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Sakpal SV, Holbeck MJ, Wade A, Singh K, Singal AK. Telemedicine in alcohol liver disease and transplantation care: Addiction therapy through video-conferencing-A case report. SAGE Open Med Case Rep 2024; 12:2050313X241235012. [PMID: 38410692 PMCID: PMC10896062 DOI: 10.1177/2050313x241235012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 02/07/2024] [Indexed: 02/28/2024] Open
Abstract
Alcohol use disorder is a major public health concern, contributing to significant morbidity and mortality worldwide. Alcohol-associated liver disease is a major consequence of alcohol use disorder, with liver transplantation becoming the leading indication for this condition. This abstract describes a case study of a 39-year-old Native American man with severe alcohol-associated liver disease, illustrating the challenges and solutions in providing comprehensive care in a remote location. The patient's treatment involved a multidisciplinary approach, combining hepatology, addiction therapy, and telemedicine services. Despite initial difficulties, the patient achieved complete abstinence and significant improvement in liver function, avoiding the need for transplantation. This case highlights the importance of interdisciplinary care and the potential of telemedicine for managing complex cases of alcohol-associated liver disease and alcohol use disorder in remote areas, ultimately improving patient outcomes and reducing healthcare burdens.
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Affiliation(s)
- Sujit Vijay Sakpal
- Avera Transplant Institute, Avera McKennan Hospital and University Health Center, Sioux Falls, SD, USA
- Department of Surgery, University of South Dakota, Sioux Falls, SD, USA
- Department of Internal Medicine, University of South Dakota, Sioux Falls, SD, USA
| | - Malia J Holbeck
- Avera Behavioral Health Services, Addiction Recovery Program, Sioux Falls, SD, USA
| | - Ann Wade
- Avera Transplant Institute, Avera McKennan Hospital and University Health Center, Sioux Falls, SD, USA
| | - Kushagra Singh
- Department of Biology and Microbiology, South Dakota State University, Brookings, SD, USA
| | - Ashwani K Singal
- Avera Transplant Institute, Avera McKennan Hospital and University Health Center, Sioux Falls, SD, USA
- Department of Internal Medicine, University of South Dakota, Sioux Falls, SD, USA
- VA Medical Center, Sioux Falls, SD, USA
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Saucedo-Crespo H, Myrmoe A, Hardie K, Uzunlar S, Sakpal SV, Auvenshine C. Combined antegrade-retrograde cystourethroscopic rendezvous procedure for the management of a severe urethral stricture during kidney transplantation: A case report. Int J Surg Case Rep 2023; 112:108992. [PMID: 37898006 PMCID: PMC10667880 DOI: 10.1016/j.ijscr.2023.108992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/12/2023] [Accepted: 10/21/2023] [Indexed: 10/30/2023] Open
Abstract
INTRODUCTION External bladder drainage with an indwelling transurethral catheter is standard during kidney transplant. Difficult Foley catheter placement is a frequent problem and one of the most common reasons for intraoperative urology consults. Suprapubic catheters are usually placed if retrograde urologic instrumentation options fail to cross the urethral obstruction. We report an alternative option with an antegrade-retrograde endoscopic approach. PRESENTATION OF CASE This case illustrates a urethral rendezvous procedure applied successfully to traverse an occult mid-urethral stricture for Foley catheter placement during kidney transplantation in a 69-year-old diabetic man with end-stage renal disease and anuria. DISCUSSION The combined antegrade-retrograde rendezvous techniques have largely been described in the treatment of complex ureteric strictures more so than urethral strictures. This technique has not been described in the setting of a complex urethral stricture encountered during kidney transplantation. After utilization of the urinary tract rendezvous technique during kidney transplantation, our patient experienced an uneventful post-operative course with excellent renal allograft function. CONCLUSION The combined antegrade-retrograde urinary tract rendezvous technique is a feasible and safe technique that can help manage occult severe urethral strictures found at the time of kidney transplantation instead of suprapubic catheter placement when retrograde urologic instrumentation options fail to cross the obstruction.
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Affiliation(s)
- Hector Saucedo-Crespo
- Avera McKennan Hospital & University Health Center: Avera Medical Group Transplant & Liver Surgery, Sioux Falls, SD, USA; Department of Surgery, University of South Dakota: Sanford School of Medicine, Sioux Falls, SD, USA.
| | - Anna Myrmoe
- Sanford School of Medicine: University of South Dakota, Sioux Falls, SD, USA
| | - Kyler Hardie
- Sanford School of Medicine: University of South Dakota, Sioux Falls, SD, USA
| | - Sena Uzunlar
- Sanford School of Medicine: University of South Dakota, Sioux Falls, SD, USA
| | - Sujit Vijay Sakpal
- Avera McKennan Hospital & University Health Center: Avera Medical Group Transplant & Liver Surgery, Sioux Falls, SD, USA; Department of Surgery, University of South Dakota: Sanford School of Medicine, Sioux Falls, SD, USA; Department of Internal Medicine, University of South Dakota: Sanford School of Medicine, Sioux Falls, SD, USA
| | - Christopher Auvenshine
- Avera McKennan Hospital & University Health Center: Avera Medical Group Transplant & Liver Surgery, Sioux Falls, SD, USA; Department of Surgery, University of South Dakota: Sanford School of Medicine, Sioux Falls, SD, USA
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Sakpal SV, Hardie K, Peters E, Saucedo-Crespo H. "Triple V-Plasty": Creation of a Single Orifice for Three Renal Arteries in Live-Donor Transplantation. Transplant Proc 2023; 55:1900-1902. [PMID: 37479542 DOI: 10.1016/j.transproceed.2023.03.094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 03/30/2023] [Indexed: 07/23/2023]
Abstract
BACKGROUND Donor renovascular anatomic variations can hinder renal transplantation (RT), especially from live donors. Back-table vascular reconstruction can be effective in the use of renal allografts with multiple renal arteries (RAs), helping to expand the pool of live donors. SURGICAL TECHNIQUE Sequential V-plasty of 3 donor RAs using fine, non-absorbable, monofilament (7-0 or 8-0 polypropylene) suture in an uninterrupted fashion successfully enabled the creation of a single, wide ostium for anastomosis with the target inflow recipient artery. RESULTS Creation of a single ostium for 3 RAs was successfully performed on a 31-year-old man during a live-donor left RT, resulting in good inflow and outflow with arterial and venous anastomoses, respectively, at graft implantation. Excellent postoperative allograft perfusion was achieved, and the patient continued to have normal allograft function at >1 year post-transplantation. CONCLUSIONS Novel ex vivo renovascular reconstruction potentiates expansion of live-donor RT successfully despite variant renovascular anatomy.
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Affiliation(s)
- Sujit Vijay Sakpal
- Avera McKennan Hospital & University Health Center: Avera Medical Group Transplant & Liver Surgery, Sioux Falls, South Dakota; Department of Surgery, University of South Dakota: Sanford School of Medicine, Sioux Falls, South Dakota; Department of Internal Medicine, University of South Dakota: Sanford School of Medicine, Sioux Falls, South Dakota.
| | - Kyler Hardie
- Sanford School of Medicine: University of South Dakota, Sioux Falls, South Dakota
| | - Eliza Peters
- Department of Biology & Microbiology, South Dakota State University, Brookings, South Dakota
| | - Hector Saucedo-Crespo
- Avera McKennan Hospital & University Health Center: Avera Medical Group Transplant & Liver Surgery, Sioux Falls, South Dakota; Department of Surgery, University of South Dakota: Sanford School of Medicine, Sioux Falls, South Dakota
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Hardie K, Peters E, Saucedo-Crespo H, Sakpal SV. Triple V-plasty: Novel Renovascular Reconstruction Technique in Live-Donor Transplantation. S D Med 2022; 75:s23. [PMID: 36745997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
INTRODUCTION Donor renovascular anomalies, including multiplicity, length and caliber of blood vessels, could hinder renal transplantation, especially from live-donors. However, meticulous back-bench vascular reconstruction ascertaining orientation and patency of individual vessels can be effective in utilization of renal grafts with multiple renal arteries, helping to expand the pool of live-donors. SURGICAL TECHNIQUE Sequential v-plasty of individual donor renal arteries using fine, non-absorbable, monofilament (7-0 or 8-0 Prolene) suture in an uninterrupted fashion enables creation of a single, wide ostium for anastomosis with the target, inflow recipient (usually external or common iliac) artery. Additionally, entwined donor hilar renovasculature may necessitate incisional separation and re-anastomosis of a bifid vein for proper renovascular orientation following graft implantation in the recipient. CONCLUSION Application of never-before described ex vivo renovascular reconstruction led to live-donor renal transplantation between two pairs of donor-recipient through the National Kidney Registry with successful long-term outcomes.
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Affiliation(s)
- Kyler Hardie
- University of South Dakota Sanford School of Medicine
| | - Eliza Peters
- University of South Dakota Sanford School of Medicine
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Vierhout T, Saucedo-Crespo H, Auvenshine C, Sakpal SV. Pledgeted plication: A novel technique to treat dialysis access-related steal syndrome. SAGE Open Med Case Rep 2022; 10:2050313X221083513. [PMID: 35308056 PMCID: PMC8928356 DOI: 10.1177/2050313x221083513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 02/07/2022] [Indexed: 12/04/2022] Open
Abstract
Steal syndrome is a potential complication of surgically created arteriovenous fistulas that can result in sensory and/or motor deficits, or tissue loss in the affected limb. Several surgical techniques have been developed to treat steal syndrome, but all have potential drawbacks. We detail a novel, modified plication technique which involves sequential, longitudinal application of pledgets along the venous outflow to gradually narrow it, and consequently decrease flow. Its potential benefits include protection of the vein from bare suture, less turbulent flow, and thus lower risk of thrombosis. Implementation of this technique in two patients resulted in symptomatic relief and continuation of uninterrupted hemodialysis at 9- and 12-month follow-up, respectively.
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Affiliation(s)
- Thomas Vierhout
- Sanford School of Medicine, University of South Dakota, Sioux Falls, SD, USA
| | - Hector Saucedo-Crespo
- Avera McKennan Hospital & University Health Center, Avera Medical Group Transplant & Liver Surgery, Sioux Falls, SD, USA
- Department of Surgery, University of South Dakota, Sioux Falls, SD, USA
| | - Christopher Auvenshine
- Avera McKennan Hospital & University Health Center, Avera Medical Group Transplant & Liver Surgery, Sioux Falls, SD, USA
- Department of Surgery, University of South Dakota, Sioux Falls, SD, USA
| | - Sujit Vijay Sakpal
- Avera McKennan Hospital & University Health Center, Avera Medical Group Transplant & Liver Surgery, Sioux Falls, SD, USA
- Department of Surgery, University of South Dakota, Sioux Falls, SD, USA
- Department of Internal Medicine, University of South Dakota, Sioux Falls, SD, USA
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Ness C, Saucedo‐Crespo H, Auvenshine C, Steers J, Sakpal SV. Eyes Tell All. Clin Liver Dis (Hoboken) 2021; 17:383-387. [PMID: 34386199 PMCID: PMC8340317 DOI: 10.1002/cld.1065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 09/15/2020] [Accepted: 10/25/2020] [Indexed: 02/04/2023] Open
Affiliation(s)
- Cody Ness
- Department of SurgeryUniversity of South DakotaSanford School of MedicineSioux FallsSD
| | - Hector Saucedo‐Crespo
- Department of SurgeryUniversity of South DakotaSanford School of MedicineSioux FallsSD,Avera Medical Group Transplant & Liver SurgeryAvera McKennan Hospital & University Health CenterSioux FallsSD
| | - Christopher Auvenshine
- Department of SurgeryUniversity of South DakotaSanford School of MedicineSioux FallsSD,Avera Medical Group Transplant & Liver SurgeryAvera McKennan Hospital & University Health CenterSioux FallsSD
| | - Jeffery Steers
- Avera Medical Group Transplant & Liver SurgeryAvera McKennan Hospital & University Health CenterSioux FallsSD
| | - Sujit Vijay Sakpal
- Department of SurgeryUniversity of South DakotaSanford School of MedicineSioux FallsSD,Avera Medical Group Transplant & Liver SurgeryAvera McKennan Hospital & University Health CenterSioux FallsSD,Department of Internal MedicineUniversity of South DakotaSanford School of MedicineSioux FallsSD
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Sakpal SV, Donahue S, Ness C, Santella RN. Kidney Transplantation in Native Americans: Time to Explore, Expel Disparity. J Health Care Poor Underserved 2021; 31:1044-1049. [PMID: 33416678 DOI: 10.1353/hpu.2020.0078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Native Americans/American Indians (NA/AI) are perhaps the most disadvantaged population in the United States due to poverty, geographic isolation, and poor health care. The prevalence of diabetes mellitus and end-stage renal disease in NA/AI is higher compared with other racial/ethnic groups. Thus, a higher rate of kidney transplantation (KT) candidacy evaluation, wait-listing, and actual transplantation would be expected among NA/AI. However, KT is an underutilized life-saving therapy in this population. Half of the 20 poorest counties in the U.S. are within NA/AI reservations. Native Americans/American Indians residing on reservations are often isolated hundreds of miles from the nearest transplant center. Additionally, factors such as poor health literacy, distrust, and substance abuse contribute to low KT rates. However, collaboration between transplant centers and Indian Health Services, use of telemedicine, constructing socioculturally-competent educational strategies, and maintaining confidence-building measures to bridge the gap, create trust, and maintain patient autonomy could improve outcomes in this population.
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Sakpal SV, Donahue S, Ness C, Saucedo-Crespo H, Auvenshine C, Steers J, Santella RN. Kidney Transplantation in United States Native Americans: Breaking Barriers. S D Med 2021; 74:21-27. [PMID: 33691053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Advances in the field of solid-organ transplantation (SOT), namely evolution of surgical techniques, developments in immunosuppressive therapies and efforts to maximize utilization of donor allografts (deceased and living), have resulted in growing numbers of SOT performed annually in the United States (U.S.) (36,529 total organs and 21,167 kidneys transplanted in 2018). However, the Native American/American Indian (NA/AI) people of the U.S. experience enormous socioeconomic barriers such as poverty, lack of adequate healthcare, poor health literacy and geographic isolation which limit access to SOT resulting in low rates of organ donation and transplantation, poor quality of life and shorter life expectancy. The NA/AI population is at increased risk for end-stage renal disease secondary to the high prevalence of diabetes mellitus. We review existing challenges to kidney transplantation in NA/AI patients and discuss potential solutions which could improve equitable delivery of specialized healthcare to this underprivileged population.
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Affiliation(s)
- Sujit Vijay Sakpal
- Avera McKennan Hospital and University Health Center, Avera Medical Group Transplant and Liver Surgery, Sioux Falls, South Dakota
- Department of Surgery and Department of Internal Medicine, University of South Dakota, Sanford School of Medicine, Sioux Falls, South Dakota
| | - Steven Donahue
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska
| | - Cody Ness
- Department of Surgery, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota
| | - Hector Saucedo-Crespo
- Avera McKennan Hospital and University Health Center, Avera Medical Group Transplant and Liver Surgery, Sioux Falls, South Dakota
- Department of Surgery, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota
| | - Christopher Auvenshine
- Avera McKennan Hospital and University Health Center, Avera Medical Group Transplant and Liver Surgery, Sioux Falls, South Dakota
- Department of Surgery, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota
| | - Jeffery Steers
- Avera McKennan Hospital and University Health Center, Avera Medical Group Transplant and Liver Surgery, Sioux Falls, South Dakota
- Department of Surgery, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota
| | - Robert N Santella
- Department of Internal Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota
- Avera McKennan Hospital and University Health Center, Avera Medical Group Transplant Nephrology, Sioux Falls, South Dakota
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Affiliation(s)
- Cody Ness
- Department of Surgery, University of South Dakota: Sanford School of Medicine, 1400 W 22nd St, Sioux Falls, South Dakota 57105
| | - Sujit Vijay Sakpal
- Department of Surgery, University of South Dakota: Sanford School of Medicine, 1400 W 22nd St, Sioux Falls, South Dakota 57105; Avera McKennan Hospital & University Health Center: Avera Medical Group Transplant & Liver Surgery, 1315 S Cliff Ave. Plaza 3 Suite 1100, Sioux Falls, South Dakota 57105; Department of Internal Medicine, University of South Dakota: Sanford School of Medicine, 1400 W 22nd St, Sioux Falls, South Dakota 57105.
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Saucedo-Crespo H, Sakpal SV, Auvenshine C, Santella RN, Nazir J, Prouse B, Mehta T, Steers J. Early Cardiopulmonary Cryptococcus neoformans Infection After Liver Transplant: A Case Report. Transplant Proc 2020; 52:2790-2794. [PMID: 32641222 DOI: 10.1016/j.transproceed.2020.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 06/04/2020] [Indexed: 10/23/2022]
Abstract
Cryptococcal infection (CI) is an uncommon fungal disease that poses a particular fatal risk to liver transplant (LT) recipients because of the potential rapid development and dissemination of the disease. Depending on the pathophysiology, CI may manifest with a wide range of clinical presentations that may delay early diagnosis and timely treatment. Additionally, most anticryptococcal therapies may threaten LT recipients owing to the associated hepatotoxicity of these medications. We report a case of a 25-year-old woman who received an LT for cryptogenic cirrhosis and developed rapidly progressive CI with pulmonary, myocardial, and cerebral involvement within a month of transplantation. She presented with severe pulmonary hypertension refractory to medical management and subsequently died despite our efforts. Herein, we review the etiology of cryptococcosis, the natural history of cryptococcal disease, and standard treatments for CI, and we highlight peculiarities of Cryptococcus neoformans infection in solid organ transplant recipients.
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Affiliation(s)
- Hector Saucedo-Crespo
- Avera Medical Group Transplant & Liver Surgery, Avera McKennan Hospital & University Health Center, Sioux Falls, South Dakota; Department of Surgery, Sanford School of Medicine, University of South Dakota, Sioux Falls, South Dakota.
| | - Sujit Vijay Sakpal
- Avera Medical Group Transplant & Liver Surgery, Avera McKennan Hospital & University Health Center, Sioux Falls, South Dakota; Department of Surgery, Sanford School of Medicine, University of South Dakota, Sioux Falls, South Dakota; Department of Internal Medicine, Sanford School of Medicine, University of South Dakota, Sioux Falls, South Dakota
| | - Christopher Auvenshine
- Avera Medical Group Transplant & Liver Surgery, Avera McKennan Hospital & University Health Center, Sioux Falls, South Dakota; Department of Surgery, Sanford School of Medicine, University of South Dakota, Sioux Falls, South Dakota
| | - Robert N Santella
- Avera Medical Group Transplant & Liver Surgery, Avera McKennan Hospital & University Health Center, Sioux Falls, South Dakota; Department of Internal Medicine, Sanford School of Medicine, University of South Dakota, Sioux Falls, South Dakota
| | - Jawad Nazir
- Department of Infectious Diseases, Avera McKennan Hospital & University Health Center, Sioux Falls, South Dakota
| | - Bruce Prouse
- Department of Pathology, Avera McKennan Hospital & University Health Center, Sioux Falls, South Dakota
| | - Tej Mehta
- Department of Interventional Radiology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Jeffery Steers
- Avera Medical Group Transplant & Liver Surgery, Avera McKennan Hospital & University Health Center, Sioux Falls, South Dakota; Department of Surgery, Sanford School of Medicine, University of South Dakota, Sioux Falls, South Dakota
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Saucedo-Crespo H, Roach E, Sakpal SV, Auvenshine C, Steers J. Spontaneous Chylous Ascites After Liver Transplantation Secondary to Everolimus: A Case Report. Transplant Proc 2020; 52:638-640. [PMID: 32029315 DOI: 10.1016/j.transproceed.2019.10.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 10/06/2019] [Indexed: 11/28/2022]
Abstract
Chylous ascites (CA) is an uncommon entity with several etiologies. Only a few cases of CA have been reported as a complication after liver transplantation (LT). Most of these cases occurred within 1 month after surgery and typically resulted from traumatic intraoperative injury leading to disruption of lymphatics. Although peripheral lymphedema has been frequently correlated with use of calcineurin inhibitors, associated spontaneous CA has only been reported in a few cases after renal transplantation. We report a case of delayed spontaneous CA after LT caused by the use of the mammalian target of rapamycin (mTOR) inhibitor everolimus. Everolimus was introduced in our patient early after transplantation because of tacrolimus-induced microangiopathy, and years later the patient presented with spontaneous CA. After excluding other causes of CA, everolimus was discontinued, and immunosuppression was maintained by increasing prednisone and continuing mycophenolate mofetil. Additionally, the patient was treated with percutaneous drain placement and began a low-fat, high-protein diet. One month later the patient had complete resolution of symptoms with no recurrence of ascites. To our knowledge, this is the first case of delayed-onset CA caused by everolimus after LT.
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Affiliation(s)
- Hector Saucedo-Crespo
- Avera McKennan Hospital & University Health Center, Avera Medical Group Transplant and Liver Surgery, Sioux Falls, South Dakota; Department of Surgery, University of South Dakota, Sanford School of Medicine, Sioux Falls, South Dakota.
| | - Eric Roach
- University of South Dakota, Sanford School of Medicine, Sioux Falls, South Dakota
| | - Sujit Vijay Sakpal
- Avera McKennan Hospital & University Health Center, Avera Medical Group Transplant and Liver Surgery, Sioux Falls, South Dakota; Department of Surgery, University of South Dakota, Sanford School of Medicine, Sioux Falls, South Dakota; Department of Internal Medicine, University of South Dakota, Sanford School of Medicine, Sioux Falls, South Dakota
| | - Christopher Auvenshine
- Avera McKennan Hospital & University Health Center, Avera Medical Group Transplant and Liver Surgery, Sioux Falls, South Dakota; Department of Surgery, University of South Dakota, Sanford School of Medicine, Sioux Falls, South Dakota
| | - Jeffery Steers
- Avera McKennan Hospital & University Health Center, Avera Medical Group Transplant and Liver Surgery, Sioux Falls, South Dakota
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Sakpal SV, Reedstrom H, Ness C, Klinkhammer T, Saucedo-Crespo H, Auvenshine C, Santella RN, Steers J. High-dose hydroxocobalamin in end-stage liver disease and liver transplantation. Drugs Ther Perspect 2019; 35:442-446. [PMID: 32288505 PMCID: PMC7102271 DOI: 10.1007/s40267-019-00643-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Distributive shock is a serious complication in patients with chronic or end-stage liver disease, and can be exacerbated by vasoplegia in this patient population. Vasoplegic syndrome (VS) is a state of shock refractory to catecholamines and vasopressin that is often multifactorial in liver failure patients, and can occur in any phase of liver transplantation (LT) [i.e., pre-transplantation, intraoperative, and post-transplantation]. Methylene blue (MB) has been a well-established pharmacologic therapy for VS. However, it has been known to cause dose-related toxicity. Hydroxocobalamin (HXC) is not currently FDA approved for the management of VS, but studies have demonstrated its ability to cause an increase in systolic blood pressure by hypothesized mechanisms with only minimal side effects. To date, only three other reports have demonstrated the use of HXC in LT patients, which highlighted its use both intraoperatively and post-transplantation. Our report illustrates the utility of HXC in four LT patients with VS. Two of these cases illustrate the usefulness of HXC in the pre-transplantation period, which has never been previously reported. HXC is a useful pharmaceutical agent in the management of VS, especially if contraindications to MB exist or in cases of MB-resistant vasoplegia. Further studies with large sample sizes are necessary to ascertain the optimal dosage of HXC in LT patients.
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Affiliation(s)
- Sujit Vijay Sakpal
- 1Avera McKennan Hospital & University Health Center, Avera Medical Group Transplant & Liver Surgery, Plaza 3, 1315 S. Cliff Ave. Suite 1100, Sioux Falls, SD 57105 USA.,2Department of Surgery, University of South Dakota-Sanford School of Medicine, Sioux Falls, SD USA.,3Department of Internal Medicine, University of South Dakota-Sanford School of Medicine, Sioux Falls, SD USA
| | - Hannah Reedstrom
- 4Department of Pharmacy, Avera McKennan Hospital & University Health Center, Sioux Falls, SD USA
| | - Cody Ness
- 2Department of Surgery, University of South Dakota-Sanford School of Medicine, Sioux Falls, SD USA
| | - Tobin Klinkhammer
- 4Department of Pharmacy, Avera McKennan Hospital & University Health Center, Sioux Falls, SD USA
| | - Hector Saucedo-Crespo
- 1Avera McKennan Hospital & University Health Center, Avera Medical Group Transplant & Liver Surgery, Plaza 3, 1315 S. Cliff Ave. Suite 1100, Sioux Falls, SD 57105 USA.,2Department of Surgery, University of South Dakota-Sanford School of Medicine, Sioux Falls, SD USA
| | - Christopher Auvenshine
- 1Avera McKennan Hospital & University Health Center, Avera Medical Group Transplant & Liver Surgery, Plaza 3, 1315 S. Cliff Ave. Suite 1100, Sioux Falls, SD 57105 USA.,2Department of Surgery, University of South Dakota-Sanford School of Medicine, Sioux Falls, SD USA
| | - Robert N Santella
- 1Avera McKennan Hospital & University Health Center, Avera Medical Group Transplant & Liver Surgery, Plaza 3, 1315 S. Cliff Ave. Suite 1100, Sioux Falls, SD 57105 USA.,3Department of Internal Medicine, University of South Dakota-Sanford School of Medicine, Sioux Falls, SD USA
| | - Jeffery Steers
- 1Avera McKennan Hospital & University Health Center, Avera Medical Group Transplant & Liver Surgery, Plaza 3, 1315 S. Cliff Ave. Suite 1100, Sioux Falls, SD 57105 USA
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Sakpal SV, Donahue S, Crespo HS, Auvenshine C, Agarwal SK, Nazir J, Santella RN, Steers J. Utility of fiber-optic bronchoscopy in pulmonary infections among abdominal solid-organ transplant patients: A comprehensive review. Respir Med 2018; 146:81-86. [PMID: 30665523 DOI: 10.1016/j.rmed.2018.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 11/28/2018] [Accepted: 12/09/2018] [Indexed: 10/27/2022]
Abstract
Pulmonary infections are frequent complications in abdominal solid-organ transplantation (aSOT) which may threaten patient and allograft survival. Accurate diagnosis and treatment of pulmonary infections in this population can be challenging. Immunosuppressive therapy not only increases the risk of acquiring opportunistic and non-opportunistic infections, but it also impairs the inflammatory responses associated with microbial invasion which in an otherwise normal host produce clinical and radiologic responses that allow for early identification of the offending pathogen. Serologic testing is not a reliable diagnostic modality. Direct microbiological sampling is often necessary to make a definitive diagnosis early in the clinical course to optimize timely, targeted therapy while reducing the risk of developing antimicrobial resistance, and minimize adverse effects of therapy, if any. Fiber-optic bronchoscopy (FOB) with bronchoalveolar lavage (BAL) or transbronchial lung biopsy (TBB) offers such diagnostic advantage and possesses a potential therapeutic value too. This comprehensive review discusses the potential benefits of FOB alongside its risks and complications, indications and contraindications, and techniques. Additionally, the essay highlights FOB's utility and yield specifically with regard to type and timing of infections in aSOT patients.
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Affiliation(s)
- Sujit Vijay Sakpal
- Avera McKennan Hospital & University Health Center: Avera Medical Group Transplant & Liver Surgery, Sioux Falls, SD, USA; Department of Surgery, University of South Dakota, Sanford School of Medicine, Sioux Falls, SD, USA; Department of Internal Medicine, University of South Dakota, Sanford School of Medicine, Sioux Falls, SD, USA.
| | - Steven Donahue
- Department of Surgery, University of South Dakota, Sanford School of Medicine, Sioux Falls, SD, USA
| | - Hector Saucedo Crespo
- Avera McKennan Hospital & University Health Center: Avera Medical Group Transplant & Liver Surgery, Sioux Falls, SD, USA; Department of Surgery, University of South Dakota, Sanford School of Medicine, Sioux Falls, SD, USA
| | - Christopher Auvenshine
- Avera McKennan Hospital & University Health Center: Avera Medical Group Transplant & Liver Surgery, Sioux Falls, SD, USA; Department of Surgery, University of South Dakota, Sanford School of Medicine, Sioux Falls, SD, USA
| | - Suresh Kumar Agarwal
- Division of Acute Care, Trauma, Surgical Critical Care, Department of Surgery, Duke University, Durham, NC, USA
| | - Jawad Nazir
- Avera McKennan Hospital & University Health Center: Avera Medical Group Transplant & Liver Surgery, Sioux Falls, SD, USA
| | - Robert N Santella
- Avera McKennan Hospital & University Health Center: Avera Medical Group Transplant & Liver Surgery, Sioux Falls, SD, USA; Department of Internal Medicine, University of South Dakota, Sanford School of Medicine, Sioux Falls, SD, USA
| | - Jeffery Steers
- Avera McKennan Hospital & University Health Center: Avera Medical Group Transplant & Liver Surgery, Sioux Falls, SD, USA
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Maharaj R, Shukla PJ, Sakpal SV, Naraynsingh V, Dan D, Hariharan S. The impact of hereditary colorectal cancer on the Indian population. Indian J Cancer 2014; 51:538-41. [PMID: 26842188 DOI: 10.4103/0019-509x.175307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUTION The incidence of colorectal cancer in India is lower compared to the Western world. In Western countries, most cases of colorectal cancer are sporadic and the hereditary variety accounts for only 10-15% of all cases. The aim of the present review is to determine the clinical and epidemiological characteristics of hereditary colorectal cancer in India. MATERIALS AND METHODS A Medline search was conducted to review the literature published from India regarding colorectal cancer. The keywords used included India, colorectal cancer, hereditary nonpolyposis, and familial adenomatous polyposis. All relevant articles were reviewed and the characteristic features of this disease in Indian population were collated and presented. RESULTS Literature search revealed eighty two articles pertinent to India, of which only ten articles had relevant information on hereditary cancers. Although the overall incidence of colorectal cancer was low in both genders, there were a high proportion of patients developing colorectal cancer before the age of 45 years. Additionally, there was a higher proportion (10-15%) of hereditary nonpolyposis colorectal cancer cases, as confirmed by microsatellite instability. CONCLUSION The overall incidence of colorectal cancer is low in India. There is a tendency to affect a relatively younger age group, and we infer that the incidence of hereditary colorectal cancer is high and is similar to the Western countries.
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Affiliation(s)
- R Maharaj
- Department of Surgical Oncology, Gastrointestinal Service, Tata Memorial Hospital, Mumbai, Maharashtra, India
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Sakpal SV, Bindra SS, Chamberlain RS. Laparoscopic appendectomy conversion rates two decades later: an analysis of surgeon and patient-specific factors resulting in open conversion. J Surg Res 2011; 176:42-9. [PMID: 21962732 DOI: 10.1016/j.jss.2011.07.019] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Revised: 06/13/2011] [Accepted: 07/11/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND The role of laparoscopy in appendicitis has gained increased popularity but remains controversial. Despite more than 20 y of experience in laparoscopy, the nationwide laparoscopic appendectomy (LA) conversion rate is reportedly 8.6%. We sought to analyze the impact of patient-specific and surgeon-specific factors that may contribute to open conversion during LA. MATERIALS AND METHODS A retrospective analysis of 745 LAs (49.9% females and 50.1% males; average age of 37.8 y performed at a large tertiary community teaching hospital over a 5-y period (May 2004-October 2008) was performed. RESULTS The overall conversion rate for the study period was 4.16% (n = 31). The most common reason for open conversion was severe acute inflammation (38.7%). Among converted cases, 77.42% had no prior abdominal surgery and only 25.81% of cases were converted due to adhesions. Females and patients ≥ 65-y-old had a higher likelihood of open conversion (4.30% versus 4.02%, P < 0.99 and 9.26% versus 3.76%, P < 0.1107). The overall conversion rate of cases performed by high-volume surgeons (≥ 50 total cases) in comparison to low-volume surgeons (10-49 total cases) was higher (4.86% versus 3.30%, P < 0.39). Conversion rates were lower among surgeons who completed residency training after 1990 (3.72% versus 4.35%, P < 0.82) and those with fellowship training (1.42% versus 5.18%, P < 0.034). CONCLUSIONS Laparoscopic conversion continues to gain popularity and remains the gold standard procedure for appendectomy. Older patients have a higher likelihood of conversion with severe acute inflammation being the most common reason for conversion. Additional minimally invasive fellowship training was the only surgeon-specific factor that significantly impacted conversion rate.
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Affiliation(s)
- Sujit Vijay Sakpal
- Department of Surgery, Saint Barnabas Medical Center, Livingston, New Jersey 07039, USA
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Shukla PJ, Sakpal SV, Maharaj R. Does pancreatic ductal anatomy play a role in determining outcomes of pancreatic anastomoses? Med Hypotheses 2010; 76:230-3. [PMID: 21071153 DOI: 10.1016/j.mehy.2010.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2010] [Revised: 09/14/2010] [Accepted: 10/08/2010] [Indexed: 10/18/2022]
Abstract
Pancreatoduodenectomy (PD) is the surgical procedure performed for cancers of the head of the pancreas. Despite a substantial reduction in mortality rates following PD, morbidity remains high secondary to major post-operative complications. Post-operative pancreatic fistula (POPF), the commonest major complication following PD, results from the failure of the pancreato-enteric anastomosis. There appears to be a correlation between intrinsic pancreatic features like the texture of the gland and duct size and the outcome of the pancreatic anastomosis. Based on current clinical research data, we propose a new hypothesis called the "pancreatic ductal anatomy" concept. We hypothesize that morphological variations, anomalies or aberrations of the main pancreatic duct play a role in the outcome of the pancreatic anastomosis, irrespective of its type. The consequence of aberrant ductal anatomy is that certain areas of the remnant pancreas remain either undrained or partially drained, or have blocked ductules/ducts. This results in localized obstructive pancreatitis causing an inflammatory reaction which jeopardizes the anastomosis. We also propose two maneuvers which could possibly play a role in predicting potential problems and also planning the surgical resection and reconstruction in order to reduce the incidence of POPF. The first modality is the use of pre-operative magnetic resonance imaging (MRI) of the pancreatic duct, and the second maneuver is the gentle cannulation test of the pancreatic duct with a soft, narrow tube following transection of the pancreatic neck. These factors would alert the surgeon about potential ductal variations and could facilitate the surgical approach.
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Affiliation(s)
- P J Shukla
- Gastrointestinal & HPB Surgical Oncology, Tata Memorial Hospital, Mumbai, India.
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Abstract
A 25-year-old African American female with no prior medical/surgical history presented with abdominal pain and fever. A computed tomography scan of the abdomen and pelvis showed jejunal wall thickening with an air-fluid-filled mass in the adjacent mesentery. At laparotomy, a segmental jejunal resection with the abscess cavity followed by primary anastomosis was performed. Pathological evaluation of the specimen revealed a large mesenteric abscess contiguous with a perforated solitary jejunal diverticulum. We provide a discussion of jejunal diverticulitis as an unusual cause of peritonitis.
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Abstract
BACKGROUND AND OBJECTIVES Now nearly 2 decades into the laparoscopic era, nationwide laparoscopic cholecystectomy conversion rates remain around 5% to 10%. We analyzed patient- and surgeon-specific factors that may impact the decision to convert to open. METHODS We retrospectively analyzed 2205 LCs performed at a large tertiary community hospital over a 52 month period (May 2004 through October 2008). RESULTS The overall conversion rate was 4.9%. The most common reason for conversion was adhesions, and the majority of these patients had prior abdominal surgery. Males and patients >50 years old had a significantly higher likelihood of open conversion. The conversion rate of high-volume surgeons (≥100 total cases) in comparison to low-volume surgeons (40 to 99 total cases) was significantly lower. Conversion rates were lower among surgeons with fellowship training and those who completed residency training after 1990. Interestingly, the percentage of conversions due to technical difficulty was lower among those with fellowship training but higher among those who completed training after 1990. CONCLUSION Conversion occurred in ∼5% of all laparoscopic cholecystectomies. Males, patients >50 years old, and cases performed by low-volume surgeons had a higher likelihood of conversion. Other surgeon-specific factors did not have a significant impact on conversion rate.
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Affiliation(s)
- Sujit Vijay Sakpal
- Department of Surgery, Saint Barnabas Medical Center, Livingston, New Jersey, USA
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Maharaj R, Sakpal SV, Deodhar K, Kulkarni A, Arya S, Ramadwar M, Shrikhande SV, Naraynsingh V, Shukla PJ. A cystic hepatic lesion: when to worry? W INDIAN MED J 2010; 59:226-229. [PMID: 21275132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
A 16-year old female presented to hospital with abdominal pain. Features on computed tomography raised the possibility of biliary cystadenoma or cystadenocarcinoma. She underwent a liver resection, and histopathology confirmed a serous biliary cystadenoma. This case is presented to highlight the radiological features of this uncommon pre-malignant condition as well as to summarize a management algorithm for cystic liver lesions.
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Affiliation(s)
- R Maharaj
- Department of Gastrointestinal and Hepatopancreatobiliary Surgical Oncology, Tata Memorial Hospital, Mumbai, India
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Chamberlain RS, Sakpal SV. A comprehensive review of single-incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) techniques for cholecystectomy. J Gastrointest Surg 2009; 13:1733-40. [PMID: 19412642 DOI: 10.1007/s11605-009-0902-y] [Citation(s) in RCA: 200] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2009] [Accepted: 04/15/2009] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Surgery of the gallbladder has evolved tremendously over the last century. Laparoscopic cholecystectomy is the gold standard for gallbladder removal and the most common laparoscopic procedure worldwide. In recent times, innovative techniques of natural orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopic surgery (SILS) have been applied in gallbladder removal as a step towards even more less-invasive procedures. DISCUSSION While NOTES and SILS represent the advent of essentially scarless surgery, limited applications of these technologies in human subjects exists. In this article, we present a comprehensive review of the potential benefits, limitations and risks of these novel techniques. CONCLUSION While much remains unknown and unanswered surrounding these procedures, it is clear that extensive research and development with regards to the ethics and the technical aspects of these procedures as well as randomized studies to compare them with traditional laparoscopy are essential.
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Abstract
BACKGROUND Globalization and intercontinental migration have not just changed the socioeconomic status of regions, but have also altered disease dynamics across the globe. Hepatolithiasis, although still rare, is becoming increasingly evident in the West because of immigration from the Asia-Pacific region, where the disease prevails in endemic proportions. Such rare but emerging diseases pose a therapeutic challenge to doctors. METHODS Here, we briefly introduce the topic of hepatolithiasis and describe features of intrahepatic stones, the aetiology of hepatolithiasis and the symptoms and sequelae of the condition. We then provide a comprehensive review of the various management modalities currently in use to treat hepatolithiasis. CONCLUSIONS In our opinion, and as is evident from the literature, surgery remains the definitive treatment for hepatolithiasis. However, non-surgical procedures such as cholangiography, although limited in their therapeutic capabilities, play a vital role in diagnosis and preoperative evaluation.
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Affiliation(s)
| | - Nitin Babel
- Department of Surgery, Saint Barnabas Medical CenterLivingston, NJ, USA
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Shukla PJ, Sakpal SV. Extended pancreatectomy for pancreatic cancers. Indian J Surg 2009; 71:2-5. [DOI: 10.1007/s12262-008-0076-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2008] [Accepted: 10/26/2008] [Indexed: 11/30/2022] Open
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Sakpal SV, Patel C, Chamberlain RS. Near lethal endometriosis and a massive (64 kg) endometrioma: case report and review of the literature. CLIN EXP OBSTET GYN 2009; 36:49-52. [PMID: 19400419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
A 51-year-old morbidly obese, hypertensive, anemic, and amenorrheic female presented with anuria and respiratory symptoms. The patient had a distinctly massive abdomen with necrotic anterior abdominal wall, and laboratory findings revealed a leukocytosis, profound anemia, coagulopathy and renal failure. An abdominal sonogram showed a large, complex intra-abdominopelvic mass and ascites. At surgery, a massive, cystic left ovarian mass, 37 1 of ascitic/cyst fluid, and several peritoneal nodules were removed--a total of 64 kg of tumorous tissue. Histopathological evaluation of the mass revealed an endometrioma. We present this rare case of severe endometriosis in a morbidly obese patient who presented with an exceptionally large endometrioma (64 kg), multifactorial respiratory and renal failure, coagulopathy, and profound anemia.
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Affiliation(s)
- S V Sakpal
- Department of Surgery, Saint Barnabas Medical Center, Livingston, New Jersey 07039, USA
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Shukla PJ, Maharaj R, Sakpal SV. Current status of laparoscopic surgery in gastrointestinal malignancies. Indian J Surg 2008; 70:261-4. [PMID: 23133081 DOI: 10.1007/s12262-008-0080-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2008] [Accepted: 10/30/2008] [Indexed: 10/21/2022] Open
Abstract
Laparoscopy has become a significant tool in a surgeon's armamentarium since the first laparoscopic cholecystectomy in 1989. Oncological surgeons have been slow in adopting laparoscopy for fear of inadequate cancer operation and occurrence of port site metastasis. Neither of these concerns have stood the test of time. Laparoscopy is being used increasingly in oncological surgery both for staging and respective surgery. This article outlines the present use of laparoscopy in GI cancer surgery.
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Affiliation(s)
- Parul J Shukla
- Department of Gastrointestinal and Hepatopancreatobiliary Surgical Oncology, Tata Memorial Hospital, Mumbai, India
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Abstract
The practice of surgery has witnessed substantial evolution over the recent years, especially with significant advancements in the field of medical diagnostics and surgical therapies. Establishment of specialized and super-specialized surgical centers has resulted in concentrated distribution of patient caseload. There is an immense thrust towards the centralization of surgery particularly for complex high-risk procedures in the Western World. However, such concepts may not apply to less populous nations, and the adoption of healthcare delivery system of specialized centers by low-volume hospitals may produce overall better outcomes.
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Affiliation(s)
- Parul J. Shukla
- Gastrintestinal Surgical Oncology, Tata Memorial HospitalMumbaiIndia
| | | | - Vijay Naraynsingh
- Department of Surgery, General Hospital, University of the West IndiesPort-of-Spain Trinidad and Tobago
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