Acute perforation in a gastrojejunocolic fistula after a laparascopic Roux-en-Y gastric bypass: case report.

BACKGROUND: Gastrojejunocolic fistulas are a rare type of fistulas after a laparascopic Roux-en-Y gastric bypass (LRYGB). They are known as a chronic complication. This case report is the first to describe an acute perforation in a gastrojejunocolic fistula after LRYGB. CASE PRESENTATION: A 61-year-old woman with a history of a laparascopic gastric bypass was diagnosed with an acute perforation in a gastrojejunocolic fistula. A laparascopic repair was performed by closing the defect in the gastrojejunal anastomosis as well as the defect in the transverse colon. However, 6 weeks later, a dehiscence of the gastrojejunal anastomosis occured. This was reconstructed by an open revision of the gastric pouch and gastrojejunal anastomosis. Long-term follow up showed no recurrence. CONCLUSIONS: Combining the findings of our case with other literature, a laparoscopic repair with wide resection of the fistula, a revision of the gastric pouch and gastrojejunal anastomosis as well as closing the defect in the colon seems to be the best approach in case of an acute perforation in a gastrojejunocolic fistula after LRYGB.

Treatment of basal cell carcinoma with vismodegib: future or present?

BACKGROUND: Since the introduction of Vismodegib as treatment of recurrent locally advanced basal cell carcinoma (laBCC), clinicians are faced with new dilemmas: 'Can Vismodegib replace complex reconstructions?', 'What is the role of neoadjuvant use of Vismodegib?' and 'What is the best approach in case of complete clinical remission after Vismodegib in a neoadjuvant setting?' METHODS: Case report and literature review. RESULTS: Case report Complete dermoscopic remission after eight months Vismodegib was obtained in a patient with recurrent laBCC. Follow-up was 12 months. Literature review: Vismodegib shows histologic clearance in 42% of patients with operable basal cell carcinoma. Recurrence after neoadjuvant use of Vismodegib in laBCC was described. Moreover, histology revealed residual tumour cells in cases of complete clinical remission after 6 months Vismodegib. CONCLUSIONS: Vismodegib cannot replace complex reconstructions. However, in unresectable laBCC, Vismodegib can provide a bridge to surgery. Due to the possibility of persistent tumour cells, we recommend imaging-assisted surgery and an imaging-based follow-up. In case of complete clinical remission after Vismodegib in a neoadjuvant setting, we recommend that Vismodegib be continued as long as the adverse effects are tolerated and an imaging-based follow-up is advised.

Operative Management of AO Type 44 Ankle Fractures: Determinants of Outcome.

The consequences of inadequate treatment of ankle fractures can be disastrous. We assessed the radiologic and functional outcomes, postoperative quality of life (QOL), and its determinants for patients treated operatively for AO type 44 ankle fractures. Evidence is lacking concerning the management of posterior malleolus fractures and syndesmotic injuries. Our retrospective adult cohort study included 432 AO/OTA type 44 ankle fractures (431 patients). The median follow-up period was 52 months. Outcomes were assessed from the medical records, radiographs, American Orthopaedic Foot and Ankle Society (AOFAS) ankle scale (functional outcome), and EuroQol EQ-5D questionnaires. The median AOFAS scale score was 88; 27.9% of patients reported restricted mobility and 40.4% pain or discomfort. In 8.8%, radiographic failure was observed. The presence of posterior malleolus fractures was significantly associated with poor functional outcomes, and a postoperative step-off correlated with radiologic failure, poor functional outcome, and poor postoperative QOL. Late syndesmotic screw removal was associated with worse EQ-5D time trade-off QOL scores. A substantial number of patients experienced functional impairment, discomfort, and pain. Syndesmotic injury was associated with ankle joint failure and poor functional outcomes. Our data indicate that all displaced posterior malleolus fracture fragments affecting the posterior articular tibial surface in patients aged ≤65 years require anatomic reduction.