A Case of Jejuno-Jejunal Intussusception Caused by Underlying Metastatic Melanoma.

Intussusception in adults is a rare finding with a majority of cases occurring in the pediatric population. It occurs infrequently and its presentation, etiology, and treatment differ from childhood intussusception. When discovered in adults, it raises suspicion for a neoplastic process serving as the pathological lead point. Cross-sectional imaging is the primary study of choice for diagnosis, but at times, a more invasive approach involving an exploratory laparotomy is required posing an increased risk for morbidity and mortality. Here we present a 64-year-old male who was found to have jejunal-jejunal intussusception that was surgically removed with pathology revealing metastatic melanoma as the lead point. This case highlights a unique presentation of a melanoma that was previously eradicated with immunotherapy and now had metastasized to the intestine many years later.

Reduced Fluoroscopy Time With Physician-Controlled Fluoroscopy During Endoscopic Retrograde Cholangiopancreatography: A Community Hospital Experience.

Background and objective Fluoroscopy during endoscopic retrograde cholangiopancreatography (ERCP) is associated with radiation exposure and related health risks. Either the physician or the radiology technologist can activate fluoroscopy during ERCP. The aim of this study was to determine if physician-controlled fluoroscopy is associated with decreased fluoroscopy time, which may correspond to less radiation exposure to patients and staff.  Methods We conducted a single-center, retrospective study; data were collected on ERCP performed using physician-controlled and technologist-controlled fluoroscopy. Fluoroscopy time, procedure complexity level, and Stanford Fluoroscopy Score were compared between the two groups. Results The median fluoroscopy time significantly differed between the two groups with 108 seconds for physician-controlled and 146 seconds for technologist-controlled procedures (p=0.004). The ratio of median fluoroscopy time to procedure complexity level was significantly lower in the physician-controlled group at 73.0 seconds compared to 97.0 seconds in the technologist-controlled group (p=0.002). The ratio of median fluoroscopy time to Stanford Fluoroscopy Score was 25.5 seconds in the physician-controlled group compared to 39.3 seconds in the technologist-controlled group, which was also statistically significant (p<0.001). A subgroup analysis of physicians with advanced training in ERCP also showed a significantly reduced median fluoroscopy time to Stanford Fluoroscopy Complexity Score ratio: 25.5 seconds for physician-controlled versus 35.0 seconds for technologist-controlled (p=0.001). Conclusion The ERCP technique with physician-controlled fluoroscopy may be associated with shorter fluoroscopy time. This may correspond to decreased radiation exposure to patients compared to radiology technologist-controlled fluoroscopy. Further investigations with larger, prospective studies are warranted.

Diet as a Therapeutic Option for Adult Inflammatory Bowel Disease.

There are many mechanisms to explain how food may drive and ameliorate inflammation. Although there are no consistent macronutrient associations inflammatory bowel disease (IBD) development, many exclusion diets have been described: IgG-4 guided exclusion diet; semivegetarian diet; low-fat, fiber-limited exclusion diet; Paleolithic diet; Maker's diet; vegan diet; Life without Bread diet; exclusive enteral nutrition (EEN), the Specific Carbohydrate Diet (SCD) and the low FODMAP diet. The literature on diet and IBD is reviewed with a particular focus on EEN, SCD, and low FODMAP diets. Lessons learned from the existing observations and strengths and shortcomings of existing data are presented.

Eosinophilic Pancreatitis Diagnosed With Endoscopic Ultrasound.

Eosinophilic pancreatitis (EP) is a rare clinical entity, and few cases have been reported. It usually presents on imaging as a pancreatic mass leading to common bile duct obstruction and jaundice. Since it can mimic a malignancy, eosinophilic pancreatitis is often diagnosed after "false positive" pancreatic resections. To our knowledge, we report the only known case of EP in which the diagnosis was made by fine needle aspiration and core biopsy of the pancreas during EUS, sparing the patient a surgical resection. After a steroid course, there was improvement of clinical symptoms.

The effect of multilevel upper airway surgery on continuous positive airway pressure therapy in obstructive sleep apnea/hypopnea syndrome.

OBJECTIVE: To investigate the effect of multilevel upper airway surgery (USA) on subsequent continuous positive airway pressure (CPAP) therapy in patients with obstructive sleep apnea/hypopnea syndrome (OSAHS). STUDY DESIGN: Fifty-two patients who underwent multilevel UAS with persistent symptoms of OSAHS represent the cohort for this study. All patients had undergone manual CPAP titrations both pre- and postoperatively. Patients were used as their own controls and were compared pre- and postoperatively with regard to body mass index, full night polysomnography (PSG), optimal CPAP pressure settings, presence of rapid eye-movement (REM) sleep, identification of mouth leakage, and CPAP compliance. RESULTS: Postoperative values for apnea index (AI), apnea hypopnea index (AHI), and minimum oxygen saturation (min SaO(2)) were all significantly decreased from their preoperative levels. Compliance with CPAP therapy significantly increased from a mean 0.02 +/- 0.14 hours per night prior to surgery to a 3.2 +/- 2.6 hours per night following surgery (P < .001). In addition, the optimal CPAP pressure setting decreased significantly for a preoperative value of 10.6 +/- 2.1 cm H(2)O to 9.8 +/- 2.1 cm H(2)O following surgery. Fifty of the 52 patients (96.2%) studied were able to maintain optimal pressure settings without mouth leak, postoperatively. CONCLUSIONS: In this study, most patients who had persistent symptoms of OSAHS after multilevel UAS did not have significant mouth leak that would preclude CPAP therapy. In this cohort of patients, CPAP pressure setting as well as compliance was significantly improved postoperatively.

So you want to be a dermasurgeon: how to get training or choose a fellowship.

BACKGROUND There are many routes to obtaining training in dermasurgery. OBJECTIVE The objective is to discuss some considerations that may guide selection of dermasurgery training. METHODS Current training options are reviewed. RESULTS Some considerations that may guide selection of type of dermasurgery training include: (1) individual temperament; (2) the subtype of dermasurgery in which training is desired (Mohs, cosmetic surgery, laser); (3) family and geographic factors; (4) preference for private practice versus academic career; and (5) proportion of future practice to be devoted to dermasurgery. CONCLUSIONS There are a growing number of training choices for budding dermasurgeons, with multiple options available for each set of particular circumstances.