Percutaneous obliteration of duodenal fistula.

High output external duodenal fistula is a difficult condition to treat and despite the advances in nutritional care, morbidity and mortality remain high. Although, non surgical methods (e.g. endoscopy, fistuloscopy and percutaneous injection of substances) have been reported sporadically in the treatment of enterocutaneous fistulae, gelfoam has not been tried. We present a case of duodenal fistula following blunt abdominal trauma which persisted for 14 weeks on conservative management. Percutaneous obliteration of the duodenal fistula was successfully performed using gelfoam injection through a catheter. This procedure is simple, safe and cheap and further experience may demonstrate that it is an easy and more practical tool in dealing with this problem.

Chest trauma in children: A local experience.

BACKGROUND: Chest trauma in childhood is relatively uncommon in clinical practice, and has been the subject of few reports in the literature. This study was undertaken to examine our experience in dealing with chest trauma in children. PATIENTS AND METHODS: This was a retrospective study of 74 children who sustained chest trauma, and were referred to King Fahad Hospital in Medina over a two-year period. The age, cause of injury, severity of injury, associated extrathoracic injuries, treatment and outcome were analyzed. RESULTS: The median age of the patients was nine years. Fifty-nine of them (80%) sustained blunt trauma, and 15 (20%) were victims of penetrating injuries. Road traffic accident was the cause of chest trauma in 62% of the children, gun shot wounds were seen in five, and stab wounds in 10 children. Head injury was the most common injury associated with thoracic trauma, and was seen in 14 patients (19%), and associated intraabdominal injuries were seen in nine patients. Chest x-ray of the blunt trauma patients revealed fractured ribs in 24 children, pneumothorax in six, hemothorax in four, hemopneumothorax in three, and pulmonary contusions in 22 patients. Fifty-one percent of children were managed conservatively, 37% required tube thoracostomy, 8% were mechanically ventilated, and 4% underwent thoracotomy. CONCLUSION: The prevalence of chest trauma in children due to road traffic accidents is high in Saudi Arabia. Head injury is thought to be the most common associated extrathoracic injuries, however, most of these patients can be managed conservatively.

Superiority of laparoscopic guided needle biopsy over percutaneous blind needle biopsy in diagnosing hepatocellular carcinoma associated with cirrhosis.

This is a retrospective study of 40 patients clinically suspected of having hepatocellular carcinoma. Group 1 (20) patients underwent laparoscopic Tru-cut needle liver biopsy and Group II (20 patients) underwent percutaneous blind needle liver biopsy. In the first group, in 17 (85%) of the patients, the diagnosis of hepatocellular carcinoma was confirmed by histopathology, direct observation of cirrhosis was seen in 8 (40%) patients, histopathology confirmation of cirrhosis was documented in 6 (35%) patients. In the second group, 14 (70%) of the patients were confirmed to have hepatocellular carcinoma histopathologically and no patients confirmed to have cirrhosis. Both procedures were safe. While ascitic leak from the infraumbilical incision was the only complication encountered in the 1st group, no complications were encountered in the 2nd group. The results support the premise that laparoscopy directed cutting needle biopsy is superior over other techniques in fulfilling all the diagnostic requirements for hepatocelullar carcinoma and associated liver cirrhosis which is important for surgical liver resection.

Unusual presentations of injury to the bronchus with literature review.

Two patients with unusual presentation of injury to the bronchi are discussed. The first had a gun shot wound of the anterior left chest with the bullet ricocheting across to the right hemithorax and puncturing the right mainstem bronchus resulting in right massive pneumothorax and subcutaneous emphysema. The second suffered a blunt thoracic trauma from a road traffic accident and presented with bilateral rib fractures and bilateral pneumothoraces treated with bilateral closed thoracostomy tube drainage. Bronchofiberscopy revealed complete transection of the left mainstem bronchus.

Analysis of laparascopic cholecystectomies in 606 patients: Experience at King Fahad Hospital, Medina.

This is a retrospective study of 606 patients who underwent laparoscopic cholecystectomy at King Fahad Hospital, Medina, Saudi Arabia. The majority of them, 488 (80.5%), were females. Fifty (8.3%) patients presented with acute cholecystitis and 556 (91.7%) were chronic cases. Common bile duct stones were detected in 22 (3.6%) patients. Laparoscopic cholecystectomy was successful in 539 (89%) patients and converted to open cholecystectomy in 67 (11%) patients due to a variety of reasons. The mean operative time was 65.9 minutes. Most of the patients (64.7%) were discharged within 72 hours. There were no deaths in this series. The overall complication rate was 5.6% and the incidence of major ductal injury was 0.8%.

Spontaneous pneumothorax: A retrospective study of twenty-five patients and literature review.

We present a retrospective study of 25 patients with spontaneous pneumothorax (three current), comprising 16 Saudis (nine males and seven females) and nine non-Saudis (eight males and one female), seen at the Asir Central Hospital, Abha, over a period of 45 months. Almost one-third of the patients (9/25) had no underlying cause discernible by our investigational facilities (chest x-ray, ultrasonography, computed tomographic scan, and flexible bronchofiberscopy). Underlying pneumonia (three patients), pulmonary tuberculosis (two patients), lung abscess (one patient), and congenital bullae (one patient) constituted the etiology in another third of the spontaneous pneumothorax patients. Other underlying pulmonary diseases precipitating spontaneous pneumothorax in the group included pulmonary fibrosis, metastatic mesothelioma, and immunosuppression in a medulloblastoma patient undergoing chemotherapy with the development of chickenpox. Closed thoracostomy tube drainage was the only method of treatment in 20 out of the 25 patients, with three failures of closed thoracostomy tube drainage needing thoracotomy and resection of blebs/bullae. The only complication was empyema in two of the patients. Two patients were successfully treated conservatively with observation alone.

Gallbladder stones analyzes, bile and wound cultures in cholelithiasis.

One hundred and fifty-two consecutive cases of cholelithiasis were studied. The gallbladder stones were analyzed to determine the constituents, the bile specimens were cultured and correlated with the cultures when wound infection occurred. Mixed gallstones were the commonest type (58.5%), pigment stones (27%) and cholesterol stones (14.5%). Positive bile cultures were found in 41 patients (27%) and Escherichia coli was the commonest organism isolated. The rate of wound infection was 14.5% and the most common organism cultured from the wound was staphylococcus epidermidis.

Empyema thoracis in adults in Saudi Arabia.

Empyema thoracis in adults is an uncommon disease in the Asir region of Saudi Arabia. In a period of seven years (1988 to 1994), 24 patients were treated for empyema thoracis with a hospital incidence of about 23 patients in 100,000 admissions. The community acquired empyemas are more common and less aggressive in non-Saudi patients (six males and one female) as compared to Saudi patients (11 males and 6 females) whose empyemas are mostly nosocomial with an aggressive course. The peak age in both Saudi and non-Saudi patients is 45 years and 25 years respectively, and the right pleura is more commonly affected than the left pleura in both groups. Risk factors include diabetes mellitus, pulmonary tuberculosis, post-pneumonectomy infections, trauma and pneumonia. The commonest organisms grown are Pseudomonas aeruginosa, Klebsiella species and Staphylococcus aureus, although in almost 40% of the patients the empyemas were sterile. The commonest method of treatment was closed thoracostomy tube drainage.

Pattern of cancer in Madina Al-Munawara region.

This is a retrospective study of 2237 histologically proven cases of cancer over a 12 year period from 1981 to 1993. There were 1687 (75.4%) Saudi and 550 (24.6%) non-Saudi patients. Among both sexes, the most common malignancies were from the gastrointestinal tract (29.3%), lymphoma/leukemia (18.4%), head and neck (8.8%) and breast (8.5%). The most common malignancies among males were lymphoma/leukemia, hepatoma, skin and stomach. Among females, the order of frequency of malignancy was breast, lymphoma/leukemia, esophagus, colon and thyroid. Comparison with other leading studies of the Kingdom has been made. The most common malignancies were discussed with the possible etiological factors.

Topical ampicillin for prophylaxis against wound infection in acute appendicitis.

A total of 249 patients, undergoing appendectomy for acute appendicitis, were prospectively randomized into two groups. Group I, comprising 132 patients, received sterile normal saline irrigation to the surgical wound at closure. Alternatively, Group II included 117 patients, who received intraoperative topical ampicillin irrigation of the wound. Both groups were comparable with regard to age, sex, duration of symptoms, and severity of appendicitis. All patients additionally received preoperative systemic gentamicin and Flagyl. Wound infection occurred in 5.3% of Group I compared to only 0.9% of Group II (P<0.05). The reduction in infection rate was significant (P<0.05) in histologically proven appendicitis. We conclude that the addition of intraoperative topical ampicillin to systemic gentamicin and Flagyl augments prophylaxis against wound infection in acute appendicitis.

Primary closure of breast abscess compared with the conventional gauze packing and daily dressings.

Because of the reported success of primary closure of Skeletal Muscle abscess we conducted a retrospective study of breast abscess treated over a period of 24 months. There were essentially two groups: In one group the abscess cavities were initially packed with gauze and then dressed daily. In the second group, the abscess cavities were primarily closed and a negative suction drain instituted for about five to seven days. The second group had shorter healing period, better scar formation and reduction of cost in terms of labour and material. But a recurrence could occur within two to three days especially if the drain is removed prematurely.

"Silent" abdominal tuberculosis: a report of six cases.

Six cases of "silent" or subclinical abdominal tuberculosis seen in patients who belong to the upper socio-economic class, but with a humble childhood are presented. The patients are usually from the Third World countries and the condition is often missed or mis-diagnosed. This condition is often precipitated by some stressful situation, and the presentation is not typical of the well-known clinical features of abdominal tuberculosis. This is most likely due to the fact that the high standard of living later in life tends to distort the classical clinical features of tuberculous abdomen as seen in the rest of the population. There is usually a dramatic response to anti-tuberculosis therapy.

Peripheral T-cell lymphoma with unique immunologic features.

BACKGROUND: The autologous mixed lymphocyte reaction (AMLR) is an important immunoregulatory phenomenon in human immune disorders. The authors have determined the phenotype and assessed the response of malignant lymph node T-cells, from histologically and immunologically proven cases of peripheral T-cell lymphoma, in AMLR and allogeneic mixed lymphocyte reaction (MLR) and studied the secretion of lymphokines. METHODS: The proliferative response, tritiated 3H-thymidine incorporation assay, was used to determine the AMLR and allogeneic MLR of the responding T-cells. An interleukin-2 (IL-2)-dependent T-cell line (CTLL) was used for the production of IL-2 by phytohemagglutinin-stimulated T-cells in a cytotoxic assay. B-cell growth and differentiation factor activity of T-cells was studied by enzyme-linked immunosorbent assay. RESULTS: The AMLR of malignant lymph node T-cells was increased characteristically in 12 of the 14 lymphoma cases studied; however, that of the blood T-cells was decreased. The allogeneic MLR of the malignant lymph node T-cells and blood-purified T-cells of the eight cases investigated was decreased. Expression or deficiency of CD2 and CD3 antigens on malignant T-cells did not show any difference in the AMLR assay. CONCLUSIONS: This study demonstrates an important tendency of malignant T-cells from patients with peripheral T-cell lymphoma to proliferate in AMLR. The highly augmented AMLR but deficient allogeneic MLR observed in these malignant T-cells indicate that autologous recognitive events may play an important role in the immunopathogenesis of this human disease.

Splenic abscess: Presentation, diagnosis and management.

Splenic abscess is infrequently encountered. This paper reports on the diagnosis and management of six cases from Southern Saudi Arabia. Common presenting features were diffuse abdominal pain and fever. Signs localized to left upper quadrant of the abdomen were present in only two patients. The difficulty of diagnosis is signified by the fact that two cases were overlooked during initial surgery. The computed tomographic (CT) scan was quite accurate in three cases while ultrasound was reliable in five patients. Known causes of splenic abscess were present in four of the six patients. Two patients had gangrenous bowel and one each had bacterial and splenectomy. Review of the literature shows that splenectomy remains the treatment of choice while CT-guided aspiration is being increasingly employed especially for the poor-risk patients with unilocular abscesses.

Management of hydatid cysts of the urinary tract.

Eleven patients with hydatid disease of the urinary tract have been seen in the last 5 years. Seven patients had cysts of the kidneys and 4 had large retrovesical hydatids. Seven of the 8 patients with renal hydatids presented with loin pain and mass. Three patients with renal communicating hydatids also presented with haematuria which was due to passing "grape skin" (hydatid membrane) in the urine. Two patients with retrovesical hydatids had bladder outflow obstruction and 2 had bilateral ureteric obstruction leading to uraemia. Eight of 11 patients had associated hydatids of other organs such as the liver (4 patients), peritoneal cavity (2) and lungs (1). Computed tomography was the most useful and specific investigation. In both renal and pelvic (retrovesical) hydatid cysts, endocystectomy with either partial excision or plication of the ectocyst is the standard treatment. In renal communicating hydatids the options are either nephrectomy (partial or total) or endocystectomy with closure of the communication. The use of cryocone and scolicidal agents is mandatory during surgery.

C-reactive protein in the differential diagnosis of the acute abdomen, especially acute appendicitis.

Serum C-reactive protein (CRP) was qualitatively determined before surgery in 189 patients undergoing appendicectomy. The sensitivity, specificity, negative predictive value and overall accuracy of CRP were assessed: CRP had a high specificity (76.3%) but a sensitivity of only 39.7%. CRP may be of value in the assessment of acute abdominal pain, by helping to exclude from surgery those patients with normal appendices.

Hydatid disease of the urinary tract: evaluation of diagnostic methods.

Eight patients with histologically proven hydatid disease of the urinary tract underwent eosinophil count, ultrasonography (US) and computed tomography (CT). The findings were compared with those in 8 age-matched controls with simple renal cysts. Eosinophilia was not significantly different in the 2 groups. Mixed echogenicity on US and multivesicular cyst with mixed density on CT were the diagnostic features of hydatid cysts. Using these factors, both US and CT could diagnose or exclude hydatid disease in a significant number of patients with renal cysts. However, CT was more sensitive (88 vs 50%) and accurate (94 vs 75%) than US in the diagnosis of urinary tract hydatid disease. Retrograde pyelography confirmed communicating renal hydatid cysts in 2 patients. A practical algorithm for the investigation of urinary tract hydatid disease is suggested.

Hydatid disease of the liver: evaluation of ultrasound and computed tomography.

We have evaluated computed tomography (CT) and ultrasonography (US) in 41 patients with hepatic hydatid disease. CT was diagnostic in all patients, while US performed on 36 patients was diagnostic in 34. In the remaining two cases, heavy calcification in one and a large amount of intracavitary air in the other prevented accurate diagnosis. The US findings in the liver regarding cyst form (multilocular or unilocular), size and location were comparable to those of CT. CT detected associated extrahepatic cysts in the abdomen and pelvis in 11 patients while US performed on the same group of patients detected such cysts in seven patients. It is suggested that the entire abdomen and pelvis should be scanned in patients suspected of hydatid disease and when a hepatic lesion is suggestive of the disease.

Pattern of primary gastrointestinal tract cancer in the southern province.

Two hundred thirty-four cases of primary gastrointestinal tract malignancy were diagnosed at the histopathology laboratory of Asir Central Hospital over a four-year period, from 1987 to 1990. The current study is a retrospective analysis of these cases regarding rank orders, distribution according to nationality, age and sex, primary sites affected and the histopathologic pattern. Eighty-eight percent of our cases were Saudi and 12% were non-Saudi nationals. The mean age of patients was 60 +/- 16 years with a male:female ratio of 2:1. Primary liver cancer was the most common malignancy (29%), followed by gastric cancer (27%), colorectal cancer (21%) and esophageal cancer (13%). Comparison of our findings to those from other provinces of the Kingdom are also included.