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

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

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

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