The Incidence of Acute Peritonitis Secondary to Different Sites of Viscus Perforation.

Objective The incidence of peritonitis secondary to viscus perforation will be examined to determine the most common sites of perforation and associated comorbidities. Methods This is a retrospective observational study based on data collected from the King Fahad Hospital of the University (KFUH). This research targeted patients who had viscus organ perforation and the relation of peritonitis secondary to it. The sample was taken from patients under the care of the General Surgery Department from the first of Feb 2016 to the 12th of Sep 2022. The final sample consisted of 450 patients. The method of diagnosis of peritonitis was mainly clinical, and the surgical approach was either through an exploratory laparotomy or a diagnostic laparoscopy. Incidental findings of viscus organ perforation were noted in addition to certain postoperative complications (e.g., adhesions) and hospital stay. Results Analysis of the results showed a significant relation (p<0.001) between viscus organ perforation and peritonitis. The most common comorbidities associated with secondary peritonitis were hypertension (12, 24.5%), diabetes mellitus (10, 20.4%), any abdominal mass (3, 6.1%), and inflammatory bowel disease (1, 2%). However, a chi-square analysis has shown no significant association between peritonitis and the targeted associated comorbidities. Conclusion Perforation of the small intestine carries the biggest association with peritonitis incidence, in addition to comorbidities such as hypertension and diabetes mellitus. Further study to establish the value of these factors might contribute to decreasing the morbidity and mortality of secondary peritonitis.

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.

Inguinal Endometriosis in a Nulliparous Woman Mimicking an Inguinal Hernia: A Case Report with Literature Review.

BACKGROUND Endometriosis is a common gynecological disorder occurring in around 10% of women of reproductive age. Inguinal endometriosis is a rare condition; however, it should be considered in the differential for inguinal masses in women of reproductive age. Usually, it occurs after implantation of endometrial tissue during previous surgical procedures. Patients with inguinal endometriosis are often multiparous women with a history of previous gynecological or obstetric surgery. It represents a diagnostic dilemma, as it is often misdiagnosed as other inguinal pathologies. CASE REPORT Herein, we report a case of a 33-year-old nulliparous woman with left groin pain for 2 years increasing in the severity during menstruation. A physical examination revealed a 1.5-cm left inguinal mass. Ultrasound showed an ill-defined speculated solid hypoechoic left inguinal mass measuring 1.6×1.4 cm. Computed tomography (CT) of the pelvis revealed a left inguinal mass measuring 1.7×1.2 cm, demonstrating central hypo-attenuation with thickening of the round ligament. Exploration of the inguinal region revealed an adherent mass to the round ligament and floor of the canal, which was excised completely with a safety margin. The inguinal canal floor was strengthened using proline mesh. Histopathological examination of the mass confirmed the diagnosis of left inguinal endometriosis. CONCLUSIONS Inguinal endometriosis is a rare clinical entity mimicking other common inguinal conditions. A high index of suspicion is crucial for its preoperative diagnosis, especially in the presence of an inguinal mass associated with cyclic changes in size and pain severity. Its standard management is surgical excision.

Transoral endoscopic thyroidectomy via vestibular approach: First case in Saudi Arabia.

INTRODUCTION: There has been increased interest in applying the principles of minimally invasive surgery in thyroid surgery which was promoted by Miccoli and his colleagues in 1999. Different surgical techniques since then were introduced, transcervical and extracervical approaches. PRESENTATION OF CASE: A 33-year-old Saudi female presented with a swelling over the left side of her neck and dysphagia for three years. The patient underwent transoral endoscopic left thyroid lobectomy, isthmusectomy and sampling of the central compartment via vestibular approach (TOETVA). To the best of our knowledge, this is the first case underwent TOETVA successfully in Saudi Arabia and gulf cooperation council countries. DISCUSSION: TOETVA is a novel promising procedure, an adaptation of the concept of natural orifice transluminal endoscopic surgery (NOTES) with advantages of scar-less result in excellent cosmesis while retaining the advantages of minimally invasive surgery and the potential value of the procedure outside the enhanced cosmesis continuous to be defined. The cosmetic superiority in avoiding visible scarring must be balanced against operative time, post-operative hospital stays, increased expense, surgical training, and steep learning curve required. The technique is novel, some thyroid surgeons opted for longer postoperative observation to exclude complications. As experience and confidence in the procedure increase, the length of stay should decrease dramatically. CONCLUSION: This procedure is feasible and safe with excellent cosmetic result. It is in its initial stage in Saudi Arabia, gulf cooperation council countries and it has a potential to be performed more frequently in near future.

Primary hepatic gastrinoma causing zollinger-ellison syndrome: a rare and challenging diagnosis.

The majority of gastrinomas causing Zollinger-Ellison syndrome (ZES) are located in the duodenum or the pancreas. Primary hepatic gastrinomas (PHG) are extremely rare and difficult to diagnose because the liver is the commonest site of metastatic disease and gastrinomas can be very small. Furthermore, gastrinomas are typically slow-growing thus a missed, occult primary tumour may not become evident for many years. The diagnosis of PHG is therefore dependent on a careful search for a primary and long-term biochemical follow-up following curative hepatic resection. We report a case of a 7 cm PHG in a 48 year old man with ZES. Preoperatively, both a basal and stimulated gastrin levels were elevated. Surgical exploration including intraoperative ultrasound and duodenotomy, failed to reveal a primary. Patient underwent a right hepatectomy. Yearly, gastrin and secretin stimulation tests remain normal 6 years following surgery. He remains symptom free off all medication. An additional 26 cases of PHG were found. Including this case, 21 had at least 1 year follow-up, however only eight had greater than 5 years (median 24 months). Post-op gastrin levels were reported in 25, however provocative testing was done in only 10. Persistence and recurrence occurred in one and four, respectively. PHG causing ZES is extremely rare. Although the current literature claims to include 26 additional cases of PHG, without a thorough search for the primary and long-term follow-up data including provocative testing, this diagnosis remains a challenge.

Plexiform neurofibroma of the submandibular gland in patient with von Recklinghausen's disease.

Plexiform neurofibroma of the submandibular gland is an extremely rare tumor. Herein, we report a case of plexiform neurofibroma in a patient with a von Recklinghausen's disease (NF-1) who presented with a submandibular mass mimicking a submandibular gland tumor. Complete surgical excision provides the best treatment and final diagnosis. A neurofibroma should be considered in the differential diagnosis for submandibular mass.

A rare case of primary tuberculosis infection with concurrent pleomorphic adenoma of the parotid gland.

Coexistence of parotid tuberculosis along with a benign parotid tumor is a rare entity with only nine cases reported in the literature. We report here a case of primary parotid tuberculosis with concurrent pleomorphic adenoma in a 51-year-old female.

Gastric immature teratoma.

Gastric teratoma GT is a rare neoplasm which accounts for less than 1% of all teratomas in children. Little more than 100 cases of GT are reported in the literature out of which, about a dozen cases are of immature variety. We present a case of immature gastric teratoma in a 7-month-old male baby.