least six‐month follow‐up (n = 635) were evaluated for overall urologic complications accounting for donor, recipient, and transplant characteristics using univariate and multivariate logistic regression. Urologic complications occurred in 29 cases (4.6%) at a median of 40 d (range 1–999) post‐transplantation and included 17 ureteral strictures (2.6%), five (0.8%) ureteral obstructions due to donor‐derived stones or intraluminal thrombus, and seven urine leaks (1.1%). All except two complications occurred within the first year of transplantation. Risk factors for urologic complications on univariate analysis were dual KTX (p = 0.04) and renal artery multiplicity (p = 0.02). On multivariate analysis, only renal artery multiplicity remained significant (aHR 2.4, 95% confidence interval 1.1, 5.1, p = 0.02). Donation after cardiac death, non‐mandatory national share kidneys, donor peak serum creatinine > 1.5 mg/dL or creatinine phosphokinase > 1000 IU/L, and donor down time were not associated with urologic complications. Our data suggest that donor artery multiplicity is an independent risk factor for urologic complications following KTX.

Patient Perception of Ideal Body Weight and the Effect of Body Mass Index

Objective. Despite much effort, obesity remains a significant public health problem. One of the main contributing factors is patients perception of their target ideal body weight. This study aimed to assess this perception. Methods. The study took place in an urban area, with the majority of participants in the study being Hispanic (65.7%) or African-American (28.0%). Patients presented to an outpatient clinic were surveyed regarding their ideal body weight and their ideal BMI calculated. Subsequently they were classified into different categories based on their actual measured BMI. Their responses for ideal BMI were compared. Results. In 254 surveys, mean measured BMI was 31.71u2009±u20098.01. Responses to ideal BMI had a range of 18.89–38.15 with a mean of 25.96u2009±u20093.25. Mean (±SD) ideal BMI for patients with a measured BMI of <18.5, 18.5–24.9, 25–29.9, and ≥30 was 20.14u2009±u20091.46, 23.11u2009±u20091.68, 25.69u2009±u20092.19, and 27.22u2009±u20093.31, respectively. These differences were highly significant (P < 0.001, ANOVA). Conclusions. Most patients had an inflated sense of their target ideal body weight. Patients with higher measured BMI had higher target numbers for their ideal BMI. Better education of patients is critical for obesity prevention programs.

Realistic Survival Outcomes After Vasopressor Use in the Intensive Care Unit

Aim: Patients in the intensive care unit (ICU) have significantly increased mortality rates. Frequently, clinicians are called upon to help families make decisions regarding aggressiveness of care. Having a realistic expectation of outcome is critical for these discussions. This article looked at survival and outcomes following initiation of vasopressors. Methods: All patients admitted to the ICU between January and June 2011were included. Patients were classified into those who had been started on vasopressors (VP+) and those who had not (VP−). Outcomes of these groups including survival were calculated and compared. Results: A total of 1023 patients were included: 169 in the VP+ group and 854 in the VP− group. The survival rate in the VP+ group was 29.6% compared to 92.0% in the VP− group. This was both clinically and statistically significant (P < .001). Conclusion: Patients started on vasopressors in the ICU have very poor outcomes. Being able to quantify this accurately is important to clinicians having discussions with family members.

Gallstone ileus with multiple stones: Where Rigler triad meets Bouveret's syndrome.

A 53-year-old man with multiple medical conditions presented to the emergency department with complaints of vomiting, anorexia and diffuse colicky abdominal pain for 3 d. A computed tomography scan of the abdomen and pelvis showed radiographic findings consistent with Rigler triad seen in small proportion of patients with small bowel obstruction secondary to gallstone impaction. In addition there was a gastric outlet obstruction, consistent with Bouverets syndrome. The patient underwent an exploratory laparotomy and enterotomy with multiple stones extracted. The patient had an uneventful post-surgical clinical course and was discharged home.

Carcinoma in situ in a 7 mm gallbladder polyp: Time to change current practice?

Detection of polypoid lesions of the gallbladder is increasing in conjunction with better imaging modalities. Accepted management of these lesions depends on their size and symptomatology. Polyps that are symptomatic and/or greater than 10 mm are generally removed, while smaller, asymptomatic polyps simply monitored. Here, a case of carcinoma-in-situ is presented in a 7 mm gallbladder polyp. A 25-year-old woman, who had undergone a routine cholecystectomy, was found to have an incidental 7 mm polyp containing carcinoma in situ. She had few to no risk factors to alert to her condition. There are few reported cases of cancer transformation in gallbladder polyps smaller than 10 mm reported in the literature. The overwhelming consensus, barring significant risk factors for cancer being present, is that such lesions should be monitored until they become symptomatic or develop signs suspicious for malignancy. In our patients case this could have led to the possibility of missing a neoplastic lesion, which could then have gone on to develop invasive cancer. As gallbladder carcinoma is an aggressive cancer, this may have led to a tragic outcome.

Laparoscopic removal of migrated intrauterine device embedded in intestine.

Introduction: The intrauterine device (IUD) is a popular family planning method worldwide. Some of the complications associated with insertion of an IUD are well described in the literature. The frequency of IUD perforation is estimated to be between 0.05 and 13 per 1000 insertions. There are many reports of migrated intrauterine devices, but far fewer reports of IUDs which have penetrated into the small intestine. Case Description: Herein we report a case of perforated intrauterine device embedded in the small intestine. By using a wound protector retraction device, and fashioning the anastomosis extra-corporeally, we were able to more easily perform this laparoscopically. This left the patient with a quicker recovery, and a better cosmetic result. Discussion: IUD perforation into the peritoneal cavity is a known complication, and necessitates close follow-up. Most, if not all, should be removed at the time of diagnosis. In the majority of previously reported cases, removal was done through laparotomy. Even in cases where removal was attempted laparoscopically, many were later converted to laparotomy. Surgeons should be aware of different techniques, including using a wound protector retraction device, in order to facilitate laparoscopic removal.

Extrahepatic Biliary Obstruction: An Unusual Presentation of Hepatic Sarcoidosis

We report this case of a 63-year-old woman who presented with progressive illness characterized by abdominal pain, weight loss, anorexia, generalized weakness, and fatigue. The patient was found to have obstructive jaundice with multiple mass lesions in the liver, spleen, and kidney on computed tomography scan of abdomen. She developed cholangitis, necessitating an emergent endoscopic retrograde cholangiopancreatography with biliary stenting and decompression. Later, she was found to have hepatic sarcoidosis on wedge biopsy of the liver. Extrinsic compression of biliary tree from mass effect of sarcoid granulomas with superimposed biliary sepsis is rare.

Non-traumatic biliary duct neuroma masquerading as a Klatskin tumour.

Obstructive jaundice is a common finding in patients presenting to surgeons. Biliary tract obstruction by malignant tumours is of main concern. The term ‘malignant masquerade’ was first used by Hadjis et al. in 1985 to describe a hepatic duct confluence benign lesion, which was diagnosed as a malignant tumour on preoperative evaluations. Although malignant lesions are the main cause of obstructive jaundice, approximately 5% to 10% of patients with preoperative diagnosis of hilar cholangiocarcinoma finally were proven to have benign lesions on post-operative pathological reports. A 31-year-old male presented with jaundice for duration of 3 weeks, which was concurrent with right upper quadrant abdominal pain, pruritus and 10-pound weight loss. Laboratory studies showed total bilirubin 12.1 mg/dL (0.2–1.3), direct bilirubin 9.5 mg/dL (0–0.4) and ALP 240 unit/L (40–130). On abdominal computed axial tomography (CT), there was a symmetric intrahepatic biliary duct dilatation with a tumour-like mass lesion at the level of porta hepatis. On magnetic resonance imaging (MRI), marked intrahepatic biliary duct dilatation with an ill-defined lesion causing obstruction was again noticed (Fig. 1a). Suspecting an intra-ductal tumour, we performed an endoscopic retrograde cholangiopancreatography (ERCP) that revealed intrahepatic biliary dilatation with a central biliary stricture. In the brushing biopsies done during ERCP, malignant cells were not identified. Subsequently, suspecting Klatskin type cholangiocarcinoma, the patient underwent exploratory laparotomy that revealed an inflamed area at the hilum of the liver. The surgery and hospital recovery were uneventful, and finally, the patient was discharged home in a stable condition. On gross pathology, a yellow-tan firm area of thickness (1.2 cm in greatest dimension) was found on the left hepatic duct. Histological evaluation revealed numerous irregular compact nerve bundles and few nerve trunks in the wall of bile duct, mainly towards the hepaticbifurcation. The nerve bundles were positive for S-100 protein (Fig. 2a–d). The diagnosis of neuroma was rendered. Biliary tract neuromas are non-neoplastic, non-encapsulated poorly circumscribed lesions that are characterized by disorderly proliferation of all normal components of a nerve bundle, for example, tangled masses of axons, Schwann cells, endoneurial cells and perineurial cells in a dense collagenous matrix. In the biliary system, a vast majority of these lesions occur in the cystic duct remnant after cholecystectomy, which is the reason for naming them as traumatic neuromas. Three of the reported cases occurred after liver transplantation and another case was described as a late complication following blunt abdominal trauma. Biliary tract neuroma without a prior history of surgery was only described in two cases. These tumours are usually asymptomatic and discovered incidentally. Patient symptoms depend on the location of the tumour, which can present as abdominal pain with findings of obstructive jaundice in common bile duct or hilar neuromas or as post-cholecystectomy pain in cystic duct stump lesions. The major challenge in management of the biliary tract neuromas is pre-surgical diagnosis and early clinical detection. Usually, these tumours are diagnosed after compression of the surrounding tissues, leading to misdiagnosis of hilar cholangiocarcinoma with similar presentations. CT, MRI, intraductal ultrasonography, ERCP and positron emission tomography are the main diagnostic techniques employed. However, each of these modalities lacks sensitivity and specificity for accurate pre-surgical diagnosis of this type of tumour and none can unequivocally exclude the presence of the cancer. On CT scan imaging, biliary tract neuromas usually present as biliary