Endoscopic tattoo: the importance and need for standardised guidelines and protocol.

Preoperative endoscopic tattoo is becoming more important with the advent of minimally invasive surgery. Current practices are variable and are operator-dependent. There are no evidence-based guidelines to aid endoscopists in clinical practice. Furthermore, there are still a number of issues with endoscopic tattoo including poor intraoperative visualisation, complications from tattooing and inaccurate documentation leading to the need for intraoperative endoscopy, prolonged operative time and reoperation due to lack of oncologic resection. This review aims to collate and summarise evidence for the best practice of endoscopic tattoo for colorectal lesions in order to provide guidance for endoscopists.

Laparoscopic-assisted percutaneous endoscopic gastrostomy: insertion of a skin-level device using a tear-away sheath.

BACKGROUND: This study describes our experience with the placement of a skin-level gastrostomy device (MIC-KEY) in a single procedure. METHODS: We identified infants, children and young adults who underwent laparoscopic-assisted percutaneous endoscopic gastrostomy (LAPEG) tube insertion between October 2009 and June 2013. The steps of this procedure include upper endoscopy, single-port laparoscopy, gastropexy via percutaneous T-fasteners and placement of a skin-level gastrostomy device (MIC-KEY) using a "push" technique with a tear-away sheath. RESULTS: We included 92 patients in our study. Mean age was 3.7 years (range 3 wk-5 yr), and mean weight was 11.2 (range 2.8-54) kg. Median procedural time was 20 (range 12-76) minutes. Total median duration for the most recent 25 procedures was lower than that of the first 25 (62 v. 79 min, p = 0.004). There were no intraoperative complications or conversions to open surgery. Postoperative complications were observed in 6 (6.5%) patients. Three retained T-fasteners were assessed endoscopically (n = 1) or removed via local excision (n = 2). Two patients experienced early dislodged feeding tubes that were replaced via interventional radiology (n = 1) or repeat LAPEG (n = 1). There was also 1 intra-abdominal fluid collection that was drained percutaneously but ultimately required a laparotomy and washout. There were no major complications in the most recent 50 procedures. CONCLUSION: Our results suggest that LAPEG is a safe, minimally invasive procedure for infants, children and young adults. This approach allows for immediate use of a skin-level gastrostomy device without the need for postoperative tube exchanges.

CONTEXTE: Cette étude décrit notre expérience avec la pose d'un dispositif de gastrostomie au niveau de la peau (MIC-KEY) en une seule intervention. MÉTHODES: Nous avons recensé les nourrissons, enfants et jeunes adultes ayant subi l'insertion d'un tube de gastrostomie par voie endoscopique percutanée sous laparoscopie (GEPL) entre octobre 2009 et juin 2013. Les étapes de cette intervention incluent une endoscopie haute, une laparoscopie à trocart unique, une gastropexie avec ancres en T percutanées et la pose d'un dispositif de gastrostomie au niveau de la peau (MIC-KEY) à l'aide de la technique « push ¼ et d'une pellicule amovible. RÉSULTATS: Nous avons inclus 92 patients dans notre étude. L'âge moyen était de 3,7 ans (de 3 semaines à 5 ans) et le poids moyen était de 11,2 (de 2,8 à 54) kg. La durée médiane de l'intervention a été de 20 minutes (entre 12 et 76 minutes). La durée totale médiane des 25 plus récentes interventions a été plus brève que celle des 25 premières (62 c. 79 minutes, p = 0,004). On n'a observé aucune complication peropératoire ni conversion vers une chirurgie ouverte. Des complications postopératoires ont été observées chez 6 (6,5 %) patients. Trois ancres en T persistantes ont été évaluées par voie endoscopique (n = 1) ou extraites par excision locale (n = 2). Les tubes d'alimentation se sont déplacés tôt chez 2 patients et ont été replacés en radiologie interventionnelle (n = 1) ou avec une nouvelle GEPL (n = 1). On a également noté un cas d'épanchement de liquide intra-abdominal qui a pu être drainé par voie percutanée, mais qui a finalement nécessité une laparotomie et un lavage. Aucune complication majeure n'a été signalée lors des 50 plus récentes interventions. CONCLUSION: Selon nos résultats, la GEPL est une intervention sécuritaire et minimalement effractive pour les nourrissons, les enfants et les jeunes adultes. Cette approche permet l'utilisation immédiate d'un dispositif de gastrostomie au niveau de la peau sans nécessiter de changements de sondes après l'intervention.

Recalcitrant prosthetic valve endocarditis requiring repeated reconstruction: running out of options.

In this report we describe a previously healthy 36-year-old man who presented with septic shock secondary to bacterial endocarditis with multiple cerebral, mesenteric, and peripheral embolic phenomena. He underwent emergent porcine prosthetic valve replacement with aortic annular reconstruction. Subsequently, he developed recalcitrant Candida parapsilosis endocarditis requiring treatment with multiple antifungal agents and 4 repeated complex reconstructions of the aortic root and fibrous trigones over 3 years, before the infection was successfully controlled. This case underscores the significant morbidity associated with fungal endocarditis and importance of an early combined medical and surgical approach.

Detection of galectin-3 and localization of advanced glycation end products (AGE) in human chronic skin wounds.

The matricellular protein galectin-3 (Gal-3) is upregulated in excisional skin repair in rats where it has been shown to modulate the inflammatory phase of repair. Recent research into kidney pathology has implicated Gal-3 as a receptor for advanced glycation end products (AGE), resulting in the binding and clearance of these molecules. AGEs are thought to contribute to defective skin repair in diabetic patients as well as a result of the normal aging process. However, the distribution and localization of Gal-3 and AGEs has never been performed in human chronic skin wound tissue. Using immunohistochemistry, the localization of Gal-3 and AGEs in tissue isolated from chronic wounds and non-involved skin from the same patient was investigated. Of the 16 patients from which tissue was isolated, 13 had type II diabetes, one had type I diabetes and 2 patients without diabetes were also examined. In non-involved dermis, Gal-3 was detected strongly in the epidermis and in the vasculature. However, at the wound edge and in the wound bed, the level of Gal-3 labelling was greatly reduced in both the epidermis and vasculature. Labelling of serial sections for Gal-3 and AGE demonstrated that where Gal-3 immunoreactivity is reduced in the epidermis and vasculature, there is a concomitant increase in the level of AGE staining. Interestingly, similar labelling patterns were evident in diabetic and non-diabetic patients. The results from our study demonstrate an inverse correlation between Gal-3 and AGEs localization, suggesting that Gal-3 may protect against accumulation of AGEs in wound healing.

Risk factors for mortality among patients with Staphylococcus aureus bacteremia: a single-centre retrospective cohort study.

INTRODUCTION: Staphylococcus aureus bacteremia is associated with significant morbidity and mortality. Given the paucity of recent Canadian data, we estimated the mortality rate associated with S. aureus bacteremia in a tertiary care hospital and identified risk factors associated with mortality. METHODS: We retrospectively reviewed the records of adults with S. aureus bacteremia admitted to a tertiary care centre in southwestern Ontario between 2008 and 2012. Cox regression analysis was used to evaluate associations between predictor variables and all-cause, in-hospital, and 90-day postdischarge mortality. RESULTS: Of the 925 patients involved in the study, 196 (21.2%) died in hospital and 62 (6.7%) died within 90 days after discharge. Risk factors associated with in-hospital and all-cause mortality included age, sepsis (adjusted hazard ratio [adjusted HR] 1.49, 95% confidence interval [CI] 1.08-2.06, p = 0.02), admission to the intensive care unit (adjusted HR 3.78, 95% CI 2.85-5.02, p < 0.0001), hepatic failure (adjusted HR 3.36, 95% CI 1.91-5.90, p < 0.0001) and metastatic cancer (adjusted HR 2.58, 95% CI 1.77-3.75, p < 0.0001). Methicillin resistance, hepatic failure, cerebrovascular disease, chronic obstructive pulmonary disease and metastatic cancer were associated with postdischarge mortality. INTERPRETATION: The all-cause mortality rate in our cohort was 27.9%. Identification of predictors of mortality may guide empiric therapy and provide prognostic clarity for patients with S. aureus bacteremia.