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Patient: Male, 77 Final Diagnosis: Undifferentiated pancreatic carcinoma with osteoclastic giant cells like tumor Symptoms: Severe abdominal pain Medication: — Clinical Procedure: — Specialty: Surgery Objective: Rare disease Background: Undifferentiated pancreatic carcinoma with osteoclast-like giant cells represents less than 1% of pancreatic cancers. Histogenesis and prognosis are still debated. Three subtypes are defined by the World Health Organization: osteoclastic, pleomorphic, and mixed. The differential diagnosis of a pancreatic tumor with giant cells varies from a benign osteoclastoma to an undifferentiated pancreatic carcinoma with osteoclastic-like cells. The specimen should be carefully examined to rule out conventional pancreatic adenocarcinoma even in the presence of the giant cells. Case Report: A 77-year-old male was diagnosed with a pancreatic tail tumor with osteoclastic like cells revealed by a biopsy done by echo-endoscopy; the patient was lost to follow up for 24 months before he was admitted to our institute for severe abdominal pain. A computed tomography showed the same lesion without progression. He was operated on using laparoscopic distal pancreatectomy with splenectomy. Pathology analysis revealed the presence of osteoclast-like giant cells without pleomorphic cells. Mutated KRAS on molecular study confirmed the diagnosis of undifferentiated pancreatic carcinoma with osteoclast-like giant cells. The patient was in good performance status and disease-free 19 months after surgery without any sign of progression. Conclusions: Undifferentiated pancreatic carcinoma with osteoclast-like cells has a challenging pathology diagnosis. Molecular and immunostaining are essential to diagnosis. The absence of pleomorphic cells in the present case has classified it into the osteoclastic subtype. Further cases and studies are needed to confirm the heterogeneity of the malignant course between subtypes.

Introduction. Obesity is increasing worldwide and in Lebanon with a negative impact on the quality of life. The primary objective of this study is to measure the quality of life in obese subjects before and after bariatric surgery, depending on age, sex, and degree of weight loss. A secondary objective is to determine the impact of bariatric surgery on comorbidities associated with obesity. Materials and methods. Patients undergoing laparoscopic sleeve gastrectomy for BMI ≥ 30 kg/m2 between August 2016 and April 2017 were included. Participants completed the Moorehead-Ardelt Quality of Life Questionnaire II (MA II) prior to operation and one year after. Statistical analysis was carried out using SPSS statistics version 20.0. Results. 75 patients participated in the study. The majority were women (75%), and the mean age was 36.3 years. The mean weight loss was 36.57 kg (16–76). Initially, the total MA II score was −0.33 ± 0.93. Postoperatively, it increased to 1.68 ± 0.62 (p≤0.001). All MA II parameters improved after surgery (p≤0.001), but this improvement was independent of age and sex. Improvement in self-esteem, physical activity, work performance, and sexual pleasure was influenced by the degree of weight loss (p≤0.001). All comorbidities associated with obesity regressed significantly after sleeve gastrectomy (p<0.05) with the exception of gastroesophageal reflux and varicose veins of the lower limbs. Conclusion. Sleeve gastrectomy improves quality of life and allows reduction of comorbidities.

Occlusive left colon cancer is a major emergency setting in colon cancer with high morbidity and mortality rates. Different surgical treatment exist since there is no clear guidelines for the best treatment. We have conducted this retrospective study in order to evaluate the safety, morbidity, and bowel movement status of the operated patients.One-hundred and one left occlusive colon cancer patients were operated of total or subtotal colon resection with primary anastomosis from March 2000 till March 2017 in Hotel Dieu de France hospital. We analyzed the sex ratio, age, caecum condition, tumor localization, number of synchronous adenoma and adenocarcinoma, Dukes stage, major complications and the number of stools per day at 3 and 12 months after surgery.Mean hospital stay was 7.8 days. Thirteen complications were observed in 11 (10.9%) patients, in which one (1%) patient had splenectomy for severe hemorrhage. Six synchronous adenocarcinoma and 40 adenoma with dysplasia were diagnosed on pathology specimens proximal to occlusion site. Caecum laceration was found in 33 (32.6%) of cases. No patient had anastomotic leak. After 12 months of surgery, the average bowel movement was 2 stools per day.Our study showed that treating occlusive left colon cancer with total or subtotal colectomy with primary anastomosis is a safe procedure, with a good bowel movement status and presents the advantage to resect an important number of synchronous tumors and adenomas proximal to the occlusion site.

Non-steroidal anti-inflammatory drugs (NSAIDs) are cornerstone in multimodal analgesia protocols. This point is of great value in morbidly obese patients due to the high prevalence of restrictive pulmonary disease and obstructive sleep apnea. The aim of this study was to test the hypothesis that NSAIDs do not increase acute bariatric surgery complications while optimizing postoperative analgesia. Databases of two medical centers were retrospectively reviewed to find all patients who underwent bariatric surgery between 1 January 2017 and 31 December 2017. Inclusion criteria were BMI greater than 30 kg/m2 and age of 16–75 years old. Patients who suffered from severe organ failure or coagulation disorders were excluded. Patient’s demographics, obesity-related diseases (diabetes, hypertension, dyslipidemia), postoperative pain scores, and morphine consumption in PACU, as well as early and late surgical complications, were collected. Patients included from the first institution (where NSAIDs analgesia was prohibited: control group) were compared to patients from the second institution (where NSAIDs analgesia was mandatory: case group). The study population included 270 patients, 134 in the control group, and 136 in the case group. NSAIDs usage produced better analgesia with significant reduction in morphine consumption and PACU length of stay. Also, incidence of surgical complications was the same in the two groups. NSAIDs administration do not increase postoperative complication rate after bariatric surgery. Although NSAID administration provided better analgesia and shorter PACU stay, future prospective studies are needed to confirm these encouraging results and to evaluate their impact on postoperative rehabilitation.

Background. Revisional surgery is becoming a common and challenging practice in bariatric centers. The aim of this study was to evaluate resectional one anastomosis gastric bypass/mini gastric bypass (R-OAGB/MGB) as a revisional procedure. Methods. From January 2016 to February 2017, data on 21 consecutive patients undergoing R-OAGB/MGB for weight loss failure after primary restrictive procedures were prospectively collected and analysed. Results. Mean age was 39 ± 12 years (18–65), and 11 (52.3%) were women. The mean operative time was 96.4 ± 20.9 min (range, 122–80), and the mean postoperative stay was 47.8 ± 7.4 hours (range, 36–73). There were no deaths and no procedure-related complications. The mean body mass index (BMI) decreased from 42.9 ± 6.5 at the time of R-OAGB/MGB to 28.5 ± 4 at the 12-month follow-up. At that time point, the mean percentage of BMI loss (%EBL) and the mean percentage of total body weight loss (%TWL) reached 81.6 ± 0.17% and 35 ± 0.01%, respectively. Conclusion. R-OAGB/MGB was technically straightforward, effective, and safe in this at-surgical risk population. R-OAGB/MGB should be added to the armamentarium of revisional bariatric procedures considering its technical aspects and the potential advantage on weight loss.

Laparoscopic sleeve gastrectomy (LSG) is currently the leading bariatric procedure and targets, among other obesity classes, patients with BMI 30-35 kg/mBetween February 2010 and August 2015, data on 541 consecutive patients with BMI 30-35 kg/mMean age was 32 ± 8 years (13-65) and 419 (77.4 %) were women. Preoperative weight was 92.0 ± 8.8 kg (65-121) and BMI was 32.6 ± 1.5 kg/mWith appropriate surgical expertise, LSG in patients with BMI 30-35 kg/m

Objective: Chronic liver diseases, including cirrhosis, may develop in obese patients. Steatosis and non-alcoholic steatohepatitis (NASH) are risk factors for progression to fibrosis. To date, diagnosis of steatosis and NASH relies on liver biopsy. The aim of the study was to identify serum markers of steatosis and NASH in obese patients using SELDI–TOF ProteinChip. Patients: Eighty obese non-alcoholic patient candidates for bariatric surgery and devoid of hepatitis B and C infection were selected. Serum samples were collected before surgery and at 6 months after surgery for 33 of these patients. Wedge liver biopsy was performed at the time of bariatric surgery. Twenty-four serum samples from healthy blood donors served as controls. The protein profiles of each serum were assessed using SELDI–TOF ProteinChip technology and were compared according to liver histological lesions. Results: Twenty-four obese patients (30%) had nonsignificant liver lesions, 32 (40%) had significant steatosis and 24 (30%) had NASH. Comparison of serum protein profiles according to liver lesions identified three peaks (CM10-7558.4, CM10-7924.2 and Q10-7926.9) the intensity of which significantly increased according to the severity of the liver lesions (steatosis and NASH) and returned to normal after bariatric surgery. None was correlated with either liver function tests or metabolic parameters. Identification using immunoSELDI assay characterised these peaks as the double charged ions of a- and b-haemoglobin subunits. Conclusion: The differential proteomic method demonstrated changes in serum protein profiles in obese patients according to severity of liver lesions. Free haemoglobin subunits may serve as a serum biomarker of the severity of liver damages.

Laparoscopic mini-gastric bypass (MGB) is being increasingly performed worldwide. Results of MGB by mini-laparotomy (minilap MGB) are hereby reported.126 patients undergoing minilap MGB from October 2004 to October 2006, were reviewed at an academic institution.Mean age was 35 +/- 11.4 years (range 15-72), preoperative BMI was 44 +/- 6.9 kg/m2 (range 35-61.8) and 80 (63.4%) were women. Co-morbidities were present in 42 (33.3%). Operative time was 144 +/- 15.8 minutes (range 120-160) and length of hospital stay was 3.32 +/- 0.62 days (range 2-18). There was no hospital mortality, and the in-hospital complication rate was 4.7%. No anastomotic leakage occurred, and the incidence of wound sepsis was 2.3%. The mean total cost of the procedure was 3408 +/- 547 USD (range 2967-6876). Five patients (3.9%) developed incisional hernias and 3 (2.3%) marginal ulcers. BMI at 6 months was 33.0 +/- 3.1 kg/m2 (range 26.8-43.5, P0.001) compared with preoperative value. At 1 year, mean excess weight loss was 68.4% and comorbidities resolved in 85%.Minilap MGB is a simple, safe, effective and low-cost gastric bypass. It represents an attractive cost-effective alternative to laparoscopic MGB.

Despite the initial success of primary gastric restrictive operations, many patients require revision for weight regain, mechanical complications or intolerance to restriction. The mini-gastric bypass (MGB) for revision of failed primary restrictive procedures was evaluated. 33 patients undergoing revisional surgery to a MGB for a failed silastic ring vertical banded gastroplasty (VBG) or a gastric banding (GB) from June 2005 to September 2006, were reviewed at an academic institution. The patients had had a minilaparotomy. Revision of the VBGs was further compared with revision of the GBs. The MGB was completed in all except 2 patients who required Roux-en-Y gastric bypass (RYGBP) because of gastric tube damage. Mean age was 41 years (range 20–4), preoperative BMI was 39.5 kg/m2 (range 28–8), and 20 (65%) were women. The revision was performed after an average of 36.3 months (range 12–4), and was more time-consuming in patients with prior VBG than GB (184 vs 155 min, P––.007). Postoperative complications occurred in 2 (6.4%) with prior VBG, and length of hospital stay was 4.65 days (range 3–7).Mean BMI at 6 months was 30.6 (range 24.8–0.0, P–lt;–.001) compared with the preoperative BMI. Reflux disease was cured, and all patients noted major improvement in the eating dimension. Open MGB through a previous mini-incision is a safe and effective operation for revision of failed gastric restrictive operations. The revision procedure was technically more difficult in patients with prior VBG and hazardous in patients with prior redo VBG.

Background: Arterial oxygenation may be compromised in morbidly obese patients undergoing bariatric surgery. The aim of this study was to evaluate the effect of a vital capacity manoeuvre (VCM), followed by ventilation with positive end-expiratory pressure (PEEP), on arterial oxygenation in morbidly obese patients undergoing open bariatric surgery. Methods: Fifty-two morbidly obese patients (body mass index >40 kg m -2 ) undergoing open bariatric surgery were enrolled in this prospective and randomized study. Anaesthesia and surgical techniques were standardized. Patients were ventilated with a tidal volume of 10 mL kg of ideal body weight, a mixture of oxygen and nitrous oxide (F i O 2 = 40%) and respiratory rate was adjusted to maintain end-tidal carbon dioxide at a level of 30-35 mmHg. After abdominal opening, patients in Group 1 had a PEEP of 8 cm H 2 O applied and patients in Group 2 had a VCM followed by PEEP of 8 cm H 2 O. This manoeuvre was defined as lung inflation by a positive inspiratory pressure of 40 cm H 2 O maintained for 15 s. PEEP was maintained until extubation in the two groups. Haemodynamics, ventilatory and arterial oxygenation parameters were measured at the following times: TO = before application of VCM and/or PEEP, T1 = 5 min after VCM and/or PEEP and T2 = before abdominal closure. Results: Patients in the two groups were comparable regarding patient characteristics, surgical, haemodynamic and ventilatory parameters. In Group 1, arterial oxygen partial pressure (PaO 2 ) and arterial haemoglobin oxygen saturation (SaO 2 ) were significantly increased and alveolar-arterial oxygen pressure gradient (A-aDO 2 ) decreased at T2 when compared with TO and T1. In Group 2, PaO 2 and SaO 2 were significantly increased and A-aDO 2 decreased at T1 and T2 when compared with TO. Arterial oxygenation parameters at T1 and T2 were significantly improved in Group 2 when compared with Group 1. Conclusion: The addition of VCM to PEEP improves intraoperative arterial oxygenation in morbidly obese patients undergoing open bariatric surgery.

Background. Coexistence of hyperthyroidism and primary hyperparathyroidism may be more prevalent than previously recognized. We report 13 cases of concomitant occurrence of both diseases to estimate their combined prevalence and its factors. Methods. Ninety-six unselected patients admitted for elective hyperthyroidism surgery were retrospectively included. Eighty-three patients were initially seen for hyperthyroidism with normocalcemia (group 1), and 13 patients were initially seen for hyperthyroidism with associated primary hyperparathyroidism (group 2). Patients' characteristics, examinations, and pathology reports were reviewed. Risk factors were identified using a logistic regression model. Results. The prevalence of concomitant hyperparathyroidism was 13.5%. No patients manifested hypercalcemia in the absence of organic parathyroid disease. Eleven patients had a parathyroid adenoma, and two patients had parathyroid hyperplasia. Group 2 patients were older (median 61 vs 43 years, p = .006). Thyroid-stimulating hormone levels were more depressed in group 2 (median 0.01 vs 0.032 UI/L, p = .034). On multivariate analysis, age was the unique factor significantly different between groups (odds ratio, 1.05; 95% confidence interval, 1.008–1.098; p = .020). Conclusions. Hypercalcemia in patients with hyperthyroidism, particularly older patients, should warrant a thorough investigation for concomitant primary hyperparathyroidism that would dictate a combined thyroidectomy and parathyroidectomy. © 2005 Wiley Periodicals, Inc. Head Neck27: 420–426, 2006

By current convention, the liver graft is revascularized, first with portal blood flow, and thereafter with arterial blood flow. Although experimental studies showed no detrimental effects of primary arterialization, this order of revascularization has not been investigated in clinical transplants.Twenty-nine patients were included in our controlled study to investigate and compare, by means of a technical procedure that permits either initial arterial revascularization (IAR) or initial portal revascularization (IPR), the effects of graft revascularization by IAR and by IPR in clinical transplants.Patients were equally divided in the IAR group (n = 15) and the IPR group (n = 14), and were homogeneous in terms of recipients and graft characteristics. Graft reperfusion was uniform and diffuse in all grafts with IAR versus 10 (71%) with IPR (p0.05). After reperfusion, the time taken for completion of the procedure was shorter in the IAR group (159 +/- 28 versus 242 +/- 39 minutes) (p0.01). Both mean blood transfusions and antifibrinolytic requirements were lower in the IAR group: 5.4 +/- 1.8 versus 7.6 +/- 3.5 packed red cell units, and 13% versus 50%, respectively (p0.05). Postoperative ASAT level, clotting factor V level, and bile flow were not different between the two groups. Early postoperative vascular or biliary complications did not occur. During a mean follow-up of 16 months (range, 7-20), one hepatic artery thrombosis occurred in the IPR group, and one anastomotic biliary stricture occurred in each group.Under adequate portal decompression, LAR is a safe option and results in better graft reperfusion, shorter post revascularization phase, and reduced transfusion and antifibrinolytic requirements.

OBJECTIVE: The authors compared operative course of patients undergoing major liver resections under portal triad clamping (PTC) or under hepatic vascular exclusion (HVE). SUMMARY BACKGROUND DATA: Reduced blood loss during liver resection is achieved by PTC or HVE. Specific complications and postoperative hepatocellular injury mediated with two procedures have not been compared. METHODS: Fifty-two noncirrhotic patients undergoing major liver resections were included in a prospective randomized study comparing both the intraoperative and postoperative courses under PTC (n = 24) or under HVE (n = 28). RESULTS: The two groups were similar at entry, but eight patients were crossed over to the other group during resection. In the HVE group, hemodynamic intolerance occurred in four (14%) patients. In the PTC group, pedicular clamping was not efficient in four patients, including three with involvement of the cavohepatic intersection and one with persistent bleeding due to tricuspid insufficiency. Intraoperative blood losses and postoperative enzyme level reflecting hepatocellular injury were similar in the two groups. Mean operative duration and mean clampage duration were significantly increased after HVE. Postoperative abdominal collections and pulmonary complications were 2.5-fold higher after HVE but without statistical significance, whereas the mean length of postoperative hospital stay was longer after HVE. CONCLUSIONS: This study shows that both methods of vascular occlusion are equally effective in reducing blood loss in major liver resections. The HVE is associated with unpredictable hemodynamic intolerance, increased postoperative complications with a longer hospital stay, and should be restricted to lesions involving the cavo-hepatic intersection.

Background. Data concerning laparoscopic sleeve gastrectomy (LSG) in mild obesity are under investigation. Aim/Objective. May 2010 to May 2012, 122 consecutive patients with preoperative body mass index (BMI) of 33 ± 2.5 kg/m2 (range 30–34.9) undergoing LSG were studied. Mean age was 33 ± 10 years (range 15–60), and 105 (86%) were women. Mean preoperative weight was 91 ± 9.7 kg (range 66–121), and preoperative excess weight was 30 ± 6.7 kg (range 19–43). Comorbidities were detected in 44 (36%) patients. Results. Mean operative time was 58 ± 15 min (range 40–95), and postoperative stay was 1.8 ± 0.19 days (range 1.5–3). There were no admissions to intensive care unit and no deaths within 30 days of surgery. The rates of leaks and strictures were 0%, and of hemorrhage 1.6%. At 12 months, BMI decreased to 24.7 ± 2, and the percentage of excess weight loss (% EWL) reached 76.5%. None of the patients had a BMI below 20 kg/m2. Comorbidities resolved in 70.5% or improved in 29.5%. Patient satisfaction scoring (1–5) at least 1 year after was 4.6 ± 0.8 for body image and 4.4 ± 0.6 for food tolerance. Conclusion. LSG for mildly obese patients has proved to be technically relatively easy, safe, and benefic in the short term.

There is growing evidence that mini-gastric bypass (MGB) is a safe and effective procedure. Operative outcome and long-term follow-up of a consecutive cohort of patients who underwent MGB are reported. The data on 1,000 patients who underwent MGB from November 2005 to January 2011 at an academic institution were reviewed. Mean age was 33.15 ± 10.17 years (range, 14-72), preoperative BMI was 42.5 ± 6.3 kg/m(2) (range, 26-75), mean preoperative weight was 121.6 ± 23.8 kg (range, 71-240), and 663 were women. Operative time and length of stay for primary vs. revisional MGB were 89 ± 12.8 min vs. 144 ± 15 min (p < 0.01) and l.85 ± 0.8 day vs. 2.35 ± 1.89 day (p < 0.01). No deaths occurred within 30 days of surgery. Short-term complications occurred in 2.7% for primary vs. 11.6% for revisionnal MGB (p < 0.01). Five (0.5%) patients presented with leakage from the gastric tube but none had anastomotic leakage. Four (0.4%) patients, all with revisional MGB, presented with severe bile reflux and were cured by stapling the afferent loop and by a latero-lateral jejunojejunostomy. Excessive weight loss occurred in four patients; two were reversed and two were converted to sleeve gastrectomy. Maximal percent excess weight loss (EWL) of 72.5% occurred at 18 months. Weight regain subsequently occurred with a mean variation of -3.9% EWL at 60 months. The 50% EWL was achieved for 95% of patients at 18 months and for 89.8% at 60 months. MGB is an effective, relatively low-risk, and low-failure bariatric procedure. In addition, it can be easily revised, converted, or reversed.

Retroperitoneal location of cystic lymphangiomas in adult patients is rare. Their clinical presentation is not specific. Magnetic resonance imaging is the best radiological exam for the diagnosis. These tumors must be distinguished from mesenteric cysts which are more frequent and can degenerate. The authors report four cases of retroperitoneal cystic lymphangioma with a literature review.

The treatment of acutely obstructed carcinoma of the left colon and sigmoid still represents a matter of controversy. The aim of this study was to assess retrospectively the results of its management by emergency subtotal or total colectomy with primary anastomosis.Sixty-seven patients were reviewed. There were 42 males and 25 females. The mean age was 70.5 years (range: 26-87 years). Mean operative time was 210 minutes. There were five synchronous colon carcinomas (7.5%) and 23 (343%) synchronous tubulous and tubulo-villous adenomas. No death was noted in the series. Ten postoperative complications (15%) occurred in nine patients including one postoperative peritonitis without evidence of anastomotic leak, one alithiasic cholecystitis, one evisceration and two intra-abdominal abscesses. The mean hospital stay was 11.4 days. Fifty-eight patients were assessed at three and twelve months for functional results. No fecal incontinence was encountered. The mean number of bowel movements per 24 hours was 3.2 at three months and 2 at twelve months. All patients were satisfied with their quality of life. Twelve patients (20.7%) occasionally needed anti-diarrheic medications.Urgent subtotal or total colectomy with primary anastomosis is a safe and efficient procedure in the management of acutely obstructed neoplasm of the left colon. It allows to treat in one stage the cancer and the obstruction, bearing no mortality, acceptable morbidity and satisfactory postoperative functional results.

The effect of obesity on surgical outcome is becoming an increasingly relevant issue given the growing rate of obesity worldwide.To investigate the specific impact of obesity on pancreaticoduodenectomy.A retrospective comparative study of a prospectively maintained database was carried out to investigate the specific impact of obesity on the technical aspects and postoperative outcome of pancreaticoduodenectomy.Between 1999 and 2006, 92 consecutive patients underwent pancreaticoduodenectomy using a standardized technique. The study population was subdivided according to the presence or absence of obesity.Nineteen (20.7%) patients were obese and 73 (79.3%) patients were non-obese. The two groups were comparable in terms of demographics, American Society of Anesthesiology (ASA) score as well as nature and type of pancreatico-digestive anastomosis. The rate of clinically relevant pancreatic fistula (36.8% vs. 15.1%; P=0.050) and hospital stay (23.1+/-13.9 vs. 17.0+/-8.0 days; P=0.015) were significantly increased in obese vs. non-obese patients, respectively. Pancreatic fistula was responsible for one-half of the deaths (2/4) and two ruptured pseudoaneurysms. The incidence of the other procedure-related and general postoperative complications were not significantly different between the two groups. Intrapancreatic fat was increased in 10 obese patients (52.6%) and correlated positively both with BMI (P=0.001) and with the occurrence of pancreatic fistula (P=0.003).Obese patients are at increased risk for developing pancreatic fistula after pancreaticoduodenectomy. Special surgical caution as well as vigilant postoperative monitoring are therefore recommended in obese patients.

Background Routine calcium and vitamin D administration and routine autotransplantation of parathyroid glands can prevent hypocalcemia after total thyroidectomy. Methods Routine autotransplantation of 1 or more parathyroid glands and oral calcium and vitamin D supplementation was used in 252 patients. Results One, 2, or 3 parathyroid glands were autotransplanted in 223, 27, and 2 patients, respectively. Routine oral calcium and vitamin D was administered in postoperative period in all patients. Postoperative hypocalcemia occurred in 17%, of whom 1.6% had minor symptoms related to hypocalcemia. No patient developed permanent hypocalcemia during the follow-up period. The postoperative stay was 1 day in 93.6% of the cases. The incidence of postoperative hypocalcemia and hospital stay was higher in patients who underwent autotransplantation of more than 1 parathyroid gland. Conclusions Routine oral calcium and vitamin D supplementation and autotransplantation of at least 1 parathyroid gland effectively reduced symptomatic hypocalcemia and permanent hypoparathyroidism in total thyroidectomy. © 2008 Wiley Periodicals, Inc. Head Neck, 2008

ObjectiveWe analyzed the relation of osteoprotegerin (OPG) with insulin sensitivity, lipid profile, serum glutamic pyruvic transaminase (SGPT), adipocytokines, and C-reactive protein (CRP) in obese and non-obese subjects.MethodsIn the study, 170 subjects (106 obese and 64 non-obese, sex ratio female/male=2.03) were included. Thirty-two obese subjects were reevaluated 6 months after the weight loss induced by bariatric surgery.ResultsOPG did not differ between obese and non-obese subjects (respective mean values 5.17 and 4.96 pmol/l) or according to gender, but was positively correlated with age (PP=0.03). After adjustment for age, no significant correlation was found between OPG and body mass index (BMI), waist, systolic and diastolic blood pressure, cholesterol, triglycerides, high density lipoprotein (HDL) cholesterol, leptin, and adiponectin in both the obese and non-obese subjects. However, OPG was positively correlated with homeostasis model assessment (HOMA) index and SGPT levels in obese subjects at baseline (r=0.295, r=0.20, Pr=0.28, r=0.20, Pr=0.30, PP=0.02, P=0.006, P=0.007, PPPPConclusionOur results show that in obese subjects, OPG is not related to BMI. However, we describe new relationships between OPG and both HOMA index and CRP.

to assess the accuracy of nasal capnography for the monitoring of ventilation in extubated morbidly obese patients, following bariatric surgery.prospective descriptive study.Post-anesthesia care unit.25 consecutive morbidly obese patients admitted to the PACU after open bariatric surgery.Patients had a nasal cannula designed to administer oxygen (3 L/min) and to sample expired CO2 by a coaxial catheter.Capnographic waveform, end-tidal CO2 (ETCO2) and respiratory rate (RRd) were displayed by a capnometer (Datex-Ohmeda). Arterial CO2 pressure (PaCO2) was measured by blood gas analysis. Respiratory rate was measured by visual inspection of chest breathing motions (RRm). Differences between PaCO2 and ETCO2 and between RRd and RRm were calculated for every simultaneous set of measurements.Bias, precision, limits of agreement (bias +/- 2 precisions) between PetCO2 and PaCO2 were respectively as follows: 3.1, 1.4, 0.3 to 5.9 mmHg with a Pearson correlation coefficient of 0.6 and a P value of 0.001. As for RRd v/s RRm the values were: 2, 0.5, 1 to 3 breaths per minute and 0.8 with the same P value for the Pearson coefficient.Limits of agreement between PaCO2 and ETCO2 pressure and between RRd and RRm are clinically acceptable. Nasal capnography is accurate for the monitoring of ventilation in extubated morbidly obese patients, following bariatric surgery.

Von Hippel-Lindau disease is a genetic disorder characterized by neoplasms with multiple organ involvement, the pancreas being involved in about half of the cases. Conservative treatment is indicated because the disease is usually asymptomatic with long-term follow-up.We herein present the case of a 64-year-old man with von Hippel-Lindau disease who presented with obstructive jaundice which resulted as being caused by a fibro-cystic pancreatic nodule. In addition, we reviewed the literature concerning pancreatic involvement in von Hippel-Lindau disease with emphasis on their presentation, type of lesions and appropriate management, especially in cases with obstructive jaundice.Conservative management is advocated in the majority of VHL disease patients with pancreatic involvement, but surgery is sometimes required, especially when patients are symptomatic (obstructive jaundice, upper gastrointestinal bleed).

Recent reports highlight the reduced mortality and morbidity rates of liver resection in the last decades. The authors report on the surgical techniques and perioperative management that have yielded a low mortality and morbidity rates.One hundred consecutive liver resections carried out from 1997 to 2005 were reviewed. Data were collected retrospectively.The indications for liver resection were malignant tumors in 73%. Major liver resection was performed in 52%. Overall, 42.5% of liver resections were performed without vascular clamping and 57% of liver resections were performed without blood transfusions. There was no intraoperative death and the overall mortality rate was 1%. The major complications rate was 28% and was related to the extent of resection. The mean length of hospital stay was 12 days.The current series shows that with accurate preoperative evaluation, standardization of the surgical technique, appropriate use of vascular clamping method, and vigilant postoperative monitoring, an in-hospital mortality of 1% was achieved in a series where more than 50% of patients underwent a major hepatectomy.

The purpose of this study was to report the magnetic resonance imaging (MRI) features of multiple biliary hamartoma (MBH) and to correlate them with histopathology. MRI features of 11 patients with MBH proven by histology were retrospectively reviewed and correlated to histopathology. MBH presented as multiple, tiny, and uniformly distributed lesions in all cases. All were hypointense on T1-weighted images and hyperintense on T2-weighted images relative to the liver parenchyma. Mural nodules were identified in 10 of 11 (91%) cases. They were isosignal on T1-weighted images, intermediate signal on T2-weighted images. Gadolinium-enhanced images showed mural nodule enhancement in 9 of 10 patients (90%) or a peripheral rim-like enhancement of the whole lesion in one case (9%). MBH were present in all liver specimens. In the six patients examined at MR cholangiography, the lesions lacked communication with the biliary tree. At histopathology, the mural nodule corresponded to an endocystic polypoid projection made of conjunctive septa. Three (27%) patients had associated focal nodular hyperplasia, and 1 (9%) had concomitant cholangiocarcinoma. MRI features allowed diagnosis of MBH with accuracy. Their recognition, especially the mural nodule, may help avoid misdiagnosis.

Clinical Summary Two months earlier, this unrestrained driver had an accident and sustained steering wheel injury as well as head trauma and multiple fractures. He was admitted to the intensive care unit for loss of consciousness at the scene and had his fractures repaired. Follow-up was unremarkable and he was discharged 1 month after the accident. A few days later, he presented with chest pain associated with ST elevation in the precordial leads on electrocardiogram and high serum level of creatine kinase with a positive MB fraction. Transthoracic echocardiography showed moderate hypokinesis of the septum and the anterior wall. MDCT coronary angiography was carried out using a 64-slice LightSpeed VCT (General Electric Healthcare, Little Chalfont, UK) with 0.625-mm collimation, cardiac gating, and intravenous injection of iopromide 370 mg (milligrams of iodine)/mL (Ultravist, Schering AG, Germany). It showed septoapical and anteroseptal subendocardial linear hypodensity (Figure 1) associated with hypokinesis on cine mode, corresponding to infarcted area of the myocardium. Left ventricle ejection fraction was 43%. Coronary artery analysis showed a left dominant distribution with arterial dissection beginning at the ostium of the left anterior descending coronary artery (LAD) and extending 10 mm distally with a dilated false lumen giving rise to a septal artery and slightly narrowing the true lumen (Figure 2). The patient had a coronary artery bypass, using the left internal thoracic artery to LAD. A year later, he is doing well and living a normal active life.

To report an uncommon consequence of hepatic artery occlusion in the management of a bleeding pseudoaneurysm following pancreaticoduodenectomy.Analysis of a case involving a single patient in which a bleeding pseudoaneurysm of the gastroduodenal arterial stump following pancreaticoduodenectomy was treated by transcatheter arterial embolization.Effective hemostasis necessitated interruption of the hepatic arterial flow and was complicated by biliary ischemia and intrahepatic biloma.

To study the epidemiology of HCC in Lebanon and prognostic factors predictive of early mortality.An observational follow-up cohort study of HCC cases diagnosed over a five-year period was carried out. Multivariate analysis was conducted to identify prognostic factors in comparison to Cancer of the Liver Italian Program (CLIP) score. Multiple variables including the etiology of underlying liver disease, the demographic characteristics of patients, and the severity of liver disease evaluated by the Child-Pugh score were studied. Tumor parameters included the time of diagnosis of HCC, alpha-fetoprotein level, number and size of nodules, presence of portal vein thrombosis, and treatment modalities. Death or loss of follow-up was considered as an end-point event.Ninety-two patients (mean 60.5 +/- 22.3 years) were included. Etiology of underlying disease was hepatitis B, C, and alcohol in 67%, 20%, and 23.5% respectively. Child-Pugh class at diagnosis was A, B, and C in 34.8%, 39.3% and 25.8% respectively. Overall survival was 44.8%, 32.8% and 17.6% at 1, 2 and 3 years respectively (mean F/U 40.2 +/- 23.5 mo). Multivariate analysis identified three predictors of early mortality (6 mo): bilirubin3.2 mg/dL (P0.01), HCC as first presentation of liver disease (P = 0.035), and creatinine1 mg/dL (P = 0.017). A score based on these variables outperformed the CLIP score by Cox proportional hazard. ROC curve showed both models to be equivalent and moderately accurate.HBV is the leading cause of HCC in Lebanon. Independent predictors of early mortality are elevated bilirubin, creatinine and HCC as first manifestation of disease. Prospective validation of a score based on these clinical parameters in predicting short-term survival is needed.

Anomalous pancreaticobiliary junction with cystic dilatation of the biliary tract is usually associated with carcinoma arising from the cyst wall. We report an extracystic location of biliary carcinoma in the presence of anomalous pancreaticobiliary junction and cysts in a patient with obstruction of the origin of the left hepatic duct who underwent hepatobiliary resection. Cholangiocarcinoma was found to have arisen in a noncystic left hepatic duct, in conjunction with cystic dilatation involving both the cystic and common bile ducts. The present case supports a relationship between anomalous pancreaticobiliary junction and biliary carcinogenesis that may affect the extracystic biliary tree.

A 34-year-old male presented with exquisite left flank pain. Computed tomography showed a hyperdense vascular structure surrounded by whirling linear streaks situated in the greater omentum under the splenic flexure of the colon. Omental stranding extended caudally into the pelvis where part of the inflamed omentum entered a left inguinal hernia sac. Surgery revealed left-sided torsion of the greater omentum. Left-sided omental torsion is infrequent and pre-operative diagnosis is rarely established. The CT findings of an omental fatty mass with a whirling pattern is characteristic of omental torsion. Preoperative diagnosis is important because conservative management has been suggested.

Despite careful selection of cirrhotic patients with hepatocellular carcinoma (HCC), liver resection remains associated with a greater risk than in patients without underlying liver disease. In this study we assessed by multivariate analysis parameters associated with in-hospital mortality and morbidity in a selected group of 108 Child-Pugh A cirrhotic patients undergoing liver resection of HCC. The overall incidences of in-hospital deaths and postoperative complications were 8.3% and 48.1%, respectively. By univariate analysis, the preoperative serum alanine transferase (ALT) level (p = 0.001) and intraoperative transfusions (p = 0.01) were significantly associated with in-hospital death; however, only the serum ALT concentration was an independent risk factor. In-hospital mortality rates in patients whose serum ALT was below 2N (twofold the upper limit of the normal value), between 2N and 4N, and more than 4N were 3.9%, 13.0%, and 37.5%, respectively. An ALT level greater than 2N was predominantly observed in patients with a hepatitis C virus infection and significantly associated with histologic features of superimposed active hepatitis. Patients with an ALT level greater than 2N experienced an increased incidence of postoperative ascites (58% versus 32%, p = 0.01), kidney failure (16% versus 0%, p = 0.0003), and upper gastrointestinal bleeding (6.4% versus 0%, p = 0.02). These results indicate that the preoperative ALT level is a reliable predictor of in-hospital mortality and morbidity following liver resection in Child-Pugh A cirrhotic patients. Cirrhotic patients with ALT2N should undergo only a limited resection; if a larger resection is required, those patients should be considered for nonsurgical therapy or liver transplantation.

Cystic dystrophy in heterotopic pancreas (CDHP) is character- izedbythepresenceofcysticformationssurroundedbyinflammationand scarring. It usually involves the duodenal wall and can be responsible for strictures and pain. The diagnosis of this disorder was previously based on pancreatoduodenectomy specimens removed for a suspected pancre- atic tumor. Six cases were observed in young men (mean age 40 years) between 1989 and 1993. Computed tomography (CT) and endoscopic ultrasonography(EUS)featuresalloweddefinitivepreoperativediagnosis of CDHP. After surgical resection of the tissue-bearing segments that included five pancreatoduodenectomies and one antrectomy, symptoms disappeared in all patients. Patients were followed 2 to 45 months; one patient experienced recurrence of pain and hyperamylasemia 17 months after surgery. The preoperative diagnosis of CDHP is presently possible because of modern imaging procedures and improved knowledge of specific signs. Resection is the most appropriate treatment. Cystic dystrophy in heterotopic pancreas (CDHP) is a poorly understood disorder. It is characterized by the presence of cystic formations surrounded by inflammation and scarring. The most commonsiteofCDHPistheduodenum.Inthepast,thediagnosis

A 50-year-old man presented with a 4-week history of jaundice that developed progressively. He had chronic hepatitis B. During the last 3 months, he had complained of repetitive bouts of right upper abdominal pain with fever. Clinical examination was normal except for …

A 70-year-old man presented with a 6-week history of jaundice and pruritus that developed progressively. No previous medical history was noted. Physical examination showed a weight loss of 3 …

OBJECTIVE: The authors compared the intra- and postoperative course of patients undergoing liver resections under continuous pedicular clamping (CPC) or intermittent pedicular clamping (IPC). SUMMARY BACKGROUND DATA: Reduced blood loss during liver resection is achieved by pedicular clamping. There is controversy about the benefits of IPC over CPC in humans in terms of hepatocellular injury and blood loss control in normal and abnormal liver parenchyma. METHODS: Eighty-six patients undergoing liver resections were included in a prospective randomized study comparing the intra- and postoperative course under CPC (n = 42) or IPC (n = 44) with periods of 15 minutes of clamping and 5 minutes of unclamping. The data were further analyzed according to the presence (steatosis >20% and chronic liver disease) or absence of abnormal liver parenchyma. RESULTS: The two groups of patients were similar in terms of age, sex, nature of the liver tumors, results of preoperative assessment, proportion of patients undergoing major or minor hepatectomy, and nature of nontumorous liver parenchyma. Intraoperative blood loss during liver transsection was significantly higher in the IPC group. In the CPC group, postoperative liver enzymes and serum bilirubin levels were significantly higher in the subgroup of patients with abnormal liver parenchyma. Major postoperative deterioration of liver function occurred in four patients with abnormal liver parenchyma, with two postoperative deaths. All of them were in the CPC group. CONCLUSIONS: This clinical controlled study clearly demonstrated the better parenchymal tolerance to IPC over CPC, especially in patients with abnormal liver parenchyma.

Cutaneous metastases arising along the exit site of an abdominal drain in one patient and within the operative wound in two others after resection of a hepatocellular carcinoma (HCC) are reported. All patients underwent curative hepatic resection, and cutaneous metastases occurred 9, 12, and 22 months after surgery respectively. Cutaneous metastases were not associated with intrahepatic recurrence and were treated by local excision. Two patients are alive and disease-free 48 and 49 months after hepatic resection, respectively; the third patient died from recurrence 39 months later. These observations suggest that cutaneous malignant seeding may occur, and the authors recommend the observance of special care during liver surgery to prevent occurrence of this complication, including the use of wound protection and avoiding the opening of the specimen by the surgeon. The follow-up of patients who have undergone liver resection for an HCC should include the examination of all operative wounds including the exit site of abdominal drains. These subcutaneous nodules should be resected as an appreciable survival can be expected.