Firas Obeidat

The challenge of pancreatic anastomosis

Background and aimsSignificant progress in surgical technique and perioperative management has substantially reduced the mortality rate of pancreatic surgery. However, morbidity remains considerably high, even in expert hands and leakage from the pancreatic stump still accounts for the majority of surgical complications after pancreatic head resection. For that reason, management of the pancreatic remnant after partial pancreatoduodenectomy remains a challenge. This review will focus on technique, pitfalls, and complication management of pancreaticoenteric anastomoses.Materials and methodsA medline search for surgical guidelines, prospective randomized controlled trials, systematic metaanalysis, and clinical reports was performed with regard to surgical technique and complication management of pancreatic anastomoses.ResultsPancreaticojejunostomy appears to be most widely performed, but pancreaticogastrostomy is a reasonable alternative. Postoperative treatment with octreotide can be recommended only for patients with soft pancreatic tissue, and neither stents of the pancreatic duct nor drainages have proven to effectively reduce anastomotic complications. Gastroparesis remains the most common complication after pancreatic surgery and should be treated conservatively. However, it may be a symptom of other local complications, such as anastomotic leakage, pancreatic fistula or abscess. All septic complications may finally result in late postoperative hemorrhage, which requires immediate diagnostic workup and therapy. Today, interventional radiology has emerged as a standard tool in the management of local septic complications and bleeding. Therefore, relaparotomy has become less frequent and salvage pancreatectomy is now a rare procedure in case of local complications.ConclusionThe surgeon’s experience with one or the other technique of pancreatic anastomosis appears to be more important than the technique itself.

Primary extensive pyomyositis in an immunocompetent patient: case report and literature review

Pyomyositis is a suppurative infection of the skeletal muscle; it mainly occurs in immunocompromised patients or, exceptionally, in immunocompetent patients in tropical or other areas. We present a 24-year-old immunocompetent lady with bilateral thigh myalgia and fever. Upon investigation, extensive multifocal bilateral fluid collections involving the extensor muscles of both thighs were demonstrated. Pus aspirate from the involved muscles proved the presence of Staphylococcus aureus. Incision and drainage of the involved muscles were performed with successful and complete recovery.

Gastric perforation secondary to metastasis from ovarian cancer: Case report

INTRODUCTION Metastasis from ovarian cancer occurs frequently through the peritoneal cavity in the form of peritoneal carcinomatosis; isolated gastric metastasis is rarely reported in literature. PRESENTATION OF CASE We present a case of 43-year-old infertile lady, who developed a picture of acute abdomen four days post total abdominal hysterectomy and salpingoopherectomy for ovarian cancer. Further contrast-enhanced CT scan demonstrated massive free gas and fluid in the abdomen. She underwent antrectomy with truncal vagotomy due to 3cm×4cm prepyloric gastric ulcer. Final pathology proved the presence of metastatic serous cystadenocarcinoma of ovarian origin. DISCUSSION Our patient had a gastric perforation secondary to ovarian metastasis. Being isolated, the absence of ascites and the transmural nature of the gastric metastasis suggest haematogenous spread .To the best of our knowledge perforated gastric metastasis secondary to ovarian cancer was not reported in literature before. CONCLUSION Gastric metastasis should be kept in mind in patients with a well-known ovarian cancer who present with gastric lesions, ulcers, bleeding or perforation.

The impact of family members on weight loss after sleeve gastrectomy

BACKGROUND Weight loss after laparoscopic sleeve gastrectomy (LSG) is multifactorial. Postoperative compliance with appropriate dietary guidance may be affected by psychosocial factors and may influence the success of surgery. OBJECTIVE To evaluate the effect of LSG in siblings compared to case-matched controls. SETTING University hospital. METHODS Siblings who had undergone LSG were compared with controls case-matched by age, sex, and body mass index. The percentage excess weight loss (%EWL) was calculated at 3, 6, and 12 months postoperatively. RESULTS We had 32 siblings, of which 4 were lost to follow-up. Thus, 28 (87.5%) siblings completed 1 year of follow-up and were included in the study. In the family group, the %EWL was 72.7±15.0% at 1 year while in the control group the mean %EWL was 62.1±21.4%. Patients in the family group had significantly greater weight loss. Within the family group, the outcomes of family order had no statistically significant difference in weight loss between the first family member who had undergone LSG and subsequent family members. In addition, family members who had resided together in the same home had no advantage over those who resided separately. CONCLUSION Genetic and environmental factors may have great influence on outcomes after bariatric surgery.

Wound infiltration with bupivacaine 0.5% with or without adrenaline does not decrease pain after thyroidectomy. A randomized controlled study

Objectives: To study the effect of local wound infiltration with and without adrenaline on pain perception after thyroidectomy using the visual analog score (VAS). Methods: A prospective randomized controlled double-blinded study was conducted between May 2015 and June 2016 at The University of Jordan Hospital, Amman, Jordan. Eighty-nine patients undergoing planned thyroidectomy were included in the study. Patients were divided randomly into 3 groups: Group A, local wound infiltration with bupivacaine 0.5% was administered; Group B, bupivacaine 0.5% with adrenaline was administered; Group C (control), no infiltration was performed. Standardized thyroidectomies were performed in the 3 groups. Pain perception was measured using VAS at 2, 4, 6, 12, and 24 hours after surgery. A comparison between the 3 groups was carried out. Results: No significant differences among the 3 groups were observed at all time points (p=0.246). Visual analog scores were significantly lower at 12 and 24 hours after operations. Conclusion: Local wound infiltration with bupivacaine 0.5% does not decrease pain perception after thyroidectomy performed under general anesthesia, and adding adrenaline does not enhance its effect.

Histopathology results of Jordanian patients after laparoscopic sleeve gastrectomy

Background: Few studies have been published on histopathological findings in patients who underwent laparoscopic sleeve gastrectomy (LSG). However, no study has been published from Jordan, addressing the main histopathological findings for patients who underwent this procedure. Objective: This study aims to identify the patterns of gastric pathology among patients underwent laproscopic sleeve gastrectomy in Jordan. Materials and Methods: A retrospective review of histopathological results was performed for 150 patients who underwent LSG at Jordan University Hospital from 2008 to 2012, performed by a single surgeon. All the specimens were examined at the Pathology Department of Jordan University Hospital. Results: The average age of patients was 34.6 years and mean body mass index (BMI) was 45.1. Females represented 79.3% of all patients. Chronic gastritis was found in140 patients (93.3%), and Helicobacter pylori (H. pylori) was found in 51.3% of patients. Conclusion: In Jordan, chronic gastritis is most common in obese patients who underwent LSG. This finding supports previously published papers that focus on the importance of examining specimens postoperatively, also addressing a possible relation to the geographical area.

Reply to the Letter to the Editor on “Helicobacter Pylori Does Not Affect Postoperative Outcomes after Sleeve Gastrectomy”

We thank Dr. Kassir and his colleagues for their attention to our manuscript entitled: Helicobacter pylori does not affect postoperative outcomes after sleeve gastrectomy [1]. First, we would like to focus that our study included patients undergoing sleeve gastrectomy (LSG) and not gastric bypass. Hence, the stomach is easily accessible for endoscopic surveillance postoperatively. We fully understand your concerns and agree that Helicobacter pylori (HP) is a well-established risk factor for gastric cancer, and it is implicated in the pathogenesis of various benign and malignant diseases. Our article discussed the timing of treatment and is not against HP eradication. This issue was evident by treating all HP-positive patients in our study two weeks postoperatively. Some papers cited in our article suggested that HP should be eradicated before surgery as it might increase the incidence of leak. However, our article showed that preoperative surveillance might not be necessary as HP infection did not affect the rate of early postoperative complications. Therefore, eradication therapy can be given postoperatively based on histopathological examination of excised stomach, which is more accurate than other methods of testing. Worth mentioning that Keren et al. [2] showed that LSG might lead to HP eradication, due to the resection of the usual sites of bacterial infection. This might suggest repeat testing for HP three months postoperatively before giving eradication therapy. With regard to GERD and Barret esophagus (BE) post sleeve gastrectomy, studies had shown controversial results. Technical considerations might be implicated in the incidence of GERD postoperatively. Data from the literature concerning the development of BE after LSG are scarce. Genco et al. [3] showed a very high incidence of BE in LSG patients. Thus, endoscopic evaluation in the postoperative surveillance of LSG patients should be encouraged.

Intestinal Behcet's disease presenting with massive lower gastrointestinal bleeding

Gastrointestinal (GI) involvement in Behcets disease (BD) is variable, with the so called Intestinal BD being a rare presentation of this disease. Furthermore, its association with massive lower GI bleeding is considered a rare presentation. In this case presentation, we report case of a 27-year-old male, known to have BD who presented with massive lower GI bleeding, requiring empirical subtotal colectomy. Intestinal BD has variable presentation that may require urgent surgical management. It is also important to keep it in the differential diagnosis when dealing with patients presenting with lower GI bleeding with history of BD.

Die Adhäsionskrankheit: Eine interdisziplinäre Herausforderung

„Kaum ein chirurgisches Gebiet bereitet so viele diagnostische und therapeutische Schwierigkeiten wie die Adhasionskrankheit.“ Dieses 100 Jahre alte Zitat von T. Naegeli hat nicht an Gultigkeit verloren. Anhand des eigenen prospektiv untersuchten Patientenkollektivs sowie nach Recherche der aktuellen Literatur wird uber den aktuellen Stand von Diagnostik und Therapien der Adhasionskrankheit berichtet. Patienten und Methoden: Seit 1994 wurden an unserer Klinik 365 Patienten prospektiv wegen Adhasionsbeschwerden erfasst. Zielgrosen unserer Untersuchung waren: – Reproduzierbarkeit der Anamnese und korperlichen Untersuchung, – Objektivierbarkeit der Beschwerden durch apparative Untersuchungen (Sono, MRT), – Ergebnisse der Adhasiolyse (Lebensqualitat, Komplikationsraten, Rezidive), – Chancen und Risiken von Adhasionsprophylaktika. Ergebnisse: Die Untersuchungsgenauigkeit der Verwachsungssonografie betrug 93%, der funktionellen Adhasions-MRT 90%. Beschwerdebesserung durch Adhasiolyse in einem Nachbeobachtungszeitraum von 3 Jahren wurde im eigenen Kollektiv von 62% der Patienten berichtet. Die Mortalitat betrug 0%. Bei 30% der 10 Anwendungen von Icodextrin (2005–2006) als Adhasionsprophylaktikum wurde im eigenen Kollektiv ohne gleichzeitige Darmeroffnung die Ausbildung einer chemisch induzierten Peritonitis beobachtet. Schlussfolgerung: Chronische Abdominalbeschwerden konnten im eignen Kollektiv durch Anamnese und korperliche Untersuchung der Adhasionskrankheit nicht sicher zugeordnet werden. Mithilfe der Adhasionssonografie und funktioneller cine-MRT konnten Adhasionen mit hoher Genauigkeit detektiert werden. Dadurch konnten die Patienten einer zielgerichteten Therapie zugefuhrt werden. Eine anhaltende Befindlichkeitsverbesserung war bei 60% der Patienten erzielt worden. Aufgrund der hohen Komplikationsrate hat sich der routinemasige Einsatz derzeit zugelassener Adhasionsprophylaktikums klinisch nicht durchsetzen, neue Praparate werden derzeit im Rahmen prospektiver Studien eingesetzt und getestet.