Vellore S. Parithivel

Case Report: Paraganglioma of the Pancreas

Extraadrenal paragangliomas are very rare tumors arising from cells derived from the neural crest. These tumors are encountered only as case reports, and as a result, little is known of their natural history. We present a case of pancreatic paraganglioma and review all previously reported cases.Paraganglioma, or extraadrenal pheochromocytomas, arise from paraganglia and are histologically akin to chemodectomas. They are rare, affecting about one in 2,000,000 people (1). Paragangliomas are essentially neural cells that have separated from developing autonomic ganglia. Hence, like autonomic ganglia, paraganglia are also found within organs (2). A paraganglioma arising from a visceral organ is exceedingly rare.

Predictors of the severity of acute pancreatitis in patients with HIV infection or AIDS.

We retrospectively reviewed the charts of 54 human immunodeficiency virus (HIV) infected patients or acquired immunodeficiency syndrome (AIDS), who were hospitalized at the Bronx-Lebanon Hospital Center with acute pancreatitis between January 1993 and December 1995. Nineteen were female and 35 were male patients. Thirty-five (65%) of 54 patients were younger than 40 years (average age, 42 years). Forty-eight (89%) of the patients had a CD4 count of <200 units/ml of blood. Seventeen (32%) patients died either of complications of acute pancreatitis or of underlying disease. The conventional prognostic criteria used to assess the severity of pancreatitis, including Ransons and Imries criteria and the APACHE II system, were applied. We determined that these criteria were not appropriate to our HIV/AIDS patients. Only serum calcium levels at 48 h after admission and serum creatinine and blood urea nitrogen (BUN) at admission and at 48 h after admission had significant p values (<0.05). We believe that the predictors commonly used to identify the severity of pancreatitis were not useful in these patients because of their low CD4 counts and preexisting liver and renal disease.

Laparoscopic vs open partial colectomy in elderly patients: Insights from the American College of Surgeons - National Surgical Quality Improvement Program database

AIM To compare the outcomes between the laparoscopic and open approaches for partial colectomy in elderly patients aged 65 years and over using the American College of Surgeons - National Surgical Quality Improvement Program (ACS NSQIP) database. METHODS The ACS NSQIP database for the years 2005-2011 was queried for all patients 65 years and above who underwent partial colectomy. 1:1 propensity score matching using the nearest- neighbor method was performed to ensure both groups had similar pre-operative comorbidities. Outcomes including post-operative complications, length of stay and mortality were compared between the laparoscopic and open groups. χ(2) and Fishers exact test were used for discrete variables and Students t-test for continuous variables. P < 0.05 was considered significant and odds ratios with 95%CI were reported when applicable. RESULTS The total number of patients in the ACS NSQIP database of the years 2005-2011 was 1777035. We identified 27604 elderly patients who underwent partial colectomy with complete data sets. 12009 (43%) of the cases were done laparoscopically and 15595 (57%) were done with open. After propensity score matching, there were 11008 patients each in the laparoscopic (LC) and open colectomy (OC) cohorts. The laparoscopic approach had lower post-operative complications (LC 15.2%, OC 23.8%, P < 0.001), shorter length of stay (LC 6.61 d, OC 9.62 d, P < 0.001) and lower mortality (LC 1.6%, OC 2.9%, P < 0.001). CONCLUSION Even after propensity score matching, elderly patients in the ACS NSQIP database having a laparoscopic partial colectomy had better outcomes than those having open colectomies. In the absence of specific contraindications, elderly patients requiring a partial colectomy should be offered the laparoscopic approach.

Ten years later: a single hospital experience with malignancy in HIV/AIDS.

We present our experience in the era of HAART with 5,112 patients having HIV infection or AIDS, treated between 2002 and 2006 in our hospital, 182 of whom had malignancies (3.56%). We compared our findings to those from a similar cohort of patients studied 10 years earlier.

Bouveret's syndrome: A rare presentation of gallstone disease

Biliary-enteric fistula is a rare complication of gallstone disease, and gallstone ileus is relatively a rare cause of intestinal obstruction. Most commonly, the stone lodges in the distal ileum, colon, or duodenum. The least common site of obstruction is the proximal duodenum or pylorus causing gastric outlet obstruction (Bouverets syndrome). Presenting signs and symptoms of Bouverets syndrome include nausea, vomiting, epigastric pain, and abdominal distension. Obstructive jaundice, gastrointestinal hemorrhage with or without hematemesis, pancreatitis, and duodenal perforation are less common. Abdominal radiography may show air in the biliary tree, mechanical bowel obstruction, and radio-opaque gallstone suggesting the diagnosis. Abdominal ultrasound or computerized tomography is diagnostic in about 60% of cases. In most cases, the treatment of Bouverets syndrome is surgical. Surgical options include (a) a single-staged enterolithotomy (or gastrostomy) with concomitant cholecystectomy and repair of the fistula or (b) an enterolithotomy alone with or without a second-stage cholecystectomy. Endoscopic extraction of the stone has been described in selected patients. Lithotripsy techniques have also been successfully used to fragment large stones. The authors present a case of Bouverets syndrome as well as a brief literature review of this topic. The following core competencies are addressed in this article: Medical knowledge and patient care. Republished with permission from: Kavuturu S, Parithivel V, Cosgrove J. Bouverets syndrome: A rare presentation of gallstone disease. OPUS 12 Scientist 2008;2(2):11-12.

Emergency Subtotal Colectomy in a Jehovah’s Witness With Massive Lower Gastrointestinal Bleeding: Challenges Encountered and Lessons Learned

A 66-year-old woman who was a Jehovahs Witness had massive lower gastrointestinal bleeding and subsequent hypovolemic shock, necessitating a subtotal colectomy. During the postoperative period, her hemoglobin level decreased to a low of 2.6 g/dL, prolonging her dependence on mechanical ventilation. Prudent perioperative care resulted in a successful outcome. Blood-conserving techniques are indispensable in the management of Jehovahs Witnesses who have massive blood loss. Maximizing oxygen transport, minimizing blood loss, using a cell saver when permissible, providing optimal ventilatory support, performing tracheostomy early if prolonged mechanical ventilation is expected, and augmenting hemoglobin production with administration of iron and erythropoietin are techniques that can facilitate successful outcome in patients who refuse blood transfusion.

Colonoscopy-Assisted ‘Trephine’ Sigmoid Colostomy

Fecal diversion is often required to treat complex traumatic, malignant or inflammatory anorectal conditions. In such circumstances, the formation of a proximal, ‘trephine’ sigmoid colostomy would avoid the need for, and the associated morbidity of, a formal laparotomy. We describe a technique which combines intraoperative colonoscopy with a diverting, ‘trephine’ sigmoid colostomy, thereby helping the surgeon to identify the correct loop of bowel, to avoid inadvertent maturing of the wrong end of the divided colon, and to exclude intracolonic lesions.

Case Report: De Garengeot’s hernia. Appendicitis within femoral hernia. Diagnosis and surgical management

Highlights • The presence of the appendix inside a femoral hernia is called De Garengeot’ s hernia.• Diagnosis is usually as an incidental findings intra operative.• We present a case of appendicitis on a strangulated femoral hernia, with pre-operative diagnosis.• We were able to reduce appendix by laparoscopy approach and later on perform open repair of femoral hernia.

Improving the Functionality of Intra-Operative Nerve Monitoring During Thyroid Surgery: Is Lidocaine an Option?

Intra-operative nerve monitoring (IONM) is rapidly becoming a standard of care in many institutions across the country. In the absence of neuromuscular blocking agents to facilitate the IONM, the depth of anesthesia required to abolish the laryngo tracheal reflexes often results in profound hemodynamic instability during surgery, necessitating the use of large doses of sympathomimetic amines. The excessive alpha and beta adrenergic effects exhibited by these agents are undesirable in the presence of cardiovascular co-morbidities. Trying to strike a balance frequently results in an unsatisfactory intra-operative course. In the course of the near total thyroidectomy performed on a 60-year-old female, we employed lidocaine infusion at 1.5 mg/kg/hour following a bolus dose of 1 mg/kg. The troublesome laryngo tracheal reflexes were successfully blunted and we were able to moderate the depth of anesthesia resulting in stable hemodynamics. A bispectral index monitor was employed to guard against “recall” and a train of four monitor was used to ensure the absence of inadvertent neuromuscular blockade. During the surgery, there was loss of signal on the left recurrent laryngeal nerve (RLN). The signal strength was restored by rotating the endotracheal tube on its long axis to realign the electrode with the vocal cords under Glidescope® visualization.

Stereotactic needle breast biopsy: a review of current status and practice

Abstract The early detection of breast cancer is a concern to women and their physicians. Although screening mammography can identify early breast lesions, many are small and non-palpable. In the past, open excisional biopsy often was required to establish the diagnosis. Recently, stereotactic breast biopsy, a minimally invasive technique, has permitted tissue diagnosis of small lesions without open surgery, with results comparable to those obtainable with excisional biopsy. We reviewed this technique, its application in identifying small breast lesions, and in diagnosing breast cancer in its early stages.