A retrospective cohort report of single-incision laparoscopic cholecystectomies in Saudi Arabia: Postoperative outcomes and patient satisfaction.

Introduction: Single incision laparoscopic cholecystectomy has become more popular recently. Because it yields shorter hospitalization, less postoperative pain, and better cosmetic outcomes. As it minimizes the number of incisions, it causes less trauma to the anterior abdominal wall and this decreases the operative mortality and morbidity. In this study, our aim is to share our results from the procedure so that surgeons in the field may consider adopting this approach when performing a laparoscopic cholecystectomy. Methods: This is a retrospective study of 125 patients that underwent single-incision cholecystectomy. These patients underwent the procedure in a specialized center. We extracted data and surveyed patients who underwent the procedure between 2017 and 2019, and that were performed by the same consultant using the standard tools of laparoscopic surgery. All patients were followed for 12 months. The postoperative survey includes; the cosmetic appearance of the surgical site, pain management after the procedure, and patient satisfaction with this experience. Results: Most of the patients were satisfied with postoperative pain management and their cosmetic appearance. Most of the patients were females diagnosed with cholelithiasis preoperatively. The mean age of the patients was 37.43 ± 10.72 years, the mean BMI of the participants was 29.68 ± 6.51 kg/m2 and the mean operative time was 25.56 ± 10.42 min. Conclusion: Single incision laparoscopic cholecystectomy has the potential to become the procedure of choice for cholecystectomy.

No-fistula vs. fistula type anorectal malformation: Outcome comparative study.

INTRODUCTION: Anorectal malformation (ARM) is a congenital defect that exists in varying presentations and no-fistula type (NFT) ARM is a rare high-type category. We aim to report our experience with management of this anomaly and its outcome, compared to the more common fistula-type (FT) ARM. METHODS: A retrospective review of medical records of patients diagnosed with high ARM and 3years and older, for the period between September 2000 and January 2015 was conducted. Demographic, anatomic, and outcome data were obtained for each group and compared. Quality of life data were collected using the Krickenbeck classification and assessed as documented at clinic visits as well as phone interviews. RESULTS: There were 100 patients managed for ARM during that period and were 3years or older. Sixteen of them were NFT (16%). For comparison purposes each NFT patient was matched with 3 FT patients. We have analyzed data on 44 patients with FT (44 males), and 16 with NFT (12 males and 4 females). The occurrence of Down syndrome in NFT patients was 56.2% compared to 0% in the FT patients (p=<0.0001). Quality of Life data showed no significant differences between the two groups with p-values of 0.39, 1.0, and 1.0 for Voluntary Bowel Movement, Soiling, and Constipation respectively. CONCLUSION: NFT ARM represents a significant number at our population (16%). There is a strong association between NFT ARM and Down syndrome. NFT ARM has similar outcomes compared to the FT ARM. TYPE OF STUDY: Clinical research paper. LEVEL OF EVIDENCE: Level III.

Reduction in neural injury with earlier delivery in a mouse model of congenital myelomeningocele: laboratory investigation.

OBJECT: The authors undertook this study to assess the effect of preterm delivery with respect to neural protection in a congenital myelomeningocele (MMC) mouse model. METHODS: After confirmation of pregnancy in 15 female mice, a congenital MMC model was produced by administration of retinoic acid on the 7th day of gestation. The pregnant mice underwent cesarean sections on Days 15 (n = 5, Group E15), 17 (n = 5, Group E17), and 19 (n = 5, Group E19). Histological analyses were conducted on the lumbar defect and on the craniocervical junction in all fetuses with MMC. RESULTS: Fetuses in Group E19 showed the most significant injury to neural tissue of the spinal cord at the MMC area followed by those in Group E17, with Group E15 being the least affected. All groups exhibited a degree of Chiari malformation; Group E19 was the most affected, followed by Group E17, and Group E15 was the least affected. CONCLUSIONS: Development of both Chiari malformation and exposed spinal cord injury are progressive during gestation. Preterm delivery in this mouse model of congenital MMC may minimize the degree of injury to the spinal cord neural tissue and the degree of Chiari malformation.

Food aversion among patients with persistent hyperinsulinemic hypoglycemia of infancy.

INTRODUCTION: Persistent hyperinsulinemic hypoglycemia of infancy (PHHI) is the most common cause of neonatal hypoglycemia. Feeding plays a major role in its management. We evaluated the magnitude of food aversion among our patients with PHHI. METHODS: A retrospective medical record review was conducted for patients with PHHI managed during the last 15 years. Demographic and clinical data were retrieved, and descriptive data were generated. RESULTS: Forty-two patients (18 were male and 24 were female) were managed for PHHI over the study period. Thirty-three patients had subtotal pancreatectomy, and 9 were managed medically, with a mean follow-up of 5 years. Nineteen patients (45%) had aversion to food, and 9 of them were developmentally delayed. Of 14 patients assessed by a speech pathologist, 5 had aversive sensory behavior, 4 had dysfunctional pharyngeal swallowing, and 5 had a normal assessment. Ten were managed with oral feeding, 4 had gastrostomy feedings, and 5 were managed with oral and nasogastric tube feeds for various periods. CONCLUSIONS: Food aversion is significantly prevalent among patients with PHHI. The presence of food aversion appears to be independent of developmental delay. Aggressive measures to manage food aversion could help in the management of patients with PHHI.

The impact of variation in access to care on the management of Hirschsprung disease.

INTRODUCTION: Variation in access to care has a significant impact on the disease management process and outcomes. Variable access to care might have similar effects on the management of Hirschsprung disease (HD). However, such variation has not been highlighted. MATERIALS AND METHODS: All patients referred to 3 academic centers (ACs) with HD were reviewed. Patient presentations, referral patterns, timing, and type of surgical intervention were compared between patients born in AC and those born in non-AC. Babies born with major congenital anomalies (MCAs) or total colonic HD were excluded. RESULTS: Between 1998 and 2011, 129 patients were identified. After excluding 30 patients, 99 were split into 20 inborn patients (AC) and 79 outborn patients. Outborn patients more often presented with constipation (95% vs 65%, P = .001), whereas inborn patients presented with feeding intolerance or vomiting (75% vs 39%, P = .004). Outborn patients were diagnosed and had their pull-through (PT) at an older median age (in days) of 186 (1-2621) vs 4.5 (1-451) (P = .001) and 345 (11-2757) vs 92 (3-928) (P = .001), respectively. Moreover, inborn patients were more likely to undergo primary PT (75% vs 46%, P = .02) and avoid bowel diversion (95% vs 66%, P = .02). CONCLUSION: Variation in access to care can have a significant impact on the quality of care delivery in HD. Limited access to AC is associated with staged PT in addition to delay in the diagnosis and management.

Surgical management of gastrointestinal basidiobolomycosis in pediatric patients.

INTRODUCTION: Gastrointestinal basidiobolomycosis (GIB) is a rare fungal disease. We reviewed our experience with this disease over the last 10 years, with special emphasis on the surgical aspects. METHODS: A retrospective chart review was conducted for pediatric patients with GIB who were managed at our institution over the last 10 years. Demographic, clinical, and follow-up data were collected, and descriptive data were generated. RESULTS: Nine patients with a median age of 7 years were managed for GIB over the study period. Six patients were managed surgically. Four had colonic and liver involvement, 1 had a left hepatic lesion, and 1 had a porta hepatic mass. One patient had multiple liver lesions and was managed medically, and 2 patients had disseminated disease and died shortly after presentation. Tissue biopsies confirmed the diagnosis, and all received antifungal treatment. Patients were followed up for a median of 6 years. All live patients are free of disease, and 4 are still on antifungal medications. CONCLUSIONS: Gastrointestinal basidiobolomycosis is an aggressive disease that requires early surgical intervention to avoid complications and hasten disease eradication. Long-term follow-up is warranted, given the significant potential for complications.

Surgical management of severe neonatal hyperparathyroidism: one center's experience.

INTRODUCTION: Neonatal severe hyperparathyroidism (NSHPT) is a rare disease that presents early with severe hypercalcemia. We reviewed our experience with NSHPT management at a tertiary-care institution. METHODS: A retrospective chart review was conducted for patients managed for NSHPT over the last 10 years. Demographic, clinical, and follow-up data were collected, and descriptive data were generated. RESULTS: Five patients were managed for NSHPT, 3 females and 2 males, with a mean age of 18 days at presentation. The mean preoperative parathyroid hormone and calcium levels were 3607 ng/L and 3.84 mmol/L, respectively. Preoperative parathyroid gland localization tests were all negative. All patients had a total parathyroidectomy and autotransplantation at a mean age of 65 days, with a mean follow-up of 5.5 years. One patient had normal parathyroid hormone and normal calcium levels 9.5 years after surgery without medication. One patient had normal levels without medication for 2 years then needed calcium and vitamin D supplements thereafter (8.5 years postoperatively). Three patients are still on calcium and vitamin D supplementation 5.5 years, 3.5 years, and 8 months, respectively, after surgery. CONCLUSIONS: Neonatal severe hyperparathyroidism is managed effectively with total parathyroidectomy. Preoperative localization studies are not helpful, and autotransplantation has a modest effect in our experience.

Surgical resident satisfaction with the current surgical training program in the Riyadh area.

BACKGROUND: The satisfaction of surgical residents with their training programs plays an important role in dictating its output. This survey was conducted to explore the satisfaction of surgical residents with their training programs in the Riyadh area. METHODS: A survey questionnaire was distributed in four major hospitals to explore the view of surgical residents regarding their training programs. Frequency tables were generated for each question in the survey. RESULTS: About 78 survey forms were distributed and 52 were retrieved (67%). About 45% of residents had a comprehensive orientation on admission to the program, but only 20% felt it was helpful. Only 40% of residents felt that their trainers were committed to training and that the consultants who were trained abroad were more committed than those trained locally (62% vs 36%, P =.01). Only 15% felt the residents themselves had enough bedside teaching or operative experience. Seventy-eight percent of the residents felt that current training does not meet their expectations. However, 85% felt that training abroad was better than local training, and 60% felt it should be mandatory. While 90% felt that training programs should be unified nationally and controlled by one organization, only 6% felt that the current governing body was capable of monitoring the training. Moreover, only 28% felt that current reviews of programs by the governing body are effective. CONCLUSIONS: These results show that surgical residents are generally dissatisfied with current training programs. The study suggests that there are significant weaknesses in the current programs and the governing body may be ineffective in monitoring the programs. We feel that a national review of surgical training programs is warranted in view of these results.

Laparoscopic vs open pancreatectomy for persistent hyperinsulinemic hypoglycemia of infancy.

BACKGROUND: Persistent hyperinsulinemic hypoglycemia of infancy (PHHI) is considered the most common cause of persistent neonatal hypoglycemia. The aim of this study is to compare laparoscopic pancreatectomy with open pancreatectomy for PHHI in one center regarding feasibility, safety, and effectiveness. METHODS: A retrospective chart review was conducted for patients managed for PHHI with either laparoscopic or open pancreatectomy for the period from 2001 to 2007 at King Faisal Specialist Hospital and Research Center (Riyadh, Saudi Arabia). Demographic and clinical data were retrieved. Continuous variables were reported as means, and categorical variables were reported as proportions for each group. Means were compared using Student's t test, and proportions were compared using chi(2) test or Fisher's Exact test where appropriate. A P value less than .05 was considered statistically significant. The study proposal was approved by the Clinical Research Committee and the Research Ethics Committee at our institution. RESULTS: Eighteen patients were managed with pancreatectomy for PHHI for that period: 10 laparoscopic and 8 open. The 2 groups were comparable regarding age and weight at surgery, sex, procedure duration, hospital stay postoperatively, need for reoperation, and development of diabetes mellitus and mental delay. Extent of resection was significantly higher in the open group (P value = .02), and the laparoscopic group was fed significantly earlier (P value = .001). The mean follow-up for the laparoscopic and the open groups were 20.4 months and 46 months, respectively (P value = .004). CONCLUSIONS: Laparoscopic pancreatectomy for PHHI is safe and feasible. Our data suggest its effectiveness compared to the open approach.

Laparoscopic pancreatectomy for persistent hyperinsulinemic hypoglycemia of infancy.

BACKGROUND: Persistent hyperinsulinemic hypoglycemia of infancy (PHHI) is considered the most common cause of persistent neonatal hypoglycemia. Management of PHHI involves use of medical agents and its failure is an indication of surgical intervention. Traditionally, an open pancreatectomy was the standard of care but recently laparoscopic pancreatectomy was described. We report our experience with laparoscopic pancreatectomy for PHHI for the period from March 2004 to February 2008. METHODS: A retrospective chart review was conducted for patients managed for PHHI with laparoscopic pancreatectomy for that period. Demographic and clinical data were retrieved. Descriptive data were generated, and SPSS version 10 statistical package (SPSS, Chicago, Ill) was used. RESULTS: Twelve patients diagnosed with PHHI were managed with laparoscopic pancreatectomy for that period. Median age at procedure was 11.5 months (range, 0.5-89 months). Median extent of pancreatectomy was 90% (range, 85%-95%). There were 2 (16%) conversions to open technique. One patient (8%) required reoperation 3 months after the procedure. Patients were followed up for a median of 23.5 months (range, 3-48 months). Four (33%) were euglycemic with no medications. Three patients remained on octreotide postoperatively to be euglycemic, and 3 patients needed a combination of octreotide and diazoxide. One patient remained euglycemic for 10 months then started on octreotide because of recurrence of hypoglycemia. One patient remained hypoglycemic postoperatively and required reoperation 3 months later to control symptoms. He became diabetic 4 months after reoperation on insulin. CONCLUSIONS: Our data suggest that laparoscopic pancreatectomy for medically unresponsive PHHI is feasible and safe. Longer follow-up is needed to ascertain effectiveness.

Feasibility and safety of laparoscopic adrenalectomy in children: special emphasis on neoplastic lesions.

BACKGROUND: Laparoscopic adrenalectomy (LA) in children became a viable option for the resection of adrenal lesions. Few reports have been published in the last few years documenting its safety and feasibility. In this paper, we report our experience with LA over the last 10 years, with special emphasis on malignant lesions. METHODS: A retrospective chart review was undertaken for patients managed with LA from 1997 to 2006 at King Faisal Specialist Hospital and Research Center. Demographic and clinical data were retrieved and descriptive data were generated. RESULTS: Twenty-nine patients were managed with LA at our institution over that period. There were 16 females and 13 males with a median age of 3 years. Adrenal lesions were left sided in 15, right sided in 11, and bilateral in 3 patients. Twenty-one patients had malignant lesions, while 8 had benign lesions. Lesions ranged in size from 2.8 to 7 cm in diameter. There were 3 conversions (10%) to the open technique. Resection margins were positive for tumor in 5 cases (17%), and all had stage IV neuroblastoma. Follow-up range was from 9 months to 9.5 years (9 months to 6.3 years for malignant lesions). There were no major postoperative complications and no port-site metastasis. Three patients had local recurrence, 2 of them had free resection margins. One patient managed for bilateral neuroblastoma has stable residual disease 17 months after resection. Hospital stay ranged from 2 to 4 days. At the time of this report, 3 patients with neuroblastoma had died with progressive metastatic refractory disease. CONCLUSIONS: Our data have shown the feasibility, safety, and effectiveness of LA for adrenal lesions, including malignant tumors. The relatively long follow-up data regarding the malignant lesions attest to its role in the management of such lesions. Appropriate selection criteria and appropriate laparoscopic surgical expertise are required to ensure its success.

Long gap esophageal atresia: an Australian experience.

BACKGROUND: The diagnosis of long gap esophageal atresia (LGEA) may preclude immediate primary anastomosis. We reviewed our experience with this entity for a period of 10 years. METHODS: A retrospective review was undertaken of the medical records of all patients managed for esophageal atresia (EA)/tracheoesophageal fistula (TEF) during the period from 1991 to 2001 at the Children's Hospital at Westmead, Sydney, Australia. Esophageal atresia was defined as long gap when primary repair was considered technically impossible by the surgeon. Also, a questionnaire was sent to all the general pediatric surgeons in Australia to explore their attitude toward LGEA management. RESULTS: One hundred three patients with EA were managed for that period, 17 (16%) of them were defined as LGEA, with mean gap of 5 cm (SD, 1cm). Eight patients (47%) had TEF. Sixteen patients had gastrostomy tube (GT) insertion at a mean age of 4 days. Six patients had esophagostomy at a mean age of 27 days. Thirteen patients had EA repair at a mean age of 146 days. Four patients died before repair and 2 after repair secondary to associated anomalies. Fifty percent of Australian Pediatric Surgeons (APS) responded to the questionnaire. Forty percent defined LGEA as a gap more than 3 to 4 vertebral bodies, whereas 24% considered the absence of TEF as an indication of LGEA. Fifty-six percent of APS will measure the gap on preoperative chest x-rays, and 80% will assess the gap at thoracotomy for ligation of TEF. Ninety-two will measure the gap by inserting a bougie into the upper pouch and into the lower esophagus via the GT. If LGEA was diagnosed, all APS will perform GT with delayed repair. Seventy-two percent of APS will attempt delayed primary repair within 3 to 6 months of age. Seventy-six percent will perform hiatal dissection, and 48% will use upper pouch myotomies. Forty-eight percent will perform gastric pull up, and 32% will use gastric tube for esophageal replacement. CONCLUSIONS: Long gap esophageal atresia represents a surgical challenge. Mortality rate is high secondary to associated anomalies. There is no consensus among APS regarding the definition of LGEA. In general, the consensus of APS would be that the preservation of the patient's own esophagus should be attempted before considering the use of an esophageal replacement.

CT-estimated volume of Wilms tumor can predict weight.

Wilms tumor weight was used to recruit patients in a recent National Wilms Tumor Study (NWTS) group trial. The authors hypothesized that a simple calculation of tumor volume based on a preoperative CT scan could predict tumor weight. The authors reviewed charts and CT images of patients with Wilms tumors who were treated at their institution between 1985 and 2002. Tumor volume was calculated as: V = 1/6pi x d (long axis) x d (short axis) x d (craniocaudal). Weight and calculated tumor volume were correlated using linear regression. Complete data of tumor weight and volume could be determined in 25 of the 49 patients. These were highly correlated (Spearman R = 0.97). Wilms tumor weight can be predicted based on a simple estimate of tumor volume on a preoperative CT scan. CT-estimated volume may replace weight as a prognostic factor and in guiding management.

Endoscopic drainage of pancreatic pseudocysts in children.

BACKGROUND/PURPOSE: Symptomatic pancreatic pseudocysts have traditionally been managed with surgical, percutaneous, and, more recently, endoscopic drainage. Although the role of the latter is well defined in the adult population, its utility in children needs to be clarified. The authors reviewed their experience with endoscopic drainage of pancreatic pseudocyst (EDPP). METHODS: A retrospective chart review was conducted, and relevant demographic and clinical data were obtained for all patients with pancreatic pseudocysts managed with endoscopic drainage in the period from 1997 through 2001, inclusive. RESULTS: Three children had successful endoscopic drainage of pancreatic pseudocysts. They were 9, 13, and 14 years old, and were all boys. The etiology of the pancreatitis was idiopathic related to anomalous pancreatic divisum ducts in the first 2 and azathioprine induced in the latter. The first 2 patients had endoscopic transpapillary drainage, whereas the third had an endoscopic cystduodenostomy. All patients had complete resolution of the pseudocyst clinically and radiologically after follow-up periods of 3, 31, and 21 months, respectively. The first needed a subsequent pancreaticojejunostomy for persistent symptoms related to chronic pancreatitis. A successful endoscopic drainage of a posttraumatic pancreatic pseudocyst has previously been reported from our institution. CONCLUSIONS: This experience would indicate that endoscopic drainage of pancreatic pseudocyst is an effective and relatively safe option of managing this problem in children.

Congenital diaphragmatic hernia: experience without extracoporeal membrane oxygenation.

While extracorporeal membrane oxygenation (ECMO) is used in the management of congenital diaphragmatic hernia (CDH), its value is questioned. The charts of all newborn infants who presented in respiratory distress due to CDH over the past 27 years were reviewed. Inborn versus outborn, year of repair, use of ultrasound (US), and the predictive value of various parameters was evaluated. Fisher's exact test and logistic regression tests were used to analyze data. There were 81 patients, 43 males and 38 females. Repair occurred after stabilization without ECMO; 65 patients survived (80%). Apgar scores at 1 min (P=0.03) and 5 min (P=0.005), best postductal PaO2 (BPDPaO2) (P=0.02), and type of repair (P=0.01) were predictive of outcome. There was no difference in survival between inborn and outborn patients or over the years of review (P=0.29). Forty-six patients had documented prenatal US scans, with no obvious impact on outcome. Thus, survival of CDH patients without ECMO is comparable to the best results reported with ECMO, suggesting that the costs and associated morbidity of ECMO may not justify its use for such patients. Apgar scores, BPDPaO2, and type of repair are good predictors of outcome.