Evaluating the Diagnostic Accuracy of the Alvarado Score and Abdominal Ultrasound for Acute Appendicitis: A Retrospective Single-Center Study.

Background: Acute appendicitis is a complex diagnosis that often requires both clinical and radiological evaluation. Significant variations in diagnostic approaches are evident among clinicians and healthcare institutions. While certain guidelines advocate for risk stratification based on clinical characteristics, others emphasize the importance of pre-operative imaging. This study seeks to explore the accuracy of the Alvarado Score and abdominal ultrasound (AUS) in diagnosing acute appendicitis. Methods: Suspected cases of appendicitis admitted to Al-Thora Hospital in Ibb, Yemen, from Jan 2021 to July 2022 were evaluated. The demographics, clinical, and laboratory data were collected and analyzed. This study assessed Alvarado scores (calculated based on clinical evaluation and laboratory data) and pre-operative AUS findings, correlating them with post-operative and histopathology findings. The Alvarado scores and AUS sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) were assessed using the ROC curve. Results: Out of 1021 cases of acute abdomen, 171 patients were suspected of appendicitis. Using AUS along with the Alvarado score, appendicitis was presumed in 137 patients who underwent appendectomy. 130 (94.9%) patients had positive intraoperative and histopathology findings while 7 (5.1%) had negative findings. The Alvarado Score had a sensitivity and specificity of 94.62% and 87.80% at cutoffs of 6, respectively [Area under the curve (AUC): 0.985; 95% confidence interval (CI), 0.954 to 0.998; p < 0.0001]. Abdominal US showed a sensitivity of 98.46% and specificity of 82.93% (AUC:0.907; 95% CI, 0.853 to 0.946; p < 0.0001). Conclusion: Alvarado's score and AUS exhibited high sensitivity and specificity in diagnosing acute appendicitis. The substantial accuracy and efficacy of both the Alvarado score and AUS support their utilization as primary investigative tools in resource-limited settings. This approach can help avoid unnecessary appendectomies and minimize the financial burden on patients.

Acute appendicitis poses a diagnostic challenge, with a high rate of false-positive cases identified post-operatively. Computed tomography has been recommended by several surgical societies; however, it is limited by unaffordability and unavailability. Herein, we utilized the Alvarado score along with abdominal ultrasound as an alternative accurate, and cost-effective diagnostic approach. In this study, the negative appendectomy rate was 5.1%. The sensitivity of abdominal ultrasound in detecting appendicitis was 98.5%, with a specificity of 82.9%. The positive predictive value, negative predictive value, and accuracy were determined to be 94.8%, 94.4%, and 94.7%, respectively. The mean Alvarado score was 6.9±2.4, with a sensitivity and specificity of 97.81% and 97.06% at cutoffs of 6, respectively. The area under the curve values of the ROC curve for Alvarado's and abdominal ultrasound were 0.985 (95% CI, 0.954 to 0.998) and (AUC:0.907; 95% CI, 0.853 to 0.946), which was statistically significant (p < 0.0001).

Utility of perioperative ultrasonography and fine-needle aspiration cytology in differentiation between benign and malignant cervical lymphadenopathy: a retrospective cohort study.

Background: The preoperative differentiation of benign form malignant cervical lymphadenopathy (CLA) is crucial in determining the need for surgical intervention. This study aims to assess the diagnostic performance of ultrasonography (US), fine-needle aspiration cytology (FNAC), and their combination with the postoperative histopathological diagnoses of CLA. Method: In a retrospective study between April 2021 and May 2023, 214 patients with CLA were assessed with preoperative US and FNAC. The morphological parameters, including tissue margins, vascularity, and fatty hilum echogenicity, were collected and analyzed retrospectively. The diagnostic efficacies of US, FNAC, and their combined use were compared to the postoperative histopathological findings. Result: In the final histopathological examination, 185 cases (86.4%) were found to be benign, while 29 cases (13.6%) were determined to be malignant. The US features of fatty hilum, echogenicity, and vascularity pattern had the highest diagnostic accuracy in characterizing CLA patterns, with values of 88.3%, 85.5%, and 85.0%, respectively. The receiver operating characteristic (ROC) curve showed a significantly higher area under the curve (AUC) value of 0.883 (95% CI: 0.832-0.923; P<0.0001) for the combined use of all US parameters with better sensitivity (93.10%) and specificity (68.65%) than individual parameters. The overall sensitivity, specificity, and accuracy of FNAC were 97.3%, 82.8%, and 95.3%, respectively. Additionally, US parameters and FNAC together showed a significantly higher AUC value of 0.924 (95% CI: 0.880-0.956; P<0.0001) and achieved a sensitivity of 86.21% and specificity of 88.65%. Conclusions: The combined use of US and FNAC provides high sensitivity, specificity, and diagnostic accuracy in characterizing CLA patterns. In limited-resources settings, this approach is feasible, less invasive, and cost-effective, thereby enabling clear management strategies and avoiding additional surgical interventions.

Microsurgical Digits Replantation in Resource-Limited Setting: A Retrospective Study.

Background: This article aims to share our experiences with microsurgical finger replantation in a resource-limited setting. Methods: This multi-institutional, retrospective study included 21 cases of finger amputation that underwent microsurgical replantation, within 7 years period. Patient demographics, preoperative assessments, surgical approaches, and outcomes were documented and analyzed. A univariate analysis was performed to obtain factors associated with digit reimplantation failure. Results: Out of 21 cases included, 8 (38.1%) had complete amputations and 13 (61.9%) had incomplete amputations. Crush injuries accounted for the majority (71.4%). On average, 2.2 ± 1.1 digits were affected, with the ring finger being the most commonly injured (71.4%). The mean operative time was 121.5 ± 26.8 minutes. The success rate of digit replantation was 76.2%. During a mean follow-up of 14.3 ± 3.7 months, 85.7% of successfully replanted digits considered their replantation results satisfactory. The majority of replanted digits demonstrated active and effective holding and grasping abilities without pain or instability (76.2%). Replantation failure was associated with a higher number of affected digits (p < 0.001), longer operative time (p = 0.004), complete avulsion (p = 0.003), current smoking (p = 0.025), diabetes (p = 0.006), hypertension (p = 0.047), procedure difficulty score (p= 0.004), and occurrence of complications (p < 0.001). Conclusion: Microsurgical finger replantation can yield favorable outcomes and acceptable survival rates, even within resource-limited settings. However, this procedure requires specialized equipment and personnel that may not be available at all institutions. Influential factors in digit replantation failure, include an increased number of damaged digits, extended operative duration, complete avulsion, current smoking, diabetes, hypertension, procedure difficulty score, and postoperative complications occurrence.

Small Bowel Obstruction in Virgin Abdomen: Predictors of Surgical Intervention Need in Resource-Limited Setting.

Background: Limited evidence is available regarding the management of small bowel obstruction in the virgin abdomen (SBO-VA), with most studies excluding this entity. This study aims to assess the available data on the treatment outcomes and predictors of surgical intervention in SBO-VA. Methods: A retrospective cross-sectional study was conducted between 2015 and 2021, including all diagnosed and managed cases of SBO-VA at Al-Nasar Hospital. Patients were divided according to the treatment approach into surgical or conservative groups. Preoperative laboratory and radiologic data were gathered and compared between groups. Results: During the study period, 67 cases, primarily males (58.2%), with an average age of 52.2±14.4 years were assessed. Common comorbidities included diabetes (20.9%) and hypertension (16.4%). Key symptoms were rebound tenderness (82.1%) and abdominal tenderness (70.1%). The predominant etiology was adhesions (23.9%). About 46.2% received conservative treatment, 53.8% underwent urgent surgery. Conservative treatment failed in 9.4% of cases, and complications arose in 23.9%, with most being fever (17.9%). Factors necessitating surgical management included older age (58.8 ±11.7 vs 44.9 ±13.8 years, p<0.001), previous hospital admission (p<0.001), presence of abdominal tenderness (p=0.030), longer abdominal pain duration (4.0 ±0.9 vs 2.1 ±0.6 days, p<0.001), higher C- reactive protein (p= 0.033), higher white blood cell (p= 0.006), longer time to hospital presentation (75.3 ±17.2 vs 39.0 ±22.8 days, p= <0.001), small bowel thickness ≥3 cm (p=0.009), and reduced bowel enhancement (p <0.001) on computed tomography imaging. In surgical group, the need for ICU admission was higher and hospital stays were shorter than in conservative group and were statistically significant (p<0.05). Conclusion: The main etiology of SBO-VA in our study was adhesions. Older age, previous hospital admission, longer abdominal pain duration, abdominal tenderness, increased inflammatory markers, and alarm signs on CT scans are the main factors for determining the need for urgent surgical exploration in patients with SBO-VA. To achieve prompt identification and intervention, it is crucial to maintain a high level of vigilance and awareness, even in individuals with no prior surgical history.

Idiopathic high-flow priapism in a 4-month-old infant: A case report and review of literature.

Key Clinical Message: High-flow priapism in pediatric population is rare, yet comprehensive clinical evaluation, along with penile Doppler ultrasound, and cavernosal blood analysis are crucial for accurate diagnosis. Conservative therapy is effective as an initial treatment. Abstract: High-flow priapism is considerably rare in the pediatric age group. We report a four-month-old infant presented with a prolonged penile erection. Diagnostic confirmation was achieved through the utilization of Doppler ultrasound and cavernous blood gas analysis. We also review published data on the management of this condition.

Management of Retrosternal Goiter in Resource-Limited Settings: Outcomes From 28 Cases Using Cervical Approach.

Background Despite thyroidectomy being the preferred approach for retrosternal goiter (RSG), controversies surround its rationale in asymptomatic cases. This study aimed to investigate the treatment of RSG in resource-limited settings. Methods A retrospective study conducted between April 2010 and June 2022 included 28 RSG cases who underwent thyroidectomy using the cervical approach at Al-Nasar Hospital, Ibb, Yemen. A bivariate analysis was performed to investigate the risk factors for postoperative complications. Results The main age was 49.4±9.9 years, and most of them (60.7%) were females. The main symptoms were cervical mass appearance and breathing difficulty in 75 %, and 32.1%, respectively. Twenty-four (86%) cases were classified as Grade 1 (above aortic arch) and four (14%) cases were classified as Grade 2 (aortic arch to the pericardium). All patients underwent total thyroidectomy through the cervical approach without needing sternotomy. The mean operative time was 121.9±26.7min (99-200 min) and the mean intraoperative bleeding was 321.2±137.4 mL. Postoperatively, the malignant entity was histopathologically proven in seven patients (25%). The postoperative complications (14%) were transient hypocalcemia in two (7.1%) and hematoma in two (7.1%). Older age, bigger thyroid mass, extension below the aortic arch (Grade 2), longer operative time and bleeding, intensive care unit admission, and malignant features are associated with postoperative complications (all p < 0.05). Conclusion Cervical approach for patients with RSG in our experience is an optimum, feasible, and less invasive surgical approach, in a resource-limited setting. Older age, bigger thyroid, extension below the aortic arch, longer operative time and bleeding, intensive care unit admission, and malignant features are associated with postoperative complications.

Prognostic determinants and treatment outcomes of Fournier's Gangrene treatment in a resource-limited setting: A retrospective study.

BACKGROUND: Fournier's gangrene (FG) is a destructive necrotizing infection with a generally poor prognosis. This study aims to share our experience in handling FG patients in a resource-limited setting and identify prognostic factors for FG mortality. METHODS: A retrospective study of thirty-six patients diagnosed with FG and treated at our teaching hospital between Jun 2010 to Oct 2022 was conducted. Laboratory and nonlaboratory data and patients' outcomes were gathered. A univariate analysis was computed for identifying prognostic factors for FG mortality. RESULT: The main age was 68.30 ± 5.61years and most (69.4%) were older than 65 years. The overall survival was 63.9% and the mortality rate was 36.1%. Univariate analysis showed that advanced age (p = 0.02), delayed in hospital presentation (p = 0.024), involvement of larger area (p = 0.001), a history of diabetes mellitus (p < 0.006), end-stage renal disease (p = 0.018), heart failure (p = 0.005), cerebrovascular accident (p = 0.003), liver cirrhosis (p = 0.001), presence of multiple comorbidities (p = 0.001), septic conditions at admission (p = 0.048), need for mechanical ventilation (p = 0.001), hypoalbuminemia (p < 0.001), and elevated blood urea nitrogen (p = 0.002) were found to be risk factors for mortality in patients with FG. CONCLUSIONS: Fournier's gangrene is a fulminant condition with a high mortality rate, especially in resource-limited settings. In this study, the mortality rate was 36.1%. Advanced age, delayed in hospital presentation, involvement of larger area, a history of diabetes mellitus, end-stage renal disease, heart failure, cerebrovascular accident, liver cirrhosis, presence of multiple comorbidities, septic conditions at admission, need for mechanical ventilation, hypoalbuminemia, and elevated blood urea nitrogen were associated with FG mortality.

Surgical management of penoscrotal hypospadias in a child with Opitz G/BBB syndrome: a case report.

Opitz G/BBB syndrome is a rare condition characterized by three significant anomalies; hypertelorism, cleft lip and palate, and hypospadias. However, other anomalies may be associated. Herein, we report a 4-year-old child presented with penoscrotal hypospadias. On examination, hypertelorism and cleft lip and palate were noticed, suggesting a diagnosis of Opitz G/BBB syndrome. The cleft lip was corrected in the first year, and a two-staged surgical approach was implemented for penoscrotal hypospadias. In the first stage, the chordee was corrected and urethral plate was reconstructed using a tabularized incised plate urethroplasty and testicular tunica vaginalis flap. In the second stage, the remanent hypospadias was corrected, and the meatal opening reached its normal location. In conclusion, a two-staged surgical approach for the treatment of penoscrotal hypospadias associated with Opitz G/BBB syndrome may provide excellent outcomes in early-recognized cases. The urologist should pay attention to abnormal facial characteristics in patients with hypospadias.

Iatrogenic Ureteral and Colonic Injuries During Emergency Cesarean Section: A Lesson Learned from a Surgical Catastrophe - A Case Report.

Introduction: Iatrogenic concomitant ureteral and colonic injury in emergency cesarean section (C-section) is an exceedingly rare, yet, catastrophic complication and has not been reported to our knowledge. Case Report: A 30-year-old woman presented with decreased urination for 2 days after a C-section. Ultrasonography showed severe left hydronephrosis and moderate abdominal free fluid. A ureteroscopy revealed a total occlusion of the left ureter, and subsequently, a ureteroneocystostomy was performed. Two days later, the patient was complicated with abdominal distension that necessitated re-exploration. The exploration revealed colonic injury (rectosigmoid), peritonitis, endometritis, and ureteral anastomosis disruption. A colostomy, repair of colonic injury, hysterectomy, and ureterocutaneous diversion were performed. The patient's hospital stay was complicated, with stomal retraction requiring operative revision and wound dehiscence, which was treated conservatively. After 6 months, the colostomy was closed, and the ureter was anastomosed via the Boari-flap procedure. Conclusion: Injuries to the urinary and gastrointestinal tracts are serious complications of a cesarean section; concurrent involvement is exceedingly rare; however, delayed recognition and intervention can worsen the prognosis.

Microsurgical reconstruction of the enormous traumatic oromandibular defect by osteocutaneous fibula-free flap in a 9-year-old child: a case report.

Enormous oromandibular defects in children remain a reconstructive challenge due to the region's unique features and the scarcity of a perfectly matched recipient site. The osteocutaneous fibula-free flap (OCFFF) is an excellent option for these defects. Most reports on oromandibular reconstruction in children are limited to surgical techniques instead of long-term follow-up, especially in resource-limited settings. We reported a 9-year-old child who presented with a massive oromandibular defect caused by a high-energy gunshot. Firstly, the patient was treated with debridement, lower defect edges approximation, and tracheostomy. After one week, the procedure of OCFFF was performed, and two months later, the lower lip was reconstructed using a tongue flap. The aesthetic outcome was excellent at two years, and the patient could speak and eat without impaired oral function. In conclusion, microsurgical reconstruction using OCFFF for massive oromandibular defects in our child patient was safe with satisfactory facial aesthetics and oral function.

Transient urocolpos due to vesicovaginal reflux in a 37-year-old woman: a case report.

Urocolpos is a urine collection in the vagina, possibly due to vesicovaginal reflux (VVR) or a fistula. Urocolpos is a rare phenomenon in adults, and it is commonly underrecognized by radiologists. The occurrence of urocolpos due to VVR after a Caesarean section in adult females is a rare phenomenon; failure to recognize it may lead to misdiagnosis as vesicovaginal fistula and often leads to unnecessary medical interventions. We report a 37-year-old female who complained of abdominal pain and intermittent daytime urinary incontinence for six months, starting after a Caesarean section for her third baby. An abdominal computed tomography scan revealed a large fluid-filled vagina on a full bladder without anatomical abnormality. A post-voiding scan showed a complete resolution. In conclusion, urocolpos is an underrecognized entity that rarely coexists with VVR. Post-voiding resolution and vaginal contrast reflux are important findings that can aid radiologists in identifying such cases.

Synchronous occurrence of papillary thyroid carcinoma and early esophageal squamous cell carcinoma in a 45-year-old female: a case report and review of the literature.

Papillary thyroid cancer (PTC) coexistent with esophageal squamous cell carcinoma (SCC) is of rare occurrence. We report a 45-year-old female who presented with painless anterior neck swelling for the past year. Ultrasonography showed a left hypoechoic thyroid mass measured 20x13 mm without lymph node enlargement. The fine-needle aspiration cytology was suggestive of PTC. Consequently, total thyroidectomy with bilateral neck dissection was performed. Incidentally, a small mass measuring 4x2 cm arising from the esophageal wall was identified and resected. Postoperatively, the patient developed a small esophageal fistula which was treated conservatively. The histopathological examination confirmed the diagnosis of PTC and SCC of esophageal mass. The patient underwent radiotherapy, and radioactive iodine therapy, and had acceptable conditions within two years of follow-up. In conclusion, even though the coexistence of PTC and esophageal SCC is rare, the possibility of concurrence of both tumors should be considered if an incidental mass was identified intraoperatively.

Assessment of demographic characteristics and histopathological pattern of thyroidectomies patients in a resource-limited setting: a retrospective cross-sectional study.

Thyroid disorders are prevalent among Yemenis. However, there is limited data regarding thyroid disease burden, surgical intervention outcomes, and predictive factors in our country. This study aims to review the indications, histopathology, and complications of thyroid surgery in a resource-limited setting where the management is provided primarily by general surgeons. A retrospective study between Jun 2010 and March 2019 included 246 cases who underwent thyroid operations for a thyroid disorder in Al-Nasr Hospital, Ibb, Yemen. The patient's demographic characteristics, operative findings, complications, fine needle aspiration biopsy (FNAB) results, final pathology, and outcomes were gathered and analyzed. The mean age was 41.60± 8.31 years. The prevalence was high (30.1%) in the age group of 31-40 years and females (87.8%) with a female-to-male ratio of 7.2: 1. The main indication for thyroidectomy was compressional symptoms (35%), and the main preoperative cytology findings were multimodular goiter (89%). There was thyroid cancer in 18(7.3%) patients, and the most type was follicular thyroid carcinoma (FTC) in 9 patients. The most typical type of surgery was near-total thyroidectomy in 186 (75.6%) patients. Complications were presented in 47 patients (19.1%), and total mortality was observed in 5(2.03%) patients. Intraoperative bleeding was the most typical complication in 36 (14.6%) patients. The sensitivity, specificity, and accuracy of FNAB were 96.34%, 44.44%, and 96.34%, respectively. Fine needle aspiration biopsy (FNAB) was not precise enough in diagnosing FTC with a sensitivity of 55%. Our result showed a considerable rate of postoperative complications of thyroid surgery, and thyroidectomy may be a viable option even in a resource-limited setting or performed by general surgeons.

Role of microsurgical free flap reconstruction in managing complex wound: a retrospective cross-sectional study.

Introduction: while reconstruction of complex wounds with severe tissue defects has been a significant problem in plastic surgery, free flap microsurgical procedures could solve many of these problems. In Yemen, data regarding free flap microsurgery for complex wounds are scarce. This study aimed to share our microsurgery experiences in repairing complex wounds using different free flaps in a resource-limited setting. Methods: a retrospective cross-sectional study between April 2019 and June 2022 conducted at 21 University-affiliated hospitals included 30 patients with complex wound defects that were not amenable for regional, pedicle procedures, or skin grafts and underwent microsurgical reconstructions with deferent free flap tissue transfer. The primary outcome was flap survival or failure, while the secondary outcome was postoperative complications. Results: the main age was 34.76 ± 16.88 years, with 24 (80%) males and 6 (20%) females. Replacing extensive tissue loss caused by road traffic accidents was the most common indication (36.6%). The mean defects required to be reconstructed were 84.9 ± 44.70 cm2. The lower extremities accounted for the majority of reconstructed defects (50%), and mostly (23.3%) involved the leg. Only 10 (33.3%) flaps were performed immediately within 48 hours of trauma. The fibulae osteo-cutaneous free flap (30.0%), radial forearms free flap (23.3%), and anterolateral thigh flap (23.3%) were used most commonly. All flaps were harvested and repaired under loupe magnification or operative microscope by a single surgeon. The overall flap success rate was 83.3%. The total complication rate was 23.3%, and postoperative infection and partial flap necrosis occurred in 3 (10.0%) and 2 (6.6%) patients, respectively. A total flap loss occurred in 5 (16.7%) patients. Conclusion: reconstruction of complex wounds with microsurgical free flaps is a viable option even in a resource-limited setting. In our study, microsurgery with fibulae osteo-cutaneous free flap was the most commonly used. Despite many limitations, microsurgical free flaps were effective in treating individuals operated on in our setup with a limb salvage rate of 83.3%.

Primary huge gastric leiomyosarcoma with multiple metastases in a 60-year-old female: a case report.

The incidence of leiomyosarcomas (LMS) has declined drastically. In fact, the introduction of immunohistochemistry (IHC) helped to differentiate LMS from other gastrointestinal stromal tumors (GIST) by receptor tyrosine kinase (KIT)-mutation detection making gastric LMS a sporadic tumor recently. We report a 60-year-old female who presented with a three-week history of abdominal pain. An abdominal computed tomography scan showed a large exophytic mass (22 ×19 ×15 cm) arising from the greater curvature of the stomach with multiple metastases. A biopsy was taken, and the initial histopathological examination was suggestive of GIST. However, further histopathological examination confirmed a high-grade gastric LMS. The patient refused any surgical intervention. Therefore, the patient had only received chemotherapy. On 9-month follow-up, the patient is still alive without disease progression. In conclusion, gastric LMS is a rare tumor. Due to the possibility of being misdiagnosed with other GIST, extensive pathological evaluation through specialized experts and IHC analysis is recommended.