Surgical Management of Intra-gastric Balloon Complications, Single-Center Experience, and Literature Review.

INTRODUCTION: In Saudi Arabia, the prevalence of obesity has multiplied in the last decades leading to a surge in bariatric surgery and other endoscopic modalities. The intra-gastric balloon (IGB) is the most used endoscopic modality. Surgical management for IGB complications is required for gastrointestinal perforation and/or obstruction. However, the literature seems to underestimate these complications. MATERIALS AND METHODS: A retrospective descriptive study was conducted in King Fahd University Hospital, Saudi Arabia, from Jan 2017 to Dec 2021, including all patients with complicated IGB who necessitated any surgical procedure. Exclusion criteria were patients with complicated IGBs that were only managed conservatively or endoscopically. RESULTS: A total of 326 patients were admitted with different complications after bariatric procedures. Of them, six patients were referred due to IGB complications that necessitated operative intervention. All patients were young females. Three patients had gastric wall perforation, and were managed by endoscopic removal of the IGBs followed by exploratory laparotomy. One patient had an intestinal obstruction on top of a migrated IGB that was surgically removed. One patient had failed endoscopic retrieval of IGB and required a laparoscopic gastrostomy. Another patient had an esophageal rupture that required left thoracotomy, pleural flap, and insertion of an esophageal stent. All cases were discharged and followed up with no related complications. CONCLUSION: IGB is an endoscopic alternative, within specific indications, for the management of obesity. However, surgical management may be necessary to manage its complications, including gastrointestinal perforation, IGB migration, and failure of endoscopic removal.

Emergency versus elective cholecystectomy: Experience at a university hospital in the Eastern Province, Saudi Arabia.

BACKGROUND: Laparoscopic cholecystectomy (LC), the procedure of choice for treating most gallbladder pathology, has become the most trusted elective procedure for treating gallstone disease because of its effectiveness and safety. While the timing is an important factor in those cases, our aim in this study was to compare emergency and elective LC, determine the differences in postoperative complications, and assess the conversion rate to open cholecystectomy. MATERIALS AND METHODS: This study included a total of 627 patients who had undergone laparoscopic cholecystectomy during 2017-2019 at King Fahd Hospital of the University (KFHU). Records of both emergency and elective cases were reviewed from Quadra-med (software package). All demographic data of the patients, presenting complaint, laboratory and inflammatory marker, type of the operation, intraoperative complications, procedure time, conversion rate from laparoscopic to open cholecystectomy, postoperative period, length of hospital stay, and pathological diagnosis were entered into an Excel sheet. The data was analyzed using SPSS 23.0. Qualitative variables were described as frequencies and percentages, and continuous variables were summarized with mean and standard deviation (SD). Chi-square test, t-test, and the Mann-Whitney U-test were applied to test for statistical significance at P ≤ 0.05. RESULTS: The mean age for patients undergoing elective LC was 39.94 years (SD=13.56) whereas, mean age of patients undergoing emergency LC was 40.64 years (SD=13.02). About 71% of cases in elective LC group were females compared to 55% in the emergency LC group. There was a significant difference in C-reactive protein (CRP) in relation to the type of surgery where P < 0.05. Twelve (1.9%) patients had subtotal cholecystectomy and two cases converted from LC to open. There was a significant association between postoperative complication and the type of surgery. The length of hospital stay (LOS) was also found to be significantly more in patients having emergency LC (6.0 vs. 4.5 d; P < 0.05). CONCLUSION: The relation between conversion to an open procedure and type of surgery (elective or emergency) in our study was nonsignificant. There was a significant association between preoperative CRP, postoperative complication, length of hospital stay, and type of surgery. Further multicenter studies are required for further investigation.

Jejunal diverticulosis: A case report.

INTRODUCTION: Jejunal diverticulosis is a rare entity that presents a challenging diagnosis due to its vague and non-specific clinical presentations. 40 % of the patients remain asymptomatic until the development of complications. CASE PRESENTATION: We report a case of 84 years old female who presented to the hospital with vomiting and abdominal pain, found to have jejunal diverticulosis complicated by perforation in a CT scan. The patient underwent emergency expletory laparotomy with segmental intestinal resection and anastomosis. DISCUSSION: The incidence of jejunal diverticulosis ranges between 3 and 5 %, with most patients discovered incidentally. Therefore, medical or surgical treatment management depends on clinical presentation and complications that necessitate surgical intervention. CONCLUSION: Jejunal diverticulosis is a rare entity that commonly affects the elderly with significant morbidity and mortality; it is an important clinical entity to consider when approaching patients with acute abdomen.

Unusual ascites post laparoscopic cholecystectomy in old patient: Case report and review of the literature.

INTRODUCTION: Ascites that precede laparoscopic cholecystectomy is an infrequent event. Its actual mechanism is not identified, but an inflammatory or allergic peritoneal reaction has been proposed. It can a life-threatening or an acute serious condition; for instance, the bile duct or other visceral injuries are eliminated. CASE PRESENTATION: We present a 83 years old, medically free, who presented with fever and right upper quadrant pain. Diagnosed with severe acute calculus cholecystitis. Diagnostic laparoscopy and laparoscopic cholecystectomy were done, with copious irrigation of the abdomen. Postoperatively, patient started to had tense with moderate tenderness abdomen. Drain output showed clear ascites fluid. Postoperative ascites culture returned back as negative. Ascites treated conservatively with fluid restriction and furosemide. As per our knowledge, this is the fourth case that was reported in the literature of medicine. DISCUSSION: This was a particular case related to ascites which emerged without any known cause. The medical history of a powerful allergic background is can be the reason for transudative ascites that take place following an uneventful, occasional laparoscopic cholecystectomy. There was a presumed abnormal peritoneal or allergic reaction to the diathermy. No specific aetiological aspect was known irrespective of an extensive search being carried out. CONCLUSION: In cases of idiopathic post-laparoscopic ascites, general care and support is needed and fluid restriction and possible diuretic might be needed with no need for surgical intervention. Further studies are recommended for understanding of the pathophysiology of the disease.

Economic impact of diabetic foot ulcers on healthcare in Saudi Arabia: a retrospective study.

BACKGROUND: Diabetic foot ulcers (DFU) are a critical complication of diabetes mellitus (DM) affecting life quality and significantly impacting healthcare resources. OBJECTIVE: Determine the direct medical costs associated with treating DFU in King Fahad Hospital of the University and identify factors that could assist in developing resource management guidelines in Saudi Arabia. DESIGN: Retrospective study. SETTING: SETTING: King Fahad Hospital of the University, Al-Khobar, Saudi Arabia. PATIENTS AND METHODS: The study included diabetic patients admitted with foot ulcerations between 2007 and 2017 inclusive. We determined management costs including drug usage, wound dressings, surgical procedures, admissions, and basic investigation. MAIN OUTCOME MEASURES: Factors affecting the direct perspective medical costs of managing DFU. SAMPLE SIZE: 99 patients. RESULTS: The overall cost of managing 99 patients with DFU was 6 618 043.3 SAR ($1 764 632.68 USD), which further translates to approximately 6684.9 SAR per patient/year ($1782.6 USD). The highest cost incurred was for admission expenditure (45.6%), followed by debridement (14.5%) and intensive care unit (ICU) admission (10.4%). CONCLUSION: The overall healthcare expenditure in treating DFU is high, with hospital admissions and surgical procedures adding a significant increase to the total cost. Focused patient education on overall glycemic control and prevention of DFU may decrease complications and hence, the overall cost. LIMITATIONS: Identified only the direct medical costs of DFU as the indirect costs were subjective and more difficult to quantify. CONFLICT OF INTEREST: None.

Abscess of the caudate lobe of the liver, a rare disease with a challenging management: a case report.

We reported a rare case of abscess of the caudate lobe of the liver in a 60-year old man. We first tried computed tomography (CT) guided percutaneous drainage of the abscess but failed to eradicate the infection. Deterioration of the general condition of the patient necessitated open surgical drainage, which resulted in cure of the abscess. The peculiar anatomical location of caudate lobe abscess introduces a great challenge for the surgeon in planning the appropriate management and paucity of patients with caudate lobe abscess has led to lack of guidelines for management. The non-operative interventional radiology approach has become the therapeutic choice for pyogenic liver abscess, but is it applicable also for caudate lobe abscess?

Evaluation of Atriplex halimus, Medicago lupulina and Portulaca oleracea for phytoremediation of Ni, Pb, and Zn.

Suitable plant species are able to accumulate heavy metals and to produce biomass useful for non-food purposes. In this study, three endemic Mediterranean plant species, Atriplex halimus, Portulaca oleracea and Medicago lupulina were grown hydroponically to assess their potential use in phytoremediation and biomass production. The experiment was carried out in a growth chamber using half strength Hoagland's solutions separately spiked with 5 concentrations of Pb and Zn (5, 10, 25, 50, and 100 mg L(-1)), and 3 concentrations of Ni (1, 2 and 5 mg L(-1)). Shoot and root biomass were determined and analyzed for their metals contents. A. halimus and M. lupulina gave high shoot biomass with relatively low metal translocation to the above ground parts. Metals uptake was a function of both metals and plant species. It is worth noting that M. lupulina was the only tested plant able to grow in treatment Pb50 and to accumulate significant amount of metal in roots. Plant metal uptake efficiency ranked as follows: A. halimus > M. lupulina > P. oleracea. Due to its high biomass production and the relatively high roots metal contents, A. halimus and M. lupulina could be successfully used in phytoremediation, and in phytostabilization, in particular.