Christopher M. Gibbs

Outcome following endoscopic transmural drainage of pancreatic fluid collections in outpatients.

Objective: To evaluate the performance of endoscopic transmural drainage of pancreatic fluid collections (PFCs) in outpatients. Patients and Methods: We retrospectively reviewed 19 consecutive outpatient cases in 18 patients who underwent attempted endoscopic transmural drainage of PFCs by a single endoscopist at the Mayo Clinic in Rochester, MN, over a 5-year period (October 1998 to October 2003). All drainages were performed without EUS-guided entry, using an aspiration needle and no cautery. Two 10-Fr stents were placed after dilation of the entry site. Results: The study group consisted of 12 men and 6 women (median age, 48 years; range, 28-79 years), with 14 cases of pseudocysts and 5 cases of pancreatic necrosis. Transmural drainage approaches included 13 transgastric, 5 transduodenal, and 1 combined transgastric/transpapillary. Drainage was established in 16 of 19 (84%) cases. Hospitalization was noted in 6 of 19 (32%) cases, with median hospitalization duration of 1.5 days (range, 1-19 days). Three patients were hospitalized for overnight observation only. In all instances, the decision to hospitalize was made while the patient was still in recovery. No deaths occurred. Follow-up imaging was available in 15 of 16 (94%) cases in which drainage was established, demonstrating PFC resolution in all 15. Conclusions: Endoscopic transmural drainage of PFCs can be performed safely and effectively in selected outpatients. It is our opinion that outpatient drainage of PFCs be considered only by experienced therapeutic endoscopists with readily available inpatient facilities. Future studies should seek to identify predictors of hospitalization and address cost-effectiveness.

Sciatic Nerve Injury After Proximal Hamstring Avulsion and Repair

Background: Muscle bellies of the hamstring muscles are intimately associated with the sciatic nerve, putting the sciatic nerve at risk of injury associated with proximal hamstring avulsion. There are few data informing the magnitude of this risk, identifying risk factors for neurologic injury, or determining neurologic outcomes in patients with distal sciatic symptoms after surgery. Purpose: To characterize the frequency and nature of sciatic nerve injury and distal sciatic nerve–related symptoms after proximal hamstring avulsion and to characterize the influence of surgery on these symptoms. Study Design: Cohort study; Level of evidence, 3. Methods: This was a retrospective review of patients with proximal partial or complete hamstring avulsion. The outcome of interest was neurologic symptoms referable to the sciatic nerve distribution below the knee. Neurologic symptoms in operative patients were compared pre- and postoperatively. Results: The cohort consisted of 162 patients: 67 (41.4%) operative and 95 (58.6%) nonoperative. Sciatic nerve–related symptoms were present in 22 operative and 23 nonoperative patients, for a total of 45 (27.8%) patients (8 [4.9%] motor deficits, 11 [6.8%] sensory deficits, and 36 [22.2%] with neuropathic pain). Among the operative cohort, 3 of 3 (100.0%) patients showed improvement in their motor deficit postoperatively, 3 of 4 (75.0%) patients’ sensory symptoms improved, and 17 of 19 (89.5%) patients had improvement in pain. A new or worsening deficit occurred in 5 (7.5%) patients postoperatively (2 [3.1%] motor deficits, 1 [1.5%] sensory deficit, and 3 [4.5%] with new pain). Predictors of operative intervention included lower age (odds ratio [OR], 0.952; 95% CI, 0.921-0.982; P = .001) and complete avulsion (OR, 10.292; 95% CI, 2.526-72.232; P < .001). Presence of neurologic deficit was not predictive. Conclusion: Sciatic nerve–related symptoms after proximal hamstring avulsion are underrecognized. Currently, neurologic symptoms are not considered when determining whether to pursue operative intervention. Given the high likelihood of improvement with surgical treatment, neurologic symptoms should be considered when making a decision regarding operative treatment.

Meal-induced dysphagia and otalgia secondary to a pyriform sinus fistula

A 30-year-old woman presented with otalgia, dysphagia, nausea, and vomiting. Dysphagia and otalgia occurred with solids and would progressively worsen during the course of a meal. She had no symptoms when fasting. An esophagogastroduodenoscopy (EGD) was obtained to investigate her dysphagia. The EGD was unremarkable, with normal-appearing esophageal mucosa. No strictures were seen. In view of her symptoms and negative EGD, a barium esophagram was obtained. The esophagram revealed a fistulous tract and cavity apparently arising from the lower cervical esophagus and displacing the esophagus to the right and posteriorly (Figure 1). The patient was given effervescent tablets, and upon distension of the cavity with air, left-sided otalgia was elicited and the filled cavity compressed the esophagus. A CT scan of the head and neck showed the fistulous tract directly connecting to the left pyriform sinus and extending adjacent to the esophagus at the level of C6–7 (Figure 2). No other abnormalities were identified. A careful review of the patient’s history was negative for acute suppurative thyroiditis or recurrent deep neck abscesses, as well as for ingestion of injurious substances. To exclude Crohn’s disease, a small bowel followthrough was obtained and was normal. A previous colonoscopy was normal. Cervical exploration revealed the fistulous tract and associated cavity, which were excised. No other abnormalities

The anatomy of the perineal branch of the sciatic nerve

A “perineal” branch of the sciatic nerve has been visualized during surgery, but there is currently no description of this nerve branch in the literature. Our study investigates the presence and frequency of occurrence of perineal innervation by the sciatic nerve and characterizes its anatomy in the posterior thigh. Fifteen cadavers were obtained for dissection. Descriptive results were recorded and analyzed statistically. Twenty‐one sciatic nerves were adequately anatomically preserved. Six sciatic nerves contained a perineal branch. Five sciatic nerves had a branch contributing to the perineal branch of the posterior femoral cutaneous (PFC) nerve. In specimens with adequate anatomical preservation, the perineal branch of the sciatic nerve passed posterior to the ischial tuberosity in three specimens and posterior to the conjoint tendon of the long head of biceps femoris and semitendinosus muscles (conjoint tendon) in one. In specimens in which the perineal branch of the PFC nerve received a contribution from the sciatic nerve, the branch passed posterior to the sacrotuberous ligament in one case and posterior to the conjoint tendon in three. Unilateral nerve anatomy was found to be a poor predictor of contralateral anatomy (Cohens kappa = 0.06). Our study demonstrates for the first time the presence and frequency of occurrence of the perineal branch of the sciatic nerve and a sciatic contribution to the perineal branch of the PFC nerve. Clinicians should be cognizant of this nerve and its varying anatomy so their practice is better informed. Clin. Anat. 31:357–363, 2018.

Endoscopic Transmural Drainage of Pancreatic Fluid Collections in Outpatients

OBJECTIVE To evaluate the performance of endoscopic transmural drainage of pancreatic fluid collections (PFCs) in outpatients. PATIENTS AND METHODS We retrospectively reviewed 19 consecutive outpatient cases in 18 patients who underwent attempted endoscopic transmural drainage of PFCs by a single endoscopist at the Mayo Clinic in Rochester, MN, over a 5-year period (October 1998 to October 2003). All drainages were performed without EUS-guided entry, using an aspiration needle and no cautery. Two 10-Fr stents were placed after dilation of the entry site. RESULTS The study group consisted of 12 men and 6 women (median age, 48 years; range, 28-79 years), with 14 cases of pseudocysts and 5 cases of pancreatic necrosis. Transmural drainage approaches included 13 transgastric, 5 transduodenal, and 1 combined transgastric/transpapillary. Drainage was established in 16 of 19 (84%) cases. Hospitalization was noted in 6 of 19 (32%) cases, with median hospitalization duration of 1.5 days (range, 1-19 days). Three patients were hospitalized for overnight observation only. In all instances, the decision to hospitalize was made while the patient was still in recovery. No deaths occurred. Follow-up imaging was available in 15 of 16 (94%) cases in which drainage was established, demonstrating PFC resolution in all 15. CONCLUSIONS Endoscopic transmural drainage of PFCs can be performed safely and effectively in selected outpatients. It is our opinion that outpatient drainage of PFCs be considered only by experienced therapeutic endoscopists with readily available inpatient facilities. Future studies should seek to identify predictors of hospitalization and address cost-effectiveness.