Minimally Invasive Management of Ectopic Pancreas

BACKGROUND

The management of ectopic pancreas is not well defined. This study aims to determine the prevalence of symptomatic ectopic pancreas and identify those who may benefit from treatment, with a particular focus on robotically assisted surgical management.

METHODS

Our institutional pathology database was queried to identify a cohort of ectopic pancreas specimens. Additional clinical data regarding clinical symptomatology, diagnostic studies, and treatment were obtained through chart review.

RESULTS

Nineteen cases of ectopic pancreas were found incidentally during surgery for another condition or found incidentally in a pathologic specimen (65.5%). Eleven patients (37.9%) reported prior symptoms, notably abdominal pain and/or gastrointestinal bleeding. The most common locations for ectopic pancreas were the duodenum and small bowel (31% and 27.6%, respectively). Three out of 29 cases (10.3%) had no symptoms, but had evidence of preneoplastic changes on pathology, while one harbored pancreatic cancer. Over the years, treatment of ectopic pancreas has shifted from open to laparoscopic and more recently to robotic surgery.

CONCLUSIONS

Our experience is in line with existing evidence supporting surgical treatment of symptomatic or complicated ectopic pancreas. In the current era, minimally invasive and robotic surgery can be used safely and successfully for treatment of ectopic pancreas.

Surgical relief of small bowel obstruction by migrated biliary stent: extraction without enterotomy

Small bowel obstruction caused by biliary stent migration may be managed without enterotomy by using a combination of laparoscopy, endoscopy, and fluoroscopy.

Background:

Distal stent migration is a well-known complication following insertion of biliary stents. Most such cases can be managed expectantly, because the stents pass through the gastrointestinal tract. However, small bowel obstruction as a result of the stent mandates surgical intervention.

Methods:

We report the case of a patient who had distal stent migration causing a small bowel obstruction. We successfully retrieved the stent without an enterotomy, by using a combination of laparoscopy, endoscopy, and fluoroscopy. Our unique technique greatly decreased the risk of bacterial peritonitis in this patient with decompensated cirrhosis and associated ascites, which in this patient population results in a high mortality.

Results:

Management of small bowel obstruction secondary to biliary stent migration necessitates operative intervention. Retrieval of a dislodged stent can be performed safely without subjecting the patient to an enterotomy or a small bowel resection. Postoperative morbidity should be significantly reduced by this approach.

Conclusion:

Retrieval of biliary stents in cases of small bowel obstruction without perforation may be successfully performed without enterotomy or bowel resection. A similar approach may be applied to other foreign bodies dislodged in the small bowel.

High prevalence of hepatitis C virus infection among immigrants from the former Soviet Union in the New York City metropolitan area: results of a community-based screening program

BACKGROUND

Inadequate sterilization and reuse of medical equipment likely contributed to hepatitis C virus (HCV) transmission in the former Soviet Union (FSU). Although New York leads the nation in the number of immigrants from the FSU, the epidemiology of HCV infection has not been evaluated in this population. The aims of this study were to determine the prevalence of and risk factors for HCV infection among immigrants from the FSU in the New York metropolitan area.

METHODS

We conducted a 3-day community-based HCV screening program in the two boroughs of the New York metropolitan area with the highest density of FSU immigrants (Brooklyn and Queens). Russian cable television was used to invite subjects to come in for free HCV testing. In the last 2 days of screening, each person also completed an HCV risk factor questionnaire.

RESULTS

The overall prevalence of HCV seropositivity among the 283 subjects was 28.3% (95% confidence interval [CI] 23.0-33.5%). The prevalence of HCV infection was similar in men and women (30.3% vs 26.5%, P = 0.48) and was highest in subjects > or = 70 yr old (35.0%). HCV seropositivity was 11.1% in immigrants from Russia, 29.0% from Uzbekistan, 31.0% from the Ukraine, and 36.8% from other regions. Intramuscular injections (odds ratio 9.1, 95% CI 2.0-42.4) and blood transfusions (odds ratio 3.2, 95% CI 1.2-9.0) were the only variables that were significantly associated with HCV infection in the multivariable analysis.

CONCLUSIONS

In this community-based screening program we found a high prevalence of HCV infection among immigrants from the FSU, and these infections likely resulted from inadequately sterilized medical equipment and blood transfusions. Universal HCV testing should be strongly considered for all FSU immigrants.

Susceptibility to hepatitis A in patients with chronic liver disease due to hepatitis C virus infection: missed opportunities for vaccination

Hepatitis A virus (HAV) superinfection is associated with a high risk of liver failure and death in patients with underlying chronic liver disease. Although HAV vaccination is recommended for all patients with chronic hepatitis C virus (HCV) infection, little is known about adherence to these recommendations in clinical practice. The aims of this study were to determine the frequency of HAV testing and vaccination among patients with chronic HCV infection. We conducted a retrospective cohort study of 1,193 patients diagnosed with chronic HCV infection over a 1-year period. During 1,646 person-years of follow-up, patients were seen by their primary care provider a median of 10.0 times (interquartile range, 4.0-20.0). HAV antibody testing was performed in 640 subjects (53.6%), and 317 (49.5%) of those tested were susceptible (HAV antibody negative). Only 94 of the 1,193 patients (7.9%) received the HAV vaccine, including 26.8% of the 317 susceptible patients, 0.9% of the 323 patients who were already immune to HAV, and 1.1% of the 553 subjects who were never tested. Among the 94 vaccinated patients, 45 received only one dose of the vaccine. Three of the unvaccinated patients developed acute HAV infection during follow-up, and 1 of them died of acute liver failure. In conclusion, despite published recommendations to vaccinate against HAV in patients with chronic HCV infection, we found that HAV testing and vaccination rates were low in clinical practice. Public health programs to increase awareness about HAV vaccination in patients with chronic liver disease are needed.