Mordechai Shimonov

Phosphate salt bowel preparation regimens alter perioperative acid-base and electrolyte balance

BackgroundHyperphosphatemic acidosis and severe electrolyte disturbances caused by phosphate salts (PO) used for mechanical bowel preparation have been described in occasional case reports prior to bowel resection surgery. We hypothesized that PO used preoperatively for bowel preparation may cause more pronounced acid base and electrolyte changes than polyethylene glycol (PG).MethodsForty American Society of Anesthesiologists physical status II–III patients were randomly allocated to receive either PO or PG for bowel preparation before intra-abdominal surgery (bowel resection or other major elective intra-abdominal surgeries). Measurements of pH, base deficit, blood gases, lactate, hemoglobin, calcium, magnesium, potassium and phosphorus were undertaken before the laxative administration, intraoperatively, and postoperatively.ResultsPreoperative demographic, hemodynamic and laboratory data were similar in the two groups. Intraoperative calcium (8.4 [0.6] vs 9 [0.5] mg·dL-1) and pH (7.35 [0.04] vs 7.41 [0.03]) were lower, while lactate (1.3 [0.4] vs 0.9 [0.3] mmol·L-1) was higher with PO. Postoperative calcium, magnesium and potassium were lower (8 [0.5] vs 8.9 [0.2] mg·dL-1, 1.68 [0.3] vs 1.8 [0.4] and 3.5 [0.36] vs 3.7 [0.33] mEq·L-1 respectively) while phosphorus (4.1 [0.3] vs 3.3 [0.2] mEq·L-1) was higher with PO. A higher percentage of abnormal values for calcium, potassium, phosphorus and base deficit (66% vs 33%, 25% vs 10%, 19% vs 2% and 28.3% vs 5% respectively) were observed with PO.ConclusionsCalcium and magnesium changes were more pronounced in patients who received PO for bowel preparation.AbstractObjectifĽacidose hyperphosphatémique et des troubles sévères des électrolytes causés par les sels phosphatés (PO) utilisés pour la préparation intestinale mécanique ont été décrits à ľoccasion dans des présentations de cas avant la résection de ľintestin. Nous avons supposé que les PO utilisés avant ľopération pour la préparation intestinale pouvaient causer plus de changements acide base et électrolytiques que le polyéthylèneglycol (PG).MéthodeQuarante patients ďétat physique ASA II–III ont reçu au hasard soit des PO, soit du PG pour la préparation de ľintestin à la chirurgie intra-abdominale comme la résection de ľintestin ou ďautres opérations majeures réglées. Les mesures du pH, du déficit basique, des gaz sanguins, du lactate, de ľhémoglobine, du calcium, du magnésium, du potassium et du phosphore ont été faites avant ľadministration du laxatif, pendant et après ľopération.RésultatsLes données démographiques, hémodynamiques et de laboratoire étaient similaires dans les deux groupes. Le calcium (8,4 [0,6] vs 9 [0,5] mg·dL-1) et le pH (7,35 [0,04] vs 7,41 [0,03]) peropératoires étaient plus bas, mais le lactate (1,3 [0,4] vs 0,9 [0,3] mmol·L-1) était plus élevé avec le PO. Le calcium, le magnésium et le potassium postopératoires ont été plus bas (8 [0,5] vs 8,9 [0,2] mg·dL-1, 1,68 [0,3] vs 1,8 [0,4] et 3,5 [0,36] vs 3,7 [0,33] mEq·L-1) tandis que le phosphore (4,1 [0,3] vs 3,3 [0,2] mEq·L-1) a été plus élevé avec le PO. Un plus fort pourcentage de valeurs anormales pour le calcium, le potassium, le phosphore et le déficit basique (66 % vs 33 %, 25 % vs 10 %, 19 % vs 2 % et 28,3 % vs 5 %) a été observé avec le PO.ConclusionLes changements notés pour le calcium et le magnésium étaient plus prononcés chez les patients qui ont reçu des PO pour une préparation intestinale.

Combined Systemic Chronotherapy and Hepatic Artery Infusion for the Treatment of Metastatic Colorectal Cancer Confined to the Liver

Background: The optimal treatment of patients with metastatic colorectal cancer is still a clinical challenge. We describe the use of combined hepatic arterial infusion (HAI) of irinotecan (CPT-11) in conjunction with systemic chronotherapy infusion of 5-fluorouracil (5FU), folinic acid and carboplatin in patients with colorectal liver metastases. Methods: Twenty-three patients with colorectal cancer and isolated liver metastases were enrolled in this trial. Intraoperative insertion of an intra-arterial catheter into the hepatic artery was accomplished during the colon operation (in cases of synchronous tumor) or as a separate procedure in colorectal cancer patients with newly diagnosed liver metastases. A systemic double-lumen double-chamber port was inserted via the subclavian vein as a separate procedure. The treatment plan included irinotecan given by intra-arterial infusion at 150 mg/m2 for 1 h. After 2 weeks of rest chronomodulated 5FU (700 mg/m2; peak delivery rate at 04:00 h), leucovorin (175 mg/m2; peak delivery rate at 04:00 h) and carboplatin (40 mg/m2; peak delivery rate at 16:00 h) for 4 days was followed by 10 days’ rest and then given again. After 10 days’ rest another HAI was introduced using the same method. Each cycle of therapy included 2 HAI courses and 2 chronotherapy courses in between. After 2 complete cycles, patients were evaluated for their response with weekly accessed toxicity recording. Results: Seven women, 8 men, median age 61 years (range 46–72). Eight patients had synchronous colon and hepatic disease and 7 patients had metachronous disease. Ten patients had previously been treated with 5FU and leucovorin while 5 patients were chemonaive. The mean number of cycles were 11.6 per patient (range 8–19). Partial response was achieved in 6 patients (40%) and was followed by laparoscopic radiofrequency ablation in 5 patients (33%). Disease stabilization was observed in 2 patients (13%) and disease progression in 7 patients (47%) mainly after previous chemotherapy failure. Side effects were infrequent and mild including grade 2 GIT complaints (5 patients), RUQ pain during HAI (9 patients) and grade 2 hematological complaints in 2 patients. Conclusion: A combined chemotherapy protocol (HAI and chronotherapy) with irinotecan (CPT-11) together with chronomodulated infusion of 5FU, folinic acid and carboplatin can be used in metastatic colorectal patients with a high efficacy rate and minor side effects especially in pretreated patients.

The role of laparoscopy and laparoscopic ultrasound in the diagnosis of cystic lesions of the pancreas

With the widespread use of advanced imaging techniques, cystic lesions of the pancreas are now diagnosed relatively frequently. The nature of these lesions vary from benign cysts (serous cvstadenoma) or an inflammatory process (pseudocyst), to premalignant (mucinous cystadenoma) or frankly malignant lesions (cystadenocarcinoma). Differentiation of various types of pancreatic cysts presents a diagnostic and therapeutic challenge, as clinical presentation may be vague. Laparoscopic ultrasonography (LAPUS), the biopsy of the cystic wall, and analysis of the cystic aspirate, although expensive and rather invasive procedures, significantly contribute to the differential diagnosis of pancreatic cystic lesions.

The role of laparoscopic ultrasound in the minimally invasive management of symptomatic hepatic cysts

BackgroundNow that the laparoscopic treatment of symptomatic liver cystic disease has proven feasible and safe, it is gaining wide acceptance. However, due to diagnostic pitfalls and a relatively high recurrence rate, further improvements and refinement of the procedure are still needed. We have evaluated the contribution of laparoscopic ultrasound in the diagnosis and management of patients with symptomatic liver cysts.MethodsTwelve patients with single or multiple cysts of the liver and two patients with polycystic liver disease were managed laparoscopically. Laparoscopic ultrasound served as an integral part of the procedure in all patients.ResultsPatients underwent either complete cyst excision (two cases) or resection of the extrahepatic cystic component (eight cases). Additionally, in two patients, deep cysts not demonstrated by preoperative imaging studies were detected and treated with a combination of laparoscopy and laparoscopic ultrasound. In one patient with a cystobiliary fistula, conversion to an open cystjejunostomy was necessary. Patients with polycystic liver disease underwent a combination of excision and unroofing of both superficial and deeper cysts using laparoscopic contact ultrasound throughout the procedure. Laparoscopic ultrasonography was found to have a significant impact on the operative strategy in five patients (36%) with multiple cysts or polycystic disease. The postoperative course was uneventful in all cases. Thirteen patients remained asymptomatic throughout the follow-up period of 30 months; one patient with polycystic liver disease developed recurrent symptoms after 5 months and was treated with left hepatectomy.ConclusionAdditional use of laparoscopic ultrasound enables the detection, differentiation, and treatment of deep, nonvisualized cystic lesions (two patients, 16.6%) and validation of the adequacy of the laparoscopic procedure.

Effects of bariatric surgery on male lower urinary tract symptoms and sexual function

To investigate the effect of bariatric surgery on male lower urinary tract symptoms (LUTS) and sexual function.

Is bariatric surgery the answer to urinary incontinence in obese women

To investigate the effect of bariatric surgery on female pelvic floor disorders.

Effects of Bariatric Surgery on Female Pelvic Floor Disorders

OBJECTIVE To assess the effect of weight loss on urinary incontinence (UI), pelvic organ prolapse, colorectal-anal complaints, and sexual dysfunction among obese women undergoing bariatric surgery. MATERIALS AND METHODS One hundred sixty consecutive women who underwent bariatric surgery were prospectively enrolled. Four validated questionnaires (International Consultation on Incontinence Questionnaire-UI [ICIQ-UI], Bristol Female Lower Urinary Tract Symptoms-SF [BFLUTS-SF], Pelvic Floor Distress Inventory-20 [PFDI-20], and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 [PISQ-12]) were used to evaluate pelvic floor disorders and sexual dysfunction before and 3-6 months after surgery. RESULTS One hundred fifty participants (mean age: 43 ± 12.8 years; mean preoperative body mass index: 42 ± 4.6 kg/m2) completed all pre- and postoperative questionnaires. Preoperatively, 56 (37.3%) women had UI, 44 (29.3%) women had pelvic organ prolapse symptoms, and 66 (44%) women had colorectal-anal symptoms. Overall, surgically induced weight loss was associated with statistically significant improvement in UI (mean ICIQ score: 9.3 ± 3.9 vs 3.3 ± 3.8, P <.001), pelvic organ prolapse symptoms (mean PFDI score: 19 ± 13.2 vs 11 ± 12.8, P <.001), and colorectal-anal symptoms (mean PFDI score: 21 ± 15.9 vs 14 ± 14.9, P = .004). Moreover, half of preoperatively incontinent women and more than one quarter of women who had either pelvic organ prolapse or colorectal-anal symptoms reported complete resolution of their symptoms. Statistically significant improvement in sexual function was suggested by both BFLUTS-SF (0.3 ± 0.8 vs 0.1 ± 0.6; P = .011) and PISQ-12 (37.9 ± 6.1 vs 39.5 ± 5; P = .003) questionnaires. CONCLUSION Surgically induced weight loss was associated with a significant improvement in pelvic floor disorders, including UI, pelvic organ prolapse, and colorectal-anal symptoms, as well as improved sexual performance.

Do Urology Male Patients Prefer Same-Gender Urologist?

There are several studies on patients’ preference for same-gender physicians, especially female preference for same-gender gynecologists. Data regarding the preferences of urology patients, of whom the majority are males, are scarce. The objective of this study is to assess provider gender preference among urology patients. One hundred and nineteen consecutive men (mean age 57.6 years) who attended a urology clinic in one university-affiliated medical center were prospectively enrolled. A self-accomplished 26-item anonymous questionnaire was used to assess patients’ preferences in selecting their urologist. Of the 119 patients, 51 (42.8%) preferred a male urologist. Patients exhibited more same-gender preference for physical examination (38.3%), or urological surgery (35.3%), than for consultation (24.4%). Most patients (97%) preferred a same-gender urologist because they felt less embarrassed. Four patient characteristics were identified to be significantly associated with preference for a male urologist: religious status, country of origin, marital status, and a prior management by a male urologist. Of these, religious status was the most predictive parameter for choosing a male urologist. The three most important factors that affected actual selection, however, were professional skills (84.6%), clinical experience (72.4%), and medical knowledge (61%), rather than physician gender per se. Many male patients express gender bias regarding their preference for urologist. However, professional skills of the clinician are considered to be more important factors when it comes to actually making a choice.

Residual curarization and postoperative respiratory complications following laparoscopic sleeve gastrectomy. The effect of reversal agents: sugammadex vs. neostigmine

Abstract Background: Incomplete muscle relaxant reversal or re-curarization may be associated with postoperative respiratory complications. In this retrospective study we compared the incidence of postoperative residual curarization and respiratory complications in association with the type of muscle relaxant reversal agent, sugammadex or neostigmine, in patients undergoing laparoscopic sleeve gastrectomy. Material and methods: We reviewed the charts of all patients (179) undergoing laparoscopic sleeve gastrectomy from July 2012 to July 2013 at Wolfson Medical Center. Sugammadex 1.5-2 mg/kg (112 patients) or neostigmine 2.5 mg (67 patients) were used as reversal agents. Results were compared by the type of reversal agent employed. Compared parameters included demographic and anaesthetic data, residual curarization, oxyhemoglobin saturation (SpO2) in the recovery room (PACU), episodes of SpO2 lower than 90% in PACU, unexpected intensive care (ICU) admissions, incidence of atelectasis and pneumonia, re-intubation and duration of hospitalization. Results: Obstructive sleep apnea syndrome (OSAS) was more frequent in the sugammadex group (19% vs. 8%; p = 0.026). Total intravenous anesthesia (TIVA) was more frequently associated with sugammadex (33% vs. 16%; p = 0.007). There were no differences in postoperative residual curarization, SpO2 < 90% episodes, reintubation, ICU admissions, pulmonary complications and duration of hospitalization. Conclusion: With the inherent limitations of a retrospective study, the use of sugammadex following laparoscopic sleeve gastrectomy showed no advantage over neostigmine in terms of residual curarization and respiratory complications.

Unusual cause of upper gastrointestinal bleeding

We report a case of recurrent severe upper gastrointestinal bleeding where the bleeding source was difficult to find during recurrent hospitalizations. Eventually videocapsule endoscopy was the modality that finally diagnosed an ulcerated lipoma within an area of intussuscepted jejunum. Segmental resection of small bowel was performed and no further bleeding episodes have occurred. Our case illustrates the value of capsule endoscopy and the rare potential of lipomas to cause serious gastrointestinal bleeding.