Laparoscopic appendicectomy in all trimesters of pregnancy.

BACKGROUND: The laparoscopic approach for appendicectomy in pregnancy was not considered the preferred procedure until recently. The aim of this study was to examine our experience with laparoscopic appendicectomy in pregnancy and review the scientific evidence available in the medical literature. METHOD: The clinical data of all patients who underwent laparoscopic appendicectomy during pregnancy at our hospital between 1999 and 2007 were collected and retrospectively analyzed. A Medline literature search restricted to English language articles on laparoscopic appendicectomy in pregnancy was carried out. RESULT: Twenty patients underwent laparoscopic appendicectomy during pregnancy. Of these, 8 were in the first trimester, 9 in the second trimester, and 3 in the third trimester. Fifteen patients had histologically confirmed appendicitis. The mean operating time was 45 minutes, and the average postoperative stay in the hospital was 1.5 days. All patients except one had a full-term normal delivery. LITERATURE SEARCH: An additional 637 patients from the English literature were reviewed and summarized. CONCLUSION: Our results demonstrate that laparoscopic appendicectomy can be safely performed during all trimesters of pregnancy. The literature search suggests that although laparoscopic appendicectomy in pregnancy is associated with a low rate of intraoperative complications in all trimesters it may be associated with a significantly higher rate of fetal loss compared with open appendicectomy.

Surgery in Oman.

During the past 3 decades, Oman (a sultanate), a country with deep-rooted history, culture, and traditions, has undergone a remarkable transformation and modernization in all fields, including education and health care. It has progressively established a nationwide network of modern health services that are accessible even at the village level and have ranked Oman with the developed world. More than 300 surgeons provide a full range of surgical services for a population of 2.5 million. Medical education is firmly established, and accredited surgical residency training has assumed increasing importance during the past decade. Given the sustained growth and dynamic planning, the surgical services will continue to develop, with Omani surgeons playing an increasing role in the future.

Adrenal oncocytic neoplasm with uncertain malignant potential.

Adrenal oncocytic neoplasms (AONs) are a rare group of tumours with a somewhat uncertain natural history and clinical behaviour. Out of 46 cases of AON reported to date, 6 cases were histologically classified as neoplasms with uncertain malignant potential. We report the case of a 35-year-old male with an incidentally-detected large AON with mostly benign morphology and some characteristics which would make its behaviour uncertain.

Large posterior mediastinal retrosternal goiter managed by a transcervical and lateral thoracotomy approach.

Most retrosternal goiters are situated in the anterior mediastinal compartment. Posterior mediastinal goiters are uncommon, comprising 10%-15% of all mediastinal goiters. Although most of the anterior mediastinal goiters can be removed by a transcervical approach, posterior mediastinal goiters may require additional extracervical incisions. We report the case of a large posterior mediastinal goiter extending retrotracheally beyond the aortic arch and azygous vein with crossover from the left to the right side. It was excised using a transcervical and right thoracotomy approach. The literature is reviewed to clarify the management of retrosternal goiters with regard to the various approaches, indications for extracervical incisions, and their complications. In conclusion, whereas most retrosternal goiters can be resected through a transcervical approach, those extending beyond the aortic arch into the posterior mediastinum are better dealt with by sternotomy or lateral thoracotomy. The overall number of complications associated with this approach, however, is higher than that seen with the transcervical approach.

Splenectomy for haematological disorders: a single center study in 150 patients from Oman.

BACKGROUND: Haematological disorders, in particular sickle cell disease (SCD) and thalassaemia, are relatively common in Oman. We report our experience of splenectomy for haematological disorders and review the literature on splenectomy role in their management. OBJECTIVES: To review our experience in the management of 150 patients with haematological disorders undergoing splenectomy with emphasis on indications and outcome. To compare our experience with those reported from outside this region. METHODS: The records of 150 patients who underwent splenectomy over a thirteen year period were reviewed retrospectively, analyzing the age and sex of the patients, indication for splenectomy, operative procedures, complications, peri-operative management and outcome. RESULTS: Of the 150 patients, 96 (64%) had SCD and 34 (22.6%) had beta-thalassaemia; the rest comprised patients with refractory idiopathic thrombocytopenic purpura (ITP) n=12, hereditary spherocytosis (HS) n=6, and auto-immune haemolytic anaemia (AHA) n=2. In SCD patients, the main indications for splenectomy were recurrent splenic sequestration (60.4%) and hypersplenism (36.4%), whereas in thalassaemic patients it was increased requirement of packed red blood cells (PRBC) transfusion (mean 310 ml, range 242-372 of PRBC/kg/year). All patients received prophylactic antibiotics and vaccination against pneumococcal infection and when the vaccine was available for Haemophilus influenzae. PRBC and platelet concentrates as well as intravenous fluids were infused preoperatively as per protocol. Concomitant procedures at laparotomy included liver biopsy (14.6%) and cholecystectomy (8.6%). The postoperative morbidity was low (8.6%) and there was no mortality. All patients were maintained on long term penicillin and proguanil, and the mean follow-up was 4.6 years. In SCD patients splenectomy eliminated the risks of life threatening acute splenic sequestration and improved significantly the blood counts of the hypersplenic cases, while in thalassaemic patients it reduced significantly the mean transfusion requirement by 100ml PRBC/kg/year (p<0.0001). Of the patients with refractory ITP, two thirds had a good response to splenectomy (p<0.0001). All HS and AHA patients benefited from splenectomy. CONCLUSION: The predominant indications for splenectomy were recurrent acute splenic sequestration and hypersplenism in SCD patients, and increased transfusion demand in the thalassaemics. Overall, splenectomy proved beneficial in eliminating the risk of splenic sequestration in SCD patients, in improving the blood counts in SCD with hypersplenism and in reducing transfusion requirement in thalassaemic patients, while in ITP group two thirds of the patients benefited.

Interleukin-1beta gene (IL-1B) and interleukin 1 receptor antagonist gene (IL-1RN) polymorphisms and gastric cancer risk in an Omani Arab population.

BACKGROUND: Gastric cancer (GC) is the most common malignancy in Oman. Interleukin-1beta gene (IL-1B) and interleukin-1 receptor antagonist gene (IL-1RN) polymorphisms have been associated with increased GC risk. No previous studies have examined their role in an Arab population. We tested the associations between polymorphisms of IL1B at positions -31, -511, and +3954 and the IL-1RN polymorphism [variable number of tandem repeats (VNTR) and TC polymorphism at the -2018 position] and GC in Omani Arab patients. METHODS: Genomic DNA was extracted from peripheral blood of 245 control subjects and 118 gastric cancer patients. The DNA samples were analyzed using the TaqMan allelic discrimination test for IL-1B -31, -511, and +3954 polymorphisms and IL-1RN -2018 polymorphism. The VNTR of IL-1RN was genotyped using the polymerase chain reaction followed by agarose gel electrophoresis. RESULTS: There was an association between the presence of IL-1RN*2 allele and gastric cancer [odds ratio (OR) = 2.2, 95% confidence interval (CI) = 1.0-3.3, P = 0.04). The GC risk further increased to OR = 3.5 (95% CI = 1.0-11.9) in Helicobacter pylori-positive patients. No association was found between any of the other polymorphisms studied and GC. CONCLUSION: IL-1RN polymorphism increased the risk of GC in an Omani Arab population, consistent with previous reports. In contrast, the IL-1B -31 polymorphism was not associated with an increased GC risk. These findings underscore the role of cytokine gene polymorphisms in the development of GC and further support the ethnic differences in the effect of IL-1B polymorphism on GC carcinogenesis.