Management of pediatric blunt abdominal trauma with split liver or spleen injuries: a retrospective study.

BACKGROUND: Blunt abdominal trauma is a prevailing cause of pediatric morbidity and mortality. It constitutes the most frequent type of pediatric injuries. Contrast-enhanced sonography (CEUS) and contrast-enhanced computed tomography (CECT) are considered pivotal diagnostic modalities in hemodynamically stable patients. AIM: To report the experience in management of pediatric split liver and spleen injuries using CEUS and CECT. PATIENTS AND METHODS: This study included 246 children who sustained blunt abdominal trauma, and admitted and treated at three tertiary hospitals in the period of 5 years. Primary resuscitation was offered to all children based on the advanced trauma and life support (ATLS) protocol. A special algorithm for decision-making was followed. It incorporated the FAST, baseline ultrasound (US), CEUS, and CECT. Patients were treated according to the imaging findings and hemodynamic stability. RESULTS: All 246 children who sustained a blunt abdominal were studied. Patients' age was 10.5 ± 2.1. Road traffic accidents were the most common cause of trauma; 155 patients (63%). CECT showed the extent of injury in 153 patients' spleen (62%) and 78 patients' liver (32%), while the remaining 15 (6%) patients had both injuries. CEUS detected 142 (57.7%) spleen injury, and 67 (27.2%) liver injury. CONCLUSIONS: CEUS may be a useful diagnostic tool among hemodynamically stable children who sustained low-to-moderate energy isolated blunt abdominal trauma. It may be also helpful for further evaluation of uncertain CECT findings and follow-up of conservatively managed traumatic injuries.

Impact of wearing personal protective equipment on the performance and decision making of surgeons during the COVID-19 pandemic: An observational cross-sectional study.

ABSTRACT: During the coronavirus disease 2019 (COVID-19) pandemic, the mandatory use of personal protective equipment (PPE) has resulted in a significant reduction in the infection rate among health care workers (HCWs). However, there are some ongoing concerns about the negative impact of using PPE for prolonged periods.This study examined the impact of wearing PPE on surgeons' performance and decision making during the COVID-19 pandemic.In this cross-sectional study, an anonymous online questionnaire was created and disseminated to surgeons all over the Eastern Province of Saudi Arabia. The questionnaire included the demographic data, the local hospital policies, the non-technical skills (e.g., communication, vision, and comfort) and the technical skills, and the process of decision making.From June 2020 to August 2020, 162 surgeons participated in this questionnaire. Of them, 80.2% were aged from 26 to 45 years, 70.4% have received a special training for PPE, and 59.3% of participants have operated on COVID-19 confirmed cases. A negative impact of wearing PPE was reported on their overall comfort, vision, and communication skills (92.6%, 95.1%, and 82.8%, respectively). The technical skills and decision making were not significantly affected (60.5% and 72.8%, respectively). More preference for conservative approach, damage control procedures, and/or open approach was reported.Despite its benefits, PPE is associated with a significant negative impact on the non-technical skills (including vision, communication, and comfort) as well as a non-significant negative impact on technical skills and decision making of surgeons. Extra efforts should be directed to improve PPE, especially during lengthy pandemics.

Stress and psychological resilience among general surgery residents during COVID-19 pandemic.

OBJECTIVES: To evaluate the impact of coronavirus-19 (COVID-19) pandemic and its consequences on general surgery residents. Methods: Cross-sectional, survey based study including surgical residents in Kingdom of Saudi Arabia and Kingdom of Bahrain. RESULTS: Surgical trainees who participated in our survey (n=234) were young (mean age 28), single (53.8%), and males (65.8%). Approximately half (50.4%) have been deployed to cover the staff shortage in intensive care units (ICUs) or emergency departments (EDs). Half of our trainees (117) scored positive in the screening tool of generalized anxiety disorder (GAD). There was a significant association between experiencing anxiety and male gender (p=0.055), level of training (p=0.002), deployment to cover ICUs (p=0.050), testing positive for COVID-19 (p=0.054) and having an infected family member (p=0.004). CONCLUSION: Coronavirus-19 pandemic has a serious effect on all healthcare workers and surgical residents have experienced a considerable amount of stress. Accordingly, this psychological burden should be appropriately addressed in organizations planning strategies. We suggest formulating guidelines to help surgical trainees to continue their learning process with least psychological burden.

Alpha-fetoprotein level to total tumor volume as a predictor of hepatocellular carcinoma recurrence after resection. A retrospective cohort study.

BACKGROUND: Total tumor volume (TTV) and serum alfa fetoprotein (AFP) level are important risk factors linked with the high possibility of hepatocellular carcinoma (HCC) recurrence. The aim of the study was to evaluate the role of AFP/TTV ratio, as a prognostic marker, in the prediction of HCC recurrence after resection. METHODS: Patients who underwent liver resection for HCC between 2010 and 2018 were retrospectively analyzed. Patients were divided into 2 groups; a group with AFP/TTV ≤2 and another group with AFP/TTV >2. Risk factors for HCC recurrence were recorded. RESULTS: A total of 286 HCC patients underwent liver resection (184 patients with AFP/TTV ≤ 2, and 102 patients with AFP/TTV > 2). There was a significant difference between the 2 groups in the preoperative total bilirubin level, serum AFP level, mean tumor diameter, TTV, operative blood loss, microvascular invasion and hospital stay (all P values < 0.05). The 1-, 3-, and 5-year tumor recurrence rates were 24.1%, 43%, and 57.6% respectively. The independent risk factors for tumor recurrence were AFP/TTV >2 (HR = 1.62, 95% CI = 1.29-1.98, P = 0.042), Macrovascular invasion (HR = 2.03, 95% CI = 2.17-2.38, P = 0.021, and microvascular invasion (HR = 1.36, 95% CI = 1.08-1.77, P = 0.019). CONCLUSION: AFP/TTV ratio is a feasible prognostic marker for prediction of HCC recurrence after resection so, it can help in providing an intensive postoperative surveillance program to high risk patients for early detection and management of any recurrence.

Total tumor volume as a prognostic value for survival following liver resection in patients with hepatocellular carcinoma. Retrospective cohort study.

BACKGROUND: Total tumor volume (TTV) can provide a simplified parameter in describing the tumor burden by incorporating the size and number of tumor nodules into one continuous variable. The aim of the study was to evaluate the prognostic value of TTV in resection of hepatocellular carcinoma (HCC). METHODS: Patients who underwent liver resection for HCC between 2012 and 2017 were retrospectively analyzed. Patients were divided into a group with TTV ≤65.5 cm³ (which nearly equal to a single tumor with a diameter of 5 cm), and another group with TTV > 65.5 cm³. RESULTS: Two hundred and four patients were included in this study (108 patients had TTV ≤ 65.5cm3, and 96 patients had TTV > 65.5 cm³). Ninety patients (44.1%) were within Milan and 114 patients (55.9%) were beyond Milan criteria. Eighteen patients (15.8%) of beyond Milan criteria had TTV ≤ 65.5 cm³, with a median survival of 32 months which is comparable to a median survival of patients with TTV< 65.5 cm³ (38 months, P = 0.38). TTV-based Cancer of Liver Italian Program (CLIP) score gained the highest value of likelihood ratio 114.7 and the highest Concordance-index 0.73 among other prognostic scoring and staging systems. In multivariate analysis, independent risk factors for diminished survival were serum AFP level >400 ng/ml, TTV >65.5 cm³, microvascular invasion, postoperative decompensation (all P values < 0.05). CONCLUSION: TTV is a feasible prognostic measure to describe the tumor burden in patients with HCC. TTV-CLIP score may provide good prognostic value for resection of HCC than other staging systems.

Risk factors and management of different types of biliary injuries in blunt abdominal trauma: Single-center retrospective cohort study.

BACKGROUND: Biliary injuries after blunt abdominal traumas are uncommon and difficult to be predicted for early management. The aim of this study is to analyze the risk factors and management of biliary injuries with blunt abdominal trauma. METHOD: Patients with blunt liver trauma in the period between 2009 to May 2019 were included in the study. Patients were divided into 2 groups for comparison; a group of liver parenchymal injury and group with traumatic biliary injuries (TBI). RESULTS: One hundred and eight patients had blunt liver trauma (46 patients with liver parenchymal injury and 62 patients with TBI). TBI were; 55 patients with bile leak, 3 patients with haemobilia, and 4 patients with late obstructive jaundice. Eight patients with major bile leak and 12 patients with minor bile leak had been resolved with a surgical drain or percutaneous pigtail drainage. Nineteen patients (34.5%) with major and minor bile leak underwent successful endoscopic retrograde cholangiopancreatography (ERCP). Sixteen patients (29.1%) underwent surgical repair for bile leak. In Multivariate analysis, the possible risk factors for prediction of biliary injuries were central liver injuries (P = 0.032), high grades liver trauma (P = 0.046), elevated serum level of bilirubin at time of admission (P = 0.019), and elevated gamma glutamyl transferase (GGT) at time of admission (P = 0.017). CONCLUSION: High-grade liver trauma, central parenchymal laceration and elevated serum level of bilirubin and GGT are possible risk factors for the prediction of TBI. Bile leak after blunt trauma can be treated conservatively, while ERCP is indicated after failure of external drainage.

Laparoscopy as a Primary Investigatory Tool in Pediatric Abdominal Masses.

BACKGROUND: Management of abdominal masses still pose a major challenge for pediatrician and surgeons with many controversy as regards the best investigatory tools. AIM OF THE WORK: This study was designated to evaluate the role of diagnostic laparoscopy in investigating equivocal pediatric masses that had undergone other imaging modalities. PATIENTS AND METHODS: A combined prospective and retrospective multicenter study over a period of 12 years from January 2005 to December 2016 was undertaken. This study included all children aged from 3 months to 15 years. Those having a documented diagnosis through other imaging modalities such as sonographic and/or computed tomography (CT) guided biopsy were excluded. All patients underwent multiport diagnostic laparoscopy for biopsy of the mass. All specimens were histologically assessed basically using Hematoxylin and Eosin (H and E) staining; some specimens had been immunohistochemically studied. RESULTS: One hundred and thirty-two patients were recruited in the study. They were 69 males and 63 females with a male to female ratio of1.1:1. The age ranged from 3 months up to 15 years with the mean age of 2.7 ± 0.8 years. Out of the total studied group, 54 patients were diagnosed with neuroblastoma (40.9%), while 66 (50%) were having nephroblastoma. The remaining 12 (9.1%) were having non-Hodgkin's abdominal lymphoma. Not all patients showed any complication related to the procedure. The mean follow up period was 3.6 years. Most of the cases (n=121) despite having a different diagnosis, were clinically staged as grade I to grade II (91.7%). Neither intraoperative nor postoperative complications were recorded during this technique. The mean operative time was 72 mins ± 20 in the earliest group; yet, it has declined to be 32 ± 12 minutes in the latest group due to the advancement of the learning curve. CONCLUSION: Laparoscopy is accurate and safe for investigating pediatric solid abdominal masses. It should be used as the sole tool for biopsy of solid abdominal tumors in pediatrics.

Reliability of sonoelastography in predicting pediatric cervical lymph node malignancy.

PURPOSE: Controversy exists as regards the best non-invasive diagnostic tool for pediatric cervical lymphadenopathy. The current work aimed to evaluate the reliability, sensitivity, specificity, and accuracy of sonoelastography in diagnosing benign and/or malignant pediatric cervical lymphadenopathy. METHODS: Prospective study took place over a period of 4 years from January 2013 to December 2016. A total of 177 lymph nodes (LNs) in 128 children with an age ranging from 11 months to 12 years were recruited in this study. Patients were 77 males and 51 females with a ratio of 3:2. All patients underwent a thorough history taking and clinical examination of the neck focusing on the cervical lymph nodes. After that, a B-mode sonography, Color Doppler ultrasound, and Sonoelastography were performed. Elastographic patterns of 1-5 were evaluated, whereas patterns of 3-5 (firm to hard) were suspected to have a malignant nature. Sonographic-guided aspiration cytology took place in 107 lymph nodes and excisional biopsy in 102 lymph nodes, whereas 13 lymph nodes responded adequately to conservative treatment. They proved to be benign reactive hyperplasia. RESULTS: The majority of LNs (87%) were of the malignant type that showed an elastographic pattern of 3-5. The same patterns were observed in only 6 (3.4%) of the benign LNs. Sonoelastography showed a sensitivity of 85.9%, specificity of 100%, PPV of 100%, NPV of 75.96%, and overall accuracy of 90.23% in distinguishing benign from malignant lymph nodes. Using the B-Mode ultrasound, an abnormal hilum was seen in 75%. The accuracy of color Doppler US reached 82.7%. CONCLUSIONS: Sonoelastography may be superior to other US modalities in elucidating different cervical lymph node biopsy helping to distinguish benign from malignant lesions. This may replace the lymph node biopsies in the future. Moreover, its use in the follow-up of patients with cervical malignancies may reduce the number of future biopsies. Further studies with more patients may be needed for a better assessment of results.

Adhesive Small Bowel Obstruction due to Pelvic Inflammatory Disease: A Case Report.

We report a rare case of a 32-year-old woman with adhesive small bowel obstruction due to pelvic inflammatory disease. She had no history of abdominal surgery, gynecological complaints or constitutional symptoms of chronic illness. The diagnosis was based on the laparoscopic findings of small bowel adhesions, free peritoneal fluid, "violin string" adhesions of Fitz-Hugh-Curtis syndrome and left hydrosalpinx. Laparoscopic adhesiolysis was performed successfully, and the patient had an uneventful postoperative course. The authors conclude that pelvic inflammatory disease should be included as a cause of adhesive small bowel obstruction in sexually active young women with no history of abdominal surgery or constitutional symptoms of chronic disease. When performed by experienced surgeons, laparoscopy in such patients is feasible and safe.

Total pancreatectomy: Short- and long-term outcomes at a high-volume pancreas center.

AIM: To identify the current indications and outcomes of total pancreatectomy at a high-volume center. METHODS: A single institutional retrospective study of patients undergoing total pancreatectomy from 1995 to 2014 was performed. RESULTS: One hundred and three patients underwent total pancreatectomy for indications including: Pancreatic ductal adenocarcinoma (n = 42, 40.8%), intraductal papillary mucinous neoplasms (n = 40, 38.8%), chronic pancreatitis (n = 8, 7.8%), pancreatic neuroendocrine tumors (n = 7, 6.8%), and miscellaneous (n = 6, 5.8%). The mean age was 66.2 years, and 59 (57.3%) were female. Twenty-four patients (23.3%) underwent a laparoscopic total pancreatectomy. Splenic preservation and portal vein resection and reconstruction were performed in 24 (23.3%) and 18 patients (17.5%), respectively. The 90 d major complications, readmission, and mortality rates were 32%, 17.5%, and 6.8% respectively. The 1-, 3-, 5-, and 7-year survival for patients with benign indications were 84%, 82%, 79.5%, and 75.9%, and for malignant indications were 64%, 40.4%, 34.7% and 30.9%, respectively. CONCLUSION: Total pancreatectomy, including laparoscopic total pancreatectomy, appears to be an appropriate option for selected patients when treated at a high-volume pancreatic center and through a multispecialty approach.

Initial Surgery in Tailoring Treatment for Children With Stage II and III Wilms' Tumor: An Experience From Resource Challenged Settings.

BACKGROUND: Although Wilms' tumor (WT) is ranked first among primary childhood's renal neoplasm, controversy still exists regarding the best approach for its management. The study aimed at evaluating the role of initial surgery in treatment of stage II and III pediatric WT as a part of the short administration schedule as in National Wilms' Tumor Study (NWTS)-4 and evaluating its effectiveness compared to the long administration schedule. METHODS: The study included 30 children who were primarily diagnosed as stage II and III WT. They were divided into two equal groups. Group I (n = 15) included those children who had undergone neoadjuvant chemotherapy followed by surgery and postoperative chemotherapy, while group II (n = 15) included those children who had undergone primary surgery as an initial management followed by chemotherapy. After a mean postoperative follow-up period of 14 ± 5 months, clinical and radiological evaluation was performed to all patients. RESULTS: In group I, 10 patients were preoperatively diagnosed as stage II and five patients as stage III while in group II, 11 patients were proved to be stage II and four patients were stage III. After a follow-up period, clinical and radiological evaluation using CT was performed to all patients. In patients with stage II, evidence of recurrence was noted in three patients of group I whereas no patient showed any evidence of recurrence in group II. In patients with stage III, rebound increase in size was seen in two patients in group I and only one patient in group II. CONCLUSIONS: Initial surgical intervention with appropriate adjuvant therapy has better outcomes than the neoadjuvant chemotherapy and delayed surgery for children primarily diagnosed as stage II and III WT. Moreover, it may act as a short administration schedule for the treatment as it is not less effective than the long administration schedule and can be administered at a substantially lower total treatment cost.

Parasitic infestation in pediatric and adolescent appendicitis: a local experience.

OBJECTIVE: The relationship between parasites and pediatric appendicitis is a highly debatable issue. This study aims to investigate the role of parasitic infestation in the etiology of acute pediatric appendicitis. METHODS: A retrospective study including 1600 pediatric and adolescent patients who had undergone surgical therapy for a diagnosis of acute appendicitis over a period of ten years from Jan 2001 to Dec 2010. Demographic data were retrieved including the patient's age, sex, clinical data, clinical presentations, laboratory investigations, operative data and pathological findings to identify the presence and type of parasites. Patients were divided into two groups according to the presence or absence of parasites in the appendix lumen. In group I (n: 88), parasitic infestation was observed, whereas in group II (n: 1502), no parasitic infestation was present. RESULTS: Parasites were present in 5.5% (88 patients), and of those 88 parasitic infestations, 45 (51.1%) were Enterobaisis, 8 (9.1%) were Schistosomiasis, 23 (26.1%) were Ascariasis, 7 (8%) Trichuriasis, and 5 (5.7%) were Teania Saginata. The percentage of patients with suppurative, gangrenous or perforated appendicitis was similar in both groups with no statistical significance, irrespective of the presence or absence of parasitic infestation. CONCLUSION: The low prevalence of parasites among the appendectomy specimens did not support the notion that parasites were a major cause of appendicitis in pediatric patients.

Examination under anesthesia for management of impalpable undescended testis: a traditional technique revisited.

BACKGROUND: Many new tools for management of impalpable testes have emerged during the last few years, yet, not many studies have compared them to the traditional ways of managing this problem. This work aims to reiterate the importance of the physical examination under general anesthesia prior to the surgical procedure in order to decide the best surgical approach for patients with impalpable undescended testis, especially in developing countries where expensive investigations are at premium. PATIENTS AND METHODS: The study included boys who were treated consecutively and recorded prospectively from 2000 to 2010. Examination under anesthesia (EUA) was performed during the study period. Those in whom the testes were palpable underwent the standard orchiopexy procedure. In those boys where EUA failed to detect the testes, laparoscopy or extended inguinal exploration was carried out, and the testes were treated accordingly. RESULTS: On initial clinical evaluation at the outpatient clinic, 545 boys were recorded to have impalpable testes. Undescended testis was unilateral in 529 boys and bilateral in 16 boys. However, on examination under anesthesia only 189 (34.7 %) were impalpable. Among boys in whom the testes were palpable after EUA, 38 had small-size testes, 18 had normal size, and the remaining 300 boys had a sac or cord-like structure. CONCLUSIONS: Meticulous EUA facilitates the accurate diagnosis and planning of the surgical approach to patients with an impalpable testis and should remain part of the surgeon's skill set. It is an inexpensive initial evaluation tool that may help in saving hospital resources, especially in developing countries.

Recurrent laryngeal nerve injury in thyroid surgery.

OBJECTIVES: Vocal cord paresis or paralysis due to iatrogenic injury of the recurrent laryngeal nerve (RLNI) is one of the main problems in thyroid surgery. Although many procedures have been introduced to prevent the nerve injury, still the incidence of recurrent laryngeal nerve palsy varies between 1.5-14%. The aim of the present study is to assess the risk factors of recurrent laryngeal nerve injury during thyroid surgery. METHODS: Patients who had thyroid surgery between 1990 and 2005 and were admitted to the surgical department of King Fahd hospital of the University, Al-Khobar, Saudi Arabia were enrolled for this retrospective review, Factors predisposing to recurrent laryngeal nerve injury were evaluated such as pathology of the lesions and the type of operations and identification of recurrent laryngeal nerve intra-operatively. Preoperative and postoperative indirect laryngoscopic examinations were performed for all patients. RESULTS: 340 patients were included in this study. Transient unilateral vocal cord problems occurred in 11 (3.2%) cases, and in 1 (0.3%) case, it became permanent (post Rt. Hemithyroidectomy). Bilateral vocal cord problems occurred in 2 cases (0.58%), but none became permanent. There were significant increases in the incidence of recurrent laryngeal nerve injury in secondary operation (21.7% in secondary vs. 2.8% in primary, p=0.001), total/near total thyroidectomy (7.2% in total vs. 1.9% in subtotal, p=0.024), non-identification of RLN during surgery (7.6% in non-identification vs. 2.6% in identification, p=0.039) and in malignant disease (12.8% in malignant vs. 2.9% in benign, p=0.004). However, there was no significant difference in the incidence of recurrent laryngeal nerve injury with regards to gender (4.1% in male vs 3.8% in female, p=0.849). CONCLUSION: The present study showed that thyroid carcinoma, re-operation for recurrent goiter, non-identification of RLN and total thyroidectomy were associated with a significantly increased risk of operative recurrent laryngeal nerve injury.

Laparoscopic management of malfunctioning peritoneal dialysis catheters.

OBJECTIVES: Continuous ambulatory peritoneal dialysis (CAPD) is an established alternative method to hemodialysis for treating end-stage renal disease patients. Malfunction of the peritoneal catheter is a frequent complication in peritoneal dialysis (PD). Laparoscopy is a minimal invasive technique that allows rescue therapy of malfunctioning catheters and consecutive immediate resumption of PD. The purpose of this study is to present our experiences with laparoscopic repair of peritoneal catheter dysfunction METHODS: Between April 2006 and March 2010, 21 cases of laparoscopic interventions were performed for the salvage of malfunctioning CAPD catheter. Two trocars (5 mm) were used. Recorded data included patient demographics, catheter implantation method, date of malfunction, cause of dysfunction, procedure performed and complications. RESULTS: The primary etiology of dysfunction was omentum and/or small bowel wrapping with adhesions in fifteen cases, malpositioning in four cases, and tunnel infection in the remaining two cases. Adhesiolysis was performed in cases with adhesions. In the cases with malpositioning but no adhesions, the catheters were repositioned in the pelvic cavity. Two catheters had to be withdrawn and exchanged because of infection. There were no mechanical or infection problems. The overall success rate of catheter function (>30 days after laparoscopy) was 100%, except for two cases in which the catheters had to be removed. CONCLUSION: Laparoscopy is a safe, highly effective and successful method for the evaluation and management of peritoneal dialysis catheter dysfunction.

Thyroid tuberculosis mimicking carcinoma: report of two cases.

Among 527 patients with thyroid disease who underwent surgery at our hospital during a 20-year period, 2 (0.4%) had tuberculous thyroiditis mimicking carcinoma. The first patient was a 44-year-old man with a solitary thyroid nodule and the second was a 24-year old man with a thyroid abscess. The unexpected diagnosis was made postoperatively and was based on histological findings in both patients. No primary focus was found elsewhere in either patient, and both responded to antituberculous chemotherapy. Although the diagnosis is usually based on examination of resected specimens, recent reports indicate that find-needle aspiration cytology is a cost-effective technique of diagnosing thyroid tuberculosis. A review of 35 cases reported in the English literature is also discussed.