Critical limb ischemia: Revascularization options and clinical outcome

To study the various options of revascularization, mainly the role of Percutaneous Transluminal Angioplasty [PTA] in the treatment of Critical Limb Ischemia [CL1] and to assess the clinical outcome. A retrospective study was performed involving 109 consecutive patients [75 men and 34 women; mean age 59 years, range 45-87]. Fifty-nine patients were diabetic, and sixty-four smokers. Balloon angioplasty for critical limb ischemia was performed in 78 limbs, while Percutaneous Transluminal Angioplasty [PTA] and/or surgery in 34 limbs. Immediate and at one year outcome was examined by case note review to determine survival, amputation-free survival, and limb salvage. In the angioplasty, technical success was achieved in 66 [84%] out of 78 limbs, while in the combined PTA and/or surgery it was 22 limbs [65%] out of 34 limbs. The overall amputation rate was 22%. The follow-up period was 12 months. The overall in-hospital mortality was five patients [4.6%]. Eighty patients [74%] had their feet spared from major amputation as a result of revascularization. Only sixty-tow patients were available for follow-up which revealed that 84% of them were doing well 12 months after their revascularizations. Patients with an initially successful angioplasty had a good outcome. The results of this study justify the use of PTA as a first-line treatment for critical limb ischemia; technical failure does not preclude conventional surgery. CLI is highly prevalent among diabetes. CLI was significantly associated with diabetes, smoking, and gangrene. Educational programs and aggressive approach are highly needed to reduce the risk of amputations

Iatrogenic Gastric Dilatation: A Rare and Transient Cause of Hepatic-portal Venous Gas

Gas in the portal veins is rare and in most cases is associated with serious diseases and poor clinical outcome. A case of gas in the hepatic-portal veins with gastric dilatation, as shown by CT-scanning for abdominal trauma, is reported. The condition was clinically benign and resolved spontaneously. An abdominal CT scan documented the findings.

Expression of p21 and p27 in gallbladder cancer

To investigate the expression of p21 and p27 factors in gallbladder cancer [GBC], and to correlate their expression with clinicopathological parameters: age, gender, stage, invasion, and grade. Thirty-two surgically resected specimens were collected between 1994-2001 from different health centers in north Jordan. Tissues belong to 25 females and 7 males were examined immunohistochemically. The study took place in the Pathology Department, Jordan University of Science and Technology, Jordan. Levels of p21 were found in 75% and p27 in 25%. Furthermore, p21 was expressed in 50% of the specimens which are belong to patients with ages <64 years, whereas all specimens for ages >64 years have p21WAF1/CIP1 expression [p=0.001]. The expression of p21 between advanced stages [stages III and IV] was 89.5% and early stages [stages I and II] was 53.8% [p=0.031]. The p27 expression was markedly decreased in GBC cases [25%] and there were no significant correlation between p27KIP1 expression and all clinicopathological parameters including gender, World Health Organization grades, stages, and invasion, whereas the expression of p21 was 75% and there was a significant correlation between p21 and the clinicopathological parameters including gender, stages, and invasion

Unusual causes of mechanical small bowel obstruction

We herein report our experience regarding unusual causes of bowel obstruction to increase the awareness of surgeons regarding this disease. From 1991 to 2003, we had experience at the University affiliated hospitals, northern Jordan with 24 patients with small bowel obstruction resulting from unusual causes. We retrospectively reviewed the medical records of these patients with regards to the mode of presentation, cause of obstruction, radiological and operative findings, management and outcome. We recorded 15 patients who underwent previous abdominal surgery. Preoperative diagnosis was correct in only one patient with an internal hernia, but the abdominal CT scan suggested the diagnosis in 5 of the 9 patients who had the scan. The final diagnosis was internal hernias in 11 patients, foreign bodies in 5, ischemic strictures in 3, carcinoid tumors in 2, endometriosis in 2, and metastatic deposit from interstitial bladder carcinoma in one patient. Nine of the 12 patients with recurrent obstruction had either short course or recurrence obstruction during the same hospital admission. W carried out bowel resections in 15 patients [5 resections were due to bowel strangulation]. Post operative death occurred in 4 patients. Awareness of these rare causes of intestinal obstruction even in patients with previous abdominal operation might improve the outcome. The tentative diagnosis of adhesion obstruction in patients with unusual obstructive etiology might lead to a higher rate of gangrenous complications. Rigorous preoperative evaluation including careful history and early abdominal CT may show the obstructive cause

Ingested chicken bone leading to aorto-esophageal fistula

We report a 38-year-old male patient who was referred to King Abdullah University Hospital, Irbid, Jordan with massive upper gastrointestinal bleeding. The bleeding proved to be due to aorto-esophageal fistula caused by accidental ingestion of a chicken wing bone 10 days earlier. The patient died during a salvage thoraco-laparotomy. Primary aorto-esophageal fistula is a very rare but catastrophic condition that is frequently missed preoperatively. A high index of suspicion is needed for early diagnosis, which might improve the chance of survival

Male breast disorders in Jordan. Disease patterns and management problems

To highlight the features and management problems of male breast disorders in an eastern country such as Jordan. Data regarding 33 male patients who underwent surgery for breast diseases in the Department of Surgery at Jordan University of Science and Technology, Irbid, Jordan, between the year 1996 and 2002 were analyzed. Gynecomastia [45.5%], ductal carcinoma [18.2%], and lipoma [12.1%] were the most frequent lesions. Endocrine testing when the clinical diagnosis was physiologic gynecomastia was not yielding. Many features of male breast carcinoma in Jordan [symptomatology, male to female ratio, high education rate, age, diagnostic yield of fine-needle aspiration, histological type, and estrogen receptor status] did not depart from the experience of others. Delayed presentation is evident from the fact that 57% of tumors were stage III. Loco-regional control was achieved by modified radical mastectomy. Tamoxifen was used in 5 patients, and chemotherapy in 4 patients. The patient with stage I is still disease free 6 years after the diagnosis. The 5-year survival rate for stages II and III was zero. Rare lesions [cystic hygroma, cystic mastopathy, fibroadenoma, duct papilloma, tuberculosis, periductal mastitis, and the previously unreported primary primitive neuroectodermal tumor of the breast] accounted for the rest of the group. The patient with primary primitive neuroectodermal tumor of right breast was treated by mastectomy and adjuvant chemotherapy. He remains disease free 31 months after the diagnosis. Unawareness and the fact that male breast enlargement is considered a social stigmata are responsible for the delayed presentation. The value of fine needle aspiration cytology and mammography is not widely appreciated. The wide spectrum of potential pathologies calls for referring all patients to specialized breast units

clinical and epidemiological features of hydatid disease in Northern Jordan

To elaborate on the epidemiology of hydatid disease in Jordan as a model for the Middle East, and highlight the obstacles that face disease control in the region. The clinical and epidemiological data for 65 patients with the diagnosis of hydatid cyst [who were treated in the Department of Surgery, Jordan University of Science and Technology, Irbid and its affiliated hospitals, between January 1994 through to September 2003] were analyzed. Fifty-five patients were interviewed for details of life style. Forty-six% of patients were below 40- years of age. Fifty-seven% were females. All interviewed patients gave history of contact with dogs and history of ingestion of raw vegetable food. The latter in addition to a high zoonotic infection rate and uncontrolled animal movement were factors contributing to the high prevalence. Optimization of control programs in the Middle East requires the establishment of a regional center. Wide traveling has made it essential for physicians practicing in non-endemic areas to be aware of the diverse presentations of this disease when dealing with immigrants from endemic areas

Cryptorchidism and testicular neoplasia

Traditionally there is a concern about the possibility of developing testicular tumors as a consequence of undescended testis. This study was conducted to investigate the correlation between testicular tumors and undescended testis. Medical records of all patients with testicular germ cell cancer were seen and examined at the Princess Basma Teaching Hospital, Jordan University of Science and Technology, Irbid, Jordan, between 1990 and 2000 [group 1] for any evidence of undescended testis. All males with undescended testis attending the infertility clinic during the period 1999-2001 [group 2] were re-evaluated for any evidence of testicular tumors. The operative records of all patients who had surgery for undescended testis during the past 30 years [group 3] were reviewed and the patients were contacted to see if any of them developed testicular tumor as expected. Forty-four patients with testicular germinal cell tumors; mean age at diagnosis were 32.6 years [range 20-50] were identified. All patients had unilateral involvement and none of them were found to have tumors in undescended testis. The tumor was in the scrotum in all patients. None of the 117 infertile patients with undescended testis had clinical or ultrasonic evidence of testicular tumors. Two thousand nine hundred and nineteen patients had an operation for undescended testicle in the past 30 years, average of 97.3 operations annually. Median age at surgery for undescended testis was 7.7 years [range 2-29 years]. None of the 2071 patients who were traceable developed testicular tumor. We found no evidence to support that patients with undescended testis are at a higher risk than the general population to develop testicular cancer

Ureteric injuries during obstetric and gynecologic procedures

To review the ureteric injuries resulting from obstetric and gynecologic procedures with a comparative analysis of current pertinent literature. From January 1994 - December 1997, the medical records of all patients who sustained ureteric injuries as a result of obstetric or gynecologic procedures and managed at the Princess Basma Teaching Hospital, North of Jordan were reviewed. The clinical presentations, investigations, features of injury and treatment modalities were studied. There were 17 patients with 19 ureteric injuries incurred during obstetric or gynecologic procedures during the study period. Patients were relatively young and presented with loin pain. The left lower ureter was injured in 11 cases. Hysterectomy, alone, accounted for 13 injuries mainly in association with malignancy. Deliveries, in general, were associated with very low rate of injury. Ureteric ligation was the most common mechanism of injury [47%]. Injuries were intraoperatively recognized in 41.2% [7/17] of cases. Patients were treated by either endourological or formal surgical repair. The overall success rate after an average of 32.3 months of follow-up was achieved in 89.5% [17/19]. This outcome was not significantly altered by either the features of injury or by the treatment schedules. Iatrogenic ureteric injury is still a major cause of harm and concern. The time taken to detect the injury remains the most important morbidity-related factor. Recent trends towards earlier intervention and the use of various endourological means of repair deserve support and promotion

Abdominal wall endometriosis an overlooked diagnosis

To study the incidence of abdominal wall endometriosis after cesarean section and its presentation to the general surgeon. Fourteen patients were treated for abdominal wall endometriosis during the period June 1997 to May 2002 at Princess Basma Teaching Hospital and King Abdulla University Hospital, Irbid, Jordan. The patient's files were reviewed to see their way and time of presentation after cesarean section, provisional diagnosis made and operative procedures performed. Symptoms suggestive of and investigations carried out to detect pelvic endometriosis were also looked for and recorded. Fourteen patients were treated within 5 years; all had painful scar-related mass. The pain was exacerbating during menstruation in 5. The clinical diagnosis was stitch granuloma in 3; incisional hernia in 3, abdominal wall tumor in 3 and abdominal wall endometrioma in 5 patients. The mean time for the mass to be noticed by the patient was 2 years. They were treated with wide local excision. Histopathological examination proved the diagnosis of abdominal wall endometriosis. None had evidence of pelvic endometriosis and none of them had recurrence. The incidence of the disease is around 0.2% of the cesarean sections performed during the same period. The treating physician should keep in mind abdominal wall endometriosis as a possible cause of post cesarean section scar-related masses

Effort thrombosis of the subclavian-axillary vein

The aim of this study is to outline the clinical patterns, diagnosis and the outcome of patients with 'effort' subclavian-axillary vein thrombosis. The medical records of 7 patients diagnosed with 'effort' subclavian-axillary vein thrombosis between 1992 and 2000 at the Princess Basma Teaching Hospital, Irbid, Jordan were reviewed. Patients with secondary subclavian-axillary vein thrombosis [catheter related or secondary to thoracic outlet compression] were excluded. The clinical presentations of this condition were swelling, pain, and cyanosis of the upper limbs. The presence of dilated superficial vein is a late sign. All patients were treated by non-fractionated heparin continued with warfarin with a favorable outcome. Effort thrombosis of subclavian-axillary vein [Paget-Von Schroetter syndrome] is less reported in the literature contrary to secondary subclavian-axillary vein thrombosis. Early and effective anticoagulation constitutes the base of curative treatment. Prevention of recurrence is mandatory

Prevalence of helicobacter pylori in Northern Jordan-endoscopy based study

Helicobacter pylori infection is considered the most common infection worldwide and is associated with many other disorders. The aim of this study is to determine the prevalence of this infection among patients undergoing endoscopy in Northern Jordan. Between November 1998 and September 2000, all patients referred from the Gastro-esophageal Clinic to the Endoscopy Unit at Princess Basma Teaching Hospital, Irbid, Northern Jordan were enrolled in this prospective study. For each patient clinical and epidemiological data was collected and endoscopy was performed. At least 3 antral biopsies were obtained from each patient, and these were examined histologically for the presence of gastritis and stained for Helicobacter pylori using modified Giemsa stain. A total of 197 consecutive patients [113 females] with a mean age of 40.2 years [range 15-91 years] were studied. Abdominal pain was the highest presenting symptom. Gastritis 91% and esophagitis 42% were the most frequent endoscopic findings. Gastritis was documented histologically in 183 [93%] of patients. Helicobacter pylori was found in 161 patients [82%], with all of these having histological gastritis. The 11 patients with gastric ulcer, compared to the 51 out of the 59 [86%] patients with duodenal ulcer, showed Helicobacter pylori in their biopsies. The prevalence of Helicobacter pylori infection in patients subjected to an upper gastrointestinal endoscopy in Jordan is high. This study confirms that Helicobacter pylori is significantly associated with gastritis and peptic ulcer. Further studies are needed to determine the types of Helicobacter pylori strains present in Jordan