Mark D. Sawyer

Esophagogastroduodenoscopy-associated gastrointestinal perforations: A single-center experience

BACKGROUND Esophagogastroduodenoscopy (EGD) is commonly used in the diagnosis and treatment of gastrointestinal (GI) disorders. Our aim was to define the risk of perforation associated with EGD and identify patients who required operative intervention. METHODS We retrospectively reviewed 72 patients from our institution plus 5 transferred patients who sustained EGD-associated perforations from January 1996 through July 2008. Percutaneous endoscopic gastrostomy, endoscopic ultrasonography, endoscopic retrograde cholangiopancreatography, transthoracic echocardiography, and concurrent colonoscopy procedures were excluded. RESULTS Perforations in 72 of 217,507 EGD procedures were identified (incidence, 0.033%); 124,844 EGDs included an interventional procedure and 92,663 were examination only. The incidence of perforation was similar whether an interventional procedure was performed or not (0.040% vs 0.029%; P = .181). The esophagus was injured most commonly (51%), followed by the duodenum (32%), jejunum (6%), stomach (3%), and common bile duct (3%). Overall mortality after perforation was 17% with a morbidity rate of 40%. Thirty-eight patients (49%) were initially treated nonoperatively, 7 of whom (18%) failed nonoperative management. The only factors we could determine that were associated with failure were free fluid or contrast extravasation on computed tomography (75% vs 23% [P < .005] and 33% vs 0% [P = .047], respectively). The morbidity of failures was equivalent to those who underwent initial operative management (63% vs 61%; P = .917), with mortality seeming to be greater (43% vs 21%; P = .09). CONCLUSION EGD is safe in the majority of patients; however, iatrogenic perforation is associated with considerable morbidity and mortality. Nonoperative management of GI perforation can be successful if there is no evidence of contrast extravasation or free fluid on radiographic studies. If nonoperative management fails, the outcomes may be worse than those treated initially with operative repair.

Fixed-dose vasopressin compared with titrated dopamine and norepinephrine as initial vasopressor therapy for septic shock.

Study Objective. To investigate the early blood pressure effects of vasopressin compared with titrated catecholamines as initial drug therapy in patients with septic shock.

Ischemic colitis in young adults: a single-institution experience☆

Ischemic colitis is not well characterized in the young adult population, despite its commonness in older patients. The aim of this study was to investigate the demographics, etiology, clinical features, and prognosis of ischemic colitis in young adults. We conducted a retrospective study of 39 young adults (<50 years of age) diagnosed with ischemic colitis over a period of 9 years (1990 to 1998). The mean age at diagnosis was 38 ±2 years (range 18 to 49 years); the female:male ratio was 1.8. Fifty-two percent (13 of 25) of women were using oral contraceptives at the time of diagnosis. Other potential associations identified were vascular thromboembolism (4 of 39), vasoactive drugs (4 of 39), hypovolemia (4 of 39), and vasculitis (2 of 39); 19 patients (49%) had no identifiable predisposing factors. Dominant presenting symptoms were abdominal pain (77%), bloody diarrhea (54%), and hematochezia (51%). Most patients were diagnosed at colonoscopy, and most disease was left sided. Twenty-nine patients were successfully managed with intravenous fluids, broad-spectrum antibiotics, and bowel rest; 10 patients required surgery. There was one disease-related death in the operative group. We found a strong female predominance and an association with oral contraceptive use, but almost half of the patients did not have an identifiable etiology. Mortality from ischemic colitis in this patient population is low.

Hemorrhagic cholecystitis in an elderly patient taking aspirin and cilostazol.

Hemorrhage is a rare complication of acute cholecystitis. Patients who develop this complication often are receiving anticoagulation therapy or have a pathologic coagulopathy. We present a case of an elderly patient who developed hemorrhagic cholecystitis while taking aspirin and cilostazol, a phosphodiesterase inhibitor. The patient underwent an emergent abdominal exploration. A large, blood-filled gallbladder was found along with a large hematoma between the liver and gallbladder. We also briefly review the literature regarding hemorrhagic cholecystitis, hemorrhage into the biliary tree, and hemorrhage as a complication of aspirin and phosphodiesterase inhibitor therapy.

Laparoscopy Assisted Transjejunal ERCP for Treatment of Pancreaticopleural Fistula

CONTEXT Pancreaticopleural fistula is a rare complication estimated to occur in 0.5% of the patients with pancreatitis and even extremely rare in surgically altered anatomy (e.g. Roux-en-Y anastomosis) patients. The conventional ERCP is difficult to treat pancreaticopleural fistula in a patient with complex upper GI anatomy because of long anatomical route. CASE REPORT We represent a case of a 47-year-old female with remote subtotal gastrectomy with Roux-en-Y gastrojejunostomy admitted with recurrent left pleural effusion due to pancreaticopleural fistula. After failed ERCP through the anatomical route, pancreaticopleural fistula was treated successfully with laparoscopy-assisted transjejunal ERCP. CONCLUSION Laparoscopy-assisted ERCP is a useful modality in patients with surgically altered anatomy.

Intravenous Metoprolol Versus Diltiazem for Rate Control in Noncardiac, Nonthoracic Postoperative Atrial Fibrillation:

Background: Little guidance exists on effective management of postoperative atrial fibrillation (POAF) following noncardiac, nonthoracic (NCNT) surgery. Objectives: The purpose of this study was to identify whether a difference exists between intravenous (IV) metoprolol and diltiazem when used to achieve hemodynamically stable rate control in POAF following NCNT surgery. Methods: This retrospective cohort study examined critically ill adult surgical patients experiencing POAF with rapid ventricular response. Inclusion in the metoprolol or diltiazem treatment group was determined by the initial rate control agent chosen by the prescriber. The primary end point was hemodynamically stable rate control, defined by heart rate (HR) <110 beats/min and blood pressure >90 mm Hg, maintained for 6 hours. Main Results: Patients on metoprolol (n = 66) and diltiazem (n = 55) were similar in age, comorbidities, surgical procedure distribution, acuity of illness, and home rate and rhythm control medications continued during hospitalization; 76% of diltiazem-treated patients achieved hemodynamically stable rate control, compared with only 53% of those receiving metoprolol (P = .005). Safety end points were similar between groups, including the portion requiring a new vasopressor or fluid bolus for hemodynamic support. Conclusions: In NCNT surgery, patients with POAF, IV diltiazem more effectively controlled HR and hemodynamics compared with metoprolol. Results warrant further research into optimal medical management of POAF in this population using these 2 agents.

ENDOSCOPIC TREATMENT OF A BENIGN COLOCUTANEOUS AND ENTEROCOLIC FISTULA BY INSERTION OF OVERLAPPING SELF-EXPANDABLE METAL STENTS

We report the successful closure of fistulae at the site of a benign colocolonic anastomotic stricture using self‐expandable metal stents (SEMS). The stricture and fistulae developed after sigmoid colon resection for diverticulitis. After closure of the fistulae with a covered stent and resolution of inflammation, 10 months later the patient elected to undergo one‐stage resection of the diseased colon and stent. Although there have been previously reported cases of SEMS for closure of malignant colonic fistula, there are limited reports of SEMS for closure of benign colonic fistulae and none demonstrate long‐term success. We conclude that this patient exemplifies the potential applications of SEMS as definitive therapy for benign colorectal disease.

Expanded spectrum of antineutrophil cytoplasmic antibody–negative vasculitis involving vessels from capillaries to medium‐sized arteries

The patient was admitted to a local hospital 2 weeks priorfor a 3-month duration of weight loss, generalized weak-ness, and progressive lower extremity pain. The symptomsstarted gradually, without any notable antecedent event.He felt weak, lost appetite, and developed intermittent drycough and pain in the lower extremities, initially in thethighs, and progressed to bilateral legs. In a matter ofmonths, his health deteriorated from being physically ac-tive and independent to mostly bedridden.Evaluation at the local hospital revealed low-grade fever(37.9°C), mild hypertension (140–150/90 mm Hg), multi-ple new lung nodules on a contrast-enhanced chest andabdominal computed tomography (CT) scan, and an ele-vated serum creatinine concentration of 2.6 mg/dl (fromhis baseline of 0.9 mg/dl approximately 6 months ago)with microscopic hematuria. Screening for hepatitis B andC, antinuclear antibodies, complements, and antineutro-phil cytoplasmic antibody (ANCA) panel (myeloperoxi-dase [MPO] and proteinase 3) was negative. His erythro-cyte sedimentation rate (ESR) was 49 mm/hour (referencerange 0–25). A transbronchial biopsy sample of severallung nodules showed no evidence of malignancy or activeinfection and was interpreted as nondiagnostic. For hislower extremity pain, he was empirically treated withintravenous (IV) immunoglobulin for possible Guillain-Barre´ syndrome. The treatment was discontinued 4 dayslater after an electromyogram sample revealed primaryaxonal sensory motor peripheral neuropathy. His kidneydysfunction worsened following intravenous contrast ex-posure for the CT scan; his serum creatinine level rose to3.4 mg/dl. He underwent a left kidney percutaneous bi-opsythatwasreadaspossiblecrescenticglomerulonephri-tis. IV methylprednisolone, 500 mg once daily, was initi-ated. During his hospital stay, the patient developedepisodic confusion. A spinal tap was performed andshowed no abnormality, nor evidence of syphilis or WestNile virus infection. Two days following the initiation ofIV methylprednisolone, his condition further deterioratedwith worsening extremity weakness to the point that hecould not ambulate with assistance and mental confusion.He was then transferred to our institution.

Patterns in deer-related traffic injuries over a decade: the Mayo clinic experience

BackgroundOur American College of Surgeons Level 1 Trauma Center serves a rural population. As a result, there is a unique set of accidents that are not present in an urban environment such as deer related motor vehicle crashes (dMVC). We characterized injury patterns between motorcycle/all-terrain vehicles (MCC) and automobile (MVC) crashes related to dMVC (deer motor vehicle crash) with the hypotheses that MCC will present with higher Injury Severity Score (ISS) and that it would be related to whether the driver struck the deer or swerved.MethodsThe records of 157 consecutive patients evaluated at our institution for injury related to dMVC from January 1st, 1997 to December 31st, 2006 were reviewed from our prospectively collected trauma database. Demographic, clinical, and crash specific parameters were abstracted. Injury severity was analyzed by the Abbreviated Injury Scale score for each body region as well as the overall Injury Severity Score (ISS).ResultsMotorcycle crashes presented with a higher median ISS than MVCs (14 vs 5, p < 0.001). Median Abbreviated Injury Score (AIS) of the spine for MCC riders was higher (3 vs 0, p < 0.001) if they swerved rather than collided. Seventy-seven percent of riders were not wearing a helmet which did not result in a statistically significant increase in median ISS (16 vs 10), head AIS (2 vs 0) or spine AIS (0 vs 0).Within the MVC group, there was no difference between swerving and hitting the deer in any AIS group. Forty-seven percent of drivers were not wearing seat belts which resulted in similar median ISS (6 vs 5) and AIS of all body regions.ConclusionsMotorcycle operators suffered higher ISS. There were no significant differences in median ISS if a driver involved in a deer-related motor vehicle crash swerved rather than collided, was helmeted, or restrained.

PORTAL VENOUS AIR AND PNEUMATOSIS INTESTINALIS

The patient is a 55-year-old male who was unable to eat or drink for 3 days after the acute onset of severe, generalized abdominal pain. His physical examination was remarkable for diffuse abdominal tenderness and moderate distension. Laboratory data were remarkable only for 9.4 leukocytes with 31 bands, creatinine 4.3 with BUN of 74. A radiograph of the abdomen showed massive portal venous air throughout the liver. CT findings included portal venous gas (fig. 1), pneumatosis intestinalis and dilated succus-filled small intestine (fig. 2). At exploratory laparotomy, the small and large intestines were mostly viable, but the small intestine had signs of resolving low flow ischemia, as evidenced by antimesenteric patches of dusky color and poor flow. The causative pathology was found to be a perforated appendix, which was excised. ‘Second-look’ procedures confirmed the return of the bowel to full viability. The abdomen was then closed definitively. Further convalescence was unremarkable, and the patient was discharged home on the 25th postoperative day.