Role of descending venography and endovenous embolization in treatment of females with lower extremity varicose veins, vulvar and posterior thigh varices

To evaluate the prevalence of refluxing pelvic veins among female patients with lower extremity varicose veins and the role of embolization treatment in these cases. Of 158 female patients suffering from primary varicose veins of the lower extremities presented to the Venous Disease Clinic at Dhahran Health Center between January 2002 and December 2004, 25 patients [15.8%] were noted to have vulvar or postero-medial thigh varices or both. Those were referred for trans-jugular descending pelvic venography with or without subsequent embolization of the contributing refluxing veins. Venous reflux contributing to the vulvoperineal or posterior thigh varices was detected in 23 patients [92%] on catheter venography. Left ovarian venous reflux was responsible for 60% of all cases. Embolization, using multiple coils, was successful in 18 patients with positive reflux [78.3%]. One patient had primary vulvar venous malformation that required additional percutaneous sclerotherapy using dehydrated ethanol. Four patients had femoro-saphenous reflux contributing to the varices and required subsequent surgical ligation excision. All treated cases showed significant improvement of their symptoms without any procedure related complications. In patients with vulvar or postero-medial thigh varicose veins, radiological study of ovarian and hypogastric venous reflux should be considered. Trans-jugular descending venography and embolization is a feasible, effective and safe diagnostic and therapeutic modality

Obesity, is it an indication or contraindication for laparoscopic appendectomy?

Laparoscopic appendectomy [LA] has been associated with a faster recovery and less postoperative pain than the open appendectomy [OA]. The aim of this study was to assess the influence of obesity [body mass index, BMI> 25] on the outcome of laparoscopic versus open appendectomy. The records of 302 patients who underwent appendectomy for acute appendicitis [open or laparoscopic] between January 2002 and December 2004 were reviewed. Eighty-seven obese patients [BMI >/= 25] were classified into LA group. [19 patients] and OA group [86 patients]. Comparison between the patients groups and their non-obese counterparts included the age, sex, pathology of the appendix, anesthesia and operative time, complications, conversion from laparoscopic to open technique, length of hospital stay and postoperative full recovery time. Obese patients had significantly higher age [30 and 41.7 years for LA and OA groups, respectively] than non-obese patients [14.9 and 24.9 years for LA and OA groups respectively]. P< 0.01 In OA, the operating time for obese patients was significantly longer than that for non-obese patients [54 vs. 34 mm, p< 0.001]. In LA, there was no difference in operating time between the normal and overweight patients. Obese patients who underwent LA had longer anesthesia times than their OA counterparts [112 vs. 73 mm, p<0.01]. However this was not related to prolonged operating time [68 vs. 54 mm, p= 0.11]. Obese patients who underwent OA had significantly greater pain than those treated with LA [p< 0.05]. There were no significant differences between the two operating techniques in terms of complications. Hospital stay was longer for obese patients than for normal weight patients undergoing OA [4 vs. 2, p < 0.01]. Time to full recovery was greater in overweight patients subjected to OA than in the overweight patients in the LA group [21 vs. 15 days, p < 0.001]. We suggest considering overweight [BMI > 25] an indication rather than contraindication for laparoscopic appendectomy

Endoscopic vs. percutaneous inguinal field block [IFB] for postoperative pain control after total extra-peritoneal [TEP] inguinal hernioplasty

Despite the proven merits of using inguinal field block in open hernia repair, there is little data examining its use in laparoscopic hernioplasty. Interestingly, complete field block can be approached endoscopically with minimal hazards. The objective of this prospective randomized study is to compare the outcome of two different approaches of inguinal field block [IFB] for postoperative pain control following endoscopic total extra-peritoneal laparoscopic [TEP] inguinal hernioplasty. Between January 2001 and December 2003, a total of 77 male patients attending Dhahran Health Center, underwent unilateral endoscopic TEP hernioplasties, were randomized to receive either preoperative percutaneous IFB [group A, n = 38] or intraopertive endoscopic IFB [group B, n = 39]: using 50 mls of levobupivacaine [0.25%]. Postoperative pain was assessed by visual analogue score on a scale from 0 to 6. The intraopertive anesthetic requirements, time from end of surgery till extubation, postoperative narcotic analgesia requirement; length of hospital stay and return to full activity were compared among the two groups. Comparison between the two groups showed that patients in group A had significantly less requirements of intraoperative [Fentanyl, analgesia 65.2 +/- 16.8 [micro g] and shorter recovemy time 7.3 +/- 1.7 [min] than patients in group B [98.4 +/- 27.9 [micro g and 8.4 +/- 2.l [min]]. Postoperative pain scores were slightly higher in group A in the first 4-6 hours [p = NS]. Postoperative IV morphine requirement was significantly higher in the first 12 hours [Day surgery cases] in group A [13.2 +/- 3 mg] than in group B [9.2 +/- 2.5 mg]. This difference was not significant among patients hospitalized within the next 24 hours. Almost one third of the patients were able to go home on same day of surgery [11 in group A and 15 in group B, p= NS] Inguinal field block for TEP hernioplasty provides merits for the patients regarding the postoperative pain control and short hospital stay. However, endoscopic IFB was shown to have better control of postoperative pain than the percutaneous IFB during the first 12 hours

Carotid endarterectomy the influence of the standard surgical technique on the outcome of surgery

Carotid endarterectomy has been validated as effective therapy for both symptomatic and asymptomatic carotid stenosis. However, many aspects of this procedure remain controversial. This retrospective study was carried out to test the influence of standardization of the surgical technique on the final outcome. During the last 5 years, at Dhahran health center, we have been utilizing internal shunting and patch angioplasty as a routine practice and on selective basis as previously practiced in the previous 5 years experience. Computerized charts and medical records of cases underwent CEA between 2000 and 2004 were reviewed. The patient data and procedure outcome were compared with our initial reported experience between 1994 and 1999. Thirty-four patients underwent 37 carotid endarterectomies between February, 2000 and December, 2004. There was no significant change in our population demographic data, underlying risk factors or the indications for the surgery. The overall stroke rate was 5.4% [2 cases] and mortality was 2.7% [one patient]. None of the patients developed postoperative cardiac events, wound infection or cranial nerve injury. The overall operative complication was significantly lower in the past 5 years than previously reported from the same institute, 5.9% and 25.7% respectively [P< 0.05]. Conclusions: Over the past 5 years of our experience there is a trend towards improved outcome of CEA with standardization of a surgical technique that is mastered by the surgical team

Incidental appendectomy during laparoscopic cholecystectomy in children with sickle cell disease and symptomatic gallstones retrospective comparative case-control study

Laparoscopic cholecystectomy [LC] has become a standard treatment for symptomatic gall stones in children and adolescents with sickle cell disease. Incidental appendectomy has been advocated during LC in order to avoid the diagnostic dilemma of differentiating surgical and medical causes of abdominal pain in this group of patients. To evaluate the impact of this proposal on the outcome of surgery; a 10 years retrospective case- control review was conducted on 106 sicklers below age of 18 years who underwent LC with or without appendectomy in the Eastern province of Saudi Arabia. The patients were divided into two groups; group I [LCA], included cases who had laparoscopic incidental appendectomy during cholecystectomy [51 cases] and group II [LC] included those who had laparoscopic cholecystectomy only [55 cases]. The groups were compared regarding the demographic and clinical patients data, operative time, conversion rate, postoperative morbidity and mortality, hospital stay and overall long term outcome. Seven out of the 106 cases were converted to open procedure [6.6%]. These cases had relatively higher morbidity [20 7%], mortality [1.8%.] and longer hospital stay [5.5 +/- 3.9] days. Other than the longer operative time in the LCA group, there was no statistical or clinical significant difference between the two groups regarding the short or long term outcome. When technically feasible, incidental appendectomy is recommended during laparoscopic cholecystectomy for.sicklers with gall stones and recurrent abdominal pain

Improved outcome of carotid endarterectomy: role of preoperative cardiac assessment

Thirty-five patients indicated for carotid enderterectomy CEA were exposed to a battery of noninvasive cardiac assessment including clinical history and examination [CE], treadmill exercise testing [TET], and myoview nuclear scanning [MS]. As' a gold standard reference technique, coronary arteriography was' per/armed for each patient after noninvasive evaluation. The sensitivity of CE was low [6/%], Treadmill exercise testing proved to be more sensitive [69%] and highly .specific [89%] but feasible only in [63%] with total accuracy of [77%]. Myoview .scanning demonstrated higher .sensitivity [87%] and less specificity [82%] with high feasibility [94%] and diagnostic accuracy [85%]. Thirteen patients [37%] required coronary revascularization prior to CEA; two of them were clinically classified at moderate risk with false negative TET and MS. There was no postoperative [one month] cardiac death and overall survival after 3 years' was 85.7%. Combined modality approach for cardiac risk assessment is reliable for identification of patients who will benefit from coronary revascularization prior to carotid endarterectomy, and may thus improve the perioperative outcome

Outcome of carotid endarterectomy with contralateral occlusion: role of selective shunting [original aricle]

A retrospective patient control group study was conducted to determine the perioperative risks and benefits of selective shunting for a specific group of patients who had undergone CEA contralateral to an occluded internal carotid artery. Ten patients who underwent CEA contralateral to the occluded internal carotid artery were compared to 26 control group patients who underwent CLI contralateral to a patent Internal carotid artery Selective shunting was used in two cases [20%] of the contralateral occlusion group and In 11 cases [42.3%] of the control group. P = 0.21. The overall perioperative death and stroke rate was 10% in the occluded group and I 1.5% in the control patient group. Carotid endarterectomy [CEA] is a highly beneficial procedure for stroke prevention In selected patients. This study investigates whether patients undergoing CEA with contralaleral occlusion experience a greater degree of perioperative complications than patients with patent contralateral carotid arterial systems