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BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is being increasingly established as a definitive procedure for weight loss. The mechanism for weight loss in LSG is gastric restriction and neurohormonal changes, but there is deficient information on its nutritional effect. The aim of this prospective study was to assess vitamin and micronutrient deficiencies following LSG (whats and when) in organized follow-up visits. PATIENTS AND METHODS: LSG was performed in 112 consecutive patients between June 2010 and December 2013. In all patients, the vitamin and micronutrient deficiencies were corrected before the LSG procedure. Patients were investigated for vitamin and micronutrient concentrations 2, 4, 6, 9, and 12 months after surgery. RESULTS: During the study time, 112 patients (65% female) underwent LSG. The mean age was 26 years (range: 20 to 37 y), and the mean preoperative body mass index was 41 (range: 35 to 52). Complications and nutrient deficiencies were observed and analyzed throughout the follow-up period. CONCLUSIONS: The appearance of vitamin and nutritional deficiencies after LSG is a common phenomenon. Correction of the deficiencies before surgery, sufficient supplementation immediately after the procedure, and routine long follow-up are important to avoid the serious consequences of the deficiencies.

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OBJECTIVE: The relationship between parasites and pediatric appendicitis is a highly debatable issue. This study aims to investigate the role of parasitic infestation in the etiology of acute pediatric appendicitis. METHODS: A retrospective study including 1600 pediatric and adolescent patients who had undergone surgical therapy for a diagnosis of acute appendicitis over a period of ten years from Jan 2001 to Dec 2010. Demographic data were retrieved including the patient's age, sex, clinical data, clinical presentations, laboratory investigations, operative data and pathological findings to identify the presence and type of parasites. Patients were divided into two groups according to the presence or absence of parasites in the appendix lumen. In group I (n: 88), parasitic infestation was observed, whereas in group II (n: 1502), no parasitic infestation was present. RESULTS: Parasites were present in 5.5% (88 patients), and of those 88 parasitic infestations, 45 (51.1%) were Enterobaisis, 8 (9.1%) were Schistosomiasis, 23 (26.1%) were Ascariasis, 7 (8%) Trichuriasis, and 5 (5.7%) were Teania Saginata. The percentage of patients with suppurative, gangrenous or perforated appendicitis was similar in both groups with no statistical significance, irrespective of the presence or absence of parasitic infestation. CONCLUSION: The low prevalence of parasites among the appendectomy specimens did not support the notion that parasites were a major cause of appendicitis in pediatric patients.

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SUMMARY BACKGROUND DATA: A gallstone is a common disease in sickle cell disease (SCD) patients, and cholecystectomy is the most common surgical procedure performed in patients with SCD. We conducted this study to determine the outcome of laparoscopic cholecystectomy (LC) as the standard surgical treatment for gallstones in adult patients with sickle cell anemia over a long period. PATIENTS AND METHODS: Data of all the SCD patients who were operated between April 1994 and December 2008 were collected retrospectively. We analyzed data including age, sex, mode of admission (elective or emergency), indication for LC (chronic or acute cholecystitis), operation time, length of hospital stay, and complications. RESULTS: : During 1994 to 2008, there were 6014 patients who underwent LC; of those, 496 (8.25%) patients were SCD patients. The results showed significant differences in the outcome, operative time, hospital stay, and complication rate between 1994 and 2008. CONCLUSIONS: LC is a safe procedure in sickle cell patients with a low morbidity rate.

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BACKGROUND/AIM: The first option for gallbladder surgery is laparoscopic cholecystectomy. The aim of this study is to analyze the outcomes for all patients who underwent laparoscopic cholecystectomy at a secondary level of care. PATIENTS AND METHODS: Between 2005 and 2008, 968 consecutive laparoscopic cholecystectomies were performed at King Fahad Hospital. We collected and analyzed data including age, gender, body mass index (kg/m2), the American Society of Anesthesiologists (ASA) class, mode of admission (elective or emergency), indication for LC (chronic or acute cholecystitis [AC]), co-morbid disease, previous abdominal surgery, conversion to open cholecystectomy, complications, operation time, and length of postoperative hospital stay. RESULTS: Nine hundred and sixty-eight patients had laparoscopic cholecystectomy at the center. There were 824 females and 144 males; the age range was 15-64 (mean 32.9 ± 12.7 years). The operating time was 45 to 180 min (median 85 min); the complication rate was 4.03% (39 patients). CONCLUSION: Laparoscopic cholecystectomy could be performed safely in the majority of patients with cholelithiasis, by an experienced surgical team at a secondary level of care.

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BACKGROUND: Sickle cell disease (SCD) is common in the Eastern Province of Saudi Arabia. Patients with this disease have an increased risk for gallstones. Cholecystectomy is the most common general surgical procedure performed in patients with SCD. Laparoscopic cholecystectomy (LC) is the standard treatment for symptomatic gallstones. To date, only small series of LC in adults with SCD have been reported. We report a large series of LC in these patients. METHODS: A retrospective study included all adults with SCD who underwent LC for symptomatic gallstones at King Fahad Hospital, Hofuf, Saudi Arabia, during a 13-year period. Data analyzed were patient demographics, preoperative blood transfusion, duration of operation, rates of conversion and morbidity, and length of hospital stay. RESULTS: There were 427 patients; 56% were women with a mean age of 21 years. Blood transfusion was used in 393 patients (92%). Nineteen patients (4.5%) had endoscopic extraction of common bile duct (CBD) stones before LC. Overall, conversion to open surgery was necessary in 21 patients (5%). However, the conversion rate significantly decreased from 9% in the first half of the study to 2% during the second half (p < 0.001). The mean operation time was 76 min. There were 31 complications (7%), mostly related to SCD. There was no mortality, and the mean hospital stay was 2.6 days. CONCLUSION: Provided that standard perioperative care is ensured and the procedure is performed by experienced surgeons, LC in adults with SCD results in low rates of conversion and morbidity, no mortality, and a short hospital stay.

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BACKGROUND: Currently, emergency laparoscopic surgery for acute abdominal conditions has become the favored surgical approach; therefore, we investigated the diagnostic accuracy and therapeutic efficacy of laparoscopy in acute abdominal pain in Saudi Arabian patients. PATIENTS AND METHODS: In this prospective study, 176 patients with acute abdominal pain (113 patients with pain localized to the right iliac region [group A] and 63 patients with generalized abdominal pain [group B] underwent emergency laparoscopy between January 2002 and December 2006. We evaluated the initial clinical diagnosis, the laparoscopic diagnosis, and the outcome in these two groups of patients. RESULTS: In group A, a definitive diagnosis was established at laparoscopy in 89% of patients, and it was therapeutic in 81.4% of the patients, and in 9 patients (8%) a conversion to laparotomy was necessary a to manage their condition. In group B, the diagnosis was accurate in 87% of patients, and it was therapeutic in 79.4% of the patients, and in 5 patients (8%) a conversion to laparotomy was necessary. There was no mortality. CONCLUSIONS: The emergency laparoscopy is a diagnostic and therapeutic option in the majority of acute abdominal pain conditions.

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BACKGROUND/AIM: Acute appendicitis during pregnancy is the most common problem encountered in general surgery. However, limited data are available regarding acute appendicitis in pregnant sickle cell disease (SCD) patients. We aimed to study was the clinical presentation, management, and outcome in SCD patients who underwent appendectomy for suspected acute appendicitis during pregnancy. MATERIALS AND METHODS: Between January 1998 and December 2006, 65 pregnant patients with clinically suspected appendicitis underwent surgery at our hospital of whom 11 were SCD patients. Data collected retrospectively included age, gestational stage, clinical signs and symptoms, operative findings, and complications. RESULTS: Eleven out of 65 (16.9%) were SCD patients. The mean age in the SCD group was 22.5 years while the mean gravida and parity values were 2.0 and 1.1, respectively. The mean HbS, HbF, and HbA2 values were 71.1, 26.2, and 2.6%, respectively. Abdominal pain and vomiting were the most common presenting symptoms regardless of the gestational age. Abdominal and rebound tenderness were the most common physical signs. The mean operative time was 49 min (range: 35-125 min) and the average length of postoperative hospital stay was 4.7 days (2-8 days). There was no maternal death but one patient had spontaneous abortion during the first trimester, two days after the operation. Two patients had premature, postoperative delivery at 30 and 31 weeks of gestation. CONCLUSION: The clinical manifestations and diagnosis of appendicitis in sickler pregnant patients are similar to those in nonsickler pregnant patients.

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OBJECTIVE: To evaluate the possible effectiveness of bowel preparation on pain after hernia repair. METHODS: This was a prospective randomized study, performed at King Fahad Hospital, Hofuf, Kingdom of Saudi Arabia between January 2000 and December 2002. The group of patient was randomly divided in 2 groups. Sixty-two patients (Group I) had bowel preparation and 65 patients (Group II) had no bowel preparation. All patients in the Group 1 received lactulose 2 days before surgery and rectal enema on the day of surgery. Patients were assessed at 8 hours interval in the hospital. They were assessed for the severity of pain during the first micturation and bowel motion. RESULTS: The pain score in the first 24 hours was significantly lower in the Group 1 (p<0.01) as well as second 24 hours (p<0.001). The pain in the first micturation (p<0.001) and during the first bowel motion (p<0.001) was less in Group I compared to Group II. CONCLUSION: Patients with bowel preparation before hernia repair had significantly less pain postoperatively even in the first micturation as well as the first bowel motion than those without bowel preparation.

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OBJECTIVE: To find out the prevalence and relation between osteoarthritis of knees and obesity in Al-Ahsa region, Kingdom of Saudi Arabia (KSA). METHODS: The study included 243 male and female patients diagnosed with osteoarthritis of knees between June 2001 to March 2003. All patients were recruited from the Physical Therapy Department, King Fahd Hofuf Hospital, Hofuf, KSA. The clinical diagnosis was supported by plain x-rays of knees, and of other joint if needed. The weight and height of all patients were taken using one standard weight and height scale, and body mass index was also calculated and recorded. RESULTS: More than 90.53% of the patients referred with osteoarthritis of the knees were obese or overweight. The mean body weight of all patients was 84.61 kg and the mean height was 1.59 meters. Osteoarthritis of the knees was more common in obese female than male patients with a female to male ratio of 2.37:1. CONCLUSION: Obesity is a disease. The aim of all health professionals and others in the community should be directed to the prevention of this disease and its risk to develop multiple complications.

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OBJECTIVE: To compare the effect of metronidazole on post conventional hemorrhoidectomy pain in patients with third and fourth degree hemorrhoids. METHODS: Two hundred consecutive patients admitted in King Fahad Hospital, Hofuf, Saudi Arabia between June 2002 and May 2004 for surgical treatment of 3rd and 4th degree hemorrhoids were randomly assigned into 2 groups. In Group 1 (100 patients) pre and postoperative metronidazole was used and in Group 2 (100 patients) no medications were given. All patients received castor oil from 2 days before surgery and lactulose after surgery for 2 weeks. Patients were discharged home when free of pain. RESULTS: Patients in group 1 had significantly less pain than those in the second group. Hospital stay and time to first bowel motion were not significantly different between both groups and, early and late complications appear similar. Return to normal activity was significantly shorter in the metronidazole group. CONCLUSION: Prophylactic metronidazole in Milligan-Morgan hemorrhoidectomy is associated with less pain and earlier return to normal activity.

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BACKGROUND: The aim of this study was to report the outcome of laparoscopic cholecystectomy in children with sickle cell disease and to compare the patients who had surgery as emergency with those who were operated as routine. MATERIALS AND METHODS: A total of 72 patients (males 48, females 24) less than 14 years of age (ranging between 6 and 14 years) underwent cholecystectomy at the King Fahad Hospital, Hofuf, in the last 5 years. The records of these patients were reviewed retrospectively, comparing the outcome of surgery in emergency and routine cases. RESULTS: The mean operating time and the mean hospital stay were longer in the emergency group (91.3 min, 8.5 days) compared to routine group (75.8 min, 4.5 days respectively), with high incidence of postoperative complication in the emergency group. CONCLUSION: This study showed that elective laparoscopic cholecystectomy by an experienced surgeon and taking necessary precautions are the safety measures to be recommended at the time of diagnosis of cholelithiasis in sickle cell disease children.

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BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) is an important agent of hospital-acquired infection. The mode of entry of MRSA in the hospital might be on admission of patients with MRSA infection or nasal colonization. The present study was undertaken to determine the prevalence of MRSA nasal colonization among patients on admission to hospital. METHODS: Six hundred patients were screened for nasal colonization of MRSA on admission to hospital. Nasal swabs were cultured on salt mannitol agar and blood agar. Age, sex, previous admission to hospital and antibiotic therapy were recorded. RESULTS: S. aureus was isolated from the nasal swabs of 122 patients (20.2%) on admission to hospital. MRSA was isolated from 7 patients (1.1%) and methicillin-sensitive S. aureus (MSSA) from 115 patients (19.1%). Nasal colonization of S. aureus was higher in younger and elderly patients and significantly higher colonization was observed among females. The MRSA strains isolated from nasal swabs had a different antibiotic susceptibility pattern than those isolated from patients having hospital-acquired MRSA infection. Previous admissions to hospital, underlying disease antibiotic therapy were not risk factors for MRSA nasal colonization. CONCLUSION: MRSA nasal colonization of patients on admission to hospital is low in this region. The screening of every new admission would not be cost effective, but patients transferred form other institutions should be screened for MRSA. Standard infection control precautions should be strictly implemented to prevent the spread and control of MRSA infections.

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BACKGROUND: The extent to which bedside patients' files become contaminated and the range of bacterial flora attributable to contamination in high-risk areas of the hospital are not known with certainty. The aim of the present study was to determine the degree of contamination of the patient's files and also to analyze and compare the spectrum of contaminant bacterial flora between the intensive care unit (ICU) and surgical wards, the 2 most high-risk areas for nosocomial transmission of infection. METHODS: Microbiologic samples were collected from the exposed outer surface of the patients' files kept bedside in the ICU and surgical wards with sterile swabs moistened with sterile normal saline. Swabs were cultured within an hour of collection on blood agar and MacConkey's agar plates, which were incubated at 37 degrees C for 48 hours. Gram-negative bacilli were identified by Gram's stain, catalase, oxidase tests, and API 20E and API 20NE. Staphylococcus species were identified by Gram's stain, catalase test, and tube coagulase test. Antibiotic susceptibility of the isolated bacteria was determined by the disk diffusion technique according to the criteria of National Committee for Clinical Laboratory Standards (NCCLS). RESULTS: In ICU, 85.2% (87/102) and, in surgical wards, 24.7% (22/89) of patient's files were found to be contaminated with pathogenic and potentially pathogenic bacteria (OR, 17.664; 95% CI: 8.050-39.423; P < .0001). Pseudomonas aeruginosa was the most commonly isolated bacteria (32.3%, 33/102) in ICUs, whereas Staphylococcus aureus was the peak contaminant (11.2%, 10/89) of the files in surgical wards. Methicillin-resistant Staphylococcus aureus (MRSA) was isolated from 6.8% (7/102) of ICU patient's files, whereas only 1.1% (1/89) of patient's files in surgical wards were contaminated with MRSA (OR, 6.484; 95% CI: 3.215-13.463; P < .0001). The multidrug-resistant P aeruginosa, Acinetobacter baumannii, Klebsiella pneumoniae, and Serretia marcesens isolated from the patient's files had the same antibiotic resistance pattern as of these bacteria isolated from the patients. CONCLUSION: The majority of the patient's files in ICUs were contaminated often with multidrug-resistant bacteria and even MRSA. Contaminated files could be a source of transmission of infection. To prevent this, handwashing practice should be strictly followed after attending the patient and before entering the case notes in the patient's file. The maintenance of good hand hygiene by the health care workers (HCWs) after handling contaminated files should perhaps be the most prudent approach to prevent patient-patient transmission of infection in high-risk areas including ICU and surgical wards.

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We report a case of a primary cutaneous cryptococcosis (PCC) in immunocompetent man diagnosed by fine-needle aspiration (FNA) and confirmed by special stains and culture study. The patient presented with a 2-wk history of two separate skin nodules over the forehead and the left lumbar region. FNA smears revealed a necrotizing suppurative granulomatous inflammation with numerous yeasts of Cryptococcus surrounded by clear halos, which were present within multinucleated giant cells and in the intercellular spaces. This was confirmed subsequently by special stains and a culture of the aspirated material. This case report reemphasizes the role of FNA as a useful modality in the early diagnosis of cutaneous cryptococcosis, especially in clinically unsuspected cases.

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Hemodialysis (HD) patients are at considerably high risk for vascular access-related blood stream infections (VRBSI) that result in serious complications. Such severe infections are a great deal more frequent with central venous catheters (CVCs) and polytetrafluoroethylene (PTFE) grafts than with arteriovenous fistula (AVF). Nonetheless, the CVCs, though having "undesirable" side effects, remain "unavoidable" for the patients requiring instant dialysis access, as a consequence of the unpredictable course of chronic renal disease. Although early antibiotic treatment should include the coverage for Staphylococcus aureus, the treatment of catheter-related blood stream infections (CRBSI) remains controversial. Antimicrobial- anticoagulant 'locks' have shown promising results in several recent randomized controlled trials in the treatment and prevention of CRBSI. Policy of increasing AVF prevalence beyond 50% is bound to have an enduring positive effect on HD outcomes. Standard infection control measures for hygiene and aseptic handling of CVCs cannot be overemphasized. The catheters with 'bioactive' surface with thrombo-resistant and infection-resistant properties will be available in the near future.

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BACKGROUND: Fine-needle aspiration biopsy (FNAB) may yield different results depending on its operator. We compared the proportions of unsatisfactory aspirates obtained by pathologists vs. surgeons. METHODS: In a retrospective review, all FNAB reports and slides performed between March 2002 and February 2003 were grouped by organ/site and according to whether they were done by a pathologist or a surgeon. The proportions of unsatisfactory aspirates for pathologists and surgeons were compared. RESULTS: Of 692 FNABs, 390 were performed by pathologists at the FNAC clinic and the remainder by surgeons. Overall, 15.5% of aspirates obtained were unsatisfactory (n=107). Of aspirates obtained by surgeons, 29.5% were unsatisfactory, compared to 4.6 % of those obtained by pathologists (P<0.001). Pathologists had significantly lower proportions of unsatisfactory aspirates in all sites. A 33% reduction in the number of lymph node excisional biopsies has been reported subsequent to establishment of the FNAC clinic. CONCLUSIONS: The advantages of a pathologist performing FNAB are that a rapid evaluation can be rendered regarding specimen adequacy and the need for repeating the procedure. In addition, pathologists can direct the distribution of aspirated material for other tests such as culture study, flow cytometry and electron microscopy, as indicated by preliminary evaluation of the smears. These factors significantly lower the proportions of unsatisfactory specimens and improve the diagnostic accuracy of FNAB technique.

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OBJECTIVE: To determine the diagnostic accuracy of cervical lymphadenopathy by fine needle aspiration (FNAC) and imprint cytology (IC). METHODS: This study included 94 patients with cervical lymphadenopathy. This study was carried out in the Departments of General Surgery and Pathology, King Fahad Hospital, Hofuf, Kingdom of Saudi Arabia, from June 2001 through to July 2002. They were subjected to clinical examination and FNAC of one of the enlarged lymph nodes. This was followed by IC and histological examination of this lymph node after its excision. RESULTS: Clinical examination was correct in 78% of the cases. The overall accuracy of fine needle aspiration was 93%. It was accurate on all cases of reactive hyperplasia, 93% of tuberculosis lymphadenitis, 90% in Hodgkin's lymphoma, 86% in non-Hodgkin's lymphoma, and 91% of metastasis lymphadenopathy. On the other hand, the overall accuracy of IC was higher than that of fine needle aspiration, being 97%. It diagnosed all cases of reactive hyperplasia and non-Hodgkin's lymphoma, 97% in tuberculosis lymphadenitis, 90% in Hodgkin's lymphoma and 95% in metastasis lymphadenopathy. CONCLUSION: These techniques proved to be reliable, rapid, and inexpensive procedures in diagnosis of lymphadenopathy. They can differentiate well between inflammatory and neoplastic lesions, in cases of lymphoma, cytological diagnosis should be followed by histological diagnosis for accurate classification and grading.

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We describe a case of thyroid marginal-zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) with extreme plasmacytic differentiation in an 80-year-old woman who had presented with a rapidly growing thyroid swelling. The diagnosis was initially suspected on fine-needle aspiration (FNA) and subsequently confirmed by flow cytometric analysis of the aspirated material. The smears revealed features of Hashimoto's thyroiditis admixed with large numbers of atypical large plasmacytoid lymphoid cells accompanied by variable numbers of small lymphocytes and mature plasma cells. The differential diagnosis of a predominantly plasmacytic smears on FNA of the thyroid is discussed herein, with emphasis on the role of immunophenotypic studies to exclude or confirm the diagnosis of lymphoma.

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