An Unexpected Challenge: Marked Small Bowel Obstruction Arising From a Poorly Differentiated Metastatic Mucinous Adenocarcinoma of the Distal Ileum in a Risk-Free Healthy Patient.

Adenocarcinoma, while constituting the predominant variant among small bowel cancers, is a component of the broader category of primary small bowel malignancies, which are notably infrequent in occurrence. The diagnosis of such malignancies is often markedly delayed, a consequence of their insidious onset and the nonspecific nature of the abdominal symptoms presented. A 69-year-old Caucasian male presented to the emergency department manifesting acute, sharp, and colicky abdominal pain accompanied by a single episode of vomiting, all developing over one day. His medical history was notable for gastroesophageal reflux disease (GERD) and regionally confined prostate adenocarcinoma, which was under meticulous surveillance by the urological team. The patient's lifestyle was characterized by abstention from alcohol and tobacco, adherence to a nutritious diet, and a commitment to regular physical activity. Subsequent examination and surgical excision of an abnormal mass, as delineated on computed tomography (CT), culminated in the diagnosis of a stage IV, poorly differentiated adenocarcinoma. We have reported this case to spark research regarding early diagnostic techniques for small bowel adenocarcinoma (SBA). In this case, a healthy individual presented with vague abdominal pain and a single episode of vomiting. Diagnosis required the surgical resection of the tumor, where metastasis was also visualized. Due to the rare nature of SBA, we believe different diagnostic measures and adjuvant therapy should be researched for earlier diagnosis and subsequently better patient outcomes.

Comparative study of wound complications: isolated panniculectomy versus panniculectomy combined with ventral hernia repair.

BACKGROUND: The resection of an abdominal pannus carries the risk of wound-related morbidity in obese patients. Surgeons often perform a panniculectomy (PAN) to gain better access to the abdomen to perform other operations. We evaluated the incidence of wound complications after PAN with and without a concomitant procedure (i.e., ventral hernia repair [VHR]). METHODS: We reviewed the prospective data from all patients who underwent PAN alone and PAN combined with VHR from 2007 to 2011 at a single institution. The demographic data, operative information, and postoperative wound complications and interventions were recorded and analyzed using standard statistical methods. Multivariate logistic regression analysis was performed to control for confounding factors. RESULTS: After excluding the patients who had undergone concomitant procedures involving the gastrointestinal or genitourinary tract, 185 patients were included in the present study (143 patients in the PAN-VHR group and 42 in the PAN group). The average patient age was 55.4 and 47.6 years in the two groups (P = 0.001). The average body mass index was 38.0 and 41.1 kg/m(2) (P = 0.69). Of the 143 patients in the PAN-VHR group, 81.1% were women. In the PAN group, 92.9% were women (P = 0.09). The mean length of follow-up was 6.5 and 3.3 mo in the PAN-VHR and PAN groups, respectively (P = 0.04). In the PAN-VHR group, 96.5% underwent hernia repair with mesh and 29% underwent component separation. Subcutaneous talc was used in 58.6% of the PAN-VHR patients and 38.1% of the PAN patients (P = 0.02). Wound pulse-a-vac irrigation with bacitracin solution was used in 37.1% of PAN-VHR patients and 19.1% of the PAN patients (P = 0.03). The rate of wound complications and interventions for the PAN-VHR and PAN groups were not significantly different statistically (P < 0.05) and included seroma, seroma drainage, wound breakdown or necrosis, cellulitis, wound interventions, including bedside debridement and vac placement, and reoperation. After controlling for age, gender, body mass index, talc use, and pulse-a-vac irrigation use in the multivariate logistic regression analysis, the PAN-VHR group were more likely to develop cellulitis than the PAN-alone group (P = 0.004). The rates of all other wound complications were not significantly different statistically between the two groups after adjusting for confounding factors. CONCLUSIONS: PAN is associated with a significant risk of wound-related complications. The risk of postoperative cellulitis is increased further in patients who undergo concomitant VHR. However, the risk of all other wound complications and the need for interventions was not increased by performing concomitant VHR.

Literature review on antiobesity medication use for metabolic and bariatric surgery patients from the American Society for Metabolic and Bariatric Surgery Clinical Issues Committee.

The following literature search is in response to inquiries made to the American Society for Metabolic and Bariatric Surgery (ASMBS) regarding antiobesity medication (AOM) use in patients who are having or have already had metabolic and bariatric surgery (MBS). These recommendations are based on current clinical knowledge, expert opinion, and published peer-reviewed scientific evidence available at this time. This paper is not intended to establish a local, regional, or national standard of care. The paper will be revised in the future as additional evidence becomes available.

How frequently and when do patients undergo cholecystectomy after bariatric surgery?

BACKGROUND: Rapid weight loss after bariatric surgery is associated with gallstone formation, and cholecystectomy is required in up to 15% of patients. Prophylactic cholecystectomy or prophylactic ursodiol administration in the postoperative period have been suggested to address this problem. The objectives of this study were to investigate the frequency and timing of cholecystectomies after bariatric surgery and to determine the associated risk factors in patients who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB), laparoscopic adjustable gastric band (LAGB), or laparoscopic sleeve gastrectomy (LSG). METHODS: Data prospectively collected in an institutional database were analyzed. Differences among the 3 procedures and the effects of ursodiol administration, patient demographic characteristics, postoperative weight loss, and individual surgeon practices on cholecystectomy rates were examined. Survival analysis and proportional hazard models were used. RESULTS: Of 1398 patients, 109 (7.8%) underwent cholecystectomy with a median follow-up of 49 (range 12-103) months. Cholecystectomy frequency was 10.6% after LRYGB, significantly higher than 2.9% after LAGB (P < .001), and 3.5% after LSG (P = .004). The frequency was highest within the first 6 months (3.7%), but declined over time to < 1% per year after 3 years. Ursodiol administration did not affect cholecystectomy rates (P = .97), and significant intersurgeon variability was noted. Excess weight loss (EWL)>25% within the first 3 months was the strongest predictor of postoperative cholecystectomy (P<.001). Cox hazards model revealed 1.25 odds ratio per 10% EWL within 3 months, and odds ratio .77 per decade of life. In addition, white patients had 1.45 times higher cholecystectomy rates than did black patients. Preoperative body mass index, gender, and surgeon did not affect cholecystectomy rates. CONCLUSION: Bariatric surgery is associated with a low frequency of postoperative cholecystectomy, which is highest early after surgery and mainly determined by the amount of EWL within the first 3 months. The results of the present study do not support routine prophylactic cholecystectomy at the time of bariatric surgery in asymptomatic patients.