Jeffrey K. Wang

Increased prevalence of celiac disease in patients with unexplained infertility in the United States.

OBJECTIVE To determine whether there might be an increased prevalence of undiagnosed celiac disease among a population of infertile women using serologic screening. STUDY DESIGN A prospective cohort study was performed at an academic infertility clinic in the United States. RESULTS The overall prevalence of celiac disease in this population was 2.1% (4/188). There was a significantly increased prevalence (5.9%) of undiagnosed celiac disease among women presenting with unexplained infertility (n = 51). CONCLUSION Women with unexplained infertility are at increased risk for having undiagnosed celiac disease, which may be a potentially modifiable (and treatable) risk factor.

Splenic Salvage After Intraoperative Splenic Injury During Colectomy

OBJECTIVE To determine the optimal surgical management of splenic injury encountered during colectomy. DESIGN Retrospective review from 1992 to 2007. SETTING Mayo Clinic in Rochester, Minnesota, a tertiary care center. PATIENTS A cohort of patients who sustained splenic injury during colectomy from 1992 to 2007. MAIN OUTCOME MEASURES Overall 30-day major morbidity and mortality and overall 5-year survival. RESULTS Of 13,897 colectomies, we identified 59 splenic injuries (0.42%). Of these, 33 (56%) were in men; there was a median age of 68 years (range, 30-93 years) and a median body mass index of 25.5 (range, 15-54). Thirty-seven injuries (63%) occurred during elective surgery, 6 (10%) occurred without splenic flexure mobilization, and 5 (8.4%) occurred during minimally invasive surgery. Injury was successfully managed by primary repair in 10 (17%), splenorrhaphy in 4 (7%), and splenectomy in 45 cases (76%). Four injuries (7%) were unrecognized and resulted in reoperation and splenectomy. Multiple attempts at splenic salvage were performed in 30 (51%); of these, 21 (70%) required splenectomy. More than 2 attempts at salvage was associated with splenectomy (P = .03). The 30-day major morbidity and mortality rates were 34% and 17%, respectively. Sepsis was the most common complication, with no confirmed episodes of postsplenectomy sepsis. Median survival after splenic injury was 7.25 years. There was no significant association between the surgical management of splenic injuries and short- or long-term outcomes. CONCLUSIONS Splenic injury is an infrequent but morbid complication. Splenic salvage is frequently unsuccessful; our data suggest that surgeons should not be reluctant to perform splenectomy when initial repair attempts fail.

Remnant Torsion Causing Budd-Chiari Syndrome After Right Hepatectomy

IntroductionTorsion or rotation of the remnant left liver after right hepatectomy is a potential cause of venous outflow obstruction. This can occur by external compression on the inferior vena cava or kinking of the left hepatic vein.DiscussionWe report a case of a young female who underwent right hepatectomy for stage IV colorectal metastases and suffered remnant left liver torsion causing acute Budd-Chiari syndrome. She was managed by placement of a metal stent across the area of stenosis which resolved her ascites and hyperbilirubinemia.

Anatomic mechanisms for splenic injury during colorectal surgery

Intraoperative iatrogenic splenic injury during colorectal surgery is rare but may cause significant morbidity. We aimed to describe the anatomic mechanisms of iatrogenic injury to the spleen during colonic surgery. All adult surgical patients who sustained a splenic injury during colectomy at our institution from 1992 to 2007 were retrospectively identified. The operative and pathologic reports were reviewed, and anatomic details of the injuries were collected. Results are reported as a proportion or median, with range reported in brackets. Of 13,897 colectomies, 71 splenic injuries among 58 patients were identified. Splenic flexure colonic mobilization occurred in 53 (91%) of these patients. The median number of tears was 1 (1–3). The average length of tear was 4.59 cm. The distribution of injury location on the spleen was 24 (34%) inferior, 14 (20%) hilar, 3 (4%) posterior, 2 (3%) lateral, and 1 (1%) superior. Three (4%) patients suffered from splenic rupture. The location of 24 (34%) injuries was not described. Capsular tears were the cause of splenic injury in 55 (95%) patients. Intraoperative splenic injury ultimately resulted in splenectomy in 44 (76%) patients. Splenic injury was a delayed finding requiring reoperation in 4 (7%) patients. The primary mechanism of intraoperative splenic injury during colectomy is capsular tears and lacerations secondary to misplaced traction and tension on the spleen during colonic mobilization. Techniques to lessen these forces may decrease the number of injuries and subsequent splenectomy. Clin. Anat. 25:212–217, 2012.

Comparative effectiveness research in urology

BackgroundComparative effectiveness research (CER) has come to remain at the forefront of political and scientific debates of health care. The aim of this article is to describe the attributes of CER and implications to the field of urology.MethodsThe authors reviewed the published urology literature and recent CER publications including the Institute of Medicine reports.ResultsCER is defined as the evaluation of the relative efficacy of diagnostic tests, treatments, and health care services against the current standards of care, with the goal of reducing health care costs while simultaneously improving quality. Significant government funds were recently devoted to CER efforts. The Institute of Medicine identified 25 of the most urgently needed areas for research of which three pertain to Urology: screening for prostate cancer, comparing effectiveness of treatments for localized prostate cancer, and use of imaging in diagnosing, staging, and monitoring cancer patients. Some of the important required strategies to formulate successful CER include involving health care stakeholders to aid in selecting appropriate topics, utilizing study populations that represent real life practice, and the development of large-scale national databases and registries.ConclusionSeveral topics of urologic care have already been identified in the first quartile of CER priorities, and many others need to be added. Following the proposed research, designs for CER should be done while abiding by robust methodology, maintaining transparency, and effectively translating research into clinical practice.

Iatrogenic splenectomy during nephrectomy for renal tumors

To evaluate risk factors associated with iatrogenic splenectomy during nephrectomy and to assess outcomes among patients undergoing nephrectomy for renal tumors.