Asymptomatic Gallstones (AsGS) – To Treat or Not to?

With ready availability of abdominal ultrasound, asymptomatic gallstones (AsGS) are being diagnosed with increasing frequency. Management decisions need to take into account the natural history of AsGS as well as the risks of cholecystectomy. Long-term follow up studies from the West have consistently shown that only a small minority of asymptomatic gallstones lead to development of symptoms or complications. Some sub-groups of patients (eg those with chronic hemolytic syndromes) have been shown to be at a higher risk of developing symptoms and complications and prophylactic cholecystectomy has been advised for them. Clear division of patients into low or high risk categories is still far from ideal and better identification of risk factors and risk stratification is needed. Overall, both open and laparoscopic cholecystectomy, are generally safe procedures. However, the incidence of bile duct injury (with all its serious consequences) continues to be higher with laparoscopic cholecystectomy and this should receive due consideration before offering prophylactic cholecystectomy to an asymptomatic patient who is not expected to receive any clinical benefit from it. Gallbladder cancer is rare in most of the developed world and prophylactic cholecystectomy has generally not been recommended to prevent development of GBC. Considering the wide geographical/ethnic variation in incidence of GBC across the world and the strong association of GBC with gallstones, it may not be prudent to extrapolate the results of studies of natural history of AsGS from one part of the world to another. Since northern India has one of the highest incidences of GBC in the world, it is imperative to have data on natural history of AsGS in patients from this area to allow formulation of precise guidelines for management of AsGs.     

Gallstones and Bariatric Surgery: To Treat or Not to Treat?

Background

Obesity and rapid weight loss after bariatric surgery are risk factors for gallstone disease.

Objectives

The present study sought to evaluate the feasibility of selective concomitant cholecystectomy only in patients with symptomatic disease and study risk factors for the development of symptomatic gallstones after bariatric surgery.

Methods

Between January 2010 and December 2012, 734 consecutive patients presenting to our institution underwent bariatric surgery. From these, 81 patients were excluded due to prior or concurrent cholecystectomy. The remaining 653 patients with in situ gallbladder were followed for 12 months and were clinically screened for symptomatic or complicated cholelithiasis. Clinical and demographic characteristics were compared at baseline and 12 months after surgery.

Results

Of the 653 patients with in situ gallbladder, only 24 (3.3 %) developed symptomatic gallstones and only nine presented complicated disease. None of the patients with asymptomatic disease at the time of surgery progressed to symptomatic or complicated disease. Patients who developed symptomatic disease were not significantly different, although there was a trend toward longer obesity evolution, lower insulin levels, and lower hepatic enzymes level. A multivariate regression analysis revealed that patients with gastric sleeve were more likely to develop symptomatic gallstones.

Conclusions

Although further studies are required, the management of gallstones in morbidly obese patients should not be different from normal-weight patients. Therefore, performing a laparoscopic cholecystectomy only in symptomatic patients is an effective approach and asymptomatic gallstones should not be treated at the time of bariatric surgery.

     

Acute Symptomatic Seizures and Provoked Seizures: to Treat or Not to Treat?

Purpose of review

Acute symptomatic and provoked seizures by definition occur in close proximity to an event and are considered to be situational. The treatment implications and likelihood of recurrence of acute symptomatic and provoked seizures differ from unprovoked seizures. In this article, the authors review the literature on acute symptomatic and provoked seizures with regard to therapeutic approach and risk of recurrence.

Recent findings

In the acute period, patients who suffer from acute symptomatic and provoked seizures have higher rates of morbidity and mortality. Patients with acute symptomatic seizures in the setting of certain conditions including subdural hemorrhage, traumatic penetrating injuries, cortical strokes, neurocysticercosis, venous sinus thrombosis, and viral encephalitis have a higher rate of seizure recurrence although the rate of recurrence of seizures is less than that of patients with unprovoked seizures.

Summary

In patients with acute symptomatic and provoked seizures, short-term treatment with anti-seizure medications is appropriate given the higher morbidity and mortality in the acute phase of illness. In patients with acute symptomatic seizures with persistent epileptiform activity on EEG and structural changes on imaging, longer-term treatment (i.e., a few months as opposed to 1 week) with anti-seizure medications can be considered due to high risk of seizure recurrence. If a patient subsequently has an unprovoked seizure, there is yet a higher risk of recurrence of seizures and likelihood of the development of epilepsy. In these patients, long-term seizure treatment can be considered, keeping in mind that although anti-seizure treatment may reduce risk of seizure recurrence in the short-term, it does not appear to influence long-term seizure remission rates.

     

Moderate Ischemic Mitral Regurgitation: to Treat or not to Treat?

There is consensus of opinion that patients with moderately severe to severe (grade 3+ or 4+) ischemic mitral regurgitation (IMR) should undergo mitral valve surgery at the time of coronary artery bypass grafting (CABG), while trace to mild (grade 1+) IMR can probably be left alone. However, the management of moderate (grade 2+) IMR continues to be a subject of constant debate and controversy. In particular, as techniques of valvular repair continue to be refined; many surgeons have advocated mitral valve repair and concomitant CABG for these patients. Others, however, have continued to treat these patients with revascularization alone and close postoperative observation of the mitral valve. In their opinion, degree of concomitant mitral valve dysfunction in this group of patients does not justify the increased operative risks associated with simultaneous mitral valve correction. We are currently practicing in an era of evidence-based medicine (EBM) in which clinical decision-making has to be guided by current best available evidence from scientific, clinical studies. This review article attempts to tackle this controversial issue and find the best approach of dealing with moderate IMR at the time of CABG by evaluating current best available evidence.     

Editorial Commentary: To Treat or Not to Treat? Are We Any Closer to Knowing What to Do With Cartilage Lesions of the Tibia?

The increasing interest and use of cartilage repair procedures in the knee has led to a better understanding of when and how chondral lesions should be treated. Nonetheless, there are still key areas where we lack understanding and need better data to guide clinical decision making. One of these areas is how to manage lesions of the tibia, particularly when they occur in conjunction with the more commonplace lesions of the femoral condyle. In this setting, a tibial chondral lesion may reflect a bigger clinical problem—a “bipolar defect” or more advanced joint disease—“established osteoarthritis.” My preferred treatment for these tibial lesions is to ignore the lesion (or perform a chondroplasty at most), except in cases of osteochondritis dissecans, focal defects in association with cysts, or tibial plateau fracture malunion.     

Should Asymptomatic Anterior Pelvic Organ Prolapse Be Corrected to Treat Irritative Urinary Symptoms?

In clinical practice, women seen with pelvic organ prolapse (POP) often present with a variety of pelvic floor symptoms: urinary incontinence, irritative or overactive bladder symptoms, fecal urgency or incontinence, obstructive voiding, sexual disorders, pelvic and perineal pain, and vaginal bulging. Among these, the only symptom reliably associated with clinically relevant POP that will resolve following vaginal reconstructive surgery is the visualization and/or sensation of a vaginal bulge. Most other symptoms often attributed to POP at best have only weak correlations with worsening pelvic anatomical support. Specifically, with respect to the anterior and/or apical vaginal compartment, there does not appear to be a correlation between irritative overactive bladder symptoms and the presence or degree of anterior vaginal wall prolapse. Furthermore, no other symptoms, urinary or otherwise, are reliably influenced by correction of anatomical defects of pelvic support, especially in the otherwise asymptomatic patient with POP without vaginal bulge. A review of the recent literature underscores the realization that the relationship between pelvic floor symptoms and anatomy is incompletely and poorly understood. With this in mind, there does not seem to be any absolute justification for the surgical correction of otherwise asymptomatic pelvic support defects.     

To Do or Not to Do?—How People Make Decisions

Outcomes in healthcare depend a great deal on the quality of decisions made by the people who care for patients. In the early days of cardiac surgery decisions were often made on the basis of authority by surgeons with broadly based knowledge and skill, developed through extensive training and very long hours of work. The philosophy of the "captain of the ship" prevailed. The advent of much greater specialization and the emergence of evidence based medicine have led to a shift to a model of decision making in which expertise trumps authority. There has also been a reduction in the length of hours worked by many doctors, and greater emphasis on involving patients in decisions about their own healthcare. The framework for understanding human error has been refined on the basis of empirical and theoretical considerations, and much importance is now placed on the way in which the system as a whole is designed. Unfortunately the complexity of healthcare today is such that some of its properties are best explained through analogies to chaos theory. Furthermore, empirical work suggests that human beings are clearly strong at recognizing patterns, and are less adroit at analyzing complex and unfamiliar situations from first principles in a short time. It follows that the very extensive experience of some of the older practitioners may have been more valuable in decision making than many of the very reasonable and logical advances that have influenced modern practice.     

Pituitary Incidentaloma: to Operate or Not to Operate ?

The wide use of sophisticated imaging techniques has led to the discovery of asymptomatic pituitary lesions, which are called ‘incidentalomas’. Their global prevalence averages 10% whereas that of macroadenomas (> 10 mm) is less than 1%. The most frequently encountered lesions are non-functioning adenomas followed by Rathke’s cleft cysts. Physiological pituitary hypertrophy is also frequent in young women. Silent functioning adenomas especially prolactin-omas can be found among incidentalomas. Hypopituitarism appears to be more frequent in larger lesions but can occur in microadenomas (< 10 mm). The incidence of tumour growth is higher in macroadenomas and solid lesions in comparison with microadenomas and cystic lesions. The baseline evaluation should include in all patients a complete history and physical examination, a screening for hormone hypersecretion and hypopituitarism and a visual field examination if the lesion abuts the optic nerves or chiasm. If there is hormone hypersecretion, an appropriate treatment is indicated (dopamine agonists for prolactinomas and surgery for tumours producing GH, ACTH or TSH). If there is hypopituitarism, adequate hormone replacement therapy is required. According to recent guidelines, the indications for surgery of non-functioning incidentalomas include a visual field deficit, other visual abnormalities such as ophtalmople-gia or a lesion abutting the optic nerves or chiasm on magnetic resonance imaging (MRI). Regarding the follow-up of incidentalomas not meeting the criteria for surgery, the following tests should be performed: MRI at 1 year for micro-incidentalomas, at 6 months for macro-incidentalomas and then less frequently if unchanged in size, visual field examination for lesions enlarging to abut or compress the optic nerves or chiasm (6 months and yearly) and endocrine testing for macro-incidentalomas (6 months and yearly). Nowadays, data are insufficient to suggest the routine use of medical therapy in non-functioning tumours. Pituitary radiotherapy may be useful as an adjunctive treatment for tumour remnants growing progressively.     

Renal Biopsy in the Elderly and Very Elderly: Useful or Not?

Longer life expectancy has led to a growing epidemic of kidney disease in the elderly (aged ≥ 65 years) and very elderly (aged ≥ 80 years). While much of the rising burden of kidney disease in these age-groups can be attributed to age-associated decline and a high prevalence of comorbidities such as hypertension and diabetes mellitus, a significant proportion of kidney disease is due to potentially reversible causes of injury in the glomerular, tubulointerstitial, and vascular compartments. A renal biopsy is crucial not only to diagnose such potentially reversible lesions but also to provide prognostic information and guide therapeutic decisions. In this review, we survey the literature on renal biopsy in the elderly and very elderly, focusing on the utility and safety of this procedure. We report the most common histopathologic findings in these age-groups and demonstrate that many of these lesions are associated with diseases that respond to appropriate therapies, regardless of age. We conclude that, in a variety of commonly encountered clinical situations, a renal biopsy is crucial for appropriate management of elderly and very elderly patients with kidney disease.     

To Band or Not to Band—Early Results of Banded Sleeve Gastrectomy

Laparoscopic sleeve gastrectomy (LSG) is the procedure with the fastest growing numbers worldwide. Although excellent weight loss can be achieved, one major obstacle of LSG is weight regain due to sleeve dilatation. Banded sleeve gastrectomy (BLSG) has been described as an option to counteract sleeve dilatation and ameliorate weight loss over time. In a retrospective study, we analysed 25 patients who underwent BLSG using a MiniMizer® ring. Twenty five patients who had previously undergone a conventional LSG were selected for matched-pair analysis. Patient follow-up was 12 months in both groups. Mean preoperative BMI was 56.1?±?7.2 kg/m² for BLSG and 57.0?±?6.3 kg/m² for LSG, P?=?0.522. Operative time was significantly shorter for BLSG (53?±?27 min vs. 68?±?20 min, P?=?0.0025). Excess weight loss (%EWL) was equal in both groups with %EWL at 12 months of 58.0?±?14.6 % for BSLG patients vs. 58.4?±?19.2 % for LSG patients. There was no procedure-related mortality in either group. At 12 months postoperative, vomiting was significantly increased in BSLG patients (OR 6.75, P?=?0.035). New onset reflux was equal in both groups (OR 0.67, P?=?0.469). Ring implantation does not increase the duration of surgery or early surgical complications. Weight loss in the first follow-up year is not influenced, but the incidence of vomiting is raised after 12 months when patients start to increase eating volume.     

How to Treat an Appendiceal Inflammatory Mass: Operatively or Nonoperatively?

Introduction

While there is consensus on how to treat acute appendicitis, the most suitable treatment for an appendiceal inflammatory mass is still debated. This study compares the outcomes of operative and nonoperative management.

Material and Methods

We retrospectively evaluated 119 patients (2007–2011) with an appendiceal inflammatory mass, 85 of whom were treated nonoperatively and 34 operatively. Of the nonoperative patients, 69 did not receive interventional treatment and 16 underwent percutaneous drainage of an accompanying abscess; the data for these patients were analyzed separately.

Results

Of the noninterventional managed patients, 49 (71.0 %) experienced at least one recurrence and 37 (53.6 %) ultimately needed an acute surgical or radiological intervention. Of the 16 patients who underwent percutaneous drainage, 7 (43.8 %) experienced at least one recurrence and 6 (37.5 %) underwent an acute surgical or (second) percutaneous intervention. None of the operated patients had a recurrence and the incidence of complications was 17.6 %. The incidence of underlying malignant tumor in our study population was 5.9 %. In 35 patients, the definitive diagnosis remained unclear because the patients did not undergo surgery or follow-up colonoscopy after nonoperative treatment. The rate of extensive (ileocecal?+?hemicolonic) resection in all operated patients was 30.8 %.

Conclusion

We conclude that the high rate of recurrence and intervention in the nonoperative group and the high proportion of these patients who did not receive adequate follow-up despite the relatively high rate (5.9 %) of bowel malignancy support the operative management of an appendiceal inflammatory mass. Noninterventional management or a percutaneous intervention should be reserved as a bridge to surgery for patients with a large accompanying abscess or as treatment for patients with significant comorbidity. If nonoperative treatment is chosen, follow-up colonoscopy is mandatory to exclude malignancy.     

Renal failure from birth—AKI or CKD? Questions

A case is presented of a neonate born at 32 weeks of gestation with intra-uterine growth retardation. The renal scan performed at 31 weeks showed oligohydramnios but normal kidneys. The neonate was oliguric from birth and required early peritoneal dialysis. Her urine showed heavy proteinuria, and the plasma albumin was very low. Post-natal ultrasonography showed large bright kidneys with reduced corticomedullary differentiation but no dysplastia; arterial and venous flow was normal on Doppler ultrasound. The quiz discusses the differential diagnosis with particular reference to whether this picture represents acute kidney injury with expected improvement or chronic kidney disease. Further questions discuss mechanisms of renal failure in this situation. Finally, with reference to previous case reports and series, a correlation between a specific mutation and this severe phenotype is proposed.