Biopsy-proven progressive fatty liver disease nine months post mini-gastric bypass surgery: A case study

IntroductionMini-gastric bypass (MGB) is a popular bariatric procedure. Its effect on non-alcoholic fatty liver disease (NAFLD), however, has not yet been comprehensively studied.Presentation of caseA 57 year-old non-alcoholic female with a body mass index of 42.8 kg/m² underwent MGB without any incident. A concurrent liver biopsy showed an NAFLD activity score (NAS) of 2/8 without fibrosis. She presented at postoperative month eight with edema, vague abdominal pain, nausea, and vomiting and was hospitalized. Her BMI had dropped to 25.7 kg/m². Her blood workup revealed mild anemia, mildly elevated liver enzymes, and hypoalbuminemia (2.5 g/dL). Liver ultrasound revealed grade-2 fatty liver. She received parenteral nutrition and intensive nutrient supplementation. Nevertheless, with regard to unsuccessful supportive measures and rising liver enzymes, revisional surgery −gastrogastrostomy- was performed. Her liver biopsy demonstrated a NAS of 7/8 at the time of revisional surgery. Her postoperative course was uneventful and she was discharged after one week.DiscussionBariatric surgery has shown favorable results regarding improvement of NAFLD in morbid obesity. This beneficial effect has been linked to the amount of weight loss. However, case reports have shown deteriorating liver function and NAFLD even after significant weight loss. They all have in common significant weight loss in a relatively short period of time. There may also be a connection between specific bariatric surgery procedures and this phenomenon.ConclusionFuture studies comparing the effect of various bariatric procedures, including MGB, are necessary to help clinicians decide the optimal procedure for patients with this liver condition.     

Use of hyperbaric oxygen therapy and PEGylated carboxyhemoglobin bovine in a Jehovah’s Witness with life-threatening anemia following postpartum hemorrhage

We present a case of a Jehovah’s Witness patient who refused blood products, with the exception of albumin and clotting factors, and underwent cesarean section under spinal anesthesia complicated by postpartum hemorrhage. She was fluid resuscitated and treated with multiple uterotonics and internal iliac artery embolization. Because of agitation she required emergency tracheal intubation. Her hemoglobin concentration dropped from a preoperative value of 12 mg/dL to 3 mg/dL on postoperative day one. She was acidotic, requiring vasopressors for hemodynamic stability and remained ventilated and sedated. She was treated with daily erythropoietin, iron therapy and cyanocobalamin. Because of ongoing hemorrhage, continued acidemia and vasopressor requirements she was co-treated with PEGylated carboxyhemoglobin bovine and hyperbaric oxygen therapy to reverse her oxygen debt. On postoperative day eight her hemoglobin concentration was 7 mg/dL, she was hemodynamically stable and vasopressors were discontinued. She was extubated and discharged from the intensive care unit on postoperative day eight. This report highlights the multiple modalities used in treating a severely anemic patient who refused blood, the use of an investigational new drug, the process of obtaining this drug via the United States Food and Drug Administration emergency expanded access regulation for single patient clinical treatment, and ethical dilemmas faced during treatment.     

Hypoalbuminaemia—a marker of malnutrition and predictor of postoperative complications and mortality after hip fractures

ObjectiveOur aim was to determine the effect of hypoalbuminaemia as a marker of malnutrition on the 30-day postoperative complication rate and mortality in patients receiving surgical treatment for hip fractures using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.MethodsWe analyzed all patients admitted with hip fractures receiving surgical treatment from 2011 to 2013. Patients were dichotomized based on their albumin levels; hypoalbuminaemia (albumin <3.5 g/dL), and nonhypoalbuminaemia (albumin >3.5 g/dL). Patient demographics, postoperative complications, and length of stay were analysed. Logistic regression analysis was conducted to assess the ability of albumin level for predicting postoperative complications, length of stay, and mortality.ResultsA total of 10,117 patients with hip fractures were identified with 5414 patients with normal albumin levels, and 4703 with low albumin. Multivariate analysis showed that when controlling for comorbidities; hypoalbuminaemia alone was a predictor of postoperative complications (death, unplanned intubation, being on a ventilator >48 h, sepsis, and blood transfusion), and increased length of stay (6.90 ± 7.23 versus 8.44 ± 8.70, CI 0.64–1.20, P < 0.001).ConclusionHypoalbuminaemia alone can predict postoperative outcomes in patients with hip fractures. Furthermore, patients with hypoalbuminaemia had a longer hospital length of stay. Further studies are needed to assess whether nutritional support can improve postoperative complications in patients with hypoalbuminaemia.     

Case report of a definitive autologous reconstruction in a patient requiring immediate postoperative anticoagulation and reduced operative time

IntroductionThe available options for post-mastectomy reconstruction in a patient requiring abbreviated operative times and immediate and sustained post-operative anticoagulation are limited.Presentation of caseA 50 year old woman with a history of multiple deep venous thromboses (DVTs) and pulmonary embolisms (PEs) requested a bilateral prophylactic mastectomy and immediate reconstruction. She had a history of multiple breast biopsies demonstrating atypia and two sisters with premenopausal breast cancer. Her hematologist requested that her anticoagulation be held for the minimal amount of time and that her theater times be kept as short as possible. As such, we felt that she was not a candidate for traditional implant-based reconstruction nor autologous flap surgery. Instead, we made use of a recently described single-stage autologous modified Goldilocks procedure to complete her bilateral mastectomy and reconstruction in 150 min. She was anticoagulated in the operating room and was restarted on her preoperative regimen twelve hours after surgery. She suffered no post-operative complications.DiscussionThere is minimal published literature discussing immediate post-mastectomy reconstruction in the anticoagulated patient. Most reconstructive surgeons find these patients unsuitable for traditional reconstructive techniques. In the current case, we utilized a recently described single-stage autologous technique which allowed us to avoid the bleeding complications associated with the muscular dissection required with implant and flap-based reconstructive surgery. The extirpation and reconstruction was completed in 150 min which is significantly quicker than traditional reconstructions.ConclusionThe modified Goldilocks procedure is an excellent option in the patient who requires immediate postoperative anticoagulation and abbreviated operative times.     

Do nondiabetic patients undergoing coronary artery bypass grafting surgery require intraoperative management of hyperglycemia?

ObjectiveTo study the effect of blood glucose (BG) control with insulin in preventing hyperglycemia during and after coronary artery bypass grafting (CABG) surgery in nondiabetic patients.MethodsIn a randomized clinical trial, 120 nondiabetic patients who underwent elective CABG surgery were enrolled for study of whether the control of hyperglycemia was a need in such a surgery in a teaching heart hospital. The patients were randomly divided into study (n = 60) and control (n = 60) groups. In the study group, insulin was infused to maintain BG level between 110 mg/dL and 126 mg/dL (a modified insulin therapy protocol, and in the control group, the patients were excepted). Insulin therapy was limited to intraoperative period. BG levels during surgery and up to 48 hours after surgery and early postoperative complications were compared between the study and control groups.ResultsOne hundred seventeen patients completed the study (59 patients in study group and 58 in control group). Peak intraoperative BG level in the study group was 126.4 ± 17.9 mg/dL and in the control group was 137.3 ± 17.6 mg/dL (p = 0.024). The frequencies of severe hyperglycemia (BG ≥ 180 mg/dL) were 6 of 59 (10.1%) in the study group and 19 of 58 (32.7%) in the control group during operation (p = 0.002). Peak postoperative BG level in the study group was 194.8 ± 41.2 mg/dL and was 199.8 ± 43.2 mg/dL in the control group (p = 0.571). There was no hypoglycemic event in either group. The frequencies of early postoperative complications were 10 of 59 (16.9%) in the study group and 19 of 58 (32.7%) in the control group (p = 0.047).ConclusionsHyperglycemia (BG ≥ 126 mg/dL) is common in nondiabetic patients undergoing CABG surgery. A modified insulin therapy to maintain BG level between 110 mg/dL and 126 mg/dL may be acceptable for avoiding hypoglycemia and keeping intraoperative BG levels in acceptable range in nondiabetics.     

Pancreatic schwannoma: A rare case and a brief literature review

IntroductionPancreatic schwannoma (PS) is an extremly rare benign tumor. Less than 50 cases of pancreatic schwannoma have been described in the English literature over the past thirty years.Presentation of case reportA 63-year-old female underwent left modified radical mastectomy 2 years ago due to breast cancer. During her routine check-up, a 65 × 63 × 55 mm measured calcified, well-demarcated, cystic-mass having septations and calcifications that localized to the pancreatic head was detected by abdominal computerized tomography. She was asymptomatic and her tumor markers were in normal ranges. A standard Whipple procedure was performed, and the histo-pathological diagnosis of the resected specimen was reported as ancient schwannoma with clear surgical margins. Patient’s postoperative course was eventful. She had a biliary leakage after surgery which was managed conservatively. She is under follow-up.DiscussionPancreatic schwannoma also known as neurilemoma or neuroma is a slowly growing, encapsulated, mostly benign tumor with smooth well-delineated margins that originates from myelin producing schwann cells located on the nerve sheath of the peripheral epineurium of either the sympathetic or parasympathetic autonomic fibers. PS’s are extremly rare. The head of pancreas being involved in the vast majority of cases (40%), followed by its body (20%). Management of pancreatic schwannomas remains largely controversial. Both enucleation and radical surgical resections have revealed great therapeutic efficiency. with a well prognosis without recurrences.ConclusionAlthough rare, PS’s should be considered in the differential diagnosis of the other solid or cystic masses of the pancreas.     

Adductor canal compression syndrome in an 18-year-old female patient leading to acute critical limb ischemia: A case report

BackgroundAdductor canal compression syndrome is a rare non-atherosclerotic cause of arterial occlusion and limb ischemia.Presentation of caseThe patient is an 18-year-old healthy female who presented to the emergency department with acute left lower extremity ischemia. Her symptoms began as sudden onset mild foot pain approximately two months ago. Over the 72 h prior to presentation, she developed severe pain, pallor, paralysis, loss of pedal pulses, paresthesia, and poikilothermia. Due to her advanced ischemia, she was taken immediately to the operating room for angiography and intervention. Initial angiography demonstrated distal superficial femoral and popliteal artery occlusions along with lack of tibial or pedal artery blood flow. She underwent percutaneous mechanical thrombectomy and initiation of catheter directed thrombolysis. After 48 h of catheter directed thrombolysis and repeat mechanical thrombectomy, computed tomography (CT) was performed and demonstrated external compression of the superficial femoral artery in the adductor canal and residual chronic thrombus. Echocardiography and CT of the thoracic aorta was also performed, and were negative, therefore excluding other potential sources of arterial embolism. She next underwent surgical exploration, division of an anomalous musculotendinous band compressing the left superficial femoral artery and thromboendarterectomy of the distal left superficial femoral artery. The patient recovered well without any post-operative complications and could return to her daily activities 3 weeks following surgery.ConclusionKnowledge of rare non-atherosclerotic vascular disorders, such as adductor canal compression syndrome, is paramount when treating patients who present with limb ischemia and lack traditional risk factors.     

The first case report of failed single-anastomosis-duodeno-ileal bypass converted to One anastomosis gastric bypass/Mini-gastric bypass

IntroductionThe established single-anastomosis-duodeno-ileal bypass with sleeve gastrectomy (SADI-S) is based on a sleeve gastrectomy (SG) as the restrictive part of the procedure. Due to preserved pylorus, SG has the disadvantage of a high-pressure system with de novo or worsening of existing gastroesophageal reflux disease (GERD).Case presentationA female patient presented herself due to protracted GERD and weight regain after multiple bariatric surgeries. At an initial weight of 158 kg (BMI 62.5 kg/m²) the patient underwent adjustable gastric banding in 2009. After band removal in slippage, the patient underwent SG at a weight of 135 kg in 2012. Nine months after SG, SADI-S was performed as a malabsorptive second step procedure. After 32 months the patient suffered from severe GERD under proton pump inhibitor therapy. Actual weight was 107.9 kg (BMI 42.7 kg/m²). Upper endoscopy showed a hiatal hernia and esophagitis B and dorsal hiatoplasty was performed. After 6 months in still existing severe GERD and weight regain indication for laparoscopic conversion to One anastomosis gastric bypass/Mini-gastric bypass (OAGB/MGB) was given, aiming to reduce the high-pressure system of SG in a low-pressure system of OAGB/MGB. One year after revisional surgery reflux was reported to be only occasionally. Further weight loss was seen (91 kg, BMI 36 kg/m², EWL 67.7%).ConclusionSG as the restrictive part of SADI-S may lead to GERD and consequently to pathologic eating of “soft” calories, that defeats the operation and results in weight regain. OAGB/MGB might be a simple method to rescue such failed SADI-S patients.     

Use of the liver maximum function capacity test (LiMAx) for the management of liver resection in cirrhosis – A case of hypopharyngeal cancer liver metastasis

IntroductionThe presence of liver cirrhosis goes along with a higher chance for the need of liver resection. As established laboratory parameters often underestimate the degree of cirrhosis this is associated with an increased risk for postoperative liver failure due to the preoperatively impaired liver function. Known liver function tests are unlikely to be performed in daily use because of high cost or expenditure of time. Liver maximum function capacity test (LiMAx) provides a novel tool for measurement of liver function and references for the safety of liver resection.Presentation of caseA 63-year old patient presented at our hospital with a large, solitary liver metastasis from hypopharyngeal cancer in segments VII/VIII with infiltration of the diaphragm. Liver resection was unsuccessful in a peripheral hospital 10 months before due to considerable macroscopic liver cirrhosis (CHILD B). Upon presentation conventional laboratory parameters revealed sufficient liver function. LiMAx was performed and showed regular liver function (354 μg/kg/h; at norm >315 μg/kg/h). Consequently, atypical liver resection (R0) was performed resulting in a postoperative LiMAx value of 281 μg/h/kg (>150 μg/kg/h). The patient was discharged from hospital 37 days after surgery without any signs of postoperative liver failure.ConclusionThe LiMAx-test enables determination of liver function at a so far unavailable level (metabolism via cytochrome P450 1A2) and hence might provide crucial additional diagnostic information to allow for safe liver resection even in cirrhotic patients.     

Malnutrition – An underestimated factor in the inpatient treatment of traumatology and orthopedic patients: A prospective evaluation of 1055 patients

IntroductionSuboptimal nutritional status is often observed among hospitalized patients across all medical specialties. The objective of the present study was to (1) analyze the prevalence of malnutrition in hospitalized orthopedic and trauma patients and (2) to evaluate the relationship between malnutrition and selected clinical outcomes.Materials and methodsThe prospective field study was conducted between 06/2014 and 06/2015 in a German level I trauma center (Department of Traumatology, Septic Trauma Surgery and Arthroplasty) with a total number of 1055 patients. At hospital admission, patients were checked for malnutrition using the validated Nutritional Risk Screening (NRS). Patients at risk for malnutrition were defined as NRS ≥ 3. Quality of life (SF-36) was assessed to evaluate the physical and mental health status prior to hospitalization. Clinical outcomes under consideration included 1) rate of adverse events, 2) length of hospitalization, and 3) mobilization after operative and conservative treatment. Patients were included independently of surgical intervention or age.Results22.3% (235) of our patients were at risk for malnutrition (NRS ≥ 3) while a regular nutritional status (NRS < 3) was diagnosed in 77.7% (819). The highest prevalence of malnutrition was found in Septic Surgery with 31.0% (106), followed by Traumatology with 19.2% (100) and Arthroplasty with 15.1% (29). Higher prevalence of malnutrition was observed among patients with typical fractures of the elderly, such as lumbar spine and pelvis (47.4%), proximal femur (36.4%) and proximal humeral (26.7%) fractures. Furthermore, patients at risk for malnutrition showed prolonged hospitalization (13.7 ± 11.1 vs. 18.2 ± 11.7 days), delayed postoperative mobilization (2.2 ± 2.9 vs. 4.0 ± 4.9 days) and delayed mobilization after conservative treatment (1.1 ± 2.7 vs. 1.8 ± 1.9 days). A statistically significant correlation of NRS with each parameter (Spearman's rank correlation, p < 0.05) was observed. The incidence of adverse events in patients at risk for malnutrition was statistically significantly higher compared to that of patients with a regular nutritional status (37.2% vs. 21.1%, p < 0.001).ConclusionsMalnutrition is widespread regarding hospitalized patients in the field of orthopedic and trauma surgery and results in suboptimal clinical outcome. It should be considered as an important factor that significantly contributes to delayed recovery. Especially elderly trauma patients and patients suffering from postoperative infections should be monitored carefully during hospitalization.     

Predicting post-transarterial chemoembolization outcomes: A comparison of direct and total bilirubin serums levels

PurposeTo retrospectively review the ability of direct bilirubin serum level to predict mortality and complications in patients undergoing transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) and compare it to the predictive value of the currently utilized total bilirubin serum level.Materials and methodsA total of 219 patients who underwent TACE for 353 hepatocelluar carcinomas (HCC) at a single institution were included. There were 165 men and 54 women, with a mean age of 61.4 ± 7.6 (SD) [range: 27–86 years]. The patients’ electronic medical records were evaluated and they were divided into cohorts based on total bilirubin (< 2, 2–3, and > 3 mg/dL) as well as direct bilirubin (< 1 and 1–2 mg/dL).ResultsDirect bilirubin serum level was significantly greater in the cohort of patients who did not survive as compared to those who survived 6 months ([0.58 ± 0.46 (SD) mg/dL; range: < 0.1–1.8 mg/dL] vs. [0.40 ± 0.31 (SD) mg/dL; range: < 0.1–1.6 mg/dL], respectively) (P = 0.04) and 12 months ([0.49 ± 0.38 (SD) mg/dL; range: < 0.1–1.8 mg/dL] vs. [0.38 ± 0.32 (SD) mg/dL; range: < 0.1–1.6 mg/dL], respectively) (P = 0.03). While total bilirubin serum level was not significantly different in those who did not and did survive 6 months ([1.54 ± 0.99 (SD) mg/dL; range: 0.3–3.9 mg/dL] vs. [1.27 ± 0.70 (SD) mg/dL; range: 0.3–3.75 mg/dL], respectively) (P = 0.16), it was significantly different when evaluating 12 months survival ([1.46 ± 0.87 (SD) mg/dL; range: 0.3–3.9 mg/dL] vs. [1.22 ± 0.65 (SD) mg/dL; range: 0.3–3.9 mg/dL]) (P = 0.03). Akaike information criterion (AIC) analysis revealed that direct bilirubin level more accurately predicted overall survival (AIC = 941.19 vs. 1000.51) and complications (AIC = 352.22 vs. 357.42) than total bilirubin serum levels.ConclusionDirect bilirubin serum level appears to outperform total bilirubin concentration for predicting complications and overall survival in patients undergoing TACE. Patients with relatively maintained direct bilirubin levels should be considered for TACE, particularly in the setting of bridging to transplant.     

Ultrasound-guided transversus abdominis plane block for postoperative analgesia in living liver donors: A prospective,randomized, double-blinded clinical trial

BackgroundTransversus abdominis plane (TAP) block is a peripheral nerve block that reduces postoperative pain, nausea, vomiting and the need for postoperative opioids following various types of abdominal surgery. The primary aim of the present study was to evaluate the effects of TAP block on postoperative analgesia and opioid consumption in living liver donors in whom a right “J” abdominal incision was used.MethodsThis prospective, double-blinded, randomized controlled study was conducted with 50 living liver donors, aged 18–65 years, who were scheduled to undergo right hepatectomy. Patients who received ultrasonography-guided subcostal TAP block were allocated into Group 1, and patients who did not receive TAP block were allocated into Group 2. The TAP blocks were performed bilaterally at the conclusion of surgery using 1.5 mg 1 kg^− 1 bupivacaine diluted with saline to reach a total volume of 40 mL. For each patient, morphine consumption, pain scores at rest and movement, sedation scores, nausea, vomiting and the need for antiemetic medication were assessed at 0, 2, 4, 6, 12 and 24 h postoperatively by researchers who were blinded to the study groups.ResultsMorphine consumption was significantly lower in Group 1 than in Group 2 at the 2nd, 6th and 24th hours (P < 0.05). The mean total morphine consumption values after 24 h were 40 mg and 65 mg in Groups 1 and 2, respectively. The TAP block significantly reduced postoperative visual analog scale pain scores both at rest and during movement at 0, 2, 4, 6, and 24 h postoperatively (P < 0.05).ConclusionsThe TAP block reduced 24-h postoperative morphine consumption and contributed to analgesia in living liver donors who underwent upper abdominal wall incisions.     

Intérêt du Geriatric Nutritional Risk Index dans la prédiction de mortalité chez les patients hémodialysés : étude préliminaire

IntroductionGeriatric Nutritional Risk Index (GNRI) is a simple and quantitative method (based on three objective measurements: weight, height, albumin) for screening patients at risk for malnutrition. However no data are available regarding its relation with mortality in Caucasian hemodialysis patients. We tested the predictive value of GNRI on mortality in a hemodialysis population followed up prospectively for 18 months.MethodsA total of 46 stable prevalent (mean age: 76 ± 11 years, range: 42–95) hemodialysis patients from one center were included in the study. GNRI with other nutritional parameters were evaluated for all patients.ResultsSixteen patients (35%) died during the 18 months of follow-up. Multiple logistic model showed that GNRI and Charlson co-morbidity score were significant predictors of mortality. Age and gender were not significant.ConclusionOur preliminary study carried out on a series of prevalent hemodialysis patients suggests that GNRI is predictor of mortality. To recommend the use of this index for the screening of hemodialysis patients with malnutrition at risk of mortality, our results should be confirmed by a large cohort study.     

Carotid free-floating thrombus causing stroke in a young woman with lupus anticoagulant: A case report and review of the literature

IntroductionIn young adults Stroke is a challenging condition and various tests are needed to diagnose and manage its underlying problems. Free floating thrombosis of internal carotid artery (FFT-ICA) is one of the rare problems among carotid artery diseases which can lead to stroke in adults. Owing to limited cases of FFT-ICA there is not a worldwide accepted consensus on management of FFT-ICA, but some recurrences after medical management have been reported in the literature.Presentation of caseA-25-year old woman was referred to hospital with sudden onset aphasia and right sided hemiparesis. Carotid duplex ultrasonography showed an iso-echogenic thrombus ranged about 5 × 10 mm partially attached to arterial wall of the right internal carotid artery. It was floating in accordance with the heartbeat. Anticoagulation therapy was initiated and subsequently she underwent an urgent operation. To explore the etiology of her problem, various lab tests were carried out; the results showed markedly elevated levels of lupus anticoagulant. She was discharged from hospital after an uneventful recovery showing gradual improvement of symptoms in follow-up visits.DiscussionFFT-ICA is one of the scarce disorders of carotid artery. Less than 150 cases have been reported in the literature indicating its common occurrence in old men. Hence the etiology of this case (FFT in a young patient with high levels of lupus anticoagulant antibody) may be the first of its type.ConclusionIn this case we chose surgical treatment resulting in complete resolution of symptoms and non-recurrence within 6 month follow-up.     

Assessing the prevalence of protein-energy wasting in haemodialysis patients: A cross-sectional monocentric study

IntroductionProtein-energy wasting (PEW) is a strong predictive factor for morbidity and mortality in haemodialysis (HD) patients. However, there is no consensus for its assessment. The present study aimed to assess the nutritional status of patients on chronic HD by use of different nutritional assessment parameters, and at verifying which can identify the greatest number of HD patients with PEW. Also, to investigate predictors of nutritional status in a haemodialysis center in Morocco.Patients and methodsThis is a cross-sectional analysis performed on 126 patients aged 44.82 ± 14.01 years, undergoing maintenance HD in the Department of nephrology of the university hospital centre of Casablanca, Morocco. Energy and nutrients intake assessment was obtained by a three-day period food recall. Biochemical parameters, bioelectric impedance analysis, and subjective global assessment (SGA), have been performed to assess nutritional status.ResultsAccording to SGA the prevalence of PEW was 74.62%. However, when using the ISRMN malnutrition criteria only 36.50% of the patients were diagnosed with PEW. Pearson correlation showed a negative association between the degree of malnutrition evaluated by SGA and serum prealbumin (r = −0.54; P = 0.0001), serum albumin (r = −0.50; P = 0.001), energy (r = −0.34; P = 0.002), protein intake (r = −0.41; P = 0.0001), and a significant positive correlation with CRP (r = 0.65; P = 0.0001) was determined, but not with anthropometric measurements nor lipids profile. The areas under the receiver operating characteristic curve were 0.841 (95% CI: 0.751–0.932) for serum prealbumin, and 0.737 (95% CI: 0.634–0.840) for serum albumin.ConclusionOur results showed a high prevalence of PEW among Haemodialysis patients. Also, our findings suggest that SGA, serum albumin and prealbumin may be relative appropriate and practical markers for assessing nutritional status in HD patients.     

Combined liver transplantation and sleeve gastrectomy for end-stage liver disease in a bariatric patient: First European case-report

IntroductionObesity is a contributor to the global burden of chronic diseases, including non-alcoholic fatty liver disease and non-alcoholic steatohepatitis (NASH). NASH cirrhosis is becoming a leading indication for liver transplant (LT). Obese transplanted patients have higher morbidity and mortality rates. One strategy, to improve the outcomes in these patients, includes bariatric surgery at the time of LT. Herein we report the first European combined LT and sleeve gastrectomy (SG).Case presentationA 53 years old woman with Hepatocellular carcinoma and Hepatitis C virus related cirrhosis, was referred to our unit. She also presented with severe morbid obesity (BMI 40 kg/m²) and insulin-dependent diabetes. Once listed for LT, she was assessed by the bariatric surgery team to undergo a combined LT/SG. At the time of transplantation the patient had a model for end-stage liver disease calculated score of 14 and a BMI of 38 kg/m².The LT was performed using a deceased donor. An experienced bariatric surgeon, following completion of the LT, performed the SG. Operation time was 8 h and 50 min. The patient had an uneventful recovery and is currently alive, 5 months after the combined procedure, with normal allograft function, significant weight loss (BMI = 29 kg/m²), and diabetes resolution.ConclusionDespite the ideal approach to the management of the obese LT patients remains unknown, we strongly support the combined procedure during LT in selected patients, offering advantages in terms of allograft and patient survival, maintenance of weigh loss that will ultimately reduce obese related co-morbidities.     

Effect of Postoperative Restrictive Fluid Therapy in the Recovery of Patients with Abdominal Vascular Surgery

ObjectiveTo compare the outcome of the postoperative administration of a restricted or standard intravenous fluid regimen in patients who underwent elective abdominal vascular surgery. The primary end point was postoperative hospital stay.DesignProspective observer-blinded, randomised controlled trial.Material and methodsPatients were considered eligible if they underwent transperitoneal aorto-iliac approach with infrarenal graft repair. During the operation and intensive care unit stay, fluids were prescribed by the anaesthetists who were unaware of the details of the study. In the vascular surgical ward, patients in the standard group (SG) received 2500 ml of fluids per day, whereas patients in the restricted group (RG) received 1500 ml of fluids per day. All the patients were evaluated on an intention-to-treat basis.ResultsForty patients were randomised to the RG (n = 20) or SG (n = 20). No significant differences were observed in the recovery of gastrointestinal function. However, the postoperative hospital stay was shorter in the RG (8 days) than in the SG (12 days) (p = 0.003).ConclusionsThe use of a restrictive postoperative fluid protocol significantly reduces the duration of hospital stay in patients who have undergone major elective abdominal vascular surgery.     

Surgical management of a giant parathyroid adenoma through minimal invasive parathyroidectomy. A case report

IntroductionPrimary hyperparathyroidism is a common endocrine disorder mostly associated to parathyroid adenomas. Although those tend to be small in size, rare cases of giant parathyroid adenomas may be present.Case presentationA 42 year old female was admitted in our department due to weakness and vague abdominal pain for the past 8 months. Preoperative laboratory exams indicated primary hyperparathyroidism as a cause to her symptomatology, with elevated values of parathormone and normal values of serum calcium. Ultrasound scan and 99 m Tc-MIBI of her cervical region uncovered a giant 3 × 2 cm parathyroid adenoma, located in the lower left thyroid lobe. Despite its size, the gland was successfully removed through implementation of minimal invasive parathyroidectomy. She was uneventfully discharged on the 1st postoperative day.DiscussionAlthough a common reason for developing hyperparathyroidism, parathyroid adenomas may rarely present with exaggerated dimensions and weight. Physical examination is usually unremarkable, while patients may present with symptomatology associated with elevated calcium levels. Treatment of this medical condition consists of surgical removal of the pathologic parathyroid gland either by bilateral neck exploration or through minimal invasive parathyroidectomy. Preoperative localization plays an important role in the second case, since the method focuses on resection of a pre-op marked hyperactive parathyroid gland, through a small incision.ConclusionClinicians must be alerted of hyperparathyroidism in patients presenting with calcium associated symptomatology. Diagnosis is straightforward through laboratory exams, while surgery offers the only permanent treatment option.