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BACKGROUND: Dorsal migration of an intervertebral lumbar disc fragment is exceedingly rare and may result in spinal cord or cauda equina compression. Radiologically, these lesions may be misdiagnosed as extradural masses or epidural hematomas. CASE DESCRIPTION: We present three cases involving dorsal migration of sequestered lumbar disc fragments resulting in cauda equina syndromes. A 31-year-old male, 79-year-old female, and 47-year-old female presented with cauda equina syndromes attributed to the migration of dorsal sequestered lumbar disc fragments. Prompt surgical decompression resulted in adequate outcomes. Here, we review the three cases and the current literature for such lesions. CONCLUSION: Dorsal migration of sequestered lumbar disc fragments is exceedingly rare, and these lesions are frequently misdiagnosed as extradural masses of other origin or epidural hematomas. Here and in the literature, prompt epidural decompression both confirmed the correct diagnosis and resulted in excellent outcomes.

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BACKGROUND AND AIMS: Endoscopic sleeve gastroplasty (ESG) reduces the gastric lumen to a size comparable with that of laparoscopic sleeve gastrectomy (LSG). However, there is a paucity of research comparing outcomes between the 2 procedures. Our study compared the 6-month weight loss outcomes and adverse events of ESG with LSG in a case-matched cohort. METHODS: We retrospectively reviewed prospectively collected data for patients undergoing ESG or LSG at a single academic center. Weight was recorded at 1 and 6 months postprocedure, and percent total body weight loss (%TBWL) was calculated. Adverse events and new-onset Gastroesophageal Reflux Disease (GERD) were also recorded. RESULTS: A total of 54 ESG patients were matched with 83 LSG patients by age, sex, and body mass index. The proportion of patients with GERD at baseline was similar in the 2 groups (16.7% in ESG group vs 25.3% in LSG group, P = .27). At the 6-month follow-up, %TBWL (compared with baseline) was significantly lower in the ESG group compared with the LSG group (17.1% ± 6.5% vs 23.6% ± 7.6%, P < .01). ESG patients had significantly lower rates of adverse events compared with LSG patients (5.2% vs 16.9%, P < .05). New-onset GERD was also significantly lower in the ESG group compared with the LSG group (1.9% vs 14.5%, P < .05). CONCLUSIONS: ESG, a minimally invasive same-day procedure, achieved less weight loss at 6 months than LSG, with the caveat that LSG caused more adverse events and new-onset GERD than ESG.

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BACKGROUND: We present our experience with same-day discharge (without an overnight stay) after laparoscopic sleeve gastrectomy (SG) in 821 consecutive patients from 2011 to 2015. This is the largest series published to date of patients undergoing ambulatory surgery for such a procedure. OBJECTIVES: To review our outcomes from ambulatory SG over 52 months to determine if SG can be safely performed in the ambulatory setting. SETTING: Ambulatory surgery center. METHODS: Retrospective review of all consecutive patients undergoing ambulatory SG from January 2011 to April 2015. All patients were discharged home the same day after surgery without an overnight stay at the hospital. Incidence of complications and admission to the hospital after discharge was reviewed up to 30 days from surgery. RESULTS: From January 2011 to April 2015, 821 consecutive patients underwent SG. Nineteen 30-day complications occurred in the series, 17 of them requiring admission to the hospital. Of the 19 cases, gastric leaks accounted for 7, intr-aabdominal abscess for 4, and dehydration/nausea/vomiting for 4; 4 were due to other causes. Complication and readmission rates at 30 days were 2.3% and 2.1%, respectively. Follow-up at 30 days was 98.4%. CONCLUSION: With stringent patient selection and utilization of enhanced recovery pathways, our study indicates that SG may be suitable for the outpatient setting. Experience and comfort with bariatric surgery is essential on the part of the operating surgeon to ensure good outcomes. Our low overall readmission and complication rate portends to the feasibility of laparoscopic SG as a safe outpatient procedure.

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BACKGROUND: We hypothesized that administration of IV acetaminophen alone would reduce the opioid consumption in post-operative colorectal surgery and reduce the side effects of narcotics. METHODS: Patients were randomized to receive either IV acetaminophen or placebo in addition to opioid PCA. Primary endpoints evaluated were opioid consumption and pain visual analogue scale score (PVASS) during first 48 h post-operatively. Secondary endpoints evaluated were time of return of GI function (ROGIF), time to diet ordered (TTDO), length of hospital stay (LOHS), and occurrence of ileus. RESULTS: 105 patients were enrolled and 97 remained in the study after exclusion (control group n = 50; study group n = 47). Mean ± SEs of opioid consumption in the study group was 21.5 ± 1.8 mg of morphine equivalent (ME) and 35.0 ± 3.3 mg ME at 24 and 48 h, respectively, versus 36.4 ± 4.1 mg ME and 59.7 ± 6.7 mg ME in the control group (p = 0.002 and 0.002). PVASS levels were lower in the study group at all intervals at 3, 8, 24, and 48 h (p = 0.02, 0.006, < 0.01, and 0.02). ROGIF, TTDO, and LOHS were also found to be lower in the study group (p ≤ 0.01, < 0.01, and 0.002). The rate of ileus was reduced by using IV acetaminophen (22% vs 2.1%; p = 0.004). CONCLUSIONS: IV acetaminophen helps to reduce opioid consumption for patients undergoing colorectal surgery. Additionally, there appears to be a shortened length of hospital stay, better pain control, reduced time to return of bowel function, and lower rate of post-operative ileus in patients receiving IV acetaminophen.

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Thrombosis of the inferior vena cava (IVC) continues to be a rare event, and there is a scarcity of evidence with regard to its etiology. One source for IVC thrombosis is external compression from adjacent structures. In this case series, we present 1 case of IVC thrombosis caused by a severely distended bladder and a case of external iliac thrombosis caused by external compression from an abnormally enlarged uterus. The treatment of each case is varied and included novel oral anticoagulation, catheter-directed thrombolysis in conjunction with mechanical thrombectomy, or a combination of these. We conclude that the choice of therapy should be tailored on a case-by-case basis.

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INTRODUCTION: Incisional hernias are a relatively common occurrence after ostomy takedown with a incidence of 30-35%. The use of biologic mesh offers a means to bolster the stoma incision site with a lower risk of infection than synthetic mesh. METHODS: This study represents a retrospective chart review of six patients who underwent stoma takedown and had biologic mesh placed in the retrorectus position during repair from March 2015 until March 2016. RESULTS: There has been a zero-rate of hernia occurrence for the six patients who underwent stoma takedown. No incisional hernias were noted on physical exam with follow up ranging from 11 to 25 months. CONCLUSION: We conclude that placement of biologic mesh is a safe and effective way of preventing incisional hernias at stoma sites.

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BACKGROUND: Intraneural hemangiomas and vascular malformations are rare, with approximately 50 cases reported in the literature. They present a therapeutic challenge; surgical resection can result in damage to the nerve and lesion recurrence is common. We introduce a new framework to classify intraneural vascular anomalies in relation to the anatomic compartments of the nerve and assess amenability to surgical resection. METHODS: We retrospectively reviewed cases of intraneural hemangiomas and vascular malformations treated at our institution between 2003 and 2013 that had high-resolution 3-T magnetic resonance imaging (MRI). A review of the literature was also performed. Our cases and reports in the literature with available MRI data were sub-categorized according to their relationship to the paraneurium and epineurium of the nerve. RESULTS: Nine patients were identified with intraneural (subparaneurial or subepineurial) vascular lesions. Two patients had a predominantly subparaneurial involvement of the nerve, six patients had predominantly subepineurial involvement, and one patient exhibited extensive involvement in both compartments. Four patients were managed surgically and the rest conservatively. Targeted resection of two subparaneurial hemangiomas provided complete relief of symptoms and freedom from recurrence at 18 month and 24 months respectively. One patient with extensive subepineurial and extraneural vascular malformations did not appear to benefit from sub-total resection with interfascicular dissection. No surgical morbidity was noted in any of the cases. CONCLUSIONS: We believe that the subparaneurial compartment-a potential space between the epineurium and paraneurium-provides a tissue plane within which benign vascular lesions can occur. Hemangiomas and vascular malformations are complex and can occupy different intraneural and extraneural compartments. The anatomic framework aids surgical decision-making and ensures that all components of the lesion are considered. We advocate a multimodal approach in the treatment of these rare lesions.

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A 77-year-old female presented with high blood pressure noted at home. She was having abdominal pain and distension for several years but attributed it to old age and ignored the symptoms. CT scan revealed a giant hepatic liver cyst. The cyst was subsequently excised via laparoscopic unroofing. The patient did well post op and her symptoms were alleviated.

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Common fibular (peroneal) nerve palsy has many etiologies. A rare cause with a poorly understood pathophysiology is common fibular nerve palsy that follows an ankle injury. Since the original description of this pathologic entity a century ago, several mechanisms have been posited. We present two cases of common fibular nerve palsy following ankle injury. These cases provide anatomic and radiologic evidence to support a hypothesis that the interosseous membrane provides the anatomic basis for this combined pattern of injury. This theory unifies previously postulated mechanisms.

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