Osama H. Al-Saif

Leiomyosarcoma of the infra-renal inferior vena cava

Leiomyosarcoma of the inferior vena cava (IVC) is a rare slow-growing retroperitoneal tumor. Two percent of leiomyosarcomas are vascular in origin, and tumors of the IVC account for the majority of the cases. The diagnosis is frequently delayed, because affected patients remain asymptomatic for a long period. It has an extremely poor prognosis, with 5-year actuarial malignancy-free survival rates of 30% to 50% after a wide surgical resection. The authors present the case of a patient with IVC leiomyosarcoma who underwent en bloc resection of the tumor along with the involved segment of the infrarenal IVC without caval reconstruction. Complete surgical resection offers the only potential of long-term survival, but survival of unresected patients is generally measured in months. Palliative resections may temporarily improve symptoms but do not offer long-term survival.

The safety of laparoscopic cholecystectomy in sickle cell disease: An update.

As surgery in sickle cell patients is associated with high morbidity, this study aims to establish the safety of minimally invasive surgery in this high-risk group. Over a four-year period, 71 sickle cell patients underwent laparoscopic cholecystectomy (LC) for cholelithiasis. Five patients had asymptomatic gallstones. Preoperative gastroscopy and endoscopic retrograde cholangiography were performed in 7 and 14 patients, respectively. Forty-two patients were given simple blood transfusions, while 13 received partial exchange transfusions. The mean operative time was 80 minutes and the conversion rate was 5.6%. There were 10 (14%) postoperative complications, the majority of which were respiratory and wound-related. One patient (1.4%) died as a result of postoperative vaso-occlusive crisis. The median hospital stay was 2.5 days. We believe that laparoscopic cholecystectomy is safe in patients with sickle cell hemoglobinopathy who are particularly at risk of developing pigmented gallstones. Therefore, the use of minimally invasive surgery is encouraged in any sickle cell patient undergoing operative intervention.

Bleeding duodenal ulcer after Roux-en-Y gastric bypass surgery: the value of laparoscopic gastroduodenoscopy.

Roux-en-Y gastric bypass is a common surgical procedure used to treat patients with morbid obesity. One of the rare, but potentially fatal complications of gastric bypass is upper gastrointestinal bleeding, which can pose diagnostic and therapeutic dilemmas. This report describes a 39-year-old male with morbid obesity who underwent a Roux-en-Y gastric bypass. Three months postoperatively, he sustained repeated and severe upper attacks of upper gastrointestinal bleeding. He received multiple blood transfusions, and had repeated upper and lower endoscopies with no diagnostic yield. Finally, he underwent laparoscopic endoscopy which revealed a bleeding duodenal ulcer. About 5 ml of saline with adrenaline was injected, followed by electrocoagulation to seal the overlying cleft and blood vessel. He was also treated with a course of a proton pump inhibitor and given treatment for H pylori eradication with no further attacks of bleeding. Taking in consideration the difficulties in accessing the bypassed stomach endoscopically, laparoscopic endoscopy is a feasible and valuable diagnostic and therapeutic procedure in patients who had gastric bypass.

Duodenal and ampullary obstruction by a Peutz-Jeghers polyp.

We report a case of Peutz-Jeghers syndrome presenting with obstruction of the second part of the duodenum and the ampulla of Vater by a large intra-luminal polyp leading to duodenal obstruction and obstructive jaundice. CT scan of the abdomen showed a large polypoidal lesion, a caecal polyp and jejuno-jejunal intussusception. At surgery, two intussusceptions were reduced and leading polyps were excised via two enterotomies; the caecal polyp was excised via caecotomy. The duodenal polyp was excised by limited duodenectomy after frozen section has shown no evidence of malignancy. Histopathological study of all the excised polyps including that of the duodenum showed hamartomatous polyps with no malignant changes. Apart from acute bleeding, this case highlights many of the surgical gastrointestinal complications of Peutz-Jeghers syndrome. It also highlights the unusual combined duodenal and common bile duct obstruction by a large Peutz-Jeghers polyp. The controversial association of this syndrome with cancer and management options is also discussed.

SCHISTOSOMAL APPENDICITIS IN THE EASTERN PROVINCE OF SAUDI ARABIA: A CLINICOPATHOLOGICAL STUDY

BACKGROUND In cases of schistosomiasis, the appendix is commonly infested. It is not known if this is a predisposing factor for appendicitis, or a mere coincidental histological finding. PATIENTS AND METHODS A total of 56 patients (51 males and 5 females) underwent appendectomy for schistosomal appendicitis over a 10-year period at Dammam Central Hospital. The histological slides of 41 of the patients (73.2%) were retrospectively studied. RESULTS The highest incidence of schistosomal appendicitis was recorded in the 21-40-year age group. Ova were seen in the submucosal layers of all the excised appendices. The most common tissue responses were submucosal fibrosis (92.7%) and eosinophilia (87.8%), followed by the presence of suppurative inflammation (80.5%). Granulomatous reaction was evident in only 13 cases (31.7%). A striking feature was atrophy of submucosal lymphoid follicles in 70.7% of the cases. Hyperplasia of lymphoid follicles and serosal granulomas were rare (2.4%). Similar tissue responses were histologically seen in four normal appendices examined. CONCLUSION Appendiceal infestation may predispose to appendicitis in the majority of affected cases, but in others, it may well be a mere coincidental histological finding. However, preoperative knowledge bears no clinical significance and does not alter management.

Iatrogenic oesophageal transection during laparoscopic sleeve gastrectomy

Laparoscopic sleeve gastrectomy has been hailed as an easy and safe procedure when compared with other bariatric operations. However, it may be associated with well-recognised early complications such as leaks and bleeding, as well as late ones such as stenosis and weight regain. Iatrogenic complete oesophageal transection has never been reported before as a complication. We report a case of complete oesophageal transection during laparoscopic sleeve gastrectomy that was not recognised intraoperatively. The repair of this iatrogenic injury was staged, with the final stage carried out some 3 months after the initial procedure. This case report highlights the possible occurrence of complete oesophageal transection during laparoscopic sleeve gastrectomy, and suggests steps to avoid and correct such complications.

Port site metastases after a laparoscopic abdominoperineal resection of rectal cancer: Report of a case

This report describes a case of port site metastases that presented 6 months after a laparoscopic abdominoperineal resection of rectal cancer in a 75-year-old man. A surgical excision was performed to improve stoma function despite disease progression with adjuvant concurrent chemoradiation. Although port site metastases are now reported less frequently, this unfortunate consequence of laparoscopic colorectal surgery for cancer can still occur, and laparoscopic colorectal surgeons should exercise all precautions to prevent its occurrence. This report includes a review of literature on port site metastases.

Pancreaticoduodenectomy in a tertiary referral center in Saudi Arabia: A retrospective case series

CONTEXT Perioperative outcome of pancreaticoduodenectomy is related to work load volume and to whether the procedure is carried out in a tertiary specialized hepato-pancreatico-biliary (HPB) unit. OBJECTIVE To evaluate the perioperative outcome associated with pancreaticoduodenectomy in a newly established HPB unit. PATIENTS Analysis of 32 patients who underwent pancreaticoduodenectomy (PD) for benign and malignant indications. DESIGN Retrospective collection of data on preoperative, intraoperative and postoperative care of all patients undergoing PD. RESULTS Thirty-two patients (16 male and 16 female) with a mean age of 59.5±12.7years were analyzed. The overall morbidity rate was high at 53%. The most common complication was wound infection (n=11; 34.4%). Pancreatic and biliary leaks were seen in 5 (15.6%) and 2 (6.2%) cases, respectively, while delayed gastric emptying was recorded in 7 (21.9%). The female sex was not associated with increased morbidity. Presence of co-morbid illness, pylorus-preserving PD, intra-operative blood loss ⩾1L, and perioperative blood transfusion were not associated with significantly increased morbidity. The overall hospital mortality was 3.1% and the cumulative overall (OS) and disease free survival (DFS) at 1year were 80% and 82.3%, respectively. The cumulative overall survival for pancreatic cancer vs ampullary tumor at 1year were 52% vs 80%, respectively. CONCLUSION PD is associated with a low risk of operative death when performed by specialized HPB surgeons even in a tertiary referral hospital. However, the postoperative morbidity rate remains high, mostly due to wound infection. Further improvement by reducing postoperative infection may help curtail the high postoperative morbidity.