Hani Al-Qadhi

Large duodenal gastrointestinal stromal tumor presenting with acute bleeding managed by a whipple resection. A review of surgical options and the prognostic indicators of outcome.

CONTEXT Duodenal gastrointestinal stromal tumors (GISTs) are uncommon and constitute a relatively small subset of GISTs which presents a unique dilemma having various surgical options. A case of a large ulcerating duodenal GIST arising from the second and third parts of the duodenum and involving the pancreas which was managed by a Whipple resection is presented. The literature is also reviewed to present the current status on surgical options, outcome, prognostic indicators and the role of imatinib mesylate in its management. CASE REPORT A 58-year-old patient presented with acute gastrointestinal bleeding which was diagnosed to be due to a duodenal GIST following CT scan and endoscopic biopsy. The mass which measured about 10x9 cm originated from the 2nd part and extended into the 3rd part of the duodenum. He underwent a Whipple resection, and histopathology confirmed a duodenal GIST having a greater than 10 mitotic count per fifty high power field and areas of necrosis. Postoperatively, he received imatinib mesylate 400 mg bid; however, 4 months later, he presented with multiple disseminated peritoneal metastases and succumbed to the disease 2 months later. CONCLUSION GISTs of the duodenum which are small in size and do not involve the papilla of Vater are better resolved using a limited resection of the duodenum since the outcome in terms of operative risk or disease recurrence is not influenced in these cases. However, large tumors with more extensive involvement would require a pancreaticoduodenectomy to achieve adequate tumor clearance. Even though duodenal GISTs have a relatively better prognosis as compared to GISTs at other sites, their aggressiveness ranges from small indolent tumors to aggressive sarcomas. Following tumor resection, a recurrence rate of about 40% has been reported. A more favorable prognosis in duodenal GISTs is attributed to a lower prevalence of P53 loss, the duodenal location of the tumor, a smaller size of the lesion and a low mitotic count. Imatinib mesylate is reported to play a role in neoadjuvant therapy as well as in the management of metastatic and recurrent disease, although some of these tumors may fail to respond.

Amyand’s Hernia: Study of four cases and literature review

The presence of the appendix in an inguinal hernial sac is described as Amyands hernia. It is a rare entity which presents mostly at the exploration of the inguinal canal. The appendix may be apparently normal or have all the features of acute appendicitis with its possible complications. We report four cases of Amyands hernia which were treated at Sultan Qaboos University Hospital, Oman. All patients underwent appendectomy. In three cases, the inguinal hernia were repaired with Vipro mesh while, in the remaining case, a darning repair was done with Prolene sutures.

Rectal bezoars due to pumpkin seeds.

Rectal bezoars commonly occur due to seeds, especially in children living in countries south of the Mediterranean and in the Middle-East. Dried seeds are considered a delicacy and consumed widely. Inadequate chewing or hastily eating without removing the hull may lead to their impaction as bezoars, which may require manual removal under general anaesthesia.

The Use of Laparoscopy in the Management of Trauma Patients: Brief review

Laparoscopy is one of the most effective intervention modalities, resulting in improved outcomes for major surgeries. In the past decade, the laparoscopic approach in trauma patients has shown better diagnostic outcomes than traditional laparotomies. Furthermore, this approach is cost-effective, significantly reduces the length of hospital stay and contributes to reduced complication rates. However, the use of laparoscopies in trauma cases is generally restricted to patients with normal haemodynamic parameters and is contraindicated for individuals with head injuries. With advances in knowledge and improved training, laparoscopies can also be used in the treatment of other conditions, such as diaphragmatic injuries and organ lacerations. This article briefly reviews the extent of laparoscopy use and its significance in the management of trauma patients.

Leiomyoma of the Round Ligament of the Uterus : Case Report and Review of Literature = تم رصد حالة و مقارنتها بالدراسات السابقة : إكتشاف ورم عضلي أملس في الرباط المستدير بالرحم

Smooth muscle tumours of the round ligament of the uterus are rare and can mimic an inguinal hernia. Preoperative diagnosis can be established by a computed tomography scan of the abdomen or an exploration of the inguinal canal. Surgical excision is the curative treatment.

Distribution of Trauma Care Facilities in Oman in Relation to High-Incidence Road Traffic Injury Sites: Pilot study

Objectives Road traffic injuries (RTIs) are considered a major public health problem worldwide. In Oman, high numbers of RTIs and RTI-related deaths are frequently registered. This study aimed to evaluate the distribution of trauma care facilities in Oman with regards to their proximity to RTI-prevalent areas. Methods This descriptive pilot study analysed RTI data recorded in the national Royal Oman Police registry from January to December 2014. The distribution of trauma care facilities was analysed by calculating distances between areas of peak RTI incidence and the closest trauma centre using Google Earth and Google Maps software (Google Inc., Googleplex, Mountain View, California, USA). Results A total of 32 trauma care facilities were identified. Four facilities (12.5%) were categorised as class V trauma centres. Of the facilities in Muscat, 42.9% were ranked as class IV or V. There were no class IV or V facilities in Musandam, Al-Wusta or Al-Buraimi. General surgery, orthopaedic surgery and neurosurgery services were available in 68.8%, 59.3% and 12.5% of the centres, respectively. Emergency services were available in 75.0% of the facilities. Intensive care units were available in 11 facilities, with four located in Muscat. The mean distance between a RTI hotspot and the nearest trauma care facility was 34.7 km; however, the mean distance to the nearest class IV or V facility was 83.3 km. Conclusion The distribution and quality of trauma care facilities in Oman needs modification. It is recommended that certain centres upgrade their levels of trauma care in order to reduce RTI-associated morbidity and mortality in Oman.

Lap Mentor-based assessment of laparoscopic surgical skills: a validation study

Objective: To validate the scores of assessments of basic laparoscopic surgical skills obtained through performance on LAP Mentor. Design: Cross-sectional validation study. Setting: Oman Medical Specialty Board (OMSB) skills lab, Muscat, Oman. Participants: Twenty-three surgical residents, registered with OMSB, at different years of residency, underwent assessment of basic laparoscopic surgical skills on the LAP Mentor. A construct validation model was used to validate the scores. Results: 35% of the candidates, all belonging to the senior group, passed the assessment. Cronbach’s alpha was 0.87 with a standard error of measurement of 1.53 (95% confidence interval). The intra-class coefficient varied from 0.88 to 0.95 for different scales. Factor analysis revealed two underlying constructs, i.e. technical skills and patient safety skills, that explained competency in laparoscopy surgery. A review of the literature supported content validity evidence. Relationships with other variables were documented through convergent and divergent evidence. A correlation for the data revealed that actual residency year and total score achieved were significantly related (r = 0.51, N = 23, P = 0.01, two-tailed). Senior residents scored significantly higher than junior residents on overall performance. Fisher’s exact test showed that more seniors than juniors passed on overall performance using specific criteria determined by factor analysis and Angoff’s method for standard setting. The majority of residents and raters agreed or strongly agreed on feasibility, conducting such tests regularly, meaningful feedback, and objectivity and reuse of the tools. Conclusions: Assessment on LAP Mentor using different rating scales and construct-based standard setting methods provides meaningful scores. Periodic summative assessment is acceptable to residents.

Delayed diagnosis of ureteral injury following penetrating abdominal trauma: A case report and review of the literature

Patient: Female, 29 Final Diagnosis: Missed ureteral injury Symptoms: Abdominal pain • anemia • fever • loose stools Medication: — Clinical Procedure: Ureteroureterostomy Specialty: Urology Objective: Mistake in diagnosis Background: Ureteral injuries are considered to be uncommon in cases of trauma. The possibility of damage to the ureters may not be considered in the setting of acute trauma when life-threatening injuries take clinical management priority. A case of acute ureteral injury is described in a patient with acute penetrating gunshot abdominal injury that had a delay in diagnosis, with a review of the literature. Case Report: A29-year-old woman presented to our hospital with a missed ureteral injury following a self-inflicted gunshot injury to the abdomen. She underwent abdominal computed tomography (CT) imaging and a retrograde pyelogram, which showed complete transection of the left upper ureter with contrast extravasation and the formation of a large urinoma. She underwent a percutaneous nephrostomy and drainage of the urinoma. An end-to-end ureteric anastomosis with excision of the intervening injured ureter, or ureteroureterostomy, was performed three weeks following the diagnosis. Conclusions: Ureteral injuries following trauma are rare, but a delay in diagnosis can be associated with clinical morbidity. A high index of clinical suspicion is important for early identification of ureteral injury in cases of acute abdominal trauma.

Use of Prophylactic Inferior Vena Cava Filters in Trauma

Venous thromboembolisms, specifically pulmonary embolisms (PEs), represent a significant burden on healthcare systems worldwide, particularly within the setting of trauma. According to the literature, PEs are the most common cause of in-hospital death; however, this condition can be prevented with a variety of prophylactic and therapeutic measures. This article aimed to examine current evidence on the use, indications for prophylaxis, outcomes and complications of prophylactic inferior vena cava filters in trauma patients.

Comparison of Postoperative Drain Insertion versus No Drain Insertion in Thyroidectomies: Retrospective case-control study from the Sultan Qaboos University Hospital, Muscat, Oman

OBJECTIVES A thyroidectomy is a frequently performed surgical procedure which can result in life-threatening complications. The insertion of a drain after a thyroidectomy has been suggested to prevent such complications. This study aimed to evaluate the use of surgical drains following thyroidectomies in relation to postoperative complications and mass sizes. METHODS This retrospective case-control study included all thyroidectomies conducted at the Sultan Qaboos University Hospital, Muscat, Oman, from January 2011 to December 2013. Length of hospital stay, readmission, postoperative complications and mass size were evaluated. RESULTS During the study period, 250 surgeries were carried out on 241 patients. The majority of patients were female (87.2%). Drains were inserted postoperatively after 202 surgeries (80.8%) compared to 48 surgeries (19.2%) without drains. A total of 32 surgeries (12.8%) were conducted on patients with thyroid masses <1 cm, 138 (55.2%) on those with masses between 1-4 cm and 80 (32.0%) on those with masses >4 cm. The association between drain use and mass size was not significant (P = 0.439). Although postoperative complications were more prevalent in patients with drains, the relationship between these factors was not significant (P >0.050). Length of hospital stay was significantly longer among patients with postoperative drains (P <0.010). CONCLUSION The routine insertion of drains after thyroid surgeries was found to result in longer hospital stays and did not reduce rates of post-thyroidectomy complications. Thyroid mass size should not be used as an indicator for the insertion of a drain after thyroidectomy.