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   Table of Contents - Current issue
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October-December 2019
Volume 7 | Issue 4
Page Nos. 133-171

Online since Thursday, December 12, 2019

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ORIGINAL ARTICLES  

Prevalence of abdominal aorta aneurysm and associated risk factors in Abha city, Saudi Arabia p. 133
Abdullah Alhaizaey, Ahmed Azazy, Mohammed Asiry, Mohammed Alsayed, Mustafa Abbass, Abdulrhman Hassan, Ahmed Gamil, Musaed Alghamdi
DOI:10.4103/ssj.ssj_19_19  
Objective: The objective was to assess the prevalence and risk factors of abdominal aorta aneurysms (AAAs) in the general population. Materials and Methods: We carried out a prospective, interventional study with patients aged over 60 years screened in the Asir Central Hospital Vascular Department from March 2017 to March 2018. Ultrasound was used to AAA screening. The maximal anteroposterior (AP) and transverse (LL) diameters of the suprarenal and infrarenal aorta were measured in each patient. AAA was defined as aortic dilatation >29 mm in the AP or LL plane. All cases with an aortic diameter >25 mm were included in the study. Results: Our study included 701 patients (531 male, 170 female; age 60–102 years). Most were Saudi nationals (87.6%). There were some smokers (1.3%), 277 (39.5%) had diabetes mellitus, and 233 (31.8%) had hypertension. Fifty-one percent of patient had ischemic heart disease (7.3%), and 13.4% had hypercholesterolemia. Patients were classified into three groups: normal aortic size of 657 patients (93.7%); aortic ectasia 26–29 mm of 24 patients (3.4%); and AAA ≥30 mm of 20 patients (2.9%). The overall prevalence of AAA was ≥30 mm (2.9%) and there is significant relation with hypertension (P < 0.05). Conclusion: Asymptomatic AAA is prevalent in our area. We may need to implement a regular screening program for men aged >60 years, especially high-risk patients to reduce AAA rupture, emergency AAA repair, and mortality.
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Experiences of choledochal cyst in pediatric and adult population: A case series p. 138
AK Roy, Sanjay Kumar Bhat, Rahul Bhushan, Nisar Ahmed Ansari, PK Mishra, Maham Ahmad, Nikhil Mehrotra, CS Rawat
DOI:10.4103/ssj.ssj_46_18  
Introduction: Choledochal cysts are a relatively uncommon disease of the bile duct which is the cystic dilatation of the intra- or extrahepatic bile ducts. Literature is scarce on its clinicopathological behavior among children and adults and its comparison. Methods: The retrospective study was aimed to study the clinical characteristics, management, and complications between pediatric and adult patients with choledochal cysts. Results: There was higher female preponderance with male to female ratio of 3:17 in pediatric age group while 1:4 in adult age. Abdominal pain was more common among adults, while palpable mass was more common among pediatrics population (P < 0.05). Jaundice was more evident in the pediatric age group, yet the classic triad of choledochal cyst (abdominal pain, jaundice, and a palpable mass) was not observed in any age group. About 76% of the cysts were type 1 cysts, which was more common among pediatric age group (40% vs. 90% P < 0.05) while with adults presented more with a type IVA cyst (60% vs. 10% P > 0.05). No patients with type II, type III, type IVB cysts, or type V were found. Sixteen patients underwent Lilly technique, with resection of the choledochal mucosa and Roux-en-Y hepaticojejunostomy, while nine patients underwent resection of the choledochal cyst and Roux-en-Y hepaticojejunostomy. Patients who received total excision had fewer surgical complications in both groups. Conclusion: Although there is a significant difference in the clinical characteristics of choledochal cysts between children and adults, yet early detection and necessary surgery is essential for patients with choledochal cysts.
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Diagnostic accuracy of triple test in breast pathologies of women above 20 years of age p. 143
Anurag Jain, Rajiv Jain
DOI:10.4103/ssj.ssj_15_19  
Background: This study is to establish the diagnostic accuracy of triple test in assessing breast pathologies in women above 20 years of age taking their histopathological report as standard. Patients and Methods: In our analytical study, we included women presenting with a complaint of breast lump or change in breast texture in an age group of above 20 years. Systematic clinical examination was done followed by mammography and finally fine-needle aspiration cytology (FNAC) for tissue sampling. Lesions were considered triple test positive, if lesions were FNAC positive and any one of the remaining two modalities also gave a positive (malignant) interpretation, supporting FNAC, but each of three components must be negative for labeling triple test as negative. Postoperatively, cumulative results were compared with histopathology reports and statistical parameters such as specificity, sensitivity, positive predictive value, negative predictive value, and accuracy of triple test were calculated. Results: We have obtained 100% sensitivity using triple test in all age groups when each element was interpreted as malignant and 100% specificity (P < 0.001) when each element was interpreted as benign with diagnostic accuracy of almost 100% in concordant cases. It was recommended that in cases, where all three modalities are not in agreement for benign pathology and in FNAC positive cases where other two parameters are not in agreement, and lesion is interpreted as suspicious on triple test, the nature of the lesion must be ascertained by excision biopsy. Conclusion: Triple test of breast pathologies is a reliable method and allows detection of breast pathologies in an effective manner, and undue delay in treatment can be minimized by using this modality in limited resource country.
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Lichtenstein repair using lightweight mesh versus laparoscopic total extraperitoneal repair using polypropylene mesh in patients with inguinal hernia: A randomized study p. 148
Sanjay Gupta, Shivani Goyal, Rajeev Sharma, Ashok Kumar Attri
DOI:10.4103/ssj.ssj_27_19  
Background: With the introduction of mesh for repair of inguinal hernia, the focus of surgeons has shifted to postoperative pain and quality of life (QOL). As compared to open procedures, laparoscopic procedures have been found to be associated with less pain and faster recovery. The present study was designed to assess whether this holds true when open Lichtenstein repair is done using lightweight mesh (LWM) because, in previous studies where laparoscopic inguinal hernia repair is compared to open Lichtenstein repair, heavyweight mesh (HWM) was used for both techniques. HWM was used for total extraperitoneal (TEP) in the current study because of higher recurrence associated with LWM. Materials and Methods: This prospective randomized study was done on 60 patients divided into two groups: the Lichtenstein group and the TEP group. Patients were followed at 1 week, 1 month, and 6 months for any postoperative complication. QOL was assessed using hernia-specific Carolinas Comfort Scale. Results: No statistically significant difference was observed between the two groups with regard to various postoperative complications. Only one recurrence was detected at 1 month in TEP group. The mean groin pain was significantly less in TEP group at 24 h, 1 week, and 1 month (P < 0.05). The sensation of mesh was significantly less in Lichtenstein group at 24 h and 1 week (P ≤ 0.001) but comparable to TEP at 1 month and 6 months. The difference in movement limitation was not significant at any time between the two groups. Conclusion: Except for less pain in the early postoperative period TEP does not offer any advantage and Lichtenstein repair using LWM can still be considered as the best option for inguinal hernia repair, especially in countries where resources are limited.
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Right congenital diaphragmatic hernia: Four cases and literature review p. 154
Charu Tiwari, Hemanshi Shah, Vikrant Kumbhar, Deepa Makhija, Jyoti Bothra, Gursev Sandlas
DOI:10.4103/ssj.ssj_42_17  
Background: Left-sided Bochdalek congenital diaphragmatic hernia (CDH) is the most common type of CDH. The right-sided Bochdalek CDH is rare and usually contains only the liver as its content. We describe four children with right CDH managed at our institution over 3 years. Materials and Methods: We present a retrospective analysis of four patients with right CDH managed at our institution from 2012 to 2015 with respect to age at presentation, sex, presenting symptoms, investigations, associated anomalies, management, and outcome. Results: The average age at presentation was 1.5 years, with range being 5 days to 4 years. The three older children presented with a history of frequent respiratory tract infections. The neonate was a preterm low-birth weight baby and had respiratory distress since birth. A chest radiograph suggested right pneumothorax for which intercostal chest drain insertion was done. A repeat chest X-ray showed suspicion of right-sided CDH which was confirmed on computerized tomography. All four patients underwent right thoracotomy with repair of the CDH. The neonate expired on the 4th postoperative day. The other three children had an uneventful postoperative recovery. Conclusion: Right-sided CDH is rare and has varied presentations and poorer outcome.
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A comparison of developing breast cancer-related lymphedema between mastectomy with reconstruction and mastectomy alone among breast cancer patients in Saudi Arabia p. 158
Malik M Almailabi, Mamoon H Daghistani, Muhammad A Khan
DOI:10.4103/ssj.ssj_8_19  
Context: The study was undertaken to compare developing breast cancer-related lymphedema between those who underwent mastectomy with reconstruction and mastectomy alone. Aims: One of the most feared consequences after a mastectomy is breast cancer-related lymphedema (BCRL). However, few papers have questioned whether breast reconstruction impacts the development of lymphedema. This study aims to determine if breast reconstruction has an effect on the incidence of BCRL. Furthermore, the effect of the time (immediate vs. delayed) and type (implant based vs. autologous) of breast reconstruction on the development of BCRL will be evaluated. Settings and Design: We conducted a retrospective cohort study on 320 patients who underwent mastectomy with reconstruction and mastectomy alone between January 1, 2007, and December 31, 2017, at King Abdulaziz Medical City – Jeddah. Subjects and Methods: We conducted a retrospective cohort study on 320 patients who underwent mastectomy with or without breast reconstruction between January 2007 and December 2017. We reviewed patient medical records progressively to extract patients' characteristics, operative details, and lymphedema information. We divided our sample into two main groups: patients who underwent mastectomy with reconstruction and mastectomy alone. Mastectomy with reconstruction group was subdivided into immediate or delayed reconstruction and autologous or implant-based reconstruction. Statistical Analysis Used: Statistical analysis was performed using the Statistical Package for the Social Sciences version 20. Results: Of the total sample size 320, only 78 (24.4% (underwent mastectomy with breast reconstruction (Group 1), while the rest 242 (75.6%) underwent mastectomy alone (Group 2). From both the groups, 24 (7.5%) patients developed lymphedema; there was no significant difference between the breast reconstruction and development of lymphedema (P = 0.67). We subdivided Group 1 (patients who underwent mastectomy with breast reconstruction) into immediate breast reconstruction (40 patients, [51%]) and delayed breast reconstruction (38 patients, [49%]). In comparison between immediate versus delayed breast reconstruction, there was no significant difference between immediate and delayed breast reconstruction (P = 0.67). In terms of the type of reconstruction, we further subdivided Group 1 (patients who underwent mastectomy with breast reconstruction) into implant-based breast reconstruction (42 patients, [54%]), and autologous breast reconstruction (36 patients, [46%]). In comparison between implant-based versus autologous breast reconstruction, there was no significant difference between implant-based and autologous breast reconstruction (P = 0.66). Conclusions: Although our result is insignificant, it suggests that patients who underwent mastectomy with reconstruction have a lower incidence of BCRL in comparison with those who underwent mastectomy alone. Moreover, our result suggests that immediate breast reconstruction and implant-based breast reconstruction have a lower incidence than delayed and autologous breast reconstruction. Further studies are needed to determine if the breast reconstruction has an effect on the development of lymphedema.
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CASE REPORTS Top

Multiple wandering jejunal intussusceptions in an adult patient with celiac disease: Atypical presentation p. 163
Abdullah Mohammed Albishi, Yahia Atiah Alhagawi, Nasser Ibraheem Alqahtani, Rafaat Chakik, Mohamed F Bazeed, M Ezzedien Rabie, Mohammed Tagelsir Elmaki, Bushra Mofreh Asiri, Mubarak Mohammed Alshahrani
DOI:10.4103/ssj.ssj_18_19  
Intussusception is a rare presentation of celiac disease. In this report, we describe the condition of a 28-year-old Saudi male known case of brucellosis diagnosed and treated 10 months ago. The patient presented to the hospital complaining of diffuse intermittent dull abdominal pain with mild abdominal distention for 1-month duration, which starts gradually with progressive course. Patient also was given history of generalized fatigability for the same duration. These symptoms were associated with a weight loss about 10 kg in the last 6 months. Abdominal examination revealed soft and lax abdomen with mild tenderness at epigastria area. Computed tomography (CT) abdomen showed jejunal loop intussusceptions with diffuse jejunal wall thickening. Gastroscopy was done and showed fissuring of duodenal folds. Biopsy report came later as duodenal villa atrophy with increased intraepithelial lymphocytosis. The patient diagnosed as celiac disease. After establishing the diagnosis, dietary advice was given and he was discharged for outpatient department follow-up. Currently, the patient remains well and repeat CT scan showed persistence of multiple intussusceptions, though at different sites of the jejunum.
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Bronchoesophageal fistula, a rare complication post laparoscopic sleeve gastrectomy: A case report and literature review p. 167
Ashraf A Maghrabi, Saleh Aldagal, Abdullah Sultan, Nisar Haider Zaidi, Murad M Aljiffry, Moaz Abulfaraj, Wisam Jamal
DOI:10.4103/ssj.ssj_41_19  
Acquired bronchoesophageal fistula (BEF) and tracheoesophageal fistula are rare disorders that result from medical disease or secondary to a complication of a procedure, most commonly due to the prolonged high-pressure endotracheal or tracheostomy cuffs in the presence of nasogastric tube in the esophagus. Rarely, esophageal injuries can result in BEF; presentation is usually after 1 week of the procedure, and the treatment is esophageal stenting or clips in the early phase, and failure will need definitive surgical management. Here, we present our case of a complex BEF post laparoscopic sleeve gastrectomy that required endoscopic and surgical management. This is a case report and literature review.
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