Appendiceal neoplasms in Saudi Arabia: prevalence and clinicopathological profile.

BACKGROUND: The appendix is a small organ with no particular known function. Primary appendiceal neoplasms (ANs) are rare. While the prevalence is increasing worldwide over the past two decades, no apparent increase in the prevalence of ANs has been reported in the Arabian Gulf States. Recently, a significant decline in the age at diagnosis of some types of ANs has been reported worldwide, with a female predominance. OBJECTIVES: Evaluate the prevalence and clinicopathological characteristics of ANs within our institution in Saudi Arabia and compare them to limited existing studies from different regions as well as the Arabian Gulf States. DESIGN: Retrospective cohort. SETTING: Tertiary care center in Riyadh. PATIENTS AND METHODS: All patients who underwent appendectomy and had the appendix submitted for histopathological evaluation between May 2015 and June 2020 were included to allow for a follow-up of 5 years or more at the time of data collection. MAIN OUTCOME MEASURES: Demographics, clinical presentations, surgical interventions, histopathological findings, complications, and recurrence rates. SAMPLE SIZE: 25 AN patients. RESULTS: Of 1110 patients, 25 had ANs (13 female and 12 male participants) with a mean (standard deviation) age of 54.6 (14.1) years. Only 40% presented with acute appendicitis, 64% had comorbidities, and less than 50% underwent laparoscopic appendectomy. Histopathologically, 72% were low-grade appendiceal mucinous neoplasms (LAMNs). Complications were minimal grades (Clavien-Dindo classification), with 80% experiencing none. The mean hospital stay was 9.96 days. Local recurrence occurred in 8% of cases, and distant metastasis was documented in one adenocarcinoma case. However, the 5-year overall and disease-free survival rates were 88% and 80%, respectively. CONCLUSIONS: The incidence of ANs is increasing in Saudi Arabia with the higher prevalence of LAMNs. The pathological examination of the resected appendix played a pivotal role in the diagnosis of ANs. LIMITATIONS: Data collected retrospectively, a single institution, and a small population.

The Prevalence, Awareness, and Associated Risk Factors of Inguinal Hernia Among the Adult Population in Saudi Arabia.

PURPOSE: Inguinal hernias lead to several potentially fatal complications such as strangulation. Assessing the prevalence, risk factors, and beliefs of a population is essential to develop appropriate preventive strategies. This study investigated the prevalence, risk factors, and awareness of inguinal hernia in the adult population of Saudi Arabia. METHODS: This cross-sectional study enrolled 461 adults aged between 18 and 60 years after excluding those aged <18 and >60 years. This study was conducted in five regions of Saudi Arabia (north, west, central, south, and east). A pre-tested questionnaire was used to collect data on the prevalence, perception, and awareness of the participants. Multivariate regression analysis was used to identify risk factors for inguinal hernia. RESULTS: The study revealed that most participants were men n=262 (56.8%), aged between 18 and 25 years n=241 (52.3%), were single n=278 (60.3%), had a bachelor's degree n=225 (48.8%) and earned less than 50,000 Saudi Riyals annually n=285 (61.8%). Most participants resided in urban areas n=366 (79.4%) with their parents n=230 (49.9%). The prevalence of inguinal hernias in adults was low (5.2%). Our results indicated a significant association between family history of inguinal hernia, chronic cough, bronchial asthma, smoking, and inguinal hernia (p < 0.001). Young adults and undergraduates displayed significantly low awareness of inguinal hernias (p < 0.001). CONCLUSION: Family history of inguinal hernia, chronic cough, bronchial asthma, and smoking were factors associated with inguinal hernia. Low awareness levels were observed among young undergraduates, with a moderate overall level of awareness.

Complete major pancreatic duct disruption complicated by pancreatico-atmospheric fistula following blunt upper abdominal trauma.

Pancreatic injury post blunt abdominal trauma is exceedingly rare. When complete major pancreatic duct (MPD) disruption occurs, a disconnection between the pancreas and the duodenum can take place, ultimately leading to fistula formation. We describe a case of MPD disruption following blunt abdominal trauma, complicated by a fistula between the pancreas and an open abdomen (pancreatico-atmospheric fistula). Although the fistula was managed using standard methods for treating pancreatic fistulas, wound care was a significant challenge in this case where the fistula exteriorized into an open abdomen.

Anticholinergic Toxidrome as a Possible Explanation for Methylene Blue Toxicity.

BACKGROUND Methylene blue has multiple uses in medicine. It is generally used to treat refractory vasoplegia and methemoglobin toxicity, and can be used as a dye to localize the parathyroid glands intra-operatively. In refractory vasoplegia, methylene blue inhibits endothelial nitric oxide and guanylate cyclase, causing vasoconstriction and potentially stabilizing blood pressure. Multiple complications have been associated with the use of methylene blue. These are related to either the sole effect of methylene blue or the combined effect of methylene blue and certain antidepressants, such as selective serotonin reuptake inhibitors (SSRIs). To the best of our knowledge, in the setting of post-cardiac surgery vasoplegia, there have been no reports of the neurological toxicity of methylene blue in the absence of SSRI use. In this case report, we describe the anticholinergic manifestations associated with the use of methylene blue in post-cardiac surgery vasoplegia. CASE REPORT A male patient in his mid-sixties with severe mitral regurgitation underwent elective mitral valve replacement. Postoperatively, he was hypotensive and required a high dose of vasopressors. Methylene blue was administered to treat refractory vasoplegia. The patient became anuric and febrile, with bilateral mydriasis. Internal cooling and continuous renal replacement therapy were initiated, and symptoms rapidly resolved. The patient was discharged after prolonged hospitalization with a permanent catheter for hemodialysis. CONCLUSIONS Anticholinergic toxidrome may explain the neurological adverse effects associated with high doses of methylene blue. Physicians should be cautious when using methylene blue in combination with other anticholinergic drugs and in conditions of renal failure. The development of methylene blue toxicity warrants the urgent discontinuation of the agent and early drug elimination.

Is Appendiceal Diverticulitis Mimicking Acute Appendicitis?

Appendicular diverticulitis (AD) is a rare entity characterized by the inflammation of the arising diverticulum of the appendix. It has been reported to carry a high risk of perioperative complications, such as bleeding and perforation. Furthermore, multiple articles have highlighted the importance of diagnosing AD early due to its strong association with malignancies. Limited published cases concerning AD in our country and globally are available in the literature. Hence, we present in this article a case series of five exciting cases of incidental findings of AD that were initially diagnosed as acute appendicitis based on clinical evaluation and imaging findings. In our series, we performed a retrograde evaluation of the computed tomography scans of all five cases that showed diverticula. In conclusion, histopathological evaluation remains the method of choice to reach the definitive diagnosis; however, it is essential to highlight the relevance of imaging in diagnosing AD preoperatively in the early stages to reduce morbidity and mortality.

Reliability and validity study of the translated Arabic version of Moorehead-Ardelt Quality of Life Questionnaire II.

OBJECTIVES: To generate a translated Arabic adaptation of the revised Moorehead-Ardelt Quality of Life Questionnaire II (MA-II), then to assess its reliability and validity. METHODS: The MA-II was translated to Arabic by 3 independent translators. Next, a concise translation, developed from the 3 translations, was re-translated to English and was compared with the original questionnaire. Both the reliability and the validity of the Arabic MA-II were assessed in 144 patients struggling with obesity before and after bariatric procedures at Khalid University Hospital, Riyadh, Saudi Arabia. Apart from the demographic data, both the MA-II and the 36-item short-form health survey (SF-36) were used to collect health-related quality of life (HRQL) data. The test-retest method and Cronbach's alpha (α)were used to assess reliability and internal consistency. RESULTS: Test-retest reliability exhibited an intraclass correlation coefficient of 0.966. The internal consistency of the translated version was also high (α=0.812). A satisfactory correlation was demonstrated between the translated Arabic version and the 8 items of the SF-36. A significant negative correlation was also observed between the MA-II and body mass index (r= -0.5778, p<0.001). CONCLUSION: The robustness and sustainability of the translated Arabic version of the MA-II suggested that this disease-specific instrument is a reliable and valid tool for the measurement of HRQL in obease Arabic-speaking people.

Clinical and Histopathologic Features of Myocarditis in Multisystem Inflammatory Syndrome (Adult)-Associated COVID-19.

BACKGROUND: Multisystem inflammatory syndrome (MIS) associated with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection is a life-threatening condition first described in children (MIS-C). It is characterized by a hyperinflammatory state that involves the cardiovascular, gastrointestinal, dermatologic, and neurologic systems without severe respiratory system involvement. Myocarditis is one of the cardiovascular presentations of MIS that might be complicated with cardiogenic shock. There are few case reports describing SARS-CoV-2-related MIS in adults (MIS-A). CASE SUMMARY: Three cases of healthy young adults diagnosed with severe acute respiratory syndrome-CoV-2 related (MIS-A). The main presentation was cardiogenic shock secondary to histologically proven myocarditis, which resolved rapidly after initiation of medical therapy including anti-inflammatory and immunosuppressive drugs. All the cases, however, required mechanical circulatory support (MCS) as a bridge to recovery. CONCLUSIONS: It appears reasonable to treat the patient with fulminant myocarditis in SARS-CoV-2-associated MIS-A with high-dose corticosteroid "pulse" therapy in order to suppress the inflammatory response and MCS to correct initial metabolic derangement and reestablish/maintain vital organ perfusion. Addition of IV immunoglobulin and other immunomodulators should be assessed in a case-by-case basis especially considering the associated cost resource allocation.

Impact of Mesenteric Defect Closure During Laparoscopic Roux-en-Y Gastric Bypass (LRYGB): a Retrospective Study for a Total of 2093 LRYGB.

BACKGROUND: Internal hernia is a rare but a potentially fatal complication of laparoscopic Roux-En-Y gastric bypass (LRYGB). The aims of this study are to determine the impact of mesenteric defects closure on the incidence of internal hernia after LRYGB and to determine the symptoms, characteristics, and management of internal hernias after LRYGB. METHODS: A retrospective study for a total of 2093 LRYGB was carried out from 1998 to December 2013. Four hundred twenty-one patients were operated without closure of the mesenteric defects (group A). From January 2005 to December 2013, 1672 patients were operated with closure of the mesenteric defects at Petersen defect (PD) and at jejunojejunal anastomosis (J-J) defect (group B). The incidence of internal hernias was compared between the two periods. RESULTS: Out of the 2093 patients who underwent LRYGB, 20 patients (0.95%) developed a symptomatic internal hernia that required primary surgical intervention; 7 patients (1.66%) in group A all at J-J DEFECT versus 13 patients (0.78%) in (group B) 6 at (J-J DEFECT), 5 at PD, and 2 at PD, J-J DEFECT. This incidence was significantly lower in (group B) (p = 0.0021). The median interval between LRYGB and reoperation was 53 months in group A and 26 months in group B. A CT scan was performed in 8 patients, 40%, and showed signs of occlusion in all cases. CONCLUSIONS: The closure of mesenteric defects during LRYGB is recommended because it is associated with a significant reduction in the incidence of internal hernia.

Single-incision laparoscopic colorectal surgery: a report of 33 cases in Saudi Arabia.

BACKGROUND: Single-incision laparoscopic surgery (SILS) has gained worldwide acceptance as a minimally invasive technique in colorectal procedures since its introduction in 2008. However, case series on its feasibility and safety in Saudi Arabia are lacking. OBJECTIVE: Evaluate the operative results and clinical outcome of single-port laparoscopic procedures in colorectal surgeries. DESIGN: Retrospective. SETTING: This study was conducted at King Khalid university Hospital, Riyadh, Saudi Arabia. PATIENTS AND METHODS: Demographic and clinical data, including pathology, and intraoperative and postoperative outcomes, were prospectively collected in patients undergoing SILS. This study was conducted during the period from January 2010 and October 2014. MAIN OUTCOME MEASURES: Demographic and postoperative outcomes in patients undergoing SILS colectomies. RESULTS: Thirty-three (33) patients underwent SILS. The mean (SD) age was 51 years (18.2 years), and the average body mass index was 26.6 (6.9) kg/m2. Patients were primarily diagnosed with cancer (n=20/33, 61%), inflammatory bowel disease (n=12/33, 36%) and diverticulitis (n=1/33, 3%). Procedures included anterior resection (n=9/33, 27%), ileocecal resection (n=8/33 24%), hemicolectomy (n=7/33, 21%), extended right hemicolectomy (n=5/33, 15%) and total colectomy (n=4/33, 12%). The mean SD operative time was 212 minutes (76.4 minutes). The mean SD size of the extraction incision was 4.2 (1.7) cm. Six percent of the cases were converted to open (n=2/33), and 9% required placement of an extra port (n=3/33). Four (12%) patients had intraoperative complications, and 30% experienced postoperative complications. The average length of hospital stay was 6.4 (4.3) days. COCNLUSIONS: SILS is technically feasible and safe for patients undergoing colorectal surgery with no unusual complications. However, comparative studies are necessary to validate the potential benefits of SILS over conventional colorectal laparoscopic surgery. LIMITATIONS: The study lacked a comparison to conventional open procedures. Additionally, some evaluation criteria were not considered, including cosmesis, pain control, patient satisfaction and cost effectiveness.

Liver retraction system by C3-muco-adhesive polymer films for laparoscopic surgery.

BACKGROUND: Conventional laparoscopic instruments used for retraction may cause trauma at the retraction site. Alternative retraction/lifting especially of heavy solid organs such as the liver may be obtained by other means. The present study was designed to explore the use of C3-muco-adhesive polymers (C3-MAPs), which exhibit strong binding to the liver shortly after application to the organ and which retain strong adhesion for sufficient time, to enable sustained retraction during laparoscopic operations. METHODS AND MATERIALS: C3-muco-adhesive polymers were produced specifically for the study. In an ex vivo experimental set-up, discs of C3-MAPs were placed on the surface of porcine livers for adhesion and retraction studies involving objective measurements by tensiometry. RESULTS: Experiments were carried out on 14 porcine livers. The force required to detach the C3-MAPs from the liver exceeded 2.0 N 30 s after application. The adhesion force by C3-MAPs files was sufficient to enable sustained retraction force necessary for exposure of the gall bladder, which was achieved by a mean retraction force of 4.85 N (SD = 0.63). This was sustained for a mean of 130 min (range 17.0-240.0). In the adhesion studies, the forces at 30 s required to detach the polymer discs from the liver exceeded 20 N (upper limit of the load cells of the Instron). The duration of the adhesion enabled sustained optimal gall bladder exposure for periods ranging from 17 to 240 min, with a mean of 130 ± 91 min. CONCLUSIONS: The results of the present study demonstrate that the adhesion and retraction properties of the engineered C3-MAP films are sufficient to enable complete exposure of the gall bladder for a period exceeding 1 h, confirming their potential for atraumatic retraction in laparoscopic and other minimal-access surgical approaches.