Surgical

Gastrointestinal basidiobolomycosis: An emerging potentially lethal fungal infection M Ezzedien Rabie, Abdulla Saad Al Qahtani, Salim Jamil, Nabil Tadros Mikhail, Ismail El Hakeem, Abdelellah Hummadi, Khaled Elsayed Elshaar, Ibrahim Abdelraheem, Dib Saudi Saudi Surgical Journal 2019 7(1):1-9 Background: Gastrointestinal basidiobolomycosis (GIB) is a newly emerging rare tropical fungal infection which affects immunocompetent individuals. Patients and Methods: Our database was reviewed to identify patients with biopsy-proven gastrointestinal basidiobolomycosis. Results: Six patients were recognized, two females and four males, with a median age of 23.5 years (range 11–70). All patients came from the same region and all had eosinophilia and they were all immunocompetent. The clinical and radiological features simulated colorectal malignancy in four patients, inflammatory bowel disease in one patient, and left iliac fossa mass in another patient. The diagnosis was established after extensive colonic surgery in four patients, after open biopsy in one patient and after ultrasound-guided biopsy in another. All patients received prolonged antifungal treatment. In those who received extensive colonic surgery, one patient died, two patients recovered, and one is still receiving antifungal treatment. Patients in whom the diagnosis was established by biopsy only, one patient recovered while the other is showing steady improvement. Conclusion: GIB is a potentially lethal fungal infection, which affects immunocompetent individuals in temperate and hot arid regions of the world, including Saudi Arabia, Iraq, Iran, and Arizona desert in the United States. The patient usually presents with features suggestive of colonic malignancy, inflammatory bowel disease, or abdominal mass. Establishing the diagnosis by endoscopic- or radiology-guided biopsy, serological tests, fungal cultures, or molecular techniques enables the institution of antifungal treatment, which may lead to complete cure without surgery. With or without surgery prolonged antifungal therapy is always required.

Comparative study of subcuticular suture, metal clips, and steri-strips for wound closure after thyroid surgery Jnaneshwari Jayaram, CM Aruna Kumar, Rhea Pinto, Leo F Tauro Saudi Surgical Journal 2019 7(1):10-13 Background: Pain and scar are the two important criteria bothering the patients after thyroid surgeries. Incisions on the neck when heal has to be scarless or minimum scar. Hence, we opted to study for the better methods of skin closure to obtain less pain and less scar. Aim: The study compared subcuticular suture, metal clips, and steristrips for wound closure after thyroid surgery based on the postoperative pain assessment, neck mobility, and cosmetic appearance. Materials and Methods: The prospective study which includes a consecutive series of 93 (n = 93). Patients undergoing thyroidectomy who were randomized to have their wound's closed by subcuticular sutures or steristrips or staples. The randomization code was generated using a table of random numbers, and the sealed envelope was opened at the end of each operation. Results: In this study, wound closure by steristrips had less postoperative pain followed by subcuticular suture and metal clips. In our study, neck mobility after thyroid surgery, steristrips had acceptable neck mobility compared to subcuticular suture and metalclips. In our study, cosmetic appearance after thyroid surgery wound closure with steristrips had excellent scar appearance followed by subcuticular suture and metal clips. Conclusion: In the final analysis, the choice of wound closure materials will depend on the surgeon's preference. However, this study showed that steristrips had less pain, acceptable neck mobility, excellent scar appearance followed by thyroidectomy surgery.

Preoperative predictors of conversion in elective laparoscopic cholecystectomy Smita Chauhan, Shakeel Masood, Anshuman Pandey Saudi Surgical Journal 2019 7(1):14-19 Introduction: Laparoscopic Cholecystectomy, the gold standard for management of gall stone disease, has a conversion rate of 1.6%-20% at different centers. We audited our elective laparoscopic cholecystectomies, to enable preoperative prediction of the probability of conversion. Method: Retrospective audit of all laparoscopic cholecystectomies from Jan 2013 to March 2017 was done. The cases that required conversion to open cholecystectomy were evaluated for pre- and intraoperative factors responsible for conversion and statistically analyzed using SPSS version 23 [IBM, USA]. Results: 764 patients (mean age 42.9 years) were taken up for laparoscopic cholecystectomies of which 33(4.31%) were converted to open cholecystectomy. The operative factors responsible for conversion were: (1) the presence of dense pericholecystic adhesions (P<0.001), (2) frozen Callot's triangle (P=0.013), (3) unclear anatomy (P=0.002) and iatrogenic injury to CBD (n=2), or bowel (duodenum and colon n=1). Pre-operative factors associated with conversion included age>60y (P=0.032), male sex (P=0.17), history of fever (P<0.032), prior ERCP (P=0.012) and anatomy complicated by cholecystoenteric fistula or Mirrizi's syndrome (P<0.001) Sonographic findings of contracted GB, thick walled GB, and stone impacted at neck of gallbladder were found to have high predictive value for conversion (P<0.001). Conclusion: Male sex, Age>60years, history of fever with pain, Mirrizi's syndrome, prior ERCP, ultrasound finding of a contracted gallbladder, thick walled gallbladder, and/or stone impaction at neck of gallbladder, significantly predispose to conversion at laparoscopic cholecystectomy. These preoperative factors translate intra-operatively into an unclear anatomy (suggesting that recurrence of inflammation causes increased fibrosis and unclear anatomy at Calot's) predisposing to a higher conversion rate.

Inguinal herniotomy: A national survey Osama Abdullah Bawazir Saudi Surgical Journal 2019 7(1):21-25 Objectives: The objective of this study was to evaluate and describe the current practice of surgical repair of inguinal herniotomy among pediatric surgeons working in Saudi Arabia. Materials and Methods: Between May and June 2018, a questionnaire of 15 multiple choices was sent to all pediatric surgery consultants working in pediatric surgery units across the kingdom of Saudi Arabia. The responses to the questionnaire were analyzed and categorized as shown in the results section. Results: A total of 215 questionnaires were sent, over half of the practitioners fill the questionnaire 56.3% (121). With fair distribution, among type of hospitals were 33% in children hospital, 33% in tertiary hospital, 7% in private hospital, and 8% in general or academic hospitals. Regarding the diagnosis, almost all the surgeons depend on the mother history of a swelling in the groin that comes and goes. The majority (97%) of surgeon will do a standard open herniotomy for male infants, and only 2% will do laparoscopic hernia repair. For ex-premature infants with an inguinal hernia and already discharged from the neonatal intensive care unit, 35% will repair the hernia at presentation regardless of the age, 27% will do it after 50 weeks of postmenstrual age, 18% will do it after 60 weeks of postmenstrual age, 12% will do it after 2 months or above 5 kg weight, and only 8% will do it on urgent basis. Conclusions: The majority of pediatric surgeons depend on a clinical diagnosis of inguinal hernia. Although the timing of surgical repair is still controversial, the majority of pediatric surgeons will repair inguinal hernia as soon as possible. Still, there is no consensus on when or if contralateral inguinal exploration is necessary.

Pretreatment clinical, laboratory, and imaging predictors of the outcome of pneumatic reduction of pediatric idiopathic ileocolic intussusception Alaa E Younes, Mohamed Al Saeed, Bilal O Al-Jiffry, Tamer Abdel-Rahman, Samir Badr, Aseel Abu-Duruk, Mohamed Hatem Saudi Surgical Journal 2019 7(1):26-31 Background/Purpose: Air enema reduction is considered by many authors to be the first line of treatment of idiopathic pediatric ileocolic intussusception. The aim of this retrospective study was to evaluate the results of the pneumatic reduction in our hospitals as a treatment of idiopathic pediatric ileocolic intussusception and to identify the pretreatment factors associated with pneumatic reduction failure. Methods: This was a multicenter chart review and database retrospective study conducted in tertiary general hospitals in Taif, Saudi Arabia. The study was conducted by revising the medical records of all pediatric patients who were admitted to the hospitals with picture suggestive of intussusception from January 2007 to December 2017. A total of 235 children were proved to have idiopathic ileocolic intussusception and initially treated by air reduction (AR) under fluoroscopic guidance. The primary outcome was the results of pneumatic reduction, and the secondary outcome was to identify the pretreatment factors associated with pneumatic reduction failure. Results: A total of 235 patients with male-to-female ratio 3:1 were included in the study with a mean age of 18.6 ± 4.3 months. The AR was successful in 87.2% of cases, perforation occurred in 0.9%, and the recurrence within the first 48 h was 6.3%. The risk factors which were significantly correlated with failed reduction were duration of symptoms >48 h, rectal bleeding, hemoglobin level <11.9 gm, neutrophils >66.8% of total neutrophil count, ultrasound poor prognostic signs, and body weight <11.7 kg. Conclusion: AR is safe and effective as a first-line treatment for pediatric idiopathic intussusception. A delay in presentation, presence of rectal bleeding, a high segmental neutrophils, low hemoglobin level, and low body weight, or/and presence of ultrasound bad prognostic signs, might be associated with reduction failure. The presence of these predictors of failure does not contraindicate the pneumatic reduction; however, the procedure should be carefully performed to avoid irreducibility and the risk of bowel perforation.

Successful use of octreotide and limited drainage in resistant chylothorax in congenital diaphragmatic hernia Rajendran Ramaswamy, Krishna R Gopala, Saif Saeed Mohamed Galib, Samir Morsi Hegab Saudi Surgical Journal 2019 7(1):32-35 In the conservative treatment of postdiaphragmatic hernia chylothorax, use of octreotide (OCT) had variable results. Limited chyle drainage has not been tried. A newborn, after the left Bochdalek diaphragmatic hernia repair, developed chylothorax. Treatment with intercostal chest tube (ICT) drainage, partial parenteral nutrition (PPN), and medium-chain triglyceride (MCT) with formula feeds was ineffective. ICT slipped out on the 13th day in the presence of significant residual chylothorax. Further drainage was not done. Addition of OCT infusion at maximum dose of 6 μg/kg/h cleared the chylothorax. No side effect of OCT was observed. The present case has proved that MCT feeding along with PPN is effective, and limited drainage of chyle is enough with OCT treatment in postdiaphragmatic hernia chylothorax.

Aortoesophageal fistula postthoracic endovascular aortic repair Abdulrhman Hassan, Abdullah Alhaizaey, Musaad Alghamdi Saudi Surgical Journal 2019 7(1):36-37 Thoracic endovascular aortic repair (TEVAR) is one of the choices for management of thoracic aortic aneurysms.[1] However, the complications of this procedure remain undetermined.[1] We present a 91 years male with a fatal post TEVAR aortoesophageal pseudoaneurysm leak and fistula to draw attention for such complication and its primary symptoms that may provide immediate treatment.

Leiomyoma of the hand Feras Altumaihi, Hattan Aljaaly, Hossam Ammar, Basem Awan Saudi Surgical Journal 2019 7(1):38-40 Leiomyoma is a benign tumor of the uterine smooth muscle that occurs in approximately half of all women by the age of 50 years. However, these tumors occasionally occur in other parts of the body. A 27-year-old woman presented with a painless, slow-growing nodule on her right index finger that had increased in size to 1.6 cm × 1.4 cm × 1.2 cm. The initial diagnostic hypotheses included a ganglionic cyst and giant cell tumor. However, surgical excision and histological analysis revealed this tumor to be a leiomyoma of the hand.

Erratum: Factors influencing decision of medical students in choosing a surgical specialty: A cross-sectional study Saudi Surgical Journal 2019 7(1):41-41