Day-case laparoscopic cholecystectomy

To assess the safety and feasibility of laparoscopic cholecystectomy as a day-case procedure. All consecutive patients who were admitted to the day-surgery unit for laparoscopic cholecystectomy at the Department of Surgery, King Saud Medical City, Riyadh, Saudi Arabia from July 2009 to June 2013 were considered for this retrospective study. The medical records were reviewed for age, gender, presenting symptoms, laboratory findings, imaging studies, American Society of Anesthesiology [ASA] grade, anesthesia, conversion to open cholecystectomy, complications, the operating surgeons, pain management, nausea, and vomiting, overnight stay, readmission, morbidity, mortality, and outpatient follow up were collected and analyzed. A total of 487 patients underwent laparoscopic cholecystectomy as a day case [ASA I=316, ASA II=171]. Surgery was performed by high surgical trainees [HSTs] [n=417] and consultants [n=70] with conversion to open cholecystectomy in 4 patients. Twenty-two [5%] patients were admitted for overnight stay for different reasons, while 465 [95%] patients were discharged before 8 pm. Two patients [0.4 %] were re-admitted to the hospital due to abdominal pain. Five patients developed umbilical port site infection [1%]. A total of 443 patients were satisfied [97%], while 14 [3%] were unsatisfied. There was no mortality or intra-abdominal septic collection. Day-case laparoscopic cholecystectomy is safe and feasible with optimal patient selection, education, and planned postoperative antiemetic and analgesia management

Early endoscopic retrograde cholangiopancreatography in mild gallstone pancreatitis with deranged liver function test. A 7-year experience in central Saudi Arabia

To determine the use of liver function tests [LFTs] as a selection tool for preoperative endoscopic retrograde cholangiopancreatography [ERCP] in patients with mild gallstone pancreatitis. All patients admitted with mild gallstone pancreatitis with deranged LFTs in King Saud Medical City, Riyadh, Kingdom of Saudi Arabia between January 2006 and February 2013 were studied retrospectively. Patients' demography, symptoms, laboratory values, imaging studies, ERCP findings, complications and its treatment, surgical intervention, intraoperative and postoperative findings, mortality, and outpatient follow up were collected and analyzed. A total of 245 patients were admitted as mild gallstone pancreatitis with admission day deranged LFTs. Pre-operative ERCP was performed in 74 patients based on admission day LFTs [Group A]. Endoscopic retrograde cholangiopancreatography was normal in 65 patients, revealed stones in 5, and sludge in 4 patients. Six patients developed ERCP complications. Endoscopic retrograde cholangiopancreatography was deferred in 171 patients [Group B] until the LFTs were repeated in 3-4 days. Liver function tests remained persistently high in 8 patients. They were submitted to preoperative ERCP, which revealed stones [n=5] and sludge [n=3]. Patients with normalized LFTs [n=163] were not submitted to ERCP. Three of them developed gallstone related complications. Patients admitted with predicted mild gallstone pancreatitis, deranged LFTs, and no evidence of cholangitis should not be submitted to ERCP unless a repeat LFT within 3-4 days shows persistently deranged LFTs. This will reduce unnecessary ERCP and its complications

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

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

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

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

Surgical management of colonic volvulus during same hospital admission

To study the local patient profile, diagnostic methods, and treatment outcome in patients with large bowel volvulus to recommend a management plan. A retrospective study of patients record with a final diagnosis of large bowel volvulus treated at King Saud Medical Complex, Riyadh, Saudi Arabia between January 2000 and December 2007 were performed for patient demography, clinical presentations, co-morbidity, diagnostic methods, anatomical types, management, and outcome. Forty-two patients with large bowel volvulus were reviewed. They represented 8.5% of all intestinal obstructions treated. Most had sigmoid volvulus [83%], were less than 60 years of age, and were male. Recognized risk factors were present in 12 [29%] patients. Diagnosis was suspected on plain abdominal x-ray in 28 patients [69%], although the characteristic signs of omega and coffee bean were seen in only 16 patients. Eight patients required emergency surgery. Endoscopic decompression was successful in 34 patients, followed by a definitive surgery in 24 patients. Seven patients refused surgery; 3 of them were readmitted with recurrence and were operated. Three patients were unfit for surgery. There were 3 deaths. Large bowel volvulus is uncommon in this area. Abdominal distension with pain, constipation, and characteristic gas pattern in plain x-ray can help diagnose most cases. Decompression can be achieved in most patients with sigmoid volvulus, followed by surgery during the same hospital admission. Transverse colon and cecal volvulus usually need emergency surgery

Management options in civilian anorectal injuries

This study aims to analyze our experience in the management of anorectal injuries with a particular reference to the use of rectal wall repair, diverting colostomy, distal rectal washout andpresacral drainage. The management of 26 patients with anorectal injuries treated at Riyadh Central Hospital, over an 8 year period [1997-2004] was reviewed. There were 15 patients with extraperitoneal injuries. Transrectal repair was possible in 12 patients, diverting colostomy was carried out in 7 patients, distal washout in 4, and none had formal presacral drainage. There were 8 patients with intraperitoneal injury. All were repaired through laparotomy, only 4 patients had diverting colostomy None were treated by either distal washout or presacral drainage. Three patients had an anal sphincter injury treated by sphincter repair and diverting colostomy and perineal drainage. There -was no mortality related to anorectal injuries in our study. We conclude that most anorectal injuries in our civilian practice are due to low velocity firearm injury or non firearm injury which produced less devastating injuries. Intraperitoneal rectal injury can be managed by rectal wall repair and that diverting loop colostomy should be performed only if there is gross peritoneal contamination. Extraperitoneal injury can be repaired if accessible, colostomy is indicated for high grade injury and if rectal wall repair is not possible. Most civilian rectal injuries can be managed without routine use of distal rectal washout and presacral drainage

Outcome of nonoperative management of blunt liver trauma

To evaluate our experience with the management of blunt liver trauma at Riyadh Central Hospital, Kingdom of Saudi Arabia. The hospital records of 68 patients treated for blunt liver trauma at Riyadh Medical Complex over a 5-year period [1997 through to 2002] were reviewed retrospectively. Patients who were hemodynamically unstable or had peritonitis were treated by urgent laparotomy [operative group]. The other group of patients were treated conservatively as they were hemodynamically stable [nonoperative group] in the intensive care unit [ICU]. All patients had computed tomogram of the abdomen with oral and intravenous contrast. Injuries grades were classified according to American Association for the Surgery of Trauma [AAST]. Follow up computed tomogram of the abdomen was performed in 1-2 weeks time. A total of 68 patients were treated over a 5-year period. Thirty-three patients [49%] were treated by immediate surgery. Hepatorraphy was performed in 22 patients, non anatomical resection in 3 patients and liver packing in 2 patients to control bleeding. No active bleeding was found in 8 patients. Nonoperative group [n=35, 51%] were managed in the ICU for close monitoring. Surgically treated group had more patients with complex liver injury [30% versus 11%], required more units of blood [3.2 versus 2.1] but had a shorter hospital stay [9 days versus 12 days]. Two patients for nonoperated group develop complications [biloma: one patient, infected hematoma: one patient], the nonoperative treatment failed in one patient who required laparotomy due to rebleeding from grade IV liver injury with failure rate of 3%. The only mortality [one patient] was in the operated group. The nonoperative treatment is a safe and effective method in the management of hemodynamically stable patients with blunt liver trauma. The nonoperative treatment should be the treatment of choice in such patients whenever computed tomogram and ICU facilities are available. However, further studies with larger number of patients are needed to support our results

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

Assessment of indicators for predicting choledeocholithiasis before laparoscopic cholecystectomy

The objective of this report was to study the sensitivity of indicators used for predicting bile duct stones and their endoscopic removal before laparoscopic cholecystectomy. A retrospective study was conducted on 104 patients who successfully underwent endoscopic retrograde cholangiopancreatogram [ERCP] before laparoscopic cholecystectomy at Riyadh Medical Complex between 1992 and 1994 [1412H-1414H]. Six indicators: jaundice, biliary pancreatitis, stones in bile duct on sonography, dilated bile duct [>7 mm] on ultrasonography, dilated bile duct with deranged liver function test, and deranged liver function test without jaundice were used for suspecting choledocholithiasis and endoscopic removal before laparoscopic cholecystectomy. Ultrasound correctly predicted bile duct stone in 75%, followed by dilated bile duct with deranged liver function test [46%]. Clinical jaundice and biliary pancreatitis were equally sensitive indicators [42% each]. Sensitivity of only dilated bile duct on ultrasonography in predicting duct stone was 36%. Deranged liver function without jaundice was the least sensitive [22%] of the predictors. Overall, these indicators correctly diagnosed bile duct stones in 34% of patients. Until laparoscopic exploration of bile duct or a noninvasive technique, such as magnetic resonance cholangiopancreatogram [MRCP], is widely available, these predictors will help in selecting patients with bile duct stones for preoperative removal. Other workers have suggested combining these indicators to improve the predictive value

Pancreatic pseudocyst: a review of 5 years' experience

This retrospective study reviews our five-year experience with the management of cases of pancreatic pseudocyst. The etiological pattern, clinical presentation, diagnostic methods, and therapeutic measures are described. Biliary pancreatitis was the leading cause in our series, accounting for 45% of the cases. The majority of patients [69%] presented with acute pancreatitis, and pseudocyst subsequently developed during hospitalization. Twenty-one percent presented with developed pancreatic pseudocyst associated with recurrent abdominal pain. No mass was palpable in 48% of the patients. Ultrasonography and computed tomographic [CT] scanning were the two most useful investigations, yielding correct diagnosis in 95% and 100% of the cases, respectively. The pseudocyst completely resolved in 24% of the patients. Patients who presented with acute pancreatitis were initially treated conservatively until the cyst was mature enough for surgical intervention. Those who presented with well-developed cysts were operated on much earlier, after a mean period of 16.5 days. Internal drainage was used in 52% of the patients. The main complications were chest infection [31%] and wound infection [9.5%]. The overall mortality was 5%

Is prophylactic antibiotic justified for routine cholecystectomy?

The routine use of prophylactic antibiotic in low risk cholecystectomised patients remains controversial. Two hundred patients were included in this prospective study, after exclusion of all identifiable risk factors. Half of them were randomly selected to be treated with antibiotics and the other half acted as controls and were not given any antibiotic. Only 2.5% of the patients needed exploration of the common bile duct. Bile culture was positive in 30.5%. The commonest organism isolated was E. coli. Eight out of the 200 patients developed wound infection, 5 from the antibiotic and 3 from the control group. As the high risk group of patients can be identified pre-operatively, routine use of antibiotic cover in low-risk patients is unnecessary