Laparoscopic Sleeve Gastrectomy in a Patient With Situs Inversus Totalis and Kartagener Syndrome

Laparoscopic sleeve gastrectomy (LSG) is a widely accepted and adopted procedure to achieves weight loss in morbid obesity. Situs inversus (SI) is when the body's visceral organs are not in the normal position with reversal of anatomical orientation. Patients with obesity and SI can be challenging to diagnose and manage. We present a case of a 23-year-old male who has SI totalis with Kartagener syndrome who underwent LSG to treat morbid obesity. Furthermore, we conducted a comprehensive review of the current medical literature. We conclude that LSG can be safely performed in SI. However, it is recommended to leave such cases to more experienced surgeons. In addition, it is advisable to consider few unconventional technical operative methods before surgery. Nevertheless, more data are needed to better study LSG in SI patients, which can be difficult given the rare nature of SI.

Percutaneous Endoscopic Gastrostomy Tube Insertion in Patient With Situs Inversus Totalis

Situs inversus totalis (SIT) is a rare congenital condition in which the abdominal and thoracic organs are completely reversed from right to left, and their diagnosis is usually incidental. However, patients with SIT need a comprehensive radiological evaluation before undertaking any invasive procedures. Percutaneous endoscopic gastrostomy (PEG) insertion is an effective procedure for enteral feeding in patients with difficulty swallowing. Many post-procedural complications have been reported after the PEG procedure. We performed PEG insertion in an 85-year-old Qatari SIT patient, who was admitted to the hospital as a case of aspiration pneumonia and on nasogastric feeding tube (NGT). The procedure was started while the patient was in left lateral decubitus position as in normal anatomy patients after careful examination and in accordance with the general principles of PEG insertion. No complications were seen, neither intraoperative nor postoperative in two months follow-up. We suggest that in a patient with SIT, PEG insertion can be performed while the patient is in left decubitus position with no additional risk or extra intraoperative time if the pre-operative anatomical position of vital organs is carefully evaluated.

Embryonic exposure to propylthiouracil disrupts left-right patterning in Xenopus embryos

Antithyroid medications are the preferred therapy for the treatment of Graves' disease during pregnancy. Propylthiouracil (PTU) is favored over methimazole (MMI) due to potential teratogenic concerns with MMI. This study was to determine the teratogenic potential of MMI and PTU using a validated Xenopus tropicalis embryo model. Embryos were exposed to 1 mM PTU (EC(50)=0.88 mM), 1 mM MMI, or vehicle control (water) from stages 2 to 45. Treated embryos were examined for gross morphological defects, ciliary function, and gene expression by in situ hybridization. Exposure to PTU, but not MMI, led to cardiac and gut looping defects and shortening along the anterior-posterior axis. PTU exposure during gastrulation (stage 8-12.5) was identified as the critical period of exposure leading to left-right (LR) patterning defects. Abnormal cilia polarization, abnormal cilia-driven leftward flow at the gastrocoel roof plate (GRP), and aberrant expression of both Coco and Pitx2c were associated with abnormal LR symmetry observed following PTU exposure. PTU is teratogenic during late blastula, gastrulation, and neurulation; whereas MMI is not. PTU alters ciliary-driven flow and disrupts the normal genetic program involved in LR axis determination. These studies have important implications for women taking PTU during early pregnancy.

Epiploic appendagitis in a female patient with situs ambiguous abnormality

We report the case of a 23 year-old obese female, with previously diagnosed situs inversus below the diaphragm, who presented with severe left upper quadrant abdominal pain. The patient was believed to have a surgical indication, possibly appendicitis or diverticulitis, and had an emergent abdominal Computed Tomography (CT) scan. The CT was interpreted as epiploic appendagitis with no signs of appendicitis. Epiploic appendagitis is a rare cause of acute abdominal pain, which involves the torsion and eventual necrosis of one of the epiploic appendages. This case was complicated by the fact that the patient had situs inversus below the diaphragm, which made it difficult to relate her localized abdominal pain to the correct anatomic area. The diagnosis allowed the patient to avoid invasive surgery and instead opt for conservative medical management. The utilization of radiologic imaging is of utmost importance in diagnosing this condition, which has characteristic findings on CT, US, and MR, all of which is discussed in this article.