Mazen E. Iskandar

Laparoscopic cholecystectomy for a left-sided gallbladder

Cholecystectomy is a common procedure. Abnormalities in the anatomy of the biliary system are common but an abnormal location of the gallbladder is much rarer. Despite frequent pre-operative imaging, the aberrant location of the gallbladder is commonly discovered at surgery. This article presents a case of a patient with the gallbladder located to the left of the falciform ligament in the absence of situs inversus totalis that presented with right upper quadrant pain. A laparoscopic cholecystectomy was performed and it was noted that the cystic duct originated from the right side. The presence of a left sided gall bladder is often associated with various biliary, portal venous and other anomalies that might lead to intra-operative injuries. The spectrum of unusual positions and anatomical gallbladder abnormalities is reviewed in order to facilitate elective and emergent cholecystectomy as well as other hepatobiliary procedures. With proper identification of the anatomy, minimally invasive approaches are still considered safe.

Factors influencing incidence and type of postmastectomy breast reconstruction in an urban multidisciplinary cancer center.

Background: On January 1, 2011, New York State amended the Public Health Law to ensure that patients receive “information and access to breast reconstruction surgery.” The purposes of this study were to investigate the early impact of this legislation on reconstruction rates and to evaluate the influence of patient variables versus physician variables on the incidence and type of breast reconstruction performed. Methods: A retrospective study was conducted on all patients who underwent mastectomy between January 1, 2010, and December 31, 2011. Reconstruction rates were analyzed in relation to timing of legislation, breast surgeon variables, plastic surgeon faculty status, type of reconstruction, and patient variables. Results: Two hundred fifty-eight patients met inclusion criteria. The overall reconstruction rate was 56.59 percent. There was no statistically significant increase in reconstruction rate after the 2011 legislation (OR, 0.45; p = 0.057). Patients whose breast surgeon was female were more likely to undergo reconstruction (OR, 5.17; p = 0.001). Patients who were Asian (OR, 0.22; p = 0.002), older than 60 years (OR, 0.09; p = 0.001), or had stage 3 and 4 cancer (OR, 0.04; p = 0.03) were less likely to undergo reconstruction. Patients reconstructed by a hospital-employed plastic surgeon were significantly more likely to undergo autologous versus implant reconstruction (OR, 6.85; p = 0.001) and to undergo microsurgical versus nonmicrosurgical autologous reconstruction (78.2 percent versus 0 percent; p = 0.001). Conclusions: Breast surgeon sex and plastic surgeon faculty status were the factors that most affected the rate and type of reconstruction, respectively. Legislation mandating the discussion of breast reconstruction options had no impact on reconstruction rate. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Diagnosis and Management of Perforated Duodenal Ulcers following Roux-En-Y Gastric Bypass: A Report of Two Cases and a Review of the Literature

Perforated duodenal ulcers are rare complications seen after roux-en-Y gastric bypass (RYGP). They often present as a diagnostic dilemma as they rarely present with pneumoperitoneum on radiologic evaluation. There is no consensus as to the pathophysiology of these ulcers; however expeditious treatment is necessary. We present two patients with perforated duodenal ulcers and a distant history of RYGP who were successfully treated. Their individual surgical management is discussed as well as a literature review. We conclude that, in patients who present with acute abdominal pain and a history of RYGB, perforated ulcer needs to be very high in the differential diagnosis even in the absence of pneumoperitoneum. In these patients an early surgical exploration is paramount to help diagnose and treat these patients.

Three synchronous, sporadic and separate periampullary and pancreatic tumors: more than a coincidence?

Three sporadic, synchronous, and separate lesions in the ampulla of Vater and the head of the pancreas presented in an 81-year-old male. One was symptomatic and two were incidental. One was detected preoperatively (the ampullary lesion) and two by examination of the resected specimen (the neuroendocrine and pancreatic carcinomas). The case is summarized and the literature and the issue of commonality are reviewed.

Complicated Sporadic Cardiac Myxomas: A Second Recurrence and Myxomatous Cerebral Aneurysms in One Patient

A second recurrence of an excised nonfamilial cardiac myxoma is rare. Myxomatous cerebral aneurysms as a complication of cardiac myxomas are equally rare. A unique case of a patient with a total of 4 myxomas over a 20-year interval is presented. Her most recent presentation was a second recurrence of a left atrial myxoma, a de novo right atrial myxoma, and multiple cerebral myxomatous aneurysms. The challenging reconstruction of the normal anatomy was achieved with the use of porcine extracellular matrix patches. A diagnostic cerebral angiogram was later performed, and the aneurysms will be monitored for growth and possible intervention.

Prevention and Early Detection of Pancreatic Cancer

Preventing cancer has much to offer. Aside from plummeting health care costs, we might enjoy a healthier life free of cancer and chronic disease. Prevention requires the adoption of healthier choices and a moderate amount of exercise. The supporting evidence is observational, clinical, and partly common sense. Further investigations reveal several substances in a whole-food plant-based diet that have protective effects and an inhibitory effect on tumor development. For pancreatic cancer, the basis of cure remains a century old operation that rarely cures. With little to lose, prevention deserves center stage and additional studies.

A Tale of 2 Techniques:Preoperative Biliary Drainage and Routine Surgical Drainage with Pancreaticoduodenectomy

Preoperative drainage of an obstructed biliary tree before pancreaticoduodenal resection (PDR) and placement of intraabdominal drains following pancreatic resection have been suggested to be both unnecessary and associated with a higher complication rate. The evidence for and against that practice is presented and analyzed to highlight its risks and benefits. A selective approach on an individual basis for preoperative biliary decompression is advocated, based on multiple factors. Additionally, the evidence for routine use of surgical drains after PDR is critically reviewed and the rationale for routine drainage is made.

Cancer of the Pancreas—Actual 5, 10, and 20+Year Survival: The Lucky and Fortunate Few

Cancer of the pancreas (CaP) is a dismal, uncommon, systemic malignancy. This article updates an earlier experience of actual long-term survival of CaP in patients treated between 1991 to 2000, and reviews the literature. Survival is expressed as actual, not projected, survival.

Familial Pancreatic Cancer: The Case for Prophylactic Pancreatectomy in Lieu of Serial Screening and Shared Decision Making

At-risk family members with familial pancreatic cancer (FCaP) face uncertainty regarding the individual risk of developing pancreatic cancer (CaP) and whether to choose serial screening or prophylactic pancreatectomy to avoid CaP. We treated 2 at-risk siblings with a history of FCaP, congenital hepatic fibrosis (CHF), and jaundice secondary to a bile duct stricture. In one, a pancreaticoduodenal resection was done and in the second a total pancreatectomy. Malignancy was not present, but extensive pancreatic intraepithelial neoplasia (PanIn) 2 was present throughout both pancreata. The clinical course and literature review are presented along with the previously unreported association of CHF and CaP.

The Iliad and the Odyssey of metallic foreign body extraction: commentary on "Novel methods of removing metallic foreign body from human soft tissue: a report of 7390 cases".

DOI of original article: 10.1016/j.jss.2012.1 * Corresponding author. Department of Surg Suite 2M, New York, NY 10003. Tel.: þ1 212 E-mail address: mleitman725@me.com (I 0022-4804/