Association of Recanalization of the Left Umbilical Vein with Umbilical Hernia in Patients with Liver Disease

Transmission of portal hypertension to the umbilical region via a recanalized left umbilical vein may explain the higher prevalence of umbilical hernia than inguinal hernia in men with advanced liver disease. Images from a computed tomography of a 49-year-old man with cirrhosis and hepatocellular carcinoma from hepatitis C virus were reconstructed in 3-dimensional color format. Rupture of the web between the left portal vein and the recanalized left umbilical vein is seen. Penetration of abdominal wall by the varices at the umbilicus is demonstrated. A dilated inferior epigastric vein is seen to drain the varices inferiorly to the right external iliac vein

Severe necrotizing pancreatitis following combined hepatitis A and B vaccination

Necrotizing pancreatitis is a severe form of pancreatitis and is associated with substantial morbidity and mortality. We report a case of necrotizing pancreatitis that developed following combined hepatitis A and B vaccination. No other causes of pancreatitis could be determined. Although confirming the diagnosis is challenging, 3 main factors suggest a possible link to the vaccine: the chronology of the events, the patient's human leukocyte antigen genotype and the incongruent immune response to the vaccine components. This report serves to alert physicians to the possible development of necrotizing pancreatitis after vaccination

Democratizing Flexible Endoscopy Training. Noninferiority Randomized Trial Comparing a Box-Trainer vs a Virtual Reality Simulator to Prepare for the Fundamental of Endoscopic Surgery Exam

Background: A considerable number of surgical residents fail the mandated endoscopy exam despite having completed the required clinical cases. Low-cost endoscopy box trainers (BTs) could democratize training; however, their effectiveness was never compared with higher-cost virtual reality simulators (VRSs). Study design: In this randomized noninferiority trial, endoscopy novices trained either on the VRS used in the Fundamental of Endoscopic Surgery manual skills (FESms) exam, or a validated BT, the Basic Endoscopic Skills Training (BEST) box. Trainees were tested at fixed timepoints on the FESms and on standardized ex-vivo models. Primary endpoint was FESms improvement at 1 week. Secondary endpoints were: FESms improvement at 2 weeks, FESms pass rates, ex-vivo tests performance and trainees' feedback. Results: 77 trainees completed the study. VRS and BT trainees showed comparable FESms improvements (25.16±14.29 vs 25.58±11.75 FESms points, respectively; p=0.89), FESms pass rates (76.32% vs 61.54%, respectively; p=0.16) and total ex-vivo tasks completion times (365.76±237.56 vs 322.68±186.04 seconds, respectively; p=0.55) after one week. Performance were comparable also after 2 weeks of training, but FESms pass rates increased significantly only in the first week. Trainees were significantly more satisfied with the BT platform (3.97±1.20 vs 4.81±0.40 points on a 5-point Likert scale for the VRS and the BT, respectively; p<0.001). Conclusions: Simulation-based training is an effective mean to develop competency in endoscopy, especially at beginning of the learning curve. Low-cost BTs like the BEST box compare well with high-tech VRSs and could help democratize endoscopy training

Malignant Bowel Obstruction in Advanced Gynecologic Cancers: An Updated Review from a Multidisciplinary Perspective

Malignant bowel obstruction (MBO) is a major complication in women with advanced gynecologic cancers which imposes a significant burden on patients, caregivers, and healthcare systems. Symptoms of MBO are challenging to palliate and result in progressive decompensation of already vulnerable patients with limited therapeutic options and a short prognosis. However, there is a paucity of guidelines or innovative approaches to improve the care of women who develop MBO. MBO is a complex clinical situation that requires a multidisciplinary approach to ensure the appropriate treatment modality and interprofessional care to optimally manage these patients. This review summarizes the current literature on the different approaches targeting MBO management including surgical intervention, chemotherapy, total parenteral nutrition, and pharmacological treatment. In addition, the impact of MBO management on patients’ quality of life (QOL) is examined. This article focuses on the challenges in developing evidence-based treatment guidelines for MBO and barriers in clinical trial design for MBO and proposes strategies to advance the MBO management. Collaboration is essential to design studies that may improve the overall care and quality of life for these patients. Prospective data are needed to inform clinical practice, establish a new benchmark for evidence-based MBO management, and better understand the biology of MBO.Peer Reviewe