Saudi Surgical Journal (Saudi Surg J) 2018 | October-December | Volume 6 | Issue 4

ORIGINAL ARTICLES
	Cone-beam computed tomography versus orthopantomography in sinus lift procedures: Two-dimensional versus three-dimensional imaging	p. 113
	S Manoj Kumar, Hazza Al Hobeira, Mohammad D Aljanakh, Sameer Shaikh, Kurian Ponnuse, Muthusamy Deivanayagi DOI:10.4103/ssj.ssj_53_17   Context: The present study was undertaken to do a comparative evaluation of the role of cone-beam computed tomography (CBCT) imaging and orthopantomography (OPG) for preoperative implant planning in combination with sinus grafting procedures to assess sinus anatomy and morphology and the existing bone height in three-dimensions (3D). Aim: The aim of the present study was to assess sinus anatomy and morphology and the existing bone height in all the 3D. Materials and Methods: Pre- and postoperative assessment of maxillary sinuses was done in 17 patients who underwent implant therapy in combination with sinus augmentation procedures using CBCT and OPG. These patients were subjected to orthopantomographs and CBCT imaging both preoperatively and postoperatively. CBCT imaging helped decide the type of sinus augmentation procedure best suited for the patients as per the individual needs and depending on the residual alveolar bone height, timing of implant placement, sinus morphology, anticipation of complication, and comparative analysis between pre- and postprocedural gain in vertical alveolar bone height and increase in bone density. Statistical Analysis Used: The results were tabulated and statistically analyzed using paired and unpaired t-tests. Results: In the majority of cases, there was a concordance between the treatment types based on pre- and postoperative CBCT scans. The assessment of sinus morphology revealed a significantly higher detection rate of aberrations in the form of sinus mucosal hypertrophy and septae on CBCT which were imperceptible on routine radiographs. The most appealing result was that vertical alveolar bone height could be measured precisely, and there was a significant increase in surgical confidence and a significantly better prediction of complications when using CBCT imaging. Conclusions: A preoperative planning based on CBCT imaging seems to improve sinus diagnostics and helps execute a better treatment plan. Furthermore, it is a good tool for the comparison of vertical alveolar bone height pre- and postoperatively following sinus augmentation procedures using various graft materials.
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	Correlations between parathyroid hormone level, adenoma size, and serum calcium level in patients with primary hyperparathyroidism	p. 122
	Jubran Al Faifi DOI:10.4103/ssj.ssj_79_17   Aim: The main goal of this study is to determine the association of preoperative parathyroid hormone (PTH) levels with parathyroid gland adenoma sizes and serum calcium levels in patients with primary hyperparathyroidism caused by single-gland adenoma. Methods: We included all patients with single parathyroid gland adenoma who were admitted to and underwent parathyroidectomy at Security Forces Hospital in Riyadh during a period of 10 years from January 1, 2000 to October 30, 2011. PTH level and serum corrected calcium were recorded 1 day before surgery. Adenoma size was recorded from pathology reports for all patients. Results: In 35 cases of parathyroid adenoma including 12 males (34.3%) and 23 females (65.7%) with an average age of 48.94 years (±13.52), the average PTH level 1 day preoperatively was 769.94 pg/mL (±793.27), the average largest dimension (LD) of parathyroid adenoma was 2.18 cm (±1.38), and the average calcium level 1 day preoperatively was 2.71 mmol/L (±0.3). The mean PTH level in males was 1098.5 pg/mL compared to 598.5 pg/mL in females (P =0.068), mean LD of parathyroid adenoma in males was 2.34 cm versus 2.09 cm in females (P = 0.72), and mean calcium level in males was 2.70 mmol/L compared to 2.72 mmol/L in females (P = 0.46). A positive correlation was found between PTH level and adenoma size, with a correlation coefficient of 0.29 (P = 0.095). The correlation between PTH level and calcium level was negative, with a correlation coefficient of −0.033 (P = 0.85). Negative correlation was also found between adenoma size and calcium level, with a correlation coefficient of −0.033 (P = 0.85). Conclusion: Based on the findings of this study, preoperative PTH level or serum calcium level cannot be used to predict adenoma size. Further prospective studies with larger sample sizes are recommended.
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	Functional outcome of anterior cruciate ligament reconstruction in Saudi patients at Western Region	p. 127
	Hatim Mohammed A. AlShareef, Abdullah H AlZahrani, Shaima Sabar, Ahmed A Alharbi, Hajar Mohammed A. Halawani, Basem A Althinayyan, Bader K Alsheikh, Asim Aldaheri DOI:10.4103/ssj.ssj_17_18   Introduction: Anterior cruciate ligament (ACL) is an integral stabilizing structure of the knee. Rupture of the ACL impairs the stability of the knee leading to difficulty with athletic performance and increasing the risk of subsequent meniscal injury. It accounts for 50% of all knee ligaments injuries. ACL reconstruction (ACLR) is the gold-standard treatment to restore the stability of the knee and improve the function. We aimed to assess the functional outcomes of the ACLR in Western area of Saudi Arabia. Materials and Methods: One hundred and four patients who had ACLR between 2014 and 2016 in King Fahad Armed Forces Hospital, Jeddah, had participated in this study by filling a self-administer questionnaire. Oxford Knee Score consisting of 12 questions is a valid and sensitive tool to assess the function and pain after ACLR. Results: One hundred and three male (99%) and one female (1%) were included in the study with a mean age of 34.92 (standard deviation [SD] of 8.3) years and mean body mass index of 27.69 (SD of 4.74) kg/m2. Sixty-five of them had results suggestive of satisfactory joint function (61.9%), 32 had results suggestive of mild-to-moderate knee pain (30.5%), 6 of had moderate-to-severe knee pain (5.7%), and only one had a result of severe knee pain. The most common difficulties claimed by the participants, rated 1 or 2 in the score are: persistent pain (16 out of 104, 15.4%), pain with kneeling (14 out of 104, 13.5%), usual daily chores (10 out of 104, 9.6%), and knee pain at night (9 out of 104, 8.6%).Conclusion: Majority of the participants were satisfied with the ACLR representing more than 60% of patients. On the other hand, out of 104 participants, only one had the worst outcome representing < 1% of the sample size.
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	Pain-free liver retraction: A simple technical innovation	p. 132
	JS Rajkumar, Anirudh Rajkumar, Hema Tadimari, Dharmendra Kollapalayam Raman, S Akbar, V Sai Vishnupriya DOI:10.4103/ssj.ssj_19_18   Aim: To present an innovative pain –free liver retraction. Introduction: Retraction of the left lobe of the liver is a vital step in most of the upper gastrointestinal laparoscopic surgeries. For these procedures, a subxiphoid port, 5 or 10 mm, is used to insert a liver retractor to keep the left lobe of the liver out of the operative field. We describe a simple, but effective and economical alternative technique, using the core shaft of the dismantlable laparoscopic hand instruments. Patients and methods: Over a 3-month period, all upper gastrointestinal laparoscopic surgeries, were done with the liver retraction performed with the core shaft of the dismantlable laparoscopic instrument. There were 41 surgeries in all, which were mainly bariatric surgeries, antireflux surgeries, and Heller's myotomy. The endpoint of the study was to evaluate how useful this modified liver retraction was as a technique, and failure of the retractor was defined as a need to convert into a 5-mm fan liver retractor. Results: Of the 41 patients operated in a 3-month period, only in two cases, both undergoing RYGB, who had enlarged fatty liver, a 5-mm metallic fan retractor was found to be necessary to complete the proposed surgery, with a conversion ratio of 4.9%. Conclusion:The two mm 'insert', the shaft of the dismantlable laparoscopic hand instruments is a safe and effective option for liver retraction in most of the upper GI laparoscopic surgeries.
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	Assessing postsurgery body mass index reduction and identifying factors associated with greater body mass index reduction in a sample of obese patients who underwent weight-loss surgery in Saudi Arabia	p. 136
	Anwar E Ahmed, Wala R Alanazi, Rayan A Ahmed, Wijdan AlJohi, Doaa A Al Buraikan, Budor A Al Rasheed, Bashayr I Al Muqbil, Amen A Bawazir, Ali M Al Shehri, Hamdan Al-Jahdali DOI:10.4103/ssj.ssj_21_18   Background: Although evidence exists that bariatric surgery can provide substantial weight loss and body mass index (BMI) reduction. However, there is a limited data about this topic among the Saudi population. The purpose of this study was to assess postsurgery BMI and identify factors associated with greater BMI reduction. Methods: A retrospective study was conducted of 318 obese patients who underwent laparoscopic sleeve gastrectomy (LSG) or Roux-en-Y gastric bypass (RYGB) at King Abdulaziz Medical City in Riyadh, Saudi Arabia, in the period between January 1, 2001 and March 31, 2017. The outcome assessed was a reduction in BMI within 12 months after surgery, and a reduction of ≥20, indicating a greater BMI loss. Results: Patients with BMI value >40 had markedly decreased from 81.5% at the baseline to 25.6% at 12 months. Greater BMI loss occurred in 12.03% of the patients. Mixed-model and Tukey multiple comparison tests show a great decrease in BMI over time, but no significant differences in BMI between surgery types: LSG and RYGB. According to bivariate logistic analysis, greater BMI reduction was noted in the male gender (odds ratio [OR] = 2.493, P = 0.017) and patients with obstructive sleep apnea (OSA) (OR = 3.130, P = 0.029). A multivariate logistic analysis showed that young age (adjusted OR = 3.755, P = 0.028) and OSA (adjusted OR = 5.034, P = 0.023) were associated with a greater BMI reduction at 12-month postsurgery. Conclusions: The study has shown that bariatric surgery led to a significant reduction in BMI, which may result in resolving a number of obesity-related comorbidities. Being young and OSA were associated with significant reduction. The procedure types, RYGB and LSG, yielded similar reduction in BMI. It is important to evaluate baseline data as it may influence BMI reduction and aid management.
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	Factors influencing decision of medical students in choosing a surgical specialty: A cross-sectional study	p. 141
	Hesham Fouad Barradah, Mohammed Ridha Algethami, Jehad Basem Bambi, Mazin Abdul Manan Alsayed, Nabeel Ghazwan Mahmalji, Mahmoud Fakiha, Hisham Rizk DOI:10.4103/ssj.ssj_28_18   Introduction: It has been noticed that the surgical field has been facing shortage in the workforce in many countries. This study aimed to take a closer look on the possible factors influencing medical students' decision in choosing surgical specialty. These factors include the gender, nationality, living conditions, the effect of the mentors during medical school years, and satisfaction with the training programs. We aim to assess different factors that affect the decision-making of medical students in Saudi Arabia when choosing a surgical specialty. Methodology: (a) A cross-sectional study was conducted at King Abdulaziz University in Jeddah. Participants were from King Abdulaziz university medical students, from preclinical years (2nd and 3rd), and clinical years (4th, 5th, and 6th). Students from other colleges and universities were excluded from the study. A questionnaire utilizing the fivepoint Likert Scale ranging from 1 (strongly disagree) to 5 (strongly agree) was used when asking students about their opinion in choosing a surgical career. Results: A total of 329 medical students completed the questionnaire. Significant demographical differences were found regarding housing and physical training (P = 0.006 and P = 0.004). Fifty-two (15.8%) and 61 (18.2%) participants showed interest in general surgery and cardiothoracic surgery, respectively. Females were mostly interested in cardiothoracic surgery (18.9%), with significant difference (P = 0.007). Conclusion: The majority of medical students are willing to pursue a surgical career and most of them believe that overseas have a good surgical training program. Based on our result, we recommend that more lectures, campaigns, and workshops should target medical students to increase their knowledge about these potential factors that could alter their decision when choosing a surgical career.
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CASE REPORTS
	Bizarre presentation of solitary rectal ulcer syndrome mimicking rectal malignancy with impending bowel obstruction	p. 146
	Khaled Elsayed Elshaar, Laila H AbuAleid, Nabil T Mikhail DOI:10.4103/ssj.ssj_30_18   Solitary rectal ulcer syndrome (SRUS) is a rare benign and chronic rectal disease that has a wide spectrum of clinical presentations with variable endoscopic findings. It mostly occurs between 20 and 29 years of ages and gives a significant female preponderance. A 23-year-old female presented with 2 years history of constipation and bleeding per rectum, with a recent complaint of tenesmus, inability to defecate along with abdominal distention, and vomiting. She was on mesalazine as advised by the gastroenterologist, without improvement. Contrast-enhanced computed tomography (CECT) abdomen showed circumferential poorly enhancing 8 cm rectal mass starting 10 cm from the anal verge with multiple mesorectal lymphadenopathy. Colonoscopy showed hard, ulcerating rectal mass obstructing the lumen, highly suspicious for malignancy. Endoscopic biopsy showed the features suggesting SRUS. However, as the patient had impending colonic obstruction along with the doubtful presence of underlying malignancy, we prepared her for exploratory laparotomy, which revealed a hard midrectum 5 cm × 5 cm × 6 cm mass, so low anterior resection had done with stapled colorectal anastomosis. Paraffin section proved the diagnosis of SRUS. SRUS should always be considered in young patients with malignant-mimicking rectal mass. A differential diagnosis of SRUS should always be kept in mind for mural thickening of the rectum on CT. However, it is important not to miss a diagnosis of rectal cancer over the diagnosis of SRUS.
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	Synchronous laparoscopic cholecystectomy and mesh repair of incarcerated femoral hernia: Is it feasible?	p. 151
	M Ezzedien Rabie, Abdelelah Hummadi, Mohammad Osama DOI:10.4103/ssj.ssj_77_17   Cholecystectomy and hernia repair are common surgical procedures. While laparoscopic cholecystectomy is the gold standard for managing gallstone disease, the situation is not similar for laparoscopic hernia repair, as the debate between the laparoscopic and open approaches continues. However, laparoscopic femoral hernia repair has been recommended by some, especially in females. In this report, we describe the clinical course of a 53-year-old female with chronic calcular cholecystitis, who presented with incarcerated femoral hernia. The patient underwent laparoscopic cholecystectomy and mesh repair of her femoral hernia. The challenge, in this case, was the application of a mesh after cholecystectomy and in the presence of hernia incarceration, with both posing a potential risk of mesh infection. However, with proper precautions to avoid bile spillage and suction irrigation to clean the hernia operative site, together with the administration of an antibiotic coverage, a successful outcome was obtained. To our knowledge, this is the first report on simultaneous laparoscopic cholecystectomy and incarcerated femoral hernia repair.
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	Primary mucinous eccrine adenocarcinoma of anterior chest wall	p. 156
	M Ramula, M Mohan Raj, R Ram Prasath DOI:10.4103/ssj.ssj_25_18   Mucinous eccrine carcinoma is a very rare cutaneous malignancy, rarely documented in literature (0.05%.) It is commonly found in lower extremities. It is a tumor of old age. Diagnosis is mainly by histopathological report, as clinical diagnosis is very difficult. A 60-year-old female residing nearby village presented with lump left breast of 6 months. A solitary lump left breast was present over nipple areola with no regional lymph nodes. Mucinous eccrine tumors are common in the 6th decade with male: female ratio 2:1. They present as nodular cutaneous swelling with no distinct clinical features, making it difficult to diagnose preoperatively. They metastasize to regional lymph nodes, lungs, liver, and bones. Five-year survival rate is 59% without metastasis. It comes down by 9% with lymph node involvement. Surgery is the principal mode of treatment; Histopathological examination confirms the diagnosis and since the cells are rich in glycogen they stain with PAS. Difficult to distinguish except by Hisochemistry from adnexal tumors. Immunohistochemistry aids in confirming the diagnosis. Primary mucinous adenoma with reported incidence of 0.05% is one of the rarest tumors. Immunohistochemistry complement in confirming the diagnosis. Wide excision is the treatment of choice. Close follow-up is essential.
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