Gastric Perforation Associated with Tuberculosis: A Case Report

Gastric tuberculosis is a rare presentation of tuberculosis infection. Gastric perforation associated with tuberculosis is exceedingly rare with five previously published cases. We present a case of a male patient that developed presumed gastric tuberculosis secondary to pulmonary tuberculosis infection. He subsequently developed gastric perforation and sepsis, for which he was treated both surgically and medically. Despite ongoing antituberculosis treatment, the patient's condition worsened and the patient died secondary to multiorgan failure. This case highlights gastric perforation as a rare but devastating complication of pulmonary tuberculosis

NSAID-Associated Perforation of a Meckel’s Diverticulum: A Case Report

Meckel’s diverticulum is the most frequent congenital malformation of the gastrointestinal tract. The most common ectopic tissue within a Meckel’s is heterotopic gastric mucosa, with bleeding being the most common presentation. However, perforation of a Meckel’s diverticulum is a rare presentation. NSAID-associated Meckel’s perforation has been suggested, however has not been documented in the literature. We present a case of a 17-year-old female with acute abdominal pain and tenderness following a 24-hour history of excessive ingestion of NSAIDS for pain related to tooth extraction. Chest radiograph demonstrated free intra-abdominal air and she was subsequently taken for exploratory laparotomy. A perforated Meckel’s diverticulum was isolated and resected. Though NSAID-associated bleeding of heterotopic gastric mucosa has been described, and perforation of the Meckel’s diverticulum has been suggested, no clear association between heterotopic gastric mucosa and perforation exists. On the other hand, the relationship between NSAIDS and gastric ulcer perforation is well documented. A similar mechanism may also play a role in NSAID-associated Meckel’s perforation. With how common NSAID use is, we believe it is important to document NSAID-associated perforation of a Meckel’s diverticulum

The Evolution of the Appendectomy: From Open to Laparoscopic to Single Incision

Beginning with its initial description by Fitz in the 19th century, acute appendicitis has been a significant long-standing medical challenge; today it remains the most common gastrointestinal emergency in adults. Already in 1894, McBurney advocated for the surgical removal of the inflamed appendix and is credited with the initial description of an Open Appendectomy (OA). With the introduction of minimally invasive surgery, this classic approach evolved into a procedure with multiple, smaller incisions; a technique termed Laparoscopic Appendectomy (LA). There is much literature describing the advantages of this newer approach. To name a few, patients have significantly less wound infections, reduced pain, and a reduction in ileus compared with the OA. In the past few years, Single Incision Laparoscopic Appendectomy (SILA) has gained popularity as the next major evolutionary advancement in the removal of the appendix. Described as a pioneer in the era of “scarless surgery,” it involves only one transumbilical incision. Patients are postulated to have reduced post-operative complications such as infection, hernias, and hematomas, as well as a quicker recovery time and less post-operative pain scores, in comparison to its predecessors. In this review, we explore the advancement of the appendectomy from open to laparoscopic to single incision

A systematic review of educational resources for teaching patient handover skills to residents

Background: As physicians reduce their work hours, transfer of patient care becomes more common; this is a time of heightened risk to patients. Training in patient handover skills may reduce this risk. The objective of this study was to systematically review the literature regarding education models available to teach handovers skills to healthcare professionals. Methods: A systematic review was conducted to identify published educational resources on patient handover skills. Two investigators independently reviewed publications for inclusion/exclusion. A third reviewer resolved any disagreement. Included papers contained an educational resource for teaching handover skills to any health profession in any patient population. Papers were rated on a previously described 4 point scale for quality. Results: 1746 papers were identified, of which twelve met the inclusion criteria These studies presented information on educational curricula, simulation technologies and didactic sessions. The most common educational method was simulation or role-playing, which is better received by learners than didactic sessions. Teaching handover practices makes residents feel more confident in their handover, and residents receiving adequate handover are more comfortable with their duties.Conclusions: Although  data are limited, effective training models for handover skills have been described in the literature. Residents and other healthcare practitioners should receive training in handover to improve practitioner comfort and patient care.

The Association between Obesity and Colorectal Cancer

Obesity has become a major issue for healthcare providers as its prevalence continues to increase throughout the world. The literature suggests that increased body mass index (BMI) is associated with the development of certain cancers such as colorectal cancer (CRC). Consequently, CRC surgeons are now encountering an increasing number of obese patients which may influence the technical aspects and outcomes of surgical treatment. For instance, obese patients present with greater comorbidities preoperatively, which adds increasing complexity and risks to surgical management. Recent literature also suggests that obesity may increase operating time and conversion rates to open colorectal surgery. Postoperative outcomes may also be influenced by obesity; however, this currently remains controversial. There is evidence that survival rates after CRC surgery are not influenced by obesity. In summary, obesity presents challenges to CRC surgeons, and further research will be needed to show how this important characteristic influences the outcomes for CRC patients

Sleeve Gastrectomy and Gastroesophageal Reflux Disease

Bariatric surgery, when combined with lifestyle and medical interventions, is a common and successful treatment modality in the obese patient. Laparoscopic sleeve gastrectomy is one such procedure that has increased in popularity as a definitive bariatric operation. Although laparoscopic sleeve gastrectomy has been shown to be effective in producing weight loss and improving type 2 diabetes mellitus, its effect on gastroesophageal reflux disease (GERD) has been inconsistent. This paper aims to summarize the available literature regarding GERD prevalence following laparoscopic sleeve gastrectomy, 8 studies demonstrate increased GERD prevalence, and 5 demonstrate decreased GERD prevalence following laparoscopic sleeve gastrectomy. The relationship between GERD and SG is complex and no clear relationship exists. The anatomic and physiologic changes caused by laparoscopic sleeve gastrectomy are discussed in the context of these inconsistent results

A Systematic Review and Meta-Analysis of Outcomes for Type 1 Diabetes after Bariatric Surgery

Background. The utility of bariatric surgery in type 1 diabetes remains controversial. The aim of the present study is to evaluate glycemic control outcomes in obese patients with type 1 diabetes after bariatric surgery. Methods. A comprehensive search of electronic databases was completed. Inclusion criteria included human adult subjects with BMI ≥35 kg/m2 and a confirmed diagnosis of type 1 diabetes who underwent a bariatric surgical procedure. Results. Thirteen primary studies (86 patients) were included. Subjects had a mean age of 41.16±6.76 years with a mean BMI of 42.50±2.65 kg/m2. There was a marked reduction in BMI postoperatively at 12 months and at study endpoint to 29.55±1.76 kg/m2 (P<0.00001) and 30.63±2.09 kg/m2 (P<0.00001), respectively. Preoperative weighted mean total daily insulin requirement was 98±26 IU/d, which decreased significantly to 36±15 IU/d (P<0.00001) and 42±11 IU/d (P<0.00001) at 12 months and at study endpoint, respectively. An improvement in HbA1c was also seen from 8.46±0.78% preoperatively to 7.95±0.55% (P=0.01) and 8.13±0.86% (P=0.03) at 12 months and at study endpoint, respectively. Conclusion. Bariatric surgery in patients with type 1 diabetes leads to significant reductions in BMI and improvements in glycemic control

Endoscopic Revision (StomaphyX) versus Formal Surgical Revision (Gastric Bypass) for Failed Vertical Band Gastroplasty

Background. Weight regain secondary to VBG pouch dilation is a typical referral for Bariatric surgeons. In this study we compare an endoluminal pouch reduction (Stomaphyx) to RYGB for revision. Methods. A retrospective review was completed for patients with a previous VBG presenting with weight regain between 2003–2010. Results. Thirty patients were identified for study 23 RYGB, 14 StomaphyX. Significant post procedure BMI loss was seen in each cohort (RYGB, 47.7 ± 7 kg/m2 to 35 ± 7 kg/m2; StomaphyX 43 ± 10 kg/m2 to 40 ± 9 kg/m2, P=0.0007). Whereas nausea and headache were the only complications observed in StomaphyX patients, the RYGB group had a 43.5% complication rate and 1 mortality. Complications following RYGB include: incisional hernia (13%), anastomotic leak (8.7%), respiratory failure (8.7%), fistula (8.7%), and perforation (4.35%). The median length of stay following RYGB was 6 days compared to 1.5 ± 0.5 days following StomaphyX. Conclusion. This study suggests that while RYGB revision may achieve greater weight loss, the complication rates and severity is discouraging. StomaphyX may be a safe alternative. Further technical modifications of the device and longer follow-up may clarify the role of this approach

Clinical Study Endoscopic Revision (StomaphyX) versus Formal Surgical Revision (Gastric Bypass) for Failed Vertical Band Gastroplasty

Background. Weight regain secondary to VBG pouch dilation is a typical referral for Bariatric surgeons. In this study we compare an endoluminal pouch reduction (Stomaphyx) to RYGB for revision. Methods. A retrospective review was completed for patients with a previous VBG presenting with weight regain between 2003-2010. Results. Thirty patients were identified for study 23 RYGB, 14 StomaphyX. Significant post procedure BMI loss was seen in each cohort (RYGB, 47.7 ± 7 kg/m 2 to 35 ± 7 kg/m 2 ; StomaphyX 43 ± 10 kg/m 2 to 40 ± 9 kg/m 2 , = 0.0007). Whereas nausea and headache were the only complications observed in StomaphyX patients, the RYGB group had a 43.5% complication rate and 1 mortality. Complications following RYGB include: incisional hernia (13%), anastomotic leak (8.7%), respiratory failure (8.7%), fistula (8.7%), and perforation (4.35%). The median length of stay following RYGB was 6 days compared to 1.5 ± 0.5 days following StomaphyX. Conclusion. This study suggests that while RYGB revision may achieve greater weight loss, the complication rates and severity is discouraging. StomaphyX may be a safe alternative. Further technical modifications of the device and longer follow-up may clarify the role of this approach