Nader Naguib

Appendicitis in paediatric age group: Correlation between preoperative inflammatory markers and postoperative histological diagnosis

INTRODUCTION Clinical diagnosis of appendicitis can be challenging, particularly in the paediatric age group. There is an increased risk of perforation in paediatrics; therefore, a need for sensitive and specific diagnostic tool is mandatory. AIM The aim of this study is to evaluate the role of preoperative inflammatory markers in supporting the clinical diagnosis of appendicitis in the paediatric age group. MATERIALS AND METHODS Retrospective study of 268 emergency paediatric appendicectomies performed in a District General Hospital in Wales, over a period of seven years (2002-2009). The data collected from hospital database include preoperative inflammatory markers, C-reactive protein (CRP) and white blood cells count (WBCC) and post-operative histology. Statistical analysis was performed using Fishers exact test. RESULTS The median age group in the study was 12 (2-16). 141 (53%) patients were <12 years, while 127 (47%) patients were 12-16 years old. Male : female ratio = 1 : 1 (134 each). Inflammatory markers were not done for 94 patients (35%). CRP was done for 149 cases (55.6%), while WBCC was done for 172 cases (64%). Both markers were done together for 147 cases (54.8%). Histology was positive (inflamed / gangrenous appendix) in 202 cases (75.4%). Eight cases were associated with Enterobious vermicularis infestation and one patient had carcinoid tumour. The sensitivity and specificity of CRP were 82% and 60%, respectively, with positive predictive value (PPV) of 87% (P<0.0001), while those of WBCC were 80% and 59%, respectively, with PPV of 88% (P<0.0001). The sensitivity and specificity of both markers together were 80% and 70%, respectively, with PPV= 81% (P = 3.11E-8). 94 patients (35%) had an appendicectomy operation based on clinical diagnosis alone without preoperative inflammatory markers having been tested. In 28 cases (30%) out of these, postoperative histology revealed normal appendix (P = 0.18). CONCLUSION CRP and WBCC are simple tests that can provide a significant role supporting the clinical diagnosis of acute appendicitis in the paediatric age group.

Portal venous gas and pneumatosis intestinalis; radiologic signs with wide range of significance in surgery.

BACKGROUND Portal vein gas (PVG) was described as an uncommon ominous radiologic sign usually harboring an intra-abdominal catastrophe. When accompanied by pneumatosis intestinalis (PI), it is more predictive of bowel ischemia. Since the wide use of computed tomography (CT), both signs could also be viewed as incidental findings during routine radiologic investigations. METHODS We present a series of 12 cases that showed either or both signs, collected in a district general hospital between 1991 and 2011. RESULTS The diagnoses in these cases varied between fatal bowel ischemia and the mere presence of radiologic signs in the absence of significant pathology. CONCLUSION PVG and PI are radiologic signs that can represent a wide range of pathology.

A review of the incidence of iatrogenic hernia in both laparoscopic and open colorectal surgery: Using CT as the gold standard of detection, cohort study

PURPOSE The incidence of incisional hernia varies considerably in the literature. The aim of our study was to calculate the incidence of various types of the occult iatrogenic hernias following colorectal surgery, both laparoscopic and open, using CT scan. METHODS The study included all patients who underwent colorectal resection procedures in a colorectal surgery department over an 11 year period between 2001 and 2012 who went on to have a CT scan post surgery. The term iatrogenic hernia included all postoperative hernias at laparotomy incision site in the open colorectal subgroup, hernias at the site of specimen extraction or port site hernias in the laparoscopic colorectal subgroup, and parastomal hernias in both subgroups. RESULTS The total number of diagnosed iatrogenic hernias was 74 (61 detected on CT scan and 13 repaired on clinical grounds). Out of the 74 diagnosed iatrogenic hernias, 23 (31.1%) required surgical repair; 11 in the LCR (6 incisional, 2 parastomal and 2 port site hernias) and 12 in the OCR (9 incisional and 3 parastomal). CONCLUSION The incidence of iatrogenic hernias is underestimated. The use of CT will increase the number detected. There is no significant difference in the incidence of iatrogenic hernias between laparoscopic and open colorectal procedures.

Patient profile and outcome of pilomatrixoma in district general hospital in United Kingdom

Introduction: A pilomatrixoma is a benign appendage tumour related to hair cells matrix. Most of the literature review about pilomatrixoma is in the form of case reports with fewer cohort studies. The objective of this cohort is to study the variable demographic characteristics, presentation and histopathology of this condition among a larger group of patients. Materials and Methods: We conducted a retrospective study of patients who had excision of pilomatrixoma between February 1998 and August 2011 in a District General Hospital in UK. Results: The study included 67 patients with histopathologically diagnosed pilomatrixoma. The mean age was 32 years. Male to Female ratio was 35:32. The average diameter of the lesion at presentation was 13 mm (range: 2–30 mm). 66 of 67 (98.5%) patients presented with solitary lesion, while 1 patient (1.5%) had two lesions. Conclusion: Pilomatrixoma is not an uncommon benign lesion. It is more common in the maxillofacial area.

Short-Term Outcomes of Laparoscopic Colorectal Resection in Patients with Previous Abdominal Operations

BACKGROUND Laparoscopic colorectal procedures (LCPs) are technically demanding; previous abdominal surgery may add to their complexity. The aim of our study was to assess the effect of previous abdominal surgery (PAS) on laparoscopic colorectal surgery. SUBJECTS AND METHODS A prospective database was used to record LCPs between 2001 and 2011. Patients were divided into two groups: Group A consisted of patients with no PAS, and Group B of patients with PAS. Data collected included prior abdominal operations, type of LCP, operative time, and conversions. Operative mortality, morbidity, and ward stay in both groups were compared. Statistical analysis was performed using Fishers exact test and Students t test. RESULTS One hundred eighty-one patients underwent LCPs: 113 in Group A and 68 in Group B. Mean operative time in Group A and Group B was 216.5 (range, 60-520) minutes and 233.2 (range, 114-544) minutes, respectively (P = .17). In the first 90 cases, the mean operative time was significantly lower for Group A (203 minutes) than in Group B (236.5 minute) (P = .02). The rate of conversion was 10.6% (12/113) in Group A and 13.2% (9/68) in Group B (P = .6). Two patients in Group B had small bowel enterotomies (1 missed on the operating table) compared with none in Group A. Morbidities were comparable in both groups. Median hospital stay was 4.5 and 4 days in Groups A and B, respectively (P=.9). There were 3 deaths in Group A (2 due to medical causes and 1 surgical-related). One surgical-related death (missed enterotomy) occurred in Group B. CONCLUSIONS Short-term outcomes of laparoscopic colorectal surgery in patients with PAS are acceptable. There is no significant difference in conversion rate, hospital stay, morbidity, or mortality. The difference in the operative time is significant only in the early part of the learning curve. Meticulous adhesiolysis to avoid and recognize enterotomy is of paramount importance.

Port site closure after laparoscopic surgery.

We have reported a novel technique for the closure of the ports after laparoscopic surgery. Using this technique all the ports are closed under vision, thus preventing port herniation.

Transanal division of the anorectal junction followed by laparoscopic low anterior resection and coloanal pouch anastomosis: A technique facilitated by a balloon port

We performed a laparoscopic ultra low anterior resection in two patients with low rectal cancers (3 cm from dentate line). A transanal division and continuous suture closure of anorectal junction was performed first followed by laparoscopic low anterior resection. A handsewn anastomosis between colonic pouch/transverse coloplasty and anal canal was facilitated by use of a transanal balloon port.