Retrieval of Gastric Band Eroding Into the Stomach: A Gastrointestinal Fistula Case Managed Through a Combined Laparoscopic and Colonoscopic Approach.

Obesity is an important public health concern worldwide. In Saudi Arabia, the overall prevalence of obesity has increased in both men and women in recent decades. The laparoscopic approach to bariatric surgery was first reported in the 1990s, with laparoscopic adjustable gastric banding (LAGB) developed soon after. The performance of bariatric procedures has increased rapidly in recent years, with safety and efficacy data available for the surgical treatment of obesity and related metabolic disorders. Herein, we report a challenging condition of a female patient who underwent LAGB insertion in 2013. The patient presented with a complaint of a foreign body passing through her rectum during defecation that was manually pushed back by the patient. Radiological imaging and upper/lower endoscopy confirmed the diagnosis of complete gastric band erosion into the stomach, and the reservoir with the remaining tube was observed inside the colon near the splenic flexure. This case was complicated by complete band erosion and gastrointestinal (GI) fistula formation following the delivery of her second child in January 2022. Colonic band erosion is a rare complication of LAGB. Most patients with gastric band erosion are asymptomatic or exhibit nonspecific symptoms. The definitive management of gastric band erosion involves band removal. Several approaches are commonly used in clinical practice. In our case, the band was removed using a combined laparoscopic and endoscopic retrieval approach, which is the first such report in the literature.

The Rate of Appendicular Neoplasm in Patients Who Underwent Appendectomy for Acute Appendicitis at King Abdulaziz Medical City, Riyadh.

Background Appendicitis is a common reason for hospitalization. Rarely do people with acute appendicitis have an appendiceal mass called an abscesses or inflamed phlegmon. The goal of this study was to determine the prevalence of different appendiceal tumors including neuroendocrine tumors, adenocarcinoma, carcinoid, and mucinous and evaluate patient demographic data (e.g., age and gender) at a major tertiary care center in Riyadh, Saudi Arabia. Materials and methods We conducted a cross-sectional analytical review of patient records of 1513 patients who received an appendectomy and were diagnosed with acute appendicitis from 2015 to 2020 at King Abdulaziz Medical City, Riyadh, Saudi Arabia. We used nonprobability sampling to collect the sample. The study included patients older than 14 years. We also recorded patient demographic information, including age, gender, history, and final pathology. Results The mean age of our study population was 27.9 years (standard deviation [SD], 12.3 years). Our study had 958 male patients and 555 female patients. One thousand four hundred fifty-eight patients (96.3%) had right lower quadrant (RLQ) tenderness, and 228 patients had fever (15.0%). One thousand one hundred thirteen patients (73.5%) had rebound tenderness, 1,178 had nausea (77.8%), and 1,100 had high white blood cell (WBC) counts (72.7%). One thousand four hundred eighty-six patients received laparoscopic surgery (98.2%). Most patients (95.3%; n=1,443) had no postoperative complications. Appendicitis pathology was present in 1,381 patients (91.3%). Only 15 patients (1%) had tumor-related pathology, and these patients were significantly older than patients with nontumor-related pathology (p<.001) and had less RLQ pain, rebound tenderness, and pain migration but higher WBC counts. Pain migration was significantly inversely correlated with age: as age increased, pain migration was reported less often (odds ratio, 0.99, 95% confidence interval, 0.98 to 0.99; p=0.001). Conclusion This study aimed to determine the prevalence and types of appendiceal tumors in cases of acute appendicitis and the corresponding patient demographic data at a major tertiary care center in Riyadh, Saudi Arabia. According to our results, patients with appendicitis present with fever, rebound tenderness, nausea, and high WBC count. Appendiceal masses mainly occur in a later age group with less migration of pain and high WBC count. However, migration of pain is inversely related to age. Physicians treating patients with acute appendicitis should bear these data in mind and consider the presence of appendiceal tumors in appropriate patients.

Do We Feel Safe About the Surgical Safety Checklist? A Cross-Sectional Study Between Two Periods.

Introduction: The aim of this study was to evaluate the change in the healthcare providers' perceptions regarding the World Health Organization Surgical Safety Checklist (WHO SSC) and patient safety in the operating room (OR) at a tertiary hospital in Riyadh, Saudi Arabia. Methods: This cross-sectional study was conducted at King Abdulaziz Medical City. Data were collected from two years (2011 and 2019) for comparison. The co-investigators distributed a self-administered Likert scale questionnaire in the various operating areas (35 ORs). Results: The total sample was 461. Number of participants enrolled from both years was 235 (51%) and 226 (49%), respectively. The results indicated a statistically significant difference in the attitude of the participants regarding all aspects of patient safety in the OR when the two periods were compared (p < 0.001). Similarly, healthcare providers' perceptions regarding the importance of the WHO SSC increased from 50% (2011) excellent to 68% excellent (2019) (p < 0.001). Conclusions: Currently, more healthcare providers recognize the importance of the WHO SSC, and more have a positive attitude toward teamwork, communication, and feeling free to speak out when surgical safety is compromised. All of these cultural changes have positive impact on the overall safety of the OR; however, there are still aspects requiring improvement to provide a safer OR and surgery. Educational interventions regarding the importance of communication and teamwork would improve the safety of surgical care in the OR.

Aggressive angiomyxoma persistently misdiagnosed as an obturator hernia managed with resection and hormonal therapy: case report.

Aggressive angiomyxoma (AA) is an uncommon mesenchymal tumor that mainly affects the perineum and pelvis in females of reproductive age. AA is commonly misdiagnosed as a Bartholin's duct cyst, abscess or levator hernia. A 42-year-old female presented with a large, progressive and painless perineal swelling. She was initially diagnosed with an obturator hernia three times over the past 10 years and underwent multiple surgeries for recurrences. For this presentation, she underwent exploratory laparotomy. No hernia was identified. A large mass over the perineal area extending from the vulvar commissure to the anus was visualized. The diagnosis of AA was made on histopathology. Leuprolide (GnRHa) was used as hormonal therapy postoperatively. AA should be considered in any pelvic mass in a young female that recurs after excision. Prompt diagnosis will contribute toward minimizing local destruction of surrounding structures.

Awareness, Concerns, and Protection Strategies Against Bloodborne Viruses Among Surgeons.

BACKGROUND: Surgeons are at high risk of contracting infectious viruses such as human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) through exposure to patients' blood. The purpose of this study was to assess the surgeons' awareness of contracting bloodborne viruses.  Methods: A cross-sectional study with a questionnaire distributed to 241 surgeons at King Abdulaziz Medical City - Riyadh (KAMC-R) during the period June 2017 through January 2018. Descriptive statistics were used to analyze data collected using Stata®, v14 (StataCorp LLC, College Station, Texas, USA). Categorical variables were analyzed using Pearson chi-square test. P-value of < 0.05 was considered significant. RESULTS: A total of 241 surgeons answered the questionnaire, 179 (74.3%) surgeons were male and 62 (25.7%) were female. The mean age ± standard deviation (SD) of male surgeons was 35.8 ± 11.0 years while for females was 33.3 ± 9.1 years. The majority of our cohort were vaccinated for HBV (96% in males and 97% in females). Two-thirds of the study cohort did not know the conversion rate post-needlestick injury by HIV, HBV, and HCV. Two-thirds of the study cohort think there is a need for HIV screening before surgery. Mixed answers were received from the cohort when asked about their concern regarding contracting HIV infection from their patients; only one-third of the surgeons were extremely concerned. When asked about the risk of needlestick injury during treating patients positive for HBV, the majority of the surgeons said no. However, a significant difference between the female and male surgeons was found in which 12 of the 62 female surgeons answered yes (19.4%) compared to 11 of the 179 male surgeons (6.1%) (p = 0.002). CONCLUSION: The majority of our surgeons are vaccinated for HBV. However, female surgeons appear to be at higher risk of needlestick injury from HBV patients. This requires further investigation into the reasons for such high incidents. More education is needed about bloodborne viruses.

Gender differences in practicing standard precautions against blood-borne pathogens among surgeons at a tertiary care center: A cross-sectional study.

BACKGROUND: Surgeons are at an increased risk of contracting blood-borne pathogens. The aim of this study was to evaluate gender difference, surgical position, surgical experience, and subspecialty regarding surgeons' compliance to standard precautions. METHODS: A cross-sectional questionnaire-based study was performed using a purposive sampling. A total of 241 surgeons were surveyed from June 2017 to January 2018. RESULTS: In total, 179 (74.3%) males and 62 (25.7%) females completed the questionnaire. The gender difference was evident when the type of surgery was extremely important in influencing the decision on wearing double gloves (DGs); 108 (60.3%) male surgeons versus 27 (43.5%) female surgeons (P = 0.022). Although a total of 17 (30.3%) surgeons reported being extremely and very concerned about contracting human immunodeficiency virus through their work, they had never tried DG (P = 0.027). CONCLUSION: This study revealed that the decision of wearing DG was affected by several factors. Surgeons' decision to wear DG was influenced by the type of surgery. This study showed that most surgeons reported lack of adherence to barrier precaution measures.

Effect of sampling procedure on the quality control metrics of cytoscan HD array for studying cytogenetic aspects of colorectal cancer.

OBJECTIVES: The method of colorectal cancer (CRC) tissue sampling would affect its molecular profile and the downstream processing. In this study, we described the impact of CRC tissue sampling procedures on the quality control (QC) metrics of cytoscan HD array. METHODS: We employed a high-resolution cytoscan HD microarray platform to investigate the chromosomal aberrations that could be associated with CRC. We compared the tissue extraction procedures and their impact on the QC parameters from the cytoscan HD array determined by chromosome analysis software (Suite3.1). Median of absolute values of all pairwise differences (MAPD), waviness-standard deviation (Waviness-SD), and single nucleotide polymorphism QC (SNPQC) were the QC parameters that were analyzed. RESULTS: From 67 patients, we collected 843 colorectal tissues. Of these, 65.7% were obtained through endoscopic procedures, and the rest was after surgical resections. The mean transit time between tissue excision and preservation was 26 ± 15.5 and 74.6 ± 24.8 min, respectively. The tissues extracted from the surgical procedure showed mean MAPD of 0.28 ± 0.06 compared to 0.24 ± 0.06, for endoscopy, P = 0.005, degree of waviness-SD of 0.20 ± 0.1 compared to 0.2 ± 0.1, P = 0.64, and SNPQC of 9.6 ± 4.2 compared to 11.1 ± 4.6, P = 0.23. CONCLUSIONS: This report provides objective results that can help in tissue sampling intended to be used for DNA based molecular studies. Tissue collection protocol should be optimized to support microarray-analysis methods. Tissue extraction from endoscopic procedures had faster transit time and relatively better quality metrics outcome than surgical procedures. However, surgical procedures have less refusal rate, higher tissue quantity, and less negative results for malignancy.

The influences of bariatric surgery on hemoglobin A1c in a sample of obese patients in Saudi Arabia.

BACKGROUND: Although the frequency of surgical weight loss interventions has increased in Saudi Arabia, literature describing the clinical outcomes of bariatric surgery in Saudi Arabia is limited. This study aimed to assess whether weight loss intervention improves hemoglobin A1c (HbA1c) in obese patients and to identify its associated factors. PATIENTS AND METHODS: A retrospective study was carried out on 318 patients with obesity class 1 or higher (body mass index [BMI] ≥ 30 kg/m2) who underwent laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass at King Abdulaziz Medical City in Riyadh, Saudi Arabia, between January 1, 2001 and March 31, 2017. Preoperatively and 12 months postoperatively, characteristics of patients were collected. BMI reduction was calculated, based on which patients were divided into three groups (0-9, 10-14, and >14 kg/m2). RESULTS: The postoperative HbA1c was 5.83±0.9, while the baseline level was 6.74±2.1 (P=0.001). Fifty-eight of the 318 patients had diabetes. We observed significantly higher HbA1c in diabetic than in non-diabetic patients preoperatively, whereas an insignificantly different HbA1c was observed postoperatively. Among those who had minimal reduction in BMI (0-9 kg/m2), we observed significantly higher HbA1c in diabetic than in non-diabetic patients, whereas among those who had large reduction in BMI (10-14 kg/m2) and (>14 kg/m2), we observed insignificant differences in HbA1c in diabetic than in non-diabetic patients. CONCLUSION: Being a diabetic patient was related to a significant reduction in HbA1c levels postoperatively. The study suggests that the reduction in HbA1c levels could be modified by BMI, wherein greater reduction in BMI leads to greater reduction in HbA1c levels.

Towards personalized medicine of colorectal cancer.

Efforts in colorectal cancer (CRC) research aim to improve early detection and treatment for metastatic stages which could translate into better prognosis of this disease. One of the major challenges that hinder these efforts is the heterogeneous nature of CRC and involvement of diverse molecular pathways. New large-scale 'omics' technologies are making it possible to generate, analyze and interpret biological data from molecular determinants of CRC. The developments of sophisticated computational analyses would allow information from different omics platforms to be integrated, thus providing new insights into the biology of CRC. Together, these technological advances and an improved mechanistic understanding might allow CRC to be clinically managed at the level of the individual patient. This review provides an account of the current challenges in CRC management and an insight into how new technologies could allow the development of personalized medicine for CRC.

Profile, outcome and predictors of mortality of abdomino-pelvic trauma patients in a tertiary intensive care unit in Saudi Arabia.

INTRODUCTION: The Kingdom of Saudi Arabia (KSA) is one of countries with the world's highest number of deaths per 100,000 populations from road traffic accidents (RTAs). Numerous trauma victims sustain abdomino-pelvic injuries, which are associated with considerable morbidity and mortality. The purpose of this study was to describe profile, outcomes and predictors of mortality of patients with abdomino-pelvic trauma admitted to the intensive care unit (ICU) in a tertiary care trauma centre in Riyadh, KSA. METHODS: This was a retrospective analysis of prospectively collected ICU database. All consecutive patients older than 14 years with abdomino-pelvic trauma from March 1999 to June 2013 were included. The followings were extracted: demographics, injury severity, mechanism and type of injury, associated injuries, use of vasopressors and mechanical ventilation, and worst laboratory results in the first 24h. The primary outcome was hospital mortality. We compared profile and outcomes between survivors and non-survivors and reported predictors of mortality. RESULTS: Of the 11,374 trauma patients who were admitted to the hospital during the study period, 2120 (18.6%) patients had abdomino-pelvic injuries, out of which 702 (33.1%) patients were admitted to the ICU. The mean age was 30.7 (SD 14.4) years and the majority was male (89.5%). RTA was the most common cause of abdomino-pelvic trauma (70.4%). Pelvis (46.2%), liver (25.8%), and spleen (23.1%) were the most frequently injured organs; and chest (55.6%), head (41.9%), and lower extremities (27.5%) were the most commonly associated injuries. Mechanical ventilation was required in 89.6% with a mean duration of 9.1 (SD 9.2) days and emergency surgery was performed in 45.0% of the patients with prolonged ICU and hospital length of stay (10.8 [SD 10.8], 56.9 [SD 96.7] days; respectively). Of the 702 patients with abdomino-pelvic trauma, 115 (16.4%) patients did not survive. Associated head trauma and retroperitoneal haematoma, higher level of lactic acid on admission and ISS, and advanced age were potential risk factors for hospital mortality. CONCLUSIONS: Abdomino-pelvic injuries are common in trauma patients, affecting mainly young male victims, and are associated with significant morbidity and mortality, and resource utilisation.

Integrated exon level expression analysis of driver genes explain their role in colorectal cancer.

Integrated analysis of genomic and transcriptomic level changes holds promise for a better understanding of colorectal cancer (CRC) biology. There is a pertinent need to explain the functional effect of genome level changes by integrating the information at the transcript level. Using high resolution cytogenetics array, we had earlier identified driver genes by 'Genomic Identification of Significant Targets In Cancer (GISTIC)' analysis of paired tumour-normal samples from colorectal cancer patients. In this study, we analyze these driver genes at three levels using exon array data--gene, exon and network. Gene level analysis revealed a small subset to experience differential expression. These results were reinforced by carrying out separate differential expression analyses (SAM and LIMMA). ATP8B1 was found to be the novel gene associated with CRC that shows changes at cytogenetic, gene and exon levels. Splice index of 29 exons corresponding to 13 genes was found to be significantly altered in tumour samples. Driver genes were used to construct regulatory networks for tumour and normal groups. There were rearrangements in transcription factor genes suggesting the presence of regulatory switching. The regulatory pattern of AHR gene was found to have the most significant alteration. Our results integrate data with focus on driver genes resulting in highly enriched novel molecules that need further studies to establish their role in CRC.

Colorectal cancer driver genes identified by patient specific comparison of cytogenetic microarray.

Colorectal cancer (CRC), which has high prevalence in Saudi Arabia and worldwide, needs better understanding by exploiting the latest available cytogenetic microarrays. We used biopsy tissue from consenting colorectal cancer patients to extract DNA and carry out microarray analysis using a CytoScan HD platform from Affymetrix. Patient specific comparisons of tumor-normal pairs were carried out. To find out the high probability key players, we performed Genomic Identification of Significant Targets in Cancer analysis and found 144 genes to form the list of driver genes. Of these, 24 genes attained high GISTIC scores and suggest being significantly associated with CRC. Loss of heterozygosity and uniparental disomy were found to affect 9 genes and suggest different mechanisms associated with CRC in every patient. Here we present the details of the methods used in carrying out the above analyses. Also, we provide some additional data on biomarker analysis that would complement the findings.

Novel genes associated with colorectal cancer are revealed by high resolution cytogenetic analysis in a patient specific manner.

Genomic abnormalities leading to colorectal cancer (CRC) include somatic events causing copy number aberrations (CNAs) as well as copy neutral manifestations such as loss of heterozygosity (LOH) and uniparental disomy (UPD). We studied the causal effect of these events by analyzing high resolution cytogenetic microarray data of 15 tumor-normal paired samples. We detected 144 genes affected by CNAs. A subset of 91 genes are known to be CRC related yet high GISTIC scores indicate 24 genes on chromosomes 7, 8, 18 and 20 to be strongly relevant. Combining GISTIC ranking with functional analyses and degree of loss/gain we identify three genes in regions of significant loss (ATP8B1, NARS, and ATP5A1) and eight in regions of gain (CTCFL, SPO11, ZNF217, PLEKHA8, HOXA3, GPNMB, IGF2BP3 and PCAT1) as novel in their association with CRC. Pathway and target prediction analysis of CNA affected genes and microRNAs, respectively indicates TGF-ß signaling pathway to be involved in causing CRC. Finally, LOH and UPD collectively affected nine cancer related genes. Transcription factor binding sites on regions of >35% copy number loss/gain influenced 16 CRC genes. Our analysis shows patient specific CRC manifestations at the genomic level and that these different events affect individual CRC patients differently.