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Fulltext Unusual Presentation of Incarcerated True Parahiatal Hernia: Management of a Rare Clinical Entity

Loo GH, Muthkumaran G, Ritza Kosai N

Cureus, 2024 Mar;16(3):e57152.
PMID: 38681472 DOI: 10.7759/cureus.57152

True parahiatal hernia is a type of diaphragmatic hernia in which herniation occurs through a defect in the diaphragm, adjacent to the normal oesophageal hiatus. Its reported incidence is very rare, and it is commonly misdiagnosed as paraoesophageal hernia. Although the clinical distinction between paraoesophageal and parahiatal hernia is difficult, it is essential to recognise these two separate entities clinically as their management differs. Clinical presentation of parahiatal hernia includes symptoms related to gastro-oesophageal reflux disease (GERD). Patients may also present emergently with symptoms of respiratory distress and chest symptoms. With that in mind, we describe a compelling case of a young lady who initially presented with symptoms suggestive of acute coronary syndrome. However, she was found to have an incarcerated parahiatal hernia.
One-Year Outcomes in a Supervised Program of Swallowable Intragastric Balloon-Analysis of 486 Patients in a High-Volume Bariatric Centre in Malaysia

Kosai NR, Ali AA, Ghita R, Muthkumaran G, Ali I, Loo GH, et al.

Obes Surg, 2024 Jul 23.
PMID: 39042306 DOI: 10.1007/s11695-024-07414-y

INTRODUCTION: The swallowable intragastric balloon (IGB) has recently emerged as a popular alternative for weight loss in Malaysia. It can reduce total body weight loss (TBWL) by 6-15%. We aim to observe positive weight loss up to a year after the swallowable IGB is implanted.
METHODS: A total of 486 consecutive patients with overweight or obesity who underwent swallowable IGB insertion were included in this prospective data collection.
RESULTS: Out of 486 patients, 404 patients (83%) had complete data at the end of 4 and 12 months. Patients included in the study had a starting mean body mass index of 35.3 ± 7.2 kg/m2 which decreased to 31.5 ± 5.7 kg/m2 (p
Reversal of Roux-en-Y Gastric Bypass to Normal Anatomy in a Severely Malnourished Patient After Metabolic Bariatric Surgery

Sadu Singh RS, Loo GH, Muthkumaran G, Azna Ali A, Ritza Kosai N

Cureus, 2024 Oct;16(10):e71240.
PMID: 39525114 DOI: 10.7759/cureus.71240

Obesity stands as a prominent health challenge in our society, with metabolic bariatric surgery (MBS) emerging as a solution due to its efficacy in addressing obesity-related type 2 diabetes mellitus (T2DM). Roux-en-Y gastric bypass (RYGB) and one-anastomosis gastric bypass (OAGB) remain the most common MBS after sleeve gastrectomy. Complications from RYGB are uncommon but include anastomotic stricture, marginal ulcers, small bowel obstruction, and nutritional complications. We present a 52-year-old lady with an initial body mass index (BMI) of 27.6 kg/m2 and poorly controlled T2DM who presented with generalized body weakness and uncontrolled weight loss after an RYGB performed four months earlier. She was cachexic with a BMI of 17 kg/m2,with generalized anasarca with a multitude of electrolyte disturbances. After nutritional optimization, she underwent a reversal surgery back to normal anatomy. Reversal of RYGB to normal anatomy is a complex surgical procedure and is often the last resort undertaken in patients experiencing severe complications from the initial surgery. Indications include malnutrition, severe dumping syndrome, excessive weight loss, and recalcitrant marginal ulcers. Our case outlines the importance of proper patient selection for MBS and highlights the preoperative management of RYGB reversal to normal anatomy. We also describe the surgical procedure using a stepwise approach. In conclusion, the reversal of RYGB to normal anatomy should only be undertaken after a careful period of prehabilitation to reduce perioperative complications. The inclusion of dietitians, endocrinologists, and physiotherapists is crucial to ensure the best possible outcome.
Incarcerated Incisional Hernia: An Unusual Presentation of Metastatic Endometrial Carcinoma

Ong MN, Loo GH, Muthkumaran G, Md Pauzi SH, Ritza Kosai N

Cureus, 2024 Oct;16(10):e71497.
PMID: 39544575 DOI: 10.7759/cureus.71497

Abdominal wall hernia is a common condition seen in the clinical practice of surgery. However, malignant tumors in the hernia sac are rare and there are limited studies on this subject. We report a case of a 77-year-old female who presented with generalized abdominal pain and vomiting. She was treated for an incarcerated incisional hernia and underwent an exploratory laparotomy, which showed a multiseptated incisional hernia sac. Histopathological examination revealed a metastatic endometrial serous carcinoma (ESC). ESC is an aggressive variant associated with poor prognosis, characterized by metastasis and extrauterine spread. Its treatment mainly involves a multidisciplinary approach, including surgical treatment and chemoradiotherapy. This report highlights the importance of considering malignant tumors in the differential diagnosis of hernia sac contents. Raising awareness among healthcare professionals and the general public can aid in the prompt diagnosis, appropriate treatment, and improved outcomes for individuals with such rare presentations.
Fulltext Proximal Margin Involvement Following Total Gastrectomy for Seiwert III Adenocarcinoma: A Management Dilemma

Sadu Singh RS, Loo GH, Muthkumaran G, Sambanthan ST, Ritza Kosai N

Cureus, 2024 Jul;16(7):e64945.
PMID: 39156343 DOI: 10.7759/cureus.64945

Oesophagogastric junction carcinoma is now being increasingly regarded as a distinct site of neoplasia, separate from its adjacent sites. Recent advances in multimodal treatment approaches, including endoscopic procedures, oesophagectomy with three-field lymph node dissection, and definitive chemoradiotherapy, have significantly improved overall patient survival rates. Despite these advancements, the recurrence rate remains around 50% within one to three years following initial surgery. A major challenge in management arises when the resected surgical margins are involved with cancer. We present a 55-year-old man who experienced progressive dysphagia and, upon further assessment, was noted to have a Siewert III oesophagogastric junction adenocarcinoma. He underwent neoadjuvant chemotherapy before undergoing total gastrectomy with D2 lymphadenectomy with a Roux-en-Y reconstruction. Histopathological examination of the resected specimen revealed a positive proximal margin involvement. After optimization, he then underwent a salvage three-field McKeown oesophagectomy with colonic conduit reconstruction and adjuvant chemotherapy. Salvage surgery can be considered for patients with locoregional recurrence after definitive chemoradiotherapy or surgery. Other options include salvage chemoradiotherapy. Our case outlines the importance of proper patient selection for salvage surgery and highlights the choices of conduit in patients undergoing total esophagectomy post gastrectomy. In conclusion, managing proximal margin involvement of cardioesophageal junction adenocarcinoma remains a complex and multifaceted challenge, necessitating a tailored, multidisciplinary approach. The decision-making process must consider the patient's functional status, previous treatments, and specific anatomical considerations.