Anastomotic stenosis after Roux-en-Y gastric bypass: A rational approach to treatment.

BACKGROUND: Anastomotic stenosis, a common sequela to Roux-en-Y gastric bypass, has a reported incidence of 1.6-27% and recurs in 17-33%. No universal guidelines for optimal treatment exist. The aim of this study was to develop guidelines to treat stenosis that achieve the lowest rate of recurrence while avoiding the complications of excessive dilation. METHODS: This prospective 2-part study enlisted consecutive patients undergoing Roux-en-Y gastric bypass who developed an anastomotic stenosis. In the first part, all patients, regardless of the grade of stenosis, underwent dilation to 12 mm and were followed up for recurrence. In the second part, patients underwent dilation according to the grade of stenosis (12 mm for low, 13.5 mm for medium, 15 mm for high) and were followed up for recurrence. RESULTS: Among 1345 consecutive Roux-en-Y gastric bypass patients, 204 developed an anastomotic stenosis (15.2%). No differences were found in gender, mean age, preoperative body mass index, or weight loss at 1 year. In part 1, the recurrence rate for low-, medium-, and high-grade stenosis was 2.6%, 34.4%, and 35.9%. In part 2, the corresponding rates were 9.7%, 26.3%, and 43.6%. The corresponding mean number of additional dilations per patient with recurrence in part 1 was 1.0, 1.5, and 2.1 and, in part 2, were 1.0, 1.0 and 1.2. CONCLUSION: The results of this study have shown that the stenosis grade can predict the risk of recurrence and determine the optimal balloon size. Definitive treatment was achieved in >90% of patients with low-grade stenosis dilated to 12 mm. Medium- and high-grade stenosis predicted > or =25% recurrence, but increasing the balloon size reduced the number of additional dilations required for patients with recurrence.     

Residents can be trained to detect abdominal aortic aneurysms using personal ultrasound imagers: a pilot study.

Our objective was to test the hypothesis that internal medicine residents can be trained to screen for abdominal aortic aneurysm (AAA) using personal ultrasound imagers. We trained 5 randomly chosen internal medicine residents to image the abdominal aorta for patients with risk factors for AAAs using personal ultrasound imagers. Residents were trained in 3 or 4 one-on-one sessions with an instructor. To be eligible, patients had to be older than 65 years and have hypertension. After training, each of the 5 residents studied 3 patients independently. In 12 of the residents' 15 unsupervised studies, their abdominal aorta measurements were within 5 mm of the instructor's measurements with standard echocardiography (mean difference 3 mm, range 0-6 mm). Residents detected 3 previously unknown AAAs measuring 5.2, 4.2, and 3.9 cm in diameter. We conclude residents can be trained to image the abdominal aorta with personal ultrasound imagers and to identify AAAs in patients at risk.     

Dipyridamole-thallium myocardial scanning in the pre-operative assessment of patients undergoing abdominal aortic aneurysmectomy

Dipyridamole thallium scanning (DTS) is an imaging technique with good sensitivity for coronary artery disease (CAD). The purpose of this study was to compare the haemodynamic courses and the correlation between pulmonary capillary wedge pressure (PCWP) and central venous pressure (CVP) in patients with normal DTS (Group 1: n = 12) with those whose scans demonstrated CAD (Group2: n = 11). Haemodynamic profiles were obtained prior to anaesthesia and at several times during surgery. The haemodynamic courses in both groups were similar with significant decreases in cardiac index, stroke index, and left ventricular stroke work index during aortic cross-clamping compared with values prior to anaesthesia. There were no significant changes in PCWP and CVP throughout the study. The correlations between PCWP and CVP were significant in both groups as were the correlations between the changes in PCWP and the changes in CVP observed at the time of cross-clamping. These correlations all had large standard errors of the estimate, however, making it impossible to predict the PCWP from the CVP with precision. It is concluded that, in a limited study population, an abnormal DTS did not identify patients in whom the PCWP and CVP correlated poorly during abdominal aortic aneurysmectomy.     

Coexisting Endogenous and Exogenous Llpold Pneumonia and Pulmonary Alveolar Proteinosis in a Patient with Neurodevelopmental Disease

We report a unique case of coexistingexogenous lipoid pneumonia, endogenous lipoid pneumonia (EU), and pulmonary alveolar proteinosis (PAP) in a 5-year-old patient with severe neurodevelop mental disease. The patient presented with gastroesophageal reflux and presumed chronic lung disease resulting from recurrent aspiration pneumonias and succumbed to respiratory failure. The autopsy showed lipid-laden macrophages and periodic acid-SchiJf9ositive granular matm'al i n alveolar spaces and multilamellated structures within both alveolar macrophages and extracellular debris.

These findings were similar to those in previous reports of coexisting E I P and PAP in the setting of gastroesophageal refux [I] . However, the present case diJfered by the presence of scattered large osmiophilic extracellular lipid vacuob. Besides strengthening the association between EIP and PAP and their relationship to gastroesophageal refux, this case suggests that t h q may arise together with exogenous lipoid pneumonia, through related mechanisms, in the setting of neurodevelopmental disease.     

ACCESSORY SOLEUS MUSCLE: A PROBLEM OF AWARENESS

Reports of accessory soleus muscle are rare, perhaps as a result of it often remaining unrecognized. It presents as a swelling behind the ankle and may be mistaken for a tumour or inflammatory lesion, as occurred in the first of a series of three cases. The other two were incidental findings, one in a 30 year old man with an open tibial fracture and the other in a 9 month old child with a club foot. Patients present with either pain or a diagnostic problem. When large, it may make wearing of footwear difficult. Computerized tomography with electromyography enables confirmation of the diagnosis. Pain is relieved by epimysiotomy and when encountered incidentally during surgery, incision of the epimysium is all that is needed. Excision of the muscle may be considered only if wearing of footwear is difficult. The significance of its presence in a case of club foot is unknown. Disinsertion of its insertion was all that was required to obtain surgical correction of the deformity in the present case. Awareness of the condition will prevent unnecessary surgery in asymptomatic cases.     

Attempted suicide in bipolar disorder pedigrees: evidence for linkage to 2p12.

BACKGROUND: We are interested in identifying susceptibility genes that predispose subjects to attempted suicide. METHODS: We conducted a secondary analysis of genome-wide linkage data from 162 bipolar pedigrees that incorporated attempted suicide as a clinical covariate. RESULTS: The strongest covariate-based linkage signal was seen on 2p12 at marker D2S1777. The logarithm of odds (LOD) score at marker D2S1777 rose from 1.56 to 3.82 after inclusion of the suicide covariate, resulting in significant chromosome-wide empirically derived p-values for the overall linkage finding (p = .01) and for the change in LOD score after the inclusion of the covariate (p = .02). CONCLUSIONS: The finding on chromosome 2 replicates results from two previous studies of attempted suicide in pedigrees with alcohol dependence and in pedigrees with recurrent early-onset depression. Combined, these three studies provide compelling evidence for a locus influencing attempted suicide on 2p12.     

Cerebral hemodynamic and metabolic profiles in fulminant hepatic failure: relationship to outcome.

The purpose of this retrospective study was to examine the potential role of cerebral hemodynamic and metabolic factors in the outcome of patients with fulminant hepatic failure (FHF). Based on the literature, a hypothetical model was proposed in which physiologic changes progress sequentially in five phases, as defined by intracranial pressure (ICP) and cerebral blood flow (CBF) measurements. Seventy-six cerebral physiologic profiles were obtained in 26 patients (2 to 5 studies each) within 6 days of FHF diagnosis. ICP was continuously measured by an extradural fiber optic monitor. Global CBF estimates were obtained by xenon clearance techniques. Jugular venous and peripheral artery catheters permitted calculation of cerebral arteriovenous oxygen differences (AVDO2), from which cerebral metabolic rate for oxygen (CMRO2) was derived. A depressed CMRO2 was found in all patients. There was no evidence of cerebral ischemia as indicated by elevated AVDO2s. Instead, over 65% of the patients revealed cerebral hyperemia. Eight of the 26 patients underwent orthotopic liver transplantation-all recovered neurologically, including 6 with elevated ICPs. Of the 18 patients receiving medical treatment only, all 7 with increased ICP died in contrast to 9 survivors whose ICP remained normal (P < 0.004). Hyperemia, per se, was not related to outcome, although it occurred more frequently at the time of ICP elevations. Six patients were studied during brain death. All 6 revealed malignant intracranial hypertension, preceded by hyperemia. In conclusion, the above findings are consistent with the hypothetical model proposed. Prospective longitudinal studies are recommended to determine the precise evolution of the pathophysiologic changes.