Cystic duct leak is rare and fairly easily diagnosed. It occurs more frequently during the learning curve, but also after much experience. ERCP and ductal decompression play a large role in treatment, but almost all standard methods of treatment yield successful outcomes with low morbidity.

In order to determine if intraoperative ultrasound (US)-guided excision is a feasible procedure, we prospectively studied 15 female patients between July 1996 and December 1998 for US-detected nonpalpable breast lesions. Intraoperative US was used by the operating surgeon to identify the lesion, guide its excision, and evaluate the specimen to document complete removal. A control group of 15 female patients with mammographically detected nonpalpable lesions was used for comparison. These patients underwent preoperative needle localization, excision of the lesions, and specimen radiographs. Age, size of the lesion, total excised tissue volume, and operative time were documented in all cases. Fifteen patients aged 20-83 years (mean 51) underwent US-guided excision, which adequately localized all lesions, and excision was successful in all patients. Specimen US documented the lesion in all cases. Lesion size ranged from 0.7 to 2 cm (mean 1.1) and the total excised tissue volume averaged 30 cc. Mean operative time was 53 minutes (range 30-75 minutes). The 15 patients of the control group ranged in age from 32 to 82 years (mean 61). Excision was successful in all cases. Lesion size ranged from 1 to 2.5 cm (average 1.5) and the average excised tissue volume was 35 cc. Mean operative time was 50 minutes (range 30-75 minutes). There were no statistically significant differences between the two groups with regard to age (p = 0.2), operative time (p = 0.5), and total excised tissue volume (p = 0.5). The size of the lesions did have a statistically significant difference (p = 0.01). There were no perioperative complications. In conclusion, US-guided excision of nonpalpable breast lesions is a feasible and effective technique. US documents results immediately, is of minimal discomfort to the patient, avoids the need for preoperative localization, allows the entire procedure to be performed in the operating room, does not require radiation, and provides the surgeon with a useful alternative in selected cases.

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Background: Multiple combined coagulation factor deficiencies have been reported, although the genetic defects associated with these conditions remain largely unknown. We present an asymptomatic female with a persistent deficiency of both coagulation Factor XI (FXI) and Factor XII (FXII). To our knowledge, this particular combination of coagulation factor deficiency has not been previously reported. Case Report: In February 2004 a healthy 33 year-old white female without personal or family medical history presented with an elevated partial thromboplastin time (PTT) incidentally found during a routine pre-operative evaluation. Her prothrombin time (PT) was normal. Her PTT was 45 seconds (reference interval 23–37 seconds), and normalized with 1:1 mixing studies of patient and normal plasma. Preliminary laboratory evaluation included negative tests for the presence of a Lupus Anticoagulant, a normal serum albumin level, and a normal urinalysis. Additional laboratory testing of coagulation and included FXI and XII activities, measured by means of a one stage APTT-based clotting assay using APTT reagent (Automated APTT, Trinity Biotech, Bray Ireland), congenitally depleted deficient plasma (HRF, Inc, Raleigh NC) using the MDA II Trinity Biotech, Bray Ireland). FXI was 46% (reference range 60–150) and FXII was 42% (reference range 50–150). In March 2004, a repeated the laboratory evaluation showed a FXI of 41% and a FXII of 46%. In April 2006, FXI was 49%, and FXII was 40%. Is to be noted that the patient has never had a documented thromboembolic episode or excessive bleeding, despite the exposure, respectively, to estrogen supplementation for seven years, to a full-term pregnancy, and to an abdominal surgical event. Conclusion: Although modern laboratory methods are able to identify novel combinations of coagulation defects, their clinical significance requires additional investigation.

Background: Lower extremity ulcers are one of the most common skin manifestation in patients (pts) with APS, observed in 20-30% of pts. These skin ulcers typically respond poorly to conventional treatment. Although incompletely understood, the pathogenesis of the skin ulcers (and most of the clinical manifestations of APS) appears to be the result of vascular endothelial damage at the microcirculation level, leading to intracapillary thrombosis and focal inflammation. Systemic treatments with immunomodulatory agents such as glucocorticoids, intravenous immunoglobulin (IVIG) and immunosuppressants have been reported to improve outcomes, but typically carry substantial side-effects, and may not be available outside specialized referralcenters. The use of anticoagulation, with or without immunosuppression, in pts with APS and skin ulcers has been reported with variable results. Our group and others have documented an excellent safety profile with the combination of ASA 81 mg orally and enoxaparin 40 mg subcutaneously given to pregnant patients with APS and recurrent pregnancy loss. Patient with APS appear to share similar microcirculatory changes in the organs involved. Methods: Case report. Results: A 72 year-old gentleman was diagnosed with APS in 2000, when he was evaluated for recurrent deep venous thrombosis in the lower extremities, and was found to have a positive lupus anticouagulant serum test. He received anticoagulation with warfarin, with a target International Normalized Ratio (INR) of 2.5-3.5. In 2011, the patient was evaluated for full-thickness ulceration of the bilateral medial distal legs. He had been treated years earlier with venous ablation, and screening for lower extremity arterial insufficiency showed adequate peripheral circulation. The ulcers were treated with moist antimicrobial wound dressings, serial wound debridement, ongoing compression therapy, and a course of skin substitute therapy. After over one year of treatment the ulcers healed. Over the next several years the patient experienced several episodes of re-ulceration of the lower extremity ulcers despite continued use of compression stockings. He was treated in the same fashion, and each episode of re-ulceration required months of therapy to achieve healing. In mid-2017 he developed another episode of re-ulceration. Similar treatment was again initiated, with little improvement over the first several months of therapy. Physical findings and the recalcitrant nature of the ulcers suggested a direct casual relation with his underlying APS. Since our pt was not a candidate for any form of immunosuppression, he was started on daily subcutaneous enoxaparin 1 mg/kg and daily oral ASA 81 mg. A complete healing of the skin ulcers was noted three months after initiation of the above therapy. He continues on this treatment without any side-effects. Conclusion: A multidisciplinary approach allows for a more detailed evaluation of these challenging cases and helps to improve clinical outcomes. Disclosures No relevant conflicts of interest to declare.