Traumatic diaphragmatic hernia: an Asir region (Saudi Arabia) experience.

Ten patients (nine males, one female), seen at the Asir Central Hospital of South-Western Saudi Arabia with proven traumatic diaphragmatic hernia between 1987 and 1997, were reviewed retrospectively. The mean age was 29.6 years, range 5 to 50 years. Chest pain and vomiting were the commonest symptoms. Blunt trauma (road traffic accident--5, fall from height--1, (accounted for 60% of the cases) while gunshot wound and stab wounds were the causes in two patients each. The chest radiograph suggested the diagnosis in all the cases. Barium meal (in two patients) and barium enema (in two patients) complemented the diagnosis. Computed tomography (CT) scan was done in only one patient. Thoracotomy (in 2 patients), laparotomy (in 5 patients) and thoraco-laparotomy (in 3 patients) were the surgical approaches to management. Common herniated organs were liver, stomach, spleen and large bowel. The injuries were on the left side in seven patients and on the right side in three cases. Immediate surgical repair was done in four patients while it was done two days to four years later in others. Complications were minimal and there was only one death.

Pathology of the appendix.

An audit of 3374 appendectomy specimens in 2578 Saudi and 796 non-Saudi nationals revealed a diagnosis rate of 74.7% of inflamed appendix, a normal appendix range of 7.8% to 22.5% with the higher rate of normal appendix found among females. The finding of high incidence of schistosomal appendicitis among Egyptian males is not surprising given the high incidence of schistosomiasis among Egyptians in general. The alternate diagnoses, which include such conditions as neoplasm, mucocele, other inflammatory conditions such as periappendicitis, and parasitic infestations, are not different from findings in the reported literature.

Bochdalek hernia in adulthood: a case report and review of recent literature.

A 37-year-old Filipino woman presented with a post road-traffic accident fracture of dorsal spine 12. Chest radiograph revealed evidence of loops of small bowel in the left lung field. She admitted to symptoms of respiratory insufficiency since birth and treatment for tuberculosis in childhood. A pre-operative diagnosis of left traumatic diaphragmatic hernia was not confirmed at laparotomy which revealed typical left congenital Bochdalek hernia with smooth edges and herniation of small bowel and spleen into the left pleural cavity. Following reduction and repair of the hernia, the patient made an uneventful recovery. Chest radiograph remains normal till now, eight years post-operatively.

Diffuse pulmonary calcinosis and multiple soft tissue calcification in renal failure patient with pathological femoral fracture.

The rare occurrence of diffuse pulmonary calcinosis is described with case illustration of a patient who presented with a pathological femoral fracture during end-stage renal failure. Associated metastatic soft tissue calcification with parathyroid hyperplasia requiring parathyroidectomy was observed. Roentgenologic evidence of hyperparathyroidism with osteitis fibrosa cystica and a high product of the calcium and phosphate values were indications for the parathyroidectomy. Recent literature review of pulmonary calcinosis and multiple soft tissue calcification is also presented.

Unusual presentations of injury to the bronchus with literature review.

Two patients with unusual presentation of injury to the bronchi are discussed. The first had a gun shot wound of the anterior left chest with the bullet ricocheting across to the right hemithorax and puncturing the right mainstem bronchus resulting in right massive pneumothorax and subcutaneous emphysema. The second suffered a blunt thoracic trauma from a road traffic accident and presented with bilateral rib fractures and bilateral pneumothoraces treated with bilateral closed thoracostomy tube drainage. Bronchofiberscopy revealed complete transection of the left mainstem bronchus.

Bronchial carcinoid tumours in southern Saudi Arabia.

Clinical presentation, pathology, surgical management and follow-up of ten bronchial carcinoid tumour (BCT) patients are described. There were five male and five female patients with age range between 5 to 85 years (mean 39.2 +/- 21.5, SD). Pathology revealed BCT on the right side in seven and on left side in three patients. The tumour was an incidental finding in four while the other six had respiratory symptoms. Cough was present in all of the later group and hemoptysis was present in four patients. Recurrent chest infections were seen in two patients. Symptoms ranged from 1 week to 15 years. Successful surgical resection was done in nine with the longest follow-up of 80 months (mean: 23 months +/- 26.3, SD) without recurrence or metastasis. Histopathological examination of these tumours revealed classical morphological features in all but one case. Grimelius stain positivity for argyrophilia confirmed the diagnosis in all the patients in this study. Electron microscopic examination was done in patient no. 9 which showed atypical morphological features and neurosecretory granules. BCT may present like pneumonias or bronchial asthma. Although BCTs have low-grade malignancy, early diagnosis and surgical resection yield curative results almost in all cases.

Spontaneous pneumothorax: A retrospective study of twenty-five patients and literature review.

We present a retrospective study of 25 patients with spontaneous pneumothorax (three current), comprising 16 Saudis (nine males and seven females) and nine non-Saudis (eight males and one female), seen at the Asir Central Hospital, Abha, over a period of 45 months. Almost one-third of the patients (9/25) had no underlying cause discernible by our investigational facilities (chest x-ray, ultrasonography, computed tomographic scan, and flexible bronchofiberscopy). Underlying pneumonia (three patients), pulmonary tuberculosis (two patients), lung abscess (one patient), and congenital bullae (one patient) constituted the etiology in another third of the spontaneous pneumothorax patients. Other underlying pulmonary diseases precipitating spontaneous pneumothorax in the group included pulmonary fibrosis, metastatic mesothelioma, and immunosuppression in a medulloblastoma patient undergoing chemotherapy with the development of chickenpox. Closed thoracostomy tube drainage was the only method of treatment in 20 out of the 25 patients, with three failures of closed thoracostomy tube drainage needing thoracotomy and resection of blebs/bullae. The only complication was empyema in two of the patients. Two patients were successfully treated conservatively with observation alone.

Empyema thoracis in adults in Saudi Arabia.

Empyema thoracis in adults is an uncommon disease in the Asir region of Saudi Arabia. In a period of seven years (1988 to 1994), 24 patients were treated for empyema thoracis with a hospital incidence of about 23 patients in 100,000 admissions. The community acquired empyemas are more common and less aggressive in non-Saudi patients (six males and one female) as compared to Saudi patients (11 males and 6 females) whose empyemas are mostly nosocomial with an aggressive course. The peak age in both Saudi and non-Saudi patients is 45 years and 25 years respectively, and the right pleura is more commonly affected than the left pleura in both groups. Risk factors include diabetes mellitus, pulmonary tuberculosis, post-pneumonectomy infections, trauma and pneumonia. The commonest organisms grown are Pseudomonas aeruginosa, Klebsiella species and Staphylococcus aureus, although in almost 40% of the patients the empyemas were sterile. The commonest method of treatment was closed thoracostomy tube drainage.

Deep venous thrombosis in Assir region of Saudi Arabia. Case-control study.

In a five-year case-control study (1988 to 1993) at Assir Central Hospital (ACH), Abha (8,000 feet above sea level), Saudi Arabia, 92 of 129 patients suspected of deep venous thrombosis (DVT) were studied with ascending contrast venography (CV) (74 patients, 80.4%) or Doppler ultrasonography (DUS) (18 patients, 19.6%). Female-to-male ratio was 2.3 to 1. Age range of patients was twelve to ninety years; mean age was 44.45 yrs +/- 17.38 years. DVT hospital incidence was 18 per 10,000 admissions. The most common associated factors included immobilization due to chronic diseases (21.7%), trauma and surgery (19.6%), and pregnancy and oral contraceptives usage (16.3%). The most common symptom and sign were limb pain and tenderness (95.6%). Limb swelling was noted in 93.5% of patients. The left lower limb was more commonly affected than the right. There was a definite increase of DVT during the winter months. Altitude was not a contributory factor. Pulmonary embolism was the greatest complication.

Management of neglected embolic occlusions in lower-limb arteries using arterial lavage.

Fourteen patients (seven males and seven females aged between 8 months and 100 years) with embolic lower-limb arterial occlusions of 1 to 6 days' duration were treated at Assir Central Hospital, Abha, Saudi Arabia over a 27-month period. On admission, the limbs were ischaemic up to mid-thigh and peripheral pulses were absent. Doppler studies showed absence of blood flow. The anatomical block was localized by angiography and ultrasonography. Fogarty catheter embolectomy was performed in all patients followed by rapid positive-pressure lavage of the vascular tree with 4-61 Ringer's lactate solution containing mannitol in an attempt to remove free radicals. Three patients died; one transmetatarsal amputation was performed. The remaining 11 limbs were salvaged and these patients remain ambulatory 21 to 42 months after surgery.

Colo-rectal carcinoma in a tropical African population: an overview report.

Fifty-one selected cases of colo-ano-rectal carcinoma seen in a tropical African population over a period of two decades were reviewed. The patients were divided into three groups. Group A were those cases seen under the age of thirty years, Group B were the resectable rectal carcinoma because they were bulky and occupied the whole of the pelvis. This we referred to as cases with "frozen" pelvis. Our modality of treatment consists of surgical excision when possible, the use of Levamisole, the use of 5-Fluoro-Uracil either intravenously, intraperitonealy and intrarectally as the case requires and radiotherapy when available. For Group A, the average survival period is 10.6 months, for Group B, it is 17.3 months and for Group C, it is 14.5 months. Symptoms of tenesmus and ascites improved by intrarectal and intraperitoneal infusion of calculated dose of 5-Fluoro-Uracil.

Catamenial pneumothorax: a case report.

A case of catamenial pneumothorax in a 17-year-old girl is presented. It is the first reported case in a Nigerian. Pleural blebs were found at thoracotomy and good response to dry sponge pleurodesis has been confirmed. The possibility of missed diagnosis of this entity in an environment where spontaneous pneumothorax is not uncommon is discussed.

Developmental anomalies of the lung in Nigerian children.

Five cases of developmental lung anomalies occurring in Nigerian children are reported; three were congenital lobar emphysema while two were scimitar syndromes. The radiological features demonstrated in each case effectively excluded the common causes of pulmonary disorders. Three patients were treated surgically with successful results in two. We believe that an increased awareness in our tropical setting would result in improved detection of these treatable but rare conditions.

Suppurative diseases of the lung and pleura: a continuing challenge in developing countries.

A retrospective study of 1,150 consecutive patients with thoracic and cardiovascular diseases seen at the University College Hospital, Ibadan, Nigeria, over a five-year period (January, 1975, to December, 1979) showed that 42% (481 patients) were treated for suppurative diseases of the lung and pleura, notably empyema thoracis, lung abscess, and bronchiectasis. Of these, 336 or 70% were treated for empyema thoracis, most of whom were less than 2 years old. Seventy-five patients (16%) had lung abscess, 53 of whom were treated medically with 8 deaths, while 22 had emergency resection for massive hemoptysis with 9 deaths. Of the 70 patients with bronchiectasis, 37 were treated medically with 2 deaths, while 33 were treated surgically with 5 deaths. These data demonstrate that infectious diseases of the lung and pleura remain the greatest challenge to the thoracic surgeons in tropical, developing countries who are often handicapped by inadequate facilities, lack of drugs, illiteracy, poverty, superstitious beliefs, and poor environmental hygiene.

Purulent pericarditis: a continuing surgical challenge.

This report presents a prospective series of 12 patients with a diagnosis of purulent pericarditis who were treated between April 1978 and September 1979 by the cardiothoracic surgical unit at the University College Hospital, Ibadan, Nigeria. These patients were studied to determine the adequacy of a therapeutic protocol consisting of systemic antibiotics and pericardiostomy tube drainage. All patients were in the pediatric age group with an average age of 6¾ years. Bronchopneumonia was the antecedent focus of sepsis in eight patients, with pyomyositis in four (33 percent). Two patients expired prior to surgery.No mortality or significant morbidity occurred in the ten patients who underwent pericardiostomy.The results of this series combined with the initial experience reported in 1978 by the same authors confirm the described protocol as the treatment of choice in their environment.

Management of tuberculous destroyed lung in Nigeria.

Between 1969 and 1979, 20 patients under-went pneumonectomy for tuberculous destroyed lungs (TDL) at the University College Hospital (UCH), Ibadan, Nigeria. Their ages ranged from 9 to 57 years, with an average age of 24 years. The left lung was involved in 16 patients (80 percent) and the right lung in four patients (20 percent). All patients had received treatment for pulmonary tuberculosis (PTB) for over three years, and all patients had negative cultures of acid-fast bacilli (AFB) at the time of operation. Pulmonary function studies were performed in 15 patients, bronchography in 18, and pulmonary angiography in four. Ninteen patients had elective resection because of mild to moderate hemoptysis without mortality. The only death occurred in a 37-year-old man who had emergency resection because of massive hemoptysis. He died intraoperatively of cardiac arrest. One patient developed bronchopleural fistula (BPF), empyema, and wound infection. The fistula closed spontaneously following prolonged chest drainage and pleural irrigation with antibiotics and antituberculous drugs. As a result of our experience with pulmonary tuberculosis in our environment, the authors now recommend elective resection for patients with TDL in order to prevent massive hemoptysis which may prove fatal.

Open pulmonary valvotomy: report of the first successful open heart surgery at the University College Hospital, Ibadan, Nigeria.

Although cardiac surgery has become the standard procedure for management of intracardiac and extracardiac defects in developed countries, it is still relatively new in Africa. This report describes our first successful open heart surgery on a 16-year-old Nigerian boy who underwent open pulmonary valvotomy under cardiopulmonary bypass for congenital pulmonary stenosis at the University College Hospital, Ibadan, Nigeria, on September 18, 1979.

Broncho-esophageal fistula presenting as bronchiectasis in a Nigerian child.

A case is presented of a five-year-old girl with history of intermittent episodes of cough and vomiting exacerbated by eating. A diagnosis of broncho-esophageal fistula was made on barium esophagography after she failed to improve on therapy for bronchiectasis and tuberculosis over a one-year period.The diagnostic considerations and management of broncho-esophageal fistula in the Nigerian child with bronchiectasis are described.