Adrenal Gland Trauma: An Observational Descriptive Analysis from a Level 1-Trauma Center.

INTRODUCTION: We aimed to describe the presentation, classification, and outcome of traumatic adrenal injury in a single Level-1 trauma center. METHODS: A retrospective study was conducted to include all patients identified to have adrenal trauma from 2011 to 2014. Data were retrieved from charts and electronic medical records for all patients with adrenal trauma with a 3-year follow-up for mortality. RESULTS: A total of 116 patients who were admitted with adrenal injury (12.9% of abdominal trauma and 20% of total solid organ injury admissions) were included in the study, 104 were males and 12 were females. In our population, 86% of adrenal injuries involved the right adrenal gland, 14% in the left, and 12% had bilateral injuries. The majority of associated injuries were rib fractures accounting for 42%, while 37% had associated lung injuries, and 35% had head injuries. As per the American Association for the Surgery of Trauma classification, 46% of adrenal traumas were grade one. Of all adrenal trauma, 25 patients were operated (21%), whereas the majority were admitted to the intensive care unit or surgical ward. Surgical interventions were indicated for associated injury to the bowel, spleen, diaphragm, mesentery, kidneys, or inferior vena cava. One patient underwent angioembolization of the adrenal vessels due to contrast leak. The mortality rate was 14.6%, and no further mortality was reported during a 3-year follow-up. On multivariable analysis, admission systolic blood pressure, Glasgow Coma Scale, and injury severity score were predictors of hospital mortality. CONCLUSIONS: Adrenal injury is not rare and often unilateral with right-sided predominance. Associated injuries influence the clinical findings, management, and outcome. Surgical interventions are rarely required except for few cases of active bleeding. Long-term outcome postadrenal injury is still not well studied.

Triple Thoracic Injury Caused by Foreign Body Ingestion: A New Approach for Managing an Unusual Case.

BACKGROUND In most cases, esophageal perforation is caused by ingested foreign bodies which can migrate through the esophageal wall, damaging nearby vital organs like the aorta or pericardium, thereby having potentially fatal outcomes. Early diagnosis and intervention are key to decreasing morbidity and mortality. Appropriate treatment involves extracting the foreign body, repairing the esophagus and other injured organs (aorta, trachea, or pericardium), and draining and cleaning the mediastinum. CASE REPORT A 31-year-old man presented with a 2-h history of severe chest pain radiating to the back and associated with profuse sweating after eating. The patient had ingested a sharp metal object that injured the thoracic esophageal wall close to the aorta and the left atrium, causing hemopericardium. The presence of pericardial effusion on echocardiogram examination raised a high suspicion of cardiac and/or aortic injury. Left thoracotomy was done because the injury was in the distal third of the esophagus. Therefore, exploration of the pericardium and drainage of the mediastinum was essential, along with the use of resuscitative endovascular balloon occlusion of the aorta (REBOA) to control the proximal aorta while exploring the thoracic aorta. CONCLUSIONS In cases of esophageal injury when aortic involvement is suspected, we suggest using REBOA in selected cases, when an expert team is available, as a mean of gaining better proximal control over the aorta to safely explore and repair any possible injuries. This is an unusual case management scenario that needs further literature and clinical support.

Single-Port Sleeve Gastrectomy Compared With Conventional Laparoscopic Sleeve Gastrectomy: 5-Year Follow-up of Weight Loss, Comorbidity Resolution, and Cost.

Background. The Single-Port Instrument Delivery Extended Reach (SPIDER) surgical system is a safe revolutionary technology that defeated difficulties of single-incision surgery. We assessed the long-term outcomes of SPIDER sleeve gastrectomy (SPIDER SG) versus conventional laparoscopic sleeve gastrectomy (LSG) in morbidly obese patients. Methods. Retrospective review of patients who underwent SPIDER SG or LSG in our center matched by the date of surgery (2012-2013). We reviewed weight loss results up to 5 years, complication rates, procedure and hospitalization durations, financial cost, and effect on comorbidities. Results. Patients underwent 200 SPIDER SG and 220 LSG. At baseline, SPIDER SG versus LSG patients had a mean body mass index of 43.8 ± 5.6 and 48.6 ± 8.1 kg/m2, respectively. At 1 year, both groups had comparable percentage of excess weight loss (%EWL). At 5 years, SPIDER SG had %EWL of 54.6 ± 24.8 compared with 57.8 ± 29.9 in LSG (P = .4). Nine SPIDER SG (4.5%) required conversion to LSG. Complications occurred in both groups: 4% versus 4.1% (P = .95). At 2-year follow-up, diabetes mellitus was reversed in 43% of SPIDER SG and 62% LSG. Despite a shorter hospital stay in SPIDER SG, the total cost was significantly higher ($2 041 477) compared with LSG ($1 773 834). The mean score of scar satisfaction was significantly more in SPIDER SG. Conclusions. SPIDER SG was safe with long-term effects on weight loss comparable to LSG. Despite the higher cost of SPIDER SG, a shorter hospital stay and better cosmesis were observed.

Management of leak after sleeve gastrectomy: outcomes of 73 cases, treatment algorithm and predictors of resolution.

INTRODUCTION: Gastric leak post laparoscopic sleeve gastrectomy (LSG) is a severe complication that has been reported in 1.5-3% of cases. Management algorithms of leak exist; however, no known factors predict the time to resolution. This study aims to share outcomes of our management algorithm of post LSG leak, including the rate of resolution, complications, admission to the intensive care unit, conversion to other techniques, and mortality. To determine if any factors can predict the resolution time. METHODS: A retrospective analysis of patients who had LSG leaks and was managed in the main tertiary center in Qatar (January 2012-December 2017). RESULTS: A total of seventy-three patients had post LSG leaks. Fifty-six (76.7%) underwent LSG outside our center. Thirteen leaks (17.8%) were after revisional LSG. Laparoscopic exploration was performed in twenty patients (27.4%) and feeding jejunostomy in nine patients (12.3%). Patients were followed up for 12 months. All healed within 8.8 ± 0.72 weeks. The resolution rate was (97.1%) without surgical conversion, while two patients required fistulo-jejunostomy. No patient died. Complications occurred; re-leak (14.9%) and splenic abscess (2.9%). Patients on jejunal feeding had shorter resolution time (HR = 2.7, P = 0.018), while patients on total parenteral nutrition and post-endoscopic dilatation had 66% and 50% increases in the resolution time; (HR = 0.34, P = 0.026) and (HR = 0.5, P = 0.047), respectively. CONCLUSION: Management of post-LSG leak is multimodal. Our clinical experience demonstrated less urge to perform extensive surgical interventions. Patients on enteral feeding had shorter resolution time while patients with sleeve stricture had a longer time to resolution.

Repeat liver resection for pure large cell neuroendocrine carcinoma of the gallbladder: a favorable outcome.

BACKGROUND: The pure large cell type is a rare variant of primary neuroendocrine carcinoma of the gallbladder. Few reports have mentioned extended survival. Although a multimodal treatment has been described in the treatment of such rare disease, redo liver resection has not yet been mentioned. CASE REPORT: A 67-year-old lady was found to have poorly differentiated, high grade, pure large cell neuroendocrine tumor of the gallbladder after cholecystectomy for gallstones. After the diagnosis, staging workup showed a lesion in segment IVB/V of the liver, and chromogranin was elevated (982 mcg/L). The patient underwent central inferior hepatectomy and wedge excision of a lesion in segment III (discovered intra-operatively), with hilar lymphadenectomy. Three months after the first liver resection, she developed a new liver lesion II/III and underwent left lateral liver resection. The patient remained disease-free for 4 months following the second liver resection but then developed recurrent liver disease and was started on chemotherapy. Further progression led to multi-organ failure and death at 26 months from initial diagnosis. CONCLUSION: This is the first reported repeat liver resection in such a rare disease that has led to extended overall survival. We suggest that a group of selected patients with this rare malignancy, and liver-limited disease, may benefit from repeated liver resection.

Does Perioperative Hemoglobin A1c Level Affect the Incidence, Pattern and Mortality of Lower Extremity Amputation?

BACKGROUND: We hypothesized that perioperative HbA1c influenced the pattern and outcomes of Lower Extremity Amputation (LEA). METHODS: A retrospective analysis was conducted for all patients who underwent LEA between 2000 and 2013. Patients were categorized into 5 groups according to their perioperative HbA1c values [Group 1 (<6.5%), Group 2 (6.5-7.4%), Group 3 (7.5-8.4%), Group 4 (8.5-9.4%) and Group 5 (≥9.5%)]. We identified 848 patients with LEA; perioperative HbA1c levels were available in 547 cases (Group 1: 18.8%, Group 2: 17.7%, Group 3: 15.0%, Group 4: 13.5% and Group 5: 34.9%). Major amputation was performed in 35%, 32%, 22%, 10.8% and 13.6%, respectively. RESULTS: The overall mortality was 36.5%; of that one quarter occurred during the index hospitalization. Mortality was higher in Group 1 (57.4%) compared with Groups 2-5 (46.9%, 38.3%, 36.1% and 31.2%, respectively, p=0.001). Cox regression analysis showed that poor glycemic control (Group 4 and 5) had lower risk of mortality post-LEA [hazard ratio 0.57 (95% CI 0.35-0.93) and hazard ratio 0.46 (95% CI 0.31-0.69)]; this mortality risk persisted even after adjustment for age and sex but was statistically insignificant. The rate of LEA was greater among poor glycemic control patients; however, the mortality was higher among patients with tight control. CONCLUSION: The effects of HbA1c on the immediate and long-term LEA outcomes and its therapeutic implications need further investigation.

Management and outcomes of hyperparathyroidism: a case series from a single institution over two decades.

BACKGROUND: Hyperparathyroidism is a frequent endocrine disorder with variable clinical manifestations and outcomes. We aimed to evaluate clinical presentations, management and outcomes of hyperparathyroidism. METHODS: A retrospective study was conducted to include all patients presented with hyperparathyroidism between 1995 and 2014 at a single tertiary hospital with an average follow-up period of 46 months. Data were reviewed for clinical presentations, diagnostic work-up, intraoperative findings, management, and outcomes. RESULT: We identified 161 patients with hyperparathyroidism; 69% were females and the mean age was 49.4±15 years. Patients presented mainly with musculoskeletal (65.8%), renal (37.3%), gastrointestinal tract (53.8%) and neuropsychiatric (8.8%) manifestations. At presentation, mean serum calcium and parathyroid hormone levels were elevated while mean vitamin D level was lower. Sestamibi-99mTc (MIBI) scintigraphy was done for 134 patients (83.2%) and was positive in 94 (70%). Primary hyperparathyroidism (67.7%) was the most frequent diagnosis followed by secondary (29.8%) and tertiary hyperparathyroidism (2.5%). The frequent indication for surgery was hypercalcemia (67.3%), bone disease (35.6%) and renal calculi (28.9%). The main postoperative pathology was parathyroid adenoma (63.1%) followed by hyperplasia (37.3%). Fourteen (8.9%) and 18 (11.4%) patients had persistent and recurrent hyperparathyroidism, respectively. Autotransplantation of parathyroid tissue was done in 36 cases. CONCLUSION: Primary hyperparathyroidism is the most frequent cause of the parathyroid disease. Parathyroidectomy is the effective surgical approach in symptomatic patients. Further studies are needed to establish the association between vitamin D levels, renal disorders and persistent or recurrent hyperparathyroidism.

Incidence, Indications, and Predictive Factors for ICU Admission in Elderly, High-Risk Patients Undergoing Laparoscopic Sleeve Gastrectomy.

BACKGROUND: Obesity affects the elderly, leading to increased prevalence of age- and obesity-associated comorbidities. There are no guidelines for indications and risk assessment for the elderly undergoing bariatric surgery. OBJECTIVES: To determine the incidence, indications, and outcomes of planned ICU admission in elderly, high-risk patients after laparoscopic sleeve gastrectomy (LSG) and to assess if preoperative risk factors for planned postoperative ICU admission in elderly patients undergoing LSG could be predicted preoperatively. METHODS: Retrospective review of prospectively collected data for all patients aged ≥ 60 years who underwent LSG (2011-2016) at Hamad General Hospital in Qatar. RESULTS: We followed up 58 patients aged 60-75 years for 28 ± 17 months. About 77.6% of patients were in the intermediate-risk group of the Obesity Surgery Mortality Risk Score (OS-MRS). Fourteen patients (24%) required ICU admission for 2 ± 1.2 days; all patients belonged to the American Society of Anesthesiologists (ASA) III class and intermediate to high risk on OS-MRS. There were no reported mortalities. The mean body mass index (BMI) decreased from 49 ± 10.6 to 37.6 ± 10.1 kg/m2. The number of patient comorbidities (OR, 1.43; 95% CI, 1.03-1.99) and the diagnosis of obstructive sleep apnea (OSA; OR, 7.8; 95% CI, 1.92-31.68) were associated with planned ICU admission. CONCLUSION: Elderly patients undergoing LSG usually have excellent postoperative course despite the associated high risk and the required ICU admission. The number of comorbidities, diagnosis of OSA, and ASA score are possible clinically significant predictive factors for the need of post-LSG ICU admission.

Five-year Outcomes of Laparoscopic Sleeve Gastrectomy: a Comparison Between Adults and Adolescents.

BACKGROUND: Bariatric surgery in adolescents is still under debate. Literature about the long-term impact of laparoscopic sleeve gastrectomy (LSG) on adolescents' obesity and associated morbidities is scarce. It is unknown if LSG shows better long-term results in the adolescent or adult group. AIM: To compare the long-term effectiveness of LSG on obesity and associated comorbidities between adolescents and adults. METHODS: This retrospective study analyzed all patients with morbid obesity who underwent LSG in (2011-2012) and were followed for up to 5 years. Patients were divided into two groups: adolescents and adults. Data were compared between the two groups. RESULTS: LSG was performed in 139 adults and 91 adolescents. The mean ages of the adults and adolescents were 37.4 ± 11.4 and 17 ± 1.5 years, respectively. The preoperative body mass index values of the adults and adolescents were 48.4 ± 8.7 and 47.6 ± 7.5 kg/m2, respectively (P = 0.95). At 5 years, percentage of total weight loss increased in adolescents (to 35.8 ± 11.5%), while it remained almost the same in adults (26.3 ± 10%). At 1 year, about 68.2% of adults and 62.5% of adolescents were cured from diabetes though, 13% of diabetic adults had relapse at 5 years and none of the adolescents relapsed. Postoperative complications occurred in both groups. CONCLUSION: LSG showed comparable weight loss results in adults and adolescents, with better results in adolescents. LSG is more effective in preventing and treating diabetes/prediabetes in the adolescent group.

A 5-Year Follow-Up Study of Laparoscopic Sleeve Gastrectomy Among Morbidly Obese Adolescents: Does It Improve Body Image and Prevent and Treat Diabetes?

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is widely used, and it is important to examine its physiologic and psychological efficacy among adolescents. We assessed LSG's efficacy for weight loss, its short- and long-term effects on resolving and improving obesity-related comorbidities, and its psychological outcomes among morbidly obese adolescents. METHODS: We retrospectively analyzed the medical records of 91 morbidly obese adolescents in Qatar who underwent LSG (2011-2014), with 1- and 5-year follow-ups. RESULTS: The mean preoperative weight and body mass index (BMI) were 132.5 ± 25.3 kg and 48 ± 7.5 kg/m2, respectively. Postoperatively, mean weight and BMI decreased to 101 ± 22 kg and 36.4 ± 7.2 kg/m2, respectively. At 1 year, the mean excess weight loss (%EWL), percent total weight loss (%TWL), and percent BMI loss (%BMIL) were 49.48 ± 25.8, 23.1 ± 11.9, and 23.16 ± 11.8%, respectively. At 5 years, %EWL, %TWL, and %BML were 78 ± 12, 35.8 ± 11.5, and 36 ± 12%, respectively. No patients developed postoperative leaks, and three patients had endoscopic dilatation due to stenosis. Overall, 64% of obstructive sleep apnea patients were cured, all prediabetic patients had total remission, and 50% of the diabetic patients were cured. The overall mean HBA1c level was 6 mmol/L, which significantly decreased to 5.1 mmol/L postoperatively (P = 0.0001). At 5 years, there was no relapse of diabetes, and 75% of the diabetic adolescents had complete remission. The only patient with hypertension showed complete resolution with laparoscopic sleeve gastrectomy. Postoperatively, overall body image satisfaction significantly improved (P = 0.0001). CONCLUSION: LSG significantly ameliorated short- and long-term obesity-related comorbidities and body image dissatisfaction among Qatari adolescents.

Role of intraoperative cholangiography for detecting residual stones after biliary pancreatitis: still useful? A retrospective study.

BACKGROUND: Intraoperative cholangiography (IOC) may detect residual stones in the common bile duct (CBD) after acute biliary pancreatitis (ABP). The aim of the present study is to analyze the utility of IOC in detecting residual stones in patients undergoing cholecystectomy for ABP and if complications are related with this procedure. METHODS: Demographic and clinical factors were assessed in patients with mild ABP who underwent IOC during laparoscopic cholecystectomy. Factors assessed included preoperative size of the CBD on ultrasonography, presence of stones in the gallbladder and the CBD, and IOC results. For the statistical analysis, χ2 or Fisher's exact tests to compare proportions and the nonparametric Mann-Whitney U test for analysis of values with abnormal distribution were used. RESULTS: The study included 113 patients, 82 males (72.6%) and 31 females (27.4%), of mean age 46.9 ± 14.7 years (range 18-86 years). All preoperative laboratory indicators were elevated. The group of the patients with stones in the CBD diagnosed by IOC was divided in patients with diameters <0.8 mm and with diameters ≥0.8 mm of the CBD diagnosed preoperatively with ultrasound. The laboratory tests do not demonstrate difference statistically significative between these two groups. The group of the patients without stones in the CBD diagnosed by IOC was also divided in patients with diameters <0.8 mm and with diameters ≥0.8 mm of the CBD. Also in these two groups, the statistical analysis of the laboratory tests does not demonstrate significative difference. Most procedures were performed by specialists (64.6%), and all patients underwent IOC. IOC showed stones in 84/113 patients (74.3%). A comparison of patients with and without stones at IOC showed similar mean times from hospitalization to surgery (5.9 days [range 2-12 days] vs. 6.1 days [range 2-23 days]), from surgery until hospital discharge (2.0 days [range 0-4 days] vs. 2.2 days [range 0-11 days]), and overall length of stay (7.9 days [range 3-19 days] vs. 8.3 days [range 3-23 days]) (P > 0.001). CONCLUSIONS: IOC is useful to diagnose residual CBD stones, without increasing complications related to the procedure itself.

Efficacy and Safety of the Over-the-Scope Clip (OTSC) System in the Management of Leak and Fistula After Laparoscopic Sleeve Gastrectomy: a Systematic Review.

BACKGROUND: Endoscopic management of leaks/fistulas after laparoscopic sleeve gastrectomy (LSG) is gaining popularity in the bariatric surgery. OBJECTIVES: This study aimed to review the efficacy and safety of over-the-scope-clip (OTSC) system in endoscopic closure of post-LSG leak/fistula. METHODS: PubMed/Medline and major journals of the field were systematically reviewed for studies on endoscopic closure of post-LSG leaks/fistula by means of the OTSC system. RESULTS: A total of ten eligible studies including 195 patients with post-LSG leaks/fistula were identified. The time between LSG and leak/fistula ranged from 1 day to 803 days. Most of the leaks/fistula were located at the proximal staple line, and they sized from 3 to 20 mm. Time between leak diagnosis and OTSC clipping ranged from 0 to 271 days. Thirty-three out of 53 patients (63.5%) required one clip for closure of the lesion. Regarding the OTSC-related complications, a leak occurred in five patients (9.3%) and OTSC migration, stenosis, and tear each in one patient (1.8%). Of the 73 patients with post-LSG leak treated with OTSC, 63 patients had an overall successful closure (86.3%). CONCLUSION: OTSC system is a promising endoscopic approach for management of post-LSG leaks in appropriately selected patients. Unfortunately, most studies are series with a small sample size, short-term follow-up, and mixed data of concomitant procedures with OTSC. Further studies should distinguish the net efficacy of the OTSC system from other concomitant procedures in treatment of post-LSG leak.

Laparoscopic sleeve gastrectomy in patients with abdominoplasty: a case-control study.

BACKGROUND: Abdominoplasty is increasingly performed after weight loss surgery. However, performing a laparoscopic sleeve gastrectomy (LSG) after abdominoplasty poses technical challenges. OBJECTIVE: The present study aimed to compare operative events and postoperative outcomes between LSG patients with and without a history of prior abdominoplasty. SETTING: University hospital, Qatar. METHODS: A case-control study was conducted on 2 groups of patients with (n = 33) and without (n = 69) prior abdominoplasty who underwent LSG. Patient demographics, baseline characteristics, as well as operative and postoperative events were compared between the 2 groups. RESULTS: A total of 102 patients with an average age of 39.6±7.7 years and body mass index (BMI) of 42.8±5.9 kg/m2 were included. There were no significant differences between the 2 groups in terms of demographic characteristics, preoperative BMI, and co-morbidities. The number of ports required was significantly higher in the LSG patients with a history of prior abdominoplasty than in the nonabdominoplasty patients. The operation time was also significantly longer in the abdominoplasty patients than in the nonabdominoplasty patients (90.3±36.7 minutes versus 57.1±17.7 minutes; P<.0001). However, no significant differences were observed in terms of postoperative complications, length of hospital stay, and weight loss results. CONCLUSION: LSG after abdominoplasty is associated with longer operative times and the need for additional port placement to overcome the decreased working space. However, operative strategies should be considered to overcome the technical challenges during LSG in patients who underwent a prior abdominoplasty.

Blunt splenic trauma: Assessment, management and outcomes.

BACKGROUND: The approach for diagnosis and management of blunt splenic injury (BSI) has been considerably shifted towards non-operative management (NOM). We aimed to review the current practice for the evaluation, diagnosis and management of BSI. METHODS: A traditional narrative literature review was carried out using PubMed, MEDLINE and Google scholar search engines. We used the keywords "Traumatic Splenic injury", "Blunt splenic trauma", "management" between December 1954 and November 2014. RESULTS: Most of the current guidelines support the NOM or minimally approaches in hemodynamically stable patients. Improvement in the diagnostic modalities guide the surgeons to decide the timely management pathway Though, there is an increasing shift from operative management (OM) to NOM of BSI; NOM of high grade injury is associated with a greater rate of failure, prolonged hospital stay, risk of delayed hemorrhage and transfusion-associated infections. Some cases with high grade BSI could be successfully treated conservatively, if clinically feasible, while some patients with lower grade injury might end-up with delayed splenic rupture. Therefore, the selection of treatment modalities for BSI should be governed by patient clinical presentation, surgeon's experience in addition to radiographic findings. CONCLUSION: About one-fourth of the blunt abdominal trauma accounted for BSI. A high index of clinical suspicion along with radiological diagnosis helps to identify and characterize splenic injuries with high accuracy and is useful for timely decision-making to choose between OM or NOM. Careful selection of NOM is associated with high success rate with a lower rate of morbidity and mortality.

Traumatic brain injury in Qatar: age matters--insights from a 4-year observational study.

BACKGROUND: Overall traumatic brain injury (TBI) incidence and related death rates vary across different age groups. Objectives. To evaluate the incidence, causes, and outcome of TBI in adolescents and young adult population in Qatar. METHOD: This was a retrospective review of all TBIs admitted to the trauma center between January 2008 and December 2011. Demographics, mechanism of injury, morbidity, and mortality were analyzed in different age groups. RESULTS: A total of 1665 patients with TBI were admitted; the majority were males (92%) with a mean age of 28 ± 16 years. The common mechanism of injury was motor vehicle crashes and falls from height (51% and 35%, resp.). TBI was incidentally higher in young adults (34%) and middle age group (21%). The most frequent injuries were contusion (40%), subarachnoid (25%), subdural (24%), and epidural hemorrhage (18%). The mortality rate was 11% among TBI patients. Mortality rates were 8% and 12% among adolescents and young adults, respectively. The highest mortality rate was observed in elderly patients (35%). Head AIS, ISS, and age were independent predictors for mortality. CONCLUSION: Adolescents and adults sustain significant portions of TBI, whereas mortality is much higher in the older group. Public awareness and injury prevention campaigns should target young population.