Clipping prevents perforation in large, flat polyps

AIM To determine if prophylactic clipping of post-polypectomy endoscopic mucosal resection(EMR) mucosal defects of large,flat,right sided polyps prevents perforations.METHODS IRB approved review of all colonoscopies,and prospective data collection of grasp and snare EMR performed by 2 endoscopists between January 1,2010 and March 31,2014 in a community ambulatory endoscopy center.The study consisted of two phases.In the first phase,all right-sided,flat polyps greater than or equal to 1.2 cm in size were removed using the grasp and snare technique.Clipping was done at the discretion of the endoscopist.In the second phase,all mucosal defects were closed using resolution clips.Phase 2 of the study was powered to detect a statistically significant difference in perforation rate with 148 EMRs,if less than or equal to 2 perforations occurred.RESULTS In phase 1 of the study,2121 colonoscopies were performed.Seventy-five patients had 95 large polyps removed.There were 4 perforations in 95 polypectomies(4.2%).The perforations occurred in polyps ranging in size from 1.5 cm to 2.5 cm.In phase 2,there were 2464 colonoscopies performed.One hundred and sixteen patients had 151 large polyps removed,and all mucosal defects were clipped.There were no perforations(P=0.0016).There were no post-polypectomy hemorrhages in either phase.An average of 2.15 clips were required to close the mucosal defects.The median time to perform the polypectomy and clipping was 13 min,and the median procedure duration was 40 min.Five percent of all patients undergoing colonoscopy in our community based,ambulatory endoscopy center had flat,right sided polyps greater than or equal to 1.2 cm in size.CONCLUSION Prophylactic clipping of the mucosal resection defect of large,right-sided,flat polyps reduces the incidence of perforation.

Congenital Absence of the Cystic Duct: A Rare but Significant Anomaly

Cholecystectomy is the most common digestive tract surgery performed worldwide and injury to the bile duct leads to both acute and chronic sequelae. The incidence of bile duct injury is increased in the presence of severe inflammation and is compounded by congenital abnormalities of the biliary tract. Congenitally absent cystic duct is one such rare anomaly with significant surgical implications. So far only nine clear cases of congenitally absent cystic duct have been reported. In this report we describe two additional cases of a congenitally absent cystic duct and provide a comprehensive discussion of the clinical significance, and appropriate surgical management of this anomaly.

Perioperative Adjunct Magnesium Decreases Postoperative Opioid Requirements—A Meta-Analysis

Objectives: Magnesium (Mg) is the fourth most common cation in the body and has numerous physiological activities and anti-nociceptive effects. The anti-nociceptive effects are primarily mediated by regulation of calcium influx into the cell and antagonism of the N-Methyl-D-aspartate glutamate receptors. Opioids are widely used as analgesics to minimize postoperative pain, but their use is associated with various side effects as well as the potential for addiction and tolerance. Systemic Mg has been proposed as an adjunct to minimize postoperative pain in numerous clinical studies. This meta-analysis aims to critically examine the ability of perioperative intravenous (IV) Mg to reduce opioid use and its’ side effects. Methods: A comprehensive literature search of Pub Med, Cochrane Central Registry of Controlled Trials, and Google Scholar (1966-2016) was performed to identify all randomized control trials (RCTs) assessing the use of perioperative IV Mg in the reduction of postoperative opioid consumption. Keywords searched included combinations of “magnesium”, “pain”, “postoperative”, “preoperative”, “analgesia” and “opioid”. Inclusion criteria included RCTs comparing the use of perioperative IV Mg with a control group in adult patients (>18 yrs) undergoing elective surgery. Cumulative opioid consumption within the first 24 hours (hrs) postoperative period and the incidence of nausea and vomiting were analyzed. Results: 14 RCTs involving 910 patients were identified (455 patients received Mg and 455 patients received placebo or no therapy). Opioid consumption was significantly decreased in the systemic Mg group (standard mean difference [SMD]: 1.39, 95% CI 1.83 to -0.96;p p p = 0.234). Systemic Mg adjunct had no significant effect on postoperative nausea and vomiting (RR = 0.63;95% CI 0.38 to 1.04;p = 0.07). Conclusion: Perioperative IV Mg administration reduces opioid use in the first 24 hours postoperatively without any serious adverse events. The decreased need for postoperative opioids in the Mg group was not associated with a decrease in opioid-related side effects such as nausea and vomiting. Mg is an efficacious adjunct for postoperative analgesia and should be considered in multimodal analgesic treatment plans. Additional studies are required to optimize the Mg dose and timing, and to address whether specific opioids display unique benefit or resistance to adjunct Mg therapy.

Percutaneous Coronary Intervention Reduces Mortality in Out-of-Hospital Cardiac Arrest after Acute Coronary Syndrome: An Outcomes-Based Study from the Nationwide Inpatient Sample Database

Introduction: Mortality following cardiac arrest (CA) is extremely high, with rates as high as 91.5% after out-of-hospital cardiac arrest (OHCA) and 76.1% after in-hospital cardiac arrest (IHCA). This study assessed the clinical profile and outcomes of a large cohort of patients undergoing primary percutaneous coronary intervention (PCI) for OHCA to determine its effect on clinical outcomes and mortality. Methods: 247,456 patients with OHCA due to acute coronary syndrome (ACS) were abstracted from the Nationwide Inpatient Sample database (2001-2011). Results: Among 247,456 OHCA patients, 11,111 (4.5%) had PCI while 236,345 (95.5%) did not. Patients who underwent PCI were younger than those who did not receive PCI (64 vs. 66 years), p p p p 65 years, female gender, AA or Hispanic race, advanced cancer, and liver dysfunction as independent factors associated with increased mortality, while PCI conferred a survival advantage in OHCA, p Conclusion: Treatment with PCI was associated with a significant decrease in mortality. PCI was performed most often in Caucasians, males, patients > 50 years old, and those with Medicare. PCI significantly reduces mortality in OHCA patients and should be considered in all OHCA patients. Further investigation and development of methods to overcome the apparent socioeconomic barriers to PCI is required.

Males at High Risk for Breast Cancer: Who Are They and How Should We Screen Them?

Background: It is estimated that 2240 males in the United States will develop invasive breast cancer (BC) in 2013, resulting in 410 deaths. Overall, male breast cancers (MBCs) are diagnosed with larger tumor size, more frequent lymphatic invasion, and advanced tumor stage compared to their female counterparts. Several risk factors have been elucidated for the development of MBC, and this paper aims to critically review the existing literature on at-risk populations and provide screening recommendations. Methods: A comprehensive search for all published studies on populations at risk for MBC using PubMed, EBSCOhost, and Google Scholar was performed (1982- 2013). The search focused specifically on genetic and epidemiologic risk factors, and screening for MBC. Keywords searched included “male breast cancer risk factors”, “male breast cancer epidemiology”, and “male breast cancer genetics”. A total of 34 studies involving 4,865,819 patients were identified. Results: Five studies (N = 327,667) focused primarily on family history of breast cancer as a risk factor for MBC. 15% - 20% of men with BC have a family history of breast or ovarian cancer, and a family history of BC among first-degree relatives confers a 2-to 3-fold increase in MBC risk (odds ratio = 3.3). Seventeen studies (N = 5451) analyzed associations between several heritable genes and MBC. Lifetime MBC risk among BRCA1 mutation carriers is 1% - 5%, while MBC risk in BRCA2 mutation carriers is higher and varies between 4% - 40%. Less clear associations between MBC and PALB2, Androgen Receptor gene, CYP17, and CHEK2 mutations have also been documented. Five studies (N = 16,667) have addressed occupational risk factors for MBC. An 8-fold increase in MBC is reported in males working in the cosmetic cream manufacturing, and the motor vehicle industries. A meta-analysis of 18 trials also identified electromagnetic field exposure as a potential MBC risk, though causation remains undocumented. Eleven studies (N = 4,843,598) analyzed the role of abnormalities in the androgen-to-estrogen ratio as a risk factor for MBC. Conditions associated with increased MBC risk include Klinefelter’s syndrome (relative risk, RR = 29.64), obesity (RR = 1.98), orchitis/epididymitis (RR = 1.84), and gynecomastia (RR = 5.86). Conclusion: Routine screening for MBC should be considered in all high risk male populations, including those with a prior history of breast carcinoma, a strong family history of BC (defined as an affected mother or sister), a positive BRCA2 mutation status (regardless of family history), and men diagnosed with Klinefelter’s syndrome, or those in the chemical or motor vehicle industries. Genetic testing for BRCA2 should be recommended for all MBC patients. Increased public and physician education on MBC is necessary to raise awareness about this rare disease and the need for screening of at-risk populations.

Advances in the management of pectus deformities in children

Pectus excavatum (PE) and pectus carinatum (PC) are relatively common deformities involving the anterior chest wall, occurring in 1:1000 and 1:1500 live births, respectively. While the etiology remains an enigma, the association of pectus deformities with other skeletal abnormalities suggests that connective tissue disease may play a role in their pathogenesis. Clinical features of these deformities vary with severity, as determined by the Haller index and Backer ratio, but frequently include cardiac and respiratory abnormalities. Importantly, there exist profound psychosocial implications for children afflicted with these defofrmities, including but not limited to feelings of embarrassment and maladaptive social behaviors. These debilitating characteristics have prompted the development of novel medical and surgical corrective techniques. The correction of pectus deformities reduces the incidence of physiological complications secondary to chest wall malformation, while simultaneously improving body image and psychosocial development in the affected pediatric population. The Ravitch (open) and Nuss (minimally invasive) procedures remain the most frequently employed methods of pectus deformity repair, with no difference in overall complication rates, though individual complication rates vary with treatment. The Nuss procedure is associated with a higher rate of recurrence due to bar migration, hemothorax, and pneumothorax. Postoperative pain management is markedly more difficult in patients who have undergone Nuss repair. Patients undergoing the Ravitch procedure require less postoperative analgesia, but have longer operation times and a larger surgical scar. The cosmetic results of the Nuss procedure and its minimally invasive nature make it preferable to the Ravitch repair. Newer treatment modalities, including the vacuum bell, magnetic mini-mover procedure (3MP), and dynamic compression bracing (DCB) appear promising, and may ultimately provide effective methods of noninvasive repair. However, these modalities suffer from a lack of extensive published evidence, and the limited number of studies currently published fail to adequately define their long-term effectiveness.

Uterine Didelphys in a Pregnant Mother

Background: Uterine Didelphys is a rare congenital condition and it can affect both mother and fetus. A 24 year-old patient presented to the emergency room with pelvic pain and a pelvic ultrasound confirmed the presence of Uterine Didelphys. She subsequently became pregnant and was first seen at 21 weeks gestation. She was designated as a high-risk patient during the second trimester when she experienced irregular contractions. She was monitored weekly with Non-Stress Tests and eventually was delivered by Cesarean Section. Uterine Didelphys can be detected in-utero in affected individuals, and clinical findings vary among individuals. Some may be asymptomatic, whereas others will experience dyspareunia, and still others may present with concurrent renal agenesis. Serial sonograms are performed throughout their pregnancy to evaluate fetal growth and well-being, as well as cervical length. Unlike many uterine anomalies, Uterine Didelphys does not affect fertility but can affect labor, fetal growth, placentation, fetal viability and fetal outcome. Uterine Didelphys frequently results in recurrent miscarriages and may cause preterm labor and necessitate cesarean section. The presentation, associated symptoms, methods of detection and management options for Uterine Didelphys will be discussed.

Surgical Outcome Following Hip Fracture in Patients >100 Years Old: Will They Ever Walk Again?

Introduction: Advances in medicine have led to a growth in the centenarian population (>100 years old). Centenarians are a largely unstudied population but as longevity increases, so will the cost of providing care for this group. Methods: One hundred and ten patients were admitted to SBMC 195 times between 2000 and 2009. Thirteen patients were treated for hip fracture. Data abstracted from the charts of these patients including age, gender, ethnicity, co-morbidities, advance directives (ADRs), functional status, length of stay (LOS), pre-operative and post-operative residential status and ambulatory status, ASA grade, type of anesthesia, duration of surgery and for complications of surgery or anesthesia. Results: The mean age was 101.2 years (100 to 104 years) with an M:F ratio of 2:11. The most common co-morbidities were hypertension, anemia, congestive heart failure (CHF) and coronary artery disease. Among the 13 patients with hip fractures, 12 had operative intervention while one was treated conservatively. The mean ASA grade was 2.75 (1 - 4). Five patients had surgery under general anesthesia and seven received spinal anesthesia. Five patients received a bi-polar hip replacement and seven patients underwent internal fixation. The mean operative time was 47.6 min (27 - 90 min). Five (41.7%) patients required a peri-operative blood transfusion. The mean post-anesthesia recovery score was 9.42 (9 - 10). All patients, except two, were returned to their pre-operative ambulatory status. Advanced directives were held by only 30.8% of patients on admission. There were 2 post-operative morbidities and 1 mortality. Conclusions: Centenarians represent a high-risk-surgical population due to their age and associated comorbidities. Hip fracture is the cause of >10% of all admissions and accounts for 29% of all surgical procedures in this age group. Despite their age and comorbidities, surgery for hip fracture is well tolerated and nearly all patients were returned to their pre-hospital ambulatory status. Education on advanced directives is lacking.

The Impact of Ethnicity on the Incidence, Tumor Characteristics and Treatment of Ductal Carcinoma in Situ—An 11-Year Clinical Experience at a High Volume Teaching Hospital

Introduction: Screening mammography has led to a marked increase in detection of in situ breast tumors in the United States. The University of Southern California/Van Nuys Prognostic Index (USC/VNPI) predicts the recurrence rates of ductal carcinoma in situ (DCIS);however variations in tumor characteristics, USC/VNPI scores, receptor and human epithelial growth factor receptor (HER)-2/neu status across different ethnicities/races have not been well studied. This study aimed to evaluate the racial trends in incidence, patient demographics, tumor characteristics and treatment variations for patients with DCIS at a high volume teaching hospital. Methods: 395 women underwent surgical intervention for DCIS between 2000 and 2011. Their race/ethnicity was divided into five mutually exclusive categories and demographic and clinicopathological data was collected. Multivariate analysis was performed to evaluate variations in patient and tumor factors with respect to age, size and surgical management among different ethnicities and races. Results: 82.1% of Caucasian women underwent simple mastectomy with sentinel lymph node biopsy (SLNB) while lumpectomy with SLNB was highest in Hispanics (40%, p = 0.005). Overall, there was no significant difference in the incidence of receptor or HER-2/neu positivity, multicentricity, necrosis or grade of DCIS in the various racial groups, but there was a significant racial difference in the USC/VNPI scores (p < 0.001). Conclusion: On a community level, screening detected DCIS accounted for the vast majority of DCIS diagnosed, which reflected national trends. Although no racial variation in DCIS with respect to patient or tumor characteristics was observed, a racial difference in USC/VNPI score was identified among the Hispanic population. Additional studies are required to validate the significance of these findings.

Renal Transplantation in Patients with Aortoiliac Prosthetic Grafts: A Case Report and Pertinent Review of Literature

Renal transplantation in a patient with aortoiliac prosthetic graft is a unique challenge. It requires that the renal artery is anastomosed directly to the vascular prosthetic graft. Nearly 0.2%-1.7% of the patients with aortoiliac prosthesis require renal transplantation in their life time. Outcomes following such procedure are controversial and anecdotal. In this report we present a unique case in which the renal artery was anastomosed to vascular prosthetic graft with a pertinent review of the literature.

The World Health Organization Surgical Safety Checklist Improves Post-Operative Outcomes: A Meta-Analysis and Systematic Review

Background: The incidence of in-hospital adverse events is about 10%, with a majority of these related to surgery, and nearly half considered preventable events. In attempts to improve patient safety, the World Health Organization (WHO) developed a checklist to be used at critical perioperative moments. This meta-analysis examines the impact of the WHO surgical safety checklist (SSC) on various patient outcomes. Methods: A comprehensive search of all published studies assessing the use of the WHO SSC in patients undergoing surgery was conducted. Studies using the WHO SSC in any surgical setting, with pre-implementation and post-implementation outcome data were included. The incidence of patient outcomes (total complications, surgical site infections, unplanned return to the operating room (OR) within 30 days, and overall mortality) and adherence to safety measures were analyzed. Results: 10 studies involving 51,125 patients (27,490 prior to implementation and 23,635 after implementation of the WHO SSC) were analyzed. The implementation of the WHO SSC significantly reduced the risk of total complications by 37.9%, surgical site infections by 45.5%, unplanned return to OR by 32.1%, and mortality by 15.3%. Increased adherence to safety measures including airway evaluation, use of pulse oximetry, prophylactic antibiotics when necessary, confirmation of patient name and surgical site, and sponge count was also observed. Conclusions: The use of the WHO SSC is associated with a significant reduction in post-operative complication rates and mortality. The WHO SSC is a valuable tool that should be universally implemented in all surgical centers and utilized in all surgical patients.

Intensive Insulin Therapy Has No Effect on Mortality and Morbidity in Cardiac Surgery Patients: A Meta-Analysis

Introduction: Optimal glycemic control in cardiac surgery patients remains a laudable but confusing practice. Existing studies have primarily employed two maintenance strategies using either intensive insulin therapy (IIT) (maintain glucose p = 0.628), ICU LOS (MD = -0.073 days, 95% CI = -0.324 to 0.178;p = 0.568), or hospital LOS (MD = 0.269, 95% CI = -2.158 to 2.696;p = 0.828). No difference in AF rates (RR = 0.887, 95% CI = 0.681 to 1.155;p = 0.375) or deep sternal infection (RR = 0.985, 95% CI = 0.357 to 2.720;p = 0.977) were observed. Conclusion: IIT targeting blood sugar levels of 80 - 120 mg/dl have no effect on perioperative outcomes in cardiac surgery patients. IIT is associated with similar mortality, ICU LOS, hospital LOS, AF rates, and deep sternal infection rates compared to more liberal glycemic strategies. IIT should not replace CIT as the standard of care in cardiac surgery patients.

Caudal and Penile Blocks Demonstrate Similar Reliability and Efficacy in Pediatric Patients Undergoing Circumcision: A Meta-Analysis

Purpose: Circumcision is one of the most common surgeries performed in the pediatric population. Multiple regional analgesic techniques, including caudal (CB) and penile block (PB), have championed as offering optimal analgesia for circumcision in the post-neonatal pediatric population without clear consensus. This meta-analysis sought to investigate CB and PB’s analgesic efficacy and the impact on postoperative analgesic requirements in pediatric circumcisions. Methods: A comprehensive literature search of PubMed, Google Scholar, and Cochrane Library (1966-2016) was completed to identify all published randomized control trials (RCTs). Keywords searched included “circumcision”, “caudal block”, “penile block”, and “analgesia”. Inclusion criteria were limited to the comparison of PB versus CB in children less than 18 years of age and its efficacy towards circumcision. The efficacy, time to first additive analgesia, time to first micturition, duration of prolonged motor blockade, incidence of vomiting, and length of stay were analyzed. Results: 9 RCTs involving 574 children (N = 287 in CB and PB) were included. No differences in analgesic efficacy (relative risk (RR) = 0.983, 95% confidence interval (CI) = 0.95 to 1.02;p = 0.328) or time to first additive analgesia were observed (standardized difference in mean (SDM) = 0.438, 95% CI = -0.04 to 0.92;p = 0.073). Time to first micturition (SDM = 0.680, 95% CI = 0.40 to 0.96;p p = 0.007) were significantly prolonged in patients receiving CB. No differences were observed between groups in regards to the incidence of vomiting (RR = 1.56, 95% CI = 0.91 to 2.67;p = 0.107) and length of stay (SDM = 0.741, 95% CI = -0.05 to 1.53;p = 0.066). Conclusion: CB and PB offer similar analgesic success rates for pediatric patients (age 18 months to 16 years) undergoing circumcision. CB is associated with a trend towards longer duration of analgesia, but is associated with prolonged urinary retention and delayed ambulation. CB use is recommended in non-ambulatory children, whereas PB is recommended in ambulatory children.