Ayman Mismar

Underlay mesh repair for spontaneous lumbar hernia.

INTRODUCTION Lumbar hernia is a rare condition with fewer than 300 cases reported in the literature. It arises through posterolateral abdominal wall defects, named the inferior triangle (Petit) and superior triangle (Grynfelt). It can be congenital or acquired, primary or secondary, peritoneal or extraperitoneal, reducible or complicated. PRESENTATION OF CASE We report a 63 year old female patient who presented to our hospital with a reducible right superior lumbar hernia. She underwent repair with underlay mesh after inversion of the sac and had a smooth postoperative course. DISCUSSION In contrast to the classical procedure the underlay mesh modification saved us from enlarging the defect, and was quick and associated with minimal tissue injury. CONCLUSION Underlay mesh repair for spontaneous lumbar hernia is feasible when the defect is small.

Gastric perforation secondary to metastasis from ovarian cancer: Case report

INTRODUCTION Metastasis from ovarian cancer occurs frequently through the peritoneal cavity in the form of peritoneal carcinomatosis; isolated gastric metastasis is rarely reported in literature. PRESENTATION OF CASE We present a case of 43-year-old infertile lady, who developed a picture of acute abdomen four days post total abdominal hysterectomy and salpingoopherectomy for ovarian cancer. Further contrast-enhanced CT scan demonstrated massive free gas and fluid in the abdomen. She underwent antrectomy with truncal vagotomy due to 3cm×4cm prepyloric gastric ulcer. Final pathology proved the presence of metastatic serous cystadenocarcinoma of ovarian origin. DISCUSSION Our patient had a gastric perforation secondary to ovarian metastasis. Being isolated, the absence of ascites and the transmural nature of the gastric metastasis suggest haematogenous spread .To the best of our knowledge perforated gastric metastasis secondary to ovarian cancer was not reported in literature before. CONCLUSION Gastric metastasis should be kept in mind in patients with a well-known ovarian cancer who present with gastric lesions, ulcers, bleeding or perforation.

Wound infiltration with bupivacaine 0.5% with or without adrenaline does not decrease pain after thyroidectomy. A randomized controlled study

Objectives: To study the effect of local wound infiltration with and without adrenaline on pain perception after thyroidectomy using the visual analog score (VAS). Methods: A prospective randomized controlled double-blinded study was conducted between May 2015 and June 2016 at The University of Jordan Hospital, Amman, Jordan. Eighty-nine patients undergoing planned thyroidectomy were included in the study. Patients were divided randomly into 3 groups: Group A, local wound infiltration with bupivacaine 0.5% was administered; Group B, bupivacaine 0.5% with adrenaline was administered; Group C (control), no infiltration was performed. Standardized thyroidectomies were performed in the 3 groups. Pain perception was measured using VAS at 2, 4, 6, 12, and 24 hours after surgery. A comparison between the 3 groups was carried out. Results: No significant differences among the 3 groups were observed at all time points (p=0.246). Visual analog scores were significantly lower at 12 and 24 hours after operations. Conclusion: Local wound infiltration with bupivacaine 0.5% does not decrease pain perception after thyroidectomy performed under general anesthesia, and adding adrenaline does not enhance its effect.

Reply to the Letter to the Editor on “Helicobacter Pylori Does Not Affect Postoperative Outcomes after Sleeve Gastrectomy”

We thank Dr. Kassir and his colleagues for their attention to our manuscript entitled: Helicobacter pylori does not affect postoperative outcomes after sleeve gastrectomy [1]. First, we would like to focus that our study included patients undergoing sleeve gastrectomy (LSG) and not gastric bypass. Hence, the stomach is easily accessible for endoscopic surveillance postoperatively. We fully understand your concerns and agree that Helicobacter pylori (HP) is a well-established risk factor for gastric cancer, and it is implicated in the pathogenesis of various benign and malignant diseases. Our article discussed the timing of treatment and is not against HP eradication. This issue was evident by treating all HP-positive patients in our study two weeks postoperatively. Some papers cited in our article suggested that HP should be eradicated before surgery as it might increase the incidence of leak. However, our article showed that preoperative surveillance might not be necessary as HP infection did not affect the rate of early postoperative complications. Therefore, eradication therapy can be given postoperatively based on histopathological examination of excised stomach, which is more accurate than other methods of testing. Worth mentioning that Keren et al. [2] showed that LSG might lead to HP eradication, due to the resection of the usual sites of bacterial infection. This might suggest repeat testing for HP three months postoperatively before giving eradication therapy. With regard to GERD and Barret esophagus (BE) post sleeve gastrectomy, studies had shown controversial results. Technical considerations might be implicated in the incidence of GERD postoperatively. Data from the literature concerning the development of BE after LSG are scarce. Genco et al. [3] showed a very high incidence of BE in LSG patients. Thus, endoscopic evaluation in the postoperative surveillance of LSG patients should be encouraged.

Upper airway obstruction by a fragmented tracheostomy tube: Case report and review of the literature

Highlights • Upper airway obstruction is common in children due to foreign bodies as including seeds, nuts and household particles.• There are a few reports describing fractured tracheostomy as a cause of airway obstruction.• We report the management of a case of foreign body aspiration in the tracheobronchial tree due to a fragmented and migrated tracheostomy tube.

The Birmingham Formula is not a Reliable Instrument for Preoperative Prediction of Thyroid Malignancy (Prospective Study)

Objective: Thyroid nodules are very common in population all around the world. Preopoerative anticipation of malignancy in a thyroid nodule is crucial for optimum management. There are limitations for all available tests especially in follicular tumors. The Birmingham formula was described to predict the malignancy risk in each individual with a thyroid nodule depending on phenotyping association. We tried to explore prospectively the predictivity of this formula in comparison with the postoperative pathological report. Methods: Data for 512 patients with a thyroid nodular disease, planned for surgery, were collected 399 of which were included in the study. Malignancy risk was calculated for each patient and compared to postoperative pathology report. Results: Statistical analysis showed a low sensitivity and a positive predictive value of around 50%, the performance of the formula did not improve when we excluded microcarcinoma. Conclusions: Data did not support the efficacy of Birmingham formula as a reliable instrument in predicting malignancy in thyroid nodules.

Ascending Infection of Foot Tendons in Diabetic Patients

Bone and soft tissue infection in the foot of diabetic patients is a well-described issue in the literature. A sound anatomical knowledge of the foot anatomy and compartments is mandatory to understand the mechanisms of infection spread. We describe four cases of diabetic foot infection complicated by long ascending infection. All did not respond initially to antibiotic treatment and the usual surgical debridement and were cured only after excision of the infected tendons. We highlight a rare but serious complication of the diabetic foot disease not commonly seen by the surgical community. We hope that this report raises the awareness of this condition so that a prompt diagnosis is made and appropriate treatment started, thereby reducing the risk of major lower limb amputations.