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Highlights • Leakage after sleeve gastrectomy is the cornerstone for most of its related morbidity and mortality. • Gastrocolic fistula is a rare complication resulting from chronic leak after laparoscopic sleeve gastrectomy. • A high index of suspicion is important in detection of rare complications including gastrocolic fistula. • Complete laparoscopic resection of gastrocolic fistula is preferred. • Gastrectomy might be the definitive surgery. • Re-do bariatric surgery should be only done by an expert bariatric surgeon with multidisciplinary team in a specialized center., Introduction Laparoscopic sleeve gastrectomy is a popular bariatric procedure. Leakage after sleeve gastrectomy is the cornerstone for most of its related morbidity and mortality. Gastrocolic fistula is a rare complication resulting from chronic leak after laparoscopic sleeve gastrectomy. Case presentation We report a case of 32-year-old male who underwent laparoscopic re-sleeve gastrectomy for weight regain after initial uneventful laparoscopic sleeve gastrectomy 3 years back. He presented to emergency department by septic shock secondary to leakage after sleeve gastrectomy. CT abdomen with IV contrast and oral gastrograffin confirmed post sleeve gastrectomy leak. Emergency diagnostic laparoscopy revealed a huge abscess cavity containing pus and dark fecal material and altered blood. A long leak was identified with eversion of gastric mucosa. Tubular structure connecting the upper part of the stomach and the colon was found which turned out to be a gastrocolic fistula. It was controlled by endoscopic linear stapler. After 6 weeks, a definitive open esophago-jeujonostomy with total gastrectomy was done successfully after difficult attempt of laparoscopic intervention. The patient was discharged home in a stable condition. Conclusion A high index of suspicion is important in detection of rare complications after laparoscopic sleeve gastrectomy including gastrocolic fistula. Complete laparoscopic resection of gastrocolic fistula is preferred. Gastrectomy might be the definitive surgery.

Introduction Gallstone ileus is a rare complication of cholelithiasis leading to small intestinal obstruction. Elderly females are commonly affected more than male. The diagnosis of this condition is challenging and Rigler’s triad is pathognomonic. Surgery is mandatory with no clear consensus about the best surgical approach that should be adopted. Case presentation An elderly female patient, with no previous history of biliary diseases, presented with small bowel obstruction. Contrast enhanced computed tomography of the abdomen showed the classical Rigler’s triad. Total laparoscopic enterolithotomy was performed successfully. She had smooth postoperative course and she was followed up regularly without occurrence of any biliary disease symptoms during the follow up period. Conclusion Gallstone ileus should be considered in differential diagnosis of small bowel obstruction mainly in old females with no previous history of abdominal surgery. Laparoscopic enterolithotomy is safe, feasible and effective when performed by experienced surgeons.

Background/PurposeThe peritoneal membrane of long-term peritoneal dialysis (PD) patients is characterized by morphological and microvascular changes. It is said that lactate-based peritoneal dialysate is implicated in the development of these changes. The aim of this study is to compare the effects of long-term exposure to glucose-based, lactate-buffered (Dianeal), and biocompatible bicarbonate/lactate-buffered, low glucose degradation product (Physioneal) peritoneal solutions on the peritoneal membrane.MethodsThirty-nine incident PD patients were randomized into two groups: 19 patients with Dianeal dialysate (Group A) and 20 with biocompatible Physioneal dialysate (Group B). All patients used automated PD for a median of 31 months in Group A and 32 months in Group B. Three biopsies at one occasion only were taken from the peritoneal membrane at the end of the study. All samples were collected and fixed in accordance with a standardized protocol, and a histopathologist blinded to the clinical status and PD solutions allocated to the patients carried out the analysis.ResultsThe commonest change observed was peritoneal fibrosis, seen in 35 out of 39 cases (89.7%); it was moderate to severe in 28 cases (71.8%) and mild in 11 (28.2%) cases. This was followed by loss of mesothelial cells (22 cases, 56.4%), elastosis (20 cases, 51.3%), increased blood vessels (15 cases, 38.5%), thick-walled blood vessels (10 cases, 25.6%), and finally chronic inflammation and mesothelial cell hyperplasia (7 cases, 17.9%, and 6 cases, 15.4%, respectively). Of the patients with blood vessel abnormalities, 22 (88.0%) exhibited significant fibrosis and only three (12.0%) did not. Of those without blood vessel changes, only six (42.9%) patients exhibited similar degree of fibrosis (p 0.05)；嚴重間質纖維化分別發生於 42.1% 及 45.0% 的病人，中度間質纖維化則分別發生於 31.6% 及 25.0% 的病人 (p > 0.05)。在 A 組及 B 組的病人之間，彈性組織變性 (elastosis) 達到 “3+” 的比率分別為 15.8% 及 20.0%，達到 “2+” 的比率分別為 15.8% 及 15.0% (p > 0.05)；異常微血管增加則分別出現於 42.1% 及 35.0% 的病人 (p > 0.05)。在糖尿病患者之間、及接受 PD 較久的病人之間，腹膜病理性變化的比率均有所增加 (p

Sialolipoma of the parotid gland is very rare. We report a case of a 38-year-old woman who presented with a painless, slowly growing, mobile lump of the parotid gland. Computed tomography revealed lipoma of the superficial lobe of the parotid gland. Superficial parotidectomy was performed with uneventful postoperative course. The histology showed sialolipoma. Review of the 25 reported cases (including our case) of parotid sialolipoma shows that this tumor is more common in the fifth decade of life, on the left side and the superficial lobe. It has a slight preference for men. Its clinical presentation mimics the standard (pure) parotid lipoma and other more common benign parotid tumors particularly pleomorphic adenoma and Warthin's tumor. Surgical excision is curative with minor complications and small recurrence rate. Histological examination is necessary to establish the diagnosis and to exclude malignancy.

Highlights • Acute intermittent porphyria is rare. • High index of suspicion is needed to diagnose acute intermittent porphyria in a patient with abdominal pain, neuro-psychiatric manifestations and hyponatremia after surgery. • Once suspected, prompt intensive care management should include high calorie intake, symptomatic treatment of hyponatremia, use of safe medications and careful fluid-electrolyte monitoring in order to avoid serious complications and mortality., Introduction Acute intermittent porphyria is a rare autosomal dominant metabolic disease. It is caused by a genetic mutation that results in deficiency of porphobilinogen deaminase enzyme, the third enzyme in heme biosynthesis. Acute intermittent porphyria precipitated by surgery is very rare. Case presentation We present a 24 year-old woman who developed acute intermittent porphyria five days after right hemi-colectomy. Her presentation included neuro-visceral and psychiatric manifestations, and severe hyponatremia. She received critical care symptomatic management including mechanical ventilation. The diagnosis was based on a positive urine test for porphobilinogen and confirmed by the presence of a heterozygous mutation in the hydroxyrmethylbilane synthase (HMBS) gene (c.760delC p Leu254). Discussion Acute intermittent porphyria is the most common and life threatining type of acute porphyrias. It is more common in women and usually presents after puberty with acute abdominal pain and diverse neuro-psychiatric manifestations that can be confused with several surgical and medical diseases. Acute intermittent porphyria after surgery is most likely due to postoperative pain and low-calorie intake. Once suspected, prompt ICU management including high calorie intake are necessary to avoid serious complications and mortality before starting definitive treatment with hematin. Conclusion Acute intermittent porphyria should be suspected in any patient, particularly young women, who develop diverse neuro-visceral and psychiatric manifestations and hyponatremia after surgery.