Saqib Saeed

The effect of bariatric surgery on renal function

BACKGROUNDnObesity is associated with albuminuria and impaired renal function. We previously reported on 38 nondiabetics with improved albuminuria after Roux-en-Y gastric bypass (RYGB).nnnMETHODSnOur objectives were to evaluate changes in renal function, urinary albumin-to-creatinine ratio (UACR), and glomerular filtration rate (GFR) in a larger cohort of patients with normal or mildly impaired renal function, undergoing RYGB or sleeve gastrectomy at 1 year postop. This was a retrospective study. Inclusions: patients with preoperative and 1 year postoperative serum and urine albumin and creatinine and weight (kg).nnnEXCLUSIONSnpreop chronic kidney disease (CKD)≥Stage 3 or macroalbuminuria (UACR≥300 mg/g).nnnPRIMARY OUTCOMESnchanges in UACR and estimated GFR (eGFR) at 1 year. The setting was in a public hospital in New York City, 2004-2011.nnnRESULTSn158 patients met inclusion criteria; 91.8% female; mean age 40.8 years; 84.2% white Hispanic, 14.6 % black. Hypertension was present in 43.0%, diabetes mellitus in 28.5%. UACR was 21.5±3.2 mg/g, decreasing to 10.2±1.2 mg/g at 1 year (P<.0001). Microalbuminuria was present in 22/158 patients (14%) preop, resolving in 82% at 1 year; pre- versus 1 year postop eGFR, 97.5±2.2 versus 87.1±2.0 mL/min (P<.0001). Hyperfiltration was present in 8.2% preop, decreasing to 4.4% 1 year postop.nnnCONCLUSIONnIn this mainly female minority population, UACR decreased within the normal range, while eGFR decreased from normal to the range for Stage 2 CKD at 1 year postop. Microalbuminuria resolved in most affected and hyperfiltration resolved in nearly half of those affected. This study is limited by its retrospective nature. Prospective studies should be performed.

Vanishing spleen syndrome post right partial nehrectomy in a sicklemic patient

Splenic infarction after contralateral laparoscopic renal surgery has not, to our knowledge, been reported. The spleen is the most affected organ in sickle cell disease and the mechanism of auto infarction is thought to result from the crystallization of abnormal hemoglobin during periods of hypoxia or acidosis resulting in parenchymal ischemia and ultimately tissue necrosis. We report a case of 45 year old female with sickle cell disease who had an unremarkable spleen at the time of a laparoscopic right partial nephrectomy and was subsequently found to have marked diminution in her splenic volume.

Paraplegia Following Spinal Cord Contusion from an Indirect Gunshot Injury

Spinal cord injuries are debilitating and life threatening. Paraplegia due to direct traumatic gunshot injury to the spinal cord is common. The most common cause of spinal cord injury is road traffic accidents. This is followed by spinal cord injury due to a fall from a height. Most of the spinal cord injuries due to gunshot wounds occur as a result of direct traumatic effects. We present a rare case of a 49-year-old male with trauma. He developed paraplegia after a gunshot wound injury to the neck and contusion to the spinal cord, with no direct trauma. Paraplegia due to direct gunshot injury can have many different outcomes. In our case, the patient was managed conservatively, and the outcome was favorable.

A Case series of candy cane limb syndrome after laparoscopic Roux-en-Y gastric bypass

Abstract Candy cane syndrome is a rare complication reported in bariatric patients following Roux-en-Y gastric bypass. It occurs when there is an excessive length of roux limb proximal to gastrojejunostomy, creating the possibility for food particles to lodge and remain in the blind redundant limb. Patients present with non-specific symptoms such as abdominal pain associated with nausea and vomiting. Most remain undiagnosed as the disease process is poorly described. We report three cases of candy cane syndrome treated successfully at our institution.

Retrograde jejunojejunal intussusception in a pregnant female after laparoscopic Roux-en-Y gastric bypass

Abstract Adult intussusception is a rare complication after laparoscopic Roux-En-Y gastric bypass (LRYGB) surgery. Incidence of intussusception is on the rise as the demand of bariatric surgeries is increased to treat morbid obesity. Among the bariatric surgeries, LRYGB gastric bypass results in significantly higher weight loss with thinning of the mesentery resulting in increased risk for intussusception. Majority of intussusception cases after gastric bypass have been reported in non-pregnant patients. We report a case of retrograde jejunojejunal intussusception in 6 weeks pregnant female following laparoscopic gastric bypass, which was diagnosed with abdominal magnetic resonance imaging and managed successfully with resection and revision of the anastomosis.

Warfarin induced mesenteric and intestinal hematoma requiring surgical resection to relieve small bowel obstruction: A case report

Highlights • Prolonged use of Anticoagulant therapy causing intramural small-bowel hematoma and ischemic bowel disease.• Patients present with abdominal pain.• CT scan is used to make the diagnosis.• Physician should have a higher index of suspicion to recognize and diagnose this complication.• Patients with a history of prolonged anti-coagulants should be monitored closely with prolonged INR values, especially in patients presenting with abdominal tenderness.• Due to the rarity of this complication, more identification of such cases, observation and close surveillance is necessary.• Early diagnosis and appropriate management with surgical resection to prevent morbidity.

Blunt Laryngeal Fracture Status Post Fall on a Paintball Gun

Laryngeal fracture is a rare but potentially lethal injury. A high degree of suspicion along with an expeditious investigation is warranted to prevent airway complications. The initial assessment of the airway is vital as the patient can suffer a severe anoxic brain injury. If the patient is stable, a computed tomography (CT) scan of the neck should be obtained; this was done urgently for our patient and was managed without any extraneous intervention. We report a case of a 38-year-old man that presented to the emergency room with anterior neck pain after falling onto the back of a paintball gun. The patient was managed conservatively and favorable outcomes were obtained.

Duodenal Diverticular Perforation after Small Bowel Obstruction: A Case Report

Introduction Duodenal diverticulum is a rare disease that can be easily missed. The incidence of duodenal diverticulum diagnosed by upper GI study is approximately 5%. Autopsy results show that 22% of the population have duodenum diverticulum. Most patients with duodenal diverticulum are asymptomatic. However, complications like inflammation, perforation with retroperitoneal abscess, sepsis, pancreatitis, bile duct obstruction, and bleeding can occur. Approximately 162 cases of perforated duodenal diverticulum have been reported in the literature. Case Presentation We present a rare case of an 82-year-old female with perforation of a duodenal diverticulum caused by small bowel obstruction; in addition to this, there was a synchronous colonic tumor. Conclusion Diagnosis and management of this rare disorder are controversial. Nonoperative management is advocated in some cases. Some of the cases require early aggressive surgical intervention. The mortality rate remains approximately 45% in all these patients.

Vanishing lung syndrome in a patient with HIV infection and recurrent pneumothorax

Vanishing lung syndrome (VLS) is a rare chronic, progressive clinical entity seen in smokers characterized by giant emphysematous bullae mainly in the upper lobes. Extensive paraseptal emphysema coalesces to form giant bullae, compressing the normal lung parenchyma. The criteria for diagnosis based on radiography was defined by Roberts et al in 1987 and includes the presence of giant bulla in one or both upper lobes, occupying at least one third of the hemithorax and compressing the surrounding normal lung parenchyma. HIV infection can worsen the disease process. We report a 56 year-old HIV positive male with a smoking history of 30 pack-years smoking history who presented to the Emergency room with chronic chest pain, dyspnea, and cough for 2-3 weeks duration. He had a history of COPD and had multiple prior admissions for recurrent pneumothoraces. Chest radiography (A) showed hyperlucent and hyperinflated lung with bilateral pleural thickening and bilateral severe bullous emphysematous changes which was suggestive of vanishing lung syndrome. Computed tomography of the chest confirmed these findings (B). Chest tube was placed on the left side for treatment of the pneumothorax. The patient had refused lung reduction surgery in the past. He was counseled on smoking cessation and was discharged home with a Heimlich valve catheter. The main complication of VLS is pneumothorax. Lung reduction surgery such as bullectomy results in improvements in dyspnea, gas exchange, and exercise tolerance. Clinical should be aware of the condition and early referral for lung reduction surgery is required. Smoking cessation is essential.

Pneumomediastinum and subcutaneous emphysema after successful laparoscopic supra-cervical hysterectomy

Abstract Laparoscopic hysterectomy is a commonly performed gynecological procedure. Although the outcomes are favorable, severe life threatening complications such as pneumothorax, pneumomediastinum and subcutaneous emphysema can occur during laparoscopy secondary to carbon dioxide insufflation. We report a 46-year-old female who was scheduled for laparoscopic-assisted supra-cervical hysterectomy for uterine fibroids. Patient tolerated the procedure and there were no intra-operative complications. Post operatively she developed hypercarbia, subcutaneous emphysema and pneumomediastinum. She was managed conservatively. This case demonstrates a rare occurrence of subcutaneous emphysema and pneumomediastinum after supra-cervical hysterectomy.