Treatment of corticotroph deficiency.

Corticotroph deficiency is a crucial element of anterior pituitary failure requiring careful management. Clinicians should always look for corticotroph deficiency in patients with pituitary disease and also consider the diagnosis in patients with unexplained fatigue, especially when associated with weight loss and/or hypotension. The diagnosis is based on the morning (8 a.m.) serum cortisol level, generally completed with a stimulation test, keeping in mind its poor sensitivity. Metopirone or insulin tolerance tests may be needed. Treatment is based on administration of hydrocortisone at the daily dose of about 20mg, fractionated into two or three doses if possible. There are no reliable biological parameters for monitoring therapeutic efficacy. Treatment is adapted as a function of clinical criteria: fatigue, blood pressure, body weight, and skin trophicity. Therapeutic education is a key element for the prevention of acute adrenal failure, which can occur if the treatment is not correctly adapted during episodes of gastrointestinal disease or stress.

Laparoscopic sleeve gastrectomy for a super-super-obese patient with situs inversus totalis.

Situs inversus totalis is a rare defect which can present difficulties in the management in laparoscopic surgery due to the mirror-image anatomy. Herein, we report a patient with situs inversus totalis and super-super-obesity (BMI 76 kg/m2). We performed successful laparoscopic sleeve gastrectomy. Technical details of this operation, with situs inversus totalis, are presented. There were no major difficulties compared to patients with usual anatomy. There are potential diseases associated with situs inversus and obesity; therefore, a careful investigation, including a chest x-ray and cardiac and abdominal ultrasounds should be performed before surgery. Sleeve gastrectomy is an adequate procedure in super-super-obese patients with situs inversus totalis.