Bleeding from a duodenal varix: a unique case of variceal hemostasis achieved using EUS-guided placement of an embolization coil and cyanoacrylate.

We report a case of a bleeding duodenal varix demonstrating excellent hemostasis achieved by endoscopic ultrasound (EUS)-directed placement of an embolization coil followed by cyanoacrylate. A 31-year-old man with decompensated Child's class C cirrhosis presented with hematemesis. An initial endoscopy revealed an actively bleeding duodenal varix. Subsequent attempt at hemostasis with ethanolamine oleate injection failed. A later attempt at hemostasis involving EUS-guided placement of an embolization coil followed by cyanoacrylate injection into the varix was successful. We reviewed the literature involving the treatment of bleeding ectopic varices and conclude that EUS provides a unique and advantageous modality for achieving variceal hemostasis of duodenal varices in patients who are not candidates for transjugular intrahepatic portosystemic shunt.

Elevated HbA1c is an independent predictor of aggressive clinical behavior in patients with colorectal cancer: a case-control study.

AIM: The aim of this study was to seek an association between the control of type 2 diabetes mellitus (T2DM), as determined by hemoglobin A1c (HbA1c) levels, and the outcome of colorectal cancer (CRC). METHODS: We performed a retrospective review of patients with T2DM who had CRC diagnosed between 1997 and 2001. We defined well-controlled T2DM as HbA1c < 7.5% and poorly controlled T2DM as HbA1c > or = 7.5%. A group of age- and gender-matched patients who had CRC without T2DM were used as controls. Forty clinical factors were reviewed, and those associated with poor clinical outcome in each group were examined by univariate analysis (UA) and by the maximum likelihood analysis of logistic regression to determine the independent predictors of cancer outcome. RESULTS: We identified 155 patients with T2DM and CRC, and 114 control patients who had CRC without T2DM. We found no significant differences in any clinical factor by UA between the patients with well-controlled T2DM and the patients who had CRC without T2DM. Compared to both of those patients groups, in contrast, the patients with poorly controlled T2DM had more right-sided CRCs (P = 0.04, OR = 2, 95% CI = 1-4.1), more advanced CRCs (P = 0.02, OR = 2.1, 95% CI = 1-4.4), a younger age of presentation (P = 0.05), greater use of exogenous insulin (P = 0.002), and a poorer 5-year survival (P = 0.001) by UA. Logistic regression showed that poorly controlled T2DM independently predicted the early onset of CRC, a more advanced stage at the time of presentation, poorer 5-year survival, and an increased incidence of right-sided CRCs. CONCLUSIONS: In patients with T2DM who have CRC, poor glycemic control is associated with a clinically aggressive course for the cancer.

Preoperative weight loss decreases the operative time of gastric bypass at a Veterans Administration hospital.

BACKGROUND: This study assessed whether preoperative weight loss resulted in favorable outcomes after open Roux-en Y gastric bypass (RYGB). METHODS: A retrospective review of all patients who underwent RYGB at the DVAMC was undertaken. Patients were divided into: patients who did not lose weight within 3 months preoperatively (n=25) and group II, those who did (n=15). RESULTS: Both groups had similar demographics, body mass index, comorbid conditions, and American Society of Anesthesiology class. Group II lost 28.2+/-6.5 lbs (8.3% of body weight) within 3 months before RYGB. Operative time was longer in group I compared to group II (180.0+/-0.0 vs 161.0+/-0.0 min; p=0.05). Both groups had the same rate of postoperative complications and the same long-term weight loss at a 2-year follow-up (n=6 both groups). CONCLUSIONS: An 8% reduction of body weight is associated with a decrease in operative time. These preliminary data suggest that preoperative weight loss results in a technically less challenging operation in the super-obese patient.