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.

Gut microbiota influence anastomotic healing in colorectal cancer surgery through modulation of mucosal proinflammatory cytokines.

OBJECTIVE: Colorectal cancer (CRC) is the third most diagnosed cancer, and requires surgical resection and reconnection, or anastomosis, of the remaining bowel to re-establish intestinal continuity. Anastomotic leak (AL) is a major complication that increases mortality and cancer recurrence. Our objective is to assess the causal role of gut microbiota in anastomotic healing. DESIGN: The causal role of gut microbiota was assessed in a murine AL model receiving faecal microbiota transplantation (FMT) from patients with CRC collected before surgery and who later developed or not, AL. Anastomotic healing and gut barrier integrity were assessed after surgery. Bacterial candidates implicated in anastomotic healing were identified using 16S rRNA gene sequencing and were isolated from faecal samples to be tested both in vitro and in vivo. RESULTS: Mice receiving FMT from patients that developed AL displayed poor anastomotic healing. Profiling of gut microbiota of patients and mice after FMT revealed correlations between healing parameters and the relative abundance of Alistipes onderdonkii and Parabacteroides goldsteinii. Oral supplementation with A. onderdonkii resulted in a higher rate of leaks in mice, while gavage with P. goldsteinii improved healing by exerting an anti-inflammatory effect. Patients with AL and mice receiving FMT from AL patients presented upregulation of mucosal MIP-1α, MIP-2, MCP-1 and IL-17A/F before surgery. Retrospective analysis revealed that patients with AL present higher circulating neutrophil and monocyte counts before surgery. CONCLUSION: Gut microbiota plays an important role in surgical colonic healing in patients with CRC. The impact of these findings may extend to a vast array of invasive gastrointestinal procedures.

Synchronous Malignant Peritoneal Mesothelioma and Sigmoid Adenocarcinoma: a Challenging Clinical Entity.

Background: Malignant peritoneal mesothelioma (MPM) represents a rare clinical entity. The synchronous existence of MPM with other malignancies as colonic adenocarcinoma have been rarely reported. Its diagnosis and management are challenging given its complexity and rarity. Objective: Herein, we report a case of epithelioid subtype of MPM occurring synchronously with sigmoid colonic adenocarcinoma, along with review of the literature. Case presentation: An elderly female patient was referred as case of rectosigmoid mass. She reported history of abdominal pain, per-rectal bleeding, anorexia, and significant weight loss. Her computed-tomography scan of the abdomen revealed a fistulizing sigmoid mass and multiple enlarged lymphnodes with omental nodulation. The colonoscopy revealed a large fungating mass and the endoscopic biopsies were reported as colonic adenocarcinoma. The patient was scheduled laparoscopic low anterior resection. However, the diagnostic laparoscopy revealed several nodules disseminated all over the peritoneum, suggestive of peritoneal mesothelioma. Therefore, the decision was changed to create transverse colostomy after examination obtaining multiple biopsies from the omental and peritoneal nodules. The histopathological revealed MPM and the final diagnosis was sigmoid adenocarcinoma with synchronous MPM. The patient was started on palliative chemotherapy (capecitabine) without active management of MPM because of her general condition. She was followed up with a good clinical course. Conclusion: MPM is an overlooked entity with vague clinical presentation. Synchronous MPM with colorectal cancer is rare with only few published case reports. Its diagnosis is challenging, and its management should be tailored according to the patient. This case is the first reported case in Saudi Arabia and the Middle East.

Acute right-sided ischemic colitis in a COVID-19 patient: a case report and review of the literature.

INTRODUCTION: In addition to attacking the respiratory system, the coronavirus disease may attack the gastrointestinal tract in various ways, one of which is by creating a coagulopathy that may lead to acute ischemia of the bowel, increasing morbidity and mortality rates in these patients. PRESENTATION OF CASE: We present a case of a white 72-year-old European male, who was admitted to the intensive care unit after developing COVID-19-induced acute respiratory distress syndrome. On the third week, despite a favorable evolution of his respiratory symptoms, the patient became clinically septic; laboratory findings showed an augmentation of his D-dimer, fibrinogen, C-reactive protein, and procalcitonin levels. Imaging showed signs of ischemia of the right colon. The patient was taken to the operating room; only the right side of his colon was ischemic, with a well demarcated cut-off. A laparoscopic right hemicolectomy with a terminal ileostomy was performed. The patient was able to go home 2 weeks after surgery. DISCUSSION AND CONCLUSION: Ischemic colitis is an uncommon pathology in the general population, and is rare in COVID-19 patients. Most cases of ischemic colitis in COVID-19 patients in the literature were limited to the left colon, with < 10 cases involving the right colon. Accurate and quick diagnosis with appropriate management is the key to avoid any mortality in those patients who are already weakened by the coronavirus.

How to Prevent Sarcopenia Occurrence during Neoadjuvant Chemotherapy for Oesogastric Adenocarcinoma?

The aim of this study was to evaluate the impact of a preoperative feeding jejunostomy (FJ) on the occurrence of sarcopenia before and after preoperative chemotherapy for patients with an oesogastric adenocarcinoma (OGA). Forty-six patients with potentially resectable OGA were enrolled in a perioperative chemotherapy protocol. Sarcopenia was evaluated by measuring muscle surfaces (psoas, paraspinal and abdominal wall muscles) on abdominal CT images at the level of the 3rd lumbar vertebra. A FJ was placed in 31 patients (67.4%) before the neoadjuvant treatment (FJ group), while 15 patients (32.6%) started neoadjuvant treatments without FJ (control group). After preoperative chemotherapy, there were significantly more sarcopenic patients in the control group, compared to the FJ group. In the FJ group, 13% of the patients (n = 4) were sarcopenic before treatment and 22.6% of them (n = 7) became sarcopenic after preoperative chemotherapy (p = 0.3). In the control group, if initially only 6.7% (n = 1) of patients were sarcopenic, the majority of the patients (60%, n = 9) became sarcopenic after chemotherapy (p = 0.012). The FJ was an independent risk factor of sarcopenia after neoadjuvant chemotherapy. FJ with enteral nutritional support during the preoperative management of OGA seemed to efficiently counteract sarcopenia occurrence during preoperative chemotherapy.

Laparoscopic Roux-en-Y Gastric Bypass for Failed Gastric Banding: One-Step or Two-Step Revisional Surgery?

BACKGROUND: Surgical revision rates are high, reaching 41% at 10 years after Laparoscopic gastric band (LAGB). Surgical revision may include re-banding, laparoscopic sleeve gastrectomy (LSG), duodenal switch (DS), or laparoscopic Roux-en-Y gastric bypass (LRYGB). LRYGBP has been proposed as the procedure of choice after failure of restrictive procedures with better results than any other procedure. LRYGB as a revisional bariatric surgery is hazardous compared with primary LRYGB. However, controversy as to whether revisional bariatric surgery should be performed as a one-step revision or as a two-step revision. OBJECTIVE: We aim to compare the mortality and morbidity between one-step versus two-step revisional surgery from LAGB to LRYGB. MATERIALS AND METHODS: Retrospective cohort study of our revisional surgery from LAGB to LRYGB between November 2007 and December 2016. Revisional surgery was indicated in cases of inadequate weight loss or weight regain and after band-related complications. Gastric band removal and conversion to LRYGB was either in a one-step or a two-step procedure, according to the indication of this revisional surgery and based on the intra-operative decision. RESULTS: One-step group included 107 patients, two-step group had 76 patients. MINOR COMPLICATIONS: Dindo-Clavien I-II: 5 complication in the one-step group, whereas 4 complication were seen in the two-step group (P = 1.000). MAJOR COMPLICATIONS: Dindo-Clavien ≥ IIIa complications: 10 complication in the one-step group, whereas 2 complications in the two-step group (P = 0.127). CONCLUSION: One-step revision is safe and feasible, without significant increased morbidity when performed in a specialized institution. However, proper patient selection is of the utmost importance.

Biliary pancreatitis in a duplicate gallbladder: a case report and review of literature.

Duplicated gallbladder is a rare congenital anomaly that require special attentions due to its clinical, surgical and diagnostic difficulties. We present a case of a 39-year-old female patient with a duplicated gallbladder who presented with an acute biliary pancreatitis, a case to our knowledge is the first in the literature. A double gallbladder in an abdominal ultrasonography was doubtful, thus a computed tomography scan, a magnetic resonance cholangiopancreatography and an endoscopic retrograde cholangiopancreatography were done that confirmed the double gallbladder. A laparoscopic cholecystectomy with an intraoperative cholangiography was performed safely two months after the acute attack. The histopathological report revealed a Y-shaped type 1 double gallbladder according to the Harlaftis et al. classification.

Bidirectional Jejunojejunal Anastomosis Prevents Early Small Bowel Obstruction Due to the Kinking After Closure of the Mesenteric Defect in the Laparoscopic Roux-en-Y Gastric Bypass.

BACKGROUND: The closure of the mesenteric defects (CMD) in Roux-en-Y gastric bypass (RYGB) reduces the risk of small bowel obstruction (SBO) due to internal hernia but might be associated with an increased risk of early SBO triggered by the jejunojejunal anastomosis (JJS) kinking. The aim of this study was to assess how enlarging the JJS with a bidirectional linear stapling can aid in avoiding the risk of early SBO by kinking. MATERIALS AND METHODS: This retrospective cohort study concerns 1327 patients who underwent RYGB with CMD between May 2007 and August 2016. The first 626 patients (group A) had a unidirectional JJS. The following 701 patients (group B) had a bidirectional side-to-side JJS and a hand-sewn closure of the remaining defect. We compared early SBO between the two groups. RESULTS: Eleven (1.75%) early SBO due to the JJS kinking occurred in group A, whereas none occurred in group B (p = 0.0012). Thirty-nine early postoperative complications happened in group A versus 32 in group B (p = 0.17). Nine (1.2%) digestive bleedings occurred in group B versus two (0.3%) in group A (OR = 4.05 [0.87-18], p = 0.054). Average operating time was 81 min [37-330] in group A and 77 min [33-240] in group B. CONCLUSION: Enlarging the JJS with a bidirectional linear stapling is associated with a reduced risk of early SBO due to the anastomosis kinking. However, it could be related to an increased risk of digestive bleedings.