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Introduction: Giant/large gallstones have high risk of complications, and technical difficulties during surgery. This case series is the largest ever reported. Presentation of cases: Case 1: Female (44 years), with one year intermittent right upper quadrant colicky pain. Ultrasound: large gallstone (normal gallbladder). Elective laparoscopic cholecystectomy (LC): 6 × 4 × 3.3 cm gallstone. Case 2: Female (41 years), presented to emergency room with 3 days right upper quadrant pain/tenderness, vomiting, and positive murphy's sign. Ultrasound: large gallstone, calculus cholecystitis. Emergency LC: 4.5 × 3.1 × 3.5 cm gallstone. Case 3: Male (38 years), with history of gallstones and acute cholecystitis presented with intermittent right upper quadrant pain (2 months) and vomiting. Normal abdominal examination. Ultrasound: large gallstone. Elective LC: 4.1 × 4 × 3.6 cm gallstone. Conclusions: Gallstones >5 cm are very rare, with higher risk of complications. Gallbladder should be removed even if asymptomatic. Gallstones >3 cm have increased risk for gallbladder cancer, biliary enteric fistula and ileus. LC has challenges that include grasping the gallbladder wall, exposure of Calot's triangle, and retrieval of gallbladder out of the abdomen. LC appears to be procedure of choice and should be performed by an experienced surgeon, considering the possibility of conversion to open cholecystectomy in case of inability to expose the anatomy or intraoperative difficulties. © 2020 The Author(s), Correspondence Address: El Ansari, W.; Department of Surgery, Hamad General Hospital, Hamad Medical Corporation, Qatar; email: welansari9@gmail.com

Introduction: Giant/large gallstones have high risk of complications, and technical difficulties during surgery. This case series is the largest ever reported. Presentation of cases: Case 1: Female (44 years), with one year intermittent right upper quadrant colicky pain. Ultrasound: large gallstone (normal gallbladder). Elective laparoscopic cholecystectomy (LC): 6 × 4 × 3.3 cm gallstone. Case 2: Female (41 years), presented to emergency room with 3 days right upper quadrant pain/tenderness, vomiting, and positive murphy's sign. Ultrasound: large gallstone, calculus cholecystitis. Emergency LC: 4.5 × 3.1 × 3.5 cm gallstone. Case 3: Male (38 years), with history of gallstones and acute cholecystitis presented with intermittent right upper quadrant pain (2 months) and vomiting. Normal abdominal examination. Ultrasound: large gallstone. Elective LC: 4.1 × 4 × 3.6 cm gallstone. Conclusions: Gallstones >5 cm are very rare, with higher risk of complications. Gallbladder should be removed even if asymptomatic. Gallstones >3 cm have increased risk for gallbladder cancer, biliary enteric fistula and ileus. LC has challenges that include grasping the gallbladder wall, exposure of Calot's triangle, and retrieval of gallbladder out of the abdomen. LC appears to be procedure of choice and should be performed by an experienced surgeon, considering the possibility of conversion to open cholecystectomy in case of inability to expose the anatomy or intraoperative difficulties. © 2020 The Author(s), Correspondence Address: El Ansari, W.; Department of Surgery, Hamad General Hospital, Hamad Medical Corporation, Qatar; email: welansari9@gmail.com

Introduction: Giant/large gallstones have high risk of complications, and technical difficulties during surgery. This case series is the largest ever reported. Presentation of cases: Case 1: Female (44 years), with one year intermittent right upper quadrant colicky pain. Ultrasound: large gallstone (normal gallbladder). Elective laparoscopic cholecystectomy (LC): 6 × 4 × 3.3 cm gallstone. Case 2: Female (41 years), presented to emergency room with 3 days right upper quadrant pain/tenderness, vomiting, and positive murphy's sign. Ultrasound: large gallstone, calculus cholecystitis. Emergency LC: 4.5 × 3.1 × 3.5 cm gallstone. Case 3: Male (38 years), with history of gallstones and acute cholecystitis presented with intermittent right upper quadrant pain (2 months) and vomiting. Normal abdominal examination. Ultrasound: large gallstone. Elective LC: 4.1 × 4 × 3.6 cm gallstone. Conclusions: Gallstones >5 cm are very rare, with higher risk of complications. Gallbladder should be removed even if asymptomatic. Gallstones >3 cm have increased risk for gallbladder cancer, biliary enteric fistula and ileus. LC has challenges that include grasping the gallbladder wall, exposure of Calot's triangle, and retrieval of gallbladder out of the abdomen. LC appears to be procedure of choice and should be performed by an experienced surgeon, considering the possibility of conversion to open cholecystectomy in case of inability to expose the anatomy or intraoperative difficulties. © 2020 The Author(s), Correspondence Address: El Ansari, W.; Department of Surgery, Hamad General Hospital, Hamad Medical Corporation, Qatar; email: welansari9@gmail.com

Introduction: Giant/large gallstones have high risk of complications, and technical difficulties during surgery. This case series is the largest ever reported. Presentation of cases: Case 1: Female (44 years), with one year intermittent right upper quadrant colicky pain. Ultrasound: large gallstone (normal gallbladder). Elective laparoscopic cholecystectomy (LC): 6 × 4 × 3.3 cm gallstone. Case 2: Female (41 years), presented to emergency room with 3 days right upper quadrant pain/tenderness, vomiting, and positive murphy's sign. Ultrasound: large gallstone, calculus cholecystitis. Emergency LC: 4.5 × 3.1 × 3.5 cm gallstone. Case 3: Male (38 years), with history of gallstones and acute cholecystitis presented with intermittent right upper quadrant pain (2 months) and vomiting. Normal abdominal examination. Ultrasound: large gallstone. Elective LC: 4.1 × 4 × 3.6 cm gallstone. Conclusions: Gallstones >5 cm are very rare, with higher risk of complications. Gallbladder should be removed even if asymptomatic. Gallstones >3 cm have increased risk for gallbladder cancer, biliary enteric fistula and ileus. LC has challenges that include grasping the gallbladder wall, exposure of Calot's triangle, and retrieval of gallbladder out of the abdomen. LC appears to be procedure of choice and should be performed by an experienced surgeon, considering the possibility of conversion to open cholecystectomy in case of inability to expose the anatomy or intraoperative difficulties. © 2020 The Author(s), Correspondence Address: El Ansari, W.; Department of Surgery, Hamad General Hospital, Hamad Medical Corporation, Qatar; email: welansari9@gmail.com

Introduction: Giant/large gallstones have high risk of complications, and technical difficulties during surgery. This case series is the largest ever reported. Presentation of cases: Case 1: Female (44 years), with one year intermittent right upper quadrant colicky pain. Ultrasound: large gallstone (normal gallbladder). Elective laparoscopic cholecystectomy (LC): 6 × 4 × 3.3 cm gallstone. Case 2: Female (41 years), presented to emergency room with 3 days right upper quadrant pain/tenderness, vomiting, and positive murphy's sign. Ultrasound: large gallstone, calculus cholecystitis. Emergency LC: 4.5 × 3.1 × 3.5 cm gallstone. Case 3: Male (38 years), with history of gallstones and acute cholecystitis presented with intermittent right upper quadrant pain (2 months) and vomiting. Normal abdominal examination. Ultrasound: large gallstone. Elective LC: 4.1 × 4 × 3.6 cm gallstone. Conclusions: Gallstones >5 cm are very rare, with higher risk of complications. Gallbladder should be removed even if asymptomatic. Gallstones >3 cm have increased risk for gallbladder cancer, biliary enteric fistula and ileus. LC has challenges that include grasping the gallbladder wall, exposure of Calot's triangle, and retrieval of gallbladder out of the abdomen. LC appears to be procedure of choice and should be performed by an experienced surgeon, considering the possibility of conversion to open cholecystectomy in case of inability to expose the anatomy or intraoperative difficulties. © 2020 The Author(s), Correspondence Address: El Ansari, W.; Department of Surgery, Hamad General Hospital, Hamad Medical Corporation, Qatar; email: welansari9@gmail.com

Introduction: Acute wrap failure post fundoplication is a rare but recognized complication and can be due to patient factors, disease factors and surgical factors. Herniation of the stomach into the thorax can mimic a pneumothorax clinically and radiologically and thus lead to bad outcomes for patients. Presentation of case: We report the case of a 20-year-old male who presented to the emergency department with progressively worsening upper abdominal pain, nausea and vomiting followed by acute onset dyspnoea, six days post a laparoscopic repair of a small hiatus hernia and a Nissen fundoplication. His chest x-ray was consistent with that of a left sided pneumothorax and was therefore, appropriately resuscitated and treated with an intercostal catheter (ICC). A subsequent CT scan of the chest revealed a left gastrothorax. The patient was taken to theatre for the surgical reduction of the paraoesophageal hernia. Discussion(s): Patients with a recent history of anti-reflux surgery, who present with a pneumothorax and respiratory distress or a tension pneumothorax should always be treated with an ICC. However, follow up imaging with a CT scan is essential to confirm diagnosis. Good control of post- operative nausea and vomiting is essential in avoiding wrap failure and ensuing complications. Conclusion(s): A high index of suspicion for a gastrothorax mimicking a pneumothorax is important in the setting of recent anti-reflux surgery.Copyright © 2018 The Author(s)

Introduction: Acute wrap failure post fundoplication is a rare but recognized complication and can be due to patient factors, disease factors and surgical factors. Herniation of the stomach into the thorax can mimic a pneumothorax clinically and radiologically and thus lead to bad outcomes for patients. Presentation of case: We report the case of a 20-year-old male who presented to the emergency department with progressively worsening upper abdominal pain, nausea and vomiting followed by acute onset dyspnoea, six days post a laparoscopic repair of a small hiatus hernia and a Nissen fundoplication. His chest x-ray was consistent with that of a left sided pneumothorax and was therefore, appropriately resuscitated and treated with an intercostal catheter (ICC). A subsequent CT scan of the chest revealed a left gastrothorax. The patient was taken to theatre for the surgical reduction of the paraoesophageal hernia. Discussion(s): Patients with a recent history of anti-reflux surgery, who present with a pneumothorax and respiratory distress or a tension pneumothorax should always be treated with an ICC. However, follow up imaging with a CT scan is essential to confirm diagnosis. Good control of post- operative nausea and vomiting is essential in avoiding wrap failure and ensuing complications. Conclusion(s): A high index of suspicion for a gastrothorax mimicking a pneumothorax is important in the setting of recent anti-reflux surgery.Copyright © 2018 The Author(s)

A single dose of the apolipoprotein (apo)A-I mimetic peptide D-4F rendered high-density lipoprotein (HDL) less inflammatory, motivating the first multiple-dose study. We aimed to assess safety/tolerability, pharmacokinetics, and pharmacodynamics of daily, orally administered D-4F. High-risk coronary heart disease (CHD) subjects added double-blinded placebo or D-4F to statin for 13 days, randomly assigned 1:3 to ascending cohorts of 100, 300, then 500 mg (n = 62; 46 men/16 women). D-4F was safe and well-tolerated. Mean ± SD plasma D-4F area under the curve (AUC, 0-8h) was 6.9 ± 5.7 ng/mL*h (100 mg), 22.7 ± 19.6 ng/mL*h (300 mg), and 104.0 ± 60.9 ng/mL*h (500 mg) among men, higher among women. Whereas placebo dropped HDL inflammatory index (HII) 28% 8 h postdose (range, 1.25-0.86), 300-500 mg D-4F effectively halved HII: 1.35-0.57 and 1.22-0.63, respectively (P < 0.03 vs. placebo). Oral D-4F peptide dose predicted HII suppression, whereas plasma D-4F exposure was dissociated, suggesting plasma penetration is unnecessary. In conclusion, oral D-4F dosing rendered HDL less inflammatory, affirming oral D-4F as a potential therapy to improve HDL function.

Introduction: Chronic cholecystitis is an elusive diagnosis, with a good outcome following treatment, making the availability of a reliable diagnostic test essential for patient management. The variable access to CCK has necessitated an alternative method for assessing gall bladder function and determining the gall bladder ejection fraction (GBEF). The purpose of our study was to determine if 600 ml of full cream milk (21.6 g of fat) was an adequate fat challenge in hepatobiliary scintigraphy for the assessment of gall bladder function and GBEF, and to determine the GBEF with the highest accuracy for prediction of chronic cholecystitis using GBEF of 23%, 35% and 50%. Method(s): Retrospective review of 151 patients who underwent milk augmented HBS with confi rmation of histological diagnosis and symptom evaluation post therapy in 58 patients. These 58 patients' results were then statistically evaluated. Result(s): Overall the best results were obtained using GBEF of 35%, with the results summarised in Table 1. (Table presented) Conclusion(s): Hepatobiliary scintigraphy using 600 ml of full cream milk is an adequate fat challenge, and is an easily reproducible test for diagnosis of chronic cholecystitis. Using this fat challenge, a GBEF of < 35% was considered the most useful GBEF for prediction of chronic cholecystitis and overall outcome prediction post-therapy with the best combination of sensitivity, specifi city and overall accuracy.

Introduction: Chronic cholecystitis is an elusive diagnosis, with a good outcome following treatment, making the availability of a reliable diagnostic test essential for patient management. The variable access to CCK has necessitated an alternative method for assessing gall bladder function and determining the gall bladder ejection fraction (GBEF). The purpose of our study was to determine if 600 ml of full cream milk (21.6 g of fat) was an adequate fat challenge in hepatobiliary scintigraphy for the assessment of gall bladder function and GBEF, and to determine the GBEF with the highest accuracy for prediction of chronic cholecystitis using GBEF of 23%, 35% and 50%. Method(s): Retrospective review of 151 patients who underwent milk augmented HBS with confi rmation of histological diagnosis and symptom evaluation post therapy in 58 patients. These 58 patients' results were then statistically evaluated. Result(s): Overall the best results were obtained using GBEF of 35%, with the results summarised in Table 1. (Table presented) Conclusion(s): Hepatobiliary scintigraphy using 600 ml of full cream milk is an adequate fat challenge, and is an easily reproducible test for diagnosis of chronic cholecystitis. Using this fat challenge, a GBEF of < 35% was considered the most useful GBEF for prediction of chronic cholecystitis and overall outcome prediction post-therapy with the best combination of sensitivity, specifi city and overall accuracy.

Aim: To determine if 600mls of full cream milk is an adequate fat challenge in hepatobiliary scintigraphic for the assessment of chronic cholecystitis using gall bladder ejection fractions (GBEF) of 35% and 50%. Material(s) and Method(s): After institutional ethics approval, we retrospectively reviewed 113 consecutive adult patients (31 males and 82 females) aged between 20 and 82 that presented to our institutions between 1/1/2008 to 31/12/2010 with upper abdominal pain. These patients were all investigated with a milk (600 mls of full cream milk, containing 21.6 g of fat) augmented - HBS study. Images were obtained at least 30 minutes after milk ingestion on a wide field of view gamma camera with an all-purpose parallel-hole collimator. All studies were reviewed by two nuclear medicine physicians blinded to outcome; any discrepancies were addressed by consensus. This was correlated with the patient outcome (obtained through histology, patient medical records and/or follow-up phone call directly to patients). Positive histology with symptom resolution post cholecystectomy was considered as a true positive and symptom resolution without cholecystectomy with alternate diagnosis of gastritis (biopsy proven) was considered as a true negative. Result(s):113 patients were reviewed, of which 52 had a histologically confirmed diagnosis of either chronic cholecystitis or gastritis, the remaining 61 were excluded.31/52 patients had cholecystectomy, all with confirmed histology of chronic cholecystitis, of which 6 (6/6 - GBEF>35%) had persistent symptoms and 25 (23/26 - GBEF<35% and 2/26 -GBEF>50%) had symptom resolution.21/52 had gastritis, of these, 21/21 (3/21-GBEF<35% and 18/21- GBEF>35%) had resolution of symptoms with medical management, and 0/21 patients had persistence of symptoms. Specificity and sensitivity for outcome following therapy using different GBEF's was as follows:-23%: 53% and 100%- 35%: 67% and 91%- 50%: 65% and 79%Using GBEF of 35% the NPV was 90% and t

Aim: To determine if 600mls of full cream milk is an adequate fat challenge in hepatobiliary scintigraphic for the assessment of chronic cholecystitis using gall bladder ejection fractions (GBEF) of 35% and 50%. Material(s) and Method(s): After institutional ethics approval, we retrospectively reviewed 113 consecutive adult patients (31 males and 82 females) aged between 20 and 82 that presented to our institutions between 1/1/2008 to 31/12/2010 with upper abdominal pain. These patients were all investigated with a milk (600 mls of full cream milk, containing 21.6 g of fat) augmented - HBS study. Images were obtained at least 30 minutes after milk ingestion on a wide field of view gamma camera with an all-purpose parallel-hole collimator. All studies were reviewed by two nuclear medicine physicians blinded to outcome; any discrepancies were addressed by consensus. This was correlated with the patient outcome (obtained through histology, patient medical records and/or follow-up phone call directly to patients). Positive histology with symptom resolution post cholecystectomy was considered as a true positive and symptom resolution without cholecystectomy with alternate diagnosis of gastritis (biopsy proven) was considered as a true negative. Result(s):113 patients were reviewed, of which 52 had a histologically confirmed diagnosis of either chronic cholecystitis or gastritis, the remaining 61 were excluded.31/52 patients had cholecystectomy, all with confirmed histology of chronic cholecystitis, of which 6 (6/6 - GBEF>35%) had persistent symptoms and 25 (23/26 - GBEF<35% and 2/26 -GBEF>50%) had symptom resolution.21/52 had gastritis, of these, 21/21 (3/21-GBEF<35% and 18/21- GBEF>35%) had resolution of symptoms with medical management, and 0/21 patients had persistence of symptoms. Specificity and sensitivity for outcome following therapy using different GBEF's was as follows:-23%: 53% and 100%- 35%: 67% and 91%- 50%: 65% and 79%Using GBEF of 35% the NPV was 90% and t