Surgical site infection following abdominal surgery: a prospective cohort study

Background: Surgical site infection (SSI) is one of the most common complications of abdominal surgery and is associated with substantial discomfort, morbidity and cost. The goal of this study was to describe the incidence, bacteriology and risk factors associated with SSI in patients undergoing abdominal surgery. Methods: In this prospective cohort study, all patients aged 14 years or more undergoing abdominal surgery between Feb. 1 and July 31, 2016, at a single large academic hospital were included. Patients undergoing vascular, gynecological, urological or plastic procedures were excluded. Patients were followed prospectively for 30 days. Wound assessment was done with the Centers for Disease Control and Prevention definition of SSI. We performed multivariate analysis to identify factors associated with SSI. Results: A total of 337 patients were included. The overall incidence of SSI was 16.3% (55/337); 5 patients (9%) had deep infections, and 25 (45%) had combined superficial and deep infections. The incidence of SSI in open versus laparoscopic operations was 35% versus 4% (p < 0.001). The bacteria most commonly isolated were extended-spectrum ß-lactamase-producing Escherichia coli, followed by Enterococcus species. Only 23% of cultured bacteria were sensitive to the prophylactic antibiotic given preoperatively. The independent predictors of SSI were open surgical approach, emergency operation, longed operation duration and male sex. Conclusion: Potentially modifiable independent risk factors for SSI after abdominal surgery including open surgical approach, contaminated wound class and emergency surgery should be addressed systematically. We recommend tailoring the antibiotic prophylactic regimen to target the commonly isolated organisms in patients at higher risk for SSI.

Contexte: L'infection de plaie opératoire (IPO) est l'une des plus fréquentes complications de la chirurgie abdominale et elle est associée à un inconfort, une morbidité et des coûts substantiels. L'objectif de cette étude était de décrire l'incidence, les données bactériologiques et les facteurs de risque associés à l'IPO chez les patients soumis à une chirurgie abdominale. Méthodes: Dans cette étude de cohorte, tous les patients de 14 ans ou plus soumis à une chirurgie abdominale entre le 1er février et le 31 juillet 2016 dans un seul grand établissement hospitalier universitaire ont été inclus. Les chirurgies vasculaires, gynécologiques, urologiques ou plastiques ont été exclues. Les patients ont été suivis de façon prospective pendant 30 jours. L'évaluation des plaies a été effectuée à partir de la définition de l'IPO des Centers for Disease Control and Prevention. Nous avons procédé à une analyse multivariée afin d'identifier les facteurs associés à l'IPO. Résultats: En tout, 337 patients ont été inclus. L'incidence globale des IPO a été de 16,3 % (55/337); 5 patients (9 %) ont présenté des infections profondes, et 25 (45 %) ont présenté des infections superficielles et profondes. L'incidence des IPO lors d'interventions ouvertes c. laparoscopiques a été de 35 % c. 4 % (p < 0,001). Les bactéries les plus souvent isolées étaient Escherichia coli productrices de ß-lactamases à spectre élargi, suivies du genre Enterococcus. Seulement 23 % des bactéries cultivées se sont révélées sensibles à l'antibioprophylaxie administrée avant l'intervention. Les prédicteurs indépendants d'une IPO étaient l'approche chirurgicale ouverte, le caractère urgent de l'intervention, sa durée prolongée et le fait d'être de sexe masculin. Conclusion: Dans le contexte de la chirurgie abdominale, les facteurs de risque d'IPO indépendants potentiellement modifiables, incluant l'approche ouverte, la classification de la contamination de la plaie et le caractère urgent de la chirurgie, méritent d'être systématiquement pris en compte et corrigés. Nous recommandons une antibioprophylaxie adaptée pour cibler les agents souvent isolés chez les patients exposés à un risque plus élevé d'IPO.

Neoadjuvant chemotherapy does not impair liver regeneration following hepatectomy or portal vein embolization for colorectal cancer liver metastases.

BACKGROUND AND OBJECTIVES: Treatment strategies for colorectal cancer liver metastasis (CRCLM) such as major hepatectomy and portal vein embolization (PVE) rely on liver regeneration. We aim to investigate the effect of neoadjuvant chemotherapy on liver regeneration occurring after PVE and after major hepatectomy. METHODS: CRCLM patients undergoing PVE or major resection were identified retrospectively from our database. Liver regeneration data (expressed as future liver remnant [FLR] and percentage of liver regeneration [%LR]), total liver volume (TLV) and clinical characteristics were collected. RESULTS: Between 2003 and 2013, 226 patients were included (85 major resection, 141 PVE). The median chemotherapy cycles was six in both groups. The median time interval between the last chemotherapy and the intervention was 51 days in the PVE group and 79 days in the hepatectomy group. In the PVE group, chemotherapy was not associated with altered liver regeneration (number of cycles [P = 0.435], timing [P = 0.563], or chemotherapy agent [P = 0.116]). Similarly in the major hepatectomy group, preoperative chemotherapy (number of cycles [P = 0.114]; agent [P = 0.061], timing [P = 0.126]) were not significantly associated with differences in liver regeneration (P = 0.592). In both groups, the predicted FLR% was inversely correlated with the %LR (P < 0.001). CONCLUSION: Chemotherapy does not affect liver regeneration following PVE or major resection. J. Surg. Oncol. 2016;113:449-455. © 2016 Wiley Periodicals, Inc.

Delayed hemobilia due to hepatic artery pseudo-aneurysm: a pitfall of laparoscopic cholecystectomy.

BACKGROUND: Hepatic artery pseudoaneurysm as a complication of laparoscopic cholecystectomy is considered a rare, potentially life threatening condition. CASE PRESENTATION: We report a case of late onset hemobilia presenting 8 months following elective laparoscopic cholecystectomy with complex biliary and vascular injury. The patient was treated surgically with primary repair of the aneurysm and hepaticojujenostomy. CONCLUSION: A high index of suspicion should be raised when encountering a patient with massive upper GI bleeding and a previous history of hepatobiliary manipulation or surgery regardless of postoperative period.

Trends in brain-dead organ donor characteristics: a 13-year analysis.

BACKGROUND: Driven by disease trends, such as obesity and metabolic syndrome, that are increasingly prevalent in the general population, we aimed to evaluate the comorbidities and attributes of the brain-dead organ donor population over time in a longitudinal study. METHODS: We compared overall health and baseline attributes of organ donors between 2000-2005 and 2006-2012 using our prospective transplant database. Descriptive and comparative analyses of the 2 historical cohorts were performed. RESULTS: A total of 1040 brain-dead organ donors were included in our analysis: 496 from the 2000-2005 period and 544 from the 2006-2012 period. Our analysis revealed that donors from the recent (2006-2012) period were more likely to have increased body mass index (26.4 ± 6.0 v. 25.0 ± 4.8, p = 0.003), smoking history (57.0% v. 27.2%, p < 0.001), coronary artery disease (14.3% v. 3.2%, p = 0.015) and dyslipidemia (19.1% v. 4.2%, p < 0.001), but less likely to have concurrent infection (1.1% v. 7.9%, p < 0.001) than those from the earlier period. CONCLUSION: Our data suggest that the characteristics and comorbidities of brain-dead organ donors have somewhat deteriorated over the last decade. Further studies are needed to evaluate the impact of these health attributes on donated organ utilization and outcomes.

CONTEXTE: Comme la prévalence de l'obésité et du syndrome métabolique est actuellement en hausse dans la population générale, nous avons voulu évaluer, dans une étude longitudinale, les comorbidités et les caractéristiques de la population de donneurs d'organes en état de mort cérébrale au fil du temps. MÉTHODES: Nous avons comparé la santé globale et les caractéristiques de base des donneurs d'organes de 2000-2005 et de 2006-2012 au moyen de notre base de données prospective sur les greffes. Des analyses descriptives et comparatives des 2 cohortes ont été effectuées. RÉSULTATS: Au total, 1040 donneurs d'organes en état de mort cérébrale ont été inclus dans notre analyse : 496 de la période de 2000-2005 et 544 de la période de 2006-2012. Notre analyse a révélé que les donneurs de la période récente (2006-2012) étaient plus susceptibles d'avoir un indice de masse corporelle élevé (26,4 ± 6,0 c. 25,0 ± 4,8, p = 0,003), des antécédents de tabagisme (57,0 % contre 27,2 %, p < 0,001), une coronaropathie (14,3 % c. 3,2 %, p = 0,015) et une dyslipidémie (19,1 % c. 4,2 %, p < 0,001), mais moins susceptibles d'avoir une infection concomitante (1,1 % c. 7,9 %, p < 0,001) que ceux de la période antérieure. CONCLUSION: Nos données semblent indiquer que les caractéristiques et les comorbidités des donneurs d'organes en état de mort cérébrale se sont quelque peu détériorées au cours de la dernière décennie. D'autres études sont nécessaires pour évaluer l'incidence de ces caractéristiques de santé sur l'utilisation des organes donnés et les résultats.

Transient small bowel intussusception in an adult: case report with intraoperative video and literature review.

BACKGROUND: The term intussusception refers to invagination of a segment of the gastrointestinal tract into the lumen of an adjacent segment. This is a rare entity and it is more prevalent in children and less common in adults. The diagnosis of intussusception in adults is difficult as a result of the nonspecific signs and symptoms. As there are many common causes of acute abdomen, intussusception should be considered when more frequent etiologies have been ruled out. The laparoscopic approach offers both a diagnostic option and a therapeutic one for intussusception in adults. CASE PRESENTATION: We report a forty-one year old male patient, who presented to our Emergency Department complaining of peri-umbilical pain associated with nausea and vomiting for 1 day. Diagnosed with transient small bowel intussusception without any obvious underlying pathology. This report is the first to present an intra-operative video showing the small bowel intussuscepting and reducing spontaneously. Furthermore, the authors present a review about this rare condition, including previously reported similar cases in literature. CONCLUSION: Transient intussusception is extremely rare and is a challenging condition. Imaging techniques, especially CT scan, are helpful in the diagnosis of intussusception. However, laparoscopy offers the advantage of distinguishing transient intussusception from persistent intussusception.

Epidemiological Features of Acute Pancreatitis (AP): Largest Single-Center, Cohort Study in the Western Region of Saudi Arabia.

BACKGROUND: Acute pancreatitis (AP) is a medical emergency which can range in severity from a mild, self-limiting condition to a catastrophic event that results in multiorgan failure. This study aimed to evaluate the epidemiological characteristics of AP. METHODS: This study included all patients diagnosed with AP at King Abdulaziz University Hospital, a tertiary care hospital in Jeddah, Saudi Arabia, between 2017 and 2021. The main aim of this study was to investigate the frequency of AP in patients who present to the hospital with abdominal pain. Secondary objectives included analyzing the causes, complications, severity, and outcomes of the patients. RESULTS: A total of 67 patients were included. AP constituted 11.6% of all cases of patients presenting to the hospital with abdominal pain. Only seven patients presented with severe AP, which was significantly associated with advanced age (over 60 years old). The primary causes of AP were biliary and idiopathic pancreatitis, accounting for 80.6% of the cases. The most frequent complications observed were peripancreatic fluid collection and atelectasis, which occurred in 40.3% of cases. CONCLUSION: AP is a prevalent condition in patients with abdominal pain, with biliary pancreatitis being the leading cause of the disease. The majority of patients exhibited mild to moderate severity of symptoms and experienced positive outcomes when treated appropriately.

Outcomes of Open Versus Laparoscopic Technique in Primary Inguinal Hernia Repair: A Retrospective Study.

Inguinal hernia repair is one of the most common surgical procedures worldwide. In clinical practice, there are two different routes to repair inguinal hernias: laparoscopic mesh repair and open. Reducing the hernia and preventing recurrence remains the mainstay treatment option of both procedures. This study aims to compare postoperative outcomes and recurrence rates for patients who had primary, non-recurrent, laparoscopic, or open hernia repair in a single tertiary hospital. A retrospective cohort study was done on 468 patients. The study was conducted at King Abdulaziz University Hospital (KAUH) between 2013 and 2022. The distribution of our study population was divided into open hernia repair 378 participants (80.8%) while the rest did laparoscopic hernia repair 90 (19.2%). Operation duration in minutes was 107.158 ± 41.402 in the open hernia repair group and was noted to be significantly higher in the laparoscopic hernia repair group, with 142.811 ± 52.102 minutes p-value (0.000). The hospital length of stay was shown to be shorter in laparoscopic hernia repair (1.58 ±1.27) compared to open hernia repair (2.05±5.33). The most common postoperative complication was scrotal swelling, commonly associated with laparoscopic (5.55%) compared to 2.11% in open hernia repair. Open repair showed a risk of scrotal hematoma with a percentage of 0.52% compared to 0% in the laparoscopic method with a p-value (0.033). Hernia recurrence was non-related with any specific group, although noted to be higher in the laparoscopic group (7.77%), while in the open group (3.4%) with a p-value (0.081). The study conducted showed no alarming percentages for recurrence in either technique, open or laparoscopic, yet the open approach had a better outcome when it comes to scrotal pain and swelling post-operatively, chronic groin pain, and readmission rate as compared to laparoscopic technique, despite having a longer hospital stay. Future larger studies should be conducted to provide equal population inclusivity.

Portal vein embolization stimulates tumour growth in patients with colorectal cancer liver metastases.

OBJECTIVES: Portal vein embolization (PVE) can facilitate the resection of previously unresectable colorectal cancer (CRC) liver metastases. Bevacizumab is being used increasingly in the treatment of metastatic CRC, although data regarding its effect on post-embolization liver regeneration and tumour growth are conflicting. The objective of this observational study was to assess the impact of pre-embolization bevacizumab on liver hypertrophy and tumour growth. METHODS: Computed tomography scans before and 4 weeks after PVE were evaluated in patients who received perioperative chemotherapy with or without bevacizumab. Scans were compared with scans obtained in a control group in which no PVE was administered. Future liver remnant (FLR), total liver volume (TLV) and total tumour volume (TTV) were measured. Bevacizumab was discontinued ≥ 4 weeks before PVE. RESULTS: A total of 109 patients and 11 control patients were included. Portal vein embolization induced a significant increase in TTV: the right lobe increased by 33.4% in PVE subjects but decreased by 34.8% in control subjects (P < 0.001), and the left lobe increased by 49.9% in PVE subjects and decreased by 33.2% in controls (P= 0.022). A total of 52.8% of the study group received bevacizumab and 47.2% did not. There was no statistical difference between the two chemotherapy groups in terms of tumour growth. Median FLR after PVE was similar in both groups (28.8% vs. 28.7%; P= 0.825). CONCLUSIONS: Adequate liver regeneration was achieved in patients who underwent PVE. However, significant tumour progression was also observed post-embolization.

Predictors of response to radio-embolization (TheraSphere®) treatment of neuroendocrine liver metastasis.

BACKGROUND: Neuroendocrine tumours (NET) frequently metastasize to the liver. NET liver metastasis has been shown to respond to Yttrium-90 microspheres therapy. The aims of the present study were to define factors that predict the response to radio-embolization in patients with NET liver metastases. METHODS: From January 2006 until March 2009, all patients with NET liver metastasis that received radio-embolization using TheraSphere® (glass microspheres) were reviewed. The response was determined by a change in the percentage of necrosis (ΔN%) after the first radio-embolization based on the modified RECIST criteria (mRECIST) criteria. The following confounding variables were measured: age, gender, size of the lesions, liver involvement, World Health Organization (WHO) classification, the presence of extra-hepatic metastasis, octereotide treatment and previous operative [surgery and (RFA)] and non-operative treatments (chemo-embolization and bland-embolization). RESULTS: In all, 25 patients were identified, with a median follow-up of 21.7 months. The median age was 64.6 years, 28% had extra-hepatic metastasis and 56% were WHO stage 2. Post-treatment, the mean ΔN% was 48.4%. Previous surgical therapy was a significant predictor of the response with a response rate of 66.7 ΔN% vs. 31.5 ΔN% (P= 0.02). Bilateral liver disease, a high percentage of liver involvement and large metastatic lesions were inversely related to the degree of tumour response although did not reach statistical significance. CONCLUSION: Radio-embolization increased the necrosis of NET liver metastasis mainly in patients with less bulky disease. This may imply that surgical therapy before radio-embolization would increase the response rates.

A Very Rare Basidiobolomycosis Case Presented with Cecal Perforation and Concomitant Hepatic Involvement in an Elderly Male Patient: A Case Study.

This is a case report of Basidiobolomycosis in a 65-year-old male patient from Jizan presenting with colonic perforation and concomitant liver involvement from February 2021 to July 2021. To control the infection, the patient underwent colonic resection and segmental liver resection, as well as three antifungal drugs. The treatment was successful, and the condition was completely resolved.

Analytical review of diagnosis and treatment strategies for dominant bile duct strictures in patients with primary sclerosing cholangitis.

BACKGROUND: The diagnosis and treatment of indeterminate dominant strictures (DS) in patients with primary sclerosing cholangitis (PSC) is challenging and the literature on the subject is scarce. OBJECTIVES: This review aims to appraise and synthesize the evidence published in the English-language medical literature on this topic. METHODS: Scientific papers published from 1950 until week 4 of July 2010 were extracted from MEDLINE, Ovid Medline In-Process, the Cochrane Database of Systematic Reviews, the Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, EMBASE, PubMed and the National Library of Medicine Gateway. RESULTS: Strategies for the optimal management of DS in PSC patients are supported only by level II and III evidence. Intraductal endoscopic ultrasound appears to be the most sensitive (64%) and specific (95%) diagnostic test for the evaluation of DS in PSC. Endoscopic and percutaneous dilatations achieve 1- and 3-year palliation in 80% and 60% of patients, respectively. Although dilatation and stenting are the most common palliative interventions in DS, no randomized trials on the optimal duration of treatment have been conducted. CONCLUSIONS: In benign DS, endoscopic dilatation with short-term stenting seems to be effective and safe and does not increase the risks for malignant transformation or complications after liver transplantation. Surgical bile duct resection and/or bilioenteric bypass are indicated only in patients with preserved liver function.

Biliary anatomy and pancreatic duct variations: A cross-sectional study.

BACKGROUND/AIM: Biliary tree and pancreatic duct can appear in different variations whose proper understanding is obligatory for surgeons. Magnetic resonance cholangiopancreatography (MRCP) is considered a safe and accurate tool for evaluating biliary tree and pancreatic duct. Typical anatomy for right hepatic duct (RHD) and left hepatic duct (LHD) is reported as 57% and 63%, respectively. The most common (4-10%) pancreatic anomaly is divisum. In the present study, we evaluated and determined the prevalence of biliary tree and pancreatic duct variations among patients at a university hospital. MATERIALS AND METHODS: The MRCP records of 370 patients from 2015 to 2017 were obtained for cross-sectional study. Images were retrospectively reviewed for variations by two independent senior radiologists. Demographic data were obtained for all the patients. Huang et al. classification was used for RHD and LHD variations. The cystic duct was reported based on its course and insertion pattern. The pancreatic duct was observed for the presence of divisum, its course, and configuration. RESULTS: Three hundred and twenty-five patients were included in the final study. Most commonly observed variant for RHD were A1 (34.2%) and A2 (32.2%). For LHD, B1 (71.4%) was the most common variant. Cystic duct insertion was commonly seen as right lateral insertion (27.7%). Pancreatic divisum was observed in 0.6% of cases. Nationality, origin, and gender-specific variations were obtained. CONCLUSION: Variations in biliary anatomy and pancreatic duct are very diverse and extend from the intrahepatic biliary system down to the pancreas. Performing a similar study on a larger population is mandatory to illustrate the range of variations present within the community.

A Large Stomach Ulcer Is Associated With Raised Mortality in a Cohort of Patients Who Underwent Open Repair of Perforated Peptic Ulcer: A Five-Year Follow-Up Study.

Introduction Perforated peptic ulcer disease (PPUD) is associated with a high postoperative mortality and morbidity rates especially within the first 90 days. The size and site of the ulcer may contribute to the prognosis of PPUD. In this study, we will describe the association of size and site of PPUD with the overall mortality and in-hospital morbidities in a tertiary care university hospital. Methods A retrospective observational cohort study was conducted at King Abdulaziz University Hospital, Jeddah, Saudi Arabia. A total of 50 patients who had PPUD and underwent open exploratory laparotomy with surgical treatment were analyzed. Patients were divided into two groups: a small ulcer group when the ulcer diameter was less than equal to 1 cm and a large ulcer group when it was more than 1 cm. For the subgroup analysis, patients were categorized according to site into small duodenum, large duodenum, small stomach, and large stomach PPUD. The primary outcome was overall mortality that was measured by survival analysis and Cox regression. Secondary outcomes were intensive care unit (ICU) admission, ICU and hospital length of stay, and in-hospital mortality, which were assessed by stepwise logistics and linear regression. Results Overall mortality at 10, 30, and 90 days was 14% (95% CI: 0.06-0.27), 24% (95% CI: 0.14-0.39), and 34% (95% CI: 0.23-0.49), respectively. Saudi patients had a 72% decreased risk of overall mortality compared to non-Saudi patients (P=0.03) over the follow-up period. Overall, patients who had stomach PPUD had a 2.23-fold increased risk of overall mortality over time compared to those who had duodenum PPUD (P=0.10). Large PPUD, >1 cm, had a 3.20-fold increased risk of overall mortality over time compared to small PPUD (P=0.04). Large stomach PPUD had a 4.22-fold increased risk of overall mortality over time compared to other ulcers (P=0.01). Conclusions Large stomach PPUD is associated with increased overall mortality and morbidity. These findings indicate that patients who have a large stomach PPUD might need careful perioperative and postoperative personalized surgical plans as these patients may eventually undergo complicated surgical procedures.

Musculoskeletal Symptoms Among Surgeons at a Tertiary Care Center: a Survey Based Study.

INTRODUCTION: Musculoskeletal (MSK) manifestations represent a common work-related physical complication that affect surgeons and impacts their life and the healthcare service negatively. AIM: The aim of this study was to determine the prevalence of work related MSK manifestations among surgeons in a tertiary care hospital and to identify the possible associated risk factors. METHODS: A Web-based self-administered cross-sectional survey was conducted. This study targeted all surgeons regardless of their nationalities, ages, genders, and marital statuses. The questionnaire assessed the participants' demographic data as well as musculoskeletal manifestations. RESULTS: Most respondents (80%) suffered from MSK manifestations that were related to performing surgeries. Back and neck areas represented the most affected body parts (71.1% and 59.8%, respectively). A significantly higher percentage of those with musculoskeletal manifestations practiced for 5-10 years (28.9%) (p = 0.006). CONCLUSION: MSK pain is common among Saudi surgeons in different specialties. More attention should be directed to improving the physical environments in which the surgeons are operating. Moreover, surgeons should be educated about the recommended ergonomic positions that can prevent or decrease their work related MSK manifestations.

Coexistence of Primary GEJ Adenocarcinoma and Pedunculated Gastric Gastrointestinal Stromal Tumor.

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the digestive system, although they account for only 0.1-3% of all gastrointestinal (GI) malignancies. They can arise anywhere along the GI tract with gastric predominance. Concurrent occurrence of GIST and gastroesophageal junction (GEJ) neoplasm is rare. We report a 55-year-old gentleman presenting with a polyp at the GEJ and a synchronous, large, and pedunculated gastric mass at the greater curvature. Those were treated with a wedge resection of the gastric pedunculated mass with negative margins along with transgastric submucosal resection of the GEJ polyp. Pathological examination confirmed synchronous invasive GEJ adenocarcinoma and a high-grade gastric GIST.

Transfusion Practices Among General Surgeons at a Tertiary Care Center: a Survey Based Study.

INTRODUCTION: Blood transfusion practices affect both patient's outcomes and utilization of institutional resources. Evidence shows that liberal blood transfusion has a detrimental effect on patient's outcome. A restrictive approach of blood transfusion is recommended by current clinical guidelines. AIM: The aim of this study was to evaluate the attitudes, knowledge, and practices of general surgery (GS) staff and residents regarding peri-operative blood transfusion and anemia management. MATERIAL AND METHODS: A self-administered, web-based questionnaire was developed, and its link was sent to the emails of all general surgeons at King Abdul-Aziz University Hospital (KAUH), Jeddah city, Saudi Arabia. The questionnaire included four parts: 1) background of surgeons; 2) preoperative assessment and management of anemia; 3) post-operative blood transfusion and alternatives; and 4) enablers and barriers. RESULTS: 56 surgeons responded to the questionnaire. We found variations in blood transfusion practices, notably the hemoglobin threshold. For stable non-cardiac cases, 7 g/dL was considered the threshold by 50% of respondents. For stable patients with past cardiac disease, a higher threshold was chosen by most (9 g/dL by 43% and 10 gm/dL by 21%). Most respondents believed that transfusion had no effect on the risk of survival (73%) and on the risk of cancer recurrence (55%) after oncologic surgical resection. Recognized facilitators were the availability of scientific evidence (84%), medicolegal concerns (57%), preference (52%), and institutional protocols (50%). CONCLUSION: Although current clinical guidelines recommend a restrictive transfusion practice, most respondents tended to over-order blood for elective procedures and were not aware of the potential complications of liberal blood transfusion. To implement the restrictive transfusion policies, health institutions should improve the awareness of surgeons and incorporate a strong supporting evidence in formulating local institutional guidelines.

Predictors of morbidity and mortality post emergency abdominal surgery: A national study.

BACKGROUND/AIM: Emergency surgeries have increased in Saudi Arabia. This study examines these surgeries and associated complications. PATIENTS AND METHODS: This was a prospective multicenter cohort study of patients undergoing emergency intraperitoneal surgery from the eight health sectors of Saudi Arabia. Patients' data were collected over 14 days. RESULTS: In total, 283 patients were included (163 men [54.06%]). The majority of cases were open surgery (204 vs. 79). The 24 h and 30-day mortality rates for the cohort were 0.7 and 2.47%, respectively. Twenty-nine patients (10.24%) required re-intervention, while 19 (8.12%) needed critical care admission. The median length of hospital stay was 3 days. Multivariate analysis showed American Society of Anesthesiologist (ASA) classification score (P = 0.0003), diagnosis (P < 0.0001), stoma formation (P = 0.0123), and anastomotic leak (P = 0.0015) to correlate significantly with 30-day mortality. CONCLUSION: American Society of Anesthesiologist score, diagnosis, stoma formation and anastomotic leak are associated with 30-day mortality after emergency surgery in Saudi Arabia.

Acute Pancreatitis: A Complication of Intragastric Balloon.

PURPOSE: This study was carried out because intragastric balloon (IGB) is a widely used method to combat obesity, and acute pancreatitis complicating IGB is rare and yet to be understood. METHOD: This study was a retrospective analysis of all patients with a history of IGB insertion, who developed acute pancreatitis before balloon removal. RESULTS: A total of 4 cases were found, with a mean age of 27±2.9 years. The mean duration of IGB insertion was 2.25±1.25 months, with an average body mass index of 37.7±3.4 kg/m. Abdominal computed tomography visualized signs of pancreatitis with the balloon compressing the pancreatic body. Pancreatitis resolved after endoscopic balloon extraction, with an average aspiration of 607.5±64.5 mL of the fluid used to fill the balloon. CONCLUSION: Our study demonstrates that acute pancreatitis can complicate IGB and recommends the need to measure amylase and lipase in patients who have a history of IGB insertion and present with a picture suggestive of pancreatitis.

Nonalcoholic fatty liver disease: Noninvasive methods of diagnosing hepatic steatosis.

Hepatic steatosis is the buildup of lipids within hepatocytes. It is the simplest stage in nonalcoholic fatty liver disease (NAFLD). It occurs in approximately 30% of the general population and as much as 90% of the obese population in the United States. It may progress to nonalcoholic steatohepatitis, which is a state of hepatocellular inflammation and damage in response to the accumulated fat. Liver biopsy remains the gold standard tool to diagnose and stage NAFLD. However, it comes with the risk of complications ranging from simple pain to life-threatening bleeding. It is also associated with sampling error. For these reasons, a variety of noninvasive radiological markers, including ultrasound, computed tomography, magnetic resonance spectroscopy, and the controlled attenuation parameter using transient elastography and Xenon-133 scan have been proposed to increase our ability to diagnose NAFLD, hence avoiding liver biopsy. The aim of this review is to discuss the utility and accuracy of using available noninvasive diagnostic modalities for fatty liver in NAFLD.

Surgical treatment for hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is an epithelial tumor derived from hepatocytes; it accounts for 80% of all primary liver cancers and ranks globally as the fourth leading cause of cancer-related deaths. HCC treatment is a multidisciplinary and a multimodal task, with surgery in the form of liver resection and liver transplantation (LT) representing the only potentially curative modality. However, there are variable opinions and discussions about applying these surgical options and using other supporting treatments. This article is a narrative review that includes articles published from 1984 to 2013 located by searching scientific databases such as PubMed, SCOPUS, and Elsevier, with the main keyword of hepatocellular carcinoma in addition to other keywords such as liver transplantation, liver resection, transarterial chemoembolization, portal vein embolization, bridging therapy, and downstaging. In this review, we focus mainly on the surgical treatment options offered for HCC, in order to illustrate the current relevant data available in the literature to help in applying these surgical options and to use other supporting treatment modalities when appropriate.