Endoscopic treatment of a large intraductal papillary mucinous neoplasm of the bile duct: tips and tricks learned during multiple treatments of a difficult case.

Video 1Endoscopic video demonstrating the ability to gain access to the biliary system using the rigidizing overtube, and subsequent attempted EMR of the neoplastic lesion, followed by successful APC with complete ablation of the neoplasm.

Post-polypectomy follow-up recommendations by practicing academic gastroenterologists-does number of years in practice matter?

AIM: Colorectal cancer (CRC) is the third most deadly and fourth most common cancer worldwide. Early detection, resection, and appropriate surveillance of precursor polyps result in better outcomes. Colonoscopy is a safe, accurate, and effective tool for surveillance and follow-up of premalignant polyps. Recommended surveillance intervals are based on polyp, procedural, and patient-related factors. The United States Multi-Society Task Force (MSTF) on CRC publishes guidelines with periodic updates on surveillance. We sought to evaluate adherence to post-polypectomy surveillance guidelines by academic gastroenterologists at a high-volume center. METHODS: One-year retrospective study evaluating compliance with post-polypectomy recommendations after average risk adult screening colonoscopies. Data was collected on number and size of polyps, quality of bowel prep, initial follow-up recommendations, polyp pathology, and follow-up recommendations. Correlation with the 2012 MSTF guidelines was also evaluated. Endoscopist experience was categorized as greater or less than 10 years of practice experience. Binomial regression was used to model the association between the providers' years of experience (<10 vs. >10) and the likelihood of agreement between initial assessment and post-pathology assessment. RESULTS: There was a greater than 85% adherence to post-polypectomy surveillance guidelines, independent of endoscopist experience. CONCLUSION: There is a high level of adherence to post-polypectomy guidelines by practicing academic gastroenterologists independent of post-fellowship clinical experience.

Acquired tracheoesophageal fistula in disseminated Mycobacterium avium complex associated with anti-interferon-gamma autoantibodies.

We describe a case of a 30-year-old previously healthy woman who presented to our hospital with a 2-month history of fevers, tender lymphadenopathy, dysphagia, globus sensation and occasional haematemesis. Further evaluation revealed cervicothoracic adenopathy and a subcarinal mass with oesophageal involvement. Imaging showed a transesophageal fistula at the level of the carina with contrast extravasation to the left main bronchus. Our patient was diagnosed with disseminated Mycobacterium avium complex (MAC) based on acid-fast bacillus noted on sputum cultures and nodal biopsies. Further investigation revealed anti-interferon-gamma autoantibodies as a possible predisposing factor for the disseminated MAC infection. This case demonstrates the importance of a broad differential diagnoses in a patient presenting with unexplained cervicothoracic lymphadenopathy, fever and dysphagia. Although acquired tracheoesophageal fistulae are uncommon, it should be considered in the clinical setting of globus sensation, haemoptysis and dysphagia. Furthermore, our case highlights a rare predisposition to disseminated Mycobacterium infection.

The Calcium Culprit: A Case of Denosumab-induced Hypocalcemia.

Denosumab is a fully human monoclonal antibody which is used to treat osteoporosis and has been shown to cause hypocalcemia in patients with underlying prostatic and bone malignancies, renal impairment, postmenopausal state, and/or vitamin D deficiency. We present a case of a male patient, with a past medical history negative for the aforementioned conditions, who presented with right shoulder pain and was found to be severely hypocalcemic secondary to denosumab.

The feasibility of transvaginal robotic surgery in the repair of pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: Pelvic organ prolapse (POP), the descent of one or more pelvic organs, occurs in an estimated 40 to 60% of parous women. Conventional transvaginal surgery for POP has been plagued with high failure rates. The purpose was to determine the safety and feasibility of robotic transvaginal POP surgery. METHODS: The da Vinci Surgical Robot, SI was used in the POP surgical procedures. There were two cadavers (aged 18 and 78 years of age; BMI 17.2 and 19.2 respectively). POP-Q scores before intervention were stage 1 for both cadavers. RESULTS: The visualization of anatomical landmarks and the placement of sutures at these locations were successful. CONCLUSION: Robotic transvaginal POP is a feasible option for POP surgery. Further studies are warranted to determine the role of robotic transvaginal POP repair.