The Use of Pre-Endoscopic Metoclopramide Does Not Prevent the Need for Repeat Endoscopy: A U.S. Based Retrospective Cohort Study

BACKGROUND

Peptic ulcer disease (PUD) can cause upper gastrointestinal bleeding (UGIB), often needing esophagogastroduodenoscopy (EGD). Second-look endoscopies verify resolution, but cost concerns prompt research on metoclopramide's efficacy compared to erythromycin.

METHODS

We analyzed the Diamond Network of TriNetX Research database, dividing UGIB patients with PUD undergoing EGD into three groups: metoclopramide, erythromycin, and no medication. Using 1:1 propensity score matching, we compared repeat EGD, post-EGD transfusion, and mortality within one month in two study arms.

RESULTS

Out of 97,040 patients, 11.5% received metoclopramide, 3.9% received erythromycin, and 84.6% received no medication. Comparing metoclopramide to no medication showed no significant difference in repeat EGD (10.1% vs. 9.7%, p = 0.34), transfusion (0.78% vs. 0.86%, p = 0.5), or mortality (1.08% vs. 1.08%, p = 0.95). However, metoclopramide had a higher repeat EGD rate compared to erythromycin (9.4% vs. 7.5%, p = 0.003), with no significant difference in transfusion or mortality.

CONCLUSIONS

The need to repeat EGD was not decreased with pre-EGD use of metoclopramide. If a prokinetic agent is to be used prior to EGD, erythromycin shows superior reduction in the need of repeat EGD as compared to metoclopramide.

Use of proton pump inhibitors improves outcomes in mild acute pancreatitis: A nationwide cohort study

Previous studies showed a potential anti-inflammatory effect of proton pump inhibitors (PPI) as well as possible inhibition of pancreatic secretion. This presents the question of their possible use in acute pancreatitis (AP). Current clinical evidence does not address the role of PPI and the present review for possible therapeutic use and safety is lacking. Therefore, our study aims to address the role of PPI in the management of AP and their association with the different outcomes of AP. We queried the Diamond Network through TriNetX-Research Network. This network included 92 healthcare organizations. Patients with mild AP with Bedside Index of Severity in Acute Pancreatitis (BISAP) score of Zero regardless of etiology were divided into 2 cohorts; 1st cohort included patients on PPI, and 2nd cohort included patients not on any PPI. Patients with BISAP score equal to or more than 1 or on PPI prior to the study date were excluded. Two well-matched cohorts were created using 1:1 propensity-scored matching model between cohorts. We compared the incidence of intensive care unit admission, mortality, and other associated complications. A total of 431,571 patients met the inclusion criteria. Of those, 32.9% (n = 142,062) were on PPI, and 67% (n = 289,509) were not on any PPI. After propensity matching, the sample included 115,630 patients on PPI vs 115,630 patients not on PPI. The PPI group had a lower rate of mortality (3.7% vs 4.4%, P < .001), a lower rate of intensive care unit admission (3.9% vs 5.5%, P < .001), a lower rate of necrotizing pancreatitis (1.1% vs 1.9%, P < .001), a lower rate of Hospital-Acquired Pneumonia (3.6% vs 4.9%, P < .001), a lower rate of respiratory failure (2.8% vs 4.2%, P < .001), and a lower rate of acute kidney injury (6.9% vs 10.1%, P < .001). There was no statistical difference in the rate of Clostridium difficile infection between the 2 cohorts (0.9% vs 0.8%, P = .5). The use of PPI in mild AP with a BISAP-score of zero is associated with reduced pancreatitis-related complications and improved mortality. Prospective studies are needed to confirm these findings.

Biliary Cyst: An Unusual Cause of Cholestasis Post Cholecystectomy

Biliary cysts are relatively uncommon and they can be congenital or acquired and can have various presentations such as cholelithiasis, cholangitis, jaundice, and pancreatitis. Biliary cysts are associated with a high risk of biliary cancers and such risk increases with age. Identification of biliary cysts warrants an aggressive approach to lower cancer risk. Surgical management has a high success rate and it lowers morbidity, mortality, and cancer risk. We present a 40-year-old female who had a cholecystectomy in 2016. She presented with obstructive jaundice and was found to have a class I biliary cyst. She underwent endoscopic retrograde cholangiopancreatography with stenting which led to complete resolution of her symptoms. Later, she underwent elective Roux-en-Y hepaticojejunostomy with cyst resection three months later. She underwent a successful recovery.

Acute Gallstone Pancreatitis in Pregnancy: A Multidisciplinary Approach

A common cause of gastrointestinal-related hospitalizations in the United States of America is acute pancreatitis (AP), with an annual incidence of up to 80 cases per 100,000 people. The incidence of AP in pregnancy varies and is approximately 1 in 1000 to 1 in 10,000 births due to the prevalence of obesity and gallstone-related conditions. Deciding on the timing of surgical intervention in acute biliary pancreatitis during pregnancy remains challenging, and there are no consensus recommendations. Gallstone pancreatitis has a high recurrence rate of up to 50% during the first trimester. A 30-year-old G3P2 at 34 weeks of gestation presented to the emergency room (ER) with recurrent intermittent sudden severe epigastric and right upper quadrant abdominal pain radiating to the back. She had no history of alcohol consumption, and lipid studies were normal on presentation. A right upper quadrant ultrasound scan showed cholelithiasis without signs of acute cholecystitis and a common bile duct diameter of 0.5 cm. However, her serum lipase level was 824, compared to normal levels on her previous ER visits. Other significant labs included elevated alkaline phosphatase (ALP) of 125 and mild transaminitis, with alanine transaminase (ALT) and aspartate aminotransferase (AST) levels of 84 and 57, respectively. She was admitted on account of suspected gallstone pancreatitis and was treated supportively with IV fluids and adequate pain control with opioids. A subsequent magnetic resonance cholangiopancreatography (MRCP) revealed no obvious choledocholithiasis. After consultation with the obstetrics, gastroenterology, and general surgery teams, it was decided to defer cholecystectomy until after delivery. The patient was induced at 36 weeks of gestation, and she had an uneventful vaginal delivery. Two weeks later, she had an elective laparoscopic cholecystectomy with no complications.

Intraoperative use of a tablet computer to aid rhinoplasty

Open septorhinoplasty enables excellent exposure to the structural components of the nasal tip. Nevertheless, it runs the risk of weakening its support mechanisms, which can lead to notable changes to tip projection and rotation as well as to the nasolabial angle. It is therefore paramount that the surgeon reconstructs the nose to the desired endpoint at the end of the operation. Currently, the gold standard of care in rhinoplasty uses preoperative photographs with the patient sitting or standing. However, this is not a true representation of the face in the operative position as the patient is placed supine and so gravity affects the appearance of the nose in a different way. Other factors such as head drapes and traction on the endotracheal tube can also cause subtle changes. We therefore advocate additional intraoperative profile view photographs to improve the accuracy of nasal tip positioning. In our department, in addition to standard preoperative photographs, immediate preoperative profile photos are taken with the patient supine, intubated and draped. Images are captured using a tablet computer at a distance of 1 meter from the patient. We ensure that the Frankfort plane is perpendicular to the floor. The picture is enlarged so that the image is full scale and the tablet is subsequently placed immediately behind the patient for direct comparison. This is then used during the procedure to check tip projection and rotation as well as at the end of the procedure following closure of the columellar incision to ensure correct placement of the nasal tip.

Estimation of tracheostomy tube cuff pressure by pilot balloon palpation

Two methods can be used to assess the intra-cuff pressure of tracheostomy tubes: digital palpation of the pilot balloon and use of a hand-held manometer. We conducted a telephone survey to determine the prevalence of both methods in intensive care units within 21 teaching hospitals across the United Kingdom. Forty-two per cent of the intensive care units surveyed used a protocol for monitoring cuff pressure with a manometer.A study to compare these two methods, using the manometer as the reference standard, was then carried out. The cuff pressure was correctly estimated in pre-inflated tracheostomy tubes, in a tracheal model, by 61 per cent of a cross-section of intensive care unit and otolaryngology staff.Using pilot balloon palpation is inaccurate and leaves a significant proportion of patients at risk of tracheal injury. We advocate the wider availability of hand-held pressure manometers in intensive care units and the institution of protocols for monitoring cuff pressure for any patient with a tracheostomy tube with an inflated cuff in situ.

Functional rhinoplasty with batten and spreader grafts for correction of internal nasal valve incompetence

OBJECTIVE

We a describe technique for correction of internal nasal valve incompetence (INVI) using functional rhinoplasty (FRP) with combined cartilaginous batten and spreader grafts and report the functional and cosmetic outcomes.

DESIGN

Prospective series using subjective improvement in nasal airway and quality of life.

SETTING

Subregional ENT centre, one operating rhinologist.

PARTICIPANTS

Twenty-three consecutive adults presenting to ENT department at North Hertfordshire NHS Trust with symptomatic INVI.

MAIN OUTCOMES MEASURES

Pre and post-operative symptom scores for nasal obstruction and its impact on overall quality of life using visual analogue scales (1-100mm). Cosmetic outcome graded using subjective scores. Statistical analysis performed using the Wilcoxon signed rank test.

RESULTS

We found a median subjective improvement on the visual analogue scale of 55 mm for nasal patency (p<0.001) and of 49 mm for quality of life (p<0.001). Twenty-two patients felt that the appearance of their nose had not changed or had significantly improved post operatively.

CONCLUSION

Combined use of batten and spreader grafts for the correction of INVI in normal or narrow nasal vaults is effective without compromising cosmesis.

How we do it: free conchal cartilage revisited for primary reconstruction of attic defects in combined approach tympanoplasty

Keypoints * There are concerns over the efficacy of free cartilage autografts in attic reconstruction (scutumplasty) for combined approach tympanoplasty (CAT). * Our operative technique uses free conchal cartilage autografts and an additional piece of conchal cartilage to buttress the reconstruction. * Of the 16 cases where this technique was used, there were two cases (13%) of failure of the attic reconstruction and a keratin pearl (residual disease) in one case (6%). This compares favourably with comparable series using a variety of reconstruction techniques.

Short-term persistence of carcinoma of the uterine cervix after radiation. An indicator of long-term prognosis

Between 1959 and 1980, 590 evaluable patients received a full course of radiation therapy as primary treatment of invasive epidermoid carcinoma of the cervix. At follow-up visits conducted between 1 and 3 months after the completion of radiation, 72 patients had physical or biopsy findings indicative of persistent disease (PER), whereas an additional 36 had findings suggestive of tumor (SUS). The remaining 482 demonstrated a complete response (CR) by 1 month after the administration of treatment. The lower the stage, the more likely was a CR by 3 months (Stage I, 94.4%; Stage II, 86.2%; Stage III, 62.7%). A higher proportion of CR was obtained in patients with tumor of less than 5 cm in diameter than in those with tumors greater than 5 cm in diameter (82.4% versus 76.3%, respectively; 0.1 greater than P greater than 0.05). CR patients enjoyed a marked survival advantage over those with PER, whereas women with SUS demonstrated intermediate 5-year survival (76.0%, 41.5%, and 7.4%, respectively; P less than 0.0001). The same survival gradient of CR greater than SUS greater than PER was demonstrated when tumors of each stage were analyzed separately. There was no difference in survival between patients with PER or SUS at 1 month and those with PER or SUS at 3 months. The proportion of recurrent tumors diagnosed as exclusively distant metastases decreased from CR to SUS to PER. Analysis of dosimetry data suggests that the likelihood of CR was not a function of treatment variability. It was concluded that tumors that do not regress promptly are likely to recur, most with distant metastases. Such poor-prognosis patients should be targeted for early adjuvant or salvage therapy.