A 45-year-old man of Middle Eastern origin, morbid obese, with a body mass index of 39 had an intra-gastric balloon, filled with 500 mL of saline/methylene blue and intended as definite therapy, inserted some 8 wk previously. He was admitted to the emergency department with abdominal cramps. An ultrasound of the abdomen was performed in ER which confirmed the balloon to be in place without any abnormality. He was discharged home on symptomatic medication. Patient remains symptomatic therefore he reported back to ER 2 d later. Computed tomography scan was performed this time for further evaluation which revealed a metallic ring present in the small bowel while the intra-gastric balloon was in its proper position. There was no clinical or radiological sign of intestinal obstruction. Patient was hospitalized for observation and conservative management. The following night, patient experienced sudden and severe abdominal pain, therefore an X-ray of the abdomen in erect position was done, which showed free air under the right dome of diaphragm. Patient was transferred to O.R for emergency laparotomy. There were two small perforations identified at the site of the metallic ring entrapment. The ring was removed and the perforations were repaired. Due to increasing prevalence of obesity and advances in modalities for its management, physicians should be aware of treatment options, their benefits, complications and clinical presentation of the known complications. Physicians need to be updated to approach these complications within time, to avoid life-threatening situations caused by these appliances.

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Background: Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced endoscopic procedure that is an essential tool in the management of pancreaticobiliary diseases. There is limited data available on the indications and outcomes of ERCP from this region. Therefore, we aim to report the characteristics of patients, indications and outcomes of ERCP in Saudi Arabia.Methods: We retrospectively looked at ERCP procedures done at a tertiary referral center covering the western region of Saudi Arabia from August 2018 until July 2020. Data were collected from the hospital's electronic patient record and endoscopy database.Results: Of 1001 ERCPs performed, full data was available on 712 procedures on 581 patients that were included in the final analysis. Mean age was 53.1 years. Four hundred four (56.7%) were female. Boardcertified consultants performed all ERCPs. The most common intervention was sphincterotomy, which was performed in 563 (96.9%) patients who underwent first-ever ERCP, followed by dilatation and stenting. The commonest indication of ERCP was confirmed or suspected choledocholithiasis (52.6%), followed by replacement or removal of a biliary stent (15.7%), 55 (7.7%) for suspected ascending cholangitis, 54 (7.5%) for acute biliary pancreatitis and 15 (2%) for suspected sphincter of Oddi dysfunction. The commonest finding among all patients was choledocholithiasis in 57.9%, debris in 15.2% and biliary stricture in 14.8%. The commonest complication was pancreatitis in 22 (3.1%) followed by post-sphincterotomy bleeding in 16 (2.2%) and perforation in nine (1.2%). Bleeding was controlled by endoscopic intervention in four (25%) and one (6.2%) patient underwent surgery. One (0.14%) patient had procedure-related mortality secondary to post-procedure pulmonary embolism and one had significant morbidity and prolonged hospitalization because of complicated perforation. The deeper common bile duct (CBD) cannulation rate was 97.3%. Conclusion:Our study results revealed that ERCP performed in the western region of Saudi Arabia has similar indications and findings as reported in the international literature. ERCP is successful in achieving the therapeutic objectives with complication rates consistent with published data.

Background: Self-expanding metallic stents (SEMSs) are increasingly used as a non-surgical alternative for the palliation of advanced esophageal cancer (EC). However, there is a scarcity of real-life experience with the use of these stents exclusively in EC. The aim of this study is to evaluate the efficacy of SEMS in inoperable ECs in the western region of Saudi Arabia.Methods: A retrospective review of SEMS placed in a tertiary referral hospital for histologically proven inoperable EC from 2016 to 2019. Demographics data, procedure success, complication, re-intervention, and mortality were analyzed.Results: Forty-eight SEMS placed in 35 patients for palliation of dysphagia. The median age of patients was 68 years (range 31-95). 69% (24) patients have a lower third of EC and the rest have a middle third. SEMSs were placed successfully in all cases with symptomatic improvement. No major stent-related complication was seen. 28% (13) patients required re-intervention with additional SEMS placement, nine of which were for tissue in growth and four for distal migration. Median survival was 114 days (range 30-498). Most of the complications seen in fully covered SEMS compared to the partially covered 50% (8/16) vs 17% (5/30), respectively, p = 0.04. Chemo and/or radiotherapy were given to 51% (18) of the patients without any significant benefit on survival (p = 0.79) or re-intervention rate (p = 0.47) compared to those who did not. Conclusion: SEMS is effective in palliating dysphagia in inoperable EC without major complications. Rates of tumors in growth and migration were comparable to other studies. SEMS provides long-term palliation.