Management of appendiceal abscess. A 10-year experience in Central Saudi Arabia.

OBJECTIVE: To study the outcome of patients with appendiceal abscess (AA) following immediate operative and non-operative management in terms of complications and hospital stay. METHODS: Medical records of all adult patients treated for AA between July 2002 and June 2011 in the Department of Surgery, King Saud Medical City, Riyadh, Kingdom of Saudi Arabia were reviewed. We identified 2 main groups of patients with the diagnosis of AA. The first group of patients were managed by CT-guided percutaneous drainage and parenteral antibiotics (non-operative management [NOM group]). The second group were patients who underwent surgical intervention (operative management [OM]). The outcome was determined in terms of complications, recurrence rate, and hospital stay. RESULTS: Eighty AA patients were managed during the study period. Forty-two patients (52.5%) received NOM, while 38 patients (47.5%) underwent immediate OM. The complication rate was significantly higher in the OM group compared with the NOM group (44.7% versus 11.9%; p=0.0012). Successful NOM was achieved in 92.8% of patients. The overall mean hospital stay of the NOM group was 8.54+/-2.25, and the OM group was 10.86+/-4.32 days (p=0.003). CONCLUSION: Non-operative management is associated with significantly lower complication rate and shorter hospital stay than OM.

Cholecystectomy without intraoperative cholangiogram in gallstone pancreatitis.

OBJECTIVE: To determine the long term outcome of cholecystectomy without intraoperative cholangiogram (IOC) in patients recovering from acute gallstone pancreatitis with normal preoperative liver function tests and imaging. METHODS: The medical records of all patients who underwent cholecystectomy without IOC for gallstone pancreatitis at King Saud Medical City, Riyadh, Saudi Arabia between January 2005 and December 2009 were studied retrospectively. Patients with severe pancreatitis and those who had preoperative endoscopic retrograde cholangio-pancreatography (ERCP) were excluded from the study. Data on patients' demography, symptoms, laboratory findings, intraoperative and postoperative findings, length of hospital stay, and outpatient follow up were collected and analyzed. RESULTS: A total of 160 patients were treated for acute gallstone pancreatitis. Forty-four patients with preoperative ERCP (n = 39), and severe pancreatitis (n = 5), were excluded. The remaining 116 patients initially underwent conservative treatment followed by cholecystectomy without IOC. All were followed up for an average of 2-4 visits. Five patients (4.3%) were re-admitted with gallstone related bilio-pancreatic complications. They underwent ERCP and CBD stone clearance. Four patients were lost to follow up. The remaining 107 patients have remained asymptomatic 12-55 months after cholecystectomy. CONCLUSION: The incidence of bilio-pancreatic complications from unsuspected CBD stones in patients of biliary pancreatitis that underwent cholecystectomy without IOC is very low. Therefore, a routine IOC in these patients can be omitted safely.

Extensive retroperitoneal hematoma in blunt trauma.

OBJECTIVE: To report our experience of managing extensive retroperitoneal hematoma (RH) in patients with blunt trauma and to determine any associated factors affecting causation and mortality. METHODS: In this retrospective observational study, patients diagnosed with extensive RH following blunt trauma admitted to King Saud Medical Complex, Riyadh, Kingdom of Saudi Arabia between January 2004 and December 2009 were included. Patient data were explored for injury severity score (ISS), associated injuries, location of hematoma, amount of blood transfusions, coagulation profile, operative management, hospital stay, and mortality. The outcomes in surviving and non-surviving patients were compared. RESULTS: Out of 290 patients presenting with RH, extensive RH was found in 46 patients (15.8%). The overall mortality was 32.6%. The pelvis was the most frequent location of RH in combination with lateral and central zones (65.2%). The lower extremity and pelvic fractures were the most common injury. Associated intra-peritoneal injuries were present in 39.1% patients. An exploratory laparotomy was performed in 58.7% patients (n=27). A high ISS (55.9 versus 35.5, p<0.0001), abnormal coagulation profile (odds ratio [OR] 7.8, 95% confidence interval [CI] 1.974-30.932, p=0.005, and associated chest injuries OR 5.94, 95% CI 1.528-23.19, p=0.014) were independent factors associated with mortality. CONCLUSION: Multiple musculoskeletal injuries in addition to intra-abdominal injuries and abnormal coagulation are major factors associated with the presence of extensive RH. High ISS, abnormal coagulation, and associated chest injuries are independent factors associated with mortality.

Pseudomyxoma peritonei. Presenting as a localized perforation of the cecum.

Pseudomyxoma peritonei (PMP), also known as jelly belly, is a rare condition with mucinous material spread throughout the abdomen. It can arise from the appendix, colon, or even a teratoma. The documented incidence is one per million per year. We present a case report of an 80-year-old female patient presenting with PMP secondary to an appendicular tumor leading to localized infiltration, and perforation of the cecal wall. A review of the literature was carried out, with emphasis on various treatment options available for this rare condition.

Impact of comorbidity on outcome among acute non-traumatic surgical patients. Evaluation of Charlson comorbidity index.

OBJECTIVE: To determine the prevalence of comorbid conditions among acute non-traumatic general surgery patients. To assess the impact of comorbidity on outcomes and evaluate the effectiveness of using Charlson comorbidity index (CCI) in these patients. METHODS: All acute non-traumatic general surgery patients admitted to King Saud Medical Complex, Riyadh, Saudi Arabia, between January 1, 2007 and December 31, 2007 were included (n=1296). Patient data were explored to record comorbidity, and the CCI score calculated. The length of hospital stay, post-operative complications and mortality were recorded as outcome measures. The outcomes in patients with comorbid conditions were compared with patients without comorbid conditions. RESULTS: We found one or more comorbid conditions in 31.9% (n=414) patients. The CCI score ranged from 1-8. All 3 outcome measures were recorded significantly higher in patients with comorbidity compared to patients with no comorbid condition; length of stay, 17.3 versus 10.6 days (p<0.0001), post-operative complications 46.3% versus 31% (p<0.0001), mortality 7.7% versus 4.4% (p<0.0001). Severe comorbidity as indicated by higher CCI score significantly correlated with length of stay, r=0.30 (p<0.0001) and mortality, r=0.2645 (p<0.0001). Overall risk of mortality was 1.81 times higher with comorbidity (odds ratio 1.81, 95% confidence interval 1.087-3.012, p=0.0182). CONCLUSION: Comorbidity caused increased hospital stay, post-operative complications, and mortality among acute non-traumatic general surgery patients. The CCI is a reliable comorbidity index, which can help in managing risks in surgical patients.

Gastrointestinal tract bleeding in intellectually disabled adults.

BACKGROUND: Gastrointestinal (GI) tract bleeding in intellectually disabled (ID) individuals presents peculiar diagnostic and management difficulties. This study details the experience of a tertiary referral teaching hospital in Central Saudi Arabia in the management of GI bleeding necessitating admission in ID adults. PATIENTS AND METHODS: Prospective collection of data was taken on consecutive ID adults admitted for GI bleeding from January 2000 through December 2004. Demographic details, clinical presentation, diagnosis, associated physical and neurologic disabilities, etiology of bleeding and treatment outcome were analyzed. RESULTS: Thirty-nine ID adults accounted for 44 admissions during the period under review. Twenty-six (66.7%) patients were admitted with upper, and 13 (33.3%) for lower GI bleeding. Reflux esophagitis (57.7%) remained the most common cause of upper GI bleeding. Five out of 26 patients with upper and 6 of 13 with lower GI bleeding needed operative treatment. Various congenital anomalies or malformations were observed frequently associated with lower GI bleeding. CONCLUSIONS: Bleeding GERD remained the most common etiology of upper GI bleeding necessitating admission. Endoscopy is the mainstay in diagnosis and initial management of ID patients. Continued surveillance endoscopy is recommended for early diagnosis of Barrett changes. Bleeding from developmental malformations may have association with intellectual disability.

Excision with or without primary closure for pilonidal sinus disease.

OBJECTIVE: To evaluate the outcome of excision with or without primary closure in the management of chronic pilonidal sinus (PNS) disease. METHODS: Between July 2002 and November 2006, a randomized trial was conducted in the Department of General Surgery, Riyadh Medical Complex, Riyadh, Kingdom of Saudi Arabia. All the patients who presented with chronic natal cleft PNS disease were included in the study. They underwent either excision with midline closure (EMC group), or excision without closure (EWC group). Patients, who came with an acute pilonidal abscess (complicated) were excluded from the study. The principle outcome measures recorded were wound infection, healing time, time off work and the recurrence rate. RESULTS: A total of 380 patients of chronic PNS were divided into EMC group, (188 patients) and EWC group (192 patients). Majority of the patients were male in both the groups (93%). The hospital stay ranged from 2 to 5 days (mean = 3.6 +/- 1.4 days) for EMC group, while it was 3-5 days (mean = 4 +/- 1.1 days) for EWC group (p < 0.002). wound infection was 4.2% in EMC group, compared to 3.12% of EWC group (MS). The mean healing time and time off work in EMC group was significantly shorter than the patients in EWC group. Median follow up of EMC group was 36.3 months (range 10-52 months) while it was 35.2 months (range 13-51 months) for EWC group. Statistically there was no significant difference in the recurrence rate of both the groups (3.7% vs. 3%). CONCLUSIONS: Excision and primary closure is recommended, as a preferred procedure in the management of chronic PNS disease. It has the advantages of early wound healing, rapid return to work and comparable recurrence rate with excision and open wound.

Squamous cell carcinoma of colon and rectum.

Primary squamous cell carcinoma SCC of the colon and rectum is a rare malignancy. Less than 100 cases have been reported in literature. We report 2 cases of pure SCC involving the rectum and sigmoid colon. A review of literature has been made starting from the first report in 1919 to the present. We have examined the theories regarding the etiology, available treatment modalities, and prognosis for this variant of colorectal carcinoma. We conclude that this tumor presents later than adenocarcinoma and follows an aggressive course. With a greater awareness among surgeons and pathologists, more cases may become known leading to a better estimation of prevalence and clinicopathological behavior of this tumor.

Suture versus mesh repair for incisional hernia.

OBJECTIVE: To compare suture with mesh repair, for incisional hernia in terms of early and late outcomes. METHODS: We reviewed the records of all the patients who presented with primary or recurrent incisional hernia in the Department of General Surgery, Riyadh Medical Complex, Riyadh, Kingdom of Saudi Arabia, from January 2000 to December 2004. We divided patients, who underwent repair, in 2 groups: Group A (suture repair) and Group B (mesh repair). The information recorded for both groups included gender, age, associated systemic illness, site of hernia, initial surgery, number and type of previous hernia repairs, size of hernial defect, techniques of repair, and hospital stay. The principal early and late outcome measures studied were septic complications and recurrence. RESULTS: A total of 123 patients qualified for the study, 72 in group A and 51 in group B. Wound infection was 5.5% in group A versus 3.9% in group B (p=0.51). Follow up ranged between 6-58 months (mean 37.5 months) for both groups. Fifteen patients (20.8%) developed recurrence in group A, while the recurrence rate in group B was only 5.8% (p=0.04). CONCLUSION: Mesh repair resulted in a lower recurrence rate, and is not associated with increased incidence of wound complications compared with suture repair.

Surgery for acute abdominal conditions in intellectually-disabled adults.

BACKGROUND: Intellectually-disabled patients with acute abdominal conditions are susceptible to late diagnosis and adverse outcome due to impaired communication, altered behaviour, neurological impairment, associated congenital anomalies, variable reaction to pain and drugs and various difficulties in perioperative management. The present study aims to present the experience of surgery for acute abdominal conditions in intellectually-disabled patients. Various difficulties encountered during the management are highlighted and measures to overcome these problems are discussed. METHODS: A prospective descriptive population study was performed through the prospective collection of data on consecutive intellectually-disabled adults operated for acute abdominal conditions over a 5-year period. Study parameters included demographic details, clinical presentation, diagnostic modalities, operative findings and outcome in terms of morbidity and mortality. RESULTS: Of 19 men and three women with a mean age of 28.3 years, anorexia, vomiting, and increasing abdominal distension were the most common presenting features. History of pica was available in 36.4% of patients. Intestinal obstruction, acute appendicitis, volvulus and pseudo-obstruction of the colon were the most frequently encountered conditions. Postoperative morbidity and mortality were 33 and 23%, respectively. CONCLUSION: Intellectually-disabled patients demand particular clinical expertise owing to various difficulties inherent to their mental and physical disabilities. Short history, anorexia, vomiting and abdominal distension should make the clinician aware of the possibility of an acute abdominal condition. History of pica should be considered a serious clinical correlate. A high index of clinical suspicion, intensive perioperative care and low threshold for an early operation are recommended to reduce the higher morbidity and mortality figures.

Transabdominal gastro-esophageal devascularization and esophageal transection for bleeding esophageal varices after failed injection sclerotherapy: long-term follow-up report.

BACKGROUND: Management of continued bleeding from esophageal varices despite adequate injection sclerotherapy remains one of the medical and surgical dilemmas. Transabdominal gastroesophageal devascularization and esophageal transection (TGDET) is considered an effective and safe procedure for such patients. AIM: This study aimed at presenting continued evaluation of TGDET. Various problems influencing the early outcome are discussed, and long-term outcome is analyzed. DESIGN: This was a prospective clinical descriptive study. METHODS: Prospective data was collected on 142 consecutive patients managed by one group of surgeons over a 5 year-period and 15 years follow-up after failed injection sclerotherapy for variceal bleeding. Evaluation was made in terms of effectiveness in controlling the acute bleeding, postoperative morbidity and mortality, recurrent bleeding, encephalopathy, and long-term survival. RESULTS: There were 133 men and 9 women. Mean age was 41.8 years. Etiology of portal hypertension was bilharziasis in 54.9% and posthepatitic in 14.8%. Child-Pugh grading on admission was A: 47.2%, B: 28.8%, and C: 14%. Hemorrhage was controlled in all cases. Clinical leak was observed in 5.6%, portal vein thrombosis in 6.3%, and staple line erosion in 2.1% of cases. No patient developed encephalopathy. In-hospital mortality was 12.7%. Complete eradication of varices was observed in 70.6% patients. Recurrent variceal bleeding was noticed in 6.9% of cases. Actuarial 15-year survival for Child-Pugh A patients was 44%, B was 22.5%, and none for C. CONCLUSION: TGDET remains a safe and effective procedure after failure of sclerotherapy when other alternatives are either not indicated or not available.

Spectrum of general surgical problems in the developmentally disabled adults.

OBJECTIVE: This study highlights the spectrum of general surgical problems necessitating admission on intellectually disabled adult patients. Problems encountered in the management and the ways to overcome various difficulties are highlighted. METHODS: Prospective collection of data on 63 consecutive developmentally disabled adult patients admitted to the Department of General Surgery, Riyadh Medical Complex (RMC), Riyadh, Kingdom of Saudi Arabia for various indications from January 2000 through December 2004. Demographic details, clinical presentation, diagnostic modalities, associated physical and neurological disabilities, coexisting medical condition, treatment options, morbidity and mortality were analyzed. Various difficulties encountered during the management and mean to overcome these problems are addressed. RESULTS: Sixty-three patients accounted for 71 admissions. Mean age was 26.7 years with a male preponderance (4.25:1). Fifty-four patients were admitted for various emergency conditions. History of pica could be obtained in 33% of the cases. Twenty-seven patients were admitted for acute abdomen. Volvulus of the colon (22.2%) and pseudo-obstruction (18.5%) were the most common causes of acute abdomen. Twenty-one patients were admitted with upper gastrointestinal bleeding. Reflux esophagitis was the most common cause of bleeding (62%). Overall morbidity was 41% for emergency admissions and 22% for elective surgery. Hospital mortality was 21.4% for emergency surgery. There was no death in elective cases. CONCLUSION: Developmentally disabled patients comprise a special class of patients with peculiar management problems. The treating clinician should be aware of various unexpected conditions not found as frequently in the normal patient population. Apparent lack of pain does not exclude an acute emergency. Possible surgical condition should be suspected if there is vomiting, abdominal distension, fever, increased irritability of recent onset. Male gender and history of pica are added risk factors.

Outcome of surgery for parotid tumours: 5-year experience of a general surgical unit in a teaching hospital.

BACKGROUND: Most of the recent reports on the surgical management of parotid gland disorders come from specialist divisions of otolaryngology, head and neck, or faciomaxillary surgery. The aim of the present study was to evaluate the outcome of surgery for parotid tumours in a general surgical unit of a teaching hospital. METHOD: A prospective clinicopathological study was undertaken over a 5-year period for consecutive patients operated on for parotid gland tumours in the King Saud University Unit of Riyadh Medical Complex. Parameters analyzed were demographic details, clinical presentation, diagnostic work-up, type of surgery, and outcome in terms of early and late morbidity. RESULTS: Thirty seven parotid operations were performed on 36 consecutive patients. All patients presented with parotid gland swelling. Mean age was 51.6 years with a male preponderance. Fine-needle aspiration diagnosed the pathology in 33 out of 37 lesions. Pleomorphic adenoma was the commonest pathology observed in 24 patients (64.9%). Warthin's tumour was more common among male patients and was the only pathology with bilateral involvement. Malignant tumour was found in five patients (13.5%). Superficial conservative parotidectomy was the most frequently performed operation (84%). Overall postoperative morbidity was 13.5%. Transient facial nerve palsy was observed in seven cases (19%). There was no recurrence identified in patients with benign diseases during the mean follow up of 38.5 months. CONCLUSION: Parotid gland surgery can still be performed in a general surgery unit with comparable outcome. However, the operation should be performed in units with special interest and experience in surgery for parotid gland disorders.

Outcome of laparoscopic cholecystectomy in acute cholecystitis.

OBJECTIVE: To evaluate the outcome of laparoscopic cholecystectomy in acute cholecystitis and to determine various pre-operative risk factors predicting conversion to open cholecystectomy. DESIGN: Observational study. PLACE AND DURATION OF STUDY: Department of Surgery, Riyadh Medical Complex, Riyadh, Saudi Arabia over 5 years period from June 1, 1997 to May 30, 2002. PATIENTS AND METHODS: Consecutive patients admitted with clinical diagnosis of acute cholecystitis confirmed subsequently by abdominal ultrasonography and undergoing laparoscopic cholecystectomy during the same admission. Patients with symptoms of more than one week duration, or various uncontrolled co-morbid conditions requiring optimization before surgery were excluded. Parameters analyzed were morbidity, mortality, incidence and etiology of conversion. Various pre-operative risk factors predicting failure of laparoscopic procedure in acute cholecystitis were further analyzed. Statistical analyses were carried out employing Chi-square test, using IBM-compatible PC, utilizing SPSS 10.0 for Windows (SPSS Inc., Chicago). RESULTS: Three hundred and eleven patients qualified the inclusion criteria. Mean age was 43.7 years with female to male ratio of 4.5:1. Majority of the patients (91%) were operated within 72 hours of onset of symptoms. Laparoscopic cholecystectomy was successfully accomplished in 86.8 % cases. Out of the 41 converted cases, disturbed anatomy in the region of Calot's triangle was the most common cause of conversion observed in 41.5% patients. Male gender, age more than 65 years, very high leucocyte count, gallbladder wall thickness of more than 4 mm on ultrasonography and complicated disease were observed as most significant determinant for conversion to open procedure. Overall morbidity was 2.9% with no mortality. CONCLUSION: Laparoscopic cholecystectomy can be accomplished with minimal morbidity in acute cholecystitis. Knowledge of various factors predicting possible conversion helps in pre-operative selection and counseling for open procedure and early conversion to open technique, with further reduction in the overall morbidity of laparoscopic cholecystectomy.

General surgical problems encountered in the Hajj pilgrims.

OBJECTIVE: The study was conducted to evaluate the pattern of general surgical admissions for future planning of staff, cost and other needs of these hospitals. METHODS: The study was conducted in 2 major hospitals in the Holy Shrine in 2 consecutive Hajj years 1423, 1424 (2003, 2004). All general surgical admissions, except those who died in the emergency room or were received dead, were included in the study. RESULTS: A total of 177 patients were admitted in both hospitals in 2 Hajj seasons. There were 139 males and 38 females with mean age of 52.7 years. Acute appendicitis and diabetic foot were the most common cause of admissions. Patients who received operative treatment totalled 87 (49.1%) and 69 (39%) were managed conservatively, while 20 (11.3%) left against medical advice. One patient was referred to higher center immediately after admission. CONCLUSION: The pilgrims are a peculiar class of patients. They should receive the best possible care but keeping in view their special needs. Furthermore, this study will help in future organization of such facilities.

Castleman disease presenting as obstructive jaundice.

A 48-year-old Saudi male was admitted with features of obstructive jaundice. Endoscopic retrograde cholangiopancreatography showed stricture in distal common bile duct CBD. Computed tomography scan revealed lymphadenopathy along CBD and in porta hepatis. Cholangiocarcinoma, lymphoma or metastatic deposits were suspected but no definite preoperative diagnosis could be established. Laparotomy disclosed lymph node enlargement in porta hepatis and along the CBD and lesser curvature of the stomach. Triple bypass procedure was performed to relieve the obstruction. Pathological examination of the lymph nodes showed Castleman disease of hyaline vascular type.

Initial factors predicting rebleeding and death in bleeding peptic ulcer disease.

OBJECTIVE: Bleeding peptic ulcer constitutes approximately half of the cases admitted with upper gastrointestinal bleeding. Although the bleeding episode stops spontaneously in most of them, rebleeding occurs in as much as 10-30% of them and has a mortality rate of 5-10%. In this study, we have evaluated the possible significant predictors associated with this adverse outcome. METHODS: The records of 205 patients admitted to gastrointestinal bleeding unit (GIBU) in Riyadh Central Hospital, during the period May 1996 through to April 1999, with endoscopic confirmed diagnosis of bleeding peptic ulcer disease were reviewed for demography, clinical presentation, hematology, biochemistry, initial blood pressure, nasogastric lavage color, co-morbid disease and endoscopic findings. All the significant factors found initially (P<0.05) were entered into odds ratio and its 95% confidence interval and finally the unconditioned logistic regression model was used to find out the significant independent predictors for both rebleeding and mortality in these patients. RESULTS: The majority of patients (85%) were males and below the age of 60 (73%). Duodenal ulcer was the source of bleeding in 84%. Endoscopy was performed in all patients within 24 hours of admission. Only 15% were actively bleeding at the time of initial endoscopy. Thirty-six patients (17%) rebelled, majority within 72 hours of initial hemostasis. Overall, 11 patients (5%) died, 6 of them were rebleeders. Initial presentation of systolic blood pressure <100 mm Hg, blood in nasogastric tube and visible vessel within the ulcer in endoscopy were independent predictors of rebleeding while initial systolic blood pressure <100 mm Hg and age >60-years were independent predictors of mortality. CONCLUSION: Improvement of outcome in patients with bleeding peptic ulcer disease can be achieved by early detection of those patients who are at risk of adverse outcome. Patients with the above mentioned independent predictors of rebleeding and mortality are best managed in the intensive care unit with endoscopic hemostasis and proton pump inhibitor (PPI) therapy for a minimum of 5-days of admission.

Outcome of nonoperative management of blunt liver trauma.

OBJECTIVE: To evaluate our experience with the management of blunt liver trauma at Riyadh Central Hospital, Kingdom of Saudi Arabia. METHODS: The hospital records of 68 patients treated for blunt liver trauma at Riyadh Medical Complex over a 5-year period (1997 through to 2002) were reviewed retrospectively. Patients who were hemodynamically unstable or had peritonitis were treated by urgent laparotomy (operative group). The other group of patients were treated conservatively as they were hemodynamically stable (nonoperative group) in the intensive care unit (ICU). All patients had computed tomogram of the abdomen with oral and intravenous contrast. Injuries grades were classified according to American Association for the Surgery of Trauma (AAST). Follow up computed tomogram of the abdomen was performed in 1-2 weeks time. RESULTS: A total of 68 patients were treated over a 5-year period. Thirty-three patients (49%) were treated by immediate surgery. Hepatorraphy was performed in 22 patients, non anatomical resection in 3 patients and liver packing in 2 patients to control bleeding. No active bleeding was found in 8 patients. Nonoperative group (n=35, 51%) were managed in the ICU for close monitoring. Surgically treated group had more patients with complex liver injury (30% versus 11%), required more units of blood (3.2 versus 2.1) but had a shorter hospital stay (9 days versus 12 days). Two patients for nonoperated group develop complications (biloma: one patient, infected hematoma: one patient), the nonoperative treatment failed in one patient who required laparotomy due to rebleeding from grade IV liver injury with failure rate of 3%. The only mortality (one patient) was in the operated group. CONCLUSION: The nonoperative treatment is a safe and effective method in the management of hemodynamically stable patients with blunt liver trauma. The nonoperative treatment should be the treatment of choice in such patients whenever computed tomogram and ICU facilities are available. However, further studies with larger number of patients are needed to support our results.

Outcome of laparoscopic cholecystectomy in acute biliary pancreatitis.

OBJECTIVE: To evaluate the efficacy, safety, and timing of laparoscopic cholecystectomy in the management of mild to moderate cases of acute biliary pancreatitis. METHODS: The medical records of 158 patients admitted to Riyadh Medical Complex, Riyadh, Kingdom of Saudi Arabia (KSA) from July 1998 to December 2001 were retrospectively reviewed. Acute biliary pancreatitis was diagnosed in patients who presented with abdominal pain with serum amylase level 3 times the normal limits in the absence of hypercalcemia or hyperlipidemia and presence of gallstones on ultrasonography. Severity of the disease was assessed using Atlanta Symposium criteria. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) was performed in 106 patients (74.6%) on selective basis. One hundred and eighteen patients underwent laparoscopic cholecystectomy after clinical and biochemical resolution of the attack. Standard 4 ports technique was used. Intraoperative and postoperative morbidity and mortality, and postoperative hospital stay were reported. RESULTS: Laparoscopic cholecystectomy was performed in 118 patients and it was possible in 110 cases (93.2%) after 3-8 days of admission. Preoperative ERCP was performed in 106 patients of mild to moderate acute biliary pancreatitis and common duct stones were retrieved in 19 cases (18%). The procedure was converted to open in 8 cases (6.7%). Postoperative complications were nausea and vomiting in 10, atelectasis in 8, chest infection in 3, and prolonged ileus in 2. The wound complication occurred in 4. One patient who had bile leak due to cystic duct stump avulsion at CBD junction was treated by endoscopic sphincterotomy plus stenting and another patient had partial CBD injury repaired primarily over a T-tube. Mean postoperative hospital stay was 2.4 days. One patient died due to uncontrolled arrhythmia and heart failure. CONCLUSION: Laparoscopic cholecystectomy can be safely performed for mild to moderate acute biliary pancreatitis after clinical and biochemical resolution of the attack during the same admission with acceptable morbidity and mortality rates. This strategy will lead to reducing the recurring acute biliary pancreatitis, number of admissions and hospital stay.

Role of ultrasonography, computed tomography and diagnostic peritoneal lavage in abdominal blunt trauma.

OBJECTIVE: To compare the diagnostic accuracy of diagnostic peritoneal lavage (DPL), ultrasonography and computed tomography in the management of blunt abdominal trauma. METHODS: A retrospective review of the charts of 233 patients with blunt abdominal trauma necessitating admission to Riyadh Medical Complex, Riyadh, Kingdom of Saudi Arabia was carried out over a 2 year period (January 2000 to December 2001). The diagnostic yields of DPL, ultrasound and computed tomography were analyzed. The results were compared with findings on subsequent laparotomy or ultimate outcome, which continued in hospital observation and conservative management. RESULTS: Mean age was 23 years and 79% patients were male. Road traffic accident remained the most common cause (70%) and 56% patients had multisystem injuries. The sensitivity for DPL, ultrasound and computed tomography scans was found to be 98%, 96% and 98% with an overall accuracy rate of 92%, 95% and 99%. Diagnostic peritoneal lavage showed false positive results with retroperitoneal injuries and missed one small bowel injury and a pancreatic injury, and resulted in one catheter related bowel injury. Computed tomography scan was able to grade, quantify and localize the injury and helped in devising a successful management plan in 76.5% cases. CONCLUSION: Diagnostic peritoneal lavage is a promising bedside investigation, but is invasive with low accuracy for retroperitoneal injuries and high probability of nontherapeutic laparotomy with false positive results. The high sensitivity and accuracy rates of computed tomography justify its use in quantifying and estimating the grade of injury in order to select the appropriate management of trauma victims. Computed tomography is recommended as the initial investigation of choice in hemodynamically stable patients with blunt abdominal trauma.