Retained enteroscopy capsule in a patient with diaphragm disease.

INTRODUCTION: Diaphragm disease is a rare consequence of small-bowel enteropathy, and usually occurs as a result of longstanding ingestion of non-steroidal anti-inflammatory drugs. DD is characterized by multiple strictures and saccular dilatations leading to symptoms of subacute intestinal obstruction. Often, the diagnosis is made on histological examination after laparotomy and resection of diseased small bowel. CASE HISTORY: Here, we report a case of an elderly female who suffered for many years from chronic, colicky abdominal pain and anaemia due to undiagnosed diaphragm disease. Eventually, she was referred to our surgical team because of a retained enteroscopy capsule. The diagnosis was made after laparotomy and bowel resection. This surgical intervention alleviated chronic symptoms, and the patient remained well at 1-year follow-up. CONCLUSIONS: This case highlights the difficulty of diagnosing diaphragm disease without laparotomy and bowel resection. A high index of suspicion must be exercised in any patient with chronic, colicky abdominal pain and anaemia together with multiple strictures and saccular dilatations on computed tomography even in the absence of longstanding NSAID ingestion. Moreover, capsule enteroscopy should be avoided as a diagnostic modality of small-bowel disease if computed tomography raises the suspicion of strictures.

Late metastatic colon cancer masquerading as primary jejunal carcinoma.

Metastasis to the small bowel from a previously resected colorectal cancer is rare and may erroneously be diagnosed as a primary small bowel carcinoma. It usually occurs several years after the primary resection. We present the case of a 67-year-old man who had undergone left hemicolectomy for colon cancer 3 years earlier and returned with subacute small bowel obstruction. This was initially thought, based on preoperative radiological findings and normal colonoscopic examination, to be due a primary jejunal cancer. Even at surgery, the lesion convincingly appeared as an obstructing primary small bowel carcinoma. However, the histology of the resected small bowel revealed metastatic colon cancer. This rare and an unusual metastatic occurrence some years after the primary resection is described and reviewed.

Standard formula for liver volume in Middle Eastern Arabic adults.

OBJECTIVES: To determine a formula for estimating the standard liver volume (SLV) in Middle Eastern Arabic adults and to compare it with the 12 standard liver volume (SLV) formulas reported for eastern and western populations. METHODS: Liver volume measured using computed tomography (CTLV) was determined in 351 Saudi Arabian adults older than 16 years without liver or body build abnormality. This measurement was correlated with body indices including age, sex, height, weight, body mass index, and body surface area to derive a new formula using multiple-step linear regression analysis. The CTLV was compared with the 12 SLV formulas using the t test, with error % as (SLV - CTLV)/CTLV × 100. RESULTS: Body weight was the only significant factor that correlated with CTLV, that is, 12.26 × body weight (kg) + 555.65 (R(2) = .37; P = .000). Only the Vauthey formula (1267.28 × body surface area (m(2)) - 794.41) yielded an estimation of SLV that did not differ significantly from CTLV (P = .26), and had the least mean % error of +1% (underestimation by 15.7 mL) and the closest agreement, that is, 62.4% demonstrated less than ±16% error). Other formulas also yielded acceptable agreement with mean % error less than 12%, although the differences from actual measurements were statistically significant. The Chengdu and Chouker formulas were the exceptions, with more than 16% underestimation or overestimation. CONCLUSIONS: Either the formulas derived in the present study and the Vauthey formula could be used to estimate SLV in Middle East Arabic adults. However, the moderate coefficient of determination (R(2) = .37) suggested wide interindividual variation. Caution must be exercised when using these formulas in preoperative planning.

Daflon for haemorrhoids: a prospective, multi-centre observational study.

BACKGROUND: Daflon, a phlebotropic agent, is of proven efficacy in the treatment of various venous disorders. Although it has been tried in the treatment of haemorrhoids, its efficacy in alleviating various haemorrhoidal symptoms has not been assessed properly. The aim of this study was to confirm the efficacy of Daflon in the treatment of haemorrhoidal symptoms. METHODS: Two hundred and sixty eight patients presenting with haemorrhoidal symptoms were recruited. This was a multicentre non-randomised observational study with no placebo arm. After establishing the extent of their symptoms and determining the position, size and degree of haemorrhoids by proctoscopy, all patients were started on Daflon, four tablets per day, in two divided doses for four weeks. Patients were seen weekly during the study period and carefully questioned as regard to symptoms, and a proctoscopy was carried out. RESULTS: There was a statistically significant improvement (p<0.001) in all haemorrhoidal symptoms (pain, heaviness, bleeding, pruritus and anal discharge) and in the proctoscopic appearance of the 'piles,' comparing baseline visit findings with the last visit four weeks after treatment with Daflon. CONCLUSIONS: Daflon has been shown to be effective in alleviating (variable degree) haemorrhoidal symptoms and improving the proctoscopic appearance of haemorrhoids. Therefore, it should be considered initially for patients presenting with haemorrhoidal symptoms. However, prospective randomised trials and longer follow-up are needed to confirm the findings of this study and delineate more precisely the role of Daflon in the management of haemorrhoidal disease

Asymptomatic gallstones in the laparoscopic era.

Recent introduction of new treatment options has significantly altered the approach towards gallstone management. There is now general agreement that cholecystectomy is the treatment of choice for symptomatic gallstones. Controversy, however, exists as to the management of asymptomatic gallstones. The ready availability of abdominal ultrasonography for the investigation of a wide range of abdominal symptoms has resulted in the increased diagnosis of asymptomatic gallstones. Management of such accidentally discovered gallstones poses a dilemma as conclusive evidence of the benefits of cholecystectomy is lacking. This is further complicated by the fact that the majority of asymptomatic gallstones remain so and patients rarely experience symptoms or complications. Furthermore, cholecystectomy is associated with a low but recognised morbidity. Recent introduction of laparoscopic cholecystectomy as the treatment of choice of symptomatic gallstones has further complicated the issue of asymptomatic gallstone management. This article reviews the current management of asymptomatic gallstones in the era of laparoscopic cholecystectomy

Duodenal and ampullary obstruction by a Peutz-Jeghers polyp.

We report a case of Peutz-Jeghers syndrome presenting with obstruction of the second part of the duodenum and the ampulla of Vater by a large intra-luminal polyp leading to duodenal obstruction and obstructive jaundice. CT scan of the abdomen showed a large polypoidal lesion, a caecal polyp and jejuno-jejunal intussusception. At surgery, two intussusceptions were reduced and leading polyps were excised via two enterotomies; the caecal polyp was excised via caecotomy. The duodenal polyp was excised by limited duodenectomy after frozen section has shown no evidence of malignancy. Histopathological study of all the excised polyps including that of the duodenum showed hamartomatous polyps with no malignant changes. Apart from acute bleeding, this case highlights many of the surgical gastrointestinal complications of Peutz-Jeghers syndrome. It also highlights the unusual combined duodenal and common bile duct obstruction by a large Peutz-Jeghers polyp. The controversial association of this syndrome with cancer and management options is also discussed.

Attitude of patients attending the surgical clinic towards a day surgical unit.

OBJECTIVES: To establish awareness and attitude of patients attending the general surgical clinic in Dammam Central Hospital, Dammam, Eastern Province towards a day surgery unit. Also, to establish the reasons for their preference to have surgery performed as inpatients or in the day surgery unit. METHODS: Some 100 consecutive patients attending the surgical clinic of a single consultant surgeon at Dammam Central Hospital were surveyed. Patients who can neither read nor write were excluded. They were asked to answer a simple questionnaire on day surgery and their preference to have their minor operations under general anesthesia performed as a day surgery procedure or as an inpatient. RESULTS: There were 64 males and 36 females of various professions. Ninety-four patients aged 15-45 years. Thirty-two patients gave the correct definition of day surgery while 38 patients did not know, and had never heard of the term and 30 patients gave wrong definitions. Only 30 patients preferred their surgery to be conducted as day surgery. Forty-five of 70 patients (64%) who preferred inpatient care felt they would be receiving better care in hospital and 16 (23%) felt happier to be looked after by their surgeon in the first few postoperative days to avoid complications. Nine females of the 70 patients who preferred inpatient surgery (13%) felt that hospital is a better place for rest after surgery and to get a way from husband, children and housework. CONCLUSION: The majority of our patients are unaware of the safety and services provided by a day surgical unit. Major work is needed to educate patients attending our clinics about the advantages of day surgery with the aim of improving their attitude towards it.

Schistosomal appendicitis in the Eastern Province of Saudi Arabia: A clinicopathological study.

BACKGROUND: In cases of schistosomiasis, the appendix is commonly infested. It is not known if this is a predisposing factor for appendicitis, or a mere coincidental histological finding. PATIENTS AND METHODS: A total of 56 patients (51 males and 5 females) underwent appendectomy for schistosomal appendicitis over a 10-year period at Dammam Central Hospital. The histological slides of 41 of the patients (73.2%) were retrospectively studied. RESULTS: The highest incidence of schistosomal appendicitis was recorded in the 21-40-year age group. Ova were seen in the submucosal layers of all the excised appendices. The most common tissue responses were submucosal fibrosis (92.7%) and eosinophilia (87.8%), followed by the presence of suppurative inflammation (80.5%). Granulomatous reaction was evident in only 13 cases (31.7%). A striking feature was atrophy of submucosal lymphoid follicles in 70.7% of the cases. Hyperplasia of lymphoid follicles and serosal granulomas were rare (2.4%). Similar tissue responses were histologically seen in four normal appendices examined. CONCLUSION: Appendiceal infestation may predispose to appendicitis in the majority of affected cases, but in others, it may well be a mere coincidental histological finding. However, preoperative knowledge bears no clinical significance and does not alter management.

International Symposium on recent advances in surgery.

Full text is available as a scanned copy of the original print version.

Sickle cell disease and the general surgeon.

Sickle cell disease (SCD) is a common genetic disorder which represents a major medical problem in certain parts of the world. It is characterized by chronic haemolytic anaemia and vaso-occlusive crises, which can lead to widespread vascular occlusion by sickled red blood cells leading to multiple organ infarctions. In this respect, SCD can be considered as a multisystem disease presenting, to various surgical disciplines, a wide variety of surgical ailments. As surgical management of these patients is associated with high morbidity and mortality, close collaboration between medical and surgical services is essential. Greater population mobility makes recognition of the surgical implications of this disease of paramount importance in surgical practice. This article reviews surgical problems with which SCD patients may present to general surgeons and discusses their management.

The safety of laparoscopic cholecystectomy in sickle cell disease: An update.

As surgery in sickle cell patients is associated with high morbidity, this study aims to establish the safety of minimally invasive surgery in this high-risk group. Over a four-year period, 71 sickle cell patients underwent laparoscopic cholecystectomy (LC) for cholelithiasis. Five patients had asymptomatic gallstones. Preoperative gastroscopy and endoscopic retrograde cholangiography were performed in 7 and 14 patients, respectively. Forty-two patients were given simple blood transfusions, while 13 received partial exchange transfusions. The mean operative time was 80 minutes and the conversion rate was 5.6%. There were 10 (14%) postoperative complications, the majority of which were respiratory and wound-related. One patient (1.4%) died as a result of postoperative vaso-occlusive crisis. The median hospital stay was 2.5 days. We believe that laparoscopic cholecystectomy is safe in patients with sickle cell hemoglobinopathy who are particularly at risk of developing pigmented gallstones. Therefore, the use of minimally invasive surgery is encouraged in any sickle cell patient undergoing operative intervention.