Dr. Amer Hashim Hassan Al Ani is a senior medical educator, laparoscopic surgeon, editor, peer reviewer and academic professional. He is a Fellow of the Royal College of Surgeon Glasgow, The Arab Council of health specialization in General Surgery, The Iraqi Council for medical specialization in Digestive Surgery and The Jordanian Council in General Surgery. Dr. Amer has a good experience in minimally invasive surgery with special interest in hernia surgery, he is well experienced in GIT & Trauma surgery too. His surgical and academic experience spans over several countries including Iraq, Jordan, Bahrain and United Arab Emirates. Dr. Amer served the Royal college of Surgeons England training center acting as faculty for intercollegiate Basic Surgical Skills courses. He has tutored several workshops and has authored more than 29 articles, with eminent physicians from Iraq, Bahrain, Jordan and United Arab Emirates. He participated actively as speaker in 42 National and International conferences. In 2012 He was granted an award from the International Emergency Management Society (TIEMS) Annual Conference for the Best Research Paper. In 2018 he was grunted a certificate of outstanding contribution in reviewing from international journal of surgery case report. Due to his active editor’s roles in several biomedical journals, and his active peer reviewer role in International surgery journals Dr. Amer has an intense professional networking with scholars and scientists across the Arab world.
Abstract Introduction: Hydrocephalus is caused by the inability of Cerebrospinal Fluid (CSF) to drain into the bloodstream. Ventriculoperitoneal shunt (VP shunt) is used frequently in the treatment of Hydrocephalus. VP shunt complications are common. Case presentation: A 4-year-old girl had VP shunt at the age of one year. Her mother noticed a tube protruded through her anus and brought her to the emergency department. Laparotomy revealed the VP shunt tube inside the peritoneal cavity. Its distal end penetrated the recto- sigmoid junction and passed into the anus. The penetrating part of the shunt was cut and removed. The perforated bowel was repaired. Discussion: VP shunt is a commonly performed procedure. It is associated with a high rate of complication. The incidence of bowel perforation with protrusion of VP shunt per anus is a rare complication. This complication is serious. Conclusion: Migration of VP shunt tube through the anus is rare. It may happen without symptoms. It can be prevented by proper technique and length of tube. The proper treatment is removal of the migrated part and closure of the perforated bowel by laparotomy or laparoscopy. Keywords: Ventriculoperitoneal shunt; Complications; Bowel perforation; Case report
INTRODUCTION: Abdominal cocoon (sclerosing encapsulating peritonitis) (SEP) is a rare condition, mostly affecting adolescent girls living in tropical/subtropical region. Its etiology is unknown. It may cause a cute or sub-acute intestinal obstruction. PRESENTATION OF CASE: We report here a 39 year old male who complained of long standing colicky abdominal pain, with significant weight loss. Abdomen CT scan showed clumping of ileal loops at the level of umbilicus, with a thin capsule surrounding it. Laparoscopy revealed abdominal cocoon, biopsy of which showed dense hypocellular fibro-collagenous tissue with no neoplastic or granulomatous process. Excision of fibrous tissue and release of adhesions was done. Patient was symptoms free after five months follow up. DISCUSSION: Abdominal exploration is usually needed for the diagnosis and treatment of abdominal cocoon. A thick fibrotic peritoneal wrapping of the bowel is usually found. Complete recovery is the result in majority of cases after surgical removal of the wrap causing the cocoon. CONCLUSION: Primary sclerosing encapsulating peritonitis (cocoon abdomen) diagnosis needs a high index of suspicion, as signs and symptoms are nonspecific and imaging findings are not always conclusive. Careful excision of the accessory peritoneal sac and lysis of adhesions between bowels is the best treatment. Prognosis is generally good.
Introduction: Many studies suggest that women who breast-fed, had a decreased risk of developing breast cancer (ranging from 10%-64%) compared to women who never breast-fed. Some studies revealed that breastfeeding had no influence on the risk of developing breast cancer. Breastfeeding may be more protective against the development of premenopausal compared to postmenopausal breast cancer. Although there are a few studies that report a decrease in the risk of breast cancer after only three or more months of breastfeeding, the evidence for risk reduction becomes more consistent with the longer women breastfeed. Breast cancer in previously lactating women is rarely dealt with in the medical literature. Patients and Methods: From January 2009 to May 2012, fifty previously lactating women with breast cancer were studied in Al Bashir Teaching Hospital, Amman, Jordan. Their age ranged from 27-70 yrs, the number of their children were ranging from 3-8 with a history of breastfeeding for 3 months to 3 yrs. The clinical presentation, and ultrasound characteristics, mammogram findings and histopathological criteria were examined. Result: Breast cancer in lactating women was present in right breast in 23 patients (46%), in the left breast in 27 patients (54%). It was present in the upper outer quadrant in 27 patients (54%), upper inner quadrant in 8 patients (16%), lower outer quadrant in 10 patients (20%), and in the lower inner quadrant in 2 patients (4%). Presenting symptoms were: mass in 25 patients (50%), nipple retraction in 10 patients (20%), ulcers in 5 patients (10%), nipple discharge, or skin tethering in 4 patients each (8%), and pain in 2 patients (4%). By ultrasound 21 lesions (42%) were hypo-echoic, 19 lesions (38%) were of mixed echogenicity, 5 lesions (10%) were isoechoic and 5 lesions (10%) were hyper-echoic. By mammogram 15 lesions (30%) were radio opaque, 12 lesions (24%) were of low opacity, and 2 lesions (4%) were radiolucent. In 4 lesions (8%) micro calcifications were present, in 3 lesions (6%) macro calcifications were present, the mass was speculated in 9 lesions (18%) and skin thickening was present in 5 patients (10%) of the lesions. Forty seven lesions (94%) were a ductal carcinoma, 2 lesions (4%) were a lobular carcinoma, and only 1 case (2%) was a malignant phylloid tumor. Thirty one lesions (62%) were poorly differentiated, 19 lesions (38%) were moderately differentiated, and no well differentiated lesions were detected. Conclusion: Breast cancer in lactating women is mostly ductal carcinoma that is present as a mass in upper outer quadrant of the left breast, which is hypo-echoic by ultrasound, radio opaque by mammogram and of poor differentiation. These findings need to be reviewed with a larger number of patients.
Cystic lymphangioma of the gallbladder is a benign albeit rare tumor. Although it develops in childhood it is generally diagnosed in adulthood, with complete excision being the most appropriate treatment, and offering the best prognosis. Laparoscopic cholecystectomy can be a management option even in the presence of gallbladder stones. We report here a 34-year-old woman with a history of morbid obesity for which she underwent gastric bypass surgery several years ago. She presented with a history of right hypochondrial pain over a period of 3 months, and an abdominal ultrasound identified a partially septated gallbladder with multiple calculi. The patient underwent uncomplicated laparoscopic cholecystectomy which revealed a 5cm x 3cm subserosal cystic swelling. The histological findings were consistent with cystic lymphangioma of the gallbladder with chronic cholecystitis.
Abstract Background: The use of radiological investigation is an accepted part of medical practice. However, there is no known safe radiation dose. Man-made radiation accounts for 13% of total radiation burden, 90% of it is due to diagnostic medical exposure. The most significant studies of the effects of radiation came from the lifetime study of the approximately 90,000 survivors of the atomic bombs dropped over Hiroshima and Nagasaki in 1945. These studies considered survivors who received whole-body doses from photons and neutrons in excess of 2.5 mSv as population liable for excess cancers. These survivors include those who were 900 to 1,500 meters away from the "hypocenter," just below the exploding bomb. Objectives: The aim of this study is to make a comparison between the whole-body doses of radiation received by the survivors of Hiroshima and Nagasaki and the dose received by patients from diagnostic radiological examinations in the first day of admission to the ER department. Materials and methods: In the period 19th October 2008 to 25th November 2008, 273 blunt trauma patients with a revised trauma score of
a b s t r a c t INTRODUCTION: Inguinal bladder hernias are rare incidents accounting for 1–3% of all inguinal hernia. Most of those cases are discovered intraoperatively accounting for the high incidence of bladder injuries during the repair. Symptoms can be variable depending on the size of the herniated bladder. PRESENTATION OF CASE: We present here a 70 years old obese male patient, with history of CVA & on regular Aspirin ingestion. He presented to the ER as a case of intestinal obstruction due to suspicion of strangulated inguinal hernia based on an unclear Ultrasound picture. He underwent an emergency exploration of the hernia where the balloon of a Foley’s catheter was found inside a diverticulum of the urinary bladder, herniated through an Ogilvie hernia. DISCUSSION: Ogilvie hernia is a rare incident that happens mostly in elderly males. The herniated part contains pre-vesical fat, bladder and or loops of intestines. Diagnosis must be made preoperatively through CT scan or Cysto-urethrogram. First line management involves surgical reduction of the bladder and hernia repair. Resection of the herniated part is generally limited to necrotic tissues. CONCLUSION: Surgeons must have high index of suspicion for elderly obese males with inguinal hernias and urinary or intestinal obstruction symptoms. Careful preoperative planning must be made to avoid repair associated bladder injuries.
Abstract BACKGROUND: Retained surgical items (RSI) are rare medical challenges with serious complications and medicolegal implications. Knowledge and preventive measures for these rare events are currently not sufficient to limit their increasing incidence. Gauzes and sponges constitute most of RSI. Forceps, needles and pins may be found too. Diagnosis of these events is challenging and often missed due to nonspecific clinical findings. PRESENTATION OF CASE: We present here a 49-year-old patient who presented to the clinic with a history of chronic scrotal sinus on the same side of a repeatedly repaired inguinal hernia 4 months before admission. He underwent exploration of the inguinal canal as elective surgery. Exploration of the inguinal canal revealed missed surgical gauze left during the previous hernia repair. The gauze was removed, and the inguinal canal was repaired. The postoperative period was uncomplicated. CONCLUSION: Retained surgical items are completely preventable near-events. Although they are rare entities, clinicians must have a high index of suspicion for any postoperative, in patients presenting with pain, sinus or palpable masses. Keywords: Retained surgical items, Inguinal canal, Foreign bodies, Case report, Retained Gauze, Surgical complications
Foreign body ingestion is a common presentation in clinical practice. Although most ingested foreign bodies pass uneventfully across the gastrointestinal tract, sharp elongated objects pose a greater risk of intestinal perforation. We report here a case of jejunal perforation following the ingestion of fishbone. A 78‑year‑old female presented with acute onset of generalised abdominal pain for few hours. Examination revealed tenderness, guarding and rigidity all over the abdomen. Erect Abdominal X‑ray findings were inconclusive. However, contrast‑enhanced computed tomography (CT) showed a thin, linear hyperdense foreign body perforating through the jejunum. Exploratory laparotomy was done, and a fishbone piercing the small bowel 50 cm distal to the ligament of Treitz was retrieved. The perforation hole was closed with primary suture. Postoperatively, the patient recovered well. Small bowel perforation is a life‑threatening emergency that necessities urgent surgical intervention. Fishbones are commonly associated with perforations and the most common site of perforation is the terminal ileum. The most important risk factor associated with intestinal perforation by fishbones is the use of dentures which impair protective sensory mechanisms. Clinical presentation can be non‑specific, and contrast‑enhanced CT is required to establish diagnosis. Intestinal perforation associated with foreign body ingestion should be considered when evaluating patients with acute abdomen. Keywords: Acute abdomen, fishbone, foreign body, ingestion, intestinal, perforation
Abstract Introduction: Sister Mary Joseph sign, refers to an umbilical nodule in individuals who invariably had a poor outcome and succumbed relatively early, due to metastasis of a malignant cancer in the pelvis, or abdomen. Presentation of case: We report here a 39 year old male presented with abdominal distension, night sweating, anorexia, and weight Loss. On examination a hard nodule in the umbilical region (Sister Mary Joseph sign) was discovered. CTscan showed omentum cake; ascites and umbilical nodule .colonoscopy showed upper rectal tumor .diagnostic laparoscopy and biopsy confirm metastatic adenocarcinoma disseminated intraperitonealy. Despite the chemotherapy, he died after two months. Discussion: Sister Joseph sign is usually represents an advanced disease, and carries a very poor prognosis. Because the nodule is so easy to biopsy and because most associated cancers are inoperable at the time of diagnosis, the ability to identify this lesion may save a patient an unnecessary diagnostic surgery. Conclusion: Clinical examination, (in the presence of high technology investigation), is still of high value in the diagnosis.
Introduction: Liver herniation through surgical incision is very rare. Moreover, it is exceptional for the left hepatic lobe to herniate through sternotomy incision. Presentation of the case: We present herein a 66-year-old woman admitted to ER complains about upper abdominal pain. Abdominal CT scan showed herniation of part of left hepatic lobe through previous sternotomy incision. Conservative measures were successful in managing her symptoms. Discussion: Till now only few cases of liver herniation through scar of sternotomy have been documented. Conclusion: Although it is rare, left hepatic lobe may herniate through sternotomy incision.
Abstract Introduction: Spontaneous Pneumomediastinum (SPM) is a benign condition defined as the presence of air in the mediastinum. Most cases are discovered incidentally. Symptoms may include chest pain, throat pain, dysphonia, dysphagia and dyspnea. Clinical course is generally uneventful, and most patients are managed conservatively. Presentation of Cases: We present 2 cases of young, fit male patients. The first patient presented with throat pain for 2 days. Clinical examination was insignificant. Radiographic investigations demonstrated evidence of pneumomediastinum with subcutaneous emphysema. The second patient was brought with 1-h history of agitation. On examination chest wall emphysema was demonstrated. Computed Tomography (CT) scan demonstrated pneumomediastinum, pneumoperitoneum and pneumoretroperitoneum. Both patients were treated conservatively and discharged well within days. Conclusion: Cases of SPM are not uncommon. CT scan and endoscopy are the cornerstone of diagnosis. Management is primarily conservative. More studies are required to accurately pin down the true incidence rate of SPM and the ideal management plan.
Introduction Testicular cancer is the most common malignancy in Males aged 15–35 years. Its incidence comprises 0.8% of all Male cancers worldwide, with a mortality rate of 0.1%. Rarely it metastasizes to the retroperitoneum and invades upper gastrointestinal tract (GIT). Complications like intestinal obstruction, hemorrhage, and perforation are usually present. Presentation of case We report a 30 year-old male, presented to GIT unit with severe anemia due to upper GIT bleeding. Esophagogastroduodenoscopy (OGD) documented duodenal growth. Histopathology findings of biopsy taken from the growth revealed, moderately differentiated adenocarcinoma of duodenum. Abdominal computed tomogram (CT) scan showed retroperitoneal mass which could be primary duodenal tumor or para − aortic lymph node. The patient was referred to surgery unit for pancreatico − duodenectomy with the diagnosis of primary duodenal malignancy. In Surgery unit, a left testicular mass was discovered. Ultrasound revealed suspicious mass in left testis. Review of duodenal biopsy (by another pathologist) was asked for. Duodenal metastatic seminoma was the diagnosis which was confirmed by immunohistochemical Stains (that was not done before). Left testicular biopsy showed testicular seminoma .Patient was treated by high inguinal orchiectomy followed by chemotherapy. One year, later the patient had no GIT symptoms, was not anemic and started to put on weight. Follow up endoscopy showed no evidence of tumor in duodenum. There was no evidence of retroperitoneal growth by follow up CT scan. Discussion Testis lymphatic drainage is through para aortic lymph nodes .These are in contact with GIT. When testicular malignancy metastasizes to retroperitoneum it may invade GIT causing confusion whether symptoms are primarily from GIT, or they are primarily extra intestinal. Conclusion High index of suspicion for testicular seminoma must be raised when treating young males with GIT complications like hemorrhage. Testicular seminoma is the most common solid tumor at this age. Sometimes it is the cause behind this complication. Keywords: Testis, Seminoma, Duodenal metastasis, Case report
ABSTRACT Background: Diabetes mellitus is a common metabolic disorder in non-tropical countries. Hand complications are very infrequent in comparison with foot complications. Tropical diabetic hand syndrome has been documented in tropical countries and it is suggested that it may occur in non-tropical countries, but is seldom recorded. Objectives: To document the presence, the causes and the mode of presentation of diabetic hand syndrome in non-tropical countries. Methods: In the period 1st of February 2009 to the 5th of March 2010 five cases of diabetic hand syndrome were studied in Al Basher teaching hospital, Amman, Jordan. On admission a detailed history and physical examination were undertaken. This included fasting blood sugar estimation, deep wound swabs and plain x-rays of the affected limbs. Results: Three of the patients were males and two were females. Their ages ranged from 55 to 74 years, with a mean of 64.5 years. The left hand was affected in three patients; while the right was affected in the other two. The clinical history of diabetes ranged from 10 to 15 years, with a mean of 11.75 years. Three patients presented with an ulcer, one with an abscess and the other presented with gangrene. The ring finger was affected in two patients, the middle finger in one, the palm in one and the dorsum of the hand in one patient. More than one microorganism was isolated from all the swab cultures; however, Staphylococcus aureus was the most common organism. Conclusion: Although it is very infrequent in non-tropical countries, diabetic hand syndrome is a devastating cause of morbidity and mortality particularly in negligent, senescent patients with poorly controlled and long standing diabetes. Keywords: diabetes; hand; tropical; syndrome
A B S T R A C T Introduction: Intradural spinal hematoma, which refers to subdural and/or subarachnoid hematomas, represent a small percentage of spinal hematoma cases, with both hematomas together being only 19.8% of all spinal hematomas. Taken individually, a traumatic cervical spine subdural hematoma is a rare presentation by itself with only 11 cases reported in literature so far. Presentation of case: A 31 years old male presented to the ER with trauma to his neck after fall from height. ASIA (American Spinal Injury Association) impairment scale showed a grade A injury with no sensory or motor function preserved in the sacral segment S4-S5, upper paraparesis and lower paraplegia. Computed Tomography scan showed fracture of C6 vertebrae. Cervical spine T1 and T2 MRI showed intradural hematoma extending from C6 to craniocervical junction. Cervical traction and corpectomy were done. Discussion: Traumatic Cervical spine intradural hematoma is a rare entity. Unlike spinal subarachnoid hematoma, spinal subdural hematomas pathophysiology is still unclear. Spinal MRI is the best imaging modality to reach the diagnosis. First line management is surgical evacuation of hematoma, but conservative management is a valid option in certain cases. Conclusion: Knowing the risk factors that increase the chance of Intradural extramedullary spinal hematomas and clinically distinguishing those who need to be managed surgically or conservatively is an important step in managing Intradural extramedullary spinal hematomas cases
Cystic lymphangiomas are rare congenital benign neoplasms that may occur at any age. They are often asymptomatic and found incidentally, they may arise within the mesentery of the small bowel. We describe a case of a case of a 22-year-old male, who presented with paraumbilical abdominal pain, on examination a large mass in the central part of the abdominal cavity was discovered. Preoperative studies defined the presence of a large cystic mass. At laparotomy, a large cystic tumor of the small bowel mesentery was excised. Histopathologic examination diagnosed the tumor as a cystic lymphangioma
Abstract Background: Rectal trauma is rare. Mostly affecting males (>85%).Its location (intra vs extraperitoneal) determines its management. Rectal injuries cause peritonitis, sepsis and even death if not detected early. Associated mortality is 3% whereas morbidity is 25%. Case Study: We report a 47 year old male presented with generalized abdominal pain after inserting a high pressure compressor in his anus. His past medical history wasn't significant. On physical examination, his abdomen was tender and distended. Laboratory findings revealed mild leukocytosis. Chest X-ray showed air under the diaphragm bilaterally. Explorative laparotomy was done. Posterior wall of upper rectum perforation was discovered. Primary repair was performed. No complications after one month follow-up. Discussion: Colo-rectal barotraumas by compressed air may cause rectal perforation. Mostly at the anti-mesenteric surface of the sigmoid colon. Plain radiographs aid diagnosis. Computed tomography (CT) is sensitive and specific for rectal injury. The gold standard treatment of intraperitoneal perforations is primary repair. Conclusion: Rectal perforation by compressed air is uncommon. Primary repair is appropriate in early presentations, minimal tissue damage and no peritoneal contamination
Introduction: Choledocal disease is uncommon biliary pathology. Most choledochal cysts will present in childhood, about one quarter of patients may only present for the first time during adulthood, with a clinical course slightly differs than that in children and some of these will show malignant transformation. Material and Methods: the clinical data of 12 patients with choledocal cysts were carefully studied from the period of January 2000 to December 2010. Results: There were 3 males and 9 females, with age range from 19 years to 45 years. 10 of the choledochal cysts belong to Todani type IA; 1 type IB and 1 type IVB. Abdominal pain was the commonest presentation. Obstructive jaundice and a malignant change within a choledocal cyst were identified in 1 case. Cholangitis and jaundice in another patient. Anomalous pancreato-biliary junction was recognized in 2 patients. 2 patients were referred after recognition of the choledochal cyst incidentally during laparoscopic cholecystectomy. 10 patients undergoes total excision of the cyst with cholecystectomy and Roux-en-Y hepatico-jejunostomy. One patient presented with liver cirrhosis and advanced hepatic insufficiency, where cystojejunostomy done only. 8 patients remained for follow up and stayed symptom free after a mean of 36 months. Conclusion: Choledochal cyst should be recognized in all patients below 45 years of age presenting with biliary pain, associated with cystic dilatation of bile duct. Cholangiocarcinoma is a dreaded complication of choledochal cyst with adverse outcome because of late diagnosis and a low possibility of resectability. Complete excision of the cyst with restoration of wide biliary_entericcommunication by Roux-en-Y hepaticojejunostomy form the basis of ideal treatment
Introduction: Morbid Obesity affects as much as 10% of the American population. The morbidly obese are subject to social stigma & to increased risk of sudden death due to heart attack, stroke & several concomitant health problems. Bariatric procedures are used to treat Morbid Obesity. Sleeve gastrectomy is one of the restrictive bariatric procedures. It includes resection of the fundus and body of stomach to create a long, tubular conduit along the lesser curve (leaving 20–30% of the stomach). Open or laparoscopic approach, can be used. The mechanisms of weight loss and improvement in comorbidities seen after Sleeve gastrectomy might be related to gastric restriction, Neuro-Humoral changes, or some other unidentified factors. Sleeve gastrectomy is not free of problems, It needs a team work, a careful patient preparation & investigation to avoid early & late post operative complications. The Aim of this study is to present our early experience in Sleeve gastrectomy. Material and Methods: 35 patients were selected, 32 females & 3 males, the age range was between 17–49 year. Their weight were between 105˘ 1.7 cm) was significantly smaller than that of non-pCR (4.7 ± 2.1 cm). The mean Ki67 index in pCR and non-pCR were 29.6 ± 16.9% and 21.3 ± 16.5%, respectively. Negative ER, negative PgR, positive HER2 status and a higher Ki67 were found to be significantly predictive of a pCR. For NAC regimen, 63 patients received either anthracycline or taxane based regimen (A or T), and 257 patients received both of them (A + T). 18 patients were received concurrent trastuzumab with taxane. 51 (20%) of the patients treated with A + T regimen achieved pCR, while only 5 (8%) of the patients treated with A or T regimen. A significant difference between them was observed. In multivariate analysis, the probability of pCR was directly associated with tumor size [OR for one cm increase, 0.706, 95% confidence interval (CI), 0.564–0.883], Ki-67 index [OR for 10% increase in the percentage of positive cells, 1.023, CI, 1.002– 1.044], ER [OR for negative 0.148, CI 0.042–0.522], HER2 [OR for positive 0.461, CI 0.213–0.999] and use of trastuzumab [OR for use 0.074, CI 0.018–0.306]. Results: An average of 10 kg loss per month were noted & a marked improvement in weight related co-morbidities (DM, Hypertension, Sleep Apnea, Dyslipidemia) were reported. Wound infection, B12 & Iron deficiency, Hair fall, Vomiting, Port Hernia & GERD were the post operative complication. One patient needed a redo operation (bypass procedure). One patient died because of Guillain-Barre´ syndrome (not related to the procedure). Conclusions: Sleeve gastrectomy as first step or the only step in treating morbid obesity is a safe procedure, with accepted weight loss, yet it is not with out side effect
Introduction: Necrotizing fascitis (flesh-eating disease) is an insidiously advancing soft tissue infection characterized by widespread fascial necrosis. It was first described in 1848. The causative bacteria may be aerobic, anaerobic, or mixed flora, and the expected clinical course varies from patient to patient. The 3 most important types of necrotizing fasciitis syndromes are type I (polymicrobial); type II (group A streptococcal); and type III gas gangrene (clostridial myonecrosis). The mean age of the patients is 38–44 years. The male-tofemale ratio is 3:1. Necrotizing fasciitis can be difficult to recognize in their early stages, but they rapidly progress. They require aggressive treatment to combat the associated high morbidity and mortality (which is in overall 70–80%). Material and Methods: A 24 year old female presented with 3 months history of right loinpain following labour, Intravenous pyelogram showed Right sided hydronephroureter due to ureteric stone. Extracorporeal Shock Wave Lithotripsy session was performed for the patient. One day later, she started to develop severe abdominal pain different from the previous one. Results: On examination she got tenderness and feeling of crepitus in the wall of the right side of the abdominal wall, which was not present previously, CT scan revealed Right abdominal wall necrotizing fasciitis, extending to the retroperitoneum, Diagnostic Laparoscopy confirm the diagnosis. We treated her by repeated aggressive wound excision, antibiotics and treatment was completed by skin graft. Conclusions: This case not only represent a concurrence of an unusual entity but also alerts us that necrotizing fasciitis may developed after Extracorporeal Shock Wave Lithotripsy. A retroperitoneal nidus of infection may be considered. Early diagnosis, aggressive and emergent surgical intervention are required for the survival of these patients
Introduction: The use of radiological investigation is an accepted part of medical practice, but there is no known safe radiation dose. Man-made radiation accounts for 13% of the total radiation burden, 90% of it is due to diagnostic medical exposures. The most significant studies of the effects of radiation came from the lifetime study of the approximately 90000 survivors of the atomic bombs dropped over Hiroshima & Nagasaki in 1945. These studies considered survivors who receive whole body doses from photons & neutrons greater than about 0.25 Sv as population liable for excess cancers. These Survivors include people who were 900 to 1500 meters away from the ‘‘hypocenter,’’ just below the exploding bomb. The aim of this study is to make a comparison between the whole body doses of radiation received by the survivors of Hiroshima, Nagasaki & the dose received by patients from the diagnostic radiological examinations in the first day of admission to the ER department. Material and Methods: In the period from 19th October 2008 to 25th November 2008; 273 blunt trauma patients with are vised trauma score of\4 were studied prospectively, in the emergency department of Al Bashir teaching hospital, Amman, Jordan. 188 (68.87%) were males, & 85 (31.13%) were females. Age range was 0.05 to 95 year (mean age 18.06 years). Results: The range of radiological examinations received by the patients was 1–14 (with a mean of 4.63 examination for each patient). radiological examination positive findings were found in 27.83% (76 patient) only, while the findings were negative in 72.17% (197 patient) . The dose of radiation received by the patients ranges between 0.1–18.5 milisivert. With a mean of 3.52 milisivert. 41.76% (114) received [0.25 milisivert, while only 58.24% (159 patient) received\0.25 milisivert. The additional risk for cancer ranges between 0.001–0.731% with a mean of 0.060%. Conclusions: Patients are receiving an unusual high dose of radiation for the diagnostic purposes. This brings an unaccepted additional risk of cancer for the patients
Introduction: Gastrointestinal stromal tumor (GIST) is a rare neoplasm exhibiting, in most cases, mutations of c-kit tyrosine kinase, it is the most common mesenchymal tumor of the gastrointestinal tract. Two thirds of all gut malignant GISTs occur in the stomach. Material and Methods: 13 patients presented with GIST tumors from the period of January 2000 to August 2010. Surgical treatment done in all patients with local Gastric wedge resection in 4 patients, subtotal gastrectomy in 3,total gastrectomy in 2, laparoscopic proximal gastrectomy in 1,distal gastrectomy in 2 patient. A very huge intraabdominal mass more than 8 kilograms was resected from intraabdominal cavity with the involved stomach. In all the patients safe margin of at least 2 cmwas ascertained and safty margin were carefully looked for with frozen section in the last 5 cases. Lymhadenectomy was not necessary. Imatinib was used post-operatively in all the patients. Results: There were 9males and 4 females, with age range from21 years to 64 years. Patients presented with upper gastrointestinal bleeding in 4 patients, abdominal mass and weight loss in 5, dysphagia in 3 patients, while one patient presented acutelywith haemoperitoneum. Preoperative diagnosis was done in 4 patients as gastric GIST, while in the remainder the diagnosis was done postoperatively. Gastric tumors located in the cardia of the stomach in 2 patients, body of the stomach in 6 patients and the antrumin 2 patients. There was no operative mortality. follow up from 6months to 6 years, there were two deaths 18months afterR1 resection in one, and 24months in the other. Other patients followed in the oncology department, with no recurrences. Conclusion: The therapy of choice of resectable GIST is complete surgical removal of the tumor. Lymphadenectomy is not necessary; GIST rarely involves the loco regional lymph nodes. The margins of resection from the tumor specimen should be carefully oriented and examined. Laparoscopic resection is feasible and was successfully applied to the management of GIST. Tumour pathological characteristics Tumor characteristics Patients Size of tumor----- 10Cm 4 Mitotic figure ----- 5/50 HPF 7 CD 117 Positive 13 Residual disease Micr 11 Positive 2
Background Entero-cutaneous fistula are a major catastrophe to the patients and surgeons and it still has high incidence of morbidity a& mortality and their management remain a big challenge. Aim Recent experience with paraentral nutrition for treatment of entero-cutaneous fistula in gastroenterology and hepatology teaching hospital is reviewed to study the main causes of the fistula and to determine the factors related to successful treatment . Methods A total of 50 consecutive patients with entero-cutaneous fistula were studied prospectively during a period of two years. Thirty seven patients received total parenteral nutrition and 18 patients underwent surgical operation attempting for fistula closure. Results in 48 patients the fistula developed postoperatively, the most common primary cause was missile injury ( 46%) , whereas only two patients fistula occurred spontaneously. In 22 patients the fistula closed by conservative treatment, the mean duration of spontaneous closure was 16.5 days . In 9 patients the fistula was closed by surgical interference and 18 patients died., In one patient the fistula was neither closed by conservative nor by surgical treatment .The mean duration for hospitalization was 25.2 days Conclusion In spite of improvement of spontaneous closure rate of patients with entero-cutaneous fistula who received total parentral nutrition .There is still high unacceptable mortality rate of this catastrophic disease , which requires additional care and improvement in intensive monitoring.
Back Ground : Hydatid disease is a Zoonotic infection , that has a world wide distribution ,It is endemic in many cattle raising regions of the Mediterranean , Middle east ( Including Iraq) Far east , South America, Australia and certain areas of North America. Purpose: Comprehensive review of 150 Iraqi patients with hepatic hydatid cysts and to compare the results with that of Iraq and surrounding countries Similar studies . Methods: This study was based on data collected from 150 patients , admitted to gastroenterology and hepatology teaching hospital in Baghdad with one or more hepatic hydatid cyst. Each patient was evaluated by history, clinical examination & investigated by complete blood picture , liver function test , abdominal ultrasound & chest X Ray. CT scan of the abdomen MRI, MRCP, Esophagogastrodudenoscopy, ERCP, were done for some of the patients .GHARBI Classification was used to categories Hydatid cysts into 5 types. Endocystectomy was the way to deal with cyst in 56.6% of the cases . CBD was explored in 10%of the cases. While ERCP was done in 44% of the cases to deal with CBD obstruction. In 52% of the patients , operation was done once for the patient. The residual cavity was dealt with in most of the patients by either leaving a drain beside the cyst ( in 32% of the patients) , Or by external drainage ( In 28.6% of the patients ) . Results : There were 74 Male and 76 female. The mean age of patient was 38.9 year ( The age range was from 3-85 year) . & patients ( 4.7%) were Asymptomatic & were accidently discovered to have abdominal hepatic hydatid disease , While 143( 95.3%) were symptomatic. Upper abdominal pain was the most common presenting symptom, in 74% of the patients . Most of the cysts were in segment 7( 23.5%) and in segment 8 ( 21.5%). Most of the patients got just one cyst in their liver( 58%). Most of the cysts were type 3( 22.3%)and type 4 ( 22.3%)according to Gharbi classification. In 27.4% of the patients the cysts were ruptured to the biliary tree at the time of diagnosis. In 52.5% of the patients the liver was involved alone by the hydatid cyst . The patients with the cysts were treated either by medical treatment alone, Interventional therapy , surgery alone , or with more than one of the mentioned treatment modalities. Recurrence was recorded in 20% of the case. The cysts were infected in 72% of the cases. 4 patients died( 2.6%). In all of them the causes of death were related to late presentation and cyst complications. Conclusions Most of our patients were young and mostly presented with upper abdominal pain. Liver is the most organ to be involved in the peritoneal cavity. Segment 7, and 8 were the most commonly involved liver segments. Cyst were mostly of type 3, and 4 according to Ghrabi classification. Cysts were ruptured into the biliary tree in 27.4% of the cases. Most of the cases were diagnosed very late , and are usually presented with complications , especially rupture into the biliary tree, or infection , which leads to high morbidity and mortality.
Abstract Introduction: Liver herniation through surgical incision is very rare. Moreover, it is exceptional for the left hepatic lobe to herniate through sternotomy incision. Presentation of the case: We present herein a 66 year old woman admitted to ER complains about upper abdominal pain. Abdominal CT scan showed herniation of part of left hepatic lobe through previous sternotomy incision. Conservative measures were successful in managing her symptoms. Discussion: Till now only few cases of liver herniation through scar of sternotomy have been documented. Conclusion: Although it is rare, left hepatic lobe may herniate through sternotomy incision. Keywords: Left lobe liver; Sternotomy; Incisional hernia
Objectives : This study elucidates number of features of primary Gastric Lymphoma (PGL) in Iraqi patients , including incidence among gastric malignancies, Signs & symptoms , Sex and age distribution, Gradings , layers involved , Macroscopical appearance , topographical and lymph node involvement, dimension of the lesion, growth pattern and treatment . An attempt was made to corelate the clinical , endoscopic and pathological findings in these patients . Methods: Over 6 years period from January 1995 to January 2001, 37 case of PGL were collected. All of them were endoscoped and multiple biopsies were taken from suspicious areas or lesions in the stomach. 21 patients were operated upon and the histopathological findings of the endoscopical biopsy and or the surgical specimen were reviewed . Results : 37 patients with primary gastric lymphoma were collected in 6 year period. 20 patients were females, 17 were males. The mean age of all patients was 45.1 years. 17 patients were of high grade , other 17 patients were of intermediate grade , and the last 3 patients were of low grade PGL.Helicobacter Pylori culture was positive in 75.6% of the patients.Distal parts of the stomach ( Antrum and pylorus) was the most frequent reion to be involved . Most of the lesions were fungating masses in appearance and growth pattern was exclusively of diffuse type. 21 patients were treated by surgery , Th others were beyond surgery Conclusion Primary gastric lymphoma (PGL) is increasing in our country. It is aproblem of middle age group.It is notalways simple to differentiate by clinical examination or endoscpy alone PGL from other malignant gastric tumors. With optimum treatment PGL gets better prognosis than that of mother malignant gastric tumors , especially if the diagnosis was made at an early stage . Probably PGL can be prevented by Helicobacter Pylori eradication
Background: Worldwide, trauma constitutes 10% of all causes of death. In the United Arab Emirates, trauma is the second leading cause of death for both national and expatriate populations, accounting for over 20% of all fatalities. Trauma affects all age groups, especially adolescents and young adults. Most trauma cases are preventable. Morbidity and mortality can be decreased after trauma by adopting a systematic approach towards trauma victims. Simulation‑based training is beneficial in that it allows us to amplify a variety of real‑life situations without compromising patient safety. Objectives: This study aims to assess the impact of trauma team training (TTT) on the performance of the trauma team and the time spent by the patient in the emergency department. Methods: In Sheikh Khalifa Medical City of Ajman, the TTT program was started early in 2016 for all members of the trauma team including (trauma team leaders, hand on surgeons, emergency room physicians, airway nurses, IV access nurses, documenting nurses and circulatory nurses) in addition to personnel recruited during trauma management like (anaesthetists, orthopaedic surgeons, blood bank physicians, radiology technicians, intensive care unit nurses, theatre nurses, laboratory and blood bank technicians, etc.).The 1-day training program, concentrated on the discipline of each member of the trauma team during simulated patient treatment, and his role in the team. Assessment of the impact of TTT on the performance of the trauma team was done by interrogating the participants in this training. The time spent to resuscitate the patient in the emergency department was measured before and after the training of the trauma team personnel. Results: After the TTT was employed, the results showed that there was a decrease by approximately 75% in the meantime of performance from 220.8 min to 54.48 min. This was in accordance to the patient’s stay in the ER which decreased significantly from 9 to 827 min pre‑training to 14–206 min post‑training. Conclusion: Training reinforces the already learned skills, corrects and minimise mistakes. Implementation of TTT is of utmost importance to be adapted in every trauma centre to achieve optimal performance and benefit to the patient.
Abstract Introduction: One of the challenges of surgery on patients with active SARS-CoV-2(severe acute respiratory syndrome coronavirus 2) infection is the increased risk of postoperative morbidity and mortality. Aim: This study will describe and compare the postoperative morbidity and mortality in asymptomatic patients or those with mild infection with those with severe COVID-19 infection undergoing elective or and emergency surgery. Materials and Methods: This is a retrospective study of 37 COVID19 patients who had the infection 7 days prior to and 30 days after emergency or elective surgery. Patients were divided to two groups. Group1: the asymptomatic or those with mild infection that is diagnosed just before surgery (14 patients). Group 2: those who were admitted to the hospital because of severe COVID-19 and were operated for COVID-19 related complications (23 patients). Morbidity and mortality of both groups was studied. Results: There was no significant difference in gender between the two groups. There were 5 females (2 in group 1, and 3 in group 2) and 32 males (12 in group 1, and 20 in group 2). Mean age for all patients was 49.8years (38 for group 1 and 57 for group2). Median age for Journal Pre-proof all patients was 50 years (37.5 for group 1 and 57 years for group 2). Sepsis developed in 7 patients (1 patient in group 1 and in 6 patients in group 2). Statistically there was no significant difference in occurrence of sepsis between the two groups. There was a significant difference in the intensive care stay between the two groups (higher in group 2). Four deaths were reported in group 1 and fourteen in group 2. Eighteen out of thirty-seven patients died. Conclusion: Severity of COVID-19 infection will prolong the hospitalization and ICU stay in surgical patients with no significant effect on mortality. Keywords: COVID-19, Surgery, Morbidity, Mortality
Background: COVID19 infection is caused by the highly contagious SARS-CoV-2(Severe acute respiratory syndrome coronavirus 2). The first outbreak of this infection was in Wuhan, China in December 2019. Since then, it has spread rapidly across the world, with more than 100000 new cases each day. Among those infected with SARS-COV-2 up to 20% develop severe disease requiring hospitalization. Among those who are hospitalized, one quarter will need ICU admission. Admission to the ICU is due to respiratory failure or pneumonia. The pneumonia associated with COVID19 infection may lead to respiratory failure requiring endotracheal intubation and mechanical ventilation. An important complication of mechanical ventilation is barotrauma. Barotrauma appears to be common in COVID19 patients. Pneumothorax developed in 25% of COVID19 patients who had barotrauma. In COVID19 the percentage of patients with mild symptoms who develop a pleural effusion is 8% compared to 28% in patients who are critically ill. Most of the COVID19 infected that have a pneumothorax or pleural effusion need a thoracostomy. In trauma cases most, thoracic injuries (leading to pneumothorax or hemothorax) are effectively treated with tube thoracostomy. Objectives: First objective is to compare the therapeutic effect of tube thoracostomy on COVID19 infected patients who have pneumothorax or pleural effusion to those non-COVID19 infected patients who had traumatic pneumothorax or pleural effusion treated by tube thoracostomy. Second objective is to study the morbidity associated with tube thoracostomy in COVID19 infected patients who have pneumothorax or pleural effusion. Patients and methods: This study was conducted in Sheikh Khalifa medical city Ajman, United Arab Emirates. It is a descriptive, observational, retrospective cohort study. One hundred patients were recruited from the January 1, 2020 to the December 31, 2020. Patients were divided into two groups. First group includes fifty adult COVID 19 infected patients who had no trauma. Second group includes fifty adult COVID19 infection free patients who had trauma. Inclusion criteria for the first group: COVID 19 infected patients with an age equal to or above 18 years, of both genders, with history of pneumothorax, pleural effusion or both of them, needed insertion of thoracostomy chest tube. Inclusion criteria for the second group: Patients with an age equal to or above 18 years, of both genders, with history of traumatic pneumothorax, pleural effusion (hemothorax) or both of them, needed insertion of thoracostomy chest tube. Exclusion criteria for the first group: Children, Adult COVID19 infected patients who didn't have pneumothorax or plural effusion, adult COVID19 infected patients who had pneumothorax or plural effusion without a need for tube thoracostomy. Exclusion criteria for the second group: Adult non-COVID19 infected patients who had trauma, but didn't have pneumothorax or pleural effusion, adult non-COVID19 infected patients who had traumatic pneumothorax or pleural effusion without a need for tube thoracostomy. The collected data was revised, coded, tabulated and introduced to a PC using Statistical package for Social Science (SPSS 25). Mann Whitney Test (U test) was used to assess the statistical significance of the difference of a non-parametric variable between two study groups. Chi-Square test was used to examine the relationship between two qualitative variables. Fisher's exact test was used to examine the relationship between two qualitative variables when the expected count is less than 5 in more than 20% of cells. Results: Most of patients in trauma group (group 2) were with the age range of 20-40-year (58.8% of patients) P value was significant (
Introduction: Primary sternal osteomyelitis is a rare condition that is frequently caused by Staphylococcus aureus. It is often confused with other cardiac and pulmonary conditions. Early antimicrobial treatment and surgical debridement is the cornerstone of treatment. Case presentation: A 51-year-old male adult came to the emergency room (ER) with a 2-week history of chest pain, fever, and malaise. His past medical history was unremarkable. Examination revealed a tender anterior chest wall swelling. White Blood Cells (WBCs) (21.6 × 104)/mm3) and C-reactive protein (CRP) (294.10 mg/L) were elevated. Pus from the swelling and blood samples were sent for culture and sensitivity. Electrocardiogram (ECG) was normal and a computed tomography (CT) scan of the chest showed a large dense anterior chest wall abscess extending deep in the chest and to both axillae which caused bony erosion of the sternum. Incision and drainage of the abscess were performed, followed by surgical debridement of the wound. Cultures along the course showed both Staphylococcus aureus and Enterococcus. The patient improved gradually and 2 months after his initial presentation, he became free of symptoms, and CT has shown complete resolution. Discussion: Osteomyelitis usually happens after an external bacterium seeds the bone where it begins to grow and thrive, leading to the destruction and pus accumulation under the periosteum. For the treatment, identifying the causative agent is critical in giving intravenous (IV) antibiotic. Thereafter, incision and drainage of an abscess can be performed, similar to what was done with the patient mentioned. Radiography, specifically a CT scan, is crucial as it clearly reveals bony margins and can differentiate between a sequestrum and an involucrum. It also identifies cortical erosion, intraosseous gases and periosteal reactions. Conclusion: Sternal osteomyelitis can have a nonspecific clinical presentation. Laboratory investigations and radiological findings are crucial for a prompt diagnosis. To prevent the progression of the disease and complications, early intervention is vital to ensure a good prognosis.
Abstract Keywords: Skull Penetrating Stab Wound; Intraparenchymal Hemorrhage; Head Computed Tomography Scan Penetrating skull injury leading to intracerebral hemorrhage (ICH) is a severe form of traumatic brain injury that can result in significant morbidity and mortality. This case report describes successful treatment of a 22-year-old male patient who developed a massive cerebral hemorrhage within two hours of a small cerebral hemorrhage after a stab wound to the head. The patient was initially observed for the small cerebral hemorrhage in the emergency department, but his condition deteriorated rapidly and he became unconscious. Urgent CT scans revealed a significant increase in the size of the hemorrhage, with mass effect and midline shift. The patient was taken to the operating room for urgent craniotomy and evacuation of the hematoma. The surgery was successful and the patient made a good recovery. This case report highlights the importance of early diagnosis and treatment of penetrating skull injuries with ICH. Introduction Penetrating skull wound leading to intracerebral hemorrhage (ICH) is a severe form of traumatic brain injury that can result in significant morbidity and mortality. Most of penetrating skull injury occur as result of assault, worker accidents, unexpected events, etc [1]. The exact incidence of penetrating and perforating injuries to the head in the civilian population is unknown, but current estimations indicate that bullets account for 4.6% and puncture wounds, stab, nail, etc., cause 0.4% of this kind of brain injuries [2,3]. The adult skull provides an effective protection of the brain from high