Maitham A. Moslim

Obesity and its implications for morbidity and mortality after cholecystectomy: A matched NSQIP analysis

BACKGROUND The risks from super obesity (SO) following cholecystectomy have not been studied. METHODS NSQIP analysis of patients undergoing cholecystectomy from 2005 to 2011. Non-obese (NO) patients (BMI 18.5-30) were matched 1:1 by age, sex, race and comorbidities to morbidly obese (MO) (BMI 35-50), and separately to SO (BMI≥50) individuals. Clavien 4 complications and 30-day mortality were compared. RESULTS 13780 MO and 1410 SO patients were matched to NO patients. Obese patients were more likely to present with chronic (CC) rather than acute cholecystitis (AC). Compared to NO patients, Clavien 4 complications were significantly increased among SO patients overall especially with AC where rate of open surgery was significantly higher. CONCLUSION SO patients have an increased risk of serious morbidity after cholecystectomy especially with AC where rate of open surgery remains high. Aggressive recommendation for cholecystectomy to reduce presentation with AC and increase likelihood for laparoscopic surgery may be beneficial in SO patients.

Simultaneous Clear Cell Sarcomas of the Duodenum and Jejunum

Clear cell sarcoma (CCS) is an uncommon tumor that usually presents as an extremity mass but can rarely manifest as a gastrointestinal tumor with a diverse spectrum of symptoms, most commonly related to a mass effect or ulceration. Herein we report a case in which two separate tumors, one in the duodenum and the other in the jejunum, present concurrently. The subject presented with symptomatic anemia and underwent imaging and endoscopic studies that culminated in the discovery of the two lesions. He subsequently underwent operative treatment with resection of both tumors and made an unremarkable recovery. The resection specimen consisted of two separate clear cell sarcomas with negative margins. Under microscopic evaluation, they demonstrated nested growths of epithelioid cells with scattered spindled cells infiltrating the enteric wall. The neoplastic cells were positive for S100 with scattered expression of Melan A. Florescence in situ hybridization revealed a translocation at the EWRS1 locus. He was disease-free for 30 months following the procedure; then he developed a rapidly progressing metastatic disease with subsequent death 4 months later.

Early genetic counseling and detection of CDH1 mutation in asymptomatic carriers improves survival in hereditary diffuse gastric cancer

Background: Hereditary diffuse gastric cancer is associated with E‐cadherin (CDH1) germline mutations. The implications of CDH1 mutations detected with multigene panels in those without family history of HDGC are uncertain. Methods: A registry of patients who underwent genetic counseling for CDH1 mutation was queried for the period 2011–2017. Results: Twenty‐one patients with CDH1 mutation were identified. The most common indication for CDH1 genetic screening was family history of hereditary diffuse gastric cancer (known risk) in 10 patients (48%); 11 patients (52%), however, were diagnosed by multigene cancer panels (unknown risk). Nine of the 21 patients underwent total gastrectomy, and 5 others had metastatic gastric cancer at presentation. In the gastrectomy group, 5 of the 9 patients (56%) were known to have gastric cancer based on preoperative screening endoscopy, but final pathologic examinations indicated diffuse gastric cancer in 8 of the 9 patients. The 11 patients with unknown risk for CDH1 mutation tended to be older (median 41 vs 24 years) and more likely to have metastatic disease and to die of the disease (43% vs 29%) compared with patients with family history of hereditary diffuse gastric cancer. Conclusion: CDH1 mutation–associated hereditary diffuse gastric cancer is a biologically aggressive variant of gastric cancer that appears to behave similarly in patients detected only by multigene panels. The detection of CDH1 mutation at a minimum warrants genetic counseling and preferably total gastrectomy.

Tailored surgical treatment of duodenal polyposis in familial adenomatous polyposis syndrome

Background. To review our experience in patients undergoing operative treatment for duodenal polypoisis associated with familial adenomatous polyposis with an emphasis on operative approach and long‐term outcomes. Methods. Duodenal polypoisis associated with familial adenomatous polyposis patients undergoing operative treatment were studied retrospectively excluding patients with preoperative duodenal cancer. Results. Of 767 patients in the database, 63 (8.2%) patients underwent operative treatment: 42 (67%) pancreas‐sparing duodenectomy, 15 (24%) pancreatoduodenectomy, and 6 (9.5%) segmental duodenal resection; the majority for Spigelman stages III and IV polyposis. Overall 9.6% had adenocarcinoma postoperatively (28.6% in the pancreatoduodenectomy group; P = .01). The proportion of Spigelman stages III and IV with cancer were 9.5% and 6.5%, respectively. Pathologic upgrade to cancer in patients with low grade dysplasia and high‐grade dysplasia on preoperative biopsy was 5.7% and 6.7%, respectively (P = .13). At a median follow‐up of 16 years, 7.7% needed a second duodenal polypoisis associated with familial adenomatous polyposis‐related operation. Progression to high grade dysplasia or cancer in the stomach occurred in 15.4% of patients. Median overall survival and recurrence‐free survival was at least 16 years and 15.6 years. No significant group‐based differences were noted on follow‐up. Conclusion. The majority of patients with duodenal polypoisis associated with familial adenomatous polyposis can achieve long‐term, cancer‐free survival with organ‐preserving approaches (pancreas‐sparing‐duodenectomy and segmental‐duodenal‐resection) with survival not dependent on the type of resection.

Hybrid Single-Port Cholecystectomy Vs Four-Port Cholecystectomy in Children

Background and Objectives: Evidence is increasing that single-port or single-incision laparoscopic cholecystectomy is a safe and feasible alternative for cholecystectomy in children. In this study, we sought to compare the single-port hybrid technique, which we originally reported in 2012, with the conventional 4-port approach, in regards of complications, outcome, operative time and cost. Methods: A retrospective, single-center comparison of hybrid single-port versus conventional 4-port laparoscopic cholecystectomy was performed in 98 consecutive pediatric patients between January 2010 and October 2014. Patient characteristics, intra- and postoperative outcomes, operative costs, and total hospitalization costs were compared between the 2 approaches using univariate and multivariate analyses. Results: The single-port technique was utilized in 56 (57%) pediatric patients who underwent laparoscopic cholecystectomy. The operative time for single-port procedures was shorter than that of the conventional technique (median, 85 minutes vs 114 minutes; P = .003). Patients with single-port procedures were less likely to have a cholangiogram compared to patients who underwent 4-port cholecystectomy. (9% vs 40%; P < .001). No statistically significant differences between the 2 cohorts were observed for intra- or postoperative outcomes. Although the 2 groups shared nearly the same median duration of hospitalization (22 hours vs 21 hours; P = .70), the single-port group demonstrated a lower total cost of hospitalization (median cost,

Abdominal aortic aneurysm in the setting of Clostridium perfringens pancreatitis

7438 vs

Management of high-grade dysplasia of the cystic duct after cholecystectomy

8783; P = .030) and lower operative cost (median,

Acute massive gastric dilatation causing ischaemic necrosis and perforation of the stomach

3918 vs

Surgical Management of Caroli's Disease: Single Center Experience and Review of the Literature.

4647; P < .001). Conclusion: Hybrid single-port laparoscopic cholecystectomy in children with uncomplicated gallbladder disease is feasible and equally safe, with similar intra- and postoperative outcomes compared with the conventional 4-port approach. It can contribute to global cost reduction because of lower operative and total hospitalization costs.

Choledochal Cyst Disease in a Western Center: A 30-Year Experience.

We report a case of a 56-year-old woman who presented with worsening abdominal pain located in the left upper quadrant together with abdominal distention, nausea and anorexia. One month prior to this admission, she had presented and had been diagnosed with concurrent acute pancreatitis and rapidly expanding abdominal aortic aneurysm. The aneurysm was prioritised over the pancreatitis and she underwent uncomplicated endovascular repair. Cross-sectional imaging was consistent with infected pancreatic necrosis and also revealed a large collection located in the anterior pararenal space with extensive gas formation. An image-guided fluid aspiration revealed Clostridium perfringens as the causative organism. She was treated by placement of large bore drains along with irrigation and targeted intravenous antibiotic for 6 weeks. The collections resolved completely and at 6 months follow-up she was well and symptom free.