Endoscopic ultrasound-guided gastroenterostomy for gastric outlet obstruction in Mexico

BACKGROUND

Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) has recently emer-ged as an alternative treatment for gastric outlet obstruction (GOO) in selected patients.

AIM

To report the initial experience of EUS-GE in patients with GOO.

METHODS

This study was a retrospective, observational, multicenter study in which the data from 10 patients who underwent EUS-GE due to GOO between September 2021 and May 2023 were collected. We analyzed technical success, clinical success, adverse events, and survival. Technical success was defined as adequate position-ing and deployment of the stent. Clinical success was defined as the patient’s ability to tolerate oral intake without vomiting 7 d after the procedure. Post-procedural adverse events were recorded.

RESULTS

Eleven procedures in 10 patients with GOO were included. The mean age of the patients was 67.5 years (range: 56-77 years). Malignant GOO was present in 9 patients. Technical success was achieved in 9/11 procedures (82%). Among them, clinical success was achieved in 9 patients (100%). Adverse events occurred in 1 patient (9%). The median survival was 3 months (n = 7; range: 1-8 months).

CONCLUSION

EUS-GE is a feasible therapeutic option in the treatment of GOO.

Sternocleidomastoid flap for reconstruction of tongue small cell carcinoma: A case report

BACKGROUND

The management of tongue carcinoma is excision and radical neck dissection followed with reconstruction. This is a case report of a patient with tongue squamous cell carcinoma (SCC) who underwent the procedure with sternocleidomastoid (SCM) flap reconstruction.

CASE SUMMARY

A 52-year-old woman without smoking history complained tongue ulcer since 3 years ago. Based on the histopathological examination, the patient was diagnosed with T2N2M0 right tongue SCC and underwent wide excision of tumor; right mandibular; neck dissection and were reconstructed with SCM flap.

CONCLUSION

SCC of the tongue requires wide excision and dissection of the neck and mandible if infiltration into the surrounding lymph nodes has been found. The SCM flap reconstruction could be used post-surgery.

Combined laparoscopic and endoscopic method for foreign body removal from descending colon: A case report

BACKGROUND

The majority of published reports on foreign bodies (FBs) involve the rectum and applied a transanal retrieval. Usually, patients with FB above the rectum are subjected to laparotomy for removal. Here, we illustrate the case of a man with an FB that had migrated into the descending colon, and its successful removal via a laparoscopic approach.

CASE SUMMARY

A 43-year-old man, who had the habit of FB insertion into his anus to aid defecation, presented upon experience of such an FB slipping through and migrating upward to the distal colon. Plain abdominal radiograph revealed a bottle-shaped FB, positioned in the left iliac fossa region. The FB was successfully removed via a laparoscopic-assisted procedure in which we combined diagnostic laparoscopic and endoscopic techniques during surgery. The patient was monitored for 2 d postoperatively and subsequently discharged home.

CONCLUSION

A minimally invasive approach should be adopted to aid extraction of colorectal FB as it is effective and safe.

Endoscopic intermuscular dissection for locally advanced rectal cancer: A case report

BACKGROUND

Endoscopic submucosal dissection is considered curative for patients with early rectal cancer when level of submucosal invasion is < 1000 microns with favourable histopathological features. Recent data suggests even deeper submucosal invasion can potentially be curative if R0 resection can be achieved and when no high-risk histopathological features are seen in the resected specimen. To achieve R0 resection, deeper dissection is required.

CASE SUMMARY

A 66 year old New Zealand European male presented with 3 mo history of per rectal bleeding. He was referred for a colonoscopy test to investigate this further. This revealed a malignant appearing lesion in the rectum. Biopsies however showed high grade dysplasia only. Given endoscopic appearances suspicious for deep submucosal invasion, patient was consented for endoscopic intermuscular dissection (EID). The case was successfully performed, and the presence of muscularis propria was confirmed in the resected specimen. There were no complications and total procedure time was 124 min. Lesion was clear of radial margins however deep margins were positive confirming it was at least a pT2 cancer. Patient was recommended to have further treatment but could not have radical surgery due to comorbidities and instead was referred for long course chemoradiotherapy.

CONCLUSION

EID is a safe and feasible option for management of rectal cancer in highly selected patients.

Alternative to mesh repair for ventral hernias: Modified rectus muscle repair

BACKGROUND

Mesh utilization for ventral hernia repair is associated with potential complications such as mesh infections, adhesions, seromas, fistula formation and significant postoperative pain. The modified rectus muscle repair (RMR) is as an option to repair midline ventral hernias without mesh.

AIM

To evaluate the short term outcomes when the modified RMR was used to repair ventral hernias.

METHODS

This was a 5-year prospective study that examined the outcome of all consecutive patients with ventral abdominal wall hernias > 5 cm in maximal diameter who underwent repair using the modified RMR technique in a single surgeon unit. Patients were reviewed in an outpatient clinic at 3, 6 and 12 mo and evaluated for hernia recurrence on clinical examination. Each patient’s abdominal wall was also assessed with using ultrasonography at 24 mo to detect recurrences. All data were examined with SPSS ver 18.0.

RESULTS

Over the 5-year study period, there were 52 patients treated for ventral hernias at this institution. Four patients were excluded and there were 48 in the final study sample, at a mean age of 56 years (range 28-80). The mean maximal diameter of the hernia defect was 7 cm (range 5-12 cm). There were 5 (10.4%) seromas and 1 recurrence (2.1%) at a mean of 36 mo follow-up.

CONCLUSION

The authors recommend the modified RMR as an acceptable alternative to mesh repair of ventral hernias. The seroma rate can be further reduced with routine use of drains. The modified RMR also has the benefit of eliminating all mesh-specific complications.

Simple lateral elbow dislocation: A case report

BACKGROUND

Simple lateral elbow dislocation (SLED) is a rare type of elbow dislocation; however, its treatment may be complicated by accompanying soft tissue or neurovascular damage. Herein, we report a rare case of SLED managed secon-darily with open reduction and soft tissue repair following failure of closed reduction.

CASE SUMMARY

A 67-year-old woman suffered SLED after falling on her outstretched left hand with her elbow extended. She developed pain, swelling, and movement restriction in the elbow; there were no neurovascular symptoms, except for numbness in the 4^th and 5^th digits. Radiologic investigation confirmed the SLED, and a closed reduction under anesthesia was performed. The follow-up radiographs at 1-wk revealed failure of reduction; accordingly, open reduction with lateral collateral ligament and common extensor origin repair were carried out. The patient regained full elbow range of motion by six weeks.

CONCLUSION

Adequate concentric reduction for SLED, conservatively or surgically, reduces complications and provides a more functional joint.

Cemento-ossifying fibroma of the left mandible: A case report

BACKGROUND

Ossifying fibroma is a type of benign fibro-osseous lesion. Most lesions affect the mandible region, particularly the molar and pre-molar areas. It predominantly affects females between the second to fourth decades of life. Larger ossifying fibroma tumors require more extensive resection.

CASE SUMMARY

A 39-year-old female complained of occasional pain and tumor enlargement on her left jaw for the 3 years prior to presentation. Intraoral examination revealed a firm swelling on her left lower gum. Extraoral examination revealed swelling on the left mandible body with no erythema and superficial ulcer. Computed tomography scan revealed a circular-shaped lesion on the patient’s left mandible body with a well-defined radiolucent border, sized 3.2 cm × 2.8 cm × 0.9 cm. The tumor was removed by marginal mandibulectomy. Biopsy from the resected tumor suggested cemento-ossifying fibroma (COF).

CONCLUSION

COF is often unnoticed, but this slow-growing tumor can cause significant symptoms regarding its distortion into adjacent structures.

Superior mesenteric artery syndrome in a patient with esophageal stenosis: A case report

BACKGROUND

Superior mesenteric artery syndrome (SMAS) is a rare condition, characterized by duodenal obstruction caused by compression of its third part by the superior mesenteric artery (SMA). Most cases of SMAS are associated with weight loss, and the most frequent clinical manifestations are nausea, vomiting, postprandial fullness, and abdominal pain. Treatment of SMAS is usually conservative, consisting mainly of adequate nutritional support, but in refractory cases surgery may be necessary, with gastrojejunostomy and duodenojejunostomy being the most commonly performed procedures.

CASE SUMMARY

We describe the case of a man in his forties with a pre-existing diagnosis of esophageal stricture due to sodium hydroxide ingestion, who suffered significant weight loss after replacement of his jejunostomy tube. He was admitted to the hospital due to pain and abdominal distension. A computerized tomography scan showed significant distension of the stomach and duodenum with narrowing of the duodenum at the point at which it is crossed by the superior mesenteric artery, thus establishing the diagnosis of SMAS. Due to the presence of the esophageal stricture, the patient was incapable of emesis; however, passage of a nasogastric tube for decompression was not possible. Considering the risk of gastric perforation due to distention, we opted for surgical treatment in the form of a surgical gastrojejunostomy after which he showed complete resolution of all symptoms and was discharged from the hospital 5 d after the procedure.

CONCLUSION

Diagnosis of SMAS can be challenging in patients with esophageal stenosis, and risk of gastric perforation may preclude conservative treatment.

Freehand-robot-assisted laparoscopic colorectal surgery: Initial experience in the Trinidad and Tobago

BACKGROUND

Laparoscopic colorectal surgery is still developing in the Anglophone Caribbean, having been first performed in the region in the year 2011. We report the initial outcomes using a robot camera holder to assist in laparoscopic colorectal operations.

AIM

To report our initial experience using the FreeHand^® robotic camera holder (Freehand 2010 Ltd., Guildford, Surrey, United Kingdom) for laparoscopic colorectal surgery in Trinidad & Tobago.

METHODS

We retrospectively collected data from all patients who underwent laparoscopic colorectal resections using the Freehand^® (Freehand 2010 Ltd., Guildford, Surrey, United Kingdom) robotic camera holder between September 30, 2021 and April 30, 2022. The following data were recorded: patient demographics, robotic arm setup time, operating time, conversions to open surgery, conversions to a human camera operator, number and duration of intra-operative lens cleaning. At the termination of the operation, before operating notes were completed, the surgeons were administered a questionnaire recording information on ergonomics, user-difficulty, requirement to convert to a human camera operator and their ability to carry out effective movements to control the robot while operating.

RESULTS

Nine patients at a mean age of 58.9 ± 7.1 years underwent colorectal operations using the FreeHand robot: Right hemicolectomies (5), left hemicolectomy (1), sigmoid colectomies (2) and anterior resection (1). The mean robot docking time was 6.33 minutes (Median 6; Range 4-10; SD ± 1.8). The mean duration of operation was 122.33 ± 78.5 min and estimated blood loss was 113.33 ± 151.08 mL. There were no conversions to a human camera holder. The laparoscope was detached from the robot for lens cleaning/defogging an average of 2.6 ± 0.88 times per case, with cumulative mean interruption time of 4.2 ± 2.15 minutes per case. The mean duration of hospitalization was 3.2 ± 1.30 days and there were no complications recorded. When the surgeons were interviewed after operation, the surgeons reported that there were good ergonomics (100%), with no limitation on instrument movement (100%), stable image (100%) and better control of surgical field (100%).

CONCLUSION

Robot-assisted laparoscopic colorectal surgery is feasible and safe in the resource-poor Caribbean setting, once there is appropriate training.

Rare case of perforated giant gastric ulcer with concurrent thyroid storm: A case report

BACKGROUND

Thyroid storm is an uncommon condition manifesting in severe thyrotoxicosis with a high mortality rate. The concurrence of peptic ulcer disease and hyperthyroidism is rare due to concurrent activation of both the sympathetic and parasympathetic pathways. We present a case of perforated giant gastric ulcer with concurrent thyroid storm who underwent damage control surgery with emergency patch repair with falciform ligament and recovered well.

CASE SUMMARY

A 53-year-old male chronic smoker, with no previous medical history, presented with severe generalized abdominal pain and vomiting for one day duration. Further history revealed weight loss, diarrhea, and anxiety over the past three months. On clinical examination, patient was febrile with temperature of 38.6 Degrees Celsius and tachycardic at 130-140 beats per minute, his blood pressure was low at 90/50mmHg. His abdomen was tender with generalized peritonism. In view of his clinical history, a thyroid screen was ordered which showed raised thyroxine (T4) levels of 90.3 pmol/L and low thyroxine stimulating hormone (TSH) levels of 0.005 μU/mL. Chest X-ray showed no sub-diaphragmatic free air, but contrasted CT scan revealed pneumoperitoneum with large amount of intraabdominal free fluid. The working diagnosis was perforated peptic ulcer complicated by thyroid storm. An urgent endocrinologist consult was made, and patient was started on beta blocker and intravenous steroids pre-operatively. The patient underwent emergency laparotomy with washout and patch repair of the perforated gastric ulcer. Patient was monitored post-operatively in intensive care unit and required IV hydrocortisone and Lugol’s iodine. Histology of the ulcer edges showed no malignancy. On post-operative day seven, T4 decreased to 20.4 pmol/L, TSH was 0.005 mLU/L. His thyroid function test subsequently normalized 3 mo post-operatively with T4 18.1 pmol/L, TSH 1.91 mLU/L. Patient’s recovery was otherwise uneventful. Thyroid receptor antibody subsequently was positive, and patient was managed for Grave’s disease by the endocrinologist.

CONCLUSION

This case highlights the rare but life-threatening clinical emergency of peptic ulcer perforation complicated by thyroid storm. Multidisciplinary perioperative management is crucial to optimize patient for surgery and damage control principles should be taken for an acute surgical patient with concurrent endocrine crisis.

Theco-thecal bypass technique elucidating a novel procedure and perspective on treatment of post-arachnoiditis syringomyelia: A case report

BACKGROUND

Post-arachnoiditis syringomyelia is a condition in which there is an intraspinal cerebrospinal fluid (CSF) blockade due to arachnoidal adhesions and bands. Although many of the techniques currently in use, namely, the theco-peritoneal, syringo-pleural, syringo-peritoneal, and syringo-subarachnoid shunts, are effective, the results are often variable.

CASE SUMMARY

A 36-year-old man with a past history of pulmonary tuberculosis, presented with progressive paraesthesia in the feet and progressive paraparesis along with constipation, difficulty in micturition, and decreased libido. He was bedridden a month before presentation. Magnetic resonance imaging revealed a dorsal multiloculated syrinx from D3-D10 vertebral levels. He underwent a D1-2 to D11 theco-thecal shunt bilaterally to abolish the CSF gradient across the level of the syrinx. There was no direct surgical handling of the spinal cord involved. At the 15-mo follow up, the patient had significant improvement in his symptoms and function.

CONCLUSION

We present a novel technique aimed at correcting the primary cause of a post-arachnoiditis syrinx, the subarachnoid cerebrospinal flow obstruction or block, which we believe is simple and effective, involves minimal handling of the normal neural structures, and attempts to restore the physiology of CSF flow across the obstruction, with favorable clinical results.

Cholangioscopy-assisted guidewire placement in a malignant biliary stricture: A case report

BACKGROUND

Cholangioscopy has been described in case reports and series to facilitate guidewire placement in difficult benign biliary strictures. Specifically, it has been infrequently used in difficult benign anastomotic liver transplant biliary strictures to visualize the stricture orifice for guidewire placement. Here we describe a case of guidewire placement through a difficult malignant biliary stricture using single operator cholangioscopy.

CASE SUMMARY

A 74-year-old female presented with jaundice and weight loss. Endoscopic ultrasound and endoscopic retrograde cholangiopancreatography (ERCP) by other endoscopists demonstrated pancreatic adenocarcinoma with a dilated cystic duct (CD) and proximal common bile duct (CBD). The associated distal CBD stricture was dilated and stented with a plastic stent. However she subsequently developed cholangitis, prompting referral for a repeat ERCP. The stent was found to have migrated distally to the confluence of the dilated CD and CBD stricture. Despite using multiple hydrophilic guidewires, the stricture could not be traversed due to preferential wire passage into the dilated CD. SpyGlass DS (Boston Scientific Corp, Marlborough, MA, United States) was then used to visualize the orifices of the CD and CBD stenosis, enabling the guidewire to be placed directly through the stricture into the proximal CBD. A WallFlex covered metal stent (Boston Scientific Corp, Marlborough, MA, United States) was successfully placed, resulting in resolution of her cholangitis.

CONCLUSION

To our knowledge, this is one of the first cases to describe successful cholangioscopic guidewire placement for malignant biliary strictures.

Regional lymphadenectomy in advanced ovarian cancer: The enigma continues

The role of regional lymphadenectomy has always been a matter of discussion in the surgical management of solid tumors – Pelvic and para-aortic lymphadenectomy in ovarian cancer is one such issue. A recently published randomized trial suggested that regional lymphadenectomy in patients with advanced ovarian cancer is unlikely to offer a survival advantage. However, para-aortic and pelvic lymphadenectomy is warranted in the presence of macroscopically suspicious nodes to achieve complete cytoreduction. A long-term follow-up of the trial will demonstrate whether a prophylactic regional lymphadenectomy is associated with survival benefit in a subgroup of patients with advanced ovarian cancer who have grossly normal regional lymphnodes as evident in a widely open retroperitoneum.

Caribbean “substitution culture” is a barrier to effective treatment of persons with diabetic foot infections

Diabetes-related amputation rates are high in the Caribbean. Many authorities have identified independent risk factors for diabetes-related amputations, but cultural factors remain underappreciated. We coined the term “Caribbean substitution culture” to describe the attitude of patients with diabetic foot infections in which they refuse to access medical care, instead voluntarily choosing to substitute “bush medicines” or other alternative therapies in the place of conventional treatment. Recognizing that the Caribbean substitution culture is a barrier to effective treatment of diabetic foot infections is the first step in curbing these practices. In this paper, we discuss the issues related to the Caribbean substitution culture, including the demographics of the population at risk, the alternative therapeutic practices and potential public health strategies to combat this practice.

Can hyperthermic intraperitoneal chemotherapy effectively control gastric cancer-associated peritoneal carcinomatosis?

Gastric cancer-associated peritoneal carcinomatosis leads to a poor prognosis and low quality of life. The current systemic chemotherapy processes cannot effectively improve survival. Hyperthermic intraperitoneal chemotherapy (HIPEC) has been used as an alternative treatment to control this disease through recurrence prevention, definitive therapeutic modality, and symptom palliation. Although HIPEC has been demonstrated to yield favorable results mainly in some Asian studies, widespread adoption of this treatment is still debatable before larger prospective randomized controlled clinical trials confirm its effectiveness.

Role of botulinum toxin a in the management of complex incisional hernias

Despite the technological breakthroughs and discover of abdominal meshes, ventral hernia has always been challenging in therapeutic strategies by the surgeons, with high recurrence rates. The use of botulinum toxin A (BTA) for the management of ventral and incisional hernia (IH) poses an increasingly interesting practice, especially for the intimidating complex one. The preoperative administration of the toxin to the lateral abdominal muscles by use of Ultra-Sound guidance causes muscle paralysis and a reduction of intra-abdominal pressure. Thus, the hernia defect can be primarily closed without tension, if the length of the defect is up to 10 cm. In larger hernia, this method can be combined with component separation techniques or the use of a mesh. The mesh placement seems to be better by laparoscopy. The site of injection and the dosage of BTA are still under discussion amongst authors. The optimal administration is proposed by some authors to be at least 2 weeks before repair. There is also an analgesic effect of BTA to the patients that underwent hernia reconstruction. Ultimately, the role of BTA in the reconstruction of ventral hernia seems to be promising, but there is a necessity for several randomized clinical trials.

A slight glance at peer review

In order to ensure that the highest quality of literature is published, most journals utilize a peer review process for manuscripts submitted. Although the primary purpose for this process is to filter out ”bad science”, the process is not perfect. While there is a general consensus among researchers and clinicians that something must be done to improve upon the method for properly vetting manuscripts, there are conflicting opinions on how to best implement new policies. In this paper, we discuss the most well-supported suggestions to improve the process, with the hopes of increasing rigor and reproducibility, ensuring double-blinding, developing set guidelines, offering early training to reviewers, and giving reviewers better feedback and recognition for their work.

Surgical treatment of a rare complication after endoscopic stent placement for anastomotic leakage after esophageal resection

The best approach to achieve cure in esophageal cancer is a combination of chemo-radiation and surgery. However, complications occur in half of patients. The current report, reports a rare but severe complication: Complete obstruction of the esophagus, induced by preoperative chemo-radiation therapy. Normally, strictures are treated by repeated dilatations, however, in case of complete obstruction, the perforation rate of standard blind anterograde wire access and dilation is severely increased. In order to minimize the risk of perforations, the rendezvous technique was introduced. This technique involves an anterograde approach in combination with a retrograde approach in order to open and dilatate the esophagus. While technical success rates between 83% and 100% have been reported in literature, data on clinical outcomes are scarcer. The limited amount of studies available claim that success was achieved in almost half of patients. The patient in our case currently has an oral diet without restrictions and rates his quality of life with a VAS-score ten out of ten.

Glycemic management in critically ill patients

Hyperglycemia associated with critical illness, also called “stress hyperglycemia” or “stress diabetes”, is a consequence of many pathophysiologic hormonal responses including increased catecholamines, cortisol, glucagon, and growth hormone. Alterations in multiple biochemical pathways result in increased hepatic and peripheral insulin resistance with an uncontrolled activation of gluconeogenesis and glycogenolysis. Hyperglycemia has a negative impact on the function of the immune system, on the host response to illness or injury, and on infectious and overall outcomes. The degree of glucose elevation is associated with increased disease severity. Large randomized controlled trials including the Van den Berghe study, the NICE-SUGAR trial, VISEP and GLUCONTROL have shown that the control of glucose levels in critically ill patients has implications on outcome and that both hyperglycemia and hypoglycemia are detrimental and should be avoided. Glucose variability has also been shown to be detrimental. Aggressive glucose control strategies have changed due to the concerns of hypoglycemia and therefore intermediate target glucose control strategies are most often adopted. Different patient populations may vary with regards to optimal glucose targets, timing and approach for glucose control, and with regards to the prognostic significance of glucose excursions and variability. Medical, surgical, and trauma patients may benefit at different rates from glucose control and the approach may need to be adapted to various medical settings and to correspond to the workflow of health providers. Effect modifiers for the success of insulin therapy for hyperglycemia include the methods of nutritional supplementation and exogenous glucose administration. Further research is required to improve insulin protocols for glucose control, to further define glucose targets, and to enhance the accuracy of glucose measuring technologies.

Surgical outcomes of pulmonary resection for lung cancer after neo-adjuvant treatment

AIM: To evaluate the outcomes of surgery for lung cancer after induction therapy.

METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2005-2012), we identified 4063 patients who underwent a pulmonary resection for lung cancer. Two hundred and thirty-six (5.8%) received neo-adjuvant therapy prior to surgery (64 chemo-radiation, 103 radiation alone, 69 chemotherapy alone). The outcomes were compared to 3827 patients (94.2%) treated with surgery alone. Primary outcome was 30-d mortality, and secondary outcomes included length of stay, operative time and NSQIP measured postoperative complications.

RESULTS: Lung cancer patients who received preoperative treatment were younger (66 vs 69, P < 0.001), were more likely to have experienced recent weight loss (6.8% vs 3.5%; P = 0.011), to be active smokers (48.3 vs 34.9, P < 0.001), and had lower preoperative hematological cell counts (abnormal white blood cell: 25.6 vs 13.4; P < 0.001; low hematocrit 53% vs 17.3%, P < 0.001). On unadjusted analysis, neo-adjuvant patients had significantly higher 30-d mortality, overall and serious morbidity (all P < 0.001). Adjusted analysis showed similar findings, while matched cohorts comparison confirmed higher morbidity, but not higher early mortality.

CONCLUSION: Our data suggest that patients who receive neo-adjuvant therapy for lung cancer have worse early surgical outcomes. Although NSQIP does not provide stage information, this analysis shows important findings that should be considered when selecting patients for induction treatment.

Should multi-gene panel testing replace limited BRCA1/2 testing? A review of genetic testing for hereditary breast and ovarian cancers

Clinical testing of patients for hereditary breast and ovarian cancer syndromes began in the mid-1990s with the identification of the BRCA1 and BRCA2 genes. Since then, mutations in dozens of other genes have been correlated to increased breast, ovarian, and other cancer risk. The following decades of data collection and patient advocacy allowed for improvements in medical, legal, social, and ethical advances in genetic testing. Technological advances have made it possible to sequence multiple genes at once in a panel to give patients a more thorough evaluation of their personal cancer risk. Panel testing increases the detection of mutations that lead to increased risk of breast, ovarian, and other cancers and can better guide individualized screening measures compared to limited BRCA testing alone. At the same time, multi-gene panel testing is more time-and cost-efficient. While the clinical application of panel testing is in its infancy, many problems arise such as lack of guidelines for management of newly identified gene mutations, high rates of variants of uncertain significance, and limited ability to screen for some cancers. Through on-going concerted efforts of pooled data collection and analysis, it is likely that the benefits of multi-gene panel testing will outweigh the risks in the near future.

Patient handoffs in surgery: Successes, failures and room for improvement

Patient handoffs are transitions where communication failures may lead to errors in patient care. Face-to-face handoffs are preferred, however may not always be feasible. Different models and strategies have been described, yet there are few experimental studies. Expanding the problem, the on-call surgeon may be responsible for many patients, few or none that they admitted. Effective handoffs improve the quality of care and result in fewer errors. Herein we review different models of patient handoffs, comment on common pitfalls, and suggest areas for new research.

Review of intraoperative parathormone monitoring with the miami criterion: A 25-year experience

With the development of imaging and localization studies, focused parathyroidectomy with use of intraoperative parathormone monitoring (IPM) is the mainstay of treatment for primary hyperparathyroidism at many health care centers both nationally and internationally. Focused parathyroidectomy guided by IPM allows for surgical excision of the offending parathyroid gland through smaller incisions. The Miami criterion is a protocol that uses a “> 50% parathormone (PTH) drop” from either the greatest pre-incision or pre-excision measurement of PTH in a blood sample taken 10 min following resection of hyperfunctioning glands. Following removal of the hyperfunctioning parathyroid gland, a > 50% PTH drop at 10 min indicates completion of parathyroidectomy, and predicts operative success at 6 mo. IPM using the Miami criterion has demonstrated equal curative rates of > 97%, which is comparable to the traditional bilateral neck exploration. The focused approach, however, is associated with shorter recovery times, improved cosmesis, and lower risk of postoperative hypocalcemia.

Malignant melanoma in the pediatric population

Controversial pigmented lesions in children are a problem for pathologist, clinicians and families that are confronted with this dilemma. Some skin lesions in this population defy diagnosis with pathologists split between a benign diagnosis and a cancer diagnosis. Three cases of controversial pigmented lesions in the pediatric population are presented. Three patients underwent radical resection of the controversial pigmented lesion, intra-operative lymphatic mapping and sentinel lymph node (SLN) biopsy. Due to the low morbidity of the SLN procedure a case is made to perform lymphatic mapping in this clinical scenario. If the SLNs are negative, not much is lost except for the scar and this becomes another line of evidence that perhaps the original lesion was benign. If the SLN shows metastatic cells, then the original skin lesion must be malignant and the patient is offered stage III recommendations that would include complete node dissections and adjuvant Interferon therapy. This strategy provides for adequate treatment of the worse-case scenario, that the skin lesion is malignant. The cost to the patient is a low morbidity procedure, the SLN biopsy.

Are stapler line reinforcement materials necessary in sleeve gastrectomy?

AIM: To investigate the effect of staple line reinforcement materials on decreasing complications related to sleeve gastrectomy.

METHODS: In this retrospective study, we analyzed 84 patients who had sleeve gastrectomy due to obesity between April 2012 and April 2015. Sleeve gastrectomy procedure was performed in patients with a body mass index (BMI) more than 40 kg/m², and the ones with a BMI between 32 and 40 kg/m² in the presence of comorbid diseases. Reinforcement materials were used in 45 patients while they were not used in 39 patients. Materials such as Peristrip, 3/0 prolene, and V-lock were used for reinforcement in the reinforcement group (RG), and the materials used showed variations during the study period. The baseline characteristics, duration of surgery, hospital stay, comorbidities including hypertension, type 2 diabetes mellitus, hypertension, hepatosteatosis, gallstones, osteoarthritis, gastroesophageal reflux, sleep disorders, as well as the complications including leaks and bleeding after surgery were recorded and compared between the reinforcement and non-RGs (NRGs).

RESULTS: There were no differences between the reinforcement and NRGs for baseline characteristics including age (P = 0.689), gender (P = 0.057), height (P = 0.483), weight (P = 0.889), BMI (P = 0.971), hospital stay (P = 0.888), or duration of surgery (P = 0.229). The most common comorbidities in the RG were hypertension (24.4%) and hepatosteatosis (24.4%), while type 2 diabetes mellitus (28.2%) and hepatosteatosis (28.2%) were the most frequent comorbidities in the NRG. There were no differences between the reinforcement and NRGs for the rates of comorbidities (P > 0.05). Leak was observed in one (2.2%) patient in the RG, and there was leak in 2 (5.1%), and bleeding in 2 (5.1%) patients in the NRG. There were no differences between the reinforcement and NRGs for the rate of staple line leaks (P = 0.446) or bleeding (P = 0.213). One of the patients with leak died in the NRG while there were no deaths in the RG.

CONCLUSION: Although staple line reinforcement materials decreased morbidity and mortality, the differences between the two groups were not statistically significant.