Limb shaking transient ischemic attack secondary to innominate artery stenosis.

Limb shaking transient ischemic attack is a rare disease manifestation typically caused by carotid stenosis but rarely caused by flow-limiting lesions involving more proximal vasculature. We demonstrate a case of limb shaking transient ischemic attack secondary to innominate stenosis in a 69-year-old woman who presented after a left leg shaking spell that caused her to fall and fracture her ipsilateral tibia. She did not experience changes in mentation and did not show any evidence of a postictal period. After receiving a comprehensive workup, she successfully underwent revascularization with innominate artery stenting. Continuous retrograde aspiration with the Enroute system (Silk Road Medical) and carotid clamping were used for embolic protection.

Vascular Complications in the Era of Transcatheter Treatment of Adult Structural Heart Disease: A Single-Center Early Experience.

Transcatheter treatment is becoming the mainstay treatment for structural heart diseases (SHD) in prohibitive surgical risk patients. Recently with the encouraging results, it is being offered to regular risk patients. Peripheral vascular complications (VCs) are still inherent to these procedures due to the nature of this atherosclerotic high-risk group and the profile of the devices. This is a single-center early first year experience with such events occurring after initiating a SHD program treating severe aortic stenosis, aortic regurgitation, mitral valve prolapse and regurgitation, as well as paravalvular leaks. Out of 33 patients in this time period, 5 developed PV complications which are detailed in this article with their associated risk factors and management. These include access-related complications, closure device issues, arterial rupture post device embolization, and vessel dissection. Vascular complications of those procedures take special interest since they are associated with a worse long-term prognosis. Thus, prevention with proper planning remains of essence along with multidisciplinary management.

Small Bowel Obstruction Secondary to a Metamucil Bezoar: Case Report and Review of the Literature.

Bezoar-induced small bowel obstruction is a rare entity. It should be highly suspected in patients with gastric hypomotility disorders, psychiatric conditions, prior abdominal or bariatric surgery, or improper intake of medication. Their diagnosis is quite challenging and surgical exploration remains the best treatment of choice to ensure the viability of the small bowel tissue and relieve the obstruction. This is a case of a 48-year-old female with no previous abdominal surgery who presented with acute abdominal pain. The patient's history was remarkable for the daily ingestion of 1.5 teaspoons of Metamucil with minimal amount of water. Computed tomography scan demonstrated dilated small bowel loops and a transition zone at the level of the mid jejunum. On laparoscopy, the patient was found to have a hard mass in the mid jejunum amenable to gentle fragmentation and breakdown. Metamucil bezoars are due to the solidification of psyllium-based substances in the gastrointestinal tract. The usual management of small bowel obstruction induced by a bezoar is exploratory laparotomy with enterotomy and primary anastomosis. Laparoscopic intervention has gained popularity among surgeons with good outcome and lower morbidity. In this unusual case, the small bowel obstruction induced by the Metamucil bezoar was safely treated with laparoscopic fragmentation alone.

Preoperative Localization of Mediastinal Parathyroid Adenoma with Intra-arterial Methylene Blue.

Ectopic parathyroid is found in 16% of patients with hyperparathyroidism. 2% of ectopic parathyroid adenomas are not accessible to standard cervical excision. In such cases, video-assisted thoracoscopic resection is the recommended definitive treatment. We present a case of mediastinal parathyroid adenoma localized preoperatively by injecting methylene blue within a branch of the internal mammary artery that is supplying the adenoma. Intra-arterial methylene blue injection facilitated visualization and resection of the adenoma. The preoperative intra-arterial infusion of methylene blue appears to be an effective and safe method for localization of ectopic mediastinal parathyroid adenomas and allows rapid identification during thoracoscopic resection.

Long-Term Outcomes of Roux-en-Y Gastric Bypass Conversion of Failed Laparoscopic Gastric Band.

BACKGROUND: Laparoscopic adjustable gastric band (LAGB) carries a high rate of failure and reoperation. Laparoscopic conversion of failed LAGB to Roux-en-Y gastric bypass (RYGB) has been shown to be safe and feasible, but long-term follow-up data is still limited. OBJECTIVES: The aim of this study is to evaluate the safety and effectiveness of RYGB after failed LAGB in our patient population. SETTING: The setting was the University Hospital, Beirut, Lebanon. METHODS: Using a prospectively collected database, we retrospectively reviewed data of patients who underwent LAGB revision to RYGB at our institution between 2006 and 2014. RESULTS: A total of 58 patients underwent RYGB after failed LAGB in our institution between 2006 and 2014. Of those, 20 patients (34.5%) had concomitant band removal while the rest underwent a two-stage RYGB after a mean of 30 months after band removal. A follow-up was achieved in 84.5, 82, 83, 95, and 76% of patients at 1, 2, 3, 4, and 5 years after RYGB. Percentage of excess weight loss (%EWL) was 62.8, 68.1, 64.2, 63.8, and 61.3% at 1, 2, 3, 4, and 5 years, respectively, while percentage of total weight loss (%TWL) was 28.4, 30.7, 29.4, 28.9, and 28.6% at the corresponding time periods. The most common short-term complications were abscesses/leaks (5.2%) while the most common long-term complications were symptomatic gallstones necessitating laparoscopic cholecystectomy (5.2%), incisional hernias (5.2%), and small-bowel obstruction (3.4%). No surgery-related mortality was recorded. CONCLUSIONS: RYGB is a safe procedure with favorable weight loss outcomes at 5 years and can be considered a good rescue procedure after failed LAGB.

Pectoralis Minor Syndrome: Case Presentation and Review of the Literature.

We present a case of a healthy young female with axillary vein compression caused by the pectoralis minor muscle. Diagnosis was made by clinical findings and dynamic venography. After pectoralis minor tenotomy, the patient had total resolution of her symptoms. Compression of the axillary vein by the pectoralis minor is a rare entity that needs a careful exam and imaging to reach its diagnosis and establish the appropriate treatment.

Preoperative lymphocyte-to-monocyte ratio predicts clinical outcome in patients undergoing radical cystectomy for transitional cell carcinoma of the bladder: a retrospective analysis.

BACKGROUND: Inflammation is a critical component of tumorigenesis, and many cancers arise from sites of infection, chronic irritation, and inflammation. Inflammatory cytokines triggered by tumors alter hematologic components, including neutrophil, lymphocyte, and monocyte counts. The neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios have been shown to be valuable prognostic markers in various types of cancers, including bladder cancer. Risk stratification based on clinicopathologic data is insufficient to support treatment-related choices in patients with bladder cancer. Novel prognostic markers are therefore needed. An elevated pretreatment lymphocyte-to-monocyte ratio (LMR) is reportedly associated with improved overall survival (OS) and a longer time to treatment recurrence (TTR) in some types of cancers. However, these data are lacking in patients with bladder cancer. The aim of the present study was to investigate the effect of the preoperative LMR on OS and TTR in a cohort of patients with bladder cancer. METHODS: Sixty-eight patients with transitional cell carcinoma of the bladder were included in this retrospective analysis. The associations between a high and low LMR with OS and TTR were analyzed using Kaplan-Meier curves and compared by the log-rank test. RESULTS: In our study cohort, an elevated preoperative LMR was significantly associated with an increased TTR (P = 0.001) and OS (P = 0.020). Patients with an LMR of ≤2.87 showed a median TTR of 2.0 years (95% CI, 0.27-3.73), whereas patients with an LMR of >2.87 had a median TTR of 11.1 years (95% CI, 2.31-19.88) (P = 0.001). Patients with an LMR of ≤2.81 showed a median OS of 2.7 years (95% CI, 0.63-4.70), whereas patients with an LMR of >2.81 had a median OS of 6.0 years (95% CI, 3.60-8.40) (P = 0.020). The clinical stage at diagnosis was the only clinicopathologic feature associated with the LMR, while tumor invasion depth showed borderline significance. CONCLUSIONS: The LMR is an easily measured and inexpensive prognostic marker that was significantly correlated with OS and TTR in the present retrospective analysis. However, because of the small sample size in this study, larger multicenter, prospective studies are needed.