Late onset and regional heterogeneity of synaptic deficits in cortical PV interneurons of Shank3B -/- mice.

Epilepsy and epileptiform patterns of cortical activity are highly prevalent in autism spectrum disorders (ASDs), but the neural substrates and pathophysiological mechanisms underlying the onset of cortical dysfunction in ASD remains elusive. Reduced cortical expression of Parvalbumin (PV) has been widely observed in ASD mouse models and human postmortem studies, suggesting a crucial role of PV interneurons (PVINs) in ASD pathogenesis. Shank3B -/- mice carrying a Δ13-16 deletion in SHANK3 exhibit cortical hyperactivity during postnatal development and reduced sensory responses in cortical GABAergic interneurons in adulthood. However, whether these phenotypes are associated with PVIN dysfunction is unknown. Using whole-cell electrophysiology and a viral-based strategy to label PVINs during postnatal development, we performed a developmental characterization of AMPAR miniature excitatory postsynaptic currents (mEPSCs) in PVINs and pyramidal (PYR) neurons of layer (L) 2/3 mPFC in Shank3B -/- mice. Surprisingly, reduced mEPSC frequency was observed in both PYR and PVIN populations, but only in adulthood. At P15, when cortical hyperactivity is already observed, both neuron types exhibited normal mEPSC amplitude and frequency, suggesting that glutamatergic connectivity deficits in these neurons emerge as compensatory mechanisms. Additionally, we found normal mEPSCs in adult PVINs of L2/3 somatosensory cortex, revealing region-specific phenotypic differences of cortical PVINs in Shank3B -/- mice. Together, these results demonstrate that loss of Shank3 alters PVIN function but suggest that PVIN glutamatergic synapses are a suboptimal therapeutic target for normalizing early cortical imbalances in SHANK3-associated disorders. More broadly, these findings underscore the complexity of interneuron dysfunction in ASDs, prompting further exploration of region and developmental stage specific phenotypes for understanding and developing effective interventions.

Microglia Regulate Cell Genesis in a Sex-dependent Manner in the Neonatal Hippocampus.

Microglia, the innate immune cells of the brain, regulate brain development through many processes such as synaptic pruning, supporting cell genesis and phagocytosing living and dying cells. There are sex differences in these same developmental processes throughout the brain, thus microglia may contribute to brain sex differences. We examined whether microglia support a known sex difference in neonatal hippocampal neurogenesis and whether juvenile hippocampal neurogenesis was impacted by the loss of neonatal microglia. We used central infusion of liposomal clodronate to selectively deplete microglia and found decreased cell genesis in the male, but not female, dentate gyrus and hippocampus. We found that loss of microglia decreased cell genesis in the cortex and amygdala of both males and females. We assessed the expression of several cytokines and growth factors that have previously been shown to support cell genesis. We found that expression of Il1b and Tnf were decreased in the hippocampus due to microglia depletion however, there were no sex differences in the expression of any immune genes. In adolescence, there was an increase in the number of mitotic cells in the subgranular zone of the dentate gyrus of previously microglia depleted rats however, the number of newly-born neurons was unchanged in the adolescent animals. We also sought to determine whether there was a sex difference in the number of progenitor cells in the dentate gyrus in the neonatal period. We found no sex differences in the number of progenitor cells. Overall, these studies show that microglia are important for regulating region-specific sex differences in cell genesis in the developing brain.

Small cells with big implications: Microglia and sex differences in brain development, plasticity and behavioral health.

Brain sex differences are programmed largely by sex hormone secretions and direct sex chromosome effects in early life, and are subsequently modulated by early life experiences. The brain's resident immune cells, called microglia, actively contribute to brain development. Recent research has shown that microglia are sexually dimorphic, especially during early life, and may participate in sex-specific organization of the brain and behavior. Likewise, sex differences in immune cells and their signaling in the adult brain have been found, although in most cases their function remains unclear. Additionally, immune cells and their signaling have been implicated in many disorders in which brain development or plasticity is altered, including autism, schizophrenia, pain disorders, major depression, and postpartum depression. This review summarizes what is currently known about sex differences in neuroimmune function in development and during other major phases of brain plasticity, as well as the current state of knowledge regarding sex-specific neuroimmune function in psychiatric disorders.

Microglia and Beyond: Innate Immune Cells As Regulators of Brain Development and Behavioral Function.

Innate immune cells play a well-documented role in the etiology and disease course of many brain-based conditions, including multiple sclerosis, Alzheimer's disease, traumatic brain and spinal cord injury, and brain cancers. In contrast, it is only recently becoming clear that innate immune cells, primarily brain resident macrophages called microglia, are also key regulators of brain development. This review summarizes the current state of knowledge regarding microglia in brain development, with particular emphasis on how microglia during development are distinct from microglia later in life. We also summarize the effects of early life perturbations on microglia function in the developing brain, the role that biological sex plays in microglia function, and the potential role that microglia may play in developmental brain disorders. Finally, given how new the field of developmental neuroimmunology is, we highlight what has yet to be learned about how innate immune cells shape the development of brain and behavior.

Sex differences in microglial phagocytosis in the neonatal hippocampus.

Microglia regulate brain development through many processes, such as promoting neurogenesis, supporting cell survival, and phagocytizing progenitor, newly-born, and dying cells. Many of these same developmental processes show robust sex differences, yet very few studies have assessed sex differences in microglia function during development. Hormonally-induced sexual differentiation of the brain occurs during the perinatal period, thus we examined sex differences in microglial morphology, phagocytosis, and proliferation in the hippocampus during the early postnatal period. We found that the neonatal female hippocampus had significantly more microglia with phagocytic cups than the male hippocampus. We subsequently found that female microglia phagocytized more neural progenitor cells and healthy cells compared to males, but there were no sex differences in the number of newly-born or dying cells targeted by microglial phagocytosis. We found that the number of phagocytic microglia in females was reduced to male-typical levels by treatment with estradiol, the hormone responsible for masculinizing the rodent brain. Females also had higher expression of several phagocytic pathway genes in the hippocampus compared to males. In contrast to robust sex differences in phagocytic microglia, we found no sex differences in the number of microglia with amoeboid, transitioning, or ramified morphologies or differences in three-dimensional reconstructions of microglial morphology. While we did not find a baseline sex difference in microglial proliferation during or following the prenatal gonadal hormone surge in males, we found that estradiol treatment increased microglia proliferation in females. Overall, these data show that there are important sex differences in microglia function in the hippocampus during the early neonatal period.

Techniques of Single-Stage Laparoscopic Conversion of Roux-en-Y Gastric Bypass to Single Anastomosis Bilio-pancreatic Diversion with Duodenal Switch.

BACKGROUND: Conversion of Roux-en-Y gastric bypass (RYGB) to single anastomosis duodenal switch can be a complicated and time-consuming operation for surgeons. PURPOSE: The purpose of this article is to present our technique of single-step laparoscopic conversion of RYGB to single anastomosis duodenal switch bilio-pancreatic diversion and vertical sleeve gastrectomy, creating a 250-cm common channel. MATERIAL AND METHODS: A laparoscopic technique was utilized in the conversion. RESULTS: After the gastrojejunostomy is completely separated from the gastric remnant, a sleeve gastrectomy was created followed by duodeno-ileal anastomosis. CONCLUSION: Conversion of RYGB to single anastomosis duodenal switch can be a complicated operation, requiring a two-stage approach in most cases. With the adoption of the described technique, it can be easier to be achieved in a single-stage.

Microglia depletion in early life programs persistent changes in social, mood-related, and locomotor behavior in male and female rats.

Microglia, the innate immune cells of the central nervous system, regulate brain development by promoting cell genesis, pruning synapses, and removing dying, newly-born or progenitor cells. However, the role of microglia in the early life programming of behavior under normal conditions is not well characterized. We used central infusion of liposomal clodronate to selectively deplete microglia from the neonatal rat brain and subsequently assessed the impact of microglial depletion on programming of juvenile and adult motivated behaviors. Liposomal clodronate treatment on postnatal days one and four led to greater than 70% loss of forebrain microglia by postnatal day 6 that lasted for approximately ten days. Neonatal microglia depletion led to reduced juvenile and adult anxiety behavior on the elevated plus maze and open field test, and increased locomotor activity. On a test of juvenile social play, microglial depletion led to decreased chase behaviors relative to control animals. There was no change in active social behavior in adults on a reciprocal social interaction test, but there was decreased passive interaction time and an increased number of social avoidance behaviors in clodronate treated rats relative to controls. There was an overall decrease in behavioral despair on the forced swim test in adult rats treated neonatally with clodronate. Females, but not males, treated neonatally with clodronate showed a blunted corticosterone response after acute stress in adulthood. These results show that microglia are important for the early life programming of juvenile and adult motivated behavior.

The immune system as a novel regulator of sex differences in brain and behavioral development.

Sexual differentiation of the brain occurs early in life as a result of sex-typical hormone action and sex chromosome effects. Immunocompetent cells are being recognized as underappreciated regulators of sex differences in brain and behavioral development, including microglia, astrocytes, and possibly other less well studied cell types, including T cells and mast cells. Immunocompetent cells in the brain are responsive to steroid hormones, but their role in sex-specific brain development is an emerging field of interest. This Review presents a summary of what is currently known about sex differences in the number, morphology, and signaling profile of immune cells in the developing brain and their role in the early-life programming of sex differences in brain and behavior. We review what is currently known about sex differences in the response to early-life perturbations, including stress, inflammation, diet, and environmental pollutants. We also discuss how and why understanding sex differences in the developing neuroimmune environment may provide insight into understanding the etiology of several neurodevelopmental disorders. This Review also highlights what remains to be discovered in this emerging field of developmental neuroimmunology and underscores the importance of filling in these knowledge gaps. © 2016 Wiley Periodicals, Inc.

Robotic-Assisted Laparoscopic Biliopancreatic Diversion, Vertical Sleeve Gastrectomy with Traditional Roux-en-Y Duodenal Switch.

BACKGROUND: Although effective, duodenal switch can be a complicated and time-consuming operation for surgeons. PURPOSE: The purpose of this article is to present our technique of biliopancreatic diversion and vertical sleeve gastrectomy, creating a 150-cm common channel and a 100-cm alimentary limb. MATERIAL AND METHODS: A robot-assisted technique was utilized in creating a biliopancreatic diversion and vertical sleeve gastrectomy. RESULTS: Laparoscopy was used for marking stitches and then the robot was docked. After creating a window behind the duodenum, sleeve gastrectomy is performed followed by duodeno-ileal anastomosis and ileo-ileal anastomosis. CONCLUSION: With the adoption of robots and the described technique, it can be easier to be achieved in less time.

SAFETY AND EFFECTIVENESS OF SINGLE ANASTOMOSIS DUODENAL SWITCH PROCEDURE: PRELIMINARY RESULT FROM A SINGLE INSTITUTION.

Background: Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) was introduced into bariatric surgery by Sanchez-Pernaute et al. as an advancement of the biliopancreatic diversion with duodenal switch. Aim: To evaluate the SADI-S procedure with regard to weight loss, comorbidity resolution, and complication rate in the super obese population. Methods: A retrospective chart review was performed on initial 72 patients who underwent laparoscopic or robot-assisted laparoscopic SADI-S between December 17th, 2013 and July 29th, 2015. Results: A total of 48 female and 21 male patients were included with a mean age of 42.4±10.0 years (range, 22-67). The mean body mass index (BMI) at the time of procedure was 58.4±8.3 kg/m2 (range, 42.3-91.8). Mean length of hospital stay was 4.3±2.6 days (range, 3-24). Thirty-day readmission rate was 4.3% (n=3), due to tachycardia (n=1), deep venous thrombosis (n=1), and viral gastroenteritis (n=1). Thirty-day reoperation rate was 5.8% (n=4) for perforation of the small bowel (n=1), leakage (n=1), duodenal stump leakage (n=1), and diagnostic laparoscopy (n=1). Percentage of excess weight loss (%EWL) was 28.5±8.8 % (range, 13.3-45.0) at three months (n=28), 41.7±11.1 % (range, 19.6-69.6) at six months (n=50), and 61.6±12.0 % (range, 40.1-91.2) at 12 months (n=23) after the procedure. A total of 18 patients (26.1%) presented with type II diabetes mellitus at the time of surgery. Of these patients, 9 (50.0%) had their diabetes resolved, and six (33.3%) had it improved by 6-12 months after SADI-S. Conclusions: SADI-S is a feasible operation with a promising weight loss and diabetes resolution in the super-obese population.

Racional: Anastomose única em bypass duodenoileal com gastrectomia vertical (SADI-S) foi introduzida na cirurgia bariátrica por Sanchez-Pernaute et al. como um avanço da derivação biliopancreática com switch duodenal. Objetivo: Avaliar o procedimento SADI-S no que diz respeito à perda de peso, resolução de comorbidades e taxa de complicações na população de superobesos. Métodos: Estudo retrospectivo com 72 pacientes iniciais que foram submetidos à laparoscopia ou por robô-assistida SADI-S laparoscópica entre 17 de dezembro de 2013 e 29 de Julho de 2015. Resultados: Foram incluídos 48 pacientes do sexo feminino e 21 do masculino com média idade de 42,4±10,0 anos (variação, 22-67). O índice de massa corporal (IMC) no momento do procedimento foi de 58,4±8,3 kg/m2 (42,3-91,8). O tempo médio de permanência hospitalar foi de 4,3±2,6 dias (3-24). A taxa de readmissão em 30 dias foi de 4,3% (n=3), devido à taquicardia (n=1), trombose venosa profunda (n=1), e gastroenterite viral (n=1). A taxa de reoperação em 30 dias foi de 5,8% (n=4) para a perfuração do intestino delgado (n=1), fístula (n=1), deiscência do coto duodenal (n=1), e laparoscopia de diagnóstico (n=1). Percentagem de excesso de perda de peso (% PEP) foi de 28,5±8,8% (13,3-45,0) em três meses (n=28), 41,7±11,1% (19,6-69,6) em seis meses (n=50), e 61,6±12,0% (40,1-91,2) aos 12 meses (n=23) após o procedimento. Um total de 18 pacientes (26,1%) apresentou-se com diabete melito tipo 2, no momento da operação. Desses, nove (50,0%) tiveram seu diabete resolvido, e seis (33,3%) tinham melhorado em 6-12 meses após SADI-S. Conclusão: SADI-S é operação viável com promissora perda de peso e de resolução do diabete melito na população de superobesos.

Centrally Synthesized Estradiol Is a Potent Anti-Inflammatory in the Injured Zebra Finch Brain.

In homeotherms, injury to the brain, such as a penetrating wound, increases microglial cytokine expression and astroglial aromatase (estrogen synthase). In songbirds, injury-induced synthesis of estrogens is neuroprotective as aromatase inhibition and replacement with estradiol (E2) exacerbates and mitigates the extent of damage, respectively. The influence of induced aromatization on inflammation, however, remains unstudied. We hypothesized that injury-induced aromatization, via E2 synthesis, may affect neuroinflammation after a penetrating brain injury. Using adult zebra finches, we first documented an increase in the transcription of cytokines but not aromatase, 2 hours after the injury. Twenty-four hours after the injury, however, aromatase was dramatically elevated and cytokine expression had returned to baseline, suggesting that aromatization may be involved in the decrease of cytokines and neuroinflammation. In two subsequent experiments, we tested the influence of the inhibition of induced aromatization and aromatase inhibition with concomitant central E2 replacement on the transcription of the cytokines TNF-α, IL-1ß, and IL-6, the enzyme cyclooxygenase-2 (cox-2), and its product prostaglandin E2 (PGE2). Administration of fadrozole, an aromatase inhibitor, caused a sustained elevation of IL-1ß in females and TNF-α, cox-2, and PGE2 in both sexes. This prolonged neuroinflammation appears to be due to a failure to synthesize E2 locally because intracranial E2 replacement lowered IL-1ß in females, TNF-α in males, and cox-2 and PGE2 in both sexes. IL-6 was not affected by injury, aromatase inhibition, or E2 replacement in either sex. These data suggest that E2 synthesis after a penetrating brain injury is a potent and inducible anti-inflammatory signal, with specific modulation of discrete cytokine signaling.

Outcomes of Roux-en-Y gastric bypass in the super obese: comparison of body mass index 50-60 kg/m(2) and≥60 kg/m(2) with the morbidly obese.

BACKGROUND: Reports on the outcomes of Roux-en-Y gastric bypass (RYGB) in super-obese patients are limited, especially on patients with body mass index (BMI)≥60 kg/m(2). OBJECTIVES: The aim of the present study was to evaluate and compare the tolerability and efficacy of RYGB in the super-obese by comparing patients with a BMI of 50-60 kg/m(2) and a BMI of≥60 kg/m(2) with patients with a BMI of 40-50 kg/m(2). SETTING: Academic practice. METHODS: Between January 2004 and November 2013, a total of 2717 patients underwent RYGB at our institution. Of these, 661 (24.3%) had a preoperative BMI of 50-60 kg/m(2) and 230 (8.5%) had a BMI≥60 kg/m(2). A retrospective review of outcomes and complications was performed, comparing these patients with 1555 patients with a BMI between 40-50 kg/m(2). RESULTS: Fifty-two (3.3%) patients in the BMI 40-50 kg/m(2) group, 15 (2.3%) patients in the BMI 50-60 kg/m(2) group, and 3 (1.3%) patients in the BMI≥60 kg/m(2) had<30 days of follow-up. Readmission rates were 10.7%, 9.2%, and 11.7%, and reoperation rates were 7.3%, 5.0%, and 6.1%, in the BMI 40-50, 50-60, and≥60 kg/m(2) groups, respectively. No significant difference was found in readmission rate among the 3 groups, and reoperation rate was significantly lower in the BMI 50-60 kg/m(2) group. Mean percentage of excess BMI loss was 58.3%, 80.6%, 85.8%, 83.3%, and 80.9% in the BMI 40-50 kg/m(2) group; 44.9%, 65.0%, 70.1%, 72.1%, and 65.9% in the BMI 50-60 kg/m(2) group; and 38.5%, 57.4%, 62.2%, 62.8%, and 59.1% in the≥60 kg/m(2) group at 6, 12, 18, 24, and 36 months, respectively. The differences in excess BMI loss were statistically significant among all 3 groups at all follow-up time points. All groups experienced a significant decrease in their mean number of co-morbidities after the procedure. CONCLUSION: Readmission and reoperation rates were similar in the BMI 40-50, 50-60, and≥60 kg/m(2) groups. Super-obese and super-super-obese patients are not at greater risk for surgical complications compared with those with lower BMIs.

SAFETY AND EFFECTIVENESS OF SINGLE ANASTOMOSIS DUODENAL SWITCH PROCEDURE: PRELIMINARY RESULT FROM A SINGLE INSTITUTION / SEGURANÇA E EFICÁCIA DE ANASTOMOSE ÚNICA NO SWITCH DUODENAL: RESULTADO PRELIMINAR DE UMA ÚNICA INSTITUIÇÃO

ABSTRACT Background: Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) was introduced into bariatric surgery by Sanchez-Pernaute et al. as an advancement of the biliopancreatic diversion with duodenal switch. Aim: To evaluate the SADI-S procedure with regard to weight loss, comorbidity resolution, and complication rate in the super obese population. Methods: A retrospective chart review was performed on initial 72 patients who underwent laparoscopic or robot-assisted laparoscopic SADI-S between December 17th, 2013 and July 29th, 2015. Results: A total of 48 female and 21 male patients were included with a mean age of 42.4±10.0 years (range, 22-67). The mean body mass index (BMI) at the time of procedure was 58.4±8.3 kg/m2 (range, 42.3-91.8). Mean length of hospital stay was 4.3±2.6 days (range, 3-24). Thirty-day readmission rate was 4.3% (n=3), due to tachycardia (n=1), deep venous thrombosis (n=1), and viral gastroenteritis (n=1). Thirty-day reoperation rate was 5.8% (n=4) for perforation of the small bowel (n=1), leakage (n=1), duodenal stump leakage (n=1), and diagnostic laparoscopy (n=1). Percentage of excess weight loss (%EWL) was 28.5±8.8 % (range, 13.3-45.0) at three months (n=28), 41.7±11.1 % (range, 19.6-69.6) at six months (n=50), and 61.6±12.0 % (range, 40.1-91.2) at 12 months (n=23) after the procedure. A total of 18 patients (26.1%) presented with type II diabetes mellitus at the time of surgery. Of these patients, 9 (50.0%) had their diabetes resolved, and six (33.3%) had it improved by 6-12 months after SADI-S. Conclusions: SADI-S is a feasible operation with a promising weight loss and diabetes resolution in the super-obese population.

RESUMO Racional: Anastomose única em bypass duodenoileal com gastrectomia vertical (SADI-S) foi introduzida na cirurgia bariátrica por Sanchez-Pernaute et al. como um avanço da derivação biliopancreática com switch duodenal. Objetivo: Avaliar o procedimento SADI-S no que diz respeito à perda de peso, resolução de comorbidades e taxa de complicações na população de superobesos. Métodos: Estudo retrospectivo com 72 pacientes iniciais que foram submetidos à laparoscopia ou por robô-assistida SADI-S laparoscópica entre 17 de dezembro de 2013 e 29 de Julho de 2015. Resultados: Foram incluídos 48 pacientes do sexo feminino e 21 do masculino com média idade de 42,4±10,0 anos (variação, 22-67). O índice de massa corporal (IMC) no momento do procedimento foi de 58,4±8,3 kg/m2 (42,3-91,8). O tempo médio de permanência hospitalar foi de 4,3±2,6 dias (3-24). A taxa de readmissão em 30 dias foi de 4,3% (n=3), devido à taquicardia (n=1), trombose venosa profunda (n=1), e gastroenterite viral (n=1). A taxa de reoperação em 30 dias foi de 5,8% (n=4) para a perfuração do intestino delgado (n=1), fístula (n=1), deiscência do coto duodenal (n=1), e laparoscopia de diagnóstico (n=1). Percentagem de excesso de perda de peso (% PEP) foi de 28,5±8,8% (13,3-45,0) em três meses (n=28), 41,7±11,1% (19,6-69,6) em seis meses (n=50), e 61,6±12,0% (40,1-91,2) aos 12 meses (n=23) após o procedimento. Um total de 18 pacientes (26,1%) apresentou-se com diabete melito tipo 2, no momento da operação. Desses, nove (50,0%) tiveram seu diabete resolvido, e seis (33,3%) tinham melhorado em 6-12 meses após SADI-S. Conclusões: SADI-S é operação viável com promissora perda de peso e de resolução do diabete melito na população de superobesos.

Methylene Blue or Upper GI, Which is More Effective for Detecting Leaks in Gastric Bypass Patients?

BACKGROUND: Postoperative leaks from the staple lines are a serious complication after laparoscopic Roux-en-Y gastric bypass (RYGB) that results in morbidity and could even lead to mortality. Bariatric surgeons have several tools to assess this adversity. There have been debates as to which method is more superior and furthermore whether these methods should be routinely or selectively used. The aim of our study is to evaluate and compare whether methylene blue or upper gastrointestinal (UGI) study is more effective in detecting an anastomotic leak after RYGB. MATERIALS AND METHODS: Between May 2013 and March 2014, 119 patients underwent laparoscopic RYGB. Linear staplers were used to create the gastrojejunostomy and the jejunojejunostomy. All patients underwent routine UGI studies and methylene blue challenges on postoperative day 1. A retrospective review of a prospectively collected database was performed for all patients. RESULTS: Of the 105 patients in this study there were 83 females (79.0%) and 22 males (21.0%). Mean age was 45.2±10.7 years (range, 21 to 66 y) and mean preoperative body mass index was 47.8±7.9 kg/m (range, 35.7 to 76.4 kg/m) at the time of procedure. Mean length of hospital stay was 3.2±6.0 days (range, 1 to 53 d).Four (3.8%) patients were found to have leaks postoperatively, but no leakage was detected in any of the initial routine UGI studies or methylene blue challenges. Both patient were diagnosed with clinical signs and underwent oversewing of the leak sites. CONCLUSIONS: UGI studies and methylene blue challenges had no significant difference in detecting a postoperative leak. Furthermore, these tests may have limited utility and may warrant adjuncts to aid in leak detection.

Duodenal stump leak following a duodenal switch: A case report.

INTRODUCTION: Duodenal switch (DS) is a superior choice for surgical weight loss in the super obese patient population. However, there is an associated risk of adverse events following a DS procedure including vitamin deficiencies, bleeding, obstruction, stricture, and leakage. PRESENTATION OF CASE: A 37-year-old female with body mass index of 67kg/m(2) and multiple comorbidities underwent a Da Vinci-assisted, laparoscopic, one-stage, single-anastomosis DS procedure. On postoperative day 11, the patient developed persistent nausea, fatigue, and severe abdominal pain. She underwent diagnostic laparoscopy and was found to have hemoperitoneum, which was evacuated, but active bleeding source was not identifiable. Three days later, the patient underwent exploratory laparotomy, for bleeding with duodenal stump blowout. DISCUSSION: Duodenal stump blowout is the result from increased pressure caused by distal obstruction with the back up of duodenal contents. Anastomotic leakage/blow-out following surgery when suspected, should be individualized and management strategy should be implemented according to the size of the leak, extent of the abscess, and status of the patient. CONCLUSION: Duodenal stump leaks must be diagnosed as early as possible, and treated appropriately with operative intervention. Regardless of the operative technique the key to appropriate treatment is stabilize the patient, repair the duodenal stump, and adequate drainage.

Chest wall malignant peripheral nerve sheath tumor in a 21-year old female.

Malignant peripheral nerve sheath tumors are aggressive sarcomas that derive from peripheral nerve cells and are associated with a poor prognosis. We report a rare case of malignant peripheral nerve sheath tumor in the anterior chest wall of a 21-year-old female. The patient underwent induction chemotherapy, and resection of the mass with negative margins. She subsequently underwent radiation therapy.