Late Complications Research Articles

Unveiling the Intricacies: Exploring Stepwise Initiation of Peritoneal Dialysis in a Single-Center Setting

Background and Objectives: Chronic kidney disease (CKD) poses a significant global health challenge, necessitating effective renal replacement therapies. Peritoneal dialysis (PD) offers a patient-friendly, home-based alternative to hemodialysis. The Stepwise Initiation of Peritoneal Dialysis (SIPD) method, used in the SPD group and involving a gradual introduction of PD, presents a potential advantage over traditional protocols, yet the scientific literature on its efficacy and safety is limited. Materials and Methods: We conducted a retrospective analysis of 39 end-stage renal disease patients undergoing SIPD and 78 patients receiving conventional PD (CPD) at a single center from 1 January 2010 to 31 December 2023. Patients were matched for age and sex. Surgical techniques, early and late complications, infection rates, and catheter survival were evaluated. Data were analyzed using statistical methods, including the chi-square test, t-test, and negative binomial regression. Results: The mean break-in period was significantly more extended for the SPD group (176.05 ± 154.39 days) compared to the CPD group (26.87 ± 58.45 days). Early complications were similar between groups, but late complications, including peritonitis, were significantly higher in the CPD group. The SPD group experienced fewer infection events (28 vs. 80, p = 0.043). Median catheter survival times were 1486 days for SPD and 1774 days for CPD, with no statistical difference. Age was a significant factor in peritonitis incidence, increasing with age in both groups. Conclusions: Our study suggests that SPD may reduce the incidence of catheter-related infections and peritonitis compared to CPD. The extended break-in period in SPD could enhance tissue healing and reduce biofilm formation, thereby contributing to fewer infectious complications. Despite these findings, no significant difference in overall catheter survival was observed. Further multi-center studies with larger sample sizes are recommended to confirm these results and explore the economic impact of SPD vs. CPD.

Combined external radiotherapy and single-fraction palliative high-dose-rate interstitial brachytherapy for a patient with a base of tongue cancer who had a previous radiation history.

Only a few studies have explored whether high-dose-rate interstitial brachytherapy (HDR-ISBT) can be indicated as a palliative/symptomatic treatment. We present the good results of palliative treatment using HDR-ISBT combined with external beam radiotherapy (ERT) in a patient of base of tongue cancer (cT4aN1M0). The patient was an 81-year-old male who complained of local pain. He had a previous irradiation history for head and neck cancer receiving ERT with systemic chemotherapy and radical surgery 15years ago. Since it might be difficult for him to receive radical radiation doses using ERT alone, palliative ERT of relatively lower doses of 37.5Gy in 15 fractions was selected. One month after ERT, HDR-ISBT was implemented as a booster. Considering the burden on physical condition, single-fraction HDR-ISBT was selected. We employed a new technique in which we did not penetrate the ventral surface of the tongue to reduce the risk of infection and bleeding. The planning-aim dose was 9.5Gy. The dose that covered 90% of the clinical target volume was 9.6Gy. The treatment ended without any problems. Acute complications were not observed. The tumor size decreased, and local pain disappeared at post-treatment day 84. No late complications were observed. Two years and 8months after the treatment, the patient is alive without any obvious recurrence. Additional single-fraction HDR-ISBT boost may be a useful modality as a palliative/symptomatic intent. The implantation technique and dose-fraction schedule may be important for the safe treatment of older patients or those with poor performance status.

Factors Associated with Postoperative Complications After Congenital Duodenal Obstruction Surgery: A Retrospective Study.

Background and Objectives: Duodenal atresia and stenosis are common causes of intestinal obstruction. Associated anomalies significantly influence early postoperative mortality, while postoperative complications impact long-term survival. Materials and Methods: Over a 13-year period from January 2010 to August 2023, a total of 74 infants and children with congenital duodenal obstruction were treated at "Grigore Alexandrescu" Children's Emergency Hospital and met the inclusion criteria. All patients diagnosed with duodenal obstruction (both instrinsic and extrinsic causes) were included. Analysed data included congenital anomalies, Apgar scores, birth weights, surgical techniques, and complications. Results: The associated anomalies included cardiac (n = 33), Down syndrome (n = 13), neurological (n = 11), pulmonary (n = 7), renal (n = 4), skeletal (n = 1), and gastrointestinal and hepatobiliopancreatic anomalies (n = 25). In total, 12 patients experienced perioperative ventilation problems. Early postoperative complications (within 30 days) occurred in 21 patients, while 6 had late postoperative complications (after 30 days). Among non-surgical complications, we noted ventilation problems, sepsis (n = 7), and pneumothorax (n = 1). Surgical complications included adhesive bowel obstruction (n = 7), incisional hernia (n = 3), peritonitis (n = 3), dysfunctional duodenoduodenostomy or duodenojejunostomy (n = 3), pneumoperitoneum (n = 5), enteric fistula (n = 3), and volvulus (n = 4). Conclusions: Surprisingly, this retrospective study revealed that an Apgar score below 8, along with neurological and pulmonary abnormalities, is associated with postoperative complications. Conversely, other congenital anomalies, low birth weight, and age at admission do not serve as prognostic factors.

Clinical and functional outcome of total transanal endorectal pull-through procedure for the management of Hirschsprung’s disease

ObjectiveThe aim of the study is to evaluate the complications and long-term bowel function in Hirschsprung’s disease (HD) patients following total transanal endorectal pull-through (TERPT) surgery operated in a tertiary hospital in Oman.MethodsA retrospective data retrieval was done for patients diagnosed with Hirschsprung’s disease and underwent total transanal endorectal pull-through procedure during the period from December 2008 to June 2019 with concomitant prospective phone call questionnaire interview to assess the long-term functional outcome of children aged 3 years and older.ResultsTotal transanal endorectal pull-through was performed in 61 patients. The mean age at the time of operation was 7.71 ± 8.26 months. The most common late complication was anal excoriation (19.7%). Of the patients, 61.5% had a normal to fair score, and the remaining 38% had a poor score in their functional outcome questionnaire. The majority had no social problems (65.4%), while 15.4% had problems causing varying degrees of social restrictions.ConclusionThe short-term outcomes of total transanal endorectal pull-through are found to be acceptable. In addition, the long-term functional outcome post total transanal endorectal pull-through was found to be satisfactory; however, longer follow-up studies with larger sample sizes are needed for more accurate functional outcome evaluation.

One stage anterior sagittal sphincter saving anorectoplasty (ASSSARP) for the repair or rectovestibular fistula: mid and long-term outcome in two tertiary centers

PurposeThis is a retrospective study of one-stage anterior sagittal sphincter saving anorectoplasty (ASSSARP) for repairing rectovestibular fistula (RVF) including operative details and postoperative complications, functional and cosmetic outcome.Patients and methodsRecords of 41 cases of RVF, managed between April 2010 and September 2019 by one-stage ASSSARP, were reviewed. Preoperative preparation, both early and late postoperative care & complications, hospital stay, and functional & cosmetic outcomes were reported.ResultsThe mean age was 6.6 months. Vaginal tear occurred in 5/41 cases, and distal rectal tears in 4/41 cases. Thirteen patients suffered mild superficial wound inflammation; while Skin dehiscence; occurred in five patients. No colostomy or redo was needed. The mean hospital stay was 6.1 days. Mean follow-up was 43.13 months; (Range; 24–100 months). Subclinical anal stricture was detected in six patients. Constipation occurred in 14 cases. Soiling grade I occurred in five patients. Thirty-two patients reached past the age of three years; two of whom showed cough/diarrhea incontinence.ConclusionOne-stage ASSSARP is safe and gives functional and cosmetic results comparable to other techniques. It provides better access during RVF repair. The avoidance of muscle incision protects against muscle breakdown, if infection sets in, and thus against incontinence. It avoids the morbidity, cost and psychological burden of performing a three-stage repair.

Obstetric Outcome and its Relationship with Mode of Delivery in Preterm Labour- A Study of 86 Patients in Combined Military Hospital, Dhaka

Background: Caesarean section in preterm pregnancy may add further pressure to the already existing poorly developed facilities for intensive perinatal care in low resource countries. The objective of the study was to determine the feto-maternal outcome and its relationship with mode of delivery in preterm labour. Methods: This was a descriptive type of cross-sectional study conducted at Department of Obstetrics and Gynecology, Combined Military Hospital (CMH), Dhaka, during March to August 20l8. The study population was total eighty-six patients having 28 to 36 weeks of gestation who were admitted in the above department and were in labour. Data were edited and analyzed by using computer-based software, statistical package for social sciences (SPSS) version 20.0. Results: Majority of the patients belonged to 26-30 years age group and were from low socioeconomic family (71.4 to 72.7) % and had below average nutritional status (88.1 to 93.2) %. The mean gestational age was 31 weeks and 35 weeks. Nulliparous (77.3 to 85.7) % and patients taking irregular antenatal check-up (69.0 to 72.8) % were predominant. About (59.1 to 66.7) % patients had vaginal delivery and (33.3 to 40.9) % patients had undergone caesarean section. Maternal morbidity was more in caesarean section (37.5%) than vaginal delivery (33.3%). Live birth babies were found 100% in caesarean section and 94.4% in vaginal delivery and among them 95.7% were from group I and 97.6% were from group ll. Perinatal mortality was higher in vaginal delivery than caesarean section (7.40% vs 2.7%) and also higher in group I than group ll (8.3% vs 2.3%). But late perinatal complications were more in caesarean section (47.2%) than vaginal delivery (45.1%) baby, and majority (60%) of them were from group l. Conclusion: Preterm pregnancy when leads to an early delivery, brings a grave consequence for both the mother and foetus. After birth, the premature newborn is at risk for complications related to incomplete development of its organ system. Caesarean section delivery in preterm labour improves foetal outcome to some extent, but not significantly, and leads the mother to more maternal morbidity. Perinatal mortality and morbidity is also inversely related to the gestational age at the time of delivery, in preterm labour - more the gestational age, less the perinatal mortality and morbidity. Bangladesh Armed Forces Med J Vol 57 No (1) June 2024, pp 43-49

Safety and feasibility of pure laparoscopic living donor right hepatectomy.

Pure laparoscopic living-donor right hepatectomy (PLDRH) has emerged as a significant advancement in liver transplantation, offering reduced donor morbidity and improved recovery times. However, PLDRH is still performed in only a limited number of centers. This retrospective study reports on the outcomes of 215 living donors who underwent PLDRH at Asan Medical Center in Seoul, Korea between November 2014 and December 2021. We reviewed donor and recipient demographics and anatomical characteristics of the donor grafts. Donor complications were classified and evaluated based on the Clavien-Dindo classification. The incidence of early donor complications within 30days of surgery was 0.9% (n = 3), with minor complications in 0.3% (n = 1) patients and major complications in 0.6% (n = 2). No biliary complications were observed and no late complications had been reported by 30days after surgery. The mean length of postoperative hospital stay was 7.2days. PLDRH was a safe and feasible surgical technique characterized by a low complication rate and short hospital stays. PLDRH has the potential to become the standard procedure for the retrieval of right liver grafts from living donors.

Scar revision for persistent pain and activity limitation after exploratory laparotomy in infancy: A case series

AbstractExploratory laparotomy in neonates is typically performed via a transverse laparotomy incision. However, this incision may be complicated by poor cosmesis and scar contracture. In three patients, primary gastroenterologists identified significant scar contractures that resulted in pain and limitations with physical activity, necessitating surgical referrals. All patients required subsequent surgical revision of their scar, which involved creation of skin flaps, repair of abdominal wall hernias if present, and reapproximation of the subcutaneous tissue. We describe this phenomenon and the resultant need for surgical management to raise awareness of these late complications and suggest subcutaneous tissue reapproximation should be performed when possible during abdominal wall closure.

Custom-Made Device (CMD) for the Repair of Thoraco-Abdominal Aneurysm (TAA): Mid-Long Term Outcomes from a Single Southeast Asian Centre Experience in Singapore.

Introduction: Given the high risk of peri-operative morbidity and mortality associated with open repair, endovascular repair for thoraco-abdominal aneurysms is increasingly performed. This study aims to describe mid to long-term results for patients who were treated with COOK Custom-Made Endograft Device at a single Southeast Asian tertiary centre. Methods: Mid to long-term results of patients treated from 2012 to 2022 were retrospectively reviewed. Indications for treatment were aortic diameter > 5.5 cm, enlargement > 5 mm in 6 months or high-risk morphology. Clinical, operative, early to late complications and reintervention details were captured. The endpoints were technical success, primary patency and primary assisted patency. Results: Electronic medical records of 29 consecutive patients (64.4 ± 1.6 years old; 26/29 males 89.6%) were reviewed. 24/29 (83%) were hypertensive, and 20/29 (69%) were smokers. The mean diameter was 5.5 cm, and the majority were treated for Crawford type IV (19/29, 65.5%). Endograft deployment was 100%. Catheterisation of fenestration was successful in 109/116 (94%). 30-day mortality and morbidity were observed in 12/29 (41%), for which access site complications were most common. No significant haemorrhage or graft explant was recorded. The mean follow-up period was 32.4 months (range 1-108 months). Primary patency was 92.9% (95% CI: 83.8-100.0) at 6 months and decreased to 77.7% (95% CI: 63.4-95.2) at 24 months. Sac shrinkage or stability was noted in 17/29 (58.6%). Re-intervention was performed in 9/29 (31%) for limb occlusion (2/9, 22.2%), renal artery stent occlusion (1/9, 11.1%) and endoleaks (6/9, 66.6%). Assisted patency was maintained at 100% for 12 months before decreasing to 66.7% (95% CI: 37.9-100.0) at 24 months. Conclusions: The study reports the first mid-long-term result in this region, though limited by the sample size. Re-intervention at 30% suggests that disease and procedures remain challenging, emphasising the need to assimilate lessons and experience at high-volume centres.

Electrocardiographic Changes, Mortality, and Late Period Findings in Methyl Alcohol Poisoning

Background: Methyl alcohol poisoning (MAP) is a common commercial compound that can lead to significant morbidity and mortality when exposed to high levels. This study aims to describe MAP-related electrocardiography (ECG) changes and post-acute late complications. Materials and Methods: The study was conducted through a retrospective data review between 2017 and 2023. Patient data were recorded, including demographic information, medication use, and laboratory results. Twelve-lead ECG recordings were evaluated and the results were recorded. The cases included in the study were grouped according to QTc distance, ECG findings, late-term complications, treatment status, and mortality. Results: The mean age of all cases included in the study (n = 227) was 43.23 ± 11.11 years, 8 (3.5%) cases were female, and the age distribution was between 19 and 68 years (p = 0.792). The age distribution of QTc groups was not significant (p = 0.792). The mean QTc distance was 442.7 ± 60.1 ms in all cases (n = 227) and 514.08 ± 5.45 ms in cases with mortality (n = 49) (p < 0.001). The mean time to application of the patients to the hospital (n = 227) was 19.1 ± 4.61 h, and blood sugar was 130.7 ± 32.09 mg/dL (p < 0.001). In addition, the mean pH of the cases (n = 227) was 7.14 ± 0.2, bicarbonate was 17.17 ± 4.86 mmol/L, the base deficit was −6.21 ± 3.18 mmol/L, the anion gap was 19.36 ± 7.31 mmol/L, and lactate was 4.82 ± 2.45 mmol/L (p < 0.001). Mortality occurred in 49 (21.6%) of the patients, and all of them were in-hospital deaths. In all cases where mortality occurred, pH was below 6.93 ± 0.22 and severe acidosis was directly related to death. MAP, sinus tachycardia in 31 (13.7%) cases, bradycardia in 8 (3.5%), atrial fibrillation in 5 (2.2%), accelerated idioventricular rhythm in 3 (1.3%), and 11 (4.8%), left bundle branch block, and right bundle branch block were detected in 22 (9.7%). All of these ECG findings were newly developed conditions with no previous history. In the 6-month follow-up after discharge, 4 (1.8%) of the cases developed neurological deficit, 15 (6.6%) had acute coronary syndrome and severe heart failure, 23 (10.1%) had permanent blindness, 6 (2.7%) had renal failure, and 6 (2.7%) had pancreatitis. Conclusion: Methyl alcohol poisoning can cause various ECG changes; sinus tachycardia, nonspecific changes, and QTc prolongation are the most common findings. These changes are more pronounced in cases of severe acidosis. Patients should be warned of late signs of MAP.

Chemotherapy-induced peripheral neuropathy among breast cancer survivors

This review investigates that effective cancer treatment enhances the number of survivors in Denmark, but late complications like chemotherapy-induced peripheral neuropathy (CIPN) are a challenge. CIPN affects sensory nerves and can persist post-treatment. Diagnosis relies on symptoms and the medical history. Treatment options are limited and management faces geographic disparities and clinical capacity issues. Future research targets predictive markers and possible preventative interventions. CIPN, among other late complications, remains a significant concern in survivorship care.

Long-term maintenance-related complications of brachiocephalic vein cannulations in neonates: A retrospective evaluation.

Neonates are relatively prone to immediate, early, and late complications related to central venous cannulation (CVC). Ultrasound-guided brachiocephalic vein (BCV) cannulation has proven to be safe in neonates. Although studies addressed the immediate and early complications of CVC via BCV in neonates, few explored long-term maintenance-related complications. To evaluate the incidences of long-term maintenance-related complications including central line-associated blood stream infection (CLABSI), central line-associated thrombosis (CLAT), and mechanical complications (CLAMC) of nontunneled BCV cannulation in neonates and their relationship with patient and catheter-related factors. This study included BCV cannulations of neonates with postconceptional age of ≤44 weeks performed between January 2018 and January 2023. The incidences of complications were determined. Correlations between complications and postconceptional age, body weight, indication for catheter placement, the size and side of the catheter, as well as catheter dwell time were analyzed. In total, 89 BCV cannulations performed in 71 neonates. The incidences were 19.3 [95%CI: 12.88-28.76] total complications, 5.9 [95%CI: 2.84-12.06] CLABSI, 3.4 [95%CI: 1.30-8.58] CLAT and 10.1 [95%CI: 5.76-17.49] CLAMC in 1000 catheter days. There were 23 (25.8%) total complications; 7 (7.9%) were CLABSI, 4 (4.5%) were CLAT, and 12 (13.5%) were CLAMC. The multivariate analysis revealed that prolonged dwell time was associated with high incidence of total complications [OR: 1.07, 95% CI: 1.00-1.14, p = .047] and the catheter of smaller size (3F in this study) was associated with higher incidence of CLABSI [OR: 8.91, 95% CI: 1.03-77.45, p = .047]. In this study, the prolonged dwell time and smaller sized catheter was found to be independent predictors of total complications and CLABSI, respectively. The independent predictive effects of postconceptional age and body weight should be addressed in larger studies as potential risk factors.

Continent urinary diversion and management of pouch calculi as a late complication: A case series

Objective: Following cystectomy, there are several reconstructive options. A continent cutaneous urinary diversion (CUD) avoids an ileal conduit if patients are unsuitable for an orthotopic neobladder. Reservoir stone formation is common, and management is challenging. Our data present incidence and management of calculi following Indiana pouch reconstruction after radical cystectomy. Patients and Methods: Prospective database review identified 30 patients with Indiana pouch CUD in our series of 450 open cystectomies. Paper, electronic medical records, and radiological imaging were reviewed. Results: Six (20%) patients with up to 15 years follow-up were identified with stones. At cystectomy, all patients were stone free with normal renal function and electrolytes. Time to first stone formation was 29–60 months. Eighty percent became recurrent stone formers. Management involved a combination of endoscopic LASER litholapaxy, percutaneous and open access. All patients had a functioning CUD following stone treatment. Time to stone recurrence improved with assessment for metabolic abnormalities, timed pouch emptying, pouch irrigation and treatment of urine infections. Conclusion: The risk of stone formation and requirement for rigorous post-operative prevention protocols should be discussed with patients. Follow-up for this group should be lifelong to include imaging and metabolic monitoring. Management requires a multimodal, multi-disciplinary approach. Level of evidence: Not applicable

8706 Hypoparathyroidism and Hypercalcemia in Premature Secondary to Excessive Vitamin D: Everything in Excess is Opposed

Abstract Disclosure: D.M. Bastos: None. A. Bastos: None. Introduction: Vitamin D intoxication in children is rare but its incidence is increasing as vitamin D is supplemented more often and in higher doses. Coma, ventricular fibrillation, and acute renal insufficiency are possible life-threatening presentations of vitamin D-induced hypercalcemia. Nephrocalcinosis, renal lithiasis, vascular calcifications, and arterial hypertension are known late complications of severe or longstanding hypercalcemia. The most common causes of vitamin D intoxication in children are manufacturing errors, parental dosing errors, and erroneous medical prescriptions. Case Presentation: A premature girl admitted to the neonatal ICU 3 months ago due to poor weight gain and was taking vitamin D and infant formulas and developed tachycardic heart rhythm with irregular rhythm and kidney changes. The investigation of the condition was re-evaluated, and the patient was seen with hypercalcemia, an increase of more than 100x in the dosage of 25(OH)vitamin D, an increase in the dosage of 1.25(OH)vitamin D, suppressed PTH, an increase in creatinine and urea. In addition, an ultrasound was performed showing the presence of small kidney stones, none of which were obstructive. After discontinuing vitamin D supplementation, the patient progressed satisfactorily with a reduction in cardiac and renal changes. Discussion: Currently, vitamin D supplementation has been carried out more frequently, as, in addition to increasing the absorption of calcium in the body, it reduces the risk of diseases, such as rickets and osteopenia of prematurity. The body is only able to produce vitamin D after exposure to sunlight. In the absence of regular exposure, dietary sources alone are not sufficient to maintain adequate levels. Cases of hypervitamin D generally occur in situations of excessive supplementation. In the present report, the dose used was 40 times higher than recommended. Initial tests revealed elevated calcium and undetectable PTH levels. The diagnosis of vitamin D intoxication is not common in cases of hypercalcemia, as it is infrequent, especially before the advent of vitamin D supplementation. Vitamin D toxicity is usually iatrogenic, or due to accidental overdose. These factors, along with a lack of public education about safe dosing, have likely contributed to the increase in reported cases of vitamin D toxicity. Conclusion: Vitamin D supplementation, especially when using compounded medications, must be adequately monitored due to the potential risk of poisoning. Vitamin D toxicity remains a pressing issue and its incidence will likely continue to grow, primarily because of the widespread availability of over-the-counter formulations and public interest. Presentation: 6/3/2024

9337 Postprandial And “Fasting” Hypoglycemia In A Patient With A History Of Gastric Bypass Surgery And Carcinoid Syndrome

Abstract Disclosure: S. Ntelis: None. M. Pennant: None. Background: Hypoglycemia is an increasingly recognized complication of bariatric surgery that can occur years after the procedure. Episodes most commonly occur 1-3 hours after meals. Fasting hypoglycemia is not typical and raises concerns for other etiologies, including adrenal insufficiency and other causes of endogenous hyperinsulinism. Clinical Case: A 51-year-old woman with a history of carcinoid tumor of unknown origin with liver metastases, treated with monthly octreotide injections, and history of Roux-en-Y gastric bypass presented with multiple episodes of symptomatic hypoglycemia up to 24 mg/dl. Symptoms included tremor and diaphoresis and improved with juice. Morning cortisol was 22.7 mcg/dL (n > 19.4 mc/dL), ruling out adrenal insufficiency. A continuous glucose monitor (CGM) was placed, and she was advised to have frequent low-carbohydrate meals mixed with healthy fats and protein. She was also advised to add cornstarch to meals, until mixed-meal testing could be performed. She was hospitalized for a seizure provoked by hypoglycemia after a heavy high-carbohydrate meal, and treatment with acarbose 25 mg three times daily was started. Mixed-meal testing was consistent with post-prandial hyper-insulinemic hypoglycemia, with elevated insulin (58 mcIU/ml, n: 2.6-24.9 mcIU/ml) and c-peptide (11.2 ng/ml, n: 1.1-4.4 ng/ml) levels during an episode of symptomatic hypoglycemia (glucose 22 mg/dL) 2.5 hours after the patient’s meal. CGM showed hypoglycemia mostly occurring after meals and some episodes of hypoglycemia early in the morning, that occurred after late-night snacks. Clinical picture and laboratory testing were suggestive of post-bariatric surgery hypoglycemia. Poor hepatic glycogen reserve, secondary to the liver metastases, was considered a contributing factor. Interestingly, although hypoglycemia was mediated by hyperinsulinemia, treatment with a somatostatin analogue provided no benefit. The frequency of hypoglycemia decreased with adherence to a low-carbohydrate diet, and episodes mostly occurred when acarbose use was delayed. Octreotide was transitioned to lantreotide. Due to persistence of early-morning low glucose values on follow-up, further work-up was pursued to rule out etiologies of fasting hypoglycemia. Glucose values remained >70 mg/dl during 72 hours of fasting. IGF-I (115 ng/ml, n: 53-287 ng/ml) and IGF-II (608 ng/ml, n: 267-616 ng/ml) levels were normal, and insulin antibodies were undetectable. Post-bariatric surgery hypoglycemia was confirmed and acarbose dose was increased to 50 mg three times daily. Conclusion: Postprandial hypoglycemia is a late complication of bariatric surgery. Early-morning hypoglycemia can also be seen after bariatric surgery in patients who have late-night meals and snacks. Presentation: 6/1/2024

Safety and efficacy of coated flow diverters in the treatment of cerebral aneurysms during single antiplatelet therapy: A multicenter study.

This multicenter study evaluates the safety and efficacy of coated flow diverters (cFDs) for the treatment of cerebral aneurysms under single antiplatelet therapy (SAPT). This is a retrospective, observational study of 41 patients (median age: 58 years) with 41 aneurysms (median size: 7 mm, 29 [71%] saccular, 9 [22%] ruptured) treated with cFDs at four neurovascular centers between 2020 and 2023. Scheduled cases received continuous SAPT starting seven days before the procedure. Emergency cases were treated with tirofiban followed by SAPT loading. The safety endpoint was ischemic complications occurring during the procedure and within four months of clinical follow-up. The Pipeline Vantage or Flex Shield was used in 26 (63%) procedures, the FRED X in 12 (29%), the p48/64 Hydrophilic Polymer Coating in 2 (5%), and the Derivo Embolization Device 2heal in 1 (2%). Single antiplatelet therapy consisted of prasugrel in 27 (66%) patients, ticagrelor in 9 (22%), and ASA in 5 (12%). There were 2 (5%) early ischemic complications (one minor stroke and one transient ischemic attack). There were no late ischemic complications in the four-month follow-up of 35 patients. The six dropouts included four nontreatment-related deaths after subarachnoid hemorrhage and two patients with a poor outcome after subarachnoid hemorrhage. Complete and favorable occlusion rates (median: 7 months) were 75% (27/36) and 89% (32/36), respectively. Coated flow diverter implantation in the setting of SAPT was safe and effective and warrants confirmation in a prospective comparative trial.

Endoscopic Ultrasound-Guided Radiofrequency Ablation (EUS-RFA) for Pancreatic Adenocarcinoma: A Review.

Pancreatic ductal adenocarcinoma (PDAC) is still one of the deadliest neoplasms in the world. Although various advancements in the treatment and management of this disease have been made, no significant overall survival benefit has been achieved. Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) has been proposed as a treatment for patients who are unfit for surgery or with inoperable PDAC. We conducted a literature review of the PubMed and Embase databases to identify and analyze studies on the use of EUS-RFA in inoperable PDAC. Eleven studies with a total of 122 patients were analyzed to assess the population characteristics, feasibility and safety of the procedure, and overall survival of the population. Technical success was achieved in 95.1% of cases, and no intraoperative complications were reported. The most common early complication reported was abdominal pain (21 out of 122 patients) with a total early complication rate of 29.6%, and none of these complications affected hospital stays or post-procedure recovery. Late complications were reported in four patients (3.2%). Post-procedure cytoreduction was achieved in all patients, although disease progression was reported in 119 of 122 patients. The overall survival rate did not differ from that reported in the literature. We found that EUS-RFA could be a valid palliative option for inoperable patients,a bridge for surgeryreducing the size of the tumor and its vascular relationship, or a first-line therapy in a subset of selected patients. Larger cohort and prospective studies should be conducted to establish guidelines for this procedure.

The anesthetic implications of lumbar tattoos.

Lumbar and sacral tattoos are popular amongst all ages. Some physicians are concerned that passing a needle through a pigmented area during lumbar puncture may deposit toxic material into the central nervous system, resulting in late complications. In this review, we highlight the tattooing process with an emphasis on anatomy and physiology of the skin, and the pathophysiology and toxicology of tattoos. We conclude that there is perhaps no evidence yet to suggest that pigment can be transported into the central nervous system from a well healed tattoo. There is insufficient evidence to endorse placement of a needle through a tattoo into the neuraxis before it is completely healed. The Fermi paradox 'absence of evidence is not evidence of absence of effect' still holds in light of emerging evidence that tattoos may be linked to lymphoma.

Association of Clinical Findings With Complications in the Cubitus Varus Deformity After Supracondylar Fracture.

Cubitus varus deformity is primarily a cosmetic complaint that causes some early and late complications. However, no studies have reported the cubitus varus deformity regarding the frequency of complications, relationship to the degree of deformity, and period from the occurrence of the initial injury. Overall, 83 patients with cubitus varus deformity were examined. The differences in the humerus-elbow-wrist angle (∆HEW-A), tilting angle (∆TA), and internal rotation angle (∆IRA) between the affected and normal sides were measured to determine varus and extension and internal rotation deformity. The period from the occurrence of the initial injury to the evaluation date was also investigated. Multivariate logistic regression analysis was conducted to identify the explanatory variables (period, ∆HEW-A, ∆TA, and ∆IRA) independently associated with complication events. Receiver-operating characteristic curve analysis was also conducted to predict the risk of events. ∆HEW-A was independently associated with the risk of cosmetic complaint (odds ratio [OR], 1.171; 95% confidence interval [95% CI], 1.056 to 1.336) and instability (OR, 1.111; 95% CI, 1.028 to 1.200). ∆TA was independently associated with the risk of limited elbow motion (OR, 1.176; 95% CI, 1.077 to 1.285) and sports disability (OR, 0.892; 95% CI, 0.836 to 0.952). The period from the occurrence of the initial injury was independently associated with risk of pain (OR, 1.063; 95% CI, 1.019 to 1.108), ulnar nerve neuropathy (OR, 1.065; 95% CI, 1.011 to 1.125), and osteoarthritis (OR, 1.188; 95% CI, 1.098 to 1.286). The receiver-operating characteristic curve analysis revealed the optimal cutoffs of 20° and 27° for ∆HEW-A to predict cosmetic complaint and instability; of 25° for ∆TA to predict limited elbow motion; and of 8.8, 8.0, and 16.0 years for the period to predict pain, ulnar nerve neuropathy, and osteoarthritis, respectively. The treatment of cubitus varus deformity should be determined because a residual deformity >20° of varus and 25° of extension could develop risk of complications over time.

Paradoxical cerebral embolism three decades after mustard surgery in a patient with complete transposition of the great arteries: a case report.

Atrial switch procedures such as the Mustard operation were previously popular for the complete transposition of the great arteries (i.e. dextro-transposition of the great arteries [d-TGA]). Patients with d-TGA who underwent atrial switch procedures approximately three decades ago have now entered adulthood. A female patient in her 30s with d-TGA had a paradoxical embolic stroke following the initiation of a low-dose oestrogen plus progesterone oral pill for dysmenorrhoea. She underwent Mustard surgery when she was 2 years old. Following a series of procedures including implantation of a permanent pacemaker that was required because of sinus node dysfunction, she had reached adulthood, was living by herself and working independently. One month after taking the low-dose oestrogen plus progesterone oral pill, venous thrombosis occurred in the left soleus and left peroneal veins; and she experienced an acute ischaemic stroke in the right middle cerebral artery area. Transoesophageal echocardiography revealed that the shunt was present only during the Valsalva manoeuvre. Based on the examinations, the patient was diagnosed with juvenile ischaemic stroke as a result of a paradoxical embolism. These findings suggest that paradoxical cerebral embolism can occur as a late complication in patients with d-TGA who underwent the Mustard operation as children.