Surgical management of retrosternal goiter: local experience at a university hospital

Retrosternal goiter [RSG] is a term that has been used to describe a goiter that extends beyond the thoracic inlet. Surgery plays an important role in the treatment of these patients, but whether all or selected patients with RSG should undergo this operation remains controversial. Our aim is to look into the demographics, presentation, and treatment of patients with RSG and essentially to determine the role of surgery in its treatment. Retrospective study, teaching hospital-based. Retrospective analysis of 537 thyroidectomies performed at King Khalid University Hospital between 2003 and 2010. The twenty-six patients with RSG were analyzed further, with regard to demographics, presentation, indications, and outcome of surgical treatment. Statistical analysis was performed, where age was expressed as mean and range, and other variables were presented as numbers and percentage. There were 26 patients [4.8%] with RSG out of 537 thyroidectomies, who underwent an operation for removal of RSGs, in a seven-year period. The most common presentation was dyspnea [34.6%] and the surgical procedure predominantly used was total thyroidectomy. The RSGs were removed by collar incision in 96% of the cases. The final histological diagnosis revealed malignancy in 26.9% of the thyroid specimens. There was no mortality and minor complications occurred in nine patients. The presence of an RSG is an indication for surgery owing to the lack of effective medical treatment, the higher incidence of symptoms related to compression, low surgical morbidity, and the risk of malignancy

Surgical Residency Training Program. Are changes needed?

To obtain a collective opinion of practicing surgeons on the current state of general surgical residency training. A data collection sheet was completed by the practicing surgeons involved in the residency training in 5 cities in Saudi Arabia, from January 2004 to December 2005. The survey questions covered mainly 3 aspects of surgical education: problems within the current education system, how education should be conducted, and the best approaches to correct education deficits. A total of 96 surgeons involved in the training program responded. Thirty-three [34.4%] were from the Ministry of Health, 59 [61.5%] of the surgeons agreed that surgical skills can be acquired outside the operating theater. The majority [58.3%] considered that, the biggest deficit in graduating residents that must be corrected is technical skills. Changes are necessary to improve our surgical training program. Collaboration between hospitals to combine the current diverse efforts to train residents outside the operating rooms is necessary to establish a structured skills training center to teach and train both junior and senior residents. Formal education courses for the educators and encouraging residents to accept more responsibilities are additional efforts to improve the process of learning

Differentiated thyroid carcinoma: the impact of initial surgical therapy

The extent of surgery for differentiated thyroid carcinoma [papillary and follicular] is still controversial, extending from simple lobectomy to extensive total thyroidectomy. The objective of this study was to assess the outcome of different types of thyroidectomy in patients with differentiated thyroid carcinoma [DTC]. The extent of primary surgical therapy for 428 patients with thyroid lesions who underwent surgery, in whom the final diagnosis were confirmed histologically, were reviewed. Those who developed recurrence after surgery were analyzed further. Forty two patients had differentiated thyroid carcinoma. Regarding surgical treatment, 27 patients had lobectomy and 15 had total thyroidectomy. Out of six patients who developed recurrence, five had lobectomy as initial surgical treatment and one underwent subtotal thyroidectomy. None of the patients in total thyroidectomy group developed recurrence. In the absence of general agreement of the optimal primary surgical therapy for DTC, our data indicate that more extensive surgery has a better outcome and with less recurrence rate

effect of some non dietary factors on adolescent's bone health

Osteoporosis is a major health problem. Bone growth during childhood and adolescence is as important as bone loss that affects the development of osteoporosis. This work is a part of a national survey carried out by the National Nutrition Institute to determine the prevalence of osteopenia and osteoporosis in Egypt among adolescents and adults and the effect of some factors on bone health conducted in the period 2001-2004. In a representative sample of Egypt, 2039 male and 2021 female adolescents in the age group [10-19] years were included [2500 families]. Among collected information was detailed medical examination and socioeconomic data. Weight and height were measured and percentile body mass index [p-BMI] was calculated and categorized in accordance to WHO [1995]. Dual energy X-ray absorptiometry was done to all subjects. Random blood sample was collected for subgroup to assess serum levels of sex hormones; testosterone and estrogen. Results showed that the prevalence of relative osteoporosis among adolescents is [16.7% and 0.9%] while the percentage of those with relative osteopenia was about [45.6% and 28.7%] among males and females respectively. Multiple regression analysis showed that increase in age, attained height and increase in body mass index have direct relations with increased bone mineral density [BMD]. Also the genetic predisposition [as reflected by parents BMD] was found to have an effect on bone health in adolescents. Results did not show any significant role for hormonal levels in both sexes. Protective strategies should be started at earlier ages as well as nutrition and health education programs to prevent and control osteoporosis

Breast carcinoma during pregnancy

The medical records of patients with pregnancy associated breast carcinoma were critically reviewed to identify the tumor characteristics, maternal details, type of treatment delivered, and disease outcome. Over the last 5 years, there were 5 patients out of 220 giving a percentage prevalence of 2.27%. The median age at presentation was 33 years. Three patients were diagnosed by the sixth week of gestational age. Three out of 5 presented with stage IIIA. Four patients has >/= 6 positive axillary lymph nodes and grade III disease. So in spite of the discovery of the tumor in the early weeks of pregnancy, our patients presented with advanced disease, which is consistent with the presentation of breast carcinoma in non-pregnant women in this part of the world. So it could be an ignored disease, which became evident with the pregnancy. We highly encourage the obstetricians to perform thorough breast examination during the prenatal period with prompt referral of any suspicious cases

Partial versus total splenectomy in the management of hemolytic disorders in children, a randomized controlled trial

The risk of septicemia in postsplenectomy pediatric patients is approximately 2%. This risk is twice as great for children less than 4 years of age. In the first year of life this risk can be 30% or higher. Partial splenectomy is an alternative to preserve the immune function of the spleen. This study aims to compare Partial versus Total Splenectomy in the management of hereditary hemolytic blood disorders in children. The study was conducted at the Cairo University Children Hospital [CUPH], department of pediatric surgery. Seventy eight patients were assigned randomly to undergo either partial or total splenectomy in the period between 2000 and 2004. Thirty eight patients underwent partial splenectomy [PS] and 40 were assigned to the total splenectomy [TS] group. The data collected included age, gender, type of hemolytic disorder, ultrasonography, and hematologic values [HB concentration, Hematocrit and reticulocytic count], levels of IgM and lgG, description of surgical procedure and early- and late-occurring complications. From 2001 to 2004, 78 children from 3 years, 9 months to 7 years of age suffering various forms of hereditary hemolytic anemias [Thalassemia Major and Spherocytosis] underwent either TS or PS. Indications were hypersplenism and severe anemia. The average age at the time of the operation was 4 years, 5 months. There was a reduction in the need for transfusion after PS and was comparable to the results of the total splenectomy group. There was confirmed preservation of the immunologic phagocytic function of the residual splenic tissue. There was no increase in the rate of complications in the PS group compared to the TS group. Subtotal splenectomy [80-90%] seems to preserve the immunologic role of the spleen and reduce the need for blood transfusion. PS is associated with a regrowth of the splenic remnant. Thus, a second operation to perform a total splenectomy can be necessary. However preserving the immunologic function of the spleen and reduction of the risk of overwhelming sepsis warrants the procedure

Validity of leukocyte count to predict the severity of acute appendicitis

To ascertain whether white blood cell [WBC] count with differential analysis may predict severity of disease in acute appendicitis. We conducted this retrospective study on appendectomy patients from 1996 to 2001, at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia. We reviewed patient's age, gender, duration of symptoms, temperature on admission, WBC count including differential and the histological diagnosis of the appendicular specimen. We further analyzed the data of those patients found to have acute, gangrenous and perforated appendicitis to determine the correlation between a high WBC count and a more advanced form of appendicitis. Out of an aggregate of 232 patients, 162 were males and 70 females with a mean age of 23.7 years [range, 12-70 years]. Mean duration of symptoms was 1.9 +/- 1.1 days, mean temperature 37.8 +/- 1.4 degree celcius, with reported elevated WBC count in 167 [71.9%] and normal in 65 [28.1%] cases. Mean WBC counts in acute were 14.5 +/- 7.3 x 109/L, gangrenous 17.1 +/- 3.9 x 109/L and perforated appendicitis 17.9 +/- 2.1 x 109/L. This reflected a persistently higher WBC count in the complex [gangrenous, perforated] appendicitis compared with acute appendicitis [p less than 0.05]. The differential analysis showed neutrophilia in 123 [53%] and lymphopenia in 112 [48%] cases and out of these, 116 [94%] with neutrophilia and 107 [95%] with lymphopenia were reported to have appendicitis. A high WBC with differential count is a reliable indicator of the severity of appendicitis and signifies a more advanced stage

Carcinoid tumors of the appendix. Our experience in a University Hospital

To present our experience of carcinoid tumors of the appendix managed at a university teaching hospital. Complex symptomatology, varied biochemical affections and different surgical therapeutic modalities are discussed. The medical records of all the patients who underwent consecutive appendectomies at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia from 1994 to 1999 were retrospectively analyzed. The data of patients identified to have histological evidence of carcinoid tumors of the appendix were further reviewed for the demographic details, indications for surgery, surgical procedure, tumor localization in the appendix and size; concomitant appendicitis and further surgical procedures were considered. During the study period, 1547 appendectomies were performed and, out of these, 9 [0.6%] cases were reported to have carcinoid tumors of the appendix. There were 4 male and 5 female patients, age range 17-51 years [median 29.8 years]. Seven subjects had a clinical evidence of appendicitis while 2 presented with chronic abdominal pain. There were 6 open and 3 laparoscopic appendectomies. Six carcinoid tumors were encountered at the appendiceal apex, 2 at the midportion, and one at the base with a mean diameter of 9.5 mm [range, 4-19 mm]. One patient had histologically confirmed residual tumor, which necessitated a right hemicolectomy 3 weeks later. All patients remained disease-free during a mean follow up of 7 years [range, 4-10 years]. Carcinoid tumors of the appendix are extremely rare and invariably remain asymptomatic. Simple appendectomy offers adequate relief while the need for further extensive surgery depends on tumor characteristics and dissemination. Despite an excellent prognosis, all reported patients should be followed up with urinary 5-hydroxyindoleacetic acid and abdominal ultrasonography

Cholesterolosis: incidence, correlation with serum cholesterol level and the role of laparoscopic cholecystectomy

To report the incidence of cholesterolosis in the surgically removed gallbladders, its association with serum cholesterol level and to review the role of laparoscopic cholecystectomy in the treatment. This retrospective study included all patients who had consecutive cholecystectomies for various gallbladder disorders, performed by 2 consultants during a 5-year period from January 1997 through to December 2002, in the College of Medicine and King Khalid University Hospital, King Saud University, Riyadh, Kingdom of Saudi Arabia. The clinical records of those found to have cholesterolosis on histopathological examination were reviewed, and the data were analyzed for their age, sex, fasting serum cholesterol level and the final outcome of cholecystectomy. The study group was comprised of 549 patients and out of which, 74 [13.4%] had cholesterolosis of the gallbladder. There were 59 [79.9%] female and 15 [20.1%] male patients. Age ranged from 18-64-years with a mean of 35.7-years. Sixty-three [85.1%] cases were reported to have abnormally high fasting serum cholesterol levels [>=5.5 mmol/L], whereas 11 [14.9%] had normal serum cholesterol level. Cholesterolosis with coexistent gallstones was documented in 47 [63.3%] patients while 27 [36.5%] subjects showed acalculous cholesterolosis. Laparoscopic cholecystectomy was performed in 71 [95.9%] individuals, whereas 3 patients ended up with open cholecystectomy [conversion rate of 4.2%]. There were no postoperative complications. Cholesterolosis of the gallbladder is a distinct pathologic entity and carries a positive correlation with high serum cholesterol level. Laparoscopic cholecystectomy is effective, safe and a feasible treatment modality for cholesterolosis

Charnley Ogee-flanged cup in primary total hip arthroplasty for acetabular dysplasia

Ogee-flanged socket was introduced by Sir John Charnley for use in low-friction hip arthroplasty. The results of 18 primary total hip arthroplasties performed in 17 patients with moderate congenital acetabular dysplasia were reviewed. Charnley total hip prosthesis including a non-modular femoral stem and an ogee-flanged acetabular socket were used in all patients. The average duration of follow up after arthroplasty was 5.3 years [range 4-7 years]. All patients were evaluated using a modified Harris hip scoring system and a standardized anteroposterior pelvis radiograph for hips. Differences between the preoperative and postoperative [last evaluation] scores were assessed with the student's t-test and Chi-square test. The mean overall modified Harris hip score was improved from 48 points preoperatively to 89 points at the last follow up evaluation, this improvement was significant. A low percentage of radiological demarcation at the bone-cement interface around the acetabular sockets was observed in the immediate postoperative and the last follow up radiographs

Reconstruction of the deficient femur by impaction - grafting in revision hip arthroplasty Apreliminary report of twenty patients

Impaction bone-grafting was performed using compressed morselized cancellous allograft and a cemented collarless polished double tapered Exeter stem in twenty revision total hip arthroplasties that were done because of aseptic loosening. The average follow-up duration was 26 months [range 13 to 30 months]. The average age at the time of the revision was 58.4 years [range 38 to 72 years]. There were 15 men and 5 women. The operation was the initial revision in 19 patients [95%] and re-revision in one patient [5%]. The postoperative Harris hip score was 89 points [range 60-96 points] and 75% of the patients were pain-free. On radiograph, subsidence was common [12 patients, 60%] and averaged 2.5mm [range 1- 6mm], however, although the study group was relatively small, the overall score may not accurately reflect the rate or amount of subsidence. On the other hand, migration of the cement mantle within the allograft reconstruction was evident in two patients only [10%], non-progressive with an average sunk of 1.5mm. Lucent lines were rare, and in 90% of the revisions the radiographs showed evidence of graft incorporation and bone remodeling. Intra-operative complications included two patients [10%] with fracture of the femur during impaction and were managed by insertion of circlage wires. Early complications included one case [5%] of superficial wound infection, DVT, and heterotopic ossification. Late complications included one case [5%] of graft resorption with no evident incorporation after one year. Further study is necessary, but these preliminary findings are encouraging and we believe that this is a reliable method for femoral revision, reconstruction, and reconstitution

Total knee arthroplasty after patellectomy

Patients with total knee arthroplasty following patellectomy have been reported to experience pain and instability. The results of sixteen consecutive primary total knee replacements, performed an average of eleven years [range, four to twenty seven years] after a patellectomy in sixteen patients, were reviewed prospectively. The average duration of follow up after the arthroplasty was 5.7 years [range, three to eight years]. The average age of the patients at the time of the arthroplasty was 66.9 years [range, 53-79 years]. There were four men and twelve women. In all patients of this study the posterior cruciate ligament was sacrificed and a posterior stabilized prosthesis was used. All patients were evaluated according to the rating system of the Knee Society. Differences between the preoperative and postoperative [last evaluation] scores were assessed with the student's t-test and chi-square test. The mean overall Knee Society clinical score was improved from 69.1 points preoperatively to 166.2 points at the last follow up evaluation. This improvement was highly significant [p<0.001]. On the basis of the evaluation of the small series included in this study, we believe that total knee arthroplasty using a posterior stabilized prosthesis may represent a safer and more predictably stable choice in patients who have had a previous patellectomy

Interlocking nailing for infected and previously infected femoral fractures

Ten femoral shaft fractures, with documented evidence of current and/or previous infection of the femur, were treated by interlocking femoral nailing as definitive surgery. Six cases had failed previous internal fixation [plating in two and Kuntcher nailing in four], four other cases had initial treatment by external fixation and pin tract infection was documented in all patients by bacteriological examination and culture. All cases had antibiotics according to culture and sensitivity tests for an average of 8.7 weeks. Three patients had minor wound healing problems and oozing, but neither local/systemic signs nor laboratory evidence suggesting deep infection was encountered postoperatively in any patient. All fractures united with an average time of 22.4 weeks. The results of the study showed that the use of interlocking nailing, in infected and previously infected femoral fractures, does not cause propagation of infection or more complications of bone infection, and retains all its advantages which make it the treatment of choice in femoral fractures

role of laparoscopic hysterectomy in modern gynecologic practice

The aim of this study is to evaluate the role of laparoscopic hysterectomy in modern gynecological practice. This study included 124 cases of laparoscopic hysterectomies that were performed using electrosurgical energy [unipolar and bipolar] throughout the procedure. The indications for the operation were the same as conventional hysterectomy. The results were compared with the results of 124 cases of conventional abdominal hysterectomy. Compared to conventional abdominal hysterectomy laparoscopic hysterectomy showed significantly less intraoperative blood loss [mean 125 +/- 40 mL], less operative time [75 +/- 10 min]. Less postoperative pain, shorter stay in hospital [1.2 +/- 0.25 days] and shorter convalescence period [5.35 +/- 2.4 day] [P<0.05]. Intraoperative bleeding requiring blood transfusion was significantly higher in conventional abdominal hysterectomy [P<0.05]. Otherwise others intraoperative and postoperative complications were comparable in both procedures. Laparoscopic hysterectomy is a real substitute for abdominal hysterectomy in a good proportion of gynecologic disorders in modem gynecological practice

role of laparoscopic hysterectomy in modern gynecologic practice

The aim of this study is to evaluate the role of laparoscopic hysterectomy in modern gynecological practice. This study included .124 cases of laparoscopic hysterectomies that were performed using electrosurgical energy [unipolar and bipolar] throughout the procedure. The indications for the operation were the same as conventional hysterectomy. The results were compared with the results of 124 cases of conventional abdominal hysterectomy. Compared to conventional abdominal hysterectomy, laparoscopic hysterectomy showed significantly less intraoperative blood loss [mean 125 +/- 40 ml], less operative time [75 +/- 10 min], less postoperative pain, shorter stay in hospital [1.2 +/- 0.25 days] and shorter convalescence period [5.35 +/- 2.4 day] [P<0.05]. Intraoperative bleeding requiring blood transfusion was significantly higher in conventional abdominal hysterectomy [P<0.05]. Otherwise others intraoperative and postoperative complications were comparable in both procedures. Laparoscopic hysterectomy is a real substitute for abdominal hysterectomy in a good proportion of gynecologic disorders in modern gynecological practice

Effects of a Muslim-style fast on blood sugar and hepatic glycogen levels in rats

Effects of a Muslim-like fasting scheme on blood glucose and liver glycogen was determined in rats. The fasting scheme consisted of periodic [12h] simultaneous food and water deprivation during the night, with free access to them in the day, for 1, 3, 10 or 21 days. Totally fasting rats showed lower fasting blood sugar than control rats [deprived of food only]. Glucose levels in totally fasting rats decreased as fasting days increased, they were 5.2 +/- 0.3, 5.05 +/- 0.2, 4.2 +/- 0.1 and 3.95 +/- 0.2 mmol/1 in 1, 3, 10 and 21 days of periodic total fasting. The glucose levels 4 hours after food in totally fasting rats were significantly higher than their matched fasting levels p