Ehab Elakkary

Do Support Groups Play a Role in Weight Loss after Laparoscopic Adjustable Gastric Banding

Background: Surgical intervention represents the only treatment with long-term efficacy for morbid obesity. Laparoscopic adjustable gastric banding (LAGB) is a minimally invasive operation that is increasing in popularity. We hypothesized that attending support groups is beneficial to achieve optimal weight loss after LAGB. Methods: 38 patients who underwent LAGB between Dec 2002 and Aug 2003 were studied retrospectively. Patients were divided into 2 groups; A included 28 patients who did not attend the support groups (surgery without support groups), and B included 10 patients who attended the support groups (surgery with support groups). Weight loss between the 2 groups was compared over a 1-year period. Results: Patients who attended support groups achieved more weight loss (mean decrease in BMI = 9.7 ± 1.9) than patients who did not attend support groups (mean decrease in BMI = 8.1 ± 2.1), P = 0.0437 (unpaired t-test). Conclusion: Support groups appear to be an important adjunct for patients who undergo LAGB, to achieve and maintain improved weight loss.

Endometrioma of the Large Bowel

Endometriosis is the presence of functioning endometrial glands and stroma outside the uterine cavity. It is one of the most common diseases in gynecology. About 10% of women of reproductive age suffer from endometriosis. In infertile patients, the proportion rises from 15% to 20% [1]. Involvement of the bowel occurs in approximately 5% of cases [2, 3], with the rectum being the most frequent location [4]. Other parts of the bowel commonly affected are the distal ileum (2%–16%) and appendix (3%–18%) [5]. The signs and symptoms are mostly correlated with menstruation, but in some cases they occur continuously [6, 7]. Intestinal endometriosis may present with lower gastrointestinal bleeding, bowel obstruction, and, rarely, perforation or malignant transformation [8, 9]. The symptoms of bowel endometriosis can vary depending on the site and include anal pain, low back pain, lower abdominal pain, bleeding per

The Shape of the Epiglottis Reflects Improvement in Upper Airway Obstruction after Weight Loss

Obstructive sleep apnea (OSA) is a sleep disorder characterized by recurrent episodes of closure of the upper airway during sleep, and is highly prevalent among overweight individuals. A significant percentage of patients with OSA remain undiagnosed. This condition creates chronic nighttime hypoxemia that can result in significant complications including systemic and pulmonary hypertension, cor pulmonale, and stroke. Polysomnography is still the most widely used method for diagnosing OSA. Studies have shown that in the majority of patients with OSA the airway obstruction involves the retroglossal region. Upon performing esophagogastroduodenoscopy on patients with a wide range of body mass indices (from 21 to 63), we noticed a gradual increase in the concavity of the posterior epiglottal surface as the BMI increases. Upon following some of the patients who underwent laparoscopic gastric banding and lost significant weight, we noticed a dramatic change in the shape of the epiglottis. This reflects a relief in the pressure on the epiglottis created by the collapsing airways in periods of apnea. Thus, the deformity in the shape of the epiglottis reflects the chronic airway collapse in obese patients, and improvement in this deformity after weight loss indicates a relief of the chronic upper airway obstruction.

Masters Allen Syndrome: A Review

Allen and Masters in their classic 1955 article [1] defined traumatic laceration of uterine support as a syndrome characterized by laceration in the posterior leaf of broad ligament along with abnormally mobile cervix designated as the universal joint 1. Since their original description, a number of authors have defined and redefined this entity to look for a plausible explanation of the symptoms that include dyspareunia and acute or chronic pelvic pain. Because of the rare occurrence of this disease and its limited reporting in the literature, it is important to recognize this as a distinct entity that must be included in the differential diagnosis of pelvic pain. Twenty-five patients with chronic pelvic pain were studied by De Brux et al. [2]; the classic tear of broad ligament was found in 17 of the patients. Similarly, Lawry [3] presented a series of 23 patients; presenting complaints included dyspareunia, excessive fatigue, general pelvic pain, and backache. None of the patients presented acutely with

Enterocutaneous fistula: a rare complication of laparoscopic adjustable gastric banding.

Morbid obesity is a refractory disease with serious co-morbidities. Laparoscopic adjustable gastric banding (LAGB) has generally been a safe and effective method for achieving sustained weight loss. We report a man who presented after LAGB with persistent wound infection at the access port-site, which failed conservative management. Diagnostic laparoscopy found an enterocutaneous fistula from herniated bowel (in a Richters hernia) into which the catheter had eroded. The small bowel and fascial defect were repaired. The catheter was then clipped and divided, and the port was removed.

Fibromyxoma of the small bowel: a review.

Fibromyxoid describes a rare tumor composed of mature fibroblasts and connective tissue originating from the embryonic tissue of the mesoderm. Cases of gastric fibromyxoma have been reported in the literature, often accompanied by symptoms of dyspepsia and anemia as a result of ulceration of the overlying mucosa [1]. Often the most common nonepithelial tumors found in the gastrointestinal tract are smooth muscle tumors, called gastrointestinal stromal tumors. The stomach and small intestine are the most common locations for these tumors [2]. Because of the rarity of this tumor and its limited reporting in the literature, it is important to recognize this as a distinct entity that must be included in the differential diagnosis when considering a tumor with these characteristics in the small bowel.

Do support groups play a role in weight loss after bariatric surgery

Purpose: Morbid obesity is an increasingly common condition with serious associated morbidity and decreased life expectancy. Surgical intervention represents the only treatment with long-term efficacy for this condition. Laparoscopic adjustable gastric band (LAGB) is a minimally invasive bariatric operation that is increasing in popularity worldwide. Methods: In this study, we discuss the role of support groups to achieve and maintain the optimal desired weight loss. We hypothesize that support groups are needed to achieve the optimal weight status after bariatric surgery represented in our study by the LAGB. We present our experience with 38 patients who underwent LAGB between December 2002 and November 2003 by the same surgeon at our hospital comparing the weight loss between two groups over a 1-year period. Group A (28 patients): Surgery without support groups. Group B (10 patients): Surgery with support groups. Results: Patients who attended support groups achieved more loss of weight (mean decrease in BMI 9.66 1.9) than patients who did not attend support groups (mean decrease in BMI 8.08 2.1). The results were statistically significant with P value of 0.0437 (unpaired t test). Conclusions: Support groups represent an important adjunct for patients who undergo bariatric surgery as LAGB to achieve and maintain optimal weight loss. PII: S1550-7289(05)00234-0

Bowel obstruction secondary to idiopathic adhesions.

To the Editor: Acquired intra-abdominal adhesions are attributed to surgery or an inflammatory process. The true proportion of adhesions secondary to inflammation is not known. Postsurgical adhesions represent the most common cause of bowel obstruction in the Western world. Congenital or inflammatory adhesions rarely give rise to intestinal obstruction, except for malrotation. We report two cases that presented with bowel obstruction secondary to extensive intraperitoneal adhesions with no previous abdominal surgery or history of acute inflammatory process in the abdomen. Case 1.A 64-year-old male was admitted to the hospital for peripheral vascular disease and impending gangrene of the right lower extremity. The patient’s medical history was positive for hypertension as well, while his surgical history was negative. An aortogram was done and showed complete occlusion of the right external iliac artery. The patient underwent crossover femoral bypass via extraperitoneal approach. A few days after surgery, the patient developed symptoms of complete bowel obstruction that failed to respond to conservative management. Abdominal x-rays and CT scan showed dilated small bowel loops and subsequently the patient was taken back to the operating room for exploratory laparotomy. On entering the abdominal cavity, multiple dense adhesions were found. After adhesions were lysed, we decided to resect a short segment of small bowel with primary anastomosis. The postoperative course was uneventful and the patient was discharged from the hospital. Case 2.A 69-year-old male with a history of benign prostatic hypertrophy and transurethral resection of the prostate 2 years previously presented to the ER with a 9-day history of nausea, vomiting, abdominal distension, and constipation that had progressed to obstipation. On examination, the patient was tachycardic. The abdomen was diffusely distended and tender, with no guarding or rigidity. An incarcerated left-sided inguinal hernia was identified. The acute abdominal series showed dilated small bowel loops. The patient was taken to the operating room after IV fluid resuscitation and NG tube decompression. Laparotomy was performed through a midline incision. On entering the abdominal cavity, multiple interloop adhesions were noted and loops of small bowel were firmly matted together. The sigmoid colon was found in the incarcerated hernial sac. Lysis of adhesions was performed and the hernia was reduced and repaired. The patient was discharged home on postoperative day 7 in good condition. Discussion. In the two cases presented we encounter intraperitoneal adhesions without previous abdominal surgery or a history of inflammatory abdominal processes. The pathogenesis of adhesion formation can be explained by understanding the mechanism of peritoneal healing. The peritoneum becomes mesothelialized, with new mesothelium developing from islands of mesothelial cells which then proliferate into sheets of cells. Organization of the fibrin gel matrix is of major importance in adhesion formation. The matrix is formed initially from fibrinogen, which forms fibrin monomer, then polymer, which interacts with proteins, including fibronectin, to form the fibrin gel matrix. Different amino acids are involved in this process and are the basis of much new research on adhesion formation. Matrix metalloproteinases (MMPs) are responsible for remodeling of collagen. The expression of MMPs varies among the serosal tissues of peritoneal organs and adhesions, and because tissue injury alters their expression, site-specific variations may predispose a particular organ to develop more adhesions. Tissue plasminogen activator (tPA) in mesothelial cells plays an important role in preventing adhesions. Finally, we conclude that intra-abdominal adhesions can form without any known etiology—“idiopathic adhesions”—which necessitates reporting these cases for further studies to define the exact pathogenesis of adhesion formation on the molecular and biochemical level.

Omental mass secondary to metastatic breast cancer.

Solitary solid tumors in the mesentery and omentum are rare lesions. The tumor mostly presents as a laterally mobile abdominal swelling with a gradual onset. A peritoneal mass can be benign or malignant (primary or metastatic) (1). Primary and secondary neoplasms of the peritoneum may present as multiple nodules, masses, or diffuse involvement of the peritoneum. When these lesions are associated with mass lesions or areas of significant peritoneal thickening, they become amenable to percutaneous image-guided fine-needle aspiration (2). We present a case of an uncommon but significant form of metastatic breast cancer presentation as a solitary omental mass 9 years after the primary cancer diagnosis.