Houssam Khodor Abtar

What could happen if you insert a BioEnterics intragastric balloon after sleeve gastrectomy

A 49-year-old previously healthy female patient with a body mass index (BMI) of 41 kg/m had undergone an SG 3 years before presentation to our hospital. She had lost 30 kg but then regained 10 kg because of increased food intake, and she had failed to maintain all conservative measures. Her treating physician has decided to insert an intragastric balloon with a capacity of 300 mL until tension on the gastric wall could be observed. She was referred to us 2 hours later as she experienced abdominal pain, retching, and hematemesis. Her vital signs and abdominal examination were normal. Therefore, the balloon was removed; however, a gastric mucosal tear was observed, but it went unrecognized as a full-thickness tear at this time. The patient was admitted for observation. Two hours later, she developed tachycardia, (heart rate [HR] 1⁄4 110 beats/ min), hematemesis, and abdominal distention. A standing abdominal film revealed a huge amount of air under the diaphragm (Fig. 1). Thus, a decision was made to perform

Management of gallbladder disease after sleeve gastrectomy in a selected Lebanese population

BACKGROUND Patients with morbid obesity are at a higher risk of developing gallstones after bariatric surgery. Studies on the incidence of symptomatic gallstones necessitating cholecystectomy after laparoscopic sleeve gastrectomy (LSG) are limited in the Middle East. OBJECTIVES This study aims to assess the incidence of cholecystectomy after LSG during a 1-year follow-up and to evaluate potential risk factors and potential prophylactic measures. SETTING Two university hospitals in Lebanon. METHODS A prospectively maintained bariatric database of 361 patients who underwent primary LSG between January 2009 and December 2012 at the American University of Beirut Medical Center and Makassed General Hospital was reviewed. Data included demographics, preoperative weight, weight at 6 and 12 months postoperatively, and incidence of postoperative symptomatic cholelithiasis. RESULTS A total of 319 patients (88.4%) were followed up at 1 year. Twenty-four (7.5%) had symptomatic gallstones and underwent cholecystectomy after LSG. Mean postoperative time for the development of symptomatic gallstones was 426 days (range, 91-1234 days). Patients who developed symptomatic gallstones were significantly younger (29.8 versus 34.8, P = 0.008) but comparable to patients who did not undergo cholecystectomy in terms of other baseline characteristics and weight loss results at 1 year. Out of the obesity-related co-morbidities, hypertension was the only co-morbidity associated with post-LSG cholecystectomy (OR = 3.35, P = 0.036) after multivariate adjustment. CONCLUSION The incidence of symptomatic gallstones requiring cholecystectomy after LSG in our study cohort was higher than that of the general population (7.5%). This incidence does not warrant prophylactic cholecystectomy or routine pre- or postoperative ultrasounds.

Highly Vascularized Primarily Inflammatory Pseudotumor of the Omentum in an Adult Male: A Case Report

Patient: Male, 38 Final Diagnosis: Inflammatory myofibroblastic tumor Symptoms: Abdominal pain • anorexia • weight loss Medication: — Clinical Procedure: Operation Specialty: Surgery Objective: Rare disease Background: Inflammatory pseudotumors can affect any organ, whereas primary omental tumors are very rare. A few cases have been reported in the literature, all affecting adult patients. They are usually difficult to diagnose preoperatively and pathology remains the criterion standard for diagnosis. Surgical resection is considered the first-line treatment in limited disease, whereas recurrent or metastatic disease is treated by re-excision. There is no role for chemo- or radio-therapy in limited disease. Here, we present a rare case of omental myofibroblastic tumor in an adult male. Case Report: A 38-year-old healthy man presented to our clinic complaining of lower abdominal pain associated with anorexia and low-grade fever, and he also reported weight loss. His initial hemoglobin was 9.7 g/dl. Magnetic resonance imaging (MRI) showed an enhancing solid mass in the lower abdomen, with close proximity to the appendix and the urinary bladder. The patient was treated successfully with laparotomy and excision of the tumor. Histopathology of the mass revealed spindle cells of vague fascicular pattern. Further immunohistochemical staining showed presence of reaction for CD68, CD34, and ALK. No omental infiltration was noted. No adjuvant treatment was applied and the patient was free of disease after 1-year follow-up. Conclusions: Omental pseudotumors are a rare pathology. They are usually slowly- growing, circumscribed tumors with a low malignant potential. They have a predilection for children. The overall mortality is reported to be 5–7% in cases with multiple recurrences.

Large ileocecal submucosal lipoma presenting as hematochezia, a case report and review of literature

Highlights • Ileocecal lipomas present typically with intussusception.There are only few reported cases of ileocecal lipomas presenting as lower GI bleeding.• Histopathological evaluation remains the gold standard in precise diagnosis.• The treatment of colonic lipomas is debatable among specialists.

Follicular carcinoma arising in a large ectopic lingual thyroid: a case report and review of literature

Abstract Ectopic lingual thyroid has been described, however, follicular carcinoma arising within it is an extremely rare entity with only 40 cases reported in the literature. Lingual thyroid carcinoma is undistinguishable from benign enlargement of lingual thyroid, the later should also be differentiated from many oropharyngeal pathologies including but not limited to thyroglossal duct cyst, lipoma, dermoid cyst and salivary gland tumors. Ectopic lingual nature of thyroid tissue can be diagnosed with scintigraphy scan; however, malignant transformation confirms just after pathological examination. Surgical excision remains the best therapy with transoral approach being the most appropriate and favorable among others due to its cosmetic results and lower incidence of infection. Herein, we report a case of an adult female who was diagnosed to have follicular carcinoma of an ectopic lingual thyroid tissue mass. Concerning the size of the mass it was the largest of all reported cases of ectopic thyroid gland.

Intramasseteric Schwanoma mimicking an isolated cheek mass: Case report and review of literature

Highlights • Intramasseteric schwannoma represents a very rare entity and only few cases are reported in the literature.• These are benign tumors, slow growing that are displacing neural structures without direct invasion.• Definitive diagnosis of intramasseteric schwannoma is delayed until surgical resection is performed.• Complete surgical excision is the standard treatment for schwannoma since radio-chemotherapy are of limited effectiveness.

First case report of bile leak from the duct of Luschka in a patient with mini-gastric bypass: The challenge of management

Introduction The incidence of Bile duct injury after laparoscopic cholecystectomy approaches 0.11%–1.4%. Ducts of Luschka are the second most common site of bile leaks. The rarity of these ducts with cases of anatomical alterations in the gastrointestinal tract such as mini-gastric bypass makes the management a challenging option. Presentation of case Hereby we present a unique case of 28 year old female patient with mini-gastric bypass who had done uneventful cholecystectomy. Day 3 postoperatively patient complained of diffuse abdominal pain. Computed tomography showed free fluid in the abdomen. Liver enzymes were normal. Relaparoscopy showed leaking bile duct of Luschka, which was closed by surgical clips and drains left in the spaces. However bile leak continued for 4 weeks then stopped. Patient did well after all. Discussion Endoscopic retrograde cholangiopancreatography with sphincterotomy played a crucial role for diagnosis and treatment of bile leaks with success rate near 94%. However no data were available using this method in a patient with Mini-gastric bypass procedure. Many authors have argued the role of relaparoscopy, but it is still an important way for adequate drainage and control of bile leakage. The only significant factor in determining clinical outcome in cases of non-surgical management is the type of bile duct injury. Conclusion To the best of our knowledge, this is the first case report of bile leak from duct of Luschka after mini-gastric bypass treated successfully with relaparoscopy and drainage. Herein we will discuss all the available options of treatment and the challenge of it.

First reported case of paratesticular seminoma in a postpubertal cryptorchid testis

Abstract Cryptorchidism is a very common anomaly, affecting 2–4% of male infants and is more common in premature infants. The long-term outcome despite orchidopexy still remains problematic and controversial with a risk of developing cancer 5–10 times greater than normal. Paratesticular tumors are mostly benign and very rare in children however malignant paratesticular tumors do arise, the most common being rhabdomyosarcoma. Primary paratesticular seminoma is extremely rare by itself and in most cases is associated with foci of seminoma within the testis. To the best of our knowledge, our case represents the fourth reported case of paratesticular seminoma in the published literature and being the first one in cryptorchid testis.

Rapid growth and local advance of an aggressive papillary thyroid cancer with anaplastic transformation in an elderly woman

A 71-year-old female was presented to our surgical department complaining of painful, erythematous and ulcerated neck mass causing bleeding (Figure 1). She also complained of shortness of breath and generalized fatigue. Her medical history included osteoporosis, hypertension and dyslipidemia. The history dates back to five years ago when she had noticed to have a cervical nodule during routine examination for elective cholecystectomy. Chest radiograph at that time noticed a well-defined nodule about 4x4 cm (Figure 2). That pathological findings was ignored by the patient till recently when that mass started to grow up, ulcerate and bleed. Patient underwent incisional biopsy of the mass which turned to be metastatic papillary carcinoma in cervical lymph node with extensive neoplastic infiltration of skin and sub-cutaneous tissue by anaplastic tumor, giant cell type. A whole body computed tomography scan showed multiple metastatic lung nodules. The rest of the body was free of metastasis. Multimodal therapeutic approaches were started including debulking surgery (R2 resection), radiation to a biologically equivalent dose and

Occult closed posterior elbow dislocation with intimal rupture of the brachial artery in a 71-year-old male

Posterior elbow dislocation with vascular injury is rarely encountered, but it is crucial for every emergency physician to diagnose it. Missing these injuries can result in neurovascular compromise, which in turn can lead to limb ischemia, compartment syndrome and potential limb loss. Having a normal X-ray on presentation makes this injury more difficult to diagnose. In this study, we present a case of occult posterior elbow dislocation with an intimal injury of the brachial artery. The rarity of these cases, the diagnostic modalities and the treatment options will be reviewed.