Challenging Orthodoxy: beyond the Critical View of Safety.

BACKGROUND: The critical view of safety (CVS) is the gold standard for performing safe cholecystectomies and minimizing common bile duct (CBD) injuries. It requires three criteria: complete clearance of the hepatocystic triangle, partial separation of the gallbladder from the cystic plate, and two structures alone entering the gallbladder. However, biliary anatomy varies widely, with frequent aberrant arterial supplies, which can mislead or disorient those attempting to acquire the CVS. This study was designed to examine the nature and frequency of cystic artery anatomic anomalies. METHODS: We conducted a prospective observational study from 2018 to 2020, compiling photos of the critical view of safety of 100 consecutive elective cholecystectomies performed at our institution. Gallbladders were dissected up to the parallel portion of the cystic plate to achieve a critical view of safety. All tubular structures were preserved and clipped. Operative reports were examined for mention of posterior cystic arteries or aberrant arterial supplies. Photos were reviewed for an adequate critical view of the safety and presence of aberrant arterial supplies. The rate of aberrant arterial supply was determined and photos were reviewed for patterns of common abnormalities. RESULTS: There were 121 patients who underwent an elective cholecystectomy; 21 lacked intraoperative pictures and were excluded from the study. Of the 100 patients included, 57 (57%) had an aberrant arterial supply with more than one cystic artery; seven had three concurrent arteries. Of those with more than one cystic artery, 21% had a recurrent cystic artery, 21% had a posterior dominant cystic artery, and 12% had a low-branching anterior cystic artery. CONCLUSION: Even with appropriate dissection for the CVS, surgeons can expect to frequently visualize more than two structures entering the gallbladder when a posterior cystic artery is present. It is, therefore, integral to distinguish this aberrant anatomy to prevent inadvertent injury to the CBD.

Endoluminal vacuum therapy for rectal anastomosis is safe and does not increase risk of strictures in a swine model.

Background: Endoluminal vacuum therapy has been experimentally used in patients with esophageal, rectal, and Roux-en-Y bypass surgery. Yorkshire pigs are good animal models for studying the safety and efficacy of endoluminal vacuum therapy and prior studies have employed these devices in rectal anastomotic defects, as rescue therapy for early anastomotic leaks, as well as prophylactic therapy as a means of protecting high risk anastomosis. Aim: The objective of this study is to assess the effects of a prophylactic vacuum assist device on bowel tissue surrounding an intact anastomosis at 30 days post device removal. Methods: A total of seven pigs underwent a rectal resection with primary anastomosis: five experimental pigs with a prophylactic endoluminal vacuum device in place for 5 days post-surgery and two control pigs with no device. All animals were euthanized on the 35th post-operative day and subjected to a necropsy with a histopathological evaluation of the rectal anastomosis. Results: No significant difference in inflammation or strictures was observed between the anastomosis of animals with the endoluminal vacuum devices and controls. Conclusion: We, therefore, conclude that endoluminal vacuum therapy is safe for prophylactic use in pigs undergoing low anterior resection and does not cause significant strictures. Relevance for Patients: Anastomotic leak is a feared complication resulting in increased costs, length of stay, and emotional distress. Endoluminal negative pressure vacuum therapy is a new technology that has been used in experimental models in both animals and humans for prevention and treatment of anastomotic leak. In this series we demonstrate endoluminal vacuum therapy is safe in a porcine model and does not result in stricture or increased adhesion formation. We expect endoluminal vacuum therapy to become more widely used in the future in both prevention and treatment of anastomotic leaks.

Evolution of homo-oligomerization of methionine S-adenosyltransferases is replete with structure-function constrains.

Homomers are prevalent in bacterial proteomes, particularly among core metabolic enzymes. Homomerization is often key to function and regulation, and interfaces that facilitate the formation of homomeric enzymes are subject to intense evolutionary change. However, our understanding of the molecular mechanisms that drive evolutionary variation in homomeric complexes is still lacking. How is the diversification of protein interfaces linked to variation in functional regulation and structural integrity of homomeric complexes? To address this question, we studied quaternary structure evolution of bacterial methionine S-adenosyltransferases (MATs)-dihedral homotetramers formed along a large and conserved dimeric interface harboring two active sites, and a small, recently evolved, interdimeric interface. Here, we show that diversity in the physicochemical properties of small interfaces is directly linked to variability in the kinetic stability of MAT quaternary complexes and in modes of their functional regulation. Specifically, hydrophobic interactions within the small interface of Escherichia coli MAT render the functional homotetramer kinetically stable yet impose severe aggregation constraints on complex assembly. These constraints are alleviated by electrostatic interactions that accelerate dimer-dimer assembly. In contrast, Neisseria gonorrhoeae MAT adopts a nonfunctional dimeric state due to the low hydrophobicity of its small interface and the high flexibility of its active site loops, which perturbs small interface integrity. Remarkably, in the presence of methionine and ATP, N. gonorrhoeae MAT undergoes substrate-induced assembly into a functional tetrameric state. We suggest that evolution acts on the interdimeric interfaces of MATs to tailor the regulation of their activity and stability to unique organismal needs.

The Rise and Fall of Percutaneous Cholecystostomy in a Community Hospital: Is It Possible to Turn the Tide of History?

BACKGROUND: Laparoscopic cholecystectomy is the gold standard for treatment of acute cholecystitis. Percutaneous cholecystostomy (PC) drains are alternatives to cholecystectomy in critically ill patients in whom surgery carries an unacceptably high risk. Recently, several studies demonstrated a significant increase in complications in patients undergoing PC in comparison to laparoscopic cholecystectomy. METHODS: We conducted a retrospective analysis of patients who underwent PC drainage or cholecystectomy from 2014 through 2019 at our institution. We determined the rate of PC use and performed a linear regression analysis to evaluate PC utilization over time. After creating institutional guidelines and reeducating physicians on appropriate use of PC drainage in 2019, we compared PC utilization to prior years. RESULTS: A total of 146 PCs and 3163 cholecystectomies were performed over the study period. Of the cholecystectomies, 754 (23.8%) were performed in hospitalized patients under urgent or emergent conditions. Of the patients with acute cholecystitis, 16.2% were treated with PC. Linear regression analysis demonstrated a significant association between year and rate of PC procedures (p<0.001). The rate of PC rose from 13.8 to 22.5% between 2014 and 2018 and dropped to 10.9% (p=0.006) in 2019 after the reeducation program. CONCLUSIONS: With a rising rate of PC utilization and in light of recent studies suggesting increased complications and healthcare costs for patients undergoing this procedure, care needs to be taken to ensure that only appropriate patients are referred for PC. Publication of institutional guidelines, resident and attending surgeon reeducation, and case review can reduce placement of unnecessary PCs.

Suicide Risk Screening in Pediatric Outpatient Neurodevelopmental Disabilities Clinics.

OBJECTIVE: The purpose of this study was to describe the implementation of universal suicide risk screening in pediatric neurodevelopmental disabilities (NDD) medical clinics, analyze demographic and clinical characteristics of eligible patients, describe outcomes of positive screenings, and describe factors that influenced participation in screenings. METHODS: A suicide risk screening protocol was developed and implemented for medical clinic patients aged 8 to 18 years. Registered nurses screened patients using the "Ask Suicide-Screening Questions" tool during triage. Positive screenings were referred for further assessment and mental health management. Demographics and clinical data were extracted from medical records using retrospective chart reviews. RESULTS: During the 6-month study period, 2961 individual patients presented for 5260 screening eligible patient visits. In total, 3854 (73.3%) screenings were completed with 261 (6.8%) positive screenings noted. Screenings were declined in 1406 (26.7%) visits. Parents of children with cognitive impairments were more likely to decline screening. Clinics serving children with autism spectrum disorder had higher rates of positive screenings compared with all other clinic attendees. Seventy-two of 187 children (38.5%) with positive screenings were identified and referred to outpatient mental health referrals. Seven (2.5%) of these children required acute psychiatric treatment. CONCLUSION: Routine screening, identification of increased suicide risk, and referral to mental health care among children with NDD are feasible. It remains unclear whether variation in rates among youth with and without NDD may indicate true differences in suicide risk or cognitive impairments or reflect psychiatric comorbidities. High rates of declined participation may have influenced identification of children with NDD and suicide risk. Preliminary findings identified groups of children with NDD at heightened risk for suicidal ideation and behavior. Further research is needed to assess the validity of suicide risk screening tools in children with neurodevelopmental disorders.

SAMase of Bacteriophage T3 Inactivates Escherichia coli's Methionine S-Adenosyltransferase by Forming Heteropolymers.

S-Adenosylmethionine lyase (SAMase) of bacteriophage T3 degrades the intracellular SAM pools of the host Escherichia coli cells, thereby inactivating a crucial metabolite involved in a plethora of cellular functions, including DNA methylation. SAMase is the first viral protein expressed upon infection, and its activity prevents methylation of the T3 genome. Maintenance of the phage genome in a fully unmethylated state has a profound effect on the infection strategy. It allows T3 to shift from a lytic infection under normal growth conditions to a transient lysogenic infection under glucose starvation. Using single-particle cryoelectron microscopy (cryo-EM) and biochemical assays, we demonstrate that SAMase performs its function by not only degrading SAM but also by interacting with and efficiently inhibiting the host's methionine S-adenosyltransferase (MAT), the enzyme that produces SAM. Specifically, SAMase triggers open-ended head-to-tail assembly of E. coli MAT into an unusual linear filamentous structure in which adjacent MAT tetramers are joined by two SAMase dimers. Molecular dynamics simulations together with normal mode analyses suggest that the entrapment of MAT tetramers within filaments leads to an allosteric inhibition of MAT activity due to a shift to low-frequency, high-amplitude active-site-deforming modes. The amplification of uncorrelated motions between active-site residues weakens MAT's substrate binding affinity, providing a possible explanation for the observed loss of function. We propose that the dual function of SAMase as an enzyme that degrades SAM and as an inhibitor of MAT activity has emerged to achieve an efficient depletion of the intracellular SAM pools. IMPORTANCE Self-assembly of enzymes into filamentous structures in response to specific metabolic cues has recently emerged as a widespread strategy of metabolic regulation. In many instances, filamentation of metabolic enzymes occurs in response to starvation and leads to functional inactivation. Here, we report that bacteriophage T3 modulates the metabolism of the host E. coli cells by recruiting a similar strategy: silencing a central metabolic enzyme by subjecting it to phage-mediated polymerization. This observation points to an intriguing possibility that virus-induced polymerization of the host metabolic enzymes is a common mechanism implemented by viruses to metabolically reprogram and subdue infected cells.

Operating-Room Procedures Do Not Increase Risk of COVID-19 Infection.

BACKGROUND AND OBJECTIVES: Operating-room procedures canceled due to the COVID-19 pandemic depleted hospital revenue and potentially worsened patient outcomes through disease progression. Despite safeguards to resume elective procedures, patients remain apprehensive of contracting COVID-19 during hospitalization and recovery. We investigated symptomatic COVID-19 infection in patients undergoing operating-room procedures during the spring 2020 outbreak in Fairfield County, CT, a heavily affected New York Metropolitan area. METHODS: We retrospectively analyzed 419 operating-room patients in Danbury and Norwalk Hospitals between 3/16/20 and 5/19/20. COVID-19 infection was assessed through test results or documented well-being within 2 weeks postdischarge. Variables studied were procedure classification, length of stay, and discharge disposition. Postprocedural COVID-19 infection was analyzed using binomial tests comparing rates to state-mandated infection data. RESULTS: Six patients developed COVID-19 after 212 urgent-elective and 207 emergent procedures. Overall postprocedural infection risk was equivalent to community infection risk (P > .05). No infections occurred in 1-2 day stays or urgent-elective procedures with discharge home (both P < .05). Discharges home reduced the risk to one-sixth of community spread (P = .03). Risk of infection doubled in hospitalizations > 5 days (P = .05) and quadrupled in discharges to extended care facilities (P = .01). DISCUSSION: Operating-room procedures did not increase the risk of symptomatic COVID-19 infection during an outbreak. Urgent-elective and emergent procedures during further outbreaks appear safe when anticipating short stays with discharges home. When anticipating prolonged hospitalization or discharges to facilities, appropriate delay of urgent-elective procedures may minimize risk of infection.

Has COVID-19 Hurt Resident Education? A Network-Wide Resident Survey on Education and Experience During the Pandemic.

PURPOSE: As the COVID-19 pandemic continues to evolve, the healthcare system has been forced to adapt in myriad ways. Residents have faced significant changes in work schedules, deployment to COVID-19 units, and alterations to didactics. This study aims to identify the effects of the COVID-19 pandemic on resident perception of their own education within the Nuvance Health Network. METHODS: We conducted an observational study assessing resident perception of changes in education and lifestyle during the COVID-19 pandemic. A survey was developed to assess the quality and quantity of resident education during this time and administered anonymously to all residents within the healthcare network. RESULTS: Eighty-four (68%) residents responded to the survey from 5 different specialties, including general surgery, internal medicine, obstetrics and gynecology, pathology, and radiology. The average change in hours per week performing clinical work was -6 hours (SD = 17; P = .003), in time studying was +0 hours (SD = 5; P = .96), in weekly didactics was -2 hours (SD = 3; P < .001), and in attending involvement was -1 hours (SD = 2; P < .001). Additionally, 32% of residents expressed concern that the pandemic has diminished their preparedness to become an attending, 13% expressed concern about completing graduation requirements, and 3% felt they would need an additional year of training. CONCLUSION: During the COVID-19 pandemic thus far, residents perceived that time spent on organized didactics/conferences decreased and that attending physicians are less involved in education. Furthermore, the majority of residents felt that the quality of didactic education diminished as a result of the pandemic. Surprisingly, while many residents expressed concerns about being prepared to become an attending, few were concerned about completing graduation requirements or needing an extra year of education. In light of these findings, it is critical to devote attention to the effects of the pandemic on residents' professional trajectories and create innovative opportunities for improving education during this challenging time.

Impacts on Surgery Resident Education at a First Wave COVID-19 Epicenter.

PURPOSE: This study aims to identify the effects of the COVID-19 pandemic on surgical resident training and education at Danbury Hospital. METHODS: We conducted an observational study at a Western Connecticut hospital heavily affected by the first wave of the COVID-19 pandemic to assess its effects on surgical residents, focusing on surgical education, clinical experience, and operative skills development. Objective data was available through recorded work hours, case logs, and formal didactics. In addition, we created an anonymous survey to assess resident perception of their residency experience during the pandemic. RESULTS: There are 22 surgical residents at our institution; all were included in the study. Resident weekly duty hours decreased by 23.9 hours with the majority of clinical time redirected to caring for COVID-19 patients. Independent studying increased by 1.6 hours (26.2%) while weekly didactics decreased by 2.1 hours (35.6%). The operative volume per resident decreased by 65.7% from 35.0 to 12.0 cases for the period of interest, with a disproportionately high effect on junior residents, who experienced a 76.2% decrease. Unsurprisingly, 70% of residents reported a negative effect of the pandemic on their surgical skills. CONCLUSIONS: During the first wave of the COVID-19 pandemic, surgical residents' usual workflows changed dramatically, as much of their time was dedicated to the critical care of patients with COVID-19. However, the consequent opportunity cost was to surgery-specific training; there was a significant decrease in operative cases and time spent in surgical didactics, along with elevated concern about overall preparedness for their intended career.

Accuracy of Ultrasound in Diagnosing Gallbladder Polyps at a Community Hospital.

BACKGROUND AND OBJECTIVES: Polyps are reported on 1-10% of routine transabdominal ultrasound studies of the gallbladder. Prior studies have reported poor sensitivity and specificity for this diagnostic modality at determining malignant potential of polyps. The aim of this study is to determine the incidence of gallbladder polyps documented on ultrasound at a community hospital, evaluate the congruency of ultrasound with final histopathology, and explore factors which may improve ultrasound accuracy at diagnosing true adenomatous polyps. METHODS: We conducted a 5-year retrospective cohort study of patients undergoing cholecystectomy at Danbury Hospital between 2014 and 2019, identifying those with a pre-operative ultrasound mention of a "polyp" or "mass." We assessed the congruency of ultrasound findings with pathology reports. RESULTS: Of the 2,549 cholecystectomies performed, 1,944 (76%) had pre-operative ultrasounds. Of those, 98 (5.0%) reported a polyp, measuring an average of 8.1 mm (SD 7.1 mm). Three (3.1%) specimens were identified as adenomas on final histopathology; the majority were benign pathologies including cholesterol polyp (18), cholesterolosis (20), adenomyoma (4), adenomyomatosis (7), and chronic or acute cholecystitis (44). Interestingly, only 1 of the 3 adenomas measured > 10 mm on ultrasound, the accepted indication for surgical resection. CONCLUSIONS: The accuracy of transabdominal ultrasound in diagnosing true polyps is poor, with only 3% of polyps identified as adenomas based on pathology. Surgeons should use caution when making clinical decisions based on polyps identified on ultrasound, and more stringent diagnostic criteria are needed in order to decrease the false positive rate for diagnosis and screening.

The interdimeric interface controls function and stability of Ureaplasma urealiticum methionine S-adenosyltransferase.

Methionine S-adenosyltransferases (MATs) are predominantly homotetramers, comprised of dimers of dimers. The larger, highly conserved intradimeric interface harbors two active sites, making the dimer the obligatory functional unit. However, functionality of the smaller, more diverged, and recently evolved interdimeric interface is largely unknown. Here, we show that the interdimeric interface of Ureaplasmaurealiticum MAT has evolved to control the catalytic activity and structural integrity of the homotetramer in response to product accumulation. When all four active sites are occupied with the product, S-adenosylmethionine (SAM), binding of four additional SAM molecules to the interdimeric interface prompts a ∼45° shift in the dimer orientation and a concomitant ∼60% increase in the interface area. This rearrangement inhibits the enzymatic activity by locking the flexible active site loops in a closed state and renders the tetramer resistant to proteolytic degradation. Our findings suggest that the interdimeric interface of MATs is subject to rapid evolutionary changes that tailor the molecular properties of the entire homotetramer to the specific needs of the organism.

Use of an Insulin Pump in the Elderly Surgical Patient: Tolerance of Total Pancreatectomy After Neoadjuvant Chemotherapy for Multifocal Pancreatic Cancer.

Introduction: Pancreatic cancer is one of the most fatal cancers if not caught early and is associated with late disease presentation. Multifocal pancreatic cancer is particularly difficult to treat as cases that are amenable to surgical resection require total pancreatectomy. Such patients will develop brittle diabetes as they require exogenous insulin after surgery and in the apancreatic state lose counter-regulatory homeostatic mechanisms (i.e., glucagon). We present an elderly patient who underwent neoadjuvant chemotherapy and total pancreatectomy. The patient has adequate glycemic control postoperatively being managed with an insulin pump and remains disease free at 3 years and 3 months after resection. Case Presentation: A 72-year-old male presented with two tumors, in the head and tail of the pancreas, respectively, which were consistent with pancreatic adenocarcinoma by endoscopic ultrasound biopsy. Neoadjuvant FOLFIRINOX had been administered and total pancreatectomy was performed. The patient did well postoperatively and was discharged on postoperative day 8. The patient was seen by endocrinology pre- and postoperatively who started an insulin pump for glycemic management 2 weeks postoperatively. The patient's HbA1c was 7.9% at 3 months. The patient remains disease free at 3 years and 3 months with an HbA1c of 7.0% and a normal CA19-9. Conclusion: This case highlights that glycemic control after total pancreatectomy with the use of an insulin pump in the elderly population is achievable. Elderly patients can struggle with certain technologies and selecting appropriate patients for insulin pump therapy after total pancreatectomy is imperative.

Endoluminal vacuum therapy for gastrojejunal anastomotic leaks after Roux-en-Y gastric bypass: a pilot study in a swine model.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) consistently produces the most sustainable weight loss among common interventions for morbid obesity. Anastomotic leaks at the gastrojejunal (GJ) connection result in severe morbidity. We apply endoluminal negative pressure vacuum devices (EVD) to heal anastomotic leaks in a swine model. METHODS: RYGB was performed in 10 pigs (3 control, 7 experimental). GJ anastomoses were fashioned, and a 2-cm defect was made across the staple line. In controls, the defects remained open. In experimental pigs, the EVD was placed across the defect and kept at continuous 50 mmHg suction. All pigs were euthanized on postoperative day seven unless they displayed signs of peritonitis or sepsis. Fluoroscopy and necropsy were performed to assess a persistent leak, and tissue specimens were sent to histology to evaluate for degree of inflammation and ischemia. RESULTS: All three control pigs' GJ anastomoses demonstrated evidence of a persistent leak. All seven experimental pigs with the EVD in place showed evidence that their leak had sealed at time of fluoroscopy (p value 0.008). CONCLUSIONS: Endoluminal vacuum therapy is well tolerated in a swine model. GJ anastomotic leaks were consistently sealed with our device in place compared to controls. This therapy shows promise as a method to address GJ leaks in the bariatric population, and thus, we believe additional evaluation is warranted.

Delayed endoluminal vacuum therapy for rectal anastomotic leaks after rectal resection in a swine model: a new treatment option.

Anastomotic leaks are a dreaded surgical complication following colorectal operations. Creation of a temporary proximal diverting ileostomy is used in high-risk anastomoses, however, additional surgical risk is accumulated with its creation and reversal. Endoluminal vacuum therapy has been shown to seal anastomotic defects in the prophylactic setting in a pig model and we hypothesized it could be utilized in a delayed fashion to rescue subjects with an active anastomotic leak. Yorkshire pigs underwent rectal resection, intentional leak confirmed by fluoroscopy, and endoluminal vacuum therapy device placement to low continuous suction. Following treatment, a contrast enema and necropsy was performed for gross and histopathology. Pigs underwent 2 (or 5) days of free intraperitoneal leak prior to device placement and 5 (or 7) subsequent days of endoluminal vacuum therapy. Six of seven early-treated pigs sealed their anastomotic defect, while two of the four treated pigs in this extended group sealed the defect. Endoluminal vacuum therapy is feasible and well tolerated in a pig model, and it has been shown to seal a significant number of freely leaking anastomoses in the early period (86%). This technology warrants further study as it may provide a noninvasive means to treatment of anastomotic leaks.

Endoluminal negative-pressure therapy for preventing rectal anastomotic leaks: a pilot study in a pig model.

BACKGROUND: Anastomotic leak after rectal resection carries substantial morbidity and mortality. A diverting ileostomy is beneficial for high-risk anastomoses, but its creation and reversal carry a surgical risk in addition to that of resection itself. We sought an alternative method for managing complications of rectal anastomosis. METHODS: We developed an endoluminal negative-pressure technology with a diverting proximal sump, and hypothesized that it would close anastomotic disruptions in pigs. We performed rectal resections on pigs, with primary anastomoses and the creation of an anastomotic defect. In animals in the treatment group we inserted an endoluminal negative-pressure device and kept it at a low level of continuous suction for 5 d. No device was inserted in a control group of animals. After the 5-d period of treatment we evaluated the anastomoses in both the treatment and control groups of animals for leakage, using contrast enemas. Specimens of anastomosed rectum were evaluated histologically for mucosal integrity and for the location and density of inflammatory responses. RESULTS: Fourteen pigs were assigned to either the treatment (n=10) or control (n=4) group. Of the pigs in the treatment group, 90% had complete closure of their rectal defect, as compared with 25% of the animals in the control group (χ(2) test, p=0.04). The animals in the treatment group had only minimal mucosal and serosal inflammation, whereas those in the control group had extensive mucosal damage with associated serositis. CONCLUSIONS: Endoluminal negative-pressure therapy was well-tolerated and led to successful closure of 90% of the anastomic rectal defects in the treatment group of animals in the present study. Additional evaluation of this therapy is warranted.

Healing of complicated gastric leaks in bariatric patients using endoscopic clips.

INTRODUCTION: Endoscopists have used clipping devices to successfully close acute, iatrogenic perforations throughout the gastrointestinal tract. We applied this technology to our bariatric patients, who tend to present with a more delayed anastomotic leak, to determine whether these leaks and fistulae would also heal with endoclip application. CASE DESCRIPTION: We describe a small series of 2 clinically stable bariatric patients who presented with postoperative anastomotic leaks who met criteria for non-operative therapy. The first underwent a laparoscopic Roux-en-Y gastric bypass and presented postoperatively with a leak at her gastrojejunal anastomosis. The location was not amenable to stent placement; therefore, 2 endoclips were placed. The leak was sealed by fluoroscopic examination 14 d later. The second had a reversal of a previous gastric bypass, creating a new gastrogastric anastomosis. A leak was found at this new connection postoperatively. After failure of a stent to seal the leak, 8 endoclips were used. This patient also had successful closure of her leak on fluoroscopy 14 d postprocedure. DISCUSSION: Anastomotic leaks after bariatric surgery can incur severe morbidity, cost, and detriment to patients' quality of life. Unstable patients require operative intervention. Stable patients are candidates for more-conservative measures. Endoscopic stents have been successful in closing gastric leaks, though some are not anatomically amenable to stent placement, and stents also have the potential to migrate distally. We demonstrate 2 cases of successful closure of leaks in bariatric patients by using endoclips and suggest that this be considered an option in appropriate cases.

Unusual anomaly complicating abdominal aortic aneurysm repair: anterior inferior vena cava.

This case illustrates an unusual anomaly of the great veins. To our knowledge, these are the first published photographs of the vena cava traversing anterior to the distal aorta. This anatomic variant caused minor technical problems during open abdominal aortic aneurysm repair.

Evaluation and management of abdominal lymphoceles after anterior lumbar spine surgery.

STUDY DESIGN: Case report. OBJECTIVE: To examine the management of abdominal lymphoceles after anterior spine surgery and to review the existing literature on lymphoceles after access to the spine. SUMMARY OF BACKGROUND DATA: Abdominal lymphoceles are a rare complication of anterior spinal approaches. METHODS: Case report and review of the literature. RESULTS: In this article, we describe the management of 2 lymphoceles. In the first case, immediate operative drainage was required because of worsening abdominal pain and distention. In the second patient, conservative management was attempted, but the lymphocele ultimately persisted and required surgical intervention. CONCLUSION: Lymphoceles are often difficult to distinguish from ureteral injury, cerebrospinal fluid-leaks and hematomas using conventional imaging techniques. Although surgery remains the gold standard for the treatment of lymphoceles, expectant observation may be reasonable in some situations.