Ahmad Zaghal

Update on totally implantable venous access devices

The use of totally implantable venous devices (TIVAD) has changed the care and quality of life for cancer patients, these devices allow chemotherapy administration, and blood sampling without the need for repeated venipuncture. These ports are used mainly when IV access is needed only intermittently over a long period of time. We are presenting a brief overview on TIVADs, with focus on the mid and long-term complications associated with these devices with their management.

Complete Catheter Disconnection and Migration of an Implantable Venous Access Device: The Disconnected Cap Sign

The use of totally implantable venous access device has provided a solution to difficult venous access. Early reports have, however, recognized several complications with their use. Catheter disruption is a rare but important complication of these devices; it may be asymptomatic but can be fatal in some cases. We present a case of a patient who had a rare and serious complication secondary to catheter disconnection from its chamber.

The Thoracic Inlet Index in patients with tracheal obstruction caused by chest wall deformity: Validation in patients and age-matched controls

AIM We present a novel index for evaluating severity of airway-threatening thoracic inlet compromise in childhood. Two indices were validated in three cases and sixty asymptomatic controls. METHODS We developed an index to determine severity of thoracic inlet narrowing. Two different measurement methods were evaluated: Thoracic Inlet Index (TII) was determined at the site of greatest airway compromise at the level of the innominate artery crossing the anterior trachea and TII (anatomic) using purely skeletal measurements, both determined from thoracic CT scan. We sought to validate both indices to determine which was more predictive of the risk of airway compromise. Three patients who presented with life threatening airway compromise were compared to sixty age matched asymptomatic controls obtained from the trauma registry. RESULTS The mean TII in controls was 3.89. The TII was consistent at various ages. In patients, mean TII was 12.16 (range of 11.31-12.95). For TII the difference between controls and symptomatic patients was highly significant (P=0.0012). The mean TII (anatomic) in controls was 3.5. The TII (anatomic) was less consistent when evaluated in different age groups. In patients mean TII (anatomic) was 6.32 (range 5.38-7.59). For TII (anatomic), the difference between controls and symptomatic patients was also significant (P=0.0474) but did not discriminate as well as the functional index. CONCLUSIONS The TII measured at the level of the innominate artery crossing on thoracic CT scan appears to be the most useful. A level of greater than 10 was highly predictive of airway compromise in our patient group.

Pancreatic Anastomosis Disruption Seven Years Postpancreaticoduodenectomy

We are reporting a case of a 22 year-old female patient, who underwent a pancreaticoduodenectomy previously for a solid-pseudopapillary neoplasm of the pancreas and was re-admitted seven years later with a pancreatic leak following disruption of the pancreatico-jejunal anastomosis. Exploratory laparotomy revealed a large collection at the level of the pancreatic anastomosis with major disruption of the pancreatico-jejunal anastomosis. The pancreatic stump was refreshed as well as the jejunal site and a duct to mucosa anastomosis was performed. She remains well with a follow up of 18 months.

Triple thrombophilic simultaneous mutations in patients after bariatric surgery: is there a role for screening in the Eastern Mediterranean?

Abstract Background and purpose: Thrombophilia is a hypercoagulable state that predisposes to thrombosis. Several genetic risk factors have been shown to predispose to thromboembolic events. Homozygosity to a thrombophilic mutation certainly predisposes the affected patient to more serious symptoms. Materials and methods: Here we present a case of a 56-year-old male patient who underwent sleeve gastrectomy for morbid obesity, presenting to our institution with abdominal pain. Investigations revealed thrombosis of the splenic, axillary vein as well as the right pulmonary artery. The patient was found to have triple thrombophilic mutations. Results: To our knowledge, this is the first reported case of three specific simultaneous thrombophilic mutations in a patient from the Eastern Middle East. Conclusion: We suggest a role for screening for thrombophilic mutations in the Eastern Mediterranean patients undergoing bariatric surgeries for morbid obesity due to the increased risk of thrombosis in this group of patients

Surgical Decision Making in Preduodenal Portal Vein: Report of Two Cases in Neonates

Preduodenal portal vein (PDPV) is a rare anomaly that can cause duodenal obstruction. PDPV is associated with other congenital anomalies, mainly cardiac and gastrointestinal. Treatment usually consists of bypassing the obstruction by duodenoduodenostomy. We report two cases of PDPV in association with atrial isomerism and malrotation with different surgical management.

Laparoscopic Exploration of Common Bile Duct

Symptomatic common bile duct stone(s). Dilated common bile duct. Common bile duct stones found during laparoscopic cholecystectomy. Common bile duct injury.

Laparoscopic Small Bowel Resection

Laparoscopic small bowel resection has the advantage over the open conventional approach as being more precise with better results in terms of postoperative outcomes. It has been shown to be effective in several small bowel pathologies, such as gastrointestinal stromal tumors. This chapter describes indications, essential steps, variations, and complications of this procedure. It provides a detailed template operative note for the procedure.

Brachial Plexus Injury

Brachial plexus injury during central venous catheter insertion is uncommon. Understanding the anatomy and the relationship between the brachial plexus and the neck veins and arteries is highly important. The brachial plexus, stellate ganglion, vagus, accessory, hypoglossal and phrenic nerves are all closely associated with the internal jugular vein. Any of these structures may be injured during cannulation attempts, with the most common complication occurring when local anesthetic injected at the time of cannulation transiently blocks these nerves.

Closure of Loop Ileostomy

A loop ileostomy is widely used in colorectal surgery. It has been reported to significantly lower the rate of clinical anastomotic leakage and the risk of subsequent complications. This chapter describes indications, essential steps, variations, and complications of this procedure. It provides a detailed template operative note for the procedure.