Effect of sleeve gastrectomy on the levels of oral volatile sulfur compounds and halitosis-related bacteria.

Background: The association between sleeve gastrectomy and halitosis remains relatively unknown. Therefore, this study aimed to evaluate the effect of sleeve gastrectomy on halitosis and the oral bacterial species associated with halitosis in patients with obesity. Methods: This was a prospective longitudinal cohort study that examined patients before and after sleeve gastrectomy and followed the patients at three time intervals (1, 3, and 6 months) after sleeve gastrectomy. Clinical periodontal measurements (plaque index [PI], gingival index [GI], and probing depth [PD]) were obtained. In addition, plaque samples were collected for quantification of the periodontopathogenic bacteria: Porphyromonas gingivalis, Tannerella forsythia, Treponema denticola, and Fusobacterium nucleatum using real-time quantitative polymerase chain reaction (qPCR). In addition, breath samples were collected to analyze the concentration of volatile sulfur compounds (VSCs), namely hydrogen sulfide (H2S), methyl mercaptan (CH3SH), and dimethyl sulfide (CH3SCH3), via portable gas chromatography (Oral Chroma™). Results: Of the 43 patients initially included, 39 completed the study, with a mean age of 32.2 ± 10.4 years. For PI and GI repeated measurements one way analysis of variance showed a significant increase (p-value < 0.001 for both) one month after surgery, with mean values of 1.3 and 1.59, respectively, compared to the baseline. During the same period, the number of P. gingivalis increased, with a p-value = 0.04. Similarly, the levels of hydrogen sulfide (H2S) and methyl mercaptan (CH3SH) increased significantly in the first month after surgery (p-value = 0.02 and 0.01, respectively). Conclusion: This study demonstrated that sleeve gastrectomy may lead to increased halitosis one month post-surgery, attributed to elevated and P. gingivalis counts, contributing to the development of gingivitis in obese patients who underwent sleeve gastrectomy. This emphasizes the importance of including oral health professionals in the multidisciplinary team for the management of patients undergoing bariatric surgery.

The impact of moderate versus deep neuromuscular blockade on the recovery characteristics following laparoscopic sleeve gastrectomy: A randomized double blind clinical trial.

Background: Anesthesia with deep neuromuscular block for laparoscopic surgery may result in less postoperative pain with lower intra-abdominal pressure. However, the results in the existing literature are controversial. This study aimed to evaluate the effect of deep versus moderate neuromuscular block (NMB) on the postoperative recovery characteristics after laparoscopic sleeve gastrectomy (LSG) for weight loss surgery. Methods: This is parallel-group, randomized clinical trial. The study was conducted at a tertiary care center. Patients undergoing LSG were included. Patients were randomly assigned to either deep (post-tetanic count 1-2) or moderate (train-of-four 1-2) NMB group. The primary outcomes were numeric rating scale scores of the postoperative pain at rest and postoperative shoulder pain. The secondary outcomes were the length of hospital stay (LOS) and postoperative complications. The statistics were performed using StatsDirect statistical software (Version 2.7.9). Results: Two groups were identified: Group D (deep NMB), 29 patients, and Group M (moderate NMB), 28 patients. The BMI mean values for groups D and M were 44 and 45 kg/m2 respectively (P > 0.05). The mean durations of surgery for were 46.7 min and 44.1 min for groups M and D, respectively (P > 0.05). The mean train-of-four (TOF) counts were 0.3 and 0 for groups M and D, respectively (P < 0.05). The mean times from giving reversal agent to tracheal extubation (minutes) were 6.5 and 6.58 min for groups M and D, respectively (P > 0.05). In the recovery room, the means of pain scores were 3 and 4 for groups M and D, respectively (P > 0.05). Upon admission to the surgical ward, the median values of the pain score were non-significant (P > 0.05) (95% CI: 0.4-0.7). The opioid consumption in the recovery room was non-significant between both groups (P > 0.05) (95% CI: 0.3-0.6). Postoperative shoulder pain was non-significant between both groups (P > 0.05) (95% CI: 0.4-0.7). The median values of surgeon opinion of both groups were non-significant (P > 0.05). Regarding the LOS, the mean values of groups D and M were 1.20 and 1.21 days, respectively (P > 0.05). Conclusions: There was no significant difference between moderate and deep NMB techniques in terms of duration of the surgical procedure, postoperative pain, shoulder pain, and length of hospital stay. Further studies on a larger sample size are required to investigate the long-term recovery characteristics of patients with obesity undergoing LSG.

The Prevalence of Hearing Symptoms Associated With Patulous Eustachian Tube Dysfunction Following Bariatric Surgery at King Khalid University Hospital, Saudi Arabia.

Background A patulous Eustachian tube (PET) is defined as a persistent tubal opening, which affects 0.3-6.6% of the population, with a female preponderance. PET is caused by the loss of subcutaneous adipose tissue enclosing the cartilaginous portion of the Eustachian tube (Ostmann's pad) as a result of acute, rapid, and substantial loss of weight which occurs during bariatric surgery. The most common complaint of PET is autophony, in which patients hear their own voices or breaths, with additional symptoms including crackling sounds, tinnitus, and aural congestion. In this study, we aimed to determine the prevalence of symptoms associated with PET dysfunction subsequent to bariatric surgery at King Khalid University Hospital (KKUH). Methodology A cross-sectional study was conducted at KKUH, Saudi Arabia. The presence of symptoms consistent with the diagnosis of PET dysfunction was assessed through in-person and telephonic interviews of bariatric surgery patients using a standardized questionnaire. Results A total of 450 patients were evaluated. The preoperative body mass index (BMI) of evaluated patients ranged from 28 to 117 kg/m2 (mean = 46.07 kg/m2), with no significant difference between symptomatic and asymptomatic groups (p = 0.303). The postoperative BMI ranged from 16 to 100 kg/m2 (mean = 29.37 kg/m2), with no significant difference between symptomatic and asymptomatic groups (p = 0.263). Hypertension was the most prevalent comorbid condition (12.2%), followed by diabetes (9.3%). In total, 91 (20.22%) patients exhibited symptoms (aural fullness and autophony) compatible with patent auditory tube dysfunction. Conclusions Overall, 20.22% of the bariatric surgery patients in our study sample displayed symptoms consistent with patulous auditory tubal dysfunction. The preoperative and postoperative BMI of symptomatic and asymptomatic patients did not differ significantly. To improve patient outcomes and satisfaction following bariatric surgery hearing symptoms associated with PET need to be included in postoperative follow-ups after bariatric surgery.

Immediate Dialysis After Simultaneous Laparoscopic Peritoneal Dialysis Catheter Placement and Laparoscopic Inguinal Hernia Repair.

Background and Objectives: Peritoneal dialysis (PD) is an accepted renal replacement therapy for end-stage renal disease (ESRD). Managing inguinal hernia in patients with PD is not standardized. Thus, this study reported the outcomes of simultaneous laparoscopic peritoneal dialysis catheter (PDC) placement and transabdominal preperitoneal (TAPP) repair of inguinal hernia. Methods: Thirteen patients with chronic renal disease and inguinal hernia attending a tertiary hospital between May 1, 2016 and June 30, 2021 were evaluated for laparoscopic PDC placement. Concurrent laparoscopic inguinal herniorrhaphy and laparoscopic PDC placement were performed. Dialysate fluid was measured intraoperatively to the level below the incised peritoneum by 1 inch. The inflow and outflow was smooth without leakage. The amount was increased gradually in the two weeks after regular PD was obtained. Results: Laparoscopic PDC was inserted for 13 patients. Ten patients had unilateral hernia and two had bilateral inguinal hernia. Associated paraumbilical hernia was discovered in two patients. The median follow-up was 30 months. The measured safe amount of dialysate fluid intraoperatively was 400 - 600 mL. There was no death, intraoperative complication, or dialysate leakage. Three PDCs were removed owing to noncompliance. No hernia recurrence was observed. Conclusion: Simultaneous laparoscopic PDC placement and laparoscopic repair of inguinal hernia with immediate dialysis is a safe and feasible surgical technique. Utilizing minimally invasive surgery affords PDC placement and inguinal hernia repair simultaneously.

Pre-incisional Laparoscopic Preperitoneal Local Anesthetic Technique in Laparoscopic Sleeve Gastrectomy.

Background: The increasing prevalence of obesity is a significant concern worldwide. Laparoscopic sleeve gastrectomy (LSG) is an effective and standard procedure for sustained weight loss. However, optimal pain control is essential for enhanced recovery after surgery. The aim of this randomized controlled study was to investigate the efficacy of a pre-incisional laparoscopic preperitoneal local anesthetic technique (PLPLAT) on recovery characteristics following LSG. Methods: A total of 120 obese patients scheduled to undergo LSG were randomized into the PLPLAT or placebo group (n = 60 patients in both groups). All patients received conventional intravenous or other analgesics postoperatively, as required. The primary outcome was the postoperative pain score. The secondary outcomes included morphine consumption, other analgesics, length of stay in the postanesthesia care unit (PACU), hemodynamic changes, postoperative nausea and vomiting (PONV), early mobilization, and length of hospital stay. Results: Pain scores in the PACU and at 12 hours after surgery in the ward were significantly lower in the PLPLAT group than in the placebo group (P < 0.05). The morphine consumption was significantly less in PLPLAT group with mean dosage of 2.95 mg (± 0.39) compared to 6.0 mg (± 0.4) in placebo group. PONV, mean arterial pressure, and PACU stay were significantly higher in the placebo group than in the PLPLAT group (P < 0.05). Conclusion: Intraoperative PLPLAT provide effective postoperative pain relief for patients undergoing LSG. The findings indicated the efficacy of PLPLAT in reducing postoperative pain, enhancing recovery, and facilitating early discharge.

The Social Problems of Morbidly Obese Patients on a Community Level: A Cross-Sectional Study in Saudi Arabia.

Objective: To identify the predictors and social problems of obese patients in Saudi Arabia. Methods: A cross-sectional study was conducted for the period between July 2016 and January 2017. The study population consisted of obese patients visiting the surgery clinics following the medical examinations required before obesity surgery. Patients were recruited from four main medical centres in Riyadh: King Fahad Medical City, University Medical City-King Khalid University Hospital, King Abdulaziz Medical City in the National Guard, and Prince Sultan Military Medical City. The study questionnaire tool was developed based on extensive literature. The questionnaire tool explored personal and demographic characteristics of obese patients and the social problems that morbidly obese patients suffer from at the community level. Logistic regression analysis was used to identify predictors of those facing social problems. Results: A total of 374 patients completed the questionnaires. We found that having a bachelor's degree, a body mass index (BMI) of 40 kg/m2 and above, and other comorbidities were important predictors that increased the likelihood of having social problems related to obesity on a community level (p<0.05). On the other hand, having a high income (11,000 SR/per month and above) was a protective factor that was associated with lower odds of having social problems related to obesity on a community level (p<0.05). Conclusion: Obese patients with low socioeconomic status, having a bachelor's degree, and those with comorbidities tend to have social problems. Future studies to investigate the predictors or social problems among obese patients on a larger scale are warranted.

Preperitoneal Local Anesthesia Technique in Laparoscopic Peritoneal Dialysis Catheter Placement.

Background and Objectives: Peritoneal dialysis is an excellent treatment for end-stage renal disease. Peritoneal dialysis is more advantageous if the catheter is positioned laparoscopically with omentopexy. General anesthesia is required for laparoscopic peritoneal dialysis catheter placement. General anesthesia is associated with increased postoperative morbidity and mortality in high-risk patients. In this retrospective study, the results of laparoscopic placement of peritoneal dialysis catheter under preperitoneal local anesthesia technique and sedation are presented for end-stage renal disease patients not fit for general anesthesia. Methods: We recruited 13 patients for laparoscopic placement of peritoneal dialysis catheter out of 99 end-stage renal disease patients who presented at a local tertiary hospital. The selection criteria were based on the American Society of Anesthesiologists classification III or above and patients unfit for general anesthesia. Results: Laparoscopic placement of peritoneal dialysis catheter was performed on 99 patients, and 13 patients were unfit for general anesthesia. Laparoscopic placement of peritoneal dialysis catheter and omentopexy were performed on these 13 patients together with capnoperitoneum, under preperitoneal local anesthesia technique and sedation. Three catheters were removed due to exit-site infection. One patient died after 2 years due to cardiac disease. The remaining patients continued with peritoneal dialysis. No omental entrapment, catheter migration, or other complications were encountered. Conclusion: Laparoscopic placement of peritoneal dialysis catheter under preperitoneal local anesthesia technique and sedation was successful for high-risk patients unfit for general anesthesia. This technique can be expanded for healthy patients to avoid general anesthesia complications, reduce costs, and speed recovery.

Reliability and validity study of the translated Arabic version of Moorehead-Ardelt Quality of Life Questionnaire II.

OBJECTIVES: To generate a translated Arabic adaptation of the revised Moorehead-Ardelt Quality of Life Questionnaire II (MA-II), then to assess its reliability and validity. METHODS: The MA-II was translated to Arabic by 3 independent translators. Next, a concise translation, developed from the 3 translations, was re-translated to English and was compared with the original questionnaire. Both the reliability and the validity of the Arabic MA-II were assessed in 144 patients struggling with obesity before and after bariatric procedures at Khalid University Hospital, Riyadh, Saudi Arabia. Apart from the demographic data, both the MA-II and the 36-item short-form health survey (SF-36) were used to collect health-related quality of life (HRQL) data. The test-retest method and Cronbach's alpha (α)were used to assess reliability and internal consistency. RESULTS: Test-retest reliability exhibited an intraclass correlation coefficient of 0.966. The internal consistency of the translated version was also high (α=0.812). A satisfactory correlation was demonstrated between the translated Arabic version and the 8 items of the SF-36. A significant negative correlation was also observed between the MA-II and body mass index (r= -0.5778, p<0.001). CONCLUSION: The robustness and sustainability of the translated Arabic version of the MA-II suggested that this disease-specific instrument is a reliable and valid tool for the measurement of HRQL in obease Arabic-speaking people.

Blood Group and Response to Bariatric Surgery in Morbidly Obese Patients: A Retrospective Study in Saudi Arabia.

OBJECTIVES: To explore the relationship between the blood group of patients and their response to bariatric surgery and to identify predictors of better outcomes. METHODS: This was a retrospective cross-sectional analysis of patients who underwent laparoscopic sleeve gastrectomy for morbid obesity between 2014 and 2020 at King Saud University Medical City in Riyadh, Saudi Arabia. RESULTS: This study included 1434 individuals. The mean change in BMI (pre- versus post-BMI) differed statistically significantly between blood groups (p ≤ 0.01). The greatest drop in body weight was seen in individuals with the AB-negative blood type (56.0 (21.4) kg), which corresponds to the greatest percentage of reduction from baseline (47.7% (14.8)). The mean BMI of the patients decreased by 34.7% (9.2) from a mean pre-operation BMI of 45.5 (8.4) kg/m2 to 29.7 (6.1) kg/m2 (p ≤ 0.001). After laparoscopic sleeve gastrectomy, male patients and those with the B-negative blood type are more likely to see a greater BMI reduction (pre-operation compared to post-operation) (p ≤ 0.05). CONCLUSIONS: For morbidly obese patients, laparoscopic sleeve gastrectomy demonstrated promising weight loss outcomes. Blood groups may be able to predict the success rate of bariatric surgery in morbidly obese patients.

Bariatric surgery in the Middle East and North Africa: narrative review with focus on culture-specific considerations.

There is an increasing volume of bariatric surgeries in the Middle East and North Africa (MENA), but the context of bariatric surgery in the region is not fully understood. Incorporating culture-specific considerations in the provision of care to patients who undergo bariatric surgery may help to optimize outcomes after surgery. We conducted a narrative review of published research studies on bariatric surgery in the MENA region, highlighting cultural and contextual aspects relevant to the care of bariatric surgery patients who undergo surgery in this geographic area. The authors searched the following online databases: PubMed, CINAHL, Embase, and Academic Search Elite from 2010-2020 for studies conducted in 18 countries in the MENA region. This narrative review identifies cultural-specific considerations that may affect bariatric care and outcomes in 6 domains: knowledge of bariatric surgery; mental health, body image, and quality of life; influence of family; religion and lifestyle; preoperative practices; and healthcare access. Provision of culturally congruent care may help patients to achieve the best possible outcomes after bariatric surgery. Results may inform efforts to provide safe and culture-specific care in the MENA region, as well as those who migrate or seek care in other countries. More research is warranted on this heterogeneous population to optimize postsurgery weight trajectory and psychosocial adjustment.

Laparoscopic Ventral Hernia Repair with Poly-4-Hydroxybutyrate Absorbable Barrier Composite Mesh.

BACKGROUND: Repair of ventral and incisional hernias (VIHR) is a common procedure, newly introduced resorbable mesh biomaterials provide an attractive option to reduce the use of permanent synthetic mesh in hernia surgery and reduce its complications. However, data on the use of slowly resorbable mesh materials remains scarce, this study aims to evaluate the use of poly-4-hydroxybutyrate/absorbable barrier composite mesh (P4HB/ABCM) in laparoscopic repair of VIHR. METHODS: This is a retrospective study of a sequential cohort of patients undergoing laparoscopic VIHR utilizing a P4HB/ABCM mesh. Perioperative characteristics and clinical outcomes were collected. RESULTS: In total, 26 patients including 10 females and 7 males underwent laparoscopic VIHR using P4HB/ABCM. All surgeries were performed in a single institution by the same surgeon. The average patient age was 52.6, and the mean BMI was 35.5. All patients had a clean wound classification. The average defect size was 136.4 cm2. All patients were seen in clinic with a median follow-up of 28 months. We observed 4 wound seromas, and no wound infections or recurrences during the follow-up period. CONCLUSION: Results of laparoscopic VIHR with P4HB/ABCM are favorable and encourages further studies on the role of absorbable biosynthetic mesh materials in hernia surgery.

Trends in bariatric surgery and incidentalomas at a single institution in Saudi Arabia: a retrospective study and literature review.

BACKGROUND: Data are lacking on trends in bariatric surgery and the frequency of incidental findings in Saudi Arabia. OBJECTIVE: Report on trends in bariatric surgery as well as our experience in incidental findings along with a literature review (mainly on gastrointestinal stromal tumor). DESIGN: Retrospective chart and literature review. SETTINGS: Academic tertiary care center. PATIENTS AND METHODS: We conducted a retrospective study at King Khalid University Hospital and analyzed the data collected from 2009 to 2019. We collected data on age, body mass index (BMI), H pylori infection, type of bariatric surgery performed, and type and location of incidental findings. MAIN OUTCOME MEASURES: Incidental findings during or after bariatric surgery (in pathology specimen). SAMPLE SIZE: 3052 bariatric surgeries, 46 patients with incidentalomas. RESULTS: The mean and standard deviation for the age of the 46 patients with incidentalomas was 42.1 (13.9) years and the mean (SD) preoperative BMI was 43.4 (6.4) kg/m2. Of 3052 bariatric surgeries performed, the most common type was sleeve gastrectomy (93.9%), followed by gastric bypass surgery (4.58%) and gastric banding (1.47%). The total frequency of incidentalomas was 1.5%; 10.8% of patients had gastrointestinal stromal tumors (GIST), with the stomach being the commonest site for incidental findings. Eighty percent of the patients with GIST were positive for H pylori (P=.01 vs negative patients). CONCLUSION: The number of incidentalomas and other findings were consistent with other reports. All these findings suggest that bariatric surgeons should take special care before, during, and after a laparoscopic operation in obese patients. LIMITATIONS: Since this is a single-center, retrospective study, we did not collect data on important variables such as gender, socioeconomic status of the patient, and family history of obesity, and we did not perform a preoperative esophagogastroduodenoscopy. CONFLICT OF INTEREST: None.

A Novel Use of Fully Absorbable PhasixTM Mesh for Laparoscopic Inguinal Hernia Repair.

BACKGROUND AND OBJECTIVES: An inguinal hernia is usually repaired with synthetic nonabsorbable mesh, resulting in collagen formation, chronic inflammation, and fibrosis, with significantly reduced hernia recurrence. However, chronic pain may affect the quality of life. Poly-4-hydroxybutyrate (P4HB) mesh was introduced to minimize complications, and starts to degrade in 12-18 months. This study assesses the consequences and results of patients undergoing transabdominal preperitoneal (TAPP) inguinal hernia repair using P4HB mesh (PhasixTM, C.R. Bard Inc., Murray Hill, NJ, USA). METHODS: We performed a pilot study of laparoscopic TAPP repair for inguinal hernias using P4HB mesh in 15 patients (14 male and one female) with an average age of 55.8 y, and an average body mass index of 27.4 kg/m2. We assessed the recurrence rate and patients' chronic pain for 30 months, with institutional review board approval (E-19-3735). The study was conducted from January 2016 to July 2017 in Medical City, King Saud University. We measured postoperative pain, reactions, mesh sensation, discomfort, and recurrence. RESULTS: In 15 patients, we encountered no recurrence or mesh sensation, except in one patient, who experienced mild chronic inguinal pain for one year, without activity restrictions. CONCLUSION: Laparoscopic TAPP inguinal hernia repair using P4HB mesh is safe for combined, direct (medial), and indirect (lateral) inguinal hernia, with no recurrence. P4HB absorbable mesh caused less chronic pain and discomfort. Longer follow-up, more patients and 15 patients repaired using synthetic mesh are necessary to assess the utility of P4HB for inguinal hernia repair globally.

Characteristics of morbid obese patients with high-risk cardiac disease undergoing laparoscopic sleeve gastrectomy surgery.

INTRODUCTION: Bariatric surgery is an efficient and safe method of weight reduction among patients who have morbid obesity which cannot be treated by the conservative approach. Safety and feasibility of bariatric surgery among high-risk patients are understudied. Therefore, we aimed to report the patient-level characteristics and outcome among high-risk obese patients undergoing laparoscopic sleeve gastrectomy surgery in Saudi Arabia. METHODS: A retrospective analysis was performed among 13 morbidly obese (BMI >39 kg/m2) patients with high-risk cardiac disease, who were referred to Upper Gastro-Intestinal Surgery Clinic at King Khalid University Hospital, which is a center of excellence in bariatric surgery, for consideration for weight loss surgery. Retrospective data on preoperative weight, height, and BMI, operative details, perioperative complications, length of stay, and information on comorbidities and endocrinal disease were collected for analysis and reporting. RESULTS: A total of 13 patients were included in the analysis. Of the total, 61.5% were males with a mean age 40.38 (SD: 16.28) and a mean BMI 51.87 (SD: 7.69). The mean duration of surgery was 33.30 min (SD: 31.01), while the mean duration of anesthesia was 83.61 min (SD: 34.73). The mean length of stay was 6.76 days (SD: 3.89). Three patients required postoperative HDU admission with a mean length of stay of 1 day, while 5 patients required postoperative ICU admission with a length of stay ranging from 1 to 3 days. Within 30 days after discharge, only 1 patient required ER visit and none of the patients reported any postoperative morbidity and mortality. CONCLUSION: Through this study, we can conclude that laparoscopic sleeve gastrectomy surgery can be considered a safe procedure. However, further studies with a large sample size and a more robust methodology are needed to build upon the findings of this study.

Incidence of symptomatic cholelithiasis after laparoscopic sleeve gastrectomy and its association with rapid weight loss.

BACKGROUND/AIM: The worldwide prevalence of obesity has increased dramatically over the past years. In the Arab region, 66%-75% of adults and 25%-40% of children are either overweight or obese. Bariatric surgery has become the most effective approach for managing obesity and its co-morbidities. An expected outcome of bariatric surgery is cholelithiasis, which is one of the established risk factors of rapid weight loss. The aim of this study is to detect the incidence of symptomatic cholelithiasis among bariatric patients. PATIENTS AND METHODS: A retrospective cohort study on 711 patients aged between 18 and 60 who underwent laparoscopic sleeve gastrectomy (LSG) was conducted at King Saud University Medical City from January 2016 to January 2018. RESULTS: The postoperative incidence of symptomatic cholelithiasis was 3.5%. The mean duration of symptom development was 12.4 months. The rates of weight loss at 6 and 12 months for patients with symptomatic cholelithiasis were 28.94 ± 4.89% and 38.51 ± 6.84%, respectively (P = 0.002), which were significantly higher than in patients without symptomatic cholelithiasis during the same follow-up period (24.41 ± 6.6% and 32.29 ± 10.28%), respectively; (P = 0.012). CONCLUSION: We found a 3.5% incidence of symptomatic cholelithiasis among post-LSG patients in a period of 2 years. Rapid weight loss was the only risk factor that contributed to the development of post-LSG gallbladder disease. STATISTICAL ANALYSIS USED: Results were expressed as absolute numbers and percentages for categorical variables and as mean and standard deviation for continuous variables. A paired sample t-test was performed to determine significant differences between means at different time stamps. Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS) version 23.0.

Incidental Duodenal Pancreatic Heterotopia During Laparoscopic Sleeve Gastrectomy: A Case Report and Literature Review.

BACKGROUND Heterotopic pancreas is pancreatic tissue that presents outside the normal anatomical location. It is mostly discovered in the upper gastrointestinal tract (mostly the foregut). We report the first case report of incidentaloma of duodenal heterotopic pancreas in obese patients during laparoscopic sleeve gastrectomy. CASE REPORT A 15-year-old Saudi male obese patient was admitted electively for laparoscopic sleeve gastrectomy. Incidentally, during intraoperative procedure, a duodenal nodule was noted in the first part of the duodenum. A wedge resection of the mass was done after a standard laparoscopic sleeve gastrectomy was accomplished and it had an uneventful postoperative course. The histopathological examination showed heterotopic pancreas tissue. CONCLUSIONS Gastrointestinal stromal tumors are found to be the most common incidental pathology during bariatric surgery. The safety and efficacy of excision of similar lesions during laparoscopic sleeve gastrectomy needs to be further investigated.

Identification of Bacterial and Fungal Pathogens in Patients with Post-Laparoscopic Sleeve Gastrectomy Leakage.

BACKGROUND: Post-laparoscopic sleeve gastrectomy (LSG) leak leads to serious complications, and death may occur. The microbial pattern should be established in order to plan empirical antimicrobial therapy. The intra-abdominal leaks post-LSG were cultured and reviewed. METHODS: Microbial cultures collected from all post-sleeve leakage cases managed at the King Khalid University Hospital (KKUH) from May 2011 until April 2016 were reviewed. RESULTS: A total of 31 patients with positive leak post-LSG were included. The mean presentation time was postoperative day 12. Computed tomography (CT) was done for all patients on presentation with CT-guided aspiration and drainage next day. Samples from the collection were aspirated first for culture then a pigtail drain was kept in place. The average time of drain removal was on the 75th postoperative day. A total of 28 patients (90.3%) had positive culture results. Candida species were the most common organism isolated from 19 patients (61.2%), among them, 10 (32.2%) were positive for Candida species only. Positive bacterial cultures were found in 18 patients (58%). Majority of which single bacterial pathogen isolate, only seven patients had two organisms, and four patients had three organisms. Klebsiella pneumoniae was the most frequent isolated bacteria [8 patients (44.4%)] followed by Streptococcus and Pseudomonas species. Candida albicans was the most common Candida species isolated, 13 patients (68.4%). CONCLUSION: Fungal microbes isolated from post-LSG leak collection are common and could be considered in the primary empirical therapy. The antibiotic choice for the leak should cover Klebsiella, Streptococcus, and Pseudomonas until definitive culture results are obtained.

Appraising the outcome and complications of peritoneal dialysis patients in self-care peritoneal dialysis and assisted peritoneal dialysis: A 5-year review of a single Saudi center.

Our objective is to study the outcomes and complications of peritoneal dialysis (PD) including comparison of self-care PD with home-care assisted PD during a five-year period. A retrospective study of PD data at King Saud University-affiliated hospital in Riyadh from January 1, 2009, to December 31, 2013. One hundred and eleven patients were included (female 55%). The average age was 47.4 (1-83) years. Twenty-one (18.91%) patients were on continuous ambulatory PD and 90 (81.08%) on automated PD. The mean time on PD was 23.5 (3-60) months. At the end of five years, 47 (42.34%) patients were continuing on PD, 12 (10.81%) had renal transplant, 33 (29.73%) patients were transferred to hemodialysis, and two (1.8%) patients were transferred to other centers. Seventeen patients died during this period giving a mortality rate of 7.13 deaths/100 patient-year during the five-year period. Six patients died due to cardiovascular causes, while five had sepsis. There was one death each due to prostate cancer, hyperoxaluria, and toxic epidermal necrolysis. Three patients died suddenly at home. Peritonitis rate was one episode/35.28 patient/month or one episode/2.94 patient/year. We compared the results for patients doing the dialysis themselves [56 (50.45%)] "self-care PD" to 55 (49.5%) patients assisted by a family member or other caregivers "assisted PD." We found no significant difference in the incidence of complications, technical outcome, mortality, and peritonitis episodes. However, we found a high prevalence of diabetes mellitus and significant increase in exit site infection in assisted PD. Our study suggests that PD patients in Saudi Arabia have a good overall outcome. Furthermore, assisted PD showed good patient and technique outcome.

Prevalence and Predictors of Gastroesophageal Reflux Disease After Laparoscopic Sleeve Gastrectomy.

BACKGROUND AND AIMS: Laparoscopic sleeve gastrectomy (LSG) might be associated with a new onset or worsening of gastroesophageal reflux disease (GERD). We aim to evaluate the prevalence of post-LSG GERD symptoms and its predictors. METHODS: We included patients who underwent primary LSG at a university hospital from 2009 to 2015. We used the GERD-Health-Related Quality of Life (GERD-HRQL) questionnaire and included questions regarding regurgitation to evaluate symptoms before and after LSG; each item was scored from 1 to 5 based on the symptom severity. RESULTS: A total of 213 patients (mean age, 36.08 ± 10.22 years; 48.36% were men) were included. The mean preoperative body mass index (BMI) was 47.84 kg/m2, mean percent total weight loss was 37.99% (95% CI, 36.64 to 39.34), mean percent excess weight loss was 84.14% (95% CI, 80.91 to 87.36), and the mean percent excess BMI loss was 84.17% (95% CI, 80.94 to 87.41). The mean heartburn score while standing increased (0.71 vs. 1.09, p < 0.01) as well as the score of heartburn requiring a diet change (0.67 vs. 1.16, p < 0.01) post-LSG. The scores for dysphagia, odynophagia, and regurgitation increased. New-onset heartburn was reported in 47.06% of our cohort. Those with high preoperative BMIs were less likely to develop new-onset or worsening symptoms of GERD (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.95-0.99). More severe heartburn symptoms while standing were associated with higher risks of developing or worsening GERD symptoms (OR, 1.22; 95% CI, 1.01-1.47). None of the other variables could predict the development or worsening of the GERD symptoms. CONCLUSION: Symptoms of heartburn and regurgitation are common after LSG; however, none of the variables preoperatively could strongly predict patients who would develop new onset or experience worsening of symptoms postoperatively.