Laparoscopic repair of a perforated marginal ulcer 2 years after gastric bypass

The authors present the case of a 43-year-old women who underwent a laparoscopic gastric bypass in 2003 for morbid obesity. They report that 2 years later, she had maintained significant weight loss, but had developed acute abdominal pain, followed by nausea and emesis. In the emergency room, she had diffuse tenderness, tachycardia, and leukocytosis. After initial resuscitation, a computed tomography was performed, which showed free air above the liver and thickened small bowel loops. She was brought emergently to the operating room for laparoscopy. At surgery, turbid fluid and inflamed small bowel loops were seen. A perforated marginal ulcer was discovered in the Roux limb, approximately 2 cm distal to the gastrojejunal anastomosis. The perforation was oversewn primarily and patched with omentum. The repair was tested by intraoperative endoscopy. A gastrostomy tube also was placed within the gastric remnant for enteral access. The patient did extremely well postoperatively, and had an uneventful postoperative course. She was discharged on postoperative day 4. The gastrostomy tube was removed at 1 month, and at this writing, she remains well since surgery. An upper endoscopy at 2 months was completely normal, and the Helicobacter pylori test results were negative. The gastric pouch had not significantly enlarged since initial surgery, as indicated by both endoscopy and barium study. Marginal ulcer is reported to be 0.6% to 16% after laparoscopic gastric bypass [1]. Etiologies include gastrogastric fistula, excessively large gastric pouch containing antral mucosa, H. pylori infection, nonsteroidal antiinflammatory use, and smoking [2]. Unfortunately, none of these applied to the reported patient. Because her exact etiology remains unknown, she at this writing continues to receive proton pump inhibitor therapy. Electronic supplementary material The online version of this article (doi: ) contains supplementary material, which is available to authorized users.     

CT Scan Diagnosis of Bleeding Peptic Ulcer after Gastric Bypass

Investigation of the bypassed stomach in patients with suspected peptic ulcer disease presents a major challenge to bariatric surgeons. Various methods have been suggested for visualization of the duodenum and bypassed stomach. These include endoscopy via percutaneous gastrostomy access, retrograde endoscopy and virtual gastroscopy using CT scan. We present a case of peptic ulcer bleeding diagnosed with the help of conventional CT scan. To the best of our knowledge, this is the second such case reported in the literature and the first in the bariatric population.     

A systematic review of electrical stimulation for pressure ulcer prevention and treatment in people with spinal cord injuries

Context

Electrical stimulation (ES) can confer benefit to pressure ulcer (PU) prevention and treatment in spinal cord injuries (SCIs). However, clinical guidelines regarding the use of ES for PU management in SCI remain limited.

Objectives

To critically appraise and synthesize the research evidence on ES for PU prevention and treatment in SCI.

Method

Review was limited to peer-reviewed studies published in English from 1970 to July 2013. Studies included randomized controlled trials (RCTs), non-RCTs, prospective cohort studies, case series, case control, and case report studies. Target population included adults with SCI. Interventions of any type of ES were accepted. Any outcome measuring effectiveness of PU prevention and treatment was included. Methodological quality was evaluated using established instruments.

Results

Twenty-seven studies were included, 9 of 27 studies were RCTs. Six RCTs were therapeutic trials. ES enhanced PU healing in all 11 therapeutic studies. Two types of ES modalities were identified in therapeutic studies (surface electrodes, anal probe), four types of modalities in preventive studies (surface electrodes, ES shorts, sacral anterior nerve root implant, neuromuscular ES implant).

Conclusion

The methodological quality of the studies was poor, in particular for prevention studies. A significant effect of ES on enhancement of PU healing is shown in limited Grade I evidence. The great variability in ES parameters, stimulating locations, and outcome measure leads to an inability to advocate any one standard approach for PU therapy or prevention. Future research is suggested to improve the design of ES devices, standardize ES parameters, and conduct more rigorous trials.     

A favourable response to surgical intervention and hyperbaric oxygen therapy in pyoderma gangrenosum

Pyoderma gangrenosum (PG) is a neutrophilic dermatosis characterised with ulcerations. Inflammatory bowel diseases (ulcerative colitis and Crohn's disease) and haematologic diseases (leukaemia, preleukaemia and monoclonal gammopathy) have been reported in about 40–50% of PG patients in whom the treatment of the underlying disease is important for the improvement of the lesions. We herein report a colorectal adenocarcinoma patient with PG, who responded partially to topical treatments and systemic immunosuppressants and healed completely with the aid of surgical wound repair and hyperbaric oxygen therapy.     

A case of a bleeding benign gastrocolic fistula in 2014

INTRODUCTION

In the era of proton pump inhibitors in the treatment of peptic ulcer disease, the incidence of a gastrocolic fistula arising from unoperated gastric ulcers is extremely low.

PRESENTATION OF CASE

We present the case of a 68-year old farmer who presented with melaena and was found to have a benign gastrocolic fistula in the setting of untreated peptic ulcer disease, chronic NSAID ingestion and heavy alcohol intake. The diagnosis was made by gastroscopy. En bloc surgery was undertaken due to the size of the fistula and concomitant significant bleeding of the ulcer which would not have made it amenable to medical management.

DISCUSSION

The symptoms of a gastrocolic fistula are undifferentiated and the diagnosis can easily be missed in the setting of other complications such as bleeding or perforation of a hollow viscus. Barium enamas are the most accurate for the diagnosis but gastroscopy with biopsy is usually performed to rule out malignancy. The mainstay of treatment is usually surgical, though patients can be medically managed if he/she is not a surgical candidate.

CONCLUSION

Benign gastrocolic fistulas are rare and its diagnosis is easily missed.     

The importance of submalleolar deformity in determining leg length discrepancy

Background and purposeThe association of leg length discrepancy (LLD) with a number of clinical disorders has made its determination a significant part of the physical examination. We believe that submalleolar causes of LLD may be under-acknowledged. The most common clinical method used to measure LLD is by tape from the anterior superior iliac spine (ASIS) to medial malleolus which disregards the potential for LLD arising from asymmetry in the foot distal to the tibiotalar joint.MethodsThe present pilot study involves a group of 5 volunteers (experimental group) and a group of 3 patients with flexible flat feet (clinical study). The differences in tibial tubercle height from the ground between full pronation and full supination were measured using the CODA MPX 30^® system (Charnwood Dynamics Limited, Leicestershire, England). Correlations of the patterns within each group were produced.ResultsA significant relationship with leg lengths was found in the experimental group when they induced maximum pronation (R-squared = 0.62, p = 0.007) while an inverse relationship occurred with supination, although marginally significant (R-squared = 0.37, p = 0.064).ConclusionsWe have demonstrated that significant leg length discrepancy can occur in patients who do not have obvious deformity when non weight bearing. We recommend using the blocks method routinely. Appropriately measuring LLD is of vital importance to properly diagnosing and treating patients with unequal leg lengths or related symptoms.     

Using Geometry for the Dorsiflexory Wedge Osteotomy of the First Metatarsal

Dorsiflexory wedge osteotomy is indicated for the correction of structural and irreducible first metatarsal deformity to effectively shorten and elevate a plantar flexed first ray. This is most commonly due to fixed forefoot valgus deformity, the cavovarus foot type, and diabetic foot pathologic features involving an ulceration or preulcerative area on the plantar aspect of the first metatarsal head. Surgeons can subjectively judge the amount of correction, such as by restoring the frontal plane alignment of the forefoot, or objectively by returning Meary's angle to a parallel relationship on a weightbearing lateral radiograph. With this tip, we propose an objective measurement, with calculation and use of Meary's angle, to preoperatively quantify the amount of desired correction. In the present study, we applied basic geometric principles based on triangles to calculate the relationship between the width of the excised wedge and the angular degrees of achieved dorsiflexion. We hope these data will provide both objective and reasonable estimates for reconstructive foot and ankle surgeons working with these deformities and with this procedure.     

Treatment of diabetic foot complications with hyperbaric oxygen therapy: A retrospective experience

BackgroundThe aim of this study is to evaluate the role of hyperbaric oxygen in the treatment of diabetic foot ulcers.MethodsWe performed a retrospective observational study of all patients with diabetic foot ulcers treated at the Institution's hyperbaric chamber between January 2010 and August 2012. Patient data was obtained upon patient hospital visit and prospective clinical record consultation.ResultsTwenty-six foot lesions including 13 foot ulcers Wagner grade 2 or greater and 13 amputation stump ulcers were submitted to hyperbaric oxygen therapy between January 2010 and August 2012 in our Institution. Of these, 23 foot lesions completed treatment and complete epithelialization of the primary lesion was achieved in 15 (65%). The mean healing period since the first hyperbaric oxygen therapy session was 16 weeks. Above-ankle amputations were performed in 3 limbs and transmetatarsal amputations in 2 limbs.ConclusionHyperbaric oxygen may be associated with ulcer healing in selected diabetic foot ulcers with impaired cicatrization.     

肿瘤患者难免性压疮预测评价指标的构建

目的探讨肿瘤患者难免性压疮的概念及预测指标,为难免性压疮管理提供依据。方法选择上海市、重庆市、广东省、湖南省、河南省、四川省共20名专家,采用德尔菲法就肿瘤患者难免性压疮的概念及预测指标进行3轮函询。结果肿瘤患者难免性压疮的概念界定为＂肿瘤患者在具有高度水肿、大小便失禁、恶病质、强迫体位等高危压疮因素的基础上,因翻身计划无法落实（≥3d）、皮肤有现存或潜在的损伤、脱离照护3项中的1项或多项所引起的压疮＂。其预测指标包括存在压疮高危因素、翻身计划持续不能实现、皮肤有现存或潜在的损伤、脱离护士照护4个条目,变异系数0.0856～0.1779,权重依次为0.2899、0.2743、0.2743、0.1615。3轮专家咨询的积极系数分别为90.9%、100%和100%;专家的权威系数为0.88。结论专家协调程度较高,肿瘤患者难免性压疮的概念和预测评价指标可作为制定肿瘤患者压疮管理制度和护理压疮的依据。     

足内侧远端筋膜蒂皮瓣修复？？及前足背皮肤缺损

目的：探讨足内侧远端筋膜蒂岛状皮瓣修复及前足背皮肤缺损的临床疗效。方法2007年8月-2012年12月,采用足内侧远端筋膜蒂岛状皮瓣修复及前足背皮肤缺损29例,皮肤缺损面积为2.0 cm×3.0 cm～5.0 cm×8.0 cm,供区直接拉拢缝合或行全厚皮片移植修复。结果本组29例皮瓣全部顺利成活,术后随访6～24个月,皮瓣质地柔软,外形及色泽良好,不臃肿,耐磨性好,恢复正常行走功能。供区植皮全部成活,愈合较满意。结论足内侧远端筋膜蒂岛状皮瓣血供可靠、操作简单、质地柔软、耐磨性好,是修复及前足背皮肤缺损的一种较好的手术方法。