1. Type 1 diabetes (due to b-cell destruction, usually leading to absolute insulin deficiency) 2. Type 2 diabetes (due to a progressive insulin secretory defect on the background of insulin resistance) 3. Gestational diabetes mellitus (GDM) (diabetes diagnosed in the second or third trimester of pregnancy that is not clearly overt diabetes) 4. Specific types of diabetes due to other causes, e.g., monogenic diabetes syndromes (such as neonatal diabetes and maturity-onset diabetes of the young [MODY]), diseases of the exocrine pancreas (such as cystic fibrosis), and drugor chemical-induced diabetes (such as in the treatment of HIV/AIDS or after organ transplantation)

Classification and diagnosis of diabetes

: In two patients, a man aged 67 and a woman aged 80, an abdominal compartment syndrome was diagnosed. The man had been treated surgically for an abdominal aortic aneurysm; he recovered after re-operation. The woman had been treated by sigmoidectomy because of ileus. A Bogota bag and a vacuum-assisted wound-closure system were applied to the abdominal wound. Her condition deteriorated, an intestinal perforation became apparent, of which she did not recover and died. An abdominal compartment syndrome should always be kept in mind when a patient at risk presents with increased intra-abdominal pressure and at least one of the following symptoms: oliguria, decreased cardiac output, increased pulmonary-artery pressure, hypotension and acidosis. Measurement of the bladder pressure remains the method of choice to establish the abdominal pressure level. However, there is a lack of correlation between the measured pressure and the clinical condition of the patient. Therefore, the combination of clinical findings and the observed trend in serial measurements of the bladder pressure is preferred to a single pressure measurement.

The abdominal compartment syndrome

Conventional cardiovascular monitoring may not detect tissue hypoxia, and conventional cardiovascular support aiming at global hemodynamics may not restore tissue oxygenation. NIRS offers non-invasive online monitoring of tissue oxygenation in a wide range of clinical scenarios. NIRS monitoring is commonly used to measure cerebral oxygenation (rSO(2)), e.g. during cardiac surgery. In this review, we will show that tissue hypoxia occurs frequently in the perioperative setting, particularly in cardiac surgery. Therefore, measuring and obtaining adequate tissue oxygenation may prevent (postoperative) complications and may thus be cost-effective. NIRS monitoring may also be used to detect tissue hypoxia in (prehospital) emergency settings, where it has prognostic significance and enables monitoring of therapeutic interventions, particularly in patients with trauma. However, optimal therapeutic agents and strategies for augmenting tissue oxygenation have yet to be determined.

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Monitoring tissue oxygenation by near infrared spectroscopy (NIRS): background and current applications

Context Referral to high-volume hospitals has been recommended for operations with a demonstrated volume-outcome relationship. The characteristics of patients who receive care at low-volume hospitals may be different from those of patients who receive care at high-volume hospitals. These differences may limit their ability to access or receive care at a high-volume hospital. Objective To identify patient characteristics associated with the use of high-volume hospitals, using California's Office of Statewide Health Planning and Development patient discharge database. Design, Setting, and Participants Retrospective study of Californians receiving the following inpatient operations from 2000 through 2004: elective abdominal aortic aneurysm repair, coronary artery bypass grafting, carotid endarterectomy, esophageal cancer resection, hip fracture repair, lung cancer resection, cardiac valve replacement, coronary angioplasty, pancreatic cancer resection, and total knee replacement. Main Outcome Measures Patient race/ethnicity and insurance status in high-volume (highest 20% of patients by mean annual volume) and in low-volume (lowest 20%) hospitals. Results A total of 719608 patients received 1 of the 10 operations. Overall, non-whites, Medicaid patients, and uninsured patients were less likely to receive care at high-volume hospitals and more likely to receive care at low-volume hospitals when controlling for other patient-level characteristics. Blacks were significantly (P<.05) less likely than whites to receive care at high-volume hospitals for 6 of the 10 operations (relative risk [RR] range, 0.40-0.72), while Asians and Hispanics were significantly less likely to receive care at high-volume hospitals for 5 (RR range, 0.60-0.91) and 9 (RR range, 0.46-0.88), respectively. Medicaid patients were significantly less likely than Medicare patients to receive care at high-volume hospitals for 7 of the operations (RR range, 0.22-0.66), while uninsured patients were less likely to be treated at high-volume hospitals for 9 (RR range, 0.20-0.81). Conclusions There are substantial disparities in the characteristics of patients receiving care at high-volume hospitals. The interest in selective referral to high-volume hospitals should include explicit efforts to identify the patient and system factors required to reduce current inequities regarding their use.

Disparities in the utilization of high-volume hospitals for complex surgery. Commentary

Cerebral and tissue oximetry

Invited commentary for: Current trends in surgical society membership: What does the future hold?

BackgroundThe extent to which age impacts surgical outcomes remains poorly characterized. This study aims to evaluate the impact of age on 30-day outcomes in patients after distal pancreatectomy.Me...

Surgical Outcomes of Distal Pancreatectomy in Elderly Patients.

Large bowel obstruction (LBO) is a potential surgical emergency, commonly caused by colorectal carcinoma, diverticular stricture, and volvulus. LBO secondary to chronic lymphocytic leukemia (CLL) and small lymphocytic lymphoma (SLL) is a rare occurrence. We report an 81-year-old man with a history of CLL/SLL who presented to the emergency department with episodes of abdominal cramps and discomfort, diarrhea, vomiting, subjective flushes, and sweats. After a thorough evaluation, the patient was found to have a malignancy-mediated mechanical LBO at the hepatic flexure due to colonic compression by extensive pericolic lymphadenopathy. After resuscitation and medical optimization, an urgent laparotomy with oncologic right hemicolectomy was performed. Analysis of resected specimens, including lymph nodes, revealed atypical CD23- CLL/SLL cells. Postoperatively, aside from temporary ileus, the patient recovered well and was discharged home.

/pdf/large-bowel-obstruction-in-the-setting-of-small-lymphocytic-3hcp6cuymt.pdf

Large Bowel Obstruction in the Setting of Small Lymphocytic Lymphoma.

Towards Reliable Hepatocytic Anatomy Segmentation in Laparoscopic Cholecystectomy Using U-Net with Auto-Encoder

Esophageal diverticula are outpouchings that protrude from the esophageal wall. They commonly are classified according to their anatomic location in the esophagus: Zenker’s diverticulum (ZD) in the upper esophagus, mid-thoracic or mediastinal diverticula in the mid-esophagus, and epiphrenic (ED) in the distal esophagus. Histologically, there are two types of esophageal diverticula: true diverticulum which consists of all layers of the esophagus and false diverticulum which includes only two layers, mucosa and submucosa. Etiologically, esophageal diverticula could be congenital, very rare, or acquired which is most common. Most esophageal diverticula are asymptomatic. However, when large, they are associated with symptoms including dysphagia, regurgitation, chest pain, and aspiration-related complications. A thorough evaluation involves a combination of contrast esophagogram and upper endoscopy to assess esophageal anatomy as well as an esophageal manometry to evaluate the functional status of the esophagus. Treatment is not required for most diverticula as they are asymptomatic. Large or symptomatic diverticula should be treated. Treatment is tailored to the pathophysiology and location of the diverticulum. Surgical options include diverticulectomy or diverticular suspension (in case of ZD) with a myotomy. Fundoplication, usually partial, is added in cases of epiphrenic diverticulum. Minimally invasive transoral endoscopic stapled diverticulectomy approach is increasing in popularity and has been performed in cases of ZD, especially in high-risk surgical patients.

Saad Shebrain

Papers

Invited commentary for: Current trends in surgical society membership: What does the future hold?

Surgical Outcomes of Distal Pancreatectomy in Elderly Patients.

Large Bowel Obstruction in the Setting of Small Lymphocytic Lymphoma.

Towards Reliable Hepatocytic Anatomy Segmentation in Laparoscopic Cholecystectomy Using U-Net with Auto-Encoder

Evaluation of Esophageal Diverticula