Anesthetic implications of laparoscopic adrenalectomy in nephrotic syndrome

During the last two decades laparoscopic surgery has become a widely practiced procedure. Laparoscopic adrenalectomy for adrenal tumor excision is one of these new applications, The anesthesia implication are special in the presence of long standing essential hypertension and nephrotic syndrome with poly-pharmacy. Objectives. To report on the first anesthesia for laparoscopic adrenalectomy Security Forces Hospital [SFH] in Riyadh. Setting: Tertiary care SFH in Riyadh. Patient: A 58 years old Saudi woman diagnosed to have essential hypertension, nephrotic syndrome, NIDDM, and right adrenal tumor, with the provisional diagnosis of pheochromocytoma. Interventions: General anesthesia, Thoracic epidural, control of hypertension with both alpha and beta blockers, and selective SICU admission for monitoring and pain relief. Measurement and the Main Preoperative ultrasound and MRI, MIBG scan of the adrenals, catecholamines serum level, intraoperative direct cardiovascular pressure measurements using Swan- Ganz catheter and arterial line. Pain control using epidural narcotics, measurement of blood glucose, blood gases, urea, creatinine and electrolytes. Adequacy of ventilation monitored by capnography and pulse oximetry. The surgical procedure included right adrenalectomy and cholecystectomy. Anesthesia for laparoscopic. adrenalectomy has special problems to solve related to the pneumoperitonium effect, poly-pharmacy and the current disease state. The use of modern anesthetic agents, cardiovascular monitoring, ventilation and proper analgesia make the hospital stay short, morbidity and mortality minimal

Laparoscopic cholecystectomy: the first year experience

A total of 307 consecutive patients with symptomatic gallstones were admitted for cholecystectomy. Two hundred seventy patients [88%] were considered suitable for laparoscopic cholecystectomy. Forty-two of these [17%] were admitted on an emergency basis. The procedure was accomplished successfully in 246 patients [91%], while in the remaining 24 patients [9%], the attempt had to be abandoned and converted to open cholecystectomy. Postoperative complications, mostly minor, occurred in 22 patients [9%]. Suspected common bile duct stones were treated with endoscopic retrograde cholangiopancreatography [ERCP] prior to surgery. The mean operative time was 82 minutes and 70% of the patients were discharged home within 48 hours after surgery and more than 90% were sent home by the third postoperative day. The results suggest that laparoscopic cholecystectomy is feasible for the majority of patients with symptomatic gallstones

single gall bladder stone- Is it innocent?

At Security Forces Hospital, 692 consecutive patients underwent surgery for gallstone disease over a period of two years. Eighty of these patients had a solitary gallbladder stone. They are compared, by their presentation, operative findings, mortality and morbidity rates, with the remaining patients harboring multiple gallstones. The demographic data were similar in both groups; however, the frequency of developing mucocele, empyema, gallbladder perforation and postoperative complications were significantly higher in the group with solitary stones than those with multiple gallstones. Furthermore, the need for emergency surgical intervention and technically difficult surgeries were also more frequent in the single stone group. It appears that a solitary gallbladder stone is associated with increased risks more than multiple stones; hence, it may be justified to offer the patient with a solitary stone more attention and surgical priority

Bariatric surgery in Saudi Arabia

Obesity is an emerging health problem in Saudi Arabia. An increasing number of patients are being referred for surgical management of their obesity. Vertical banded gastroplasty [VBG] was performed on 39 patients as treatment for morbid obesity. The mean weight loss at one year [38 patients] was 39% in males and 33% in females. At four years [23 patients] the mean weight loss was 42% in males and 41% in female patients. The mortality rate was 2.5% while the failure rate reached 13%. Vertical banded gastroplasty is considered to be an effective treatment to achieve and sustain near ideal body weight in morbidly obese Saudi patients

Penetrating abdominal injury: toward more conservative management

Over a period of five years, 139 patients were admitted to general surgical wards at the Riyadh Central Hospital because of penetrating wounds to the abdomen. Of these, 56% of the patients sustained stab wounds and the remaining 44% were victims of gunshot or compressed air gun injuries. All patients were admitted initially for clinical evaluation and observation with the aid of a few diagnostic laboratory and radiology tests. Exploratory laparotomy was performed in 82% of the patients. The rate of negative findings at laparotomy was unacceptably high at 25%. Mortality and morbidity occurred only in the patients who underwent laparotomy. Of analysis of the data support adoption of a more conservative approach in the treatment of such patients, provided they are evaluated carefully and observed by experienced staff

Incidence of deep vein thrombosis after major abdominal surgery as observed in Saudi Arabia

The reported incidence of postoperative deep vein thrombosis [DVT] ranges from 3 to 47%. We were unable to locate any report in the literature regarding the incidence of DVT in the population of the Arabian peninsula. We therefore studied the incidence of DVT after major abdominal surgery as assessed by 125I fibrinogen scanning in 103 local patients. DVT developed in 14 patients [13.6%]. This is significantly lower than that reported from temperate regions. However, the morbidity rate among the DVT-positive group was high [21%]. Our findings suggest that prophylactic measures against DVT should be a mandatory feature of patients care

Obstructive jaundice due to tuberculous adenitis

Obstructive jaundice due to tuberculous adenitis is rare, and even rarer when the extrinsic compression of the common bile duct is due to an isolated lesion with no evidence of a primary focus elsewhere. A 27-year-old Yemeni male presented with obstructive jaundice. Extensive preoperative diagnostic measures failed to discover the cause of obstruction. Exploratory laparotomy revealed isolated tuberculous adenitis of peripancreatic lymph nodes, partial excision of which, with administration of antituberculous drugs, resulted in complete recovery

Routine or selective antibiotic prophylaxis in biliary surgery

The microbial flora of the bile were prospectively studied in 229 patients admitted for biliary surgery. None of those patients received any antibiotic before the bile specimens were obtained. Positive bile cultures were found in 89 patients [30%]. Aerobic organisms alone were isolated in 90% of those patients. The incidence of wound infection was significantly higher in the positive bile group, and serous postoperative complications occurred only in this group. To rationalize the use of prophylactic antibiotics in biliary surgery and to identify the groups of patients at risk, we correlated the positive bile cultures with certain clinical, biochemical, and radiological factors such as presence of cholangitis, dilatation of biliary ducts, diabetes, and age. The study concluded that prophylactic antibiotics should be administered to patients with one or more of the risk factors studies. This policy products 82% of the patients at risk and spares 70% of the patients with sterile bile from receiving antibiotics unnecessarily

Chronic acalculous cholecystitis

Chronic acalculous cholecystitis is a controversial disorder, and surgeons are reluctant to perform cholecystectomy in the absence of clear evidence of biliary calculi. This report describes the clinical picture, investigations, and results of cholecystectomy in 20 patients diagnosed as having chronic acalculous cholecystitis. All the patients had right upper quadrant pain, highly suggestive of gallbladder origin. In six patients ultrasonography and cholecystography were completely normal, two patients showed evidence of "biliary sludge" in the gallbladder, and in the remaining 12 patients, the sole abnormality was ultrasonographic demonstration of a thickened gallbladder wall. At assessment 1 year after cholecystectomy, 17 patients were completely relieved symptoms, two were improved, and only one patient failed to benefit. Despite the increasing sophistication of biliary tract investigative methods, the diagnosis of chronic acalculous cholecytitis remains predominantly clinical. In the presence of typical symptoms, and with exclusive of other upper abdominal pathology, cholecystectomy successfully relieves the majority of symptoms

Observations relating to the pattern of acute appendicitis in Saudi Arabia

This prospective study examines clinical and operative findings in two population groups of patients who underwent acute appendicectomy at the King Khalid University Hospital in Riyadh. Of the group of 100 Saudi patients, 77% presented with colicky pain, vomiting being an associated symptom in 59%, and 86% showed retrocaecal appendicitis. 80% of the group of 100 non-Saudi patients complained of colicky pain, with vomiting a feature in 61% but the appendix was shown to be retrocaecal in only 47%. Raised leucocyte counts were consistent with the diagnosis of acute appendicitis. Peritonitis was a finding in 5% of all patients, and the postoperative wound infection rate was 7.5%. The overall 'white' appendicectomy rate was 4.5%

Roux-en-Y diversion for bile reflux gastritis

Roux-en-Y diversion can prove effective in the surgical management of troublesome post-operative bile reflux gastritis. In nineteen patients here reported, diversion afforded complete symptomatic relief in 89%. The criteria for selection of patients and the method of the operative procedure are discussed

Experience with arteriovenous fistulas at the anatomical snuffbox for maintenance hemodialysis

The number of pastients requirining maintenance hemodialysis is increasing. Recently, I have introduced the technique of constructing the arteriovenous fistula in the anatomical snuffbox. We have been very much impressed by the ease of the technique and its functional efficiency. The patients tolerated the procedure very well. In this paper, we describe the operative technique and our results in 10 fistulas constructed over the last 6 months