Sharfi Sarker

Predicting cancer on excision of atypical ductal hyperplasia

BACKGROUND There are no specific histopathologic factors that allow identification of patients with atypical ductal hyperplasia (ADH) who will have cancer on final excision. METHODS This was a retrospective study of all patients who had ADH on biopsy followed by excision from 1999 to 2006. RESULTS Fifty-one patients were found to have ADH on core biopsy. Eight (15.7%) patients had invasive carcinoma on surgical excision, 9 (17.5%) had ductal carcinoma-in-situ (DCIS), 21 (41.5%) had ADH, 4 (8%) patients had atypical lobular hyperplasia, and 9 (17.5%) had benign tumors. The grade of atypia on the core biopsy was mild in 13 (25%) patients, moderate in 22 (43%), and marked in 16 (32%). On multivariate analysis of histopathologic factors, the grade of atypia was the only significant variable that predicted a diagnosis of cancer on final surgical excision (P = .001). CONCLUSIONS The grade of atypia correlated with the presence of cancer on surgical excision.

To ‘gram or not’? Indications for intraopertive cholangiogram

BACKGROUND The purpose of this study was to evaluate the current practice patterns and results for use of intraoperative cholangiogram (IOC) during laparoscopic cholecystectomy (LC). METHODS We performed a retrospective review of all patients who underwent LC between January 1, 2005 and December 31, 2009. Data variables included: preoperative laboratory and radiographic studies, indication for and findings of IOC, and perioperative management of choledocholithiasis and retained common bile duct (CBD) stones. RESULTS There were 1,308 patients who underwent LC by 23 surgeons, of whom 266 also had an IOC (20%) performed. The majority had ultrasonography performed, 242 had an abdominal compute tomography (CT) scan, and 129 patients had a hepatobiliary iminodiacetic acid (HIDA) scan. Indications for an IOC included: diagnosis of choledocholithiasis or gallstone pancreatitis (n = 116), abnormal liver function tests (n = 187), and a dilated CBD ≥ 10 mm (n = 182). Of the 266 IOCs, 36 patients (13.5%) had a CBD stone with the majority (n = 26; 72%) having normal preoperative imaging studies. Only 6 patients (17%) with a CBD calculi on IOC underwent successful clearance of the calculi at the time of LC. Twenty-nine of the remaining 30 patients with a retained calculus on IOC underwent postoperative endoscopic retrograde cholangiopancreatography (ERCP) with extraction of the calculi. Of the 1,042 LCs performed without an IOC, 31 patients (3%) were diagnosed with a retained stone managed successfully by ERCP. CONCLUSION Our data reveals that the selective use of IOC is helpful in diagnosing and clearing CBD calculi, that the use of preoperative CBD size aids in selecting patients for IOC, and that choledocholithiasis identified with IOC or after discharge can be managed successfully with ERCP.

Management of slipped adjustable gastric bands

BACKGROUND A small percentage of patients undergoing laparoscopic adjustable gastric banding (LAGB) experience band slippage that might require subsequent surgical intervention. We present our experience with band slippage in 660 consecutive LAGBs performed since November 2001 in order to determine the optimal management for slipped gastric bands. METHODS The treatment options for patients with slipped bands include band removal, gastric reduction and reapplication of the original band, and band replacement. Data from electronic medical records, as well as telephone interviews, were collected and tabulated. The original weight and body mass index, weight and body mass index before the revisional procedure, and the most recent weight, body mass index, and percentage of excess weight loss are presented. RESULTS Of the 660 LAGB patients, 34 (5%) experienced band slippage and required 40 subsequent operative procedures. Of the 34 patients, 6 underwent multiple procedures for their slipped band. Overall, 10 removals, 13 gastric reductions, and 17 replacements were performed (40 total procedures). Of the 34 patients, 28 (82%) were available for follow-up. This group of 28 patients underwent 34 operative procedures (7 removals, 11 gastric reductions, and 16 replacements). No complications were associated with these 34 operations. Of the 11 patients with gastric reduction, 6 (55%) had subsequent recurrence of band slippage, resulting in 6 additional operations (5 replacements and 1 removal). CONCLUSION After band slippage, all 3 management options result in maintenance of most of the lost weight. However, because a large number of patients who undergo gastric reduction experience repeated slippage and require additional surgical intervention, gastric reduction should not be routinely performed in this population. Given the overall experience with revisional surgery after band slippage, additional investigation of the etiology of band slippage and its prevention is warranted.

Obstructive sleep apnea in general surgery patients: is it more common than we think?

BACKGROUND To determine the risk of obstructive sleep apnea (OSA) in preoperative surgical patients. METHODS Three hundred seventy-one new patients presenting to an outpatient general surgery clinic were prospectively screened for risk of OSA using the STOP-Bang questionnaire. Patients were classified as high risk with a score of >3 on the STOP-Bang questionnaire. Polysomnography results were reviewed when available. RESULTS Complete questionnaires were available on 367 (98.9%) patients. Two hundred thirty-seven patients (64.6%) were classified as high risk of OSA on the questionnaire. Polysomnography results available on 49 patients revealed severe OSA in 17 (34.5%), moderate in 8 (16.5%), mild in 14 (28.5%), and no OSA in 10 (20.5%) patients. The positive predictive value and sensitivity of the questionnaire were 76%, and 92% for the STOP-Bang questionnaire, respectively. The sensitivity increased to 100% for severe OSA. CONCLUSION Preoperative screening for OSA should be considered to diagnose patients at risk.

Laparoscopic cholecystectomy for biliary dyskinesia: Which patients have long term benefit?

PURPOSE Biliary dyskinesia (BD) is described as biliary colic in the absence of gallstones. The diagnosis relies on imaging studies and decreased excretion of bile in response to cholecystokinin during quantitative cholescintigraphy. The purpose of this study was to evaluate the success of laparoscopic cholecystectomy (LC) for relieving symptoms in patients diagnosed with BD and correlate gallbladder ejection fraction (EF) with symptom relief. METHODS A retrospective review was performed at a single institution of all patients who underwent LC for BD from January 2005 through January 2012. The diagnosis of BD was determined by a normal gallbladder as viewed with ultrasonography and cholescintigraphy with a gallbladder EF less than or equal to 45%. Data collection included demographics, results of imaging studies, pathologic diagnosis, and early postoperative pain relief. Patients were contacted by phone after being discharged from the surgeons care for evaluation of symptom relief. Data were analyzed with nonparametric statistical methods, including Mann-Whitney U test, receiver operator characteristic, Fisher exact test, and χ(2) test. All data are expressed as median and 25th and 75th percentile range. RESULTS There were 126 patients who had a LC for BD during the study period. The median biliary EF was 20% (10-29%). The most common pathologic finding was chronic cholecystitis (n = 95; 75%). Median length of follow-up in the perioperative period was 11 days (8-17), during which time 98 patients (78%) had relief of symptoms. Phone interviews (n = 53; 42%) confirmed 66% (n = 35) of patients remained free of pain. There was no difference in the mean EF among those with resolution of pain 20% (10-29%) compared with patients with persistent pain 23% (11-29%), P = .62. Obese patients were more likely to have persistent symptoms in the perioperative period with a shift to lower body mass index at the time of the phone survey. Receiver operator characteristic characteristic for the association between scintigraphic EF and resolution of postoperative pain demonstrated no association, with the area under the curve equal to 0.47. CONCLUSION The majority of patients in this series with BD had resolution of symptoms with LC. However, cholescintigraphy EF did not correlate with outcome. Further studies are needed to better identify patients diagnosed with BD who will benefit from LC.

Histopathologic characteristics of the primary tumor in breast cancer patients with isolated tumor cells of the sentinel node

BACKGROUND Clinicians often rely on primary tumor characteristics to decide on adjuvant treatment for patients with breast cancer with isolated tumor cells (ITC) in the sentinel lymph node. The purpose of this study was to determine if there is a significant difference in primary tumor characteristics between ITC and other nodal groups. METHODS Patients undergoing sentinel lymphadenectomy were divided into 3 groups: N0, no metastases; ITC, metastasis less than 0.2 mm; and micro- or macrometastases (MM), metastasis greater than 0.2 mm. The chi-square test and analysis of variance were used. RESULTS A total of 552 patients underwent sentinel lymphadenectomy; 197 (36%) had tumor-positive sentinel lymph nodes. Of these, 35 (18%) were classified as ITC and 162 (82%) as MM. When primary tumor characteristics were compared, the ITC group had significantly more lymphovascular invasion and higher proliferative rate than the N0 group (P < .05) and significantly less lymphovascular invasion, lower proliferative rate, and smaller tumor size (P < .05) than the MM group. There were no significant differences in the age, hormone receptor status, histologic type, or tumor grade among the patient groups. CONCLUSIONS Proliferation and lymphovascular invasion of the primary tumor are significantly different between the ITC, N0, and MM groups suggesting that ITC tumors may have different biology than the N0 or MM tumors.

Diagnosis and management of acute gastric distention following laparoscopic adjustable gastric banding.

Laparoscopic adjustable gastric banding (LAGB) is commonly performed for weight reduction in the morbidly obese population. Morbidly obese patients often suffer from many co-morbid conditions including diabetes. Diabetic patients may suffer from symptomatic or asymptomatic gastric dysmotility resulting in intermittent gastric distention. Following gastric banding, in the early postoperative period, patients may be unable to decompress trapped air in the stomach and may develop severe acute distention with associated risk for catastrophic results. We present the case of a diabetic patient who underwent an uneventful LAGB but returned to the hospital with severe abdominal and back pain. Following the diagnosis of acute gastric distention using an abdominal roentgenogram, the stomach was decompressed using a naso-gastric tube. Following initiation of promotility agents, the patient was successfully discharged home without symptoms. A high index of suspicion, prompt diagnosis and appropriate management can prevent complications of acute gastric distention in this patient population.

Laparoscopic-assisted lumboperitoneal shunt placement for idiopathic intracranial hypertension.

Lumboperitoneal (LP) shunting is considered an effective method of cerebrospinal fluid (CSF) diversion in patients with idiopathic intracranial hypertension (IIH). Confirmation of flow out of the distal portion of the catheter once in its final position can be difficult, especially in obese individuals. A new technique to improve placement of the peritoneal catheter involves laparoscopic catheter insertion. We performed laparoscopic-assisted LP shunt placement for IIH on four patients. Improvement in preoperative IIH symptomatology was noted in all patients. No laparoscopic-procedure-related complications were noted. No problems were noted in shunt functioning and none of the shunts have required revision surgery at last follow-up. LP shunt related complications were noted in two of the four patients. Complications included bilateral lower extremity lumbar radiculopathy in one patient that resolved with a short course of gabapentin, spinal headache in one patient that resolved with bed rest and fluids, and development of a small intracranial subdural hygroma without mass effect in one patient that is asymptomatic and being followed without clinical consequence. Laparoscopic insertion of the abdominal catheter is safe and effective and does not appear to independently cause an increased risk of complications.

A rare case of mesh infection 3 years after a laparoscopic totally extraperitoneal (TEP) inguinal hernia repair.

Late complications after a laparoscopic inguinal hernia repair are extremely rare and have only recently entered into the literature. One such late complication is mesh infection, of which there have been a handful of cases reported in the literature. Mesh infections occurring many years after inguinal hernia repairs are not only of significance because they are not well documented in the literature, and the pathogenesis and risk factors contributing to their development are not well understood. This report details a rare case of mesh infection 3 years after a laparoscopic totally extraperitoneal inguinal hernia repair, describes our management of the condition, highlights the current options for management, and attempts to define its pathophysiology.

Combined laparoscopic cholecystectomy with ileostomy reversal: A method of delayed definitive management of postoperative gallstone pancreatitis.

Traditional management of gallstone pancreatitis (GP) has been to perform cholecystectomy during the same hospital admission after resolution. However, when GP develops in the immediate postoperative period from a major colorectal operation, cholecystectomy may be fraught with difficulty due to the inflammatory response that occurs. Thus, delaying cholecystectomy until the inflammatory response subsides may be worthwhile, and it maximizes the chances of completing the cholecystectomy laparoscopically. We have described our management of 2 patients with GP occurring after colorectal operations, which required proximal diverting ileostomy. In both cases, we deferred management of GP with either endoscopic retrograde cholangiopancreatography (ERCP) or medical conservative measures during the acute attack and performed laparoscopic cholecystectomy during ostomy reversal surgery utilizing the existing ostomy takedown site for port placement. Both patients tolerated this management well.