experience of laparoscopic sleeve gastrectomy in obese, morbidly obese, and super morbid obese patients

To report experience with laparoscopic sleeve gastrectomy [LSG] in obese, morbidly obese, and super morbid obese patients, and to evaluate comparative efficacy of LSG among these patient groups. A total of 147 patients underwent LSG between March 2008 and December 2011 at the Department of Surgery, King Saud Medical City, Riyadh, Kingdom of Saudi Arabia. Patients were grouped according to the preoperative body mass index [BMI] into obese [35-39.9 kg/m[2]], morbidly obese [40-49.9 kg/m[2]], and super morbid obese [>50 kg/m[2]]. Patients who did not have a regular follow-up [n=38] were excluded, and 108 patients were included in this prospective study. The mean total weight loss [TWL] among the super morbid obese group [41.31 +/- 21.23 kg] was statistically significantly greater compared to the obese group [24.31 +/- 13.00 kg, p=0.009] and morbidly obese group [26.81 +/- 15.56 kg, p=0.001]. The mean percentage excess weight loss [EWL] was clinically significant among obese [57.8%], morbidly obese [42.5%], and super morbid obese patients [45.7%], however, it was not statistically significant between the groups [F[2,105] =2.132, p=0.124]. There was no mortality; however, 6 major complications occurred including intra-abdominal collection with suspected leak, staple line bleeding, bowel ischemia, and inferior vena cava injury. Laparoscopic sleeve gastrectomy resulted in satisfactory and effective EWL in all 3 groups of obesity patients at 30-months follow-up

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

Extensive retroperitoneal hematoma in blunt trauma

To report our experience of managing extensive retroperitoneal hematoma [RH] in patients with blunt trauma and to determine any associated factors affecting causation and mortality. In this retrospective observational study, patients diagnosed with extensive RH following blunt trauma admitted to King Saud Medical Complex, Riyadh, Kingdom of Saudi Arabia between January 2004 and December 2009 were included. Patient data were explored for injury severity score [ISS], data were explored for injury severity score [ISS], associated injuries, location of hematoma, amount of blood transfusions, coagulation profile, operative management, hospital stay, and mortality. The outcomes in surviving and non-surviving patients were compared. Out of 290 patients presenting with RH, extensive RH was found in 46 patients [15.8%]. The overall mortality was 32.6%. The pelvis was the most frequent location of RH in combination with lateral and central zones [65.2%]. The lower extremity and pelvic fractures were the most common injury. Associated intra-peritoneal injuries were present in 39.1% patients. An exploratory laparotomy was performed in 58.7% patients [n=27]. A high ISS [55.95 versus 35.5, p<0.0001], abnormal coagulation profile [odds ratio [OR] 7.8, 95% confidence interval [CI] 1.974-30.932, p=0.005], and associated chest injuries [OR 5.94, 95% CI 1.528-23.19, p=0.014] were independent factors associated with mortality. Multiple musculoskeletal injuries in addition to intra-abdominal injuries and abnormal coagulation are major factors associated with the presence of extensive RH. High ISS, abnormal coagulation, and associated chest injuries are independent factors associated with mortality

Routine or selective interval appendectomy for non-surgically treated appendiceal mass

The purpose of this study was to evaluate the need for interval appendectomy after a successful conservative treatment of an appendiceal mass. This retrospective study was conducted on patients admitted with appendiceal mass at King Saud Medical City during between July-2004 to July-2009. Only patients who were successfully treated conservatively [non-surgical] were included in the study. Data on patient demography, clinical presentations, investigations1 follow up, relapse of symptoms and/or recurrent acute appendicitis were collected and analyzed. Seventy-three patients were successfully treated conservatively for appendiceal mass. After discharge from the hospital, all were followed up in an OPD clinic. Seven patients [9.6%] developed recurrent symptoms appendicitis and underwent appendectomy. Sixty six patients [90.4%] were discharged from the outpatient clinic as they remained asymptomatic. All were seen in OPD at least twice before discharge. At the time of data collection for this study, all of them were contacted and recalled for assessment in the outpatient department. Five patients [6.8%] had emergency appendectomy elsewhere after discharge from the OPD clinic. Overall, 12 patients [16.4%] needed appendectomy after a successful conservative treatment for appendiceal mass. Sixty one patients [83.6%] have remained asymptomatic since their discharge from the clinic. Routine interval appendectomy is unnecessary after a successful conservative treatment of an appendiceal mass. It should be recommended selectively to those who develop recurrent symptom or recurrent acute appendicitis

Impact of comorbidity on outcome among acute non-traumatic surgical patients. Evaluation of Charlson comorbidity index

To determine the prevalence of comorbid conditions among acute non-traumatic general surgery patients. To assess the impact of comorbidity on outcomes and evaluate the effectiveness of using Charlson comorbidity index [CCI] in these patients. All acute non-traumatic general surgery patients admitted to King Saud Medical Complex, Riyadh, Saudi Arabia, between January 1, 2007 and December 31, 2007 were included [n=1296]. Patient data were explored to record comorbidity, and the CCI score calculated. The length of hospital stay, post-operative complications and mortality were recorded as outcome measures. The outcomes in patients with comorbid conditions were compared with patients without comorbid conditions. We found one or more comorbid conditions in 31.9% [n=414] patients. The CCI score ranged from 1-8. All 3 outcome measures were recorded significantly higher in patients with comorbidity compared to patients with no comorbid condition; length of stay, 17.3 versus 10.6 days [p < 0.0001], post-operative complications 46.3% versus 31% [p < 0.0001], mortality 7.7% versus 4.4% [p < 0.0001]. Severe comorbidity as indicated by higher CCI score significantly correlated with length of stay, r=0.30 [p < 0.0001] and mortality, r=0.2645 [p < 0.0001]. Overall risk of mortality was 1.81 times higher with comorbidity [odds ratio 1.81, 95% confidence interval 1.087-3.012, p=0.0182]. Comorbidity caused increased hospital stay, post-operative complications, and mortality among acute non-traumatic general surgery patients. The CCI is a reliable comorbidity index, which can help in managing risks in surgical patients

Pseudomyxoma peritonei: presenting as a localized perforation of the cecum

Pseudomyxoma peritonei [PMP], also known as [jelly belly,] is a rare condition with mucinous material spread throughout the abdomen. It can arise from the appendix, colon, or even a teratoma. The documented incidence is one per million per year. We present a case report of an 80-year-old female patient presenting with PMP secondary to an appendicular tumor leading to localized infiltration, and perforation of the cecal wall. A review of the literature was carried out, with emphasis on various treatment options available for this rare condition

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

Spectrum of general surgical problems in the developmentally disabled adults

This study highlights the spectrum of general surgical problems necessitating admission on intellectually disabled adult patients. Problems encountered in the management and the ways to overcome various difficulties are highlighted. Prospective collection of data on 63 consecutive developmentally disabled adult patients admitted to the Department of General Surgery, Riyadh Medical Complex [RMC], Riyadh, Kingdom of Saudi Arabia for various indications from January 2000 through December 2004. Demographic details, clinical presentation, diagnostic modalities, associated physical and neurological disabilities, coexisting medical condition, treatment options, morbidity and mortality were analyzed. Various difficulties encountered during the management and mean to overcome these problems are addressed. Sixty-three patients accounted for 71 admissions. Mean age was 26.7 years with a male preponderance [4.25:1]. Fifty-four patients were admitted for various emergency conditions. History of pica could be obtained in 33% of the cases. Twenty-seven patients were admitted for acute abdomen. Volvulus of the colon [22.2%] and pseudo-obstruction [18.5%] were the most common causes of acute abdomen. Twenty-one patients were admitted with upper gastrointestinal bleeding. Reflux esophagitis was the most common cause of bleeding [62%]. Overall morbidity was 41% for emergency admissions and 22% for elective surgery. Hospital mortality was 21.4% for emergency surgery. There was no death in elective cases. Developmentally disabled patients comprise a special class of patients with peculiar management problems. The treating clinician should be aware of various unexpected conditions not found as frequently in the normal patient population. Apparent lack of pain does not exclude an acute emergency. Possible surgical condition should be suspected if there is vomiting, abdominal distension, fever, increased irritability of recent onset. Male gender and history of pica are added risk factors

Squamous cell carcinoma of colon and rectum

Primary squamous cell carcinoma SCC of the colon and rectum is a rare malignancy. Less than 100 cases have been reported in literature. We report 2 cases of pure SCC involving the rectum and sigmoid colon. A review of literature has been made starting from the first report in 1919 to the present. We have examined the theories regarding the etiology, available treatment modalities, and prognosis for this variant of colorectal carcinoma. We conclude that this tumor presents later than adenocarcinoma and follows an aggressive course. With a greater awareness among surgeons and pathologists, more cases may become known leading to a better estimation of prevalence and clinicopathological behavior of this tumor

Castleman disease presenting as obstructive jaundice

A 48-year-old Saudi male was admitted with features of obstructive jaundice. Endoscopic retrograde cholangiopancreatography showed stricture in distal common bile duct CBD. Computed tomography scan revealed lymphadenopathy along CBD and in porta hepatis. Cholangiocarcinoma, lymphoma or metastatic deposits were suspected but no definite preoperative diagnosis could be established. Laparotomy disclosed lymph node enlargement in porta hepatis and along the CBD and lesser curvature of the stomach. Triple bypass procedure was performed to relieve the obstruction. Pathological examination of the lymph nodes showed Castleman disease of hyaline vascular type

Outcome of laparoscopic cholecystectomy in acute cholecystitis

To evaluate the outcome of laparoscopic cholecystectomy in acute cholecystitis and to determine various preoperative risk factors predicting conversion to open cholecystectomy. Observational study. Department of Surgery, Riyadh Medical Complex, Riyadh, Saudi Arabia over 5 years period from June 1, 1997 to May 30, 2002. Consecutive patients admitted with clinical diagnosis of acute cholecystitis confirmed subsequently by abdominal ultrasonography and undergoing laparoscopic cholecystectomy during the same admission. Patients with symptoms of more than one week duration, or various uncontrolled co-morbid conditions requiring optimization before surgery were excluded. Parameters analyzed were morbidity, mortality, incidence and etiology of conversion. Various pre-operative risk factors predicting failure of laparoscopic procedure in acute cholecystitis were further analyzed. Statistical analyses were carried out employing Chi-square test, using IBM-compatible PC, utilizing SPSS 10.0 for Windows [SPSS Inc., Chicago]. Three hundred and eleven patients qualified the inclusion criteria. Mean age was 43.7 years with female to male ratio of 4.5:1. Majority of the patients [91%] were operated within 72 hours of onset of symptoms. Laparoscopic cholecystectomy was successfully accomplished in 86.8% cases. Out of the 41 converted cases, disturbed anatomy in the region of Calot's triangle was the most common cause of conversion observed in 41.5% patients. Male gender, age more than 65 years, very high leucocyte count, gallbladder wall thickness of more than 4 mm on ultrasonography and complicated disease were observed as most significant determinant for conversion to open procedure. Overall morbidity was 2.9% with no mortality. Laparoscopic cholecystectomy can be accomplished with minimal morbidity in acute cholecystitis. Knowledge of various factors predicting possible conversion helps in pre-operative selection and counseling for open procedure and early conversion to open technique, with further reduction in the overall morbidity of laparoscopic cholecystectomy

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

Outcome of laparoscopic cholecystectomy in acute biliary pancreatitis

To evaluate the efficacy, safety, and timing of laparoscopic cholecystectomy in the management of mild to moderate cases of acute biliary pancreatitis. The medical records of 158 patients admitted to Riyadh Medical Complex, Riyadh, Kingdom of Saudi Arabia [KSA] from July 1998 to December 2001 were retrospectively reviewed. Acute biliary pancreatitis was diagnosed in patients who presented with abdominal pain with serum amylase level 3 times the normal limits in the absence of hypercalcemia or hyperlipidemia and presence of gallstones on ultrasonography. Severity of the disease was assessed using Atlanta Symposium criteria. Preoperative endoscopic retrograde cholangiopancreatography [ERCP] was performed in 106 patients [74.6%] on selective basis. One hundred and eighteen patients underwent laparoscopic cholecystectomy after clinical and biochemical resolution of the attack. Standard 4-ports technique was used. Intraoperative and postoperative morbidity and mortality, and postoperative hospital stay were reported. Laparoscopic cholecystectomy was performed in 118 patients and it was possible in 110 cases [93.2%] after 3-8 days of admission. Preoperative ERCP was performed in 106 patients of mild to moderate acute biliary pancreatitis and common duct stones were retrieved in 19 cases [18%]. The procedure was converted to open in 8 cases [6.7%]. Postoperative complications were nausea and vomiting in 10, atelectasis in 8, chest infection in 3, and prolonged ileus in 2. The wound complication occurred in 4. One patient who had bile leak due to cystic duct stump avulsion at CBD junction was treated by endoscopic sphincterotomy plus stenting and another patient had partial CBD injury repaired primarily over a T-tube. Mean postoperative hospital stay was 2.4 days. One patient died due to uncontrolled arrhythmia and heart failure. Laparoscopic cholecystectomy can be safely performed for mild to moderate acute biliary pancreatitis after clinical and biochemical resolution of the attack during the same admission with acceptable morbidity and mortality rates. This strategy will lead to reducing the recurring acute biliary pancreatitis, number of admissions and hospital stay

Role of ultrasonography, computed tomography and diagnostic peritoneal lavage in abdominal blunt trauma

To compare the diagnostic accuracy of diagnostic peritoneal lavage [DPL], ultrasonography and computed tomography in the management of blunt abdominal trauma. A retrospective review of the charts of 233 patients with blunt abdominal trauma necessitating admission to Riyadh Medical Complex, Riyadh, Kingdom of Saudi Arabia was carried out over a 2 year period [January 2000 to December 2001]. The diagnostic yields of DPL, ultrasound and computed tomography were analyzed. The results were compared with findings on subsequent laparotomy or ultimate outcome, which continued in hospital observation and conservative management. Mean age was 23 years and 79% patients were male. Road traffic accident remained the most common cause [70%] and 56% patients had multisystem injuries. The sensitivity for DPL, ultrasound and computed tomography scans was found to be 98%, 96% and 98% with an overall accuracy rate of 92%, 95% and 99%. Diagnostic peritoneal lavage showed false positive results with retroperitoneal injuries and missed one small bowel injury and a pancreatic injury, and resulted in one catheter related bowel injury. Computed tomography scan was able to grade, quantify and localize the injury and helped in devising a successful management plan in 76.5% cases. Diagnostic peritoneal lavage is a promising bedside investigation, but is invasive with low accuracy for retroperitoneal injuries and high probability of nontherapeutic laparotomy with false positive results. The high sensitivity and accuracy rates of computed tomography justify its use in quantifying and estimating the grade of injury in order to select the appropriate management of trauma victims. Computed tomography is recommended as the initial investigation of choice in hemodynamically stable patients with blunt abdominal trauma

Management of gastrointestinal smooth muscle tumors: Seven years experience of a teaching hospital in Saudi Arabia

Gastrointestinal [GI] smooth muscle tumors are a group of intramural GI tumors formerly known as leiomyoma and leiomyosarcoma. This retrospective study was made to review our experience in surgical management of GI smooth muscle tumors. The clinical records for patients with GI smooth muscle tumors during 1993-1999 were reviewed. Ten tumors were located in stomach. Abdominal pain was the main presenting symptom followed by GI bleeding. The preoperative diagnosis wad made by enhanced computerized tomography [CI] on eleven patients out of thirteen, while upper GI endoscopy with biopsy identified six tumors out of thirteen patients had the test. Tumors were treated by conservative excision in four and radical excision in fourteen. Histology was leiomyoma in six patients [with mitotic figures <4 per 10 high power field] and leiomyosarcoma was found in twelve patients [with mitotic figures >4 per 10 high power field]. Median follow-up was 4 years. There was one recurrence for leiomyoma [size: 6cm]. All patients with leiomyosarcoma presented later with metastasis and died. Size and mitotic activity of tumors are the main determinant factors. Enhanced CT remains the proper diagnostic tool