A rare complication with superior mesenteric vein thrombosis after laparoscopic sleeve gastrectomy: A case report.

Laparoscopic sleeve gastrectomy (LSG) has become a frequent procedure to reduce weight and morbid obesity. The procedure involves laparoscopic resection of more than 75% of the greater curvature of the stomach, resulting in early satiety and neuro-hormonal changes that collectively promote effective weight loss. We present a rare case of complication of superior mesenteric vein thrombosis (SMVT) and splenic vein after LSG, with consequent bowel ischemia that was treated with open laparotomy and appropriate anticoagulation therapy. A 56-year-old obese woman (BMI of 42.5 kg/m2), smoker for 30 years, presented to the emergency department with symptoms such as abdominal pain, fever, nausea and vomiting, 2 weeks after LSG intervention. Her white blood cell count was 15.5 (normal values: 3.8-10.4 × 103 /µL), while C- reactive protein level was 193 (normal values: 0.0-6.0 mg/L) and her D-Dimer level 4.69 (normal values: 0-0.50 mg/L). Abdominal CT with contrast showed a filling defect in the superior mesenteric and splenic vein, free perihepatic and Douglas pouch fluid, as well as small bowel thickening. An open laparotomy was performed and the necrotic segment of bowel of 80 cm was removed. The postoperative period went relatively well, despite the diarrhea that continued for the next 4 months after the intervention. The most common causes leading the development of this complication include: hypercoagulable state, dehydration, increased intra-abdominal pressure during the procedure and other secondary factors. The main symptom is abdominal pain, followed by nausea, vomiting, diarrhea and bleeding from the gastrointestinal tract. SMVT and SVT should be considered as a possible complication in patients with abdominal pain and increased inflammatory parameters after LSG. Early diagnosis through CT imaging and rapid anticoagulation therapy is considered to reduce further complications such as intestinal infarction and portal hypertension.

Non-steroidal anti-inflammatory drugs and gastroprotection in primary health care users.

OBJECTIVE: The aim of this study is to assess the prevalence of gastroprotection and identify the main factors that influence the taking of protective drugs by the adult population treated with non-steroidal anti-inflammatory drugs (NSAID). METHODS: This study was cross-sectional, conducted by including a contingent of 800 users of primary health care services (n=369, 46% males and n=431, 54% females). Included in the study were individuals of both genders aged 18+ who sought counselling or treatment during the three-month period. The data collection of this study was based on the completion of a structured questionnaire, which included questions related to the use of NSAIDs, the way these drugs were prescribed and administered and the simultaneous taking of gastroprotective drugs. RESULTS: The prevalence of the gastroprotective drugs use was higher among the elderly, individuals living in urban areas, those with higher education, those with daily use of NSAID, individuals receiving prescriptions from their own doctors, and those suffering from side effects from the use of NSAID, as well as subjects that had a longer duration of NSAID use. Diclofenac was the most prescribed NSAID. Gastric pain and dizziness were the most experienced side effects. CONCLUSION: This paper demonstrates the need to improve the quality of primary health care service through informing and educating patients regarding the need to take gastro-protective drugs for those at high risk of adverse effects manifested by the use of NSAIDs.

Expression of immunohistochemical markers of progression in pre-cancerous and cancerous human colon: correlation with serum vitamin D levels.

BACKGROUND/AIM: We aimed to evaluate vitamin D levels in blood, as well as the immunohistological expression of ß-catenin, p21 activated kinase (PAK1), p53 and Ki67 in relation to histological type and grading of colonic tumors. RESULTS were compared to the expression in normal and adenomatous colon. MATERIALS AND METHODS: We analyzed colorectal specimens from 20 patients with colorectal tumors for expression of ß-catenin, PAK1, p53 and Ki67. Associations between the expression of these markers and levels of vitamin D in serum were analyzed. RESULTS: The average 25-hydroxy-vitamin D (25OHD) level in a healthy population was 20.53 ng/ml, while that in patients with colorectal cancer was 5.99 ng/ml. The average vitamin D level in patients with positive nuclear ß-catenin was 4.58 ng/ml, which was lower than that of patients with negative nuclear ß-catenin expression. Patients with positive nuclear PAK1 also had low vitamin D levels in their blood (4.51 ng/ml). Patients with positive nuclear p53 had significantly lower vitamin D levels (4.18 ng/ml), compared to patients without nuclear p53 expression. In patients with Ki67 expression in at least 50% of cells, the average vitamin D level was 6.27 ng/ml, while in patients with Ki67 staining in fewer than 50% of cells, the average vitamin D levels in serum was double (13.42 ng/ml).

Small intestinal gastrointestinal stromal tumor in a young adult woman: a case report and review of the literature.

INTRODUCTION: Gastrointestinal stromal tumor is the most common sarcoma of the gastrointestinal tract. We report a case of gastrointestinal stromal tumor in a small intestine, initially suspected for leiomyosarcoma given that gastrointestinal stromal tumors in young adult patients are limited due to their rarity. CASE PRESENTATION: A 30-year-old Caucasian ethnic Albanian woman from Kosovo presented with abdominal pain, nausea and vomiting. Subsequently, the tumor was detected in her small intestine, as an infiltrating mass approximately 10 cm in diameter. The tumor was resected en bloc and duodenojejunal terminal-terminal anastomosis was performed. The tumor was a large, bulky, intramural mass, with fish-flesh to tan-brown appearance, as well as with foci of hemorrhage and necrosis. On histological examination the tumor showed transmural growth, deep infiltrative pattern and malignant feature, with mitotic count >5 per 50 high-power field, dense cellularity with plump spindle cells, and with eosinophilic cytoplasm within variably hyalinized and edematous stroma, skeinoid fibers (extracellular collagen globules) and foci of hemorrhage. In addition, the tumor was composed of areas with epithelioid morphology. The immunohistochemistry results showed high expression of proto-oncogene c-kit, CD117, CD34 and vimentin, whereas α-smooth muscle actin was focally positive. Desmin and S-100 protein were negative. CONCLUSIONS: Gastrointestinal stromal tumor should be included in the differential diagnoses of intestinal mesenchymal tumors presenting as a single mass in young female adults. Given that gastrointestinal stromal tumors in young adults represent a more heterogeneous group than gastrointestinal stromal tumor in pediatric cases, more effort should be made to investigate its pathogenesis and potentially more specific treatment.

Laser Hemorrhoidoplasty Procedure vs Open Surgical Hemorrhoidectomy: a Trial Comparing 2 Treatments for Hemorrhoids of Third and Fourth Degree.

OBJECTIVE: According to the ''vascular'' theory, arterial overflow in the superior hemorrhoidal arteries would lead to dilatation of the hemorrhoidal venous plexus. Hemorrhoid laser procedure (LHP) is a new laser procedure for outpatient treatment of hemorrhoids in which hemorrhoidal arterial flow feeding the hemorrhoidal plexus is stopped by laser coagulation. AIM: Our aim was to compare the hemorrhoid laser procedure with open surgical procedure for outpatient treatment of symptomatic hemorrhoids. MATERIAL AND METHOD: A comparison trial between hemorrhoid laser procedure or open surgical hemorrhoidectomy was made. This study was conducted at Aloka hospital in Kosovo. Patients with symptomatic grade III or grade IV hemorrhoids with minimal or complete mucosal prolapse were eligible for the study: 20 patients treated with the laser hemorrhoidoplasty, and 20 patients-with open surgery hemorrhoidectomy. Operative time and postoperative pain with visual analog scale, were evaluated. RESULTS: A total number of 40 patients (23 men and 17 women, mean age, 46 years) entered the trial. Significant differences between laser hemorrhoidoplasty and open surgical procedure were observed in operative time and early postoperative pain. There was a statistically significant difference between the two groups regarding the early postoperative period: 1 week, 2 weeks, 3 weeks and 1 month after respective procedure (p<0.01). The procedure time for LHP was 15.94 min vs. 26.76 min for open surgery (p<0.01). CONCLUSION: The laser hemorrhoidoplasty procedure was more effective than open surgical hemorrhoidectomy. Postoperative pain and duration time are only two indicators for this difference between there procedures.

What are Predictive Factors for Developing of Barrett's Esophagus in Patients with Gerd-our Experience.

INTRODUCTION: Barrett's esophagus (BE) is a condition in which the normal squamous epithelium of the esophagus is replaced with metaplastic intestinal-type epithelium. This epithelium can progress sequentially from metaplasia to low-grade dysplasia, then to high-grade dysplasia and finally to invasive adenocarcinoma. Many factors that appear to be risk factors for the presence of BE include obesity, the presence of hiatal hernia, and interestingly, the absence of Helicobacter pylori infection. THE AIM: The aim of this study was to determine the predictive factors for progression of gastroesophageal reflux disease (GERD) to BE. METHODS: 42 patients with endoscopically diagnosed and histopathologically verified BE were included in this prospective study. We analysed predictive factors such as: age, sex, obesity, alcohol consumption and smoking, reflux symptom duration in this patients, prevalence of short and long segment of BE, and the presence of hiatal hernia. After endoscopic examination of these patients, the presence of BE was verified with histopathological examination and finally, infection with H. pylori was determined. RESULTS: Among 42 subjects, 25 (59%) were males and 17 (41%) were females, with mean age of 52.8±3.28 years. Obesity was present in 24 of 42 patients (57%). 27 of 42 patients (64%) were smokers. Symptom duration in this patients was approximately 9.4 years. From total number of patients, 52% were with SSBE and 48% patients were with LSBE. Hiatal hernia was present in 64% of patients, of which 66% were with LSBE and 34% with SSBE. In these patients, prevalence of infection with H. pylori was present in 12% of cases, 9.5% in patients with SSBE and 2.5% in patients with LSBE. CONCLUSIONS: The important risk factors for appearance of BE in GERD patients were male sex, middle age, smooking and alcohol consumption. Obesity is an important factor for development of BE. Most of patients with BE also had hiatal hernia, in majority of cases these were patients with LSBE. The prevalence of infection with H. Pylori in patients with BE was lower and this may predict a protective role of this microorganism.

Helicobacter pylori infection and precancerous lesions of the stomach.

INTRODUCTION: Chronic atrophic gastritis, intestinal metaplasia, hereditary non-polyposos colon cancer, gastric dysplasia, gastric adenoma, Barrett esophagitis and familiar adenomatous polyposis are confirmed precancerous lesions of the stomach. Most of these conditions are correlated with long-term infections with Helicobacter pylori. MATERIAL AND METHOD: Patients which were included in our study underwent gastro endoscopy with multiple biopsies from antrum and corpus ventricle, also urease test and histopathological examination, using special coloring for Helicobacter pylori. RESULTS: 802 patients entered this study, of which 369 female and 483 male. Among female patients 56.4% resulted Helicobacter pylori positive, whereas among male patients this was at a rate of 62.6%. The most affected age was 40-49 years, in which group Helicobacter pylori infection was 64.2%. In each precancerous lesion positivity of Helicobacter pylori infection was very high.-in patients with intestinal metaplasia: 71.7%, with gastric dysplasia: 71.4%, with gastric ulcer: 68.4%, with atrophic gastritis: 66.0% and with Barrett esophagitis: 55.0%. DISCUSSION: The main purpose of this study was to determine the percentage of Helicobacter pylori infection among patients with precancerous lesions, which resulted to be very high. The highest percentage of infection resulted in patients with intestinal metaplasia (71.7%). CONCLUSIONS: Precancerous lesions of stomach are associated with high percentage of Helicobacter pylori infection. This confirms once more the importance of Helicobacter pylori eradication in early stages and patient's surveillance.

Small-bowel carcinoid with no liver metastases.

INTRODUCTION: Carcinoid is a slowly-growing tumor from the group of neuroendocrine or APUD tumors. Characteristic of these tumors is the production of biogene amins & polypeptide hormones. 90% of all carcinoids are located in the GI system. CASE REPORT: A female patient, 68 years old, comes for a visit with signs of diffuse abdominal pain, diarrhea, irregular bowel movements, weakness, dyspnea and pretibial edemas. The gastroenterologist gives her only symptomatic therapy at first, and starts the examinations after her hospitalization (initial dg: Enterocolitis). One month later she visits again with the same complains. CT scan result shows steatosis hepatica and lots of liquids in the small bowel and colon. She underwent operation--resection of 20 cm of the small bowel with tumor masses and part-time ileostoma. The biopsy of the resected segment of the bowel shows multiple carcinoids. DISCUSSION: Our patient had no flushing of the skin and therefore couldn't be suspected clinically for this diagnosis. The intestinal carcinoid does not usually produce the carcionid syndrome unless hepatic metastases have occurred. The infiltration of the mesentery provokes an intense fibrotic reaction resulting in kinking of the bowel segments, which causes intestinal obstruction as it happened in this patient. As long as in our clinic we don't have this technique, it is much harder to make an early diagnosis. Fortunately our patient was diagnosed before liver metastases occurred, and therefore her treatment was successful.