Right hypochondrial abscess: A rare consequence of supportive cholecystitis.

INTRODUCTION: Spontaneous cholecystocutaneous abscess is an extremely uncommon complication of acute suppurative cholecystitis. Over the past century very few cases of spontaneous cholecystocutaneous fistulas have been described in the medical literature. We, here, report a case of abdominal wall abscess secondary to cholecystocutaneous fistula. CASE REPORT: A 78 -year-old male presented as an emergency with a 2 days history of fever, malaise and a right subcostal mass. CT scan of abdomen showed huge abdominal wall abscess communicating intraabdominally to subhepatic area related to gallbladder. CONCLUSION: A high index of suspicion is necessary to diagnose this entity preoperatively and to avoid associated morbidity.

Improvement of psychometric properties of the objective structured clinical examination when assessing problem solving skills of surgical clerkship.

OBJECTIVE: To improve the psychometric properties of the objective structured clinical examination (OSCE) and elevate staff motivation. METHODS: The OSCE was conducted in May 2006 at the Department of Surgery, King Saud University, Riyadh, Saudi Arabia as a pilot study for 95 students split over 2 consecutive days lasting 120 minutes each day. There were 15 actual stations on each day consisting of 10 stations that addressed problem solving skills, and 5 addressed clinical skills testing. RESULTS: The stability of the OSCE measured by Cronbach's alpha on day one was 0.87, and 0.88 on day 2. The internal consistency of the OSCE measured by Carmine's theta on day one was 0.76, and 0.79 on day 2. Overall, OSCE's reliability for each day was high (r=0.8), without a significant difference between the 2 days. Credibility and comprehensiveness of the the OSCE were considered good by both staff and students. Accuracy of the OSCE measured by Pearson's correlation with multiple choice question scores was 0.65. Feasibility of the OSCE has also improved remarkably compared with previous OSCEs. CONCLUSION: The OSCE proved to be highly reliable, and a valid format when more problem solving skills testing has been emphasized for the final year surgical clerkship. Feasibility has also improved remarkably after using this strategy, marked by more staff participation and enthusiasm.

The use of 0.2% glyceryl trinirate oinment for anal fissures.

AIM OF THE STUDY: To assess the clinical efficacy of 0.2% glyceryl trinitrate ointment in the management of acute and chronic anal fissures. PATIENTS AND METHODS: A prospective clinical study conducted on consecutive patients presented to the surgical clinic of King Khalid University Hospital, Riyadh with acute and chronic anal fissures, from January to December 2003. These patients were treated with topical 0.2% glyceryl trinitrate paste in soft white paraffin three times a day. Patients were examined at regular intervals to evaluate the fissure status, adverse reactions, symptomatic control and recurrence. RESULTS: This study comprised 121 patients, six of them were lost to follow-up and 109 (94.7%) of the remaining 115 patients were cured. Of those cured, 13 patients (11.3%) presented with acute and 102 (88.7%) with chronic fissures. There were 98 male and 17 female patients with median age of 41 years (range, 14-70 years). Complete symptomatic relief was achieved in all patients within one month of therapy. Two patients, with chronic anal fissures presented with recurrent symptoms within one month of the completion of therapy both of them were successfully treated with repeat glyceryl trinitrate course. Treatment had to be terminated in six (5.2%) patients: five (4.3%) experienced intolerable adverse effects and one (0.8%) patient failed to respond. All these patients were successfully treated with lateral internal sphincterotomy. No patient complained of change in continence. CONCLUSION: Glyceryl trinitrate ointment produces adequate symptomatic control and healing of the anal fissures and can be considered as one of the recommended treatment options.

Laparoscopic cholecystectomy for acute cholecystitis. Can preoperative factors predict conversion?

OBJECTIVE: To determine if preoperative clinical, laboratory and radiology data can predict conversion of laparoscopic cholecystectomy for acute cholecystitis to open procedure. METHODS: Retrospective analysis of 44 laparoscopic cholecystectomies were performed for acute cholecystitis between August 2000 and July 2002 at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia. Data related to age and sex of patients, maximum body temperature, white blood cell count, gallbladder wall thickness on ultrasonography and timing of surgery from onset of symptoms were collected. RESULTS: The procedure was converted from laparoscopic to open cholecystectomy in 10 patients (23%). Conversion rate was significantly high (33% versus zero; p=0.01) if the gallbladder wall was thickened. Conversion rate was significantly low (zero versus 32%: p=0.01) if the procedure was performed within 48 hours from the onset of symptoms. The data related to age, sex, white blood cell count and body temperature did not reliably predict conversion of laparoscopic cholecystectomy for acute cholecystitis to open procedure. There was no mortality or major morbidity. CONCLUSION: Laparoscopic cholecystectomy is a safe modality of treatment for acute cholecystitis. Factors associated with increased conversion rate are thickened gallbladder wall on ultrasonography and delay in surgery for more than 48 hours from the onset of symptoms.