Malrotation in an Adult Patient With Pneumoperitoneum Following Nissen-Sleeve Gastrectomy: A Case Report.

Intestinal malrotation is typically encountered in the first year of life and is rarely seen in adult populations. Herein, we present the case of a 48-year-old woman with a surgical history of laparoscopic Nissen-sleeve gastrectomy before 11 months who was referred to the general surgery service after presenting to the emergency department with acute epigastric abdominal pain for one-day duration. Radiography and a computed tomography (CT) scan of the abdomen revealed a large pneumoperitoneum. Subsequently, a diagnostic laparoscopy was performed, which detected a sealed perforation in the fundus of the wrapped-sleeved stomach, along with an incidental finding of intestinal malrotation. The encountered variation of anatomy created an intraoperative challenge during the conversion from Nissen-Sleeve gastrectomy to single anastomosis gastric bypass. The diagnosis of intestinal malrotation in adults is often overlooked, posing substantial diagnostic and management challenges when encountered.

Internal Hernia Post-Single Anastomosis Gastric Bypass: Case Series with Review of Literature.

Obesity is an emerging worldwide health care issue. It has a direct and indirect bearing on health-related outcomes. Rates of overweight and obesity have grown manifold in the past few decades globally. Once considered a problem of the affluent societies only, obesity is now dramatically on the rise in low- and middle-income countries also. Single anastomosis gastric bypass (SAGB) is one of the combined bariatric procedures adopted for weight loss in patients failing maximal medical therapy. Internal hernia (IH) after SAGB is a less recognized clinical entity. We hereby report our experience with four such cases under light of current available literature. Bariatric procedures are associated with some short- and long-term limitations. IHs are among one of the dreaded complications associated with some bariatric procedures with rates reaching up to 16% after classic Roux-en-Y gastric bypass. The incidence of IH post-SAGB is comparatively rare and is very less frequently reported. Symptoms of IH post-SAGB are quite nonspecific and depend on the time and extent of herniation. The symptoms can vary from benign intermittent colicky pain to severe intra-abdominal pain presenting as a surgical emergency. Routine physical examination and biochemical investigations are nonspecific and unreliable in evaluating those patients. Computed tomography (CT) with intravenous and oral contrast is the most common imaging modality used for preoperative evaluation of those symptoms. The CT findings can be unremarkable in patients having intermittent symptoms/herniation. Diagnostic laparoscopy is the cornerstone for diagnosis and management of patients having high suspicion of IH.

Giant Paratubal Cyst Mimicking Mesenteric Cyst.

Paratubal cysts are adnexal masses located in the broad ligament; whenever the size of the cyst is >20 cm, it is considered a giant cyst and can present with complications including ovarian torsion and perforation. Diagnosis can be made clinically with the help of radiological investigations, although the gold standard diagnostic tool is diagnostic laparoscopy. Managing this condition relies mainly on surgical intervention (open or laparoscopic). Giant paratubal cysts carry challenges in their surgical excision as they carry a higher risk of spillage. We present a case of giant paratubal cyst in a 26-year-old Bahraini female who presented with abdominal distension and pain for 3 years.

Intersigmoid Internal Hernia: Laparoscopic Repair of a Rare Cause of Bowel Obstruction.

Intersigmoid hernia is a hernia of an abdominal viscus into the intersigmoid fossa, and it is one of the rare forms of internal hernia that can present with bowel obstruction. Intersigmoid hernia poses challenges in its diagnosis and treatment due to its rarity and vague signs and symptoms. As such, a high index of suspicion should be maintained, and early diagnostic examination should be done that includes an abdominal CT that may show signs suggestive of internal hernia. Managing this condition relies mainly on surgical intervention (open or laparoscopic) in a timely manner to prevent further complications, such as bowel ischemia. We present a case of intersigmoid hernia in a 51-year-old Bahraini male who presented with vague abdominal pain and vomiting.

Benign cystic mesothelioma: A case report on the presentation of an unusual tumor.

INTRODUCTION: Benign cystic mesothelioma of the peritoneum is a rare, benign abdominal tumor. It can present with vague signs and symptoms and is often found on imaging or incidentally during surgery. PRESENTATION OF CASE: We report the case of a 30-year-old man presenting with acute abdominal pain that radiated to the right iliac fossa. No masses were found on superficial or deep palpation or on conducting a sonography. The patient underwent a diagnostic laparoscopy with an appendectomy, which revealed a perforated appendix and two cysts in the pelvis and iliac fossa. DISCUSSION: A benign cystic mesothelioma is an inclusion cyst found in the peritoneal cavity and has no specific clinical presentation. It can be symptomatic or found incidentally during surgery. Benign cystic mesotheliomas have a high recurrence rate and may undergo malignant transformation. CONCLUSION: Complete surgical excision of benign cystic mesothelioma must always be the first step of the treatment plan for this condition. It is difficult to treat with no evidence-based treatment modality available; thus, treatment should only be undertaken in a specialized center.

Effect of Bariatric Surgery on Weight Loss, Nutritional Deficiencies, Postoperative Complications and Adherence to Dietary and Lifestyle Recommendations: A retrospective cohort study from Bahrain.

OBJECTIVES: This study aimed to investigate the effect of bariatric surgery on degree of weight loss, as well as the prevalence of nutritional deficiencies, postoperative complications and adherence to dietary and lifestyle recommendations in a cohort of patients from Bahrain. METHODS: This retrospective cohort study took place between March and September 2018 at two hospitals in Bahrain. All adult patients who had undergone bariatric surgery between 2012-2017 were included. Sociodemographic and clinical information was collected from the patients' medical records and during phone interviews. RESULTS: A total of 341 patients participated in the study. The mean age was 39.82 ± 9.95 years and 67.7% were female. There was a significant relationship between postoperative body mass index and both the type of surgery and time since surgery (P = 0.025 and 0.008, respectively). While type of surgery had no significant effect on percent of excess weight loss (EWL) or percent of total weight loss (TWL), time since surgery significantly affected both of these weight loss measures (P = 0.006 and 0.001, respectively). Biochemical tests revealed haemoglobin, mean corpuscular volume, 25-hydroxy vitamin D, ferritin and iron deficiencies. Commonly reported complications included hair loss (59.5%), flatulence/abdominal pain (39.3%), dry skin (34.3%) and gastroesophageal reflux disease (33.1%). The level of adherence to dietary and lifestyle recommendations was high to moderate. CONCLUSION: Bariatric surgery was effective in accelerating EWL and TWL; however, it also resulted in complications such as nutritional deficiencies and gastrointestinal side-effects.

Efficacy of Intraperitoneal Instillation of Bupivacaine after Bariatric Surgery: Randomized Controlled Trial.

INTRODUCTION: Obesity is one of the greatest health problems. Bariatric surgery is more effective than non-surgical options; however, postoperative pain is bound to a greater morbidity. Control of postoperative pain is important in facilitating patient convalescence. In this study, we assessed the efficacy of intraperitoneal instillation of bupivacaine after bariatric surgery. METHODS: A hundred patients who underwent bariatric procedures including sleeve gastrectomy, sleeve gastrectomy with cardioplasty, gastric bypass, and gastric mini bypass (one anastomosis gastric bypass) were included in the study. Patients were divided into two groups randomly, 50 patients for each; group I had intraperitoneal instillation of 40 ml bupivacaine 0.25% at the end of the procedure, while group II had normal saline instillation. Monitoring of pain control in the first 24 h after surgery was done using the visual analogue scale (VAS) to assess the efficacy of intraperitoneal bupivacaine instillation and its effect on the overall opioid usage, postoperative nausea and vomiting (PONV), and shoulder tip pain. RESULTS: Pain scores were significantly lower in group I compared to group II at recovery, 2, 4 and 6 h after surgery, P = 0.004, 0.001, < 0.001, and 0.001 respectively. However, there were no significant differences between 12 and 24 h postoperatively. Additionally, there was a significant difference regarding the need for rescue analgesia at recovery P = < 0.001*. Further analysis revealed lower morphine consumption via PCA in group I compared to group II P = 0.013*. There were no significant differences with the use of intraperitoneal bupivacaine as regards nausea, vomiting, or shoulder tip pain, P = 0.688, 0.249, and 0.487, respectively. CONCLUSIONS: Intraperitoneal instillation of bupivacaine provides a good analgesia in the early postoperative period, reduces the overall consumption of opioid, and decreases the rescue analgesia requirement in the first 24 h after surgery.

An undiagnosed giant right renal hydatid cyst treated laparoscopically: Case report and review of literature.

Hydatid disease caused by the tape worm Echinococcus granulosus is a rare occurrence in the urinary system in general. We are hereby presenting a case of a gentleman in his fourth decade with a giant right renal hydatid cyst. The clinical manifestations, radiological features, and serology were all not suggestive of hydatid disease; however, typical Echinococcus scolices were detected histologically following cyst aspiration. The giant cyst was successfully treated laparoscopically.