Emad Hokkam

Assessment of risk factors in diabetic foot ulceration and their impact on the outcome of the disease

AIMS The current study aims to identify risk factors for diabetic foot ulcer and their impact on the outcome of the disease. METHODS Three hundred diabetic patients were enrolled in the study. One hundred eighty subjects with diabetic foot ulcer and 120 diabetic controls without foot lesions. All expected risk factors were studied in all patients and after a follow up period, patients with diabetic foot ulcer were classified into group A (patients with healed ulcers) and group B (patients with persistent ulcer or ended by amputation). The risk factors were reanalyzed in both groups to find out their impact on the outcome of the disease. RESULTS The following variables were significant factors for foot ulceration: Male gender (P=0.009), previous foot ulcer (P=0.003), peripheral vascular disease (P=0.004), and peripheral neuropathy (P=0.006). Also lack of frequent foot self-examination was independently related to foot ulcer risk. The outcome was related to longer diabetes duration (P=0.004), poor glycaemic control (P=0.006) and anaemia (P=0.003) and presence of infection (P<0.001). CONCLUSIONS Peripheral vascular disease and peripheral neuropathy together with lack of foot self-examination, poor glycaemic control and anaemia are main significant risk factors for diabetic foot ulceration.

Laparoscopic elective cholecystectomy with and without drain: A controlled randomised trial

BACKGROUND: Laparoscopic cholecystectomy is the main method of treatment of symptomatic gallstones. Routine drainage after laparoscopic cholecystectomy is an issue of considerable debate. Therefore, a controlled randomised trial was designed to assess the value of drains in elective laparoscopic cholecystectomy. MATERIALS AND METHODS: During a two-year period (From April 2008 to January 2010), 80 patients were simply randomised to have a drain placed (group A), an 8-mm pentose tube drain was retained below the liver bed, whereas 80 patients were randomised not to have a drain (group B) placed in the subhepatic space. End points of this trial were to detect any differences in morbidity, postoperative pain, wound infection and hospital stay between the two groups. RESULTS: There was no mortality in either group and no statistically significant difference in postoperative pain, nausea and vomiting, wound infection or abdominal collection between the two groups. However, hospital stay was longer in the drain group than in group without drain and it is appearing that the use of drain delays hospital discharge. CONCLUSION: The routine use of a drain in non-complicated laparoscopic cholecystectomy has nothing to offer; in contrast, it is associated with longer hospital stay.

Intraincisional vs intraperitoneal infiltration of local anaesthetic for controlling early post-laparoscopic cholecystectomy pain

BACKGROUND: The study was designed to compare the effect of intraincisional vs intraperitoneal infiltration of levobupivacaine 0.25% on post-operative pain in laparoscopic cholecystectomy. MATERIALS AND METHODS: This randomised controlled study was carried out on 189 patients who underwent laparoscopic cholecystectomy. Group 1 was the control group and did not receive either intraperitoneal or intraincisional levobupivacaine. Group 2 was assigned to receive local infiltration (intraincisional) of 20 ml solution of levobupivacaine 0.25%, while Group 3 received 20 ml solution of levobupivacaine 0.25% intraperitoneally. Post-operative pain was recorded for 24 hours post-operatively. RESULTS: Post-operative abdominal pain was significantly lower with intraincisional infiltration of levobupivacaine 0.25% in group 2. This difference was reported from 30 minutes till 24 hours post-operatively. Right shoulder pain showed significantly lower incidence in group 2 and group 3 compared to control group. Although statistically insignificant, shoulder pain was less in group 3 than group 2. CONCLUSION: Intraincisional infiltration of levobupivacaine is more effective than intraperitoneal route in controlling post-operative abdominal pain. It decreases the need for rescue analgesia.

Operative Outcome and Patient Satisfaction in Early and Delayed Laparoscopic Cholecystectomy for Acute Cholecystitis

Introduction. Early laparoscopic cholecystectomy is usually associated with reduced hospital stay, sick leave, and health care expenditures. Early diagnosis and treatment of acute cholecystitis reduce both mortality and morbidity and the accurate diagnosis requires specific diagnostic criteria of clinical data and imaging studies. Objectives. To compare early versus delayed laparoscopic cholecystectomy regarding the operative outcome and patient satisfaction. Patients and Methods. Patients with acute cholecystitis were divided into two groups, early (A) and delayed (B) cholecystectomy. Diagnosis of acute cholecystitis was confirmed by clinical examination, laboratory data, and ultrasound study. The primary end point was operative and postoperative outcome and the secondary was patients satisfaction. Results. The number of readmissions in delayed treatment group B was three times in 10% of patients, twice in 23.3%, and once in 66.7% while the number of readmissions was once only in patients in group A and the mean total hospital stays were higher in group B than in group A. The overall patients satisfaction was 92.66 ± 6.8 in group A compared with 75.34 ± 12.85 in group B. Conclusion. Early laparoscopic cholecystectomy resulted in significant reduction in length of hospital stay and accepted rate of operative complications and conversion rates when compared with delayed techniques.

The use of topical phenytoin for healing of chronic venous ulcerations

BACKGROUND Many topical agents have been used for promotion of healing of chronic venous ulcers. One such agent that has been tried is phenytoin. The effect of phenytoin on cutaneous healing has been suggested. This study was designed to evaluate the efficacy of topical phenytoin in healing of venous ulcerations. METHODS One hundred and four patients with chronic venous ulcers were recruited in this study. They were divided into study group and control group. The study group was 54 patients while control group was 50 patients. Patients in the study group were subjected to dressing of their ulcers with topical phenytoin once daily while patients in the control group were subjected to dressing with normal saline. All patients were followed up for eight weeks and assessed for their ulcer status and recorded as: complete healing, partial healing, no improvement or worsening of the condition. RESULTS By the end of the eight weeks, complete healing was evident in 35/54 of the patients (64.8%) in the study group and 26/50 of the patients (52%) in the control group. It was statistically significant (p = .04). The rate of reduction in the mean surface area of the ulcers was faster in the study group than control group. Minor side effects were reported among 4 patients (7.4%) of the study group in the form of burning sensation. CONCLUSION Topical phenytoin can be used to enhance healing of chronic venous ulcers in conjunction with the established treatment. It has favorable results and tolerable local side effects.

Assessment of causes and patterns of recurrent varicose veins after surgery

Background: Varicose vein surgery is characterized by high recurrence rate of 60% after 5 years of follow-up observation, and this is a disappointing finding, both for the patient and surgeon. Aim: To identify the possible causes and patterns of recurrent varicose veins. Materials and Methods: 92 patients with recurrent varicose veins were enrolled in this study. Full detailed history, examination, and investigations were done. Results: 30 patients had recurrence after saphenofemoral disconnection, 22 patients with recurrence after saphenofemoral disconnection and stripping below knee, 28 patients recurrence after saphenofemoral disconnection with stripping above knee and 12 patients recurrence after sapheno-popliteal disconnection with stripping. The double great saphenous veins, neovascularization and deep venous thrombosis before and after surgery were the most observed patterns of recurrence. The anatomical patterns of recurrence were more in leg then both leg and thigh pattern. Conclusion: Saphenofemoral ligation with below knee stripping has the least frequency of recurrence, while Trendlenberg operation alone has the highest.

The efficacy of laparoscopy in the diagnosis and management of chronic abdominal pain.

BACKGROUND: Chronic abdominal pain is a difficult complaint. It leads to evident suffering and disability, both physically and psychologically. Many diagnostic and therapeutic procedures have been described in literature, but with little proof or evidence of success. Laparoscopy is one of the modalities that could be of benefit in such cases. We aim to evaluate the diagnostic and therapeutic value of laparoscopy in cases with chronic abdominal pain. MATERIALS AND METHODS: Thirty patients with chronic abdominal pain were included in this prospective descriptive cross-sectional study. The pain in all patients was of unclear etiology despite all the investigative procedures. All patients were subjected to laparoscopic evaluation for their conditions. The findings and outcomes of the laparoscopy were recorded and analyzed. RESULTS: The most common site of pain was the periumbilical region (30%). A definitive diagnosis was made in 25 patients (83.3%), while five patients (16.7%) had no obvious pathology. Adhesions were the most common laparoscopic findings (63.3%) followed by appendiceal pathology (10%), hernia (3.3%), gall bladder pathology (3.3%), and mesenteric lymphadenopathy (3.3%). Postoperatively, pain relief was achieved in 24 patients (80%) after two months. CONCLUSION: Laparoscopy is an effective diagnostic and therapeutic modality in the management of patients with chronic abdominal pain.

Trauma patterns in patients attending the Emergency Department of Jazan General Hospital, Saudi Arabia.

BACKGROUND Modern civilization and the sharp rise in living standards have led to dramatic changes in trauma pattern in Saudi Arabia. This study aimed to describe the different patterns of injuries of patients attending the Emergency Department of Jazan General Hospital (JGH) in the southwest corner of Saudi Arabia. METHODS A total number of 1 050 patients were enrolled in the study. A pre-organized data sheet was prepared for each patient attended the Emergency Department of JGH from February 2012 to January 2013. It contains data about socio-demographics, trauma data, clinical evaluation results, investigations as well as treatment strategies. RESULTS The mean age of the patients was 25.3±16.8 years. Most (45.1%) of the patients were at age of 18-30 years. Males (64.3%) were affected by trauma more common than females. More than half (60.6%) of the patients were from urban areas. The commonest kind of injury was minor injury (60%), followed by blunt trauma (30.9%) and then penetrating trauma (9.1%). The mean time from the incident to arrival at hospital was 41.3±79.8 minutes. The majority (48.2%) of the patients were discharged after management of trivial trauma, whereas 2.3% were admitted to ICU, 7.7% transferred to inpatient wards, and 17.7% observed and subsequently discharged. The mortality rate of the patients was 2.6%. CONCLUSION Trauma is a major health problem, especially in the young population in Saudi Arabia. Blunt trauma is more frequent than penetrating trauma, with road traffic accidents accounting for the majority.

Laparoscopic transabdominal preperitoneal approach for recurrent inguinal hernia: A randomized trial

Introduction: The repair of the recurrent hernia is a daunting task because of already weakened tissues and distorted anatomy. Open posterior preperitoneal approach gives results far superior to those of the anterior approach. Laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair is an evolving technique associated with advantages of a minimally invasive approach. The present work aimed at comparing these three approaches for repair of recurrent inguinal hernia regarding complications and early recurrence. Materials and Methods: A total of 180 patients were divided randomly into three equal groups: A, B, and C. Group A patients were subjected to open posterior preperitoneal approach , those of group B were subjected to transinguinal anterior tension-free repair and group C patients were subjected to TAPP. The primary end point was recurrence and the secondary end points were time off from work, postoperative pain, scrotal swelling, and wound infections. Results: The mean hospital stay, the mean time to return to work and the mean time off from work were less in group C then A and B. Chronic postoperative pain was observed in eight patients in group A (13.33%), in 18 patients in group B (30%) and six patients in group C (10%). The overall complication rate was 19.7% in both groups A and C and 34.36% in group B. Conclusion: In recurrent inguinal hernia, the laparoscopic and open posterior approaches are equally effective in term of operative outcome. The open preperitoneal hernia repair is inexpensive, has a low recurrence rate. Postoperative recovery is short and postoperative pain is minimal. This approach gives results far superior to those of the commonly used anterior approach. However, while laparoscopic hernia repair requires a lengthy learning curve and is difficult to learn and perform, it has advantages of less post-operative pain, early recovery with minimal hospital stay, low post-operative complications and recurrence. Trial Registration ACTRN12613001050741

Topical nitroglycerin versus lateral internal sphincterotomy for chronic anal fissure

ZusammenfassungGRUNDLAGEN: Es galt, die Wirkung von lokalem Nitroglyzerin versus Sphinkterotomie beim Management der chronischen Analfissur zu vergleichen. METHODIK: 80 Personen mit chronischer Analfissur wurden mit GTN 0,2 % (n = 40) oder mit interner Sphinkterotomie (n = 40) behandelt und die Wirksamkeit der Methoden verglichen. ERGEBNISSE: In der GTN-Gruppe war in 85 % der Fälle nach 8 Wochen Therapie eine Abheilung der Fissur zu beobachten. Kopfschmerz als Nebenwirkung bestand bei 65 % der Fälle. In der Sphinkterotomie-Gruppe trat Beschwerdefreiheit bei 97,5 % der Personen nach 8 Wochen ein. Inkontinenz für Gas bestand bei 3 Patienten (7,5 %), Stuhlschmieren bei 2 Personen (5 %) und 1 Patient hatte eine Wundinfektion. Alle Komplikationen waren transient, außer Persistenz für Gas-Inkontinenz bei einem Patienten. SCHLUSSFOLGERUNGEN: Lokales GTN sollte die initiale Therapie bei chronischer Analfissur sein, während die Sphinkterotomie bei Personen angewendet werden, die nicht auf GTN ansprechen oder starke Beschwerden haben.SummaryBACKGROUND: To compare the effectiveness of local glyceryl trinitrate (GTN) versus internal sphincterotomy in the management of chronic anal fissure. METHODS: Eighty patients with chronic anal fissure were enrolled in the study. They were divided into two groups; group (1) included 40 patients treated with topical GTN 0.2% on liposomal base applied to the anoderm twice daily and group (2) included 40 patients treated with internal sphincterotomy. We compared the effectiveness of both techniques in the management of chronic anal fissure. RESULTS: In group 1, healing of fissures occurred in 85% of patients after 8 weeks therapy. Headache as a side effect developed in 65% of patients. In group 2, healing occurred in 97.5% of patients after 8 weeks. Incontinence to flatus occurred in 3 patients (7.5%), mild soiling in 2 patients (5%), and one patient developed wound infection. All complications were temporary except for one patient with persistent incontinence to flatus. At the end of 8 weeks both groups were equal in pain scoring. CONCLUSIONS: Topical GTN should be the initial treatment in chronic anal fissure while internal sphincterotomy may be reserved for patients who did not respond to GTN therapy and those with severe pain (as healing is faster with sphincterotomy).