Management of appendiceal abscess. a 10-year experience in central Saudi Arabia

To study the outcome of patients with appendiceal abscess [AA] following immediate operative and non-operative management in terms of complications and hospital stay. Medical records of all adult patients treated for AA between July 2002 and June 2011 in the Department of Surgery, King Saud Medical City, Riyadh, Kingdom of Saudi Arabia were reviewed. We identified 2 main groups of patients with the diagnosis of AA. The first group of patients were managed by CT-guided percutaneous drainage and parenteral antibiotics [non-operative management [NOM group]]. The second group were patients who underwent surgical intervention [operative management [OM]]. The outcome was determined in terms of complications, recurrence rate, and hospital stay. Eighty AA patients were managed during the study period. Forty-two patients [52.5%] received NOM, while 38 patients [47.5%] underwent immediate OM. The complication rate was significantly higher in the OM group compared with the NOM group [44.7% versus 11.9%; p=0.0012]. Successful NOM was achieved in 92.8% of patients. The overall mean hospital stay of the NOM group was 8.54 +/- 2.25, and the OM group was 10.86 +/- 4.32 days [p=0.003]. Non-operative management is associated with significantly lower complication rate and shorter hospital stay than OM

Extraskeletal osteosarcoma, telangiectatic variant arising from the small bowel mesentery

Extraskeletal osteosarcoma [EOS] is a highly aggressive and rare malignant soft tissue tumor, characterized by the production of neoplastic osseous tissue without attachment to the bone or periosteum. It rarely involves the visceral organs. Only 3 cases of mesenteric EOS have been reported in English literature. Here, we describe a male patient of 40 years, who was diagnosed to have EOS arising from small bowel mesentery This patient presented with lower gastrointestinal [GI] bleeding. Upper GI endoscopy and colonoscopy were normal. Computed tomography scan demonstrated a well defined multi-loculated mixed density mass lesion measuring about 13x7x7 cm in lower abdomen adjacent to small bowel loops with liver metastasis. Palliative en bloc resection of tumor with adjacent small bowel was performed. The histopathology revealed a telangiectatic type osteosarcoma of mesentery. Diagnosis of EOS, its management and the outcome in context of the current literature are discussed

Cholecystectomy without intraoperative cholangiogram in gallstone pancreatitis

To determine the long term outcome of cholecystectomy without intraoperative cholangiogram [IOC] in patients recovering from acute gallstone pancreatitis with normal preoperative liver function tests and imaging. The medical records of all patients who underwent cholecystectomy without IOC for gallstone pancreatitis at King Saud Medical City, Riyadh, Saudi Arabia between January 2005 and December 2009 were studied retrospectively. Patients with severe pancreatitis and those who had preoperative endoscopic retrograde cholangio-pancreatography [ERCP] were excluded from the study. Data on patients' demography, symptoms, laboratory findings, intraoperative and postoperative findings, length of hospital stay, and outpatient follow up were collected and analyzed. A total of 160 patients were treated for acute gallstone pancreatitis. Forty-four patients with preoperative ERCP [n=39], and severe pancreatitis [n=5], were excluded. The remaining 116 patients initially underwent conservative treatment followed by cholecystectomy without IOC. All were followed up for an average of 2-4 visits. Five patients [4.3%] were re-admitted with gallstone related bilio-pancreatic complications. They underwent ERCP and CBD stone clearance. Four patients were lost to follow up. The remaining 107 patients have remained asymptomatic 12-55 months after cholecystectomy. The incidence of bilio-pancreatic complications from unsuspected CBD stones in patients of biliary pancreatitis that underwent cholecystectomy without IOC is very low. Therefore, a routine IOC in these patients can be omitted safely

Pneumomediastinum, pneumothorax, and subcutaneous emphysema due to duodenal ulcer

The presence of pneumothorax, pneumomediastinum, or cervical subcutaneous emphysema due to perforated duodenal ulcer is a rare presentation. We report a 23-year man who showed bilateral cervical subcutaneous emphysema, pneumomediastinum, and pneumothorax with no respiratory abnormality. He was found to have active duodenal ulcers, but no detectable pneumoperitoneum or duodenal leal. A sealed perforation from the duodenal ulcers was suspected, and he fully improved after conservative management

Operative management of liver trauma: a 10-year experience ib Riyadh, Saudi Arabia

To analyze our experience and the outcome of operative management of liver trauma, and to suggest ways to improve the management of such patients. This retrospective study was conducted on patients admitted with liver trauma to King Saud Medical Complex, Riyadh, Kingdom of Saudi Arabia between January 1997 and December 2006. Only patients who underwent operative management were included in this study. Sixty-four out of 138 patients with liver injury were treated surgically. Most of the patients were young [mean 29.4 years], and male [84%]. Fifty-six patients sustained blunt trauma. Eight patients had grade I, 17 had grade II, 21 had grade III, 12 had grade IV, and 6 patients had grade V liver injuries. Hepatorrhaphy [n=28] was the most common surgical technique used followed by peri-hepatic packing [n=12], simple hemostatic measures [n=9], and non-anatomical hepatic resections [n=8]. Laparotomy was non-therapeutic in 7 patients [11%]. Liver injury related morbidity was 19%, and mortality was 11%. Hepatorrhaphy was the most common surgical modality employed to control bleeding. Peri-hepatic packing was used in unstable patients. In 25% of patients, bleeding had either stopped from the injured liver or needed only simple hemostatic measures

Inital factors predicting rebleeding and death in bleeding peptic ulcer disease

Bleeding peptic ulcer constitutes approximately half of the cases admitted with upper gastrointestinal bleeding. Although the bleeding episode stops spontaneously in most of them, rebleeding occurs in as much as 10-30% of them and has a mortality rate of 5-10%. In this study, we have evaluated the possible significant predictors associated with this adverse outcome. The records of 205 patients admitted to gastrointestinal bleeding unit [GIBU] in Riyadh Central Hospital, during the period May 1996 through to April 1999, with endoscopic confirmed diagnosis of bleeding peptic ulcer disease were reviewed for demography, clinical presentation, hematology, biochemistry, initial blood pressure, nasogastric lavage color, co-morbid disease and endoscopic findings. All the significant factors found initially [P<0.05] were entered into odds ratio and its 95% confidence interval and finally the unconditioned logistic regression model was used to find out the significant independent predictors for both rebleeding and mortality in these patients. The majority of patients [85%] were males and below the age of 60 [73%]. Duodenal ulcer was the source of bleeding in 84%. Endoscopy was performed in all patients within 24 hours of admission. Only 15% were actively bleeding at the time of initial endoscopy. Thirty-six patients [17%] rebelled, majority within 72 hours of initial hemostasis. Overall, 11 patients [5%] died, 6 of them were rebleeders. Initial presentation of systolic blood pressure <100 mm Hg, blood in nasogastric tube and visible vessel within the ulcer in endoscopy were independent predictors of rebleeding while initial systolic blood pressure <100 mm Hg and age >60-years were independent predictors of mortality. Improvement of outcome in patients with bleeding peptic ulcer disease can be achieved by early detection of those patients who are at risk of adverse outcome. Patients with the above mentioned independent predictors of rebleeding and mortality are best managed in the intensive care unit with endoscopic hemostasis and proton pump inhibitor [PPI] therapy for a minimum of 5- days of admission

Dual thyroid ectopia

Ectopic thyroid gland is a rare embryological fault of thyroid development. Dual ectopic thyroid is even more rare and only 8 cases have been reported in the literature. The author presents a case of dual ectopic thyroid in a 16-year-old boy with an anterior neck mass, which is gradually growing in size particularly in the last 2 years. The initial diagnosis was thyroglossal duct cyst. Thyroid function test revealed elevated thyroid-stimulating hormone. Ultrasound of the neck did not show thyroid gland in its normal pretracheal position. Thyroid scan [Technetium 99] revealed the diagnosis of dual thyroid ectopia [lingual and subhyoid]