Carcinoid tumourlets associated with diffuse bronchiectasis and intralobar sequestration.

Innumerable carcinoid tumourlets may develop within pulmonary lobes should there be scarring from intralobar sequestration; these tumourlets may, in turn, be the cause of chronic lung disease. This report documents the incidental detection of multifocal carcinoid tumourlets in the lung of a 65-year-old man who had repeated episodes of lung infection, progressive dyspnea and haemoptysis; he lived at high altitude. The left lower lobe of the lung was resected surgically, during which procedure an aberrant systemic arterial supply was noticed. The patient had diffuse bronchiectasis and intralobar sequestration. The latter implies the development of abnormal lung tissue located within lobar tissue--but which does not communicate with the bronchial tree; it is supplied with arterial blood from a branch of the aorta--arising either above or below the diaphragm. There was loss of demarcation between the sequestered lung and the surrounding lower lobe lung parenchyma. The proliferation of pulmonary neuroendocrine cells in the form of tumourlets, had probably occurred as an adaptive response to the chronic hypoxia experienced. The combination of intralobar sequestration, bronchiectasis and carcinoid tumourlets, although uncommon, may arise when intralobar sequestration of the lung has not been resected at an incipient stage.

Traumatic diaphragmatic hernia: an Asir region (Saudi Arabia) experience.

Ten patients (nine males, one female), seen at the Asir Central Hospital of South-Western Saudi Arabia with proven traumatic diaphragmatic hernia between 1987 and 1997, were reviewed retrospectively. The mean age was 29.6 years, range 5 to 50 years. Chest pain and vomiting were the commonest symptoms. Blunt trauma (road traffic accident--5, fall from height--1, (accounted for 60% of the cases) while gunshot wound and stab wounds were the causes in two patients each. The chest radiograph suggested the diagnosis in all the cases. Barium meal (in two patients) and barium enema (in two patients) complemented the diagnosis. Computed tomography (CT) scan was done in only one patient. Thoracotomy (in 2 patients), laparotomy (in 5 patients) and thoraco-laparotomy (in 3 patients) were the surgical approaches to management. Common herniated organs were liver, stomach, spleen and large bowel. The injuries were on the left side in seven patients and on the right side in three cases. Immediate surgical repair was done in four patients while it was done two days to four years later in others. Complications were minimal and there was only one death.

Diffuse pulmonary calcinosis and multiple soft tissue calcification in renal failure patient with pathological femoral fracture.

The rare occurrence of diffuse pulmonary calcinosis is described with case illustration of a patient who presented with a pathological femoral fracture during end-stage renal failure. Associated metastatic soft tissue calcification with parathyroid hyperplasia requiring parathyroidectomy was observed. Roentgenologic evidence of hyperparathyroidism with osteitis fibrosa cystica and a high product of the calcium and phosphate values were indications for the parathyroidectomy. Recent literature review of pulmonary calcinosis and multiple soft tissue calcification is also presented.

Bronchial carcinoid tumours in southern Saudi Arabia.

Clinical presentation, pathology, surgical management and follow-up of ten bronchial carcinoid tumour (BCT) patients are described. There were five male and five female patients with age range between 5 to 85 years (mean 39.2 +/- 21.5, SD). Pathology revealed BCT on the right side in seven and on left side in three patients. The tumour was an incidental finding in four while the other six had respiratory symptoms. Cough was present in all of the later group and hemoptysis was present in four patients. Recurrent chest infections were seen in two patients. Symptoms ranged from 1 week to 15 years. Successful surgical resection was done in nine with the longest follow-up of 80 months (mean: 23 months +/- 26.3, SD) without recurrence or metastasis. Histopathological examination of these tumours revealed classical morphological features in all but one case. Grimelius stain positivity for argyrophilia confirmed the diagnosis in all the patients in this study. Electron microscopic examination was done in patient no. 9 which showed atypical morphological features and neurosecretory granules. BCT may present like pneumonias or bronchial asthma. Although BCTs have low-grade malignancy, early diagnosis and surgical resection yield curative results almost in all cases.

Hydatid cyst disease (Echinococcus granulosus): experience at Asir Central Hospital.

In a six-year period, starting from the commissioning of Asir Central Hospital in 1408 H (1988), 43 cases of hydatid cyst disease caused by echinococcus granulosus seen in Asir Central Hospital were studied. The pattern was not significantly different from other workers' experiences. There was equal sex distribution and the average age was 41.7 years. The clinical presentations depended essentially on the organs affected, and computed tomography usually confirmed the diagnosis. The serological test at times gave a false negative result. Most of the patients came from Abha in Asir region and the most commonly involved organ was the right lobe of the liver. All the patients had laparotomy, excision or incision and drainage of the cyst, depending on whether the cyst could be safely excised or only drained. The average hospital stay was 17 days. We believe that surgical intervention should be the first line of treatment especially when the cyst is large.

Gall bladder disease and ABO blood group.

Because it had been shown that an elevated total serum cholesterol was associated with phenotype A in many western European and Japanese populations as compared to non-A phenotype, a study was conducted to see whether there was any correlation between ABO blood group and gall bladder disease in our environment. No correlation was found between ABO blood group and gall bladder disease. However, the incidence of gall bladder disease was much higher in females than in males and the incidence was found to be highest in the fourth and fifth decades of life.

Primary mediastinal tumours in the southern region of Saudi Arabia.

A retrospective review of 16 patients operated upon for primary mediastinal tumours was carried out. Anterior mediastinal tumours seen included retrosternal goitre (2), benign cystic teratoma (1), benign thymoma (1), malignant thymoma, spindle cell type (1) and Hodgkin's lymphoma, nodular sclerosing type (1). Mid-mediastinal tumours included bronchial cyst (1), mediastinal granuloma (1), and pulmonary arterio-venous fistula (1). Neurilemmoma (2), neuroblastoma (1), ganglioneuroma (1), Askin tumour (1), neurofibroma (1) and benign histiocytoma (1) constituted the tumours of the posterior mediastinum. The tumours were successfully resected with minimal operative morbidity and no mortality.

Spontaneous pneumothorax: A retrospective study of twenty-five patients and literature review.

We present a retrospective study of 25 patients with spontaneous pneumothorax (three current), comprising 16 Saudis (nine males and seven females) and nine non-Saudis (eight males and one female), seen at the Asir Central Hospital, Abha, over a period of 45 months. Almost one-third of the patients (9/25) had no underlying cause discernible by our investigational facilities (chest x-ray, ultrasonography, computed tomographic scan, and flexible bronchofiberscopy). Underlying pneumonia (three patients), pulmonary tuberculosis (two patients), lung abscess (one patient), and congenital bullae (one patient) constituted the etiology in another third of the spontaneous pneumothorax patients. Other underlying pulmonary diseases precipitating spontaneous pneumothorax in the group included pulmonary fibrosis, metastatic mesothelioma, and immunosuppression in a medulloblastoma patient undergoing chemotherapy with the development of chickenpox. Closed thoracostomy tube drainage was the only method of treatment in 20 out of the 25 patients, with three failures of closed thoracostomy tube drainage needing thoracotomy and resection of blebs/bullae. The only complication was empyema in two of the patients. Two patients were successfully treated conservatively with observation alone.

Gallbladder stones analyzes, bile and wound cultures in cholelithiasis.

One hundred and fifty-two consecutive cases of cholelithiasis were studied. The gallbladder stones were analyzed to determine the constituents, the bile specimens were cultured and correlated with the cultures when wound infection occurred. Mixed gallstones were the commonest type (58.5%), pigment stones (27%) and cholesterol stones (14.5%). Positive bile cultures were found in 41 patients (27%) and Escherichia coli was the commonest organism isolated. The rate of wound infection was 14.5% and the most common organism cultured from the wound was staphylococcus epidermidis.

Empyema thoracis in adults in Saudi Arabia.

Empyema thoracis in adults is an uncommon disease in the Asir region of Saudi Arabia. In a period of seven years (1988 to 1994), 24 patients were treated for empyema thoracis with a hospital incidence of about 23 patients in 100,000 admissions. The community acquired empyemas are more common and less aggressive in non-Saudi patients (six males and one female) as compared to Saudi patients (11 males and 6 females) whose empyemas are mostly nosocomial with an aggressive course. The peak age in both Saudi and non-Saudi patients is 45 years and 25 years respectively, and the right pleura is more commonly affected than the left pleura in both groups. Risk factors include diabetes mellitus, pulmonary tuberculosis, post-pneumonectomy infections, trauma and pneumonia. The commonest organisms grown are Pseudomonas aeruginosa, Klebsiella species and Staphylococcus aureus, although in almost 40% of the patients the empyemas were sterile. The commonest method of treatment was closed thoracostomy tube drainage.

Thyroid malignancy in multinodular goitre and solitary nodule.

This is a retrospective study of 361 thyroid specimens during a 6 1/2-year period with the objective of investigating the prevalence and pattern of thyroid malignancy associated with multinodular goitre (MNG) and solitary nodule (SN). Fourteen of 172 MNG (8%) and 16 of 105 SN (15.2%) were associated with malignancy, a statistically insignificant difference (P = 0.06). Unlike in males, malignancy was significantly commoner in females with SN than those with MNG (P = 0.03) and generally occurred at a significantly older age (P < 0.05). On analysing thyroid carcinoma and lymphoma separately, patients with SN had a higher incidence of carcinoma compared with those with MNG (P = 0.01). It is concluded that surgical intervention may be the appropriate method of treating male patients presenting with MNG. However, in females, conservative management of MNG should be adopted unless surgery is indicated depending on clinical judgement and, if feasible, the result of fine needle aspiration biopsy.

Acute appendicitis in females--a clinical study of 366 cases.

A study was carried out on 366 female patients admitted consecutively to Asir Central Hospital with clinical diagnosis of acute appendicitis during the period between 1988 through 1991. In this study, 271 patients had histopathologically proven appendicitis for a diagnostic accuracy of 74%. Ninety-five (26%) patients did not have appendicitis, however, 27 (7.4%) of them had other disorders indicating surgical intervention. Consequently, 18.6% of the patients studied had negative laparotomy. This study showed insignificant (P > 0.05) relation between age, site of pain and its duration, presence of urinary symptoms, post-operative complications and hospitalization in one hand, and the final diagnosis on the other hand. The marital status, the presence of gynaecological symptoms, white blood cells count, neutrophils and lymphocytes percentages were, however, significantly related to the final diagnosis (P < 0.05). A conservative approach with in-hospital observation and repeated clinical examination of the doubted appendicitis cases are recommended so as to reduce the rate of the negative laparotomy with its considerable complications.

Damage to the bile ducts at cholecystectomy.

Six patients who incurred iatrogenic injury to the extrahepatic bile duct following elective cholecystectomy are described. All cases were diagnosed three weeks to one year after operation. In none of the patients was an operative cholangiogram performed during the original cholecystectomy to detect congenital biliary tree anomalies or obstruction. Possible risk factors contributing to such injuries were intraoperative bleeding, common bile duct exploration in patients with obstructive jaundice, and poor surgical assistance. Obesity was not found to be of significance since all six patients were thin. Iatrogenic bile duct injuries are best managed at the time of injury during the primary operation. When recognized later in the postoperative period, choledocho/hepaticojejunostomy gives the best result.

Gastric torsion: Not such a rare entity.

We describe seven patients who suffered chronic gastric torsion, seen during a 28-month period. Four were children, of which three were infants. The infants had projectile vomiting and two also had failure to thrive. The adults presented with epigastric pain and vomiting. Upper gastrointestinal series clinched the diagnosis in all patients. The classic radiographic presentation of a stomach lying across the epigastrium with the cardia and fundus in a dependent position to the body of the stomach and pylorus may be overlooked in some cases. Choice of surgical procedure in its management has been discussed. There was no associated abnormality in four of the six operated cases. One infant had an atretic bowel, vascular anomalies, umbilical hernia, and previous meconium peritonitis; a second infant had jejunojejunal intussusception. A high index of suspicion is warranted in patients presenting with recurrent abdominal pain or in infants with unexplained vomiting and failure to thrive. Upper gastrointestinal series in adults should preferably be performed while the pain is present.

Surgical audit: A prospective study of the morbidity and mortality of acute appendicitis.

Between March and September 1989, acute apendicitis was clinically diagnosed in 317 patients who were studied as part of a prospective surgical audit. The study was designed to determine the accuracy of diagnosis, comparison of the macroscopic appearance of the appendix at operation, and subsequent histopathology and complications associated with the morbidity and mortality of emergency appendectomy. The clinical diagnosis was correct in 278 patients (88%). Thirty-nine (12%) of the patients had a negative laparotomy. There was no mortality, and wound infection was the source of increased morbidity in 37 (12%) patients. The highest incidence of wound infection was among those who had pus in the peritoneum (20%) or had a perforated or gangrenous appendix (25%). When the macroscopic appearance of the appendix was compared with the subsequent histopathological findings, a false positive error of 7% and a false negative error of 42% was found. During appendectomy the gross appearance of the appendix must be carefully noted so that a meticulous surgical technique can be complemented by appropriate antibiotic prophylaxis against wound infection, started at the time of surgery.