Deep Inferior Epigastric Perforator (DIEP) flap is the most common form of autologous breast reconstruction. Enhanced recovery protocols often include transversus abdominis plane (TAP) blocks using liposomal bupivacaine, but cost limits use. Dexamethasone added to bupivacaine is a low-cost strategy to prolong block duration. We compared the efficacy of liposomal bupivacaine to bupivacaine with dexamethasone for TAP blocks in DIEP patients. A retrospective single-institution study (2018-2023) of DIEP patients receiving intraoperative, ultrasound-guided TAP blocks were identified and divided into two: Group 1 (commercially-available liposomal bupivacaine) and Group 2 (30 mL 0.25% bupivacaine + 1 mg dexamethasone). Outcomes included length of stay (LOS), total post-operative morphine milligram equivalents (MME), and Numeric Pain Rating Scale scores. Demographics were assessed and p<0.05 were considered significant. Among 178 patients (Group 1: 95; Group 2: 83), there was no difference in age, BMI>30 kg/m 2, smoking status, laterality, perforator selection, and wound complications across cohorts. Group 2 had a shorter LOS (2.88 days vs 3.49 days; p<0.001), lower total post-operative MME usage (70.6 ± 60.0 vs 104.7 ± 72.8; p<0.001), and lower pain scores (3.44 ± 1.50 vs 4.53 ± 1.57; p<0.001) on post-operative day one compared to Group 1. No differences were noted in pain scores on subsequent post-operative days (POD 2, 3, 4). TAP blocks using dexamethasone with bupivacaine added may represent a cost-effective and clinically effective alternative approach for post-operative pain management during DIEP flap breast reconstruction compared to commercially marketed liposomal bupivacaine.

Marked elevations of pancreatic enzymes are commonly interpreted as evidence of acute pancreatitis. However, in patients with end-stage renal disease (ESRD), serum amylase and lipase may be elevated without pancreatic inflammation, posing a significant diagnostic challenge. We present a case illustrating the diagnostic dilemma of extreme pancreatic enzyme elevation in an ESRD patient undergoing peritoneal dialysis without clinical or radiologic evidence of pancreatitis. A 50-year-old man with ESRD on peritoneal dialysis and known gastroparesis presented with intractable nausea and vomiting. Initial laboratory testing revealed markedly elevated pancreatic enzymes, with lipase levels peaking above 4,000 U/L and serum amylase at 545 U/L, raising concern for acute pancreatitis. However, the patient lacked characteristic epigastric pain, and contrast-enhanced abdominal CT demonstrated a normal pancreas without inflammatory changes or peripancreatic fluid collections. Autoimmune pancreatitis was excluded with negative IgG4 levels. Analysis of peritoneal dialysis fluid revealed very low amylase levels (less than 30 U/L), arguing against pancreatic enzyme leakage into the peritoneal cavity. Enzyme levels gradually declined over the course of hospitalization, and polyethylene glycol precipitation testing was pursued to evaluate for macroenzyme formation. The marked discordance between extremely elevated serum pancreatic enzymes and the absence of clinical symptoms, radiologic abnormalities, or dialysate enzyme elevation strongly suggested macrolipasemia and macroamylasemia in the context of ESRD. These findings likely reflect reduced renal clearance and macroenzyme complex formation rather than true pancreatic inflammation. This case highlights that extreme elevations of pancreatic enzymes may mimic acute pancreatitis in ESRD patients despite the absence of pancreatic disease. Careful correlation of symptoms, imaging findings, dialysis fluid analysis, and targeted laboratory testing is essential to avoid misdiagnosis and unnecessary interventions. Recognition of macroenzyme-associated hyperlipasemia should be considered when evaluating dialysis patients with markedly elevated pancreatic enzymes.

Intra-abdominal hemorrhage is an extremely rare complication of endoscopic retrograde cholangiopancreatography (ERCP). We report a case of intra-abdominal bleeding that occurred after ERCP for choledocholithiasis with cholangitis in a patient with a cascade stomach. A man in his 70s underwent ERCP for severe acute cholangitis due to a common bile duct stone. The procedure was initially attempted using a TJF-260 V duodenoscope (Olympus); however, insertion into the duodenum was difficult because of the stomach cascade. The scope was changed to a JF-260 V (Olympus), and duodenal access was successfully achieved using a large-diameter sliding tube (ST-CB1; Olympus), followed by biliary stent placement. No sphincterotomy or other invasive procedure was performed. Two hours after the procedure, the patient developed severe epigastric pain, hypotension, and progressive anemia. Contrast-enhanced computed tomography (CT) revealed a large hematoma centered on the gastrosplenic ligament, indicating an intra-abdominal hemorrhage that was likely caused by a traction injury resulting from scope manipulation. No evidence of contrast extravasation was found, and conservative management was performed. The patient's condition improved with blood transfusion and discontinuation of aspirin, and follow-up CT demonstrated resolution of the hematoma. Inserting a scope can be challenging owing to anatomical deformities such as a cascade stomach, and excessive torque or traction may result in vascular injury. Careful insertion using a sliding tube and positional adjustment are essential, with awareness that intra-abdominal hemorrhage, although rare, can be a serious complication.

Gastric cancer usually presents late with nonspecific symptoms such as epigastric discomfort, anorexia, weight loss, nausea, anemia, or gastrointestinal bleeding. Initial presentation with osteoporosis-like manifestations and multiple bone metastases in the absence of gastrointestinal symptoms is rare.

Standard time-to-surgery after neoadjuvant chemoradiotherapy for esophageal cancer has historically been 4-6 weeks. Observational studies have suggested improved oncological outcomes and health-related quality of life in patients after prolonged time-to-surgery. This study aimed to investigate whether prolonged time-to-surgery is associated with improved health-related quality of life compared to the standard interval. This study is a secondary endpoint analysis within the NeoRes II trial, in which patients with locally advanced resectable esophageal cancer were randomized to either standard time-to-surgery (4-6 weeks) or prolonged time-to-surgery (10-12 weeks). The primary endpoints have been reported previously. Health-related quality of life was assessed using the EORTC QLQ-C30 and QLQ-OG25 questionnaires at time of diagnosis, preoperatively, and at 6-months and 1-5 years postoperatively. A total of 249 patients were randomized of whom 192 were available for health-related quality of life analyses, with 97 (51%) assigned to standard time-to-surgery and 95 (49%) to prolonged time-to-surgery. The groups were well-matched regarding baseline characteristics. Preoperatively, within a week of the day of surgery, patients in the prolonged time-to-surgery group reported better global quality of life, improved physical functioning, and less fatigue, coughing, dysphagia, odynophagia, pain, discomfort, and weight loss compared to those in the standard time-to-surgery group. These benefits were observed at 6 months postoperatively, but not thereafter during follow-up, where no significant differences were observed. Although prolonged time-to-surgery was associated with better preoperative health-related quality of life, no such benefits were observed postoperatively. In addition, the results from the primary endpoint analysis suggested that longer time-to-surgery was associated with worse oncological outcomes. This, together with the results of the current sub-study, strongly supports that the standard time-to-surgery of 4-6 weeks should be recommended after neoadjuvant chemoradiotherapy for esophageal cancer.