Spontaneous calf haematoma: case report

Spontaneous calf haematoma is a rare condition and few case reports have been published in the English literature. Common conditions like deep vein thrombosis and traumatic gastrocnemius muscle tear need to be considered when a patient presents with unilateral calf swelling and tenderness. Ultrasound and Magnetic Resonance Imaging are essential for confirmation of diagnosis. The purpose of this paper is to report on a rare case of spontaneous calf hematoma and its diagnosis and management

Bariatric surgery as a long-term treatment for type 2 diabetes/metabolic syndrome

Metabolic surgery is increasingly becoming recognized as a more effective treatment for patients with type 2 diabetes (T2D) and obesity as compared to lifestyle modification and medical management alone. Both observational studies and clinical trials have shown metabolic surgery to result in sustained weight loss (20-30%), T2D remission rates ranging from 23% to 60%, and improvement in cardiovascular risk factors such as hypertension and dyslipidemia. Metabolic surgery is cost-effective and relatively safe, with perioperative risks and mortality comparable to low-risk procedures such as cholecystectomy, hysterectomy, and appendectomy. International diabetes and medical organizations have endorsed metabolic surgery as a standard treatment for T2D with obesity

Combined laparoscopic and thoracoscopic repair of a large traumatic diaphragmatic hernia: a case report

Traumatic diaphragmatic hernia is a well known complication of blunt trauma to the abdomen and thorax. In the acute setting, laparotomy is mandatory. In this current era, this condition can be managed with minimally invasive surgery. We hereby report a case of delayed large left diaphragmatic hernia that was repaired with a combination of laparoscopic and thoracoscopic approach

Idiopathic duodenal varix presenting as a massive upper gastrointestinal bleeding: a case report

Ectopic variceal bleeding is both a diagnostic dilemma and a therapeutic challenge, especially when it is located in the third part of the duodenum. Varix is rare in the absence of cirrhosis or portal hypertension. Because the diagnosis of this condition is usually delayed, treatment is administered late resulting in high morbidity and mortality rate. We report a case of a 61-year-old lady with an idiopathic duodenal varix presenting as an upper gastrointestinal bleeding

Combined Laparoscopic and Thoracoscopic Repair of A Large Traumatic Diaphragmatic Hernia: A Case Report

SUMMARY Traumatic diaphragmatic hernia is a well known complication of blunt trauma to the abdomen and thorax. In the acute setting, laparotomy is mandatory. In this current era, this condition can be managed with minimally invasive surgery. We hereby report a case of delayed large left diaphragmatic hernia that was repaired with a combination of laparoscopic and thoracoscopic approach. KEY WORDS: Diaphragmatic hernia, laparoscopic, thoracoscopic, trauma INTRODUCTION Mechanisms of traumatic diaphragmatic hernia have been well described after blunt injury to the chest and abdominal cavity. Diaphragmatic ruptures can occur from 0.8% to 7.0% of blunt abdominal trauma, with left hemi diaphragm involvement the commonest; a ratio of 9:1. 1, 2 Conventionally, laparotomy is indicated in all patients with other associated injuries in the acute setting. However, when the diagnosis is missed during early post trauma period, thoracotomy and repair were recommended. In this present era of minimally invasive surgery, laparoscopy is a useful means to treat diaphragmatic rupture even during the acute phase. 1, 2 Here, we report a case with a delayed large left diaphragmatic hernia that was repaired with a combination of laparoscopy and thoracoscopic approach. CASE REPORT A 30 year old gentleman presented to the emergency department with sudden onset breathlessness on exertion. He had a history of left rib fracture due to motor vehicle accident four years ago, but otherwise asymptomatic prior to current complaint. On examination, the left chest had reduced breath sounds and his abdomen was scaphoid but non tender. Plain chest x-ray showed loops of bowel in the left thorax. Computerized tomography of the thorax and abdomen revealed large left diaphragmatic hernia with bowel occupying almost all the left thorax (figure 1). Elective laparoscopic and thoracoscopic repair of incarcerated diaphragmatic hernia with mesh was performed. He was put in supine position with slightly left sided up. Five trocars were placed; 1x12mm (camera port at infra umbilicus) and 4x5mm (two ports at right upper quadrant, one port at left 4th intercostal space anterior axillary line and another port at the lateral aspect of left upper quadrant). The omentum, small bowel and transverse colon were found densely adhered into the left hemithorax through the left anterolateral diaphragmatic hernia that measured 10x5 cm (figure 2). A combination of blunt and sharp dissection was used to reduce the hernia content to the abdominal cavity. Thoracoscopic approach was used to release the dense adhesion at the upper lobe of the lung to the left lateral thoracic wall. Upon reduction, the hernia defect was then closed with ethibon 2/0. Before placing the mesh, the anaesthetist increased the tidal volume to expand the collapsed left lower lobe of the lung and a chest drain size 28F was placed in the left pleural space. Composite mesh 10x15cm was reinforced with secure strap tackers. Portex drain size 27F was placed at left sub diaphragmatic space. The patient was then transferred to the intensive care unit (ICU) postoperatively. He was extubated on day one in ICU and on postoperative day two, he was transferred out to the general ward. Chest x-ray immediate post-operative showed expansion of the left lung with minimal pleural effusion. He was discharged on post-operative day six. He recovered well and during clinic follow up to six months, there was no evidence of recurrence or infection. DISCUSSION Chronic traumatic diaphragmatic hernia is conventionally repaired using the thoracotomy approach, reduction of intraabdominal content and closure of the defect primarily. Where else in acute cases, a laparotomy is performed to reduce and repair the diaphragmatic hernia defect. In 1976, thoracoscopy was used to evaluate diaphragmatic injuries. Laparoscopy was used in a case series of suspected diaphragmatic injury in 1984

Development of de novo diabetes in long-term follow-up after bariatric surgery

Introduction: While bariatric surgery leads to significant prevention and improvement of type 2 diabetes, patients may rarely develop diabetes after bariatric surgery. The aim of this study was to determine the incidence and the characteristic of new-onset diabetes after bariatric surgery over a 17-year period at our institution. Methods: Non-diabetic patients who underwent bariatric surgery at a single academic center (1997–2013) and had a postoperative glycated hemoglobin (HbA1c) ≥ 6.5%, fasting blood glucose (FBG) ≥ 126 mg/dl, or positive glucose tolerance test were identified and studied. Results: Out of 2263 non-diabetic patients at the time of bariatric surgery, 11 patients had new-onset diabetes in the median follow-up time of 9 years (interquartile range [IQR], 4–12). Bariatric procedures performed were Roux-en-Y gastric bypass (n = 7), adjustable gastric banding (n = 3), and sleeve gastrectomy (n = 1). The median interval between surgery and diagnosis of diabetes was 6 years (IQR, 2–9). At the last follow-up, the median HbA1c and FBG values were 6.3% (IQR, 6.1–6.5) and 95 mg/dl (IQR, 85–122), respectively. Possible etiologic factors leading to diabetes were weight regain to baseline (n = 6, 55%), steroid-induced after renal transplantation (n = 1), pancreatic insufficiency after pancreatitis (n = 1), and unknown (n = 3). Conclusion: De novo diabetes after bariatric surgery is rare with an incidence of 0.4% based on our cohort. Weight regain was common (> 50%) in patients who developed new-onset diabetes suggesting recurrent severe obesity as a potential etiologic factor. All patients had good glycemic control (HbA1c ≤ 7%) in the long-term postoperative follow-up

Laparoscopic loop duodenaljejunal bypass with sleeve gastrectomy in type 2 diabetic patients

Background: Laparoscopic loop duodenojejunal bypass with sleeve gastrectomy (LDJB-SG) is a new metabolic procedure. Our initial data on type 2 diabetes (T2D) remission after LDJB-SG were promising. Objectives: The aim of this study was to look at our intermediate outcomes after LDJB-SG. Setting: An academic medical center. Methods: A prospective analysis of T2D patients who underwent LDJB-SG between October 2011 and October 2014 was performed. Data collected included baseline demographic, body mass index, fasting blood glucose, glycosylated hemoglobin, C-peptide, resolution of co-morbidities, and postoperative complications. Results: A total of 163 patients with minimum of follow-up >1 year were enrolled in this study (57 men and 106 women). The mean age and body mass index were 47.7 (±10.7) years and a 30.2 (±5.1) kg/m2, respectively. There were 119 patients on oral hypoglycemic agents only, 29 patients were on oral hypoglycemic agents and insulin, 3 patients were on insulin only, and the other 12 patients were not on diabetic medication. Mean operation time and length of hospital stay were 144.7 (± 45.1) minutes and 2.4 (± 1.0) days, respectively. Seven patients (3.6%) needed reoperation due to bleeding (n = 1), anastomotic leak (n = 2), sleeve strictures (n = 2), and incisional hernia (n = 2). At 2 years of follow-up, there were 56 patients. None of the patients were on insulin and only 20% of patients were on oral hypoglycemic agents. Mean body mass index significantly dropped to 22.9 (±5.6) kg/m2 at 2 years. The mean preoperative fasting blood glucose, glycosylated hemoglobin, and C-peptide levels were 174.7 mg/dL (± 61.0), 8.8% (±1.8), and 2.6 (±1.7) ng/mL, respectively. The mean fasting blood glucose, glycosylated hemoglobin, and C-peptide at 2 years were 112.5 (±60.7) mg/dL, 6.4% (±2.0), and 1.5 (±0.6) ng/mL, respectively. No patient needed revisional surgery because of dumping syndrome, marginal ulcer, or gastroesophageal reflux disease at the last follow up period. Conclusion: At 2 years, LDJB-SG is a relatively safe and effective metabolic surgery with significant weight loss and resolution of co-morbidities

Late relapse of diabetes after bariatric surgery should not be considered as a failure

Background: Although the impressive metabolic effects of bariatric surgery in patients with Type 2 Diabetes (T2DM) are known, bariatric surgery is criticized for late relapse of diabetes. Methods: Outcomes of 736 patients with T2DM who underwent Roux-en-Y Gastric Bypass (RYGB) and Sleeve Gastrectomy (SG) at an academic center (2004-2012) and had ≥5-year glycemic follow-up were assessed. Out of 736 patients, 425 (58%) experienced diabetes remission (HbA1c <6·5% off medications) in the first year after surgery. The latter subgroup was followed to characterize late relapse of T2DM which was defined as fasting glucose (FBG) or HbA1c in the diabetic range (≥126mg/dL and ≥6·5%, respectively) or need for antidiabetic medication after initial remission. Findings: The median postoperative follow-up time was 8 years (range, 5- 14). Of those 425 patients who initially achieved remission in shortterm, 136 (32%) had a late relapse of T2DM. Independent predictors of late relapse were the preoperative number of diabetes medications (OR:1·85,95%CI:1·35-2·53, p=0·0001), duration of T2DM (OR:1·08,95%CI:1·02- 1·15,p=0·012), and SG vs RYGB (OR:1·95,95%CI:1·00-3·70,p=0·049). In patients who experienced late relapse, a significant improvement in glycemic control, number of diabetes medications including the use of insulin, blood pressure, and lipid profile was still observed at longterm. Among patients with relapse, 77% maintained glycemic control (HbA1c <7%). Interpretation: While late relapse is a real phenomenon (one-third of our cohort), relapse of T2DM years after bariatric surgery should not be considered as a failure, as the trajectory of cardio-metabolic risk factors is changed by surgery. Earlier surgical intervention and RYGB (compared with SG) would be associated with less diabetes relapse in long-term

Long-term impact of bariatric surgery in diabetic nephropathy

Background: Bariatric surgery has been shown to improve and resolve diabetes. However, limited literature about its impact on end-organ complications of diabetes is available. The aim of this study was to examine the long-term effect of bariatric surgery on albuminuria. Methods: We studied 101 patients with pre-operative diabetes and albuminuria [defined as urine albumin:creatinine ratio (uACR) > 30 mg/g] who underwent bariatric surgery at an academic center from 2005 to 2014. Results: Fifty-seven patients (56%) were female with a mean age of 53 (± 11) years. The mean pre-operative BMI and glycated hemoglobin (HbA1c) were 43.1 (± 7.6) kg/m2 and 8.4 (± 1.8)%, respectively. The median pre-operative uACR was 80.0 (45.0-231.0) mg/g. Bariatric procedures included Roux-en-Y gastric bypass (n = 75, 74%) and sleeve gastrectomy (n = 26, 26%). The mean follow-up period was 61 (± 29) months. At last follow-up, the mean BMI was 33.8 (± 8.3) kg/m2. The overall glycemic control improved after bariatric surgery. At last follow-up, 73% had good glycemic control (HbA1c < 7%) and 27% met diabetes remission criteria. The mean HbA1c at last follow-up was 6.7 (± 1.0)% and the median uACR was 30 (IQR 7-94) mg/g. Albuminuria improved in 77% and resolved in 51% of patients at long-term. Conclusions: Bariatric surgery has a significantly positive impact on albuminuria in patients with obesity and type 2 diabetes. Our data showed almost an 80% improvement in albuminuria at the short- and long-term period after bariatric surgery

Impact of early postbariatric surgery acute kidney injury on long-term renal function

Background: Bariatric surgery can improve renal dysfunction associated with obesity and diabetes. However, acute kidney injury (AKI) can complicate the early postoperative course after bariatric surgery. The long-term consequences of early postoperative AKI on renal function are unknown. Methods: Patient undergoing bariatric surgery from 2008 to 2015 who developed AKI within 60 days after surgery were studied. Patients on dialysis before surgery were excluded. Results: Out of 4722 patients, 42 patients (0.9%) developed early postoperative AKI after bariatric surgery of whom five had chronic kidney disease (CKD) preoperatively including CKD stage 3 (n = 2), stage 4 (n = 2), and stage 5 (n = 1). Etiologies of AKI included prerenal in 37 and renal in 5 patients. Nine patients (21%) underwent hemodialysis in early postoperative period for AKI. The median duration of follow-up was 28 months (interquartile range, 4–59). Of the 40 patients eligible for follow-up, 36 patients (90%) returned to their baseline renal function. However, four patients (10%) had worsening of renal function at follow-up. Conclusions: The incidence of early postoperative AKI after bariatric surgery is about 1%. The most common causes of AKI after bariatric surgery are dehydration and infectious complications. In our series, 10% of patients who developed AKI in early postoperative period had worsening of renal function in long-term follow-up. In the absence of severe sepsis and severe underlying kidney dysfunction (CKD stages 4 and 5), full recovery is expected after postoperative AKI