Surgical approach to coexistent inguinal endometriosis and inguinal hernial defect: a case report.

The presence of ectopic endometrial and myometrial tissue is referred to as endometriosis. The majority of cases of inguinal endometriosis are linked to prior uterine surgery. We present a 39-year-old female presented to the general surgery clinic in June 2013 with mild right inguinal pain and swelling. Enhanced computed tomography scan of the abdominal and pelvis revealed an elongated cystic mass in the right groin region. Diagnostic laparoscopy was performed and the uterus, both ovaries, and pouch of Douglas were examined. Two endometrial deposits were detected: on in the superoposteriar part of the uterus and another below the base of the right fallopian tube. In addition to the right inguinal hernia, a cystic lesion was noted on the surface of the round ligament. The entire round ligament, including the canal of Nuck, and cyst were dissected and excised completely. The right inguinal hernia was repaired.

Laparoscopic intraperitoneal bladder injury repair of a trauma patient: A case report.

The standard intraperitoneal bladder injury repair approach is an open technique; however, in some cases of isolated bladder injury, it can be alternatively repaired by laparoscopy. A 28-years-old male who sustained a motor vehicle accident found to have isolated intraperitoneal bladder injury which was repaired laparoscopically. Cystogram after 2 weeks confirmed the successful outcome. Although laparoscopic repair technique found to be safe and efficient, careful patient selection is mandatory.

Outcomes of emergency appendectomies and cholecystectomies performed at weekends.

PURPOSE: To determine the impact of hospital admissions and operations at weekends on two common emergency general surgeries (cholecystectomy and appendectomy) and their outcomes. METHODS: A total of 539 patients were included in the study. Information on patient demographics, comorbidities, admission date, surgery date, complications, readmission, and follow-up details were collected from electronic medical records. RESULTS: Most patients were admitted to hospital on weekdays (n = 391), and 444 surgeries were performed on weekdays, while 86 surgeries were performed at weekends. No significant difference was found between the type of surgery performed on weekday and weekend admissions (P = 0.384). Surgical procedures of patients admitted to hospital on a weekend tended to be delayed by a median of one day compared with weekday admissions, with a similar overall length of stay for both groups. Weekend admissions were associated with higher complication rates than weekday admissions (12.2 vs. 6.1%). Patients who were operated on at weekends were younger in age than those admitted on weekdays (32 vs. 30 years old, P = 0.019). More appendectomies were performed at weekends (77.9% vs. 45.9%), and fewer cholecystectomies were performed (22.1 vs. 54.1%, P = 0.000). CONCLUSIONS: The surgical procedures of patients admitted to hospital on weekends tended to be delayed by 1 day and had a higher rate of complications. Appendectomy was the most common performed weekend surgery.

The prevalence of long-term rehabilitation following motor-vehicle crashes in Saudi Arabia: a multicenter study.

INTRODUCTION: In Saudi Arabia, motor-vehicle crashes (MVC) are the leading cause of disability-adjusted life years (DALYs). There is limited information locally on the magnitude and need for rehabilitation following MVC. This study examined the prevalence of MVC patients requiring long-term rehabilitation and the epidemiology of associated injuries. METHODS: A retrospective study was conducted at four hospitals of the National Guard Hospitals Affairs from January 2016 to March 2019. The study used data from an institutional trauma registry of all MVC admissions. Chi-square tests, bivariate and multivariate analyses were conducted to compare patients requiring long-term and short-term rehabilitation. RESULTS: The study included 506 patients. The study population was relatively young, with an average age was 32.8 ± 15.5 years, and the majority were males. Over two-thirds (71.3%) of patients required long-term rehabilitation. Half the patients sustained multiple fractures, and 17.0% sustained traumatic brain injuries. Overall, 53.1 and 61.8% of patients required occupational and physiotherapy, respectively. Those admitted to the intensive care unit were four times more likely to need long-term rehabilitation. CONCLUSIONS: We found a significant burden of long-term rehabilitation following MVC. Patients were relatively young, thus posing a significant burden on future healthcare utilization. Policymakers should use these findings to guide primary, secondary, and tertiary prevention to improve health outcomes.

Cost of healthcare rehabilitation services following road traffic injuries: Results from a Level-I trauma center in Saudi Arabia.

BACKGROUND: Road traffic injuries (RTIs) are the second leading cause of mortality in Saudi Arabia. The high rate of RTIs puts a strain on rehabilitation services. Yet, little is known of the economic burden of nonfatal RTIs and rehabilitation services. This study, therefore, aims to describe the annual rehabilitation costs associated with RTIs at a local trauma center. MATERIALS AND METHODS: This study was conducted among all the 17 years or older patients hospitalized at King Abdulaziz Medical City in Riyadh following RTIs and required rehabilitation care. We included 299 patients who met the inclusion criteria and were followed for one year after discharge from the index hospital. The data was abstracted through retrospective review of patients' medical records. All rehabilitative services utilized by the healthcare system were recorded. To describe the economic burden, the mean, median, standard deviation, and interquartile range (IQR) were calculated. Total costs were aggregated for all patients to estimate overall costs. RESULTS: The study population was relatively young (31 years ± 14.4). The total annual rehabilitation cost of patients was Saudi Riyals (SAR) 6,113,781 (IQR: 20,589.3 - 3,125 = 17,464.3), and the average for each patient was SAR 20,447 (median = 7875). Patients aged 40-59 years and ≥60 years accounted for the highest average rehabilitation cost of SAR 31,563.99 and 32,639.21, respectively. Rehabilitation visits incurred the highest cost (mean SAR 1,494,124), followed by bed utilization which cost SAR 1,311,972 and radiology examination at SAR 1,032,261. The cost of motorcycle injuries was relatively higher (SAR 44,441.0) than other injury mechanisms. CONCLUSION: This study underlines the economic burden of rehabilitation services resulting from RTIs. Public health interventions are needed to reduce the burden of RTIs by dealing with their preventable causes and improving road safety measures. These findings may be useful to policymakers and researchers to support and improve rehabilitation services in Saudi Arabia.

A case of intestinal obstruction in a 90-year-old patient at a tertiary hospital in Central Saudi Arabia with a rare cause: obturator hernia!

Obturator hernia is a pelvic floor type of hernia in which abdominal or pelvic contents protrude through the obturator foramen. It is considered rare in patients with signs and symptoms of intestinal obstruction causing a diagnostic challenge for clinicians. This case reports a 91-year-old multiparous female who presented with vague lower abdominal pain associated with obstipation and vomiting. We present a successful laparoscopic repair of obturator hernia in an elderly female.

Risk factors for the systemic inflammatory response syndrome and sepsis following surgical management of acute intestinal obstruction.

OBJECTIVES: Infection is one of the major complications following intestinal obstruction surgery, yet predictors of its occurrence are not sufficiently reported. In this study, we examine the factors leading to postoperative inflammatory response syndrome (SIRS) and sepsis. METHODS: The data of 213 patients who underwent intestinal obstruction surgery between 2015 to 2020 in King Abdulaziz Medical City, Riyadh, Saudi Arabia, were reviewed retrospectively. Patients' demographic characteristics and preoperative, intraoperative, and 30-day postoperative data were compared between patients who had postoperative SIRS/sepsis and patients who had no complications. RESULTS: Ninety-six patients (44%) developed SIRS/sepsis within 30 days after surgery. More than half of the patients were males (55.8%), and the mean age at operation was 56.7(SD=20.0)years. Preoperative high heart rate, low albumin levels, and postoperative intensive care unit (ICU) admission were independently and significantly associated with developing SIRS/sepsis post-operation. The mortality rate in this study was estimated to be 7.5%; of those, 93.8% had SIRS/sepsis. CONCLUSION: The 30-day mortality rate is considerably higher among patients who developed SIRS/sepsis after intestinal obstruction surgery. The independent risk factors of developing SIRS/sepsis after operation were elevated heart rate, low albumin levels preoperation, and ICU admission post-operation.

Infarcted wandering spleen: A case report from Saudi Arabia.

Spleen is normally positioned in the left upper quadrant. Abnormal location where it is not found in its normal anatomical position is called wandering spleen (WS). Wandering spleen is a rare medical condition that occurs due to developmental abnormality or acquired laxity of the ligaments that hold the spleen in its normal anatomical position. It affects children and young adults, especially childbearing age women. Patients affected with this condition may present with nonspecific symptoms requiring a high index of suspicion. Here, we are presenting a 20-year-old female known to have WS ended up with infarcted WS requiring emergency splenectomy.

Healthcare costs of road injuries in Saudi Arabia: A quantile regression analysis.

BACKGROUND: Road traffic injuries (RTIs) are the second leading cause of death in Saudi Arabia. Their economic burden is significant but poorly quantified, as limited literature exists locally. We aim to estimate the impact of RTIs on healthcare costs. METHODS: We included all patients from the hospital's trauma registry for the year 2017 (n = 381). Due to the availability of data, the analysis focused only on direct medical costs incurred during the hospitalization period. We computed the components of hospitalization costs and evaluated the association between patient and RTI characteristics and total hospitalization costs (the average and median) using quantile and log-linear regression techniques respectively. RESULTS: Patients were relatively young with an average age of 31 years (SD ± 14.6). Overall, patients treated for RTIs cost the hospital around 77,657 Saudi Riyal (SAR) on average. Pedestrian injuries incurred the highest costs. Motor vehicle injuries accounted for the highest procedure-related costs (SAR 19,537). The quantile regressions results suggest that Glasgow coma scale (GCS), admission to intensive care unit (ICU), and hospital length of stay were significantly associated with an increase in hospitalization cost. Hospital home disposition was however, associated with a decrease in cost. One additional day of stay in the hospital increases total hospitalization cost by SAR 3,508. Additionally, the log-linear showed injury severity score (ISS < 16) was associated with a 20% decrease in the geometric mean of the hospitalization costs (p < 0.001). CONCLUSIONS: This study underlines the economic burden of RTIs in addition to their impact on population health. The findings may be used to inform policymakers, researchers, and the public about the increasing burden of traffic crashes in the Kingdom. Public health interventions are warranted to reduce the severity and frequency of RTIs in order to improve traffic safety and reduce associated healthcare costs.

The Impact of COVID-19 Lockdown on Injuries in Saudi Arabia: Results From a Level-I Trauma Center.

Background: The COVID-19 pandemic has placed an enormous strain on global health. Due to precautionary measures, the epidemiology of health conditions may have been affected. Saudi Arabia imposed a lockdown order on March 25, 2020. This study investigated the impact of the pandemic lockdown on injuries in a level-I trauma center in King Abdulaziz Medical City, Riyadh, Saudi Arabia. Methods: This retrospective study identified all injured patients seeking emergency care during the lockdown period (March 25-June 21, 2020) and a similar period in two previous year (March 25-June 21) 2018 and 2019. The collected data included patients' demographics, injury types, mechanisms, and health outcomes. Results: Two hundred sixty nine injured patients sought emergency care during the lockdown, while 626 and 696 patients were treated in the same period of 2018 and 2019, respectively. There was a significant reduction in motor vehicle crashes (OR: 0.47; 95% CI: 0.31-0.73) and burns (OR: 0.24; 95% CI: 0.08-0.66), coupled with a significant increase in assault injuries (OR: 2.20; 95% CI: 1.30-3.74) in the lockdown period compared to 2019. Apart from the intensive care unit (ICU) admission and hospital length of stay, there were no differences between the two periods in the health outcomes. ICU admission was significantly reduced by 57% during the lockdown period (OR: 0.43; 95% CI: 0.22-0.83). Mechanisms of injuries were not significant predictors of deaths or ICU admission or both in the lockdown period. Conclusion: The COVID-19 lockdown had a clear impact on the volume and mechanisms of injuries. The findings highlight that injury risk factors are modifiable and emphasize the importance of public health measures for preventing injuries and the significance of maintaining trauma services capacity during pandemics.

Pilonidal sinus disease recurrence at a tertiary care center in Riyadh.

BACKGROUND: Pilonidal sinus disease (PSD) is a chronic inflammatory disease of the sacrococcygeal area. Pilonidal sinus recurrence is a matter of concern to both patients and healthcare providers. OBJECTIVES: Estimate the rate of PSD recurrence in our center and identify any risk factors contributing to disease recurrence. DESIGN: Retrospective. SETTING: Tertiary care center in Riyadh. PATIENTS AND METHODS: All patients who underwent surgery for primary or recurrent pilonidal sinus between 1 January 2016 to 30 June 2019 were included to allow for at least 1-year of follow-up at the time of data collection. MAIN OUTCOME MEASURE: Recurrence rate of PSD and risk factors for recurrence. SAMPLE SIZE AND CHARACTERISTICS: 369 patients: 329 males (89.2%) and 40 (10.8%) females. Median (interquartile range) age was 21 (18-26) years. RESULTS: Of the 369 included patients, recurrence was identified in 84 (22.8%) cases [95% confidence interval (CI) 18.6-27.4], and the mean timing of recurrence was 1.8 (1.6) years after the primary surgery. In a multivariate logistic regression analysis, increased age and post-operative seroma fluid discharge were independent risk factors for recurrence. In contrast, preoperative antibiotic prophylaxis and postoperative hair removal were effective in reducing recurrence. Type of surgery closure had no effect on recurrence, yet primary closure was associated with early onset of recurrence compared to secondary closure (P=.02). CONCLUSION: Our findings on the factors associated with recurrence of PSD are consistent with many reports in the literature. Reported prevalence estimates vary widely. LIMITATION: Single center, small sample size, retrospective. CONFLICT OF INTEREST: None.

Laparoscopic exploration of the retroperitoneum in a gunshot victim: A case report.

INTRODUCTION: Non-operative management and minimally invasive surgery reduce the burden of negative laparotomies in patients with penetrating gunshot wounds (GSW). Careful patient selection is key. Although challenging, in experienced hands laparoscopic exploration of the retroperitoneal space can be carried out. CASE PRESENTATION: A 38year old man was brought to the emergency room after sustaining a GSW to his right groin. Due to evidence of intoxication, clinical picture was unreliable, although the patient was hemodynamically stable and there were no signs of peritonitis. Furthermore, the presence of retained bullet fragments created significant artifact on imaging. Clinical and radiological uncertainty urged us to proceed with laparoscopic exploration. Following mobilization, the ascending colon wall was fully inspected and no injury was identified. The pelvic fracture was managed non-operatively. After an uneventful hospital course, the patient was discharged home in stable condition and outpatient follow up was re-assuring. DISCUSSION: Avoiding morbidity from missed colonic injury is important, particularly in patients with unclear clinical and radiological findings, that were present in our case. Non-operative management by serial examination and minimally invasive surgical techniques are considered an alternative to the classical exploratory laparotomy approach. Furthermore, utilization of laparoscopy in retroperitoneal injury has gained much attention in the recent years particularly in well-established centers. CONCLUSION: Laparoscopic exploration is a safe and effective surgical approach in patients who have sustained GSW to the abdomen and to the retroperitoneal space. However, it requires careful patient selection and surgical expertise.

Successful surgical management of a through-and-through right atrial penetrating injury with a complete transaction of the right internal mammary artery: a case report.

An injury to the pericardium or the great vessels is considered a true medical emergency, with a poor survival rate. The early identification and immediate response from all the medical services play a significant role in the management of this type of injury. In this case report, we report a young male patient brought to the emergency room (ER) after sustaining two stab wounds to the chest. We present the successful management of the patient from admission to the ER until discharge a few days later, after a successful surgical intervention for a penetrating cardiac injury.

The prevalence of head and facial injuries among children in Saudi Arabia following road traffic crashes.

BACKGROUND: Motor vehicle crashes (MVCs) are the leading cause of death among children in Saudi Arabia. Childhood injuries can be prevented or minimized if safety measures, such as car seats, are implemented. The literature on the epidemiology of head and facial injury among children is limited, which affects the ability to understand the extent of the burden and hinders investment in public health prevention. OBJECTIVE: Describe the epidemiology of head and facial injuries among children admitted to the hospital following MVCs. DESIGN: Retrospective chart review. SETTING: Five hospitals in several regions. PATIENTS AND METHODS: We collected data on all patients ≤16 years old, who were admitted to the hospital following MVCs between 2016-2019. Differences in various characteristics like head injury status and age groups were compared. MAIN OUTCOME MEASURES: Head and facial injuries. SAMPLE SIZE: 253 patients. RESULTS: Of the injured population, 97 (38.3%) sustained a head injury, and 88 (34.8%) had a facial injury. Thirteen (9.1%) children were driving the car at the time of the crash. About half of the children were seated in the back (53.8%) without a seatbelt or safety seat. CONCLUSION: The prevalence of head and facial injuries is striking. In addition, the study revealed that driving among children is not uncommon, which warrants monitoring and implementing interventions. Improved documentation of restraint use and police enforcement of safety laws can play a significant role in reducing associated injuries. The study findings highlight the importance of combination or rear seating as well as age-appropriate restraint in order to reduce the likelihood of head or facial injuries among children. LIMITATIONS: Retrospective study using the electronic search system to identify patients, but may have missed cases that were not coded correctly. Large amount of missing data for some variables. Additionally, the analysis was limited to those admitted to the hospital. CONFLICT OF INTEREST: None.

The association between family cohesion and disability following blunt trauma: findings from a level-I trauma center in Saudi Arabia.

BACKGROUND: Injuries pose a significant burden on population health of Saudi Arabia. Even in nonfatal injuries, the burden varies from temporary to permanent disabilities. Health outcomes following injuries can vary, and predictors of recovery from disability are not well understood. In the Kingdom, family values and cohesion can differ from other countries due to several factors, including religious beliefs and cultural traditions. Learning about predictors of injury recovery can improve prevention as well as planning for rehabilitation programs. Therefore, the study aims to evaluate the association between family cohesion and recovery following blunt injuries. METHODS: This prospective study included 249 patients who were hospitalized for at least 1 day following blunt trauma in King Abdulaziz Medical City, Riyadh. Adult patients were interviewed twice: initially during admission, and a second interview via the phone 3 months after discharge. Baseline information included: demographics, injury characteristics, the five dimensions EQ-5D and family support scale. The follow-up interview captured only EQ-5D. Suboptimal family cohesion was defined as any issue with the relationship with parents, spouse, or siblings. Any disability was defined as a reported limitation in one or more domains of the EQ-5D scale. Logistic regression was used to assess the association between family cohesion and recovery at 3 months. RESULTS: Of the overall sample, 169 (67.8%) responded to the second interview, and three patients passed away. About 95.2% of patients reported disabilities at baseline, while 88.1% continued to report disabilities after 3 months. Forty patients (16.1%) reported suboptimal family cohesion. Of these patients, 37(94.87%) were in pain, 33(82.5%) reported problems with usual activities, 32(80%) faced problems with self-care, 32 (80%) patients had difficulty in mobility, and 23(57.5%) were depressed. Multivariable regression suggested that patients with suboptimal family cohesion were less likely to recover from disabilities. CONCLUSION: The prevalence of any disability 3 months after discharge is striking. This study suggests that health outcomes after blunt trauma are affected by the strength of the patient's family cohesion. More research is needed to identify effective ways through which the provision of social support can reduce short term disability after trauma.

The incidence and predictors of pneumothorax among trauma patients in Saudi Arabia. Findings from a level-I trauma center.

OBJECTIVES: To investigate the incidence and predictors of traumatic pneumothorax using data from a Level-I trauma center in Riyadh, Saudi Arabia. METHODS: This is a retrospective chart-review study carried out in King Abdulaziz Medical City, Riyadh, Saudi Arabia. Data were extracted from the hospital's trauma registry (2016-2018). A total of 2,109 trauma patients were included. Inclusion criteria were patients ≥16 years  old admitted for a traumatic injury. Variables included patient demographics, transport mode, trauma team activation, mechanism of injury, mortality rate, Glasgow Coma Scale and Injury Severity Scores. A logistic regression analysis was constructed to evaluate potential predictors of pneumothorax. Results: Of 2,109 patients included from the trauma registry, 236 (11.2%) were diagnosed with pneumothorax. The majority of the study population was young (19-49 years) (60.7%) and male (79.4%.) Injury mechanism was significantly associated with the presence of pneumothorax (p greater than 0.001). Regression analysis indicated that the odds of having pneumothorax among intentional injury victims was 15 times higher than fall injury victims (OR=15.3, 95% CI= 7.2-32.9). Participants who sustained motor vehicle collision injuries had 3 times higher odds of developing pneumothorax than those who suffered fall injuries (OR=3.1, 95% CI= 1.5-6.1). Conclusion: The incidence of traumatic pneumothorax is sizable and highly associated with the mechanism of injury. Efforts to reduce motor vehicle collision burden should be directly associated with decreasing the burden of traumatic pneumothorax.

Appendiceal diverticulitis presenting as acute appendicitis diagnosed postoperatively.

Appendiceal diverticular disease is a rare entity. We report a case of appendiceal diverticulitis mimicking acute appendicitis and diagnosed postoperatively on histopathology. A 28-year-old female presented with a 2-day history of shifting periumbilical pain associated with nausea and anorexia. A computed tomography scan of the abdomen demonstrated acute appendicitis. She was taken to laparoscopic appendectomy. Histopathology showed appendiceal diverticulitis, and perforation of an inflamed diverticulum with periappendicitis. Diverticulosis of the appendix is classified as congenital and acquired. Diagnosis can be made preoperatively by imaging. In this case, diverticulosis was not radiologically evident, and was interpreted as acute appendicitis. Gross appearance of the resected appendix was not suggestive of diverticulitis. Other cases reported that the gross specimen had evidence of diverticular disease. Surgeons should be aware that inflamed appendixes may harbor different pathologies warranting further management.

The Association between Mobile Phone Use and Severe Traffic Injuries: A Case-Control Study from Saudi Arabia.

Road traffic injury (RTI) is the third leading cause of death in Saudi Arabia. Using a mobile phone when driving is associated with distracted driving, which may result in RTIs. Because of limited empirical data, we investigated the association between mobile phone use and RTI in injured patients and community controls in Riyadh. Cases were patients admitted to King Abdulaziz Medical City (KAMC) between October 2016 and March 2018 due to RTIs. During admission, mobile phone use at the time of the accident was investigated. The controls were drivers observed at various locations citywide. A logistic regression model was constructed to estimate the association between mobile phone use while driving and sustaining RTIs. We included 318 cases and 1700 controls. For the cases, using a mobile phone was associated with higher severity and prevalence of disability. In addition, using a mobile phone while driving is associated with 44% higher odds of incurring a severe RTI (p = 0.04). Mobile phone use while driving is prevalent in Riyadh and pose a significant threat of disability. In addition, the low prevalence of seatbelt use is alarming and requires significant improvement. Prevention programs may use these findings to educate the public and policymakers and to advocate for increased visibility of enforcement to reduce RTIs and improve population health.

Injuries following motorcycle crashes at a level-1 trauma center in Riyadh.

BACKGROUND: Motor vehicle crashes are the third leading cause of death in Saudi Arabia. Motorcycle riders, in particular, are considered more vulnerable than occupants, yet there are no previous studies that have examined the epidemiology of their injuries and outcomes in the country. Better understanding is needed to inform policymakers and guide future prevention programs. OBJECTIVE: Describe patterns of injury among conscious and unconscious patients injured in motorcycle crashes. DESIGN: Retrospective chart review. SETTINGS: Level 1 trauma center in Riyadh. PATIENTS AND METHODS: This retrospective study included all patients involved in motorcycle crashes who were admitted between 2001 and 2017. Medical records were reviewed, and data about injury characteristics, outcomes and healthcare utilization were ascertained. MAIN OUTCOME MEASURES: Injury site and mortality rate. SAMPLE SIZE AND CHARACTERISTICS: 572 patients included 488 males (85.3%) and 232 <18 years of age (40.5%), mean (SD) age 21.1 (11.6) years. RESULTS: About 3% of patients died either before or after admission. Extremity injuries (356, 62.2%) were most common followed by head injuries (229, 40%). Fifty-six (9%) suffered amputation, mostly to a lower limb. CONCLUSION: This study underscores the significant burden of motorcycle-related injuries on population health of Saudi Arabia. The number of amputations due to motorcycle injuries is striking. Therefore, we need to increase enforcement of safety measures during recreational use of motorcycles and to raise awareness about the dangers of motorcycle crashes to improve traffic safety and ultimately population health. LIMITATIONS: The study was conducted at a single hospital which may affect the generalizability of the data to the Saudi population. CONFLICT OF INTEREST: None.