Kalispell Regional Healthcare

A 57-year-old woman presented with a 5-day history of worsening right upper quadrant pain, bilious emesis and approximately 20 pounds of weight loss. The patient was afebrile, without jaundice and had mild tenderness in her right upper quadrant. She noted an incidental finding of asymptomatic cholelithiasis on imaging 4 years earlier. An abdominal radiograph revealed pneumobilia and a large ectopic calculus. An abdominal CT scan confirmed pneumobilia, a large concretion completely obstructing the third portion of the duodenum and a soft tissue communication between the gallbladder and proximal duodenum. She was brought to the operating room for definitive treatment and had the obstructing gallstone removed via a transverse duodenotomy. Bouveret syndrome is a rare cause of small bowel obstruction that requires a high index of suspicion for diagnosis. It should be considered in older patients with clinical evidence of gastric or duodenal obstruction, particularly with a history of cholelithiasis.

BackgroundIndigenous food systems have been displaced with the emergence of colonization, industrialization, and cultural, economic, political, and environmental changes. This disruption can be seen in marked health and food environment disparities that contribute to high obesity and diabetes mellitus prevalence among Native American peoples.MethodsA Community-Based Participatory Research (CBPR) approach was used to document food environment experiences among residents of the Flathead Reservation in rural Montana. Participants were identified using purposive sampling techniques to participate in a survey and a semi-structured interview. Descriptive statistics helped to describe participant demographics, food access variables, and household food security status. Food environment perceptions were analyzed using the constant comparison method among trained researchers.ResultsParticipants completed surveys (n = 79) and interviews (n = 76). A large number participated in federal nutrition assistance programs. Many self-reported experiencing diet-related chronic diseases. Major themes included the community food environment, dietary norms, and food-health connections. Subthemes were represented by perceptions of food environment transitions and the important role of food in familial life. Further, opportunities and challenges were identified for improving community food environments.ConclusionsPerceptions of the food environment were linked to strategies that could be targeted to improve dietary quality along a social-ecological model continuum. There is need for skill-based education that directly addresses the time and monetary constraints that were commonly experienced by residents. Coinciding food environment interventions to promote dietary quality that engage community members, store management, and government policy stakeholders are also needed to reestablish healthy Native American food systems and environments within this community.

Constipation is a common problem and represents up to 25 % of pediatric gastroenterology clinical practice. A subset of these children will develop chronic intractable constipation (CIC), which is refractory to medical therapy with the exception of frequent enemas to accomplish fecal evacuation. For patients who demonstrate compliance with these regimens, enteral access for administration of antegrade continence enemas (ACE) can provide greater independence and increased quality of life. Malone popularized an appendicostomy with a continence valve mechanism initially, which was later modified to be performed laparoscopically. Variations of this procedure have been developed to establish enteral access for patients with a surgically absent appendix, establishing a neo-appendix from colonic or ileal segments. Further methods utilize surgical endoscopy and hybrid endoscopic/laparoscopic techniques to place commercially available cecostomy tubes. In general, procedures are well tolerated and recovery is rapid. However, in many cases, establishing enteral access imposes a lifelong commitment to ACE administration; thus careful patient selection and patient education are necessary to maximize odds of success.

Background and Objectives:Transumbilical laparoscopic-assisted appendectomy (TULAA) carries a high risk for surgical site infection. We investigated the effect of a bio-occlusive umbilical vacuum dressing on wound infection rates after TULAA for patients with acute appendicitis and compared to it with a conventional 3-port appendectomy with a nonvacuum dressing.Methods:This study was a retrospective chart review of 1377 patients (2–20 years) undergoing laparoscopic appendectomy for acute appendicitis in 2 tertiary care referral centers from January 2007 through December 2012. Twenty-two different operative technique/dressing variations were documented. The 6 technique/dressing groups with >50 patients were assessed, including a total of 1283 patients.Results:The surgical site infection rate of the 220 patients treated with TULAA and application of an umbilical vacuum dressing with dry gauze is 1.8% (95% CI, 0.0–10.3%). This compares to an infection rate of 4.1% (95% CI, 1.3–10.5%) in 97 patients with dry dressing without vacuum. In the 395 patients who received an umbilical vacuum dressing with gauze and bacitracin, the surgical site infection rate was found to be 4.3% (95% CI, 2.7–6.8%).Conclusions:Application of an umbilical negative-pressure dressing with dry gauze lowers the rate of umbilical site infections in patients undergoing transumbilical laparoscopic-assisted appendectomy for acute appendicitis.