It is generally believed that balloon angioplasty of diffuse, long-segment aortic coarctation is not effective. In this report, we describe two neonates with diffuse, long-segment coarctation in association with complex congenital heart defects in whom we were successful in effectively treating coarctation with transumbilical artery balloon angioplasty. Based on this experience, it may be concluded that balloon angioplasty of long-segment coarctation in neonates is feasible and effective, but confirmation in a larger group of patients may be necessary prior to general adoption of this concept.
Introduction: Postprandial hypoglycemia induced by Dumping Syndrome (DS) represents a side effect of bariatric surgery linked to glucose-dependent hyperinsulinemia, which can cause serious symptoms 2-3 hours after the meal hypoglycemia. This clinical case shows the effectiveness of semaglutide, a long-acting GLP1 receptor agonist, in one patient previously subjected to gastric bypass (GBP), with persistent late postprandial hypoglycaemic symptoms occurring after surgery. Case Report:: A female patient, 31 years old, subjected to GBP 10 years earlier, with the diagnosis of diabetes, was admitted to our unit for persistent post-prandial reactive hypoglycemia, confirmed by Flash Glucose Monitoring (FGM) FreeStyle. The patient was intolerant to metformin, had been treated with acarbose with poor results. HbA1c 7.9%. Acarbose was suspended, and semaglutide was started sc at increasing doses, 0.25 mg/week for 1 month and subsequently 0.5 mg/week. After the first few weeks, symptoms of DS were significantly reduced with improvement of the daily glycemic profile and disappearance of hypoglycemic events. The time-below range, time spent with blood glucose <70 mg/dl, decreased by 12% to 4% during treatment with semaglutide 0.25 mg/week, up to 1% with a dose of 0.5 mg/week. The effect of the drug on reducing hypoglycemic episodes was persistent for up to 8 months. Conclusion:: Treatment of post-bariatric reactive hypoglycemia includes nutritional therapy, the use of glucosidase inhibitors, and somatostatin analogues. The use of short-acting GLP-1RA analogues has also recently been reported. In our patient, therapy with semaglutide s.c. significantly reduced episodes of reactive hypoglycemia with an improvement in the quality of life.
Pancreas divisum is a variant of pancreatic ductal drainage. Its existence is being observed more frequently with the widespread use of endoscopic retrograde cholangiopancreatography (ERCP). On occasion, a relative stenosis of the accessory sphincter will cause a symptom complex which includes nausea, vomiting, upper abdominal pain, and intermittent pancreatitis. In 20 patients seen over the past 4 years, symptoms have been severe enough to consider the patient for transduodenal sphincteroplasty. The use of morphine prostigmine stimulation as a screening tool, has been helpful in 79 per cent of the patients in the series. Intravenous secretin has been a valuable adjunct to both ERCP identification and cannulation of the duct, as well as in two patients in whom the diagnosis was only suspected, and confirmed at the operating table. Operative common duct manometry has shown 40 per cent of the patients to have abnormal flow dynamics, suggesting possible disturbance in the biliary sphincter, as well as the accessory pancreatic sphincter. Pathologic examination has demonstrated abnormal gallbladders in nine of nine patients without previous cholecystectomy. The suggested procedure of dual sphincteroplasty has resulted in no mortalities, but a 50 per cent complication rate. Follow-up shows 70 per cent of the patients to be currently asymptomatic, two patients have had recurrent pancreatitis, and four patients have other problems causing continued post-operative pain. This study suggests dual sphincteroplasty is an acceptable form of therapy for patients with pancreatic divisum and no other source for their pain. Further follow-up will be necessary to insure that therapy is truly curative.
