Medhat M. Farghaly

Surgical Treatment of Thoracic and Lumbar Tuberculosis by Anterior Interbody Fusion and Posterior Instrumentation

Objective: To evaluate the efficacy and clinical outcome of simultaneous or sequential anterior and posterior surgical approaches in the management of spinal tuberculosis in the form of anterior extirpation of the tuberculous lesion, strut bone grafting of the defect produced and posterior instrumentation for spinal fixation. Subjects and Methods: Twenty-two patients who had tuberculosis of the thoracic and lumbar spine with moderate to severe localized kyphosis and variable degrees of neurological deficits were treated at Al Razi Hospital (Kuwait) in the period from 1998 to 2000 by anterior debridement and autogenous strut bone grafting with simultaneous or staged posterior spinal fixation using either USS or SOCON spinal instrumentation. Appropriate antituberculosis treatment was given to all patients for 9–12 months. The postoperative follow-up period was 18 months. Results: Of the 22 cases the average of preoperative kyphosis was 42°. The average of immediate postoperative correction was 27°. At the last follow-up the average correction was 24° and the loss of correction did not exceed 3°. Average fusion times were 5 months for one-segment fusions and 8 months for two-segment fusions. There was no recurrence of the disease in any of the cases. Conclusion: Posterior instrumental stabilization and anterior interbody fusion were found to be effective in arresting the disease, correcting kyphotic deformity and maintaining correction until solid spinal fusion.

Infection after laparoscopic cholecystectomy: effect of infected bile and infected gallbladder wall.

OBJECTIVE To assess the incidence of infected bile and gallbladder wall infection at the time of laparoscopic cholecystectomy, and find out if they influenced the rate of postoperative infective complications. DESIGN Prospective study. SETTING District hospital, Kuwait. SUBJECTS All 279 patients who had their gallbladders removed laparoscopically for gallbladder disease between September 1995 and August 1998. INTERVENTIONS Samples of bile and gallbladder wall were taken from all patients and cultured separately for aerobic and anaerobic bacteria. Patients with complicated gallbladder disease (n = 80) were given preoperative therapeutic antibiotics for five days (cephalosporin plus metronidazole), and other high-risk patients (n = 138) were given prophylactic ceftriaxone either 1 g x 3 starting at induction of anaesthesia (n = 42), or a single dose at induction (n = 96). MAIN OUTCOME MEASURES Incidence of infected cultures, and infective morbidity. RESULTS 26 specimens of bile (9%) and 56 specimens of gallbladder wall (20%) were infected. Two patients in whom neither specimen had shown any growth developed minor infections at the umbilical port. No patient in whom either specimen was infected developed an infective complication. CONCLUSIONS The overall rate of infective complications was negligible, and did not correlate with the presence of bacteria in the bile or gallbladder wall. This is probably a reflection of our aggressive antibiotic regimen in the management of high-risk patients.

Acute Renal Failure, Compartment Syndrome, and Systemic Capillary Leak Syndrome Complicating Carbon Monoxide Poisoning

CASE REPORT Five Indian labourers sharing one room were found lying on the floor unconscious. A coal fire had been lit to provide heat during the cold night and was still burning inside the room. Two of the men were pronounced dead at the scene. The other three were transferred to the hospital in critical condition. This paper contains the case reports of the three patients who were transferred to the hospital. One of the patients died 60 h after admission. The other two patients were successfully treated and released. The three patients developed severe rhabdomyolysis complicated by compartment syndrome. The patient who died developed compartment syndrome in three extremities. Two patients required blood transfusion due to very severe hemolysis. The hemolysis in the third patient was less severe and did not require blood transfusion. Two patients developed anuric acute renal failure due to acute tubular necrosis as shown by renal biopsy. Two patients developed the full blown picture of systemic capillary leak syndrome. Gross and microscopic examination of specimens taken at autopsy showed extensive necrosis of all skeletal muscles, myocardial necrosis and acute tubular necrosis affecting both kidneys.

Management of liver trauma in Kuwait.

Objectives: The aim of this study was to introduce the concept of non-operative management (NOM) for blunt liver trauma by establishing a protocol and a prospective Liver Trauma Registry in Kuwait. Subjects and Methods: A prospective Liver Trauma Registry was started in 4 hospitals and it included 117 patients who had sustained blunt liver trauma (94 men and 23 women). Unstable patients were taken to surgery while stable patients were managed conservatively regardless of the grade of liver injury. High-grade (III-VI) liver injuries were managed in collaboration with the liver surgery specialist. Results: The mean age of the 117 patients was 29.02 ± 11.18 years (range 7-63). NOM was successful in 94 (96%) patients and failed in 4 (4%) (these 4 then underwent successful surgery). Nineteen (16.2%) were unstable and underwent surgery immediately; 15 (79%) of them survived (they had had grade III-V injuries) and 4 died (2 with grade V injuries and 2 with grade VI injuries). Perihepatic packing was necessary in 8/19 (42%) patients. The overall mortality was 3.4% (4/117). Conclusions: This study showed that NOM was successful in a majority of patients with blunt liver trauma. In addition, it confirmed that the magnitude of liver injury and haemoperitoneum did not preclude NOM as long as the patient was haemodynamically stable.

Carcinoma Originating from the Ectopic Mammary Gland of the Axilla

Carcinoma originating from ectopic breast tissue is a rare condition comprising only 0.3% of all breast cancers. The case presented here is the first of its kind to be reported in Kuwait. A review of the literature is provided, and a rationale for the treatment of this condition.

Abdominal Scar Endometrioma Mimicking Incisional Hernia: A Diagnostic Pitfall

Objective: Abdominal scar endometriosis is a recognized condition that has been described following a wide variety of gynaecological procedures. We report a case of endometrioma, presenting as a painful subumbilical swelling, mimicking an incarcerated incisional hernia. Clinical Presentation: A 35-year-old woman presented with a painful subumbilical swelling that had been present for 6 months, but had increased in size and become more painful the day prior to admission. Her past medical history included four caesarean sections. Physical examination revealed a firm, tender and irreducible subumbilical nodule with no cough impulses, mimicking a small incarcerated incisional hernia. Intervention: Exploratory laparotomy through the same lower midline incision revealed a subcutaneous swelling resembling an organized chocolate cyst of endometriosis. Apart from intra-abdominal adhesions, no connection to intra-abdominal structures was identified. Histopathology of the specimen was consistent with abdominal scar endometriosis. Conclusion: Endometrioma was diagnosed in this 35-year-old woman following histological examination of a specimen removed during laparotomy. It is recommended that endometrioma should be considered in the differential diagnosis of subcutaneous, scar-related hernias and various abdominal wall masses following gynaecological operations.

Thoracoscopic Upper Thoracic Sympathectomy for Upper Limb Hyperhidrosis

Objectives: To present a 30-month experience in thoracoscopic upper thoracic sympathectomy (TUTS) in Kuwait in 20 patients with upper limb hyperhidrosis (ULH). Methods: We performed 40 TUTSs in 20 patients with bilateral ULH. The T2–4 or T2–5 sympathetic ganglia were resected in 36 cases. Only the T2–3 ganglia were resected in 4 cases due to difficult localization of the 4th ganglion. Both sides were performed simultaneously. Chest tube drainage was performed at the end of each procedure. Results: The male:female ratio was 9:1, ranging in age from 13 to 43 years (mean age 26.95 years). Two patients had bilateral dense pleural adhesions, but the procedure was successful. Most patients were discharged on the 2nd postoperative day. Follow-up at 5–30 months (mean 16.3 months) was excellent both for immediate and permanent relief of ULH. Eleven of the 15 patients with pedal hyperhidrosis also had dry feet. Two patients developed transient Horner’s eye syndrome. One patient had persistent right pneumothorax that required chest tube drainage for 7 days. Four patients developed compensatory hyperhidrosis of the trunk and upper thighs. Fifteen patients (75%) expressed complete satisfaction. Five patients (25%) reported return of some moisture to their hands and axillae. Conclusion: TUTS is minimally invasive, feasible and effective. It has a low complication rate. We recommend this procedure as the method of choice for the management of ULH.

Ruptured Hepatoma: Report of 5 Cases in Arabs

Objective and Importance: Ruptured hepatic tumours are common among South East Asians. They are rare in whites and in Arabs. Arab cirrhotics who develop acute abdominal pain associated with hypovolaemia and evidence of intra-abdominal bleeding ought to be suspected of ruptured hepatocellular carcinoma. Clinical Presentation: Five cases of ruptured hepatocellular carcinoma in Arabs are reported. All patients had liver cirrhosis, and radical surgery was not possible due to the advanced stage of the tumour. Two patients who underwent common hepatic artery ligation survived for more than 9 months after the acute episode. The other 3 died in the hospital due to liver failure. Conclusion: Hepatic dearterialization was found effective in controlling bleeding from ruptured hepatoma. Other modalities of management such as hepatic artery embolization or intratumoural alcohol injection have been found effective in controlling bleeding.