The Peri-operative Bariatric Surgery Care in the Middle East Region.

BACKGROUND: Bariatric surgery is common in the Middle East region. However, regional accreditation bodies and guidelines are lacking. We present the current peri-operative practice of bariatric surgery in the Middle East region. SETTING: Public and private practice in the Middle East region. METHODS: A questionnaire was designed to study trends of peri-operative care in bariatric surgery. It was sent to members of the Pan Arab Society for Metabolic and Bariatric Surgery (PASMBS). RESULTS: Ninety-three surgeons (88.6%) responded, 63.4% were in private practice, 68.5% have been in practice for more than 5 years, and 61.1% performed more than 125 cases per year. Laparoscopic sleeve gastrectomy (LSG) was the commonest procedure performed, then laparoscopic Roux-en-Y gastric bypass (LRYGB), one anastomosis gastric bypass/mini gastric bypass (OAGB/MGB), and laparoscopic adjustable gastric banding (LAGB). Pre-operatively as a routine, 65% referred patients for dietitian and (78.3%) for smoking cessation. In contrast as a routine, 22.6% referred patients to a psychologist, 30% screened for obstructive sleep apnea (OSA), and when they did, they did not use a questionnaire. For patients 50 years of age, 22% performed a screening colonoscopy and 33.7% referred patients to a cardiologist. Intra-operatively as a routine, 25.3% placed a drain and 42.2% placed urinary catheters. In contrast, 77.1% performed a leak test (82.7% as a methylene blue leak test). Post-operatively, 79.5% used chemoprophylaxis for venous thromboembolism and 89% required patients to take vitamins. In contrast, 25% prescribed ursodeoxycholic acid. CONCLUSION: The wide variation in the peri-operative care of bariatric surgery in the Middle East region highlights the need for regional guidelines based on international guidelines.

Congenital Morgagni's hernia: a national multicenter study.

BACKGROUND: Congenital Morgagni's hernia (CMH) is rare and represents less than 5% of all congenital diaphragmatic hernias. This is a national review of our experience with CMH outlining clinical presentation, methods of diagnosis, associated anomalies, treatment, and outcome. PATIENTS AND METHODS: The medical records of all patients with the diagnosis of CMH treated at four pediatric surgery units in Saudi Arabia were retrospectively reviewed for age at diagnosis, sex, presenting symptoms, associated anomalies, diagnosis, operative findings, treatment, and outcome. RESULTS: During a 20-year period (January 1990-December 2010), 53 infants and children with CMH were treated. There were 38 males and 15 females. Their age at diagnosis ranged from 1 month to 9 years (mean 22.2 months). Forty-three (81%) presented with recurrent chest infection. Twenty-two (44.5%) had right CMH, 15 (28.3%) had left-sided hernia and 16 (30.2%) had bilateral hernia. In 7, the diagnosis of bilaterality was made at the time of surgery. Associated anomalies were seen in 38 (71.7%). Twenty-one (39.6%) had congenital heart disease, 8 (15%) had malrotation, and 15 (28.3%) had Down syndrome. All were operated on. Twenty-nine (54.7%) underwent repair via an open approach. The remaining 24 (45.3%) underwent repair using minimal invasive surgery, laparoscopic-assisted hernia repair (19 patients) or totally laparoscopic approach (5 patients). At the time of surgery, the hernia sac content included the colon in 33 (62.3%), part of the left lobe of the liver in 13 (24.5%), the small intestines in 11 (20.75%), the omentum in 5 (9.4%), and the stomach in 4 (7.5%). In 12 (22.6%), the hernia sac was empty. When compared to the open repair, the laparoscopic-assisted approach was associated with a shorter operative time, an earlier commencement of feeds, less requirement for postoperative analgesia, a shorter hospital stay, and better cosmetic appearance. There was no mortality. On follow-up, 2 (7%) of the open surgical group developed recurrence. CONCLUSIONS: CMH is rare and in the pediatric age group commonly presents with recurrent chest infection and has a high incidence of associated anomalies, commonly congenital heart disease and Down syndrome. We advocate a laparoscopic-assisted approach to repair CMH. This is a simple technique that produces a sound repair, and when compared with the open approach it takes less operative time, requires less analgesia, allows earlier commencement of feeds, is associated with a shorter hospital stay, and has a better cosmetic outcome.

Strategy to combat obesity and to promote physical activity in Arab countries.

Obesity has become a major public health problem in the Arab countries, creating a health and economic burden on these countries' government services. There is an urgent need to develop a strategy for prevention and control of obesity. The third Arab Conference on Obesity and Physical Activity was held in Bahrain in January 2010, and proposed the Strategy to Combat Obesity and Promote Physical Activity in Arab Countries. This strategy provides useful guidelines for each Arab country to prepare its own strategy or plan of action to prevent and control obesity. The strategy focused on expected outcomes, objectives, indicators to measure the objectives, and action needs for 9 target areas: child-care centers for preschool children, schools, primary health care, secondary care, food companies, food preparation institutes, media, public benefit organizations, and the workplace. Follow-up and future developments of this strategy were also included.

Hepatobiliary anomalies in conjoined twins.

INTRODUCTION: Conjoined twinning is an extremely rare anomaly. Very few diagrammatic descriptions are provided for the various hepatobiliary anomalies seen in these twins. We aimed to review our experience with the various subtypes of hepatobiliary anomalies and their association with the inability to separate as well as provide diagrammatic descriptions of these anomalies. METHODS: We retrospectively reviewed our experiences within separating twins. We reviewed patterns of hepatobiliary anomalies and the required investigations and intraoperative workups. RESULTS: Of the 60 cases we evaluated, 28 were successfully separated. The reasons for nonseparation were possession of: a single heart, major communicating hearts, or major chromosomal anomalies. The liver was involved in 17 cases (60.7%) in the operative group and 23 cases (71.8%) in the nonoperative group. All cases had a computed tomographic scan and ultrasound as preoperative workup. Only 2 cases required a magnetic resonance cholangiopancreatography for preoperative evaluation. Intraoperative ultrasound was not used, and only 3 cases required an intraoperative cholangiogram. Diagrammatic depictions of the various categories of anomalies are presented. CONCLUSION: In our experience, we did not find hepatobiliary anomalies to be the sole reason for inseparability in any of the conjoined sets. Hepatobiliary anomalies seem to be more frequent in the nonseparable group.

Management of neonatal massive anterior mediastinal teratoma--a case report.

We report a challenging case of a newborn with a massive anterior mediastinal teratoma (MT), occupying nearly the right hemithorax, presenting at birth with life threatening respiratory distress (RD). Optimal approach and outcome was achieved with a coordinated, multidisciplinary approach.

Thoracoscopic division of vascular rings in infants and children.

OBJECTIVE: Traditionally vascular rings in infants and children are treated through an open thoracotomy. Recently, thoracoscopic surgery has been used for these complex procedures. This study reports our early experience with thoracoscopic division of vascular rings and evaluates the efficacy and safety of this approach. MATERIAL AND METHODS: Patients who underwent thoracoscopic division of vascular rings at King Khalid University Hospital, Riyadh, Saudi Arabia, from December 2004 to January 2006 are included. Their data were carefully analyzed looking at demographics, clinical presentation, diagnostic modality, type of the anomaly, operative details, complications, and outcome. RESULTS: A total of 9 patients underwent thoracoscopic division of vascular rings. Age at surgery ranged between 2 and 108 months (mean, 24 months). Weight varied between 5.3 and 32 kg (mean, 10.3 kg). All patients were symptomatic. Computed tomographic scan was diagnostic and accurately defined the type of anomaly in all the patients. Four patients had a right aortic arch with an aberrant left subclavian artery and left ductus/ligamentum arteriosum, 2 had double aortic arches, and 3 had a right aberrant subclavian artery. One patient developed right-sided pneumothorax on the contralateral site, and another one developed apnea 12 hours after surgery, requiring mechanical ventilation. There was no mortality. Operative time ranged between 50 and 145 minutes, the mean being 107 minutes. The average hospital stay was 4 days. Five patients had their preoperative symptoms completely resolved, and the rest are showing steady improvement. The average follow-up period is 6 months. CONCLUSION: Our early experience indicates that thoracoscopic division of vascular rings is safe and effective. Because it takes away the need for thoracotomy, it is likely that it can result in less postoperative pain and rapid convalescence. It also prevents the ill effects of thoracotomy and gives good cosmetic results.

Laparoscopic adjustable gastric banding in adolescent: safety and efficacy.

BACKGROUND: Obesity prevalence is rapidly increasing among children and adolescents worldwide. It is considered one of the most alarming public health issues facing the world today. The adult experience has demonstrated that surgery is the only effective means of achieving persistent weight loss in obese patients. However, little is known about bariatric surgery in children and adolescents. The aim of this study is to evaluate the safety and efficacy of laparoscopic adjustable gastric banding (LAGB) in this group of patients. METHODS: A retrospective review included all children and adolescents who underwent LAGB from January 2003 to December 2005. RESULTS: Fifty-one patients underwent LAGB. The mean age was 16.8 years (range, 9-19), and the mean body mass index was 49.9 kg/m2 (range, 38-63). Mean excess weight loss was 42% at 6 months and 60% at 1 year follow-up. The most prevalent comorbidities were obstructive sleep apnea, limited physical activities, hypertension, and diabetes mellitus. Band adjustments were performed under fluoroscopic guidance in 5 patients and direct access as a clinic procedure in the remaining. One patient required port repositioning under fluoroscopic guidance. The mean follow-up was 16 months (range, 3-34). There was no mortality or significant postoperative complications. CONCLUSION: The absence of significant nutritional deficiency, the continued adjustability, and potential reversibility of LAGB make it the safest, least invasive, and most effective bariatric surgery that can be offered to the young and adolescent population.

Laparoscopic appendectomy is a favorable alternative for complicated appendicitis in children.

Laparoscopic appendectomy in children is a generally accepted procedure for the treatment of non-complicated acute appendicitis. Nevertheless, the role of laparoscopy in complicated appendicitis is more controversial. The objective of this study was to examine the safety, efficacy and complications of laparoscopy in children with complicated appendicitis. This is a retrospective review of the children who underwent laparoscopic appendectomy for complicated appendicitis at King Khalid University Hospital, Riyadh, Saudi Arabia between January 1998 and March 2006. Complicated appendicitis includes perforated appendicitis, gangrenous appendicitis and appendicular masses found intra-operatively. Data collected include demographic, duration of symptoms, operative time, analgesia, complications, length of hospitalization and histopathology. Laparoscopic appendectomy was done by three trocar technique in all cases. During the study period, 59 children aged 3-12 years underwent laparoscopic appendectomy for complicated appendicitis. There were 34 patients with perforated appendicitis, 12 patients with gangrenous appendicitis and 13 patients with appendicular mass. The average operating time was 62 min. The average length of hospitalization was 5 days. The post-operative narcotic analgesic requirement was minimal. Laparoscopy was converted to open surgery in two patients (3.38%). These two cases were excluded from further analysis. Four out of 57 patients (7.01%) had post-operative complications. Three patients (5.26%) developed wound infection. One patient (1.75%) developed haematoma at umbilical port site. There was no post-operative intra-abdominal collection. Laparoscopic appendectomy is a safe alternative for the treatment of complicated appendicitis. It does not increase the incidence of complications even with complicated appendicitis. Contrary to the previous studies, we did not have increased incidence of intra-abdominal collection in this review. However, prospective randomized controlled trials are needed to verify these findings.

Minimal access surgery in neonates and infants.

BACKGROUND: Minimal access surgery (MAS) in small infants carries an important consideration. The tolerance of these small babies and the assumed physiological effect of MAS, in addition to the required anesthetic and surgical skills, have made it difficult to perform these types of procedures in many international centers. The present article reviews our experience with MAS in neonates and infants in the first year of life. METHODS: The medical records of all neonates and infants (<1 year) who underwent MAS over a period of 3 years were retrospectively reviewed for demographic information, procedures, operative time, complications, outcomes, and follow-up. Most of the operations were performed with 3-mm instruments and scopes and mean insufflation pressure of 10 mm Hg (range, 4-15 mm Hg). RESULT: Seventy neonates and infants were included in this study: 19 females and 51 males. The weight ranged from 1.3 to 8.2 kg (mean, 4.3 kg). The mean age was 93 days (range, 1 day to 12 months). Twenty-four (34%) were neonates (first 30 days of life). Procedures performed included repair of tracheoesophageal fistula, lobectomy, repair of diaphragmatic or hiatus hernias, pull-through for imperforated anus and Hirschsprung's disease, plication of the diaphragm, Kasai procedure, excision of choledochal cyst, pyloromyotomy, Ladd's procedure, and reduction of intussusceptions. There were 2 conversions, both in neonates with tracheoesophageal fistula. All patients tolerated the procedure very well, with lesser degrees in neonates undergoing thoracoscopic procedures. Two neonates had postoperative hypothermia (<35 degrees C) and 1 neonate had high PCO2 postoperatively. There was 1 mortality and no morbidities. The follow-up ranged from 1 month to 3 years (mean, 19 months). CONCLUSION: Minimal access surgery in neonates and infants is safe and well tolerated. Intraoperative monitoring of end-tidal CO2 and core temperature is essential in avoiding unwanted effects of performing these procedures, especially in neonates.

Traumatic pediatric bile duct injury: nonoperative intervention as an alternative to surgical intervention.

BACKGROUND: Nonoperative management of blunt pediatric liver injuries has become the standard of care in the absence of hemodynamic instability. However, associated bile duct injuries remain as difficult challenges. Few case reports have demonstrated the benefits of conservative approaches, but others have found better outcomes with surgical intervention. In this study, we report on our experience with interventional endoscopic and radiologic management of 5 pediatric patients with bile duct injuries who underwent unsuccessful surgical interventions. METHODS: We conducted a retrospective review of medical records of all pediatric patients who were admitted with major blunt liver trauma and bile duct injuries over a period of 5 years. RESULTS: There were 5 patients (4 boys and 1 girl) whose ages range from 3 to 11 years in this study. All patients had major liver laceration and bilomas. Two had intrahepatic and 3 had extra hepatic bile duct injuries (2 right hepatic ducts and 1 junction of cystic duct with common bile duct). All of them underwent previous laparotomies, once in 2 patients, twice in 2 patients, and thrice in 1 patient. All 5 patients were eventually treated successfully with interventional endoscopic and radiologic techniques. Three underwent endoscopic retrograde cholangiopancreatography stenting with percutaneous drainage. Two patients were managed with percutaneous drainage alone. The follow-up is up to 2.5 years with normal liver function test and bile duct ultrasound. CONCLUSION: With the current advancement in endoscopic retrograde cholangiopancreatography and intervention radiology techniques, we believe that interventional endoscopic and radiologic management of bile duct injuries caused by blunt trauma in children is successful and efficacious even after multiple laparotomies.

Thoracoscopic treatment of pulmonary hydatid cyst in a child.

Hydatid disease has a wide geographic distribution around the world. In human, the lungs are the second most commonly affected sites. Pulmonary hydatidosis is much more frequently encountered in children than in adults. Surgical treatment has remained the standard option in the management of hydatid disease. However, surgeons were able to replicate the principles of conventional surgery using minimally invasive techniques. Herein, we report a case of pulmonary hydatid cyst in a 9-year-old girl treated successfully using the thoracoscopic approach.

Endobronchial tumors in children: Institutional experience and literature review.

BACKGROUND/PURPOSE: Endobronchial tumors are rare in children and often misdiagnosed as benign conditions resulting in delayed definitive treatment. The authors reviewed their experience to highlight pertinent aspects of diagnosis and treatment. METHODS: A retrospective chart review was conducted of children with endobronchial tumors diagnosed between 1980 and 2002. RESULTS: Nine patients had endobronchial tumors (5 girls, 4 boys), with average age of 13 years (range, 8.5 to 15 years). There were 5 carcinoid tumors, 3 mucoepidermoid carcinomas, and one pseudotumor. Preoperative bronchoscopic biopsy confirmed the diagnosis in 6 patients, was inconclusive in one, and not done in 2. All except one (pseudotumor) underwent surgical resection. Laser ablation was performed in 2 cases with complete cure in one. All had an uneventful postoperative course except one patient in whom ipsilateral pneumonia developed. Long-term follow-up was obtained with clinical examination, pulmonary x-ray, abdominal ultrasound scan, chest computed tomography scan, and serum 5-HIAA in those with carcinoid tumor. Bronchoscopy was performed twice yearly for the first 2 years, then yearly. No evidence of local or distant recurrence was reported. CONCLUSIONS: Endobronchial lesions should be considered in children with persistent pneumonia despite adequate treatment or with undiagnosed respiratory symptoms. Prognosis is excellent with surgical resection. Specific follow-up protocol is recommended.

Lengthening technique for long gap esophageal atresia and early anastomosis.

BACKGROUND/PURPOSE: The treatment of long gap esophageal atresia remains a major surgical challenge. Whereas many approaches have been used for this problem, none are ideal. The authors used a technique originally described by Dr John E. Foker and accomplished early repair in 3 infants with long gap atresia. METHODS: Three infants with esophageal atresia underwent thoracotomy shortly after birth and had a long gap preventing primary anastomosis. External traction sutures were placed on each esophageal pouch and exteriorized through the thoracic wall. The esophageal ends were approximated 1 to 2 mm daily by traction on the sutures. Anastomosis was performed when the 2 ends came together. RESULTS: Three infants were included (31, 34, 37 weeks gestation, weights 1.38 kg, 1.9 kg, and 2.3 kg, respectively). The esophageal gaps were 3, 5, and 4.5 cm, respectively. Definitive anastomosis was performed at 14, 17, and 10 days, respectively. Two patients had anastomotic leaks that were treated conservatively. One patient had an esophageal stenosis that required dilatation. CONCLUSIONS: This technique allowed rapid esophageal lengthening in these 3 cases and led to early repair of long gap esophageal atresia, avoiding the need for a prolonged hospitalization or eventual replacement as well as long-term swallowing difficulties.