Metachronous Metastatic Renal Cell Carcinoma to the Jejunum Presenting with Massive Lower Gastrointestinal Bleeding.

Metastatic renal cell carcinoma (MRCC) is a rare cause of massive lower gastrointestinal bleeding (LGIB). We report a 51-year man who underwent left nephrectomy for renal cell carcinoma (RCC) 6 years ago. presenting with massive LGIB. Preoperative abdominal computed tomography (CT) revealed small bowel mass. Exploration of the abdomen revealed jejunal mass. Resection of the mass along with the jejunal segment with end-to-end anastomosis was performed. Histopathology of the jejunal mass confirmed MRCC. MRCC should be expected as a source of massive LGIB in a patient with history of RCC. Surgical intervention should not be delayed in a hemodynamically unstable patient and persistent bleeding.

Comparison of Harmless Acute Pancreatitis Score with Ranson's Score in Predicting the Severity of Acute Pancreatitis.

OBJECTIVE: To determine the predictability of harmless acute pancreatitis score (HAPS) in determining the severity of acute pancreatitis (AP) and compare it with Ranson's score. STUDY DESIGN: Prospective cohort study. PLACE AND DURATION OF STUDY: King Saud Medical City, Riyadh, Kingdom of Saudi Arabia, between January 2012 and December 2015. METHODOLOGY: All patients admitted with AP at King Saud Medical City, Riyadh, during 2012 - 2015 were studied prospectively. Patients were assessed by HAPS and Ranson's score. Predictability values of the two systems were analysed and compared. RESULTS: Out of 116 patients studied, 104 (89.6%) were HAPS positive and predicted to have mild disease. Pancreatitis was mild in 101 (87%) but severe in 3 (2.6%) patients who scored ≥ 3 Ranson's criteria. Among 12 HAPS negative patients, 10 scored ≥ 3 Ranson's criteria and developed severe pancreatitis while 2 (1.7%) with 2 positive Ranson's criteria developed mild pancreatitis. HAPS correctly predicted the disease severity in 101 (87%) patients, a sensitivity of 98% specificity of 77% and accuracy of 96%. Ranson's system predicted correctly in all but took 48 hours for assessment. Statistical analysis showed moderate agreement (Kappa = 0.776, p < 0.001), and positive relation (rs = 0.777, p < 0.001) between the two scores. CONCLUSION: HAPS is effective in rapid identification of patient who will run non-severe course of AP. Assessment can be completed within one hour from presentation. Ranson's score, although more accurate, takes 48 hours to complete.

Intraoperative Dilatation and Air-Tight Testing of the Hepaticojejunostomy: A New Technique.

OBJECTIVE: To evaluate the effect of creating an air-tight anastomosis and intraoperative dilatation of the hepaticojejunostomy (HJ) in reducing the early and long-term complications. STUDY DESIGN: Interventional study. PLACE AND DURATION OF STUDY: Department of Surgery, King Saud University, Riyadh, between March 2008 and January 2016. METHODOLOGY: After completion of HJ, the anastomosis was tested for air-tightness, and dilated with Kelly clamp in all patients undergoing the procedure. The anastomosis was reinforced with extra suture in cases of air leak. Comparison was performed between the patients who underwent HJ by the same surgeon, after and before the new technique. RESULTS: Sixty-seven patients underwent HJ during the study period. Air leaks from HJ were observed in 3 patients before anastomotic dilatation. The anastomosis was reinforced in these patients. No air leak was observed after dilatation of the anastomosis. There was no postoperative bile leak in any patient. However, during the follow-up 3 patients presented with recurrent cholangitis and stricture formation at the HJ site required surgical revision. The new technique had significantly reduced the rate of bile leak (p=0.029) and stricture (p=0.037) at the site of HJ when compared with patients who underwent HJ without the new technique. CONCLUSION: Creation of air-tight HJ anastomosis has completely eliminated the postoperative bile leak and reduced the rate of HJ stricture formation. The addition technique resulted in insignificant prolongation of operative time. There was no technique related complication.

Enteric duplication cyst as a leading point for ileoileal intussusception in an adult: A rare cause of complete small intestinal obstruction.

Duplication of alimentary tract (DAT) presenting as an ileoileal intussusception is a very rare clinical entity. Herein, a case of an ileoileal intussusception due to DAT is presented. A 32-year-old woman was hospitalized due to diffuse, intermittent abdominal pain, vomiting and constipation for 3 d associated with abdominal distention. Plain abdominal X-ray revealed dilated small bowel. Abdominal computed tomography showed grossly dilated small bowel with "sausage" and "doughnut" signs of small bowel intussusception. She underwent laparotomy, with findings of ileoileal intussusception due to a cystic lesion adjacent to the mesenteric side. Resection of the cystic lesion along with the affected segment of intestine, with an end to end anastomosis was performed. The histopathology was consistent with enteric duplication cyst. This case highlights the DAT, although, an uncommon cause of adult ileoileal intussusception should be considered in the differential diagnosis of intussusception in adults, particularly when the leading point is a cystic lesion.

Pseudomyxoma Retroperitonei: ARare Cause of Retroperitoneal Cystic Mass.

Pseudomyxoma retroperitonei is a rare condition, characterized by accumulation of mucinous material in the retroperitoneal space, originating predominantly from the appendiceal mucinous neoplasms. A72-year-old male patient presented with a history of progressive right side abdominal pain for 5 months with a palpable abdominal mass. Ultrasound, computerized tomography, and magnetic resonance imaging showed large right abdominal multiloculated cystic lesion with heterogeneous echoic contents. Colonoscopy revealed normal mucosa with extramural pressure on the right colon and cecum. He underwent complete excision of the mass along with right hemicolectomy. The cystic mass was containing gelatinous material. Histopathology revealed low grade mucinous neoplasm. Pseudomyxoma retroperitonei should be considered in the differential diagnosis of patient presenting with progressive right side abdominal pain and retroperitoneal cystic mass.

Unsupervised recognition of retinal vascular junction points.

Landmark points in retinal images can be used to create a graph representation to understand and to diagnose not only different pathologies of the eye, but also a variety of more general diseases. Aim of this paper is the description of a non-supervised methodology to distinguish between bifurcations and crossings of the retinal vessels, which can be used in differentiating between arteries and veins. A thinned representation of the binarized image, is used to identify pixels with three or more neighbors. Junction points are classified into bifurcations or crossovers according to their geometrical and topological properties. The proposed approach is successfully compared with the state-of-the-art methods with the benchmarks DRIVE and STARE. The recall, precision and F-score average detection values are 91.5%, 88.8% and 89.8% respectively.

Outcome of open Tenckhoff catheter insertions: 5 years experience in a major tertiary centre in central Saudi Arabia.

BACKGROUND: Continuous ambulatory peritoneal dialysis (CAPD) has become a popular and established form of renal replacement therapy in patients with end-stage renal disease (ESRD). The objective of this study was to analyse the outcome of open Tenckhoff catheter insertions in patients with ESRD in term of catheter related complications. METHODS: From December 2006 to November 2011, 337 Tenckhoff catheters were placed in 305 patients with ESRD for CAPD, by general surgeons in King Saud Medical City, Riyadh, Saudi Arabia. Medical record of all these patients was reviewed retrospectively regarding the demography, causes of ESRD, catheter related complications, and their management. RESULTS: Mean age of the patients was 51.2 +/- 14.5 (range, 16-87 years). Majority of the patients were female 164 (53.7%). Forty three patients (14.1%) had previous abdominal surgery. Diabetic nephropathy was the commonest (51.4%) primary cause of ESRD. Ninety three insertions (27.5%) were associated with complications. Post insertion peritonitis was the commonest complication (9.2%) in our series, followed by mechanical dysfunction (8.6%). Fifty two catheters (15.4%) were removed because of different complications. Follow up ranged between 4-47 months with a mean of 21.4 +/- 11.2 months. CONCLUSIONS: Open surgical approach is simple, safe, and effective method of Tenckhoff catheter insertion with an acceptable complication rate, provided patients are adequately optimized and prepared for surgery.

Role of postoperative antibiotics after appendectomy in non-perforated appendicitis.

OBJECTIVE: To determine the role of postoperative antibiotics in reducing the surgical site infections (SSIs) after open appendectomy in patients with non-perforated appendicitis (NPA). STUDY DESIGN: Randomized controlled trial. PLACE AND DURATION OF STUDY: The Department of Surgery, King Saud Medical City, Riyadh, Kingdom of Saudi Arabia, from January 2010 to July 2011. METHODOLOGY: Three hundred and seventy seven patients, who underwent appendectomy for NPA and fulfilled the selection criteria, were randomized into two groups. The patients in group A received a single dose of pre- operative antibiotics (cefuroxime sodium and metronidazole), while the group B patients received one more dose of the same antibiotics postoperatively. Patients of both the groups were followed-up for 30 days to assess the postoperative infective complications. RESULTS: Group A had 195, while group B comprised of 182 patients. The groups were comparable in the baseline characteristics. Statistically there was no significant difference in rates of SSIs between both the groups (p = 0.9182). Mean hospital stay was 2.29 ± 0.81 and 2.35 ± 0.48 days for group A and B respectively (p = 0.4403). None of the patients developed intraabdominal collection. CONCLUSION: Single dose of pre-operative antibiotics (cefuroxime and metronidazole) was sufficient in reducing the SSIs after appendectomy for NPA. Postoperative antibiotics did not add an appreciable clinical benefit in these patients.

Alvarado score as an admission criterion for suspected appendicitis in adults.

BACKGROUND: Acute appendicitis is a common surgical problem. AIM OF THE STUDY: To assess Alvarado score as an admission criterion for adult patients with suspected appendicitis in order to decrease unnecessary admissions to surgical wards. PATIENTS AND METHODS: A prospective study of consecutive patients attending the Emergency Department (ED) of Riyadh Medical Complex with suspected appendicitis. The patients were managed according to the algorithm of the study protocol and discharged after clinical improvement either from ED or from the ward. They were followed by telephone 2-3 days later. Alvarado score was obtained in the ED in all patients. RESULTS: The study included 211 patients, 60 patients were observed in ED and discharged, 151 patients were admitted and 137 of them were operated with a negative rate of 12.5%. The remaining 14 patients were observed and discharged. No patients with a score of 4 or less had appendicitis. CONCLUSION: Though the diagnosis of acute appendicitis remains mainly clinical, Alvarado score can be recommended as a helpful tool for the admission criteria and further management in order to reduce unnecessary admissions and to reduce the morbidity and mortality of acute appendicitis.