Insulin resistance induced by de novo pathway-generated C16-ceramide is associated with type 2 diabetes in an obese population.

BACKGROUND: Obesity and diabetes are two chronic metabolic diseases whose prevalence is increasing at an alarming rate globally. A close association between obesity, diabetes, and insulin resistance has been identified, and many studies have pinpointed obesity as a causal risk factor for insulin resistance. However, the mechanism underlying this association is not entirely understood. In the past decade, ceramides have gained attention due to their accumulation in certain tissues and their suggested role in initiating insulin resistance. This study aims to determine the association of specific ceramides and their major metabolizing enzymes with obesity-associated insulin resistance. METHODS: The samples comprised subcutaneous adipose tissues collected from three cohorts: lean non-diabetic (controls; n = 20), obese-non-diabetic (n = 66), and obese-diabetic (n = 32). Ceramide levels were quantified using LC-MS/MS and mRNA expression level for different enzymes were estimated using real-time PCR-based RNA expression analysis. RESULTS: C16-ceramide (P = 0.023), C16-dihydro-ceramide (P < 0.005), C18-dihydro-ceramide (P = 0.009) and C24-ceramide (P = 0.040) levels were significantly increased in the obese cohort compared to the control group. However, stratification of the obese group revealed a significant increase in the C16-ceramide levels (P = 0.027) and mRNA over expression of the serine palmitoyl transferases enzyme subunit SPT1 (P < 0.005) in the obese-diabetic cohort compared to the obese-non-diabetic cohort. CONCLUSIONS: The present study indicates that C16-ceramide plays a pivotal role in inducing insulin resistance. Overexpression of SPT1 in the obese-diabetic group and its positive correlation with C16-ceramide suggest that C16-ceramide was generated through the de novo pathway.

Reconstruction of Infected Mediastinal Wound with an Omental Flap Harvested Laparoscopically After Cardiac Surgery: Report of Two Cases and Literature Review.

Background: Deep sternal wound infection and dehiscence are two serious complications after open cardiac surgery. Omental flap harvesting is recognized as one of the management options, with traditionally non-favorable outcomes due to laparotomy stress on patients. Objective: Herein, however, we report our experience with two patients who have developed a mediastinal wound infection following coronary artery bypass grafting and were reconstructed with omental flaps harvested laparoscopically. Case Presentation: Two 74-year-old females, who were known to have multiple comorbidities, developed a sternal wound infection after coronary artery bypass graft. Several operative trials and non-operative measures have been attempted to manage the infections and/or reconstruct the wound but failed. Both patients then underwent laparoscopic omental flap harvesting for reconstruction and exhibited significant clinical improvement postoperatively. Discussion: Omental flap is considered a feasible option for reconstruction of sternal wound dehiscence developing after open cardiac surgery because it is usually well-vascularized, contains a large number of immunologically active cells and has the ability to absorb wound secretions. The traditional method of harvesting is conventional laparotomy, but it carries high rates of morbidity. Therefore, laparoscopic harvesting can be utilized as an alternative with better outcomes. Conclusion: Laparoscopic omental flap harvesting is considered a feasible and safe procedure to manage sternal wound dehiscence after open cardiac surgery, with satisfactory surgical outcomes.

Dilemma of Blunt Abdominal Trauma in Patients with Crohn's Disease, Can Intestinal Perforation be Missed?

Background: Isolated intestinal injury after blunt abdominal trauma is a rare challenging clinical entity. Patients with Crohn's disease (CD) are considered more prone to spontaneous intestinal perforation rather than normal population However, spontaneous intestinal perforation remains rare. In the literature, there are few cases reports discussing intestinal perforation after blunt abdominal trauma in CD patients. Objective: Herein, we report a young male patient with CD who had missed traumatic intestinal perforation along with literature review of similar cases. Case Presentation: A young male patient, known to have CD, was brought to the emergency department after a road traffic accident. He had mild tenderness over his right iliac fossa with no signs of peritonitis. His chest X-rays revealed right-sided pneumothorax. His pan-computed tomography revealed thickened terminal ileum and minimal collection between the intestinal loops that were interpreted as interval regression of his Crohn's disease. On the second day, he remained hemodynamically-stable with no signs of peritonitis but his chest X-rays showed air under diaphragm. A repeated CT showed pneumoperitoneum, air foci around the terminal ileum and mild free fluid. An ileal perforation was found around 25 cm from the ileo-cecal valve. The involved ileal segment was completely resected with double-barrel ileostomy. Conclusion: Traumatic intestinal injury in patients with Crohn's disease represent both diagnostic and management dilemma. Inaccurate interpretation of radiological signs may lead to a delayed or missed diagnosis and surgical intervention. Abdominal CT scan should be routinely repeated, within 24 hours, for such patients, regardless absence of symptoms or signs suggestive of intestinal perforation.

Successful Surgical Management of Gastric Antral Vascular Ectasia in a Patient with End-Stage Renal Disease: A Case Report and Literature Review.

BACKGROUND Gastric antral vascular ectasia (GAVE) is a rare clinical entity that presents with acute upper-gastrointestinal bleeding or chronic anemia. It is characterized by endoscopic watermelon appearance of the stomach. It is usually associated with other comorbidities; however, few articles have previously described GAVE in patients with end-stage renal disease. Its management is controversial, and endoscopic management is considered the treatment of choice. CASE REPORT A middle-age female patient, on regular hemodialysis for ESRD, was referred to the surgical out-patient clinic as a refractory GAVE after failure of endoscopic management as she became blood transfusion-dependent. She underwent laparoscopic subtotal gastrectomy with a Billroth II reconstruction of gastrojejunostomy. She had a smooth postoperative course and was followed up in the clinic for 12 months with no complications. Her hemoglobin level was stable at 9.4 g/dL without further blood transfusion. CONCLUSIONS Gastric antral vascular ectasia is usually associated with other comorbidities; however, an association between GAVE and CKD is rare. Its management is controversial, and endoscopic management is considered the preferred method of treatment. Laparoscopic subtotal gastrectomy is an effective management modality for GAVE, with dramatic improvement and good outcomes in terms of bleeding, blood transfusion requirements, and nutritional status.

Surgical Management of Intra-gastric Balloon Complications, Single-Center Experience, and Literature Review.

INTRODUCTION: In Saudi Arabia, the prevalence of obesity has multiplied in the last decades leading to a surge in bariatric surgery and other endoscopic modalities. The intra-gastric balloon (IGB) is the most used endoscopic modality. Surgical management for IGB complications is required for gastrointestinal perforation and/or obstruction. However, the literature seems to underestimate these complications. MATERIALS AND METHODS: A retrospective descriptive study was conducted in King Fahd University Hospital, Saudi Arabia, from Jan 2017 to Dec 2021, including all patients with complicated IGB who necessitated any surgical procedure. Exclusion criteria were patients with complicated IGBs that were only managed conservatively or endoscopically. RESULTS: A total of 326 patients were admitted with different complications after bariatric procedures. Of them, six patients were referred due to IGB complications that necessitated operative intervention. All patients were young females. Three patients had gastric wall perforation, and were managed by endoscopic removal of the IGBs followed by exploratory laparotomy. One patient had an intestinal obstruction on top of a migrated IGB that was surgically removed. One patient had failed endoscopic retrieval of IGB and required a laparoscopic gastrostomy. Another patient had an esophageal rupture that required left thoracotomy, pleural flap, and insertion of an esophageal stent. All cases were discharged and followed up with no related complications. CONCLUSION: IGB is an endoscopic alternative, within specific indications, for the management of obesity. However, surgical management may be necessary to manage its complications, including gastrointestinal perforation, IGB migration, and failure of endoscopic removal.

Acquired right-sided diaphragmatic hernia in a patient with retroperitoneal hydatidosis: a case report and review of the literature.

BACKGROUND: Diaphragmatic hernia is primarily congenital in origin and has potentially devastating pulmonary complications. Acquired diaphragmatic hernia as a complication of hydatid disease remains a rare clinical entity. Retroperitoneal hydatidosis, in particular is an exceptionally rare cause behind a similar presentation. This paper aims to present the first case of acquired diaphragmatic hernia likely caused by eroding retroperitoneal hydatid cysts and provide a succinct literature review regarding the causative association between hydatid disease and diaphragmatic defects. CASE PRESENTATION: A 71-year-old Saudi man, with a history of hydatid disease involving several areas including the retroperitoneum, presented with multiple episodes of shortness of breath and abdominal pain of 10 months' duration. Computed tomography scans of the chest and abdomen demonstrated the presence of a large diaphragmatic defect, with herniation of bowel loops into the chest cavity. Initially, the patient underwent a diagnostic laparoscopy which was then converted to a posterolateral thoracotomy to repair the defect. CONCLUSIONS: The ability of hydatid disease to involve several body organs makes diagnosis and management of resultant complications a challenge in some cases, like ours. Knowledge about a reported rare complication could enable early detection and management to avoid serious complications, including abdominal viscera incarceration and strangulation.

Iatrogenic Esophageal Perforation After Laparoscopic Heller's Myotomy Treated Successfully with Endoscopic Stent: Case Report and Literature Review.

BACKGROUND Achalasia cardia is a neuro-degenerative motility disorder, which results in the loss of esophageal peristalsis along with failure of the lower sphincter to relax in response to swallowing. It is relatively rare, with a prevalence of 10 cases per 100 000 individuals. The criterion standard in the management of achalasia is laparoscopic Heller's myotomy with partial fundoplication. Esophageal perforation is one of the earliest major complications that could be managed by primary repair. However, it has been reported that esophageal perforations in achalasia cases can be managed with esophageal stenting after primary repair failure. CASE REPORT We are reporting a case of achalasia after Heller's myotomy in a 37-year-old man, which was complicated by iatrogenic esophageal perforation and was successfully managed by esophageal stenting after failed primary repair. CONCLUSIONS Esophageal stenting is a safe and effective management in cases of esophageal perforation after Heller's myotomy procedure.

Sclerosing Encapsulating Carcinomatous Peritonitis: A Case Report.

Sclerosing encapsulating peritonitis (SEP) is a rare clinical condition characterized by the formation of a thick, fibrous membrane encasing the intestines, which may lead to intestinal obstruction. The pathogenesis is not completely understood, but various risk factors are well established. However, there are only few reported cases of SEP associated with peritoneal carcinomatosis. Herein, we report a case of a 69-year-old male patient who presented clinically with acute intestinal obstruction 2 years after undergoing a resection procedure for gastric cancer. An abdominal computed tomography revealed findings typical of SEP. Consequently, the patient underwent exploratory laparoscopy, which confirmed the diagnosis of SEP and established the etiology as peritoneal metastases. The patient was managed conservatively, and his symptoms showed some improvement. The patient was at an advanced stage of the disease, and thus remained on palliative care and passed away 1 month later. Although very rare, physicians should consider SEP in their differential diagnoses of intestinal obstruction in patients, particularly in those with a history of intra-abdominal malignancies.

Gastrocolic fistula after laparoscopic sleeve gastrectomy: Case report and literature review.

INTRODUCTION: Laparoscopic sleeve gastrectomy is a popular bariatric procedure. Leakage after sleeve gastrectomy is the cornerstone for most of its related morbidity and mortality. Gastrocolic fistula is a rare complication resulting from chronic leak after laparoscopic sleeve gastrectomy. CASE PRESENTATION: We report a case of 32-year-old male who underwent laparoscopic re-sleeve gastrectomy for weight regain after initial uneventful laparoscopic sleeve gastrectomy 3 years back. He presented to emergency department by septic shock secondary to leakage after sleeve gastrectomy. CT abdomen with IV contrast and oral gastrograffin confirmed post sleeve gastrectomy leak. Emergency diagnostic laparoscopy revealed a huge abscess cavity containing pus and dark fecal material and altered blood. A long leak was identified with eversion of gastric mucosa. Tubular structure connecting the upper part of the stomach and the colon was found which turned out to be a gastrocolic fistula. It was controlled by endoscopic linear stapler. After 6 weeks, a definitive open esophago-jeujonostomy with total gastrectomy was done successfully after difficult attempt of laparoscopic intervention. The patient was discharged home in a stable condition. CONCLUSION: A high index of suspicion is important in detection of rare complications after laparoscopic sleeve gastrectomy including gastrocolic fistula. Complete laparoscopic resection of gastrocolic fistula is preferred. Gastrectomy might be the definitive surgery.

Laparoscopic Double-Tract Esophago-Jejunostomy Reconstruction for Iatrogenic Esophageal Perforation After Endoscopic Pneumatic Dilatation for Achalasia: A Case Report.

BACKGROUND Achalasia is a rare primary esophageal motility disorder of unknown etiology, with significant negative impact on patient quality of life. Esophageal perforation is the most serious complication after pneumatic dilatation for achalasia, with a high mortality rate of up to 20%. Double-tract reconstruction is used mainly after proximal gastrectomy for gastric cancer, with the advantage of functional preservation of the stomach. We report a case of iatrogenic esophageal perforation after endoscopic pneumatic dilatation for achalasia that was successfully managed by laparoscopic proximal gastrectomy with double-tract reconstruction. CASE REPORT An elderly man started to manifest desaturation during endoscopic dilatation for achalasia, and multiple esophageal perforations were confirmed just above the gastroesophageal junction. During diagnostic laparoscopy, multiple perforations were found 2 cm proximal to the gastroesophageal junction extending 5 cm proximally with multiple linear mucosal tears. A trial of primary repair was difficult and double-tract reconstruction was performed by transection of the distal esophagus above the perforations and proximal gastrectomy. Then, 3 anastomoses were performed: end-to-end esophago-jejunostomy, end-to-side jejuno-jejunostomy, and side-to-side gastro-jejunostomy 15 cm distal to the esophago-jejunostomy site. After a smooth postoperative course, he was discharged home and was followed up regularly. CONCLUSIONS Esophageal perforation is the most serious complication after endoscopic pneumatic dilatation for achalasia. Double-tract reconstruction is a feasible and effective reconstruction modality following esophageal resection that avoids complications of esophago-gastrostomy. This technique deserves to be considered a valid treatment modality for advanced and complicated cases of achalasia, but further research is needed.

Splenosis of the Mesoappendix with Acute Appendicitis: A Case Report.

BACKGROUND Splenosis is a benign condition involving the auto-transplantation of splenic tissue at various locations, resulting from splenic injury or splenectomy. CASE REPORT A 40-year-old male, with a history of remote exploratory laparotomy with splenectomy secondary to blunt abdominal trauma, presented with symptoms consistent with acute appendicitis, which was subsequently confirmed by computed tomography scan of the abdomen that further demonstrated the presence of multiple abdominal nodules, one of which was adjacent to the appendix. A laparoscopic appendectomy was then performed along with resection of the nodule located in the mesoappendix, which was confirmed to be a splenic tissue based on histopathological examination. CONCLUSIONS Abdominal splenosis is not an uncommon condition in patients with a history of splenic injury. However, the involvement of the mesoappendix, which may or may not contribute to acute inflammation of the appendix, is very rare.

Gastric Schwannoma In a Patient Undergoing Sleeve Gastrectomy: Uncommon Gastric Tumor Discovered Incidentally During a Common Gastric Procedure.

BACKGROUND Obesity is a major global health issue associated with significant co-morbidities. Regarding its treatment, the use of bariatric procedures is increasing due to their efficacy in weight reduction and improved management of the associated medical conditions. Although comprehensive preoperative evaluation is essential, routine upper endoscopy is controversial. CASE REPORT We present the case of a 27-year-old woman with a history of morbid obesity, hypertension, and diabetes mellitus. She had multiple unsuccessful attempts at lifestyle modification for weight reduction. Accordingly, she was scheduled for sleeve gastrectomy. However, the operation was canceled due to the incidental intra-operative finding of a gastric mass. She was diagnosed as having gastric schwannoma, which is considered a rare gastrointestinal neoplasm. CONCLUSIONS Comprehensive preoperative evaluation of patients undergoing bariatric procedures is essential. The present case is a good example of the value of upper endoscopy in the evaluation of patients, including those who are asymptomatic.

Laparoscopic removal of gastric balloon after failure of endoscopic retrieval.

INTRODUCTION: Different therapeutic measures have been developed in the treatment of obesity. Gastric balloon is a minimally-invasive modality in obesity treatment, but it is not without a risk of complications. PRESENTATION OF CASE: We present a 44-year-old morbidly obese lady who underwent gastric balloon insertion and refused to remove it at the recommended time. Unfortunately, after 18 months from insertion of the balloon, she was brought to the Emergency Department with symptoms of gastric outlet obstructions. Endoscopic retrieval of the balloon has failed. Hence, surgical intervention was planned and the balloon was successfully removed laparoscopically. DISCUSSION: Gastric balloons are designed to remain in the stomach for 6 months. Delayed extraction of the balloon associated with increase in the rate of complications. In our case, it was difficult to retrieve the balloon endoscopically due to thickened balloon wall, which was then removed laparoscopically safely without any complications. CONCLUSION: Laparoscopic extraction of the gastric balloon is a safe and feasible option in the management of difficult endoscopic retrieval.

Incidental Morgagni hernia found during laparoscopic repair of hiatal hernia: Case report & review of literature.

INTRODUCTION: Morgagni hernia is rare clinical entity accounting for 3% of all surgically treated diaphragmatic hernias. Similarly, paraesophageal hernia constitutes only 5% of all hiatal hernia. The co-existing of these two hernias is extremely rare with only 10 cases reported in the literature. PRESENTATION OF CASE: We present a case of 53-year-old female patient with 6-year history of reflux disease. Her symptoms were poorly controlled by medications and she was seeking a surgical treatment. Preoperative assessment revealed a giant paraesophageal hernia for which a laparoscopic repair was planned. During the surgery, left-sided Morgagni hernia was discovered and both hernias were repaired at the same time. The patient tolerated the procedure well without complications. CONCLUSION: The co-existence of Morgagni and Hiatal hernia is rare and the simultaneously laparoscopic repair of both hernias is safe and feasible.

Gastro-splenic fistula, a rare presentation of sickle cell disease patient with splenic abscess: Case report and literature review.

INTRODUCTION: Hemoglobinopathies such as Thalassemia and Sickle Cell Disease are risk factors for splenic abscess formation. Gastro-splenic fistula is a rare complication of splenic abscess. In the literature, there are no reported cases of gastro-splenic fistula in patients with hemoglobinopathies. PRESENTATION OF CASE: We are presenting a rare case of a 15-year-old boy with undiagnosed sickle cell trait with splenic sequestration crisis as first presentation of his disease. This was complicated by splenic abscess formation. Gastro-Splenic fistula was not apparent in computed tomography and upper gastrointestinal endoscopy findings were misinterpreted initially, which lead to delay in diagnosis and management. The patient was managed initially with antibiotics, followed by splenectomy and partial gastrectomy. DISCUSSION: Gastro-splenic fistula is not a common entity. It may be caused by gastric or splenic pathologies. In our case, which is the first reported in literature, the fistula developed as a complication of splenic abscess in patient with sickle cell disease. Its presentation depends on the underlying condition. CT scan is the modality of choice for diagnosis. Upper GI endoscopy findings of the fistula is often misinterpreted. The treatment of fistula is splenectomy and partial gastrectomy. CONCLUSION: Delayed diagnosis and management of splenic abscess in patients with sickle cell disease predisposes to fistula formation.

Clinical Significance of the Prognostic Nutritional Index for Predicting Short- and Long-Term Surgical Outcomes After Gastrectomy: A Retrospective Analysis of 7781 Gastric Cancer Patients.

To evaluate the predictive and prognostic significance of the prognostic nutritional index (PNI) in a large cohort of gastric cancer patients who underwent gastrectomy.Assessing a patient's immune and nutritional status, PNI has been reported as a predictive marker for surgical outcomes in various types of cancer.We retrospectively reviewed data from a prospectively maintained database of 7781 gastric cancer patients who underwent gastrectomy from January 2001 to December 2010 at a single center. From this data, we analyzed clinicopathologic characteristics, PNI, and short- and long-term surgical outcomes for each patient. We used the PNI value for the 10th percentile (46.70) of the study cohort as a cut-off for dividing patients into low and high PNI groups.Regarding short-term outcomes, multivariate analysis showed a low PNI (odds ratio [OR] = 1.505, 95% CI = 1.212-1.869, P <0.001), old age, male sex, high body mass index, medical comorbidity, total gastrectomy, and combined resection to be independent predictors of postoperative complications. Among these, only low PNI (OR = 4.279, 95% CI = 1.760-10.404, P = 0.001) and medical comorbidity were independent predictors of postoperative mortality. For long-term outcomes, low PNI was a poor prognostic factor for overall survival, but not recurrence (overall survival: hazard ratio [HR] = 1.383, 95% CI = 1.221-1.568, P < 0.001; recurrence-free survival: HR = 1.142, 95% CI = 0.985-1.325, P = 0.078).PNI can be used to predict patients at increased risk of postoperative morbidity and mortality. Although PNI was an independent prognostic factor for overall survival, the index was not associated with cancer recurrence.