Kamal E. Bani-Hani

Retained Surgical Sponges (Gossypiboma)

OBJECTIVE Retained surgical sponges are seldom reported due to medicolegal implications. Awareness of this problem among surgeons and radiologists is essential to avoid unnecessary morbidity. We present our experience with this entity and review the related literature. METHODS The medical records of 11 patients who were diagnosed as having retained surgical sponges from 1990 to 2003 were reviewed. RESULTS The incidence was 1:5,027 inpatient operations. There were four males and seven females with a median age of 45 years. The original operations were gynaecological (n=4), general (n=4), urological (n=2) and laminectomy (n=1). In seven cases, the original operation was performed on an emergency basis. Five patients were obese. A presumed correct sponge count was documented in eight cases. The median time between the original procedure and diagnosis of retained sponges was 12 months. The tentative diagnosis was intestinal obstruction (4 patients), urinary tract infection (1 patient), Crohns disease (1 patient) and tumour recurrence (1 patient). The correct diagnosis was suggested in the remaining four patients. Surgical removal of the retained sponges was carried out in all cases except one, in which the patient passed the sponge spontaneously through the rectum. CONCLUSION Retained sponges are more common in obese patients and after emergency surgery. A high degree of suspicion is important for preoperative diagnosis. Despite the use of radio-opaque sponges and thorough sponge counting, this moribund mishap still occurs. Although human errors cannot be completely abolished, continuous medical training and strict adherence to regulations should reduce the incidence to a minimum.

Idiopathic Granulomatous Mastitis: Time to Avoid Unnecessary Mastectomies

Abstract:  Idiopathic granulomatous mastitis is a rare disease of the breast. Clinically and radiologically it may mimic breast carcinoma. Awareness of surgeons, pathologists, and radiologists is essential to avoid unnecessary mastectomies. Data regarding 24 patients with histologically confirmed idiopathic granulomatous mastitis treated at our center over 8 years were analyzed. The mean age of patients was 34.3 years. Breast lump was the most common presentation. The right breast was affected in 16 cases. Four patients were pregnant at the time of presentation. Lactation within 6 months of presentation was documented in four patients. Two patients used contraceptives pills. A clinical suspicion of malignancy was present in 17 cases. Mammography was performed in 16 patients and showed focal asymmetrical dense lesions in 9, well‐circumscribed opacity in 4, spiculated lesion in 1, and was normal in 2. Fine‐needle aspiration was performed in 17 patients, of which 2 were reported as malignant. Wide local excision was the mainstay of treatment. One patient underwent mastectomy upon clinical, mammographic, and repeated cytologic findings consistent with malignancy, and the final histology confirmed idiopathic granulomatous mastitis with no evidence of malignancy. Four patients developed recurrence after a mean follow‐up of 31.2 months. A greater awareness of the rare entity of idiopathic granulomatous mastitis is mandatory to avoid unnecessary mastectomies. Clinical, radiologic, and even cytologic findings are sometimes confused with malignancy. To the best of our knowledge, our patient who developed the disease at the age of 11 years is the youngest reported case. 

Meckel's Diverticulum: Comparison of Incidental and Symptomatic Cases

Although Meckel’s diverticulum is the commonest congenital gastrointestinal anomaly, there is still debate concerning the proper management of asymptomatic diverticula. Records of all patients whose Meckel’s diverticulum was resected at our hospitals between 1990 and 2002 were reviewed. Clinical characteristics, mode of presentations, and management for all patients were analyzed. Meckel’s diverticula were resected in 68 patients. Patients were divided into two groups: the incidental group included 40 patients (24 males) in whom the diagnosis of diverticula was incidental. The symptomatic group included 28 patients (20 males) who presented with diverticulum-related complications. Preoperative diagnosis was possible in only four cases. In four patients from the symptomatic group, Meckel’s diverticula were found and left untouched during a previous laparotomy. There was no significant difference between the two groups with respect to gender (p = 0.48). Patients in the symptomatic group were significantly younger than patients in the incidental group (p = 0.002). The diverticula in the symptomatic group tended to be longer (p = 0.001) with a narrower base (p = 0.001) than the diverticula in the incidental group. A diameter of ≤ 2 cm was significantly associated with more complications (p = 0.01). Heterotopic tissue was present more significantly in the symptomatic group than the incidental group (p = 0.01). There was no significant difference in the morbidity rate between the two groups (p = 0.71), and there was no mortality in either group. Preoperative diagnosis of Meckel’s diverticulum is difficult and should be kept in mind in cases of acute abdomen. Resection of incidentally found diverticula is not associated with increased operative morbidity or mortality.

Risk of mortality and cancer incidence in Barrett's esophagus.

Background: There are very few prospective follow-up studies of Barrett esophagus (BE) cohorts assessing the risk of extraesophageal cancer incidence or mortality. Such studies are necessary in order to understand the overall risks of cancer and death experienced by patients with BE. Methods: A cohort of 502 patients with BE were identified at Leeds General Infirmary, England. Mortality and cancer incidence information were provided by the Office for National Statistics. Standardized mortality ratios (SMR) and standardized incidence ratios (SIR) were calculated using indirect standardization. Results: All-cause mortality was found to be elevated in patients with BE [SMR, 1.21; 95% confidence interval (95% CI), 1.06, 1.37] and remained so after esophageal cancers were excluded (SMR, 1.16; 95% CI, 1.01-1.32). Increased mortality risks were also found for malignant neoplasms of the esophagus (SMR, 7.26; 95% CI, 3.87-12.42) and diseases of the digestive system (SMR, 2.03; 95% CI, 1.11-3.40). The remaining disease categories produced no altered risk estimates. Circulatory disease mortality was borderline statistically significant (SMR, 1.24; 95% CI, 1.00-1.52; P = 0.053) for those with a specialized intestinal metaplasia diagnosis of BE. In the cancer incidence analyses, esophageal malignancies (SIR, 8.66; 95% CI, 4.73-14.53) and esophageal adenocarcinomas (SIR, 14.29; 95% CI, 7.13-22.56) were found to be increased in BE. All remaining analyses provided unaltered risks, including that of colorectal cancer. Conclusions: This study has shown evidence of an increased risk of esophageal cancer incidence and mortality in BE. It has also shown that those who have a histologic BE diagnosis may also have an increased risk of circulatory disease mortality. (Cancer Epidemiol Biomarkers Prev 2007;16(10):2090–6)

barrett's oesophagus : results from a 13-year surveillance programme

Objectives To review the results of a 13‐year surveillance programme of patients with Barretts oesophagus to determine the incidence of adenocarcinoma. Although the risk of cancer in Barretts oesophagus is well established, the magnitude of this risk is still controversial. Design Records of all patients with histologically confirmed Barretts oesophagus in our 13‐year surveillance programme were examined retrospectively. Setting Integrated gastroenterology and gastrointestinal surgical service in a large teaching hospital. Participants During the study period, 597 patients had a diagnosis of Barretts oesophagus; of these, 357 entered a yearly endoscopy and biopsy surveillance programme. Main outcome measures The development of oesophageal adenocarcinoma. Results After a mean follow‐up of 43 months, 12 patients, all with specialized epithelium, developed adenocarcinoma (11 men), an incidence for men of one cancer per 69 patient‐years; and for women, one cancer per 537 patient‐years follow‐up (P < 0.01). If only patients with specialized mucosa were included the incidence of cancer was one per 95 patient‐years of follow‐up (men, one per 61 patient‐years; women, one per 468 patient‐years). Conclusions Whilst the role of screening patients with Barretts oesophagus remains controversial, this study supports the routine surveillance of male patients with specialized epithelium. Eur J Gastroenterol Hepatol 12:649‐654

Helicobacter pylori genotypes identified in gastric biopsy specimens from Jordanian patients

BackgroundThe genetic diversity of Helicobacter pylori can be analyzed at two different levels: the genomic variation between strains originating from different individuals, and the variation in bacterial populations within an individual host. We reported for the first time the H. pylori genotypes in Jordanian patients with gastrointestinal diseases.MethodsUpper endoscopy was performed on 250 patients with symptoms of gastrointestinal diseases. Multiple gastric biopsy specimens were taken from the antrum. All the biopsies were tested by PCR for the H. pylori virulence genes vacA, cagA, and iceA, and 151 were tested by histology.ResultsThe biopsies positive for H. pylori by PCR were 110/250 (44%), and by histology 117/151 (77.5%), and these results were highly associated (P < 0.02). Analyses of virulence genes revealed that iceA2 (73.6%) was the predominant genotype, the vacAs2 allele was more frequently identified than the vacAs1 allele, while the cagA genotype was low (26.4%). The presence of certain genotypes might be associated with each other, but the presence of certain genotypes was not significantly associated with the age, or gender of the patient.ConclusionThe results illustrate the geographic nature of the genetic diversity of H. pylori, as the identified genotypes are similar to those reported in neighboring countries. This study provides a baseline data of H. pylori genotypes identified in gastric biopsy specimens from Jordan, serving as a powerful epidemiological tool for prospective investigations to better understand the genetic diversity of this pathogen.

Effect of Timing of Surgery, Type of Inflammation, and Sex on Outcome of Laparoscopic Cholecystectomy for Acute Cholecystitis

BACKGROUND AND PURPOSE Studies have shown the safety and effectiveness of laparoscopic cholecystectomy (LC) for acute cholecystitis (AC). Our aim was to establish the outcome of LC in patients with AC on the basis of duration of the attack before surgery took place, the type of gallbladder inflammation, and patient sex. PATIENTS AND METHODS All 204 patients at Princess Basma Teaching Hospital who underwent LC for AC by the authors between September 1994 and June 1999, were retrospectively reviewed. They were categorized into Group I, where surgery took place within 72 hours of the acute attack (N = 78; 54 women and 24 men), and Group II, if later than that (N = 126; 70 women and 56 men). Gallbladder pathology was classified as gangrenous, empyema, edematous, mucocele, or AC along with contracted fibrosed gallbladder. RESULTS Conversion to open cholecystectomy was needed in 12% of the total series. In Group I, 3.8% of the patients needed conversion compared with 16.7% in Group II patients (P = 0.01). Also, 4% of the female patients needed conversion compared with 24% of the male patients (P = 0.000). There was an association between the pathological type of AC and the likelihood of conversion (P = 0.002), conversion being least common in those with mucocele and most common in those with empyema and gangrene. The median operation time was 75 +/- 36 minutes, but the operation time for Group II patients was significantly longer (P = 0.001) than in Group I patients. Operation time in the male patients was significantly longer than in the female patients (P = 0.000). There was no statistically significant difference in the duration of hospital stay in the two groups or in men and women. There were no deaths or main bile duct injuries in the series. In successful LC, missed stones occurred in 3.3% of the patients. Bile collection, which was treated by open surgery, developed in one female patient. CONCLUSION Laparoscopic cholecystectomy is a reliable and safe modality for the management of AC. It was not associated with an increased incidence of bile duct injury in this series. It should be the first choice before resorting to open surgery. Factors associated with increased conversion include delay in surgery of more than 3 days from the acute attack and certain pathology, with conversion being more likely in empyema. Conversion also was more likely in male patients.

Combined Evaluation of Expressions of Cyclin E and p53 Proteins as Prognostic Factors for Patients with Gastric Cancer

Background: There is a lack of consistency regarding the prognostic value of cyclin E overexpression in gastric cancer (gastric cancer). Our aim was to report on this overexpression and to analyze its correlations with the clinicopathologic variables. Another aim was to examine if aberrant expression of both cyclin E and p53 might increase the malignant potential of gastric cancer. Methods: Specimens from 89 patients with gastric cancer treated with “curative” intent were evaluated for cyclin E and p53 expressions using immunohistochemical method. The correlations between cyclin E overexpression alone or in combination with p53 expression and the patients clinicopathologic variables were analyzed. Results: Cyclin E overexpression and p53 expression were shown in 35 (39.3%) and 46 (51.7%) tumors, respectively. The incidence of cyclin E overexpression was significantly higher in deeply invasive cancers (P < 0.0001), in cancers with lymph node metastasis (P = 0.003), and in cancers with advanced stages (P < 0.0001). There were no significant correlations with other clinicopathologic variables. Patients in whom their tumors showed cyclin E overexpression alone or in combination with p53 survived less than patients with negative cyclin E tumors. Multivariate analysis revealed that combined cyclin E overexpression and p53 expression was significantly associated with poor survival after adjusting for other variables (hazard ratio, 3.12; P = 0.009). Conclusions: Cyclin E overexpression is a common event in gastric cancer. Gastric cancer with cyclin E overexpression exhibit increased aggressiveness in the presence of aberrant p53. The combination of cyclin E overexpression with the p53 expression in gastric cancer further distinguished a subgroup of patients with poor prognosis.

Agenesis of the gallbladder : Difficulties in management

Abstract  Gallbladder agenesis is a rare congenital biliary anomaly that may be associated with other biliary and extrabiliary congenital anomalies. Awareness of this entity by clinicians and radiologists is essential because many of these patients present with biliary symptoms and have unnecessary operations. In the present article, the relative epidemiological, etiological (embryology and development), pathophysiological, diagnostic tools and pitfalls and management aspects of this rare anatomic anomaly are briefly discussed through review of the literature. Particular reference to the difficulty in preoperative diagnosis is highlighted. The importance of the possibility of preoperative diagnosis to avoid unnecessary surgery is stressed.

Validation of a Food Frequency Questionnaire to Assess Macronutrient and Micronutrient Intake among Jordanians

The aim of this study was to examine the validity and reliability of a food frequency questionnaire (FFQ) among a convenience sample of healthy adults in Jordan. A modified version of the questionnaire known as Diet History Questionnaire I, which measures dietary intakes over a 1-year period, was administrated to 101 apparently healthy men and women recruited from three large medical centers in Jordan. Fifty-five participants completed the modified FFQ and three 24-hour recalls. Participants (N=101) completed the FFQ two times separated by a 1-month period. Reliability of the FFQ was assessed using test-retest method. Mean age of participants was 33.4±18.5 years. Energy, carbohydrate, fiber, fat, saturated fat, calcium, and iron had deattenuated correlations of .732, .563, .544, .487, .484, .451, and .459, respectively. The FFQ and 24-hour recalls produced similar agreement percentages ranging between 25.5% and 43.6%. Mean energy-adjusted reliability coefficients ranged from .695 to .943. A Cronbachs α for the total FFQ items of .857 was found. The modified FFQ has reasonable relative validity and reliability for energy, carbohydrate, fiber, fat, saturated fat, calcium, and iron intakes in Jordanian adults over a 1-year period. However, its application may require additional modifications and validation efforts. Future research is warranted to further modify and test the FFQ in a larger and more diverse sample of Jordanians as well as to develop FFQ for the use among other age groups.