Varun K. Bhalla

Postoperative Diet Advancement Surgical Dogma vs Evidence-Based Medicine

Postoperative ileus is a natural part of recovery following abdominal and intestinal surgery. Research in the laboratory and clinical arenas has challenged the long-held belief that enteral nutrition (EN) should not be administered until bowel function has resumed, which is typically judged by a subjective bowel function assessment. Traditional postoperative management begins with clinical monitoring of return of bowel function, followed by a clear liquid diet that is advanced to regular solid food as tolerated. Studies have consistently demonstrated that early EN is safe and well tolerated, showing a reduction in wound morbidity and healing, fewer septic complications, diminished weight loss, and improved protein kinetics in patients administered early EN. Barriers to early enteral feeding include fear of GI morbidity, anastomotic disruption or leak but have not been proven valid in clinical or experimental trials. A clear liquid diet is the most frequently ordered first postoperative meal regardless of early or delayed administration. Although generally well tolerated, this diet fails to provide adequate nutrients to the postsurgical patient. In contrast, advancement to a regular diet as the initial meal has been shown to be well tolerated and provides significantly more nutrients than a clear liquid diet. This article reviews basic GI physiology, including motility, nutrient absorption, and the changes that occur in regulation and function of the GI tract following surgery, as well as clinical data regarding postoperative GI function and diet advancement. This will be applied to the clinical practices of postoperative dietary advancement to discuss the timing and choice of initial feeding in the postoperative patient.

Popliteal pseudoaneurysm caused by Nora's lesion of the femur in a young child: A rare presentation and first report

Bizarre parosteal osteochondromatous proliferation (BPOP), or Noras lesion, was first described by Nora et al. in 1983 as a rare, tumor-like lesion involving the bones of the hands and feet. Popliteal artery pseudoaneursyms in the pediatric population are also unusual. Here, we present a case of a young male with a popliteal artery pseudoaneurysm and distal femur lesion originally thought to be an osteochondroma. A 10-year old, Caucasian male was referred to our facility following an MRI concerning for a popliteal artery pseudoaneurysm. On physical exam, there was a palpable 5 × 5-cm pulsatile mass in the upper popliteal fossa with a normal pulse exam bilaterally. A computed tomographic angiogram demonstrated a 4.5-cm by 1.8-cm by 3.6-cm pseudoaneurysm adherent to a 3.5-cm thick, exostotic lesion of the posterior right femur. He was taken to the operating room for repair of the popliteal pseudoaneurysm and resection of his bone lesion. The final pathology was consistent with a popliteal pseudoaneurysm, osteochondroma, and bizarre parosteal osteochondromatous proliferation (BPOP), otherwise known as Noras lesion. The location of the lesion and the age of our patient were both atypical for BPOP and to our knowledge, this represents the first report of a resulting popliteal artery pseudoaneurysm.

Müllerian-type, cutaneous ciliated cyst in the gluteal cleft mimicking a pilonidal cyst.

Abstract A cutaneous ciliated cyst is a rare entity found predominantly in the lower extremities and perineal region of young females. Although initially described by Hess in 1890, the present day term, “cutaneous ciliated cyst,” was proposed by Farmer in 1978 and includes a wide array of cyst types. Despite their typical female predominance and location, many have described cutaneous ciliated cysts in males and atypical locations. In addition, Mullerian cysts in the posterior mediastinum and the retroperitoneum have been reported. To date, only 40 cases have been reported in the literature of a Mullerian-type, cutaneous ciliated cyst. Here, we report a case of 13-year-old female with one in the gluteal cleft, initially presenting as a pilonidal cyst. We also discuss the differential diagnosis of pediatric sacrococcygeal lesions and pathogenesis of a Mullerian-type, cutaneous ciliated cyst.

Gastroschisis associated with an omphalocele and intestinal atresia

An omphalocele and gastroschisis represent two common pediatric congenital abdominal wall defects, but are rarely associated with each other. An omphalocele results from an incomplete closure of the lateral body folds leading to a midline defect in the anterior abdominal wall. This manifests as herniated intra-abdominal contents into a membrane-covered sac, made up of an inner peritoneal and outer amniotic layer [1, 2]. With an incidence of 1 in 3,000 births, an omphalocele has a higher prevalence in males and is associated with chromosomal abnormalities in up to 40 % of patients [2]. On the other hand, a gastroschisis is a congenital abdominal wall defect that typically occurs to the right of the umbilicus and may be separated by a skin bridge [3]. The incidence is 0.3–1 per 10,000 births with associated anomalies present in up to 10 % of cases [3, 4]. Distal atresias, with a normal incidence of 1 in 1,500–5,000 births, represent one such anomaly with the ileum most commonly affected. We present a case with all three congenital anomalies, a finding we believe has never been reported. Case report

Roux-en-Y gastric bypass in the setting of congenital malrotation: A report and review of the literature

Roux-en-Y gastric bypass in the setting of congenital malrotation: A report and review of the literature Brandy N. Cross, M.D., Varun K. Bhalla, M.D.*, Jeremy A. Warren, M.D. Georgia Regents University, Department of General Surgery, Augusta, Georgia Georgia Regents University, Department of General Surgery, Section of Minimally Invasive and Digestive Diseases Surgery, Augusta, Georgia Received February 16, 2013; accepted February 26, 2013

Laparoscopic Treatment of Simultaneously Occurring Pyloric Stenosis and Malrotation

Hypertrophic pyloric stenosis (HPS) is a common cause of nonbilious vomiting in the neonatal period with an incidence of approximately 1 to 3 per 1000 live births. The Ramstedt pyloromyotomy has been the standard treatment since 1912. In 1991, Alain et al. reported a novel approach to HPS using laparoscopy. Since this original description, the laparoscopic pyloromyotomy has become progressively more popular and, in many institutions, has replaced the open approach. Similarly, malrotation is a condition affecting the neonatal population, resulting from incomplete intestinal rotation about the superior mesenteric artery during weeks 10 through 11 of development. If left untreated, it can lead to abnormal mesenteric attachments and a narrowed mesenteric base, placing the patient at risk for midgut volvulus. The standard surgical treatment has been the open Ladd procedure first described in 1932. In 1996, Gross described a minimally invasive procedure to address malrotation. The association of concurrent pyloric stenosis and malrotation has rarely been reported in the pediatric literature. This is the first published report of a laparoscopic treatment of HPS and malrotation simultaneously.