DIETARY LIFESTYLE, HYPOALBUMINAEMIA AND ANAEMIA AMONG OLDER ADULTS ATTENDING A PRIMARY CARE CLINIC IN NIGERIA: A CROSS-SECTIONAL STUDY

Introduction

Anaemia has been extensively studied in children and women of reproductive age. However, there are few data on anaemia and related conditions in the elderly from developing countries.

Objectives

To determine the prevalence and severity pattern of anaemia, and assess the relationship between dietary lifestyle, hypoalbuminaemia, and anaemia in older persons.

Methodology

A cross-sectional study involving 378 patients aged≥60 years who presented at the General Outpatient Clinic. Dietary lifestyle was assessed using a structured questionnaire. Samples were collected for packed cell volume and serum albumin. Inferential statistical analyses were used to determine the associations between variables.

Results

A total of 348 respondents completed the study. The mean age of respondents was 67.83 ±7.53 years with female (60.9%) predominance. The prevalence of anaemia and hypoalbuminaemia were 42.2% and 17.8% respectively. Hypoalbuminaemia (β=0.335, 95%CI=0.131-0.229, P<0.001), long duration of co-morbidities (β= - 0.179, 95%CI= -0.165-0.047, P<0.001), one full meal/day (β=0.130, 95%CI=0.224-1.879, P=0.013), and low monthly income (β=0.122, 95%CI=0.179-1.543, P=0.026) were the predictors of anaemia among the elderly in this study.

Conclusion

Data on the predictors of anaemia from this study will be useful in developing guidelines and strategies for managing the condition in primary care settings and other similar sites.

Functional and Aesthetic Outcomes of No-Dissection Nasal Dorsum Using Subdorsal Septal Excision in Preservation Rhinoplasty

BACKGROUND

Dorsal preservation (DP) caused privilege change in the concept of rhinoplasty and a promising superior functional and aesthetic transformation in rhinoplasty surgery. Avoiding dissection of the dorsal nasal bone and cartilage will leave the soft-tissue envelope intact, leading to a fine and smooth appearance, faster operation with less subsequent edema, and overall preservation of the dorsal aesthetic line.

METHODS

This prospective study included 113 patients who underwent DP rhinoplasty for nasal hump treatment with minimum dissection of nasal dorsum soft-tissue envelope. Results were evaluated using the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS).

RESULTS

The mean preoperative SCHNOS score was 7.21; the mean obstructive score was 2.95 ± 1.068 and the mean aesthetic score was 4.27 ± 0.771. The average lowering of the dorsal hump was 4.4 mm. Approximately 96% of patients showed improvement in the SCHNOS score after surgery, 86.7% (98 patients) showed improvement in the obstructive symptoms and 95.6% (108 patients) showed improvement in the aesthetic score. Complications were seen in 22.11% (most commonly residual hump in 13.27% of cases and dorsal indentation in 5.31%), bleeding was seen in 2.65%, and granuloma formation at the dorsal osteotomy site was seen in 0.88%. There was a very significant improvement in the aesthetic, obstructive, and overall SCHNOS score ( P = 0.000) for each parameter.

CONCLUSIONS

DP rhinoplasty is a safe and very effective procedure, with very low risk of complications. Most of the treated patients have improvement of the obstructive and aesthetic outcome after surgery.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

The clinical behavior of different molecular subtypes of breast cancer

BACKGROUND

Breast cancer is a heterogeneous group of tumors classified, according to different gene expressions that encodes for the hormone receptor status, into 4 main categories which are: luminal types A and B, triple negative/basal-like, and Her-2 molecular subtypes.

PATIENTS AND METHODS

This retrospective study included 311 breast cancer females. Patients were classified according to the expression of hormone receptors into: Luminal-A, luminal-B, HER-2 enriched and basal-like types. All groups were then studied for differences in clinical course of the disease.

RESULTS

Luminal-B type was the commonest molecular type (43.73%). Invasive ductal carcinoma was the commonest histological type (89.1%). Stages IIB and IIIA were the commonest clinical stages (24.4% & 22.2%) respectively. Most patients had no recurrence (85.5%), the commonest recurrence was local and axillary ones (7.1%). Low grade tumors were less frequent than intermediate and high grades (3.5%, 51.1%, and 45.3%). We found a significant correlation between molecular subtypes and survival status, tumor grade, and histopathological types (P values 0.029, 0.001, and 0.006) respectively, while it was not significant with age, BMI, recurrence & metastatic disease, overall survival, and TNM stage (P values 0.648, 0.398, 0.5, 0.063 and 0.319).

CONCLUSION

Luminal types A and B are the commonest molecular subtypes of breast cancer. Luminal type A is associated with improved survival, and basal like has the highest breast cancer fatality rates. Invasive ductal carcinomas of specific types mostly found in patients with luminal types A and B, while other rare forms like Paget's disease was diagnosed HER-2 enriched types.

Impact of miR-155 (rs767649 A>T) and miR-146a (rs57095329 A>G) polymorphisms in System Lupus Erythematosus susceptibility in an Egyptian cohort

OBJECTIVE

Systemic Lupus Erythematosus (SLE) is an autoimmune inflammatory disease. miR-155 and miR-146a were expressed in many autoimmune diseases such as rheumatoid arthritis. The aim of this study was to examine miR-155 rs767649 and miR-146a rs57095329 polymorphisms in SLE susceptibility in an Egyptian cohort and to investigate the correlation between them and clinical data and disease activity.

PATIENTS AND METHODS

The two SNPs were analyzed in 120 patients with SLE and 100 healthy controls using RT-PCR.

RESULTS

The TT genotype and T allele of miR-155 rs767649 were associated with a significant increase in the risk of SLE, particularly in females. On the other hand, miR-146a (rs57095329) polymorphism was not associated with SLE risk. The AT/TT genotypes of miR-155 rs767649 showed higher distributions among patients with higher SLEDAI and nephritis.

CONCLUSIONS

This study had demonstrated for the first time the association between miR-155 rs767649 and the risk of development of SLE in an Egyptian cohort, mostly in females.

The correlation of antioxidant levels of breast cancer: A case controlled study

Many free radicles are implicated to activate a number of oncogenic signaling, cause damage to deoxyribonucleic acid and tumor suppressor genes, or promote expression of proto-oncogenes. Reduced level of antioxidants and increases oxidative stress markers are associated with the development of various types of cancer.This prospective study included 60 women who were grouped into equal groups. Patients group included 30 breast cancer women and control group consisting of 30 apparently healthy women. Both groups were compared regarding the serum levels of antioxidants biomarkers (vitamin C, ceruloplasmin, glutathione) and oxidative stress biomarkers, malondialdehyde (MDA), peroxynitrite, and gamma-glutamyl transferase.In regard to the antioxidant biomarkers, there was a significant difference between the patients and the controls regarding the levels of serum ceruloplasmin and glutathione, (P values .000) for each while vitamin C showed no significant correlation (P value .053), while regarding oxidative stress biomarkers, the correlation was significant for both peroxynitrite and MDA (P value .000 and .001) respectively, and not significant for gamma-glutamyl transferase (P value 1.00).Reduced level both ceruloplasmin and glutathione is seen in patients with breast cancer while vitamin C is not associated. Elevated levels of both peroxynitrite and MDA is seen in patients with breast cancer which may be used as serum markers for the early detection of breast cancer.

Can mini PCNL achieve the same results as RIRS? The initial single center experience

BACKGROUND

Urolithiasis is a prevalent disease worldwide with high recurrence rate, minimally invasive interventions have largely replaced open ones, namely PCNL and RIRS. Miniaturization, optical improvements, and modern laser types made these procedures safe and effective in the management of single renal stones.Aim of the study: Is to compare the effectiveness of mini PCNL with RIRS in the treatment of single renal stone of ≤25 mm.

PATIENTS AND METHODS

This prospective study that included 60 patients with single renal stones of ≤25 mm and were treated by either mini PCNL (group A) or RIRS (group B). The study was performed during the period from October 2020 to April 2021.

RESULTS

The mean operative time RIRS group was 43.6 ± 10.493, while for miniPCNL it was 36.6 ± 7.035 (P = 0.004). The stone free rate in RIRS and miniPCNL group was 70% and 90% respectively (P = 0.053). The need for JJ stent was higher in RIRS compared to miniPCNL group (70% vs. 40%) respectively (P = 0.02). The duration of hospital stay in miniPCNL was 38.2 h compared to 16.7 h for RIRS group (p = 0.0001). The rate of postoperative hemoglobin drop was higher in MiniPCNL compared to RIRS (P = 0.0001). There was no significant difference regarding complication rates between both groups.

CONCLUSION

Mini-PCNL FOR the treatment of renal stones sized ≤25 mm has high stone free rate, shorter operative time, less requirement for JJ stent and near similar post-operative pain and complications compared to RIRS.

Missed Elevated Blood Pressure in Triaged Outpatients: A Preliminary Cross-Sectional Multicentre Study in Northern Nigeria

BACKGROUND

Hypertension is a common medical condition but largely undiagnosed, untreated, poorly controlled, and undertreated in low- and middle-income countries. Studies have reported missed hypertension during triage in Emergency Departments; however, little is known about missed elevated blood pressure (EBP) during triage in primary care settings. This study assessed the prevalence and predictors of missed EBP among triaged patients attending General Outpatient Clinics in Northern Nigeria.

METHODS

This was a descriptive cross-sectional multi-centre study involving 187 adults randomly selected from patients triaged in four General Outpatient Clinics in northern Nigeria. An investigator-administered questionnaire was employed to obtain data regarding participants' socio-demographic, triage blood pressure (BP) measurement, physician-led BP measurement, and physicians' clinical decision characteristics. Chi-square test and logistic regression analysis were used to determine factors associated with and predictors of missed EBP, respectively.

RESULTS

Participants' mean age was 40.6±14.7years. They were predominantly females (122, 65.2%). EBP was missed in 28 (15%) participants at the triage. Participants' age (>40years) (Odds ratio [OR]=3.82, 95% Confidence interval [CI]=1.43-10.22, P=0.008), study site (OR=0.32, 95% CI=0.12-0.82, P=0.018) and perceived receipt of explanation on BP measurement procedure (OR=2.97, 95% CI=1.25-7.07, P=0.014) were predictors of missed EBP among participants.

CONCLUSION

The prevalence of missed EBP was low but remarkable because of its huge public health implications. Age, study site, perceived receipt of explanation on BP measurement procedure predicted missed EBP. Effective interventions are needed to curtail missed EBP in these and similar settings.

Hydatid cyst of the ovary - a very rare type of cystic ovarian lesion: A case report

Background

Hydatid disease is a zoonotic condition caused by the adult or the larval stages of tapeworms belonging to the species Echinococcus granulosus or less commonly Echinococcus multilocularis. The presentation depends on the site of involvement. Many cases are not symptomatic and may be discovered accidentally. Hydatid cyst of the ovary is an extremely rare presentation and accounts for 0.2–1% of the diagnosed cases. It may be mistaken for ovarian cysts or cystic tumors of the ovary.

Case Presentation

An 18-year-old woman complained of episodes of lower abdominal pain and frequent urination for the last 3 months. During abdominal examination, there was deep tenderness in the supra-pubic region with no palpable organs or masses. Ultrasound of the abdomen showed evidence of cystic left adnexal lesions. A computerized tomography scan of the abdomen revealed evidence of cystic left adnexal lesion with no enhancement after contrast injection. Laparoscopy was performed and there was evidence of a hydatid cyst of the left ovary. The cyst was extracted from the cavity using a retrieval bag. Anthelmintic medications were prescribed for 3 months, and follow-up ultrasound after 6 months was normal.

Conclusion

A high index of suspicion is required for the diagnosis, particularly in the presence of any cystic lesion, in any part of the world. The enzyme-linked immunosorbent assay test may be informative in the active stages of the disease. Laparoscopic management involves cyst excision. Anthelmintic drugs are required after surgery to decrease the recurrence rate.

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Hydatid disease is common in certain parts of the world.

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The diagnosis is mostly radiological.

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Hydatid cyst of the ovary is often misdiagnosed as an ovarian cyst or tumor.

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Laparoscopic management involves cyst excision.

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Anthelmintic drugs are required after surgery to decrease the recurrence rate.

Comparison of multimodal analgesia with thoracic epidural after transthoracic oesophagectomy

BACKGROUND

Thoracic epidural analgesia (TEA) has been regarded as the standard of care after oesophagectomy for pain control, but has several side-effects. Multimodal (intrathecal diamorphine, paravertebral and rectus sheath catheters) analgesia (MA) may facilitate postoperative mobilization by reducing hypotensive episodes and the need for vasopressors, but uncertainty exists about whether it provides comparable analgesia. This study aimed to determine whether MA provides comparable analgesia to TEA following transthoracic oesophagectomy.

METHODS

Consecutive patients undergoing oesophagectomy for cancer between January 2015 and December 2018 were grouped according to postoperative analgesia regimen. Propensity score matching (PSM) was used to account for treatment selection bias. Pain scores at rest and on movement, graded from 0 to 10, were used. The incidence of hypotensive episodes and the requirement for vasopressors were evaluated.

RESULTS

The study included 293 patients; 142 (48.5 per cent) received TEA and 151 (51.5 per cent) MA. After PSM, 100 patients remained in each group. Mean pain scores were significantly higher at rest in the MA group (day 1: 1.5 versus 0.8 in the TEA group, P = 0.017; day 2: 1.7 versus 0.9 respectively, P = 0.014; day 3: 1.2 versus 0.6, P = 0.047). Fewer patients receiving MA had a hypotensive episode (25 per cent versus 45 per cent in the TEA group; P = 0.003) and fewer required vasopressors (36 versus 53 per cent respectively; P = 0.016). There was no significant difference in the overall complication rate (71.0 versus 61.0 per cent; P = 0.136).

CONCLUSION

MA is less effective than TEA at controlling pain, but this difference may not be clinically significant. However, fewer patients experienced hypotension or required vasopressor support with MA; this may be beneficial within an enhanced recovery programme.

Gallbladder agenesis: An accidental finding during laparotomy for hepatic tumor

BACKGROUND

Anomalies of the biliary system are frequently encountered. Agenesis of the gall bladder is a rare. The exact incidence is not known as most cases are asymptomatic and diagnosed incidentally during surgeries for unrelated conditions or at autopsy. This anomaly may occur alone or in association with other anomalies such as other biliary anomalies, portal vein anomalies and other vascular anomalies, or in some cases hepatic, gastrointestinal or anomalies in other body systems.

CASE PRESENTATION

An elderly man diagnoses with segment VI liver tumor and planned for surgical resection. During surgery we accidentally discovered gall bladder agenesis with slightly dilated common bile duct. The tumor resected successfully and the final diagnosis was well differentiated with hepatocellular carcinoma.

CONCLUSION

Careful search for the gall bladder must be done before diagnosing agenesis of the gall bladder. No conversion is required provided adequate visualization and search for the gall bladder is done during laparoscopy. Postoperative MCRP will define the biliary anatomy and to help the surgeons to have postoperative accurate decision.

Strangulated small-bowel internal hernia through a defect in the broad ligament of the uterus presenting as acute intestinal obstruction: A case report

Background

Internal hernias rarely lead to bowel obstruction; they are caused by a natural or unnatural opening within the peritoneal cavity. Defects in the broad ligament are extremely rare. Patients present with features of intestinal obstruction and most cases are diagnosed during surgery.

Case presentation

A 62-year-old parous woman presented with epigastric pain and attacks of vomiting for 1 week. The patient had had constipation for the last 5 days. She had no history of abdominal surgery. Abdominal examination revealed a distended abdomen with evidence of generalized abdominal tenderness.

Abdominal CT scan showed evidence of intestinal obstruction. During laparotomy there were dilated small-bowel loops with an evidence of internal hernia through a 3 cm × 3 cm defect in the left broad ligament, through which a segment of strangulated terminal ileum was passing. Resection of the strangulated bowel was performed with end-to-end intestinal anastomosis. The broad ligament defect was closed with a slowly absorbable suture material.

Conclusion

Surgery for intestinal obstruction due to internal hernias should follow the same principles of any case of intestinal obstruction, whether performed by the open conventional technique or laparoscopically. Surgery should not be delayed, to avoid increased morbidity and mortality. During surgery it is mandatory that the surgeon looks for any other possible defects and close them to avoid recurrence. Internal hernias caused by broad ligament defects are best managed by either closure of the defect or salpingectomy; the course of the ureter must be identified during surgery to prevent injury.

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Internal hernias caused by broad ligament defects are very rare.

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The defect in the board ligament may be unilateral or bilateral.

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Cystic remnants of müllerian ducts may rupture and result in such defects.

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Most cases are diagnosed intraoperatively.

Impact of vitamin D level on glycemic control in diabetes mellitus type 2 in Duhok

Background

Vitamin D deficiency is prevalent in most parts of the world. Its insufficiency or deficiency is implicated in bone diseases, some cancers, infectious diseases, heart disease, autoimmune and metabolic diseases including type 2 diabetes mellitus.

Results

The mean age of patients was 49.94 ± 9.36, while the mean age the controls was 48.95 ± 10.56. Females constituted 56.1% and males 43.9% in the cases group, while for the control group females were 54.8% and males were 43.9%. Low vitamin D levels were detected in 110 (71%) of cases and 63 (40.6%) of controls. There was a significant difference in vitamin D levels among cases and controls (p < 0.001), vitamin D level was lower among females compared to males, p < 0.001 and those living in urban areas compared to rural areas, p < 0.001, BMI and dyslipidemia had a significant effect on vitamin D levels among diabetics, p values 0.002 and < 0.001 respectively. The serum 25(OH)-D level was significantly lower in patients with poor glycemic control compared to those with good glycemic control and in patients with a diabetes duration greater than 5 years, p values < 0.001 and 0.002 respectively. No significant correlation was detected with age and smoking, p values 0.181 and 0.260 respectively.

Conclusion

There is a high prevalence of hypo-vitaminosis D among patients with type-2 diabetes, particularly among patients with poor glycemic control and in those with longer diabetes durations. Vitamin-D deficiency is more prevalence in females, and those living in urban areas, those with obesity and patients with dyslipidemia.

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Vitamin D deficiency is prevalent in most parts of the world.

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There is a high prevalence of hypovitaminosis D among patients with type 2 diabetes.

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Vitamin D deficiency is implicated many diseases including type 2 diabetes mellitus.

Dorsal urethro-cutaneous fistula caused by an impacted stone at the bulbar urethra: Case report

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Penile ureteral stones constitutes less than 1% of the urinary tract stones.

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They are either primary (native) or secondary (migrated).

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Secondary urethral stones are commoner and larger in size.

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The clinical diagnosis require high index of suspicion.

Background

Penile urethral stones are very and constitutes less than 1% of the urinary tract stones and commoner in males. They are either primary or secondary. The clinical diagnosis require high index of suspicion.

Case presentation

A 30-year-old male was complaining of penile pain, weak urinary stream and dribbling at the end of micturition for 2 months, later on he developed severe dysuria and a tender nodule over the dorsal penile surface. An attempted urethral catheterization was failed. There was no history of urethral trauma or instrumentation. Examination of genitalia revealed a normal meatus with a fistula at dorsal mid penile shaft and the urine were coming out from that opening with surrounding redness and edema with palpable firm nodule in the penile shaft. A pelvic x-ray revealed a mid-urethral radiopaque shadow, cystoscopy revealed an impacted stone in mid-bulbar urethra, attempts of stone extraction was failed. An open ventral urethral incision was made and the stone was removed, dorsal fistulectomy and repair was performed. Foley's catheter was placed and removed later after 21 days. The patient had uneventful postoperative period and the follow up was done up to 6 months with no postoperative complications.

Conclusion

The clinical diagnosis of penile urethral stones require high index of suspicion. Management options are variable depending on impaction site, the size, and associated urethral pathologies. The fistula tract require excised and repair.

Mammary duct ectasia in adult females; risk factors for the disease, a case control study

Introduction

Mammary duct ectasia is a common clinical condition characterized by abnormal dilatation of the central milk ducts with chronic inflammation and fibrosis, it may affect one or both breasts. Patients may be completely asymptomatic or have mastalgia or nipple discharge which is usually from multiple ducts. It mostly affects females and is very rare in males.

Patients and methods

This is a case control study which included 236 females grouped into two equal groups, the first group were patients with duct ectasia compared and the other one apparently healthy females and both groups were compared regarding different characteristics.

Results

Most patients were young with a mean age of 35 years, a most of them were overweight (42.4%) and obese (33.1%). Most were menstruating (86.4%) with regular cycles (79.7%). Most patients had breast pain (67.8%), tenderness (54.2%), and no nodularity (98.3%). About 47.5% had nipple discharge mostly from multiple ducts (43.2%), 52.5% had no discharge. There was a significant correlation between the development of duct ectasia and each of marital status, lactational status, coffee consumption, pain, nodularity, and breast tenderness (P values 0.026, 0.016, 0.034, 0.000, 0.000, and 0.000).

Conclusion

Duct ectasia is a very common complaint in females, it is commoner in overweight and obese females, married females and those with history of lactation. Coffee consumption may be a cause. The regularity of the menstruation has no correlation with its development. The presence of mastalgia, tenderness, and nodularity are highly suggestive for the disease.

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The breast is a dynamic structure that undergo various stages of development.

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Mammary duct ectasia is a common clinical condition.

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It may affect single breast or both breasts.

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It is common in obese females, married females and those with history of lactation.

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Patients have mastalgia, breast tenderness, and nodularity.

Mature cystic teratoma of the neck misdiagnosed at cystic hygroma; Case report

BACKGROUND

Teratomas arise from primordial germ cells which arrest during its migration from the hindgut allantois the gonads during the first weeks of gestational life, they may occur in both gonadal and extra-gonadal locations. They occur in 1/40,000 live births. The most common anatomical locations are the sacro-coccygeal region and the ovary, neck teratomas constituted about 1.5%. Malignant transformation has been reported.

CASE PRESENTATION

A 2-year-old boy presented with a gradually enlarging mass in the left side of the neck causing stridor and difficulties in respiration especially during sleep, the parents noticed difficulties during swallowing. The mass was misdiagnosed as cystic hygroma and the patient underwent 2 sessions of sclerotherapy with no improvement. Clinical examination showed a large mass in the left side of the neck which was multilobulated causing tracheal shift to the opposite side. There were no signs of inflammations over the mass. CT-scan showed evidence of enhancing multi-cystic lesion with multiple flecks of calcification. Complete surgical resection was done successfully and the histopathological study of the mass showed mature elements of ectodermal, mesodermal, and ectodermal germinal layers which was consistent with mature cystic teratoma. The follow up showed no postoperative complications.

CONCLUSION

Mature cystic teratoma of the neck is very rare and may be difficult to be differentiated both clinically and radiologically from other neck masses. The accurate diagnosis must be made before any kind of treatment is started. Complete surgical resection is the main management option and required to decrease the recurrence.

Effects of dietary supplementation of a probiotic (Bacillus subtilis) on bone mass and meat quality of broiler chickens

The aim of this study was to investigate the effect of a dietary probiotic supplement on bone mass and meat quality of broiler chickens. Two hundred ten 1-day-old male Ross 708 broiler chicks were divided among 21 floor pens (10 chicks per pen). The pens were randomly distributed to 1 of 3 dietary treatments containing a probiotic, Bacillus subtilis, at 0 (control), 0.25 (0.25X), and 0.5 (0.5X) g/kg (n = 7). Gait score, footpad dermatitis (FPD), leg straightness, and hock burn (HB) were examined at day 33, and a latency-to-lie test was performed at day 34. At the end of the experiment (day 35), plasma, right leg, and litter samples were collected for mineral contents, meat quality, bone morphometric parameters, and litter quality assessments. The results indicated that probiotic-fed birds stood much longer during the latency-to-lie test with a greater tibial length, weight, and strength as well as higher plasma levels of calcium and phosphorus compared with the controls. In addition, probiotic-fed birds' leg muscle had higher color lightness at both 30 min and 5 h postmortem and greater water-holding capacity with a trend for less cooking loss (P = 0.056) and lower pH values (P < 0.05) at 5 h postmortem. Probiotic-fed birds' leg meat was tastier (P < 0.05) at 24 h after slaughter. These probiotic effects were greater in the 0.5X group than in the 0.25X group. There were no treatment effects on other measured parameters including gait score, HB, FPD, tibial lateral and medial wall thickness, diaphysis and medullary canal diameters, robusticity and tibiotarsal indexes, plasma magnesium concentrations, and litter moisture and pH values (P > 0.05). These findings indicate that the probiotic supplement could be a useful management tool for improving broiler production and welfare by enhanced bone mass and meat quality.

Grading operative findings at laparoscopic cholecystectomy following the new scoring system in Duhok governorate: Cross sectional study

Introduction

Numerous preoperative scoring systems predict difficult laparoscopic cholecystectomy. Recently, the intraoperative difficulties which are facing surgeons are studied. A new scoring system categorize patients according to many intraoperative findings with a final outcome whether converting to open cholecystectomy or continuing laparoscopically.

Patients and methods

This prospective study included 120 patients admitted for laparoscopic cholecystectomy for symptomatic gallstones from October 2019 to August 2020. Intraoperative difficulties were evaluated and patients were categorized according to intraoperative scoring for cholecystitis severity and compared depending to the rate of conversion to the open technique.

Results

Most patient were middle aged females having multiple gallstones, the mean operation time was 35 min and 7.8% of patients were converted to open cholecystectomy because of intraoperative difficulty.

There was a significant correlation between the conversion rate and each of distended and/or contracted gall bladder, inability to grasp the gall bladder with traumatic forceps, stone ≥1 cm impacted in Hartman's pouch, and bile or pus outside gallbladder (P values: 0.002, 0.000, 0.008 and 0.015) respectively, and no significant correlation with gallbladder adhesions, adhesions from previous upper abdominal surgery, BMI>30, and Time to identify cystic artery and duct >90 min (P values: 0.123, 1, 1, 0.078) respectively.

Conclusion

New intraoperative scoring systems are valuable in predicting difficulties and preventing increase operation time and possible injuries. The main points of difficulties are distended or contracted gallbladder, large stone impaction, difficult grasping the wall of the gall bladder and the presence of bile or pus outside the gall bladder.

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Laparoscopic cholecystectomy is a safe procedure with some difficulties.

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The definition of difficult LC is not well established until now.

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Recently intraoperative difficulties facing the surgeons are studied.

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Inflammation, adhesions, and obesity are some factors for difficulty.

Triphallia (triple penis), the first reported case in human

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Supernumerary penises is an extremely rare congenital anomaly.

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It affects one in every 5–6 million live births.

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Each case has a unique presentation and no cases are identical.

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Around 100 cases of diphallia are reported till now.

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No cases of Triphallia is reported before.

Introduction

Supernumerary penises is an extremely rare congenital anomaly which affects one in every 5–6 million live births. Affected patients may have only a rudimentary penis, supernumerary penile glances or complete duplication or triplication of penises. Some patients may have some other associated congenital anomalies.

Presentation of case

A 3-month-old child presented because of left side hydrocele. There were evidence of two supernumerary penises in the perineum, the first one was about 2 cm in length with a glans and was attached to the root of the penis, and the third one was about 1 cm and was below the scrotum. Hydrocelectomy was performed. The two supernumerary penises were extending to perineal region and were attached to original penis, both had corpora cavernosum and spongiosum with no urethra inside. Both supernumerary penises were excised and both corpora were sutured with a fine slowly absorbable suture material. The patient was discharged with no postoperative events and follow up was done for one years with no reported adverse events.

Conclusion

Triphallia (three penises) is unreported condition in human until now. Patients with supernumerary penises have unique presentation and no cases are identical. The position of the penis may be ectopic or orthotopic. Treatment is difficult because it poses medical, ethical, and cosmetic aspects. A combined multidisciplinary team is required for the management and long term follow up is required. Excision or reconstruction of the duplicate penis is required depending on the corporal development and anatomy of the urethra.

Vitamin D level and endogenous DNA damage in patients with cancers in Duhok city, KRG-Iraq

Introduction

Many clinical and pre-clinical studies suggested the protective effect of vitamin D against cancer development and cancer progression. Vitamin D deficiency is highly prevalent worldwide, and its link to DNA damage is worthy to study. It has been shown that vitamin D supplementation can reduce the risk of cancer with a favorable prognosis. Studies on DNA damage in different types of cancer and its link to plasma vitamin D has not been found in literature.

Patients and methods

In this study we included 45 patients with different types of cancers and 35 healthy individuals as controls. The plasma vitamin D levels were measured in all participants. DNA damage levels of peripheral blood (mononuclear) cells in 45 newly diagnosed and untreated cancer patients and in 35 healthy individuals were measured using Alkaline Comet Assay technique.

Results

The DNA damage observed in cancer patients was significantly higher than in healthy individuals. Interestingly, we have found a significant inverse correlation between the plasma levels of vitamin D and DNA damage in cancer patients (p < 0.0001) and in healthy individuals (p < 0.001).

Conclusion

There is an inverse association between endogenous DNA damage and plasma vitamin D levels. Patients with vitamin D deficiency show highest levels of DNA damage suggesting that deficiency of vitamin D is probably one of the factors which increases the risk of cancer.

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Vitamin D deficiency is highly prevalent worldwide, and its link to DNA damage is worthy to study.

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Transformation of normal tissue to neoplasms are the result of molecular changes in genetic materials.

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Deficiency of vitamin D probably one of the risk factors of cancer.

Hamartoma of hypothalamus presented as precocious puberty and epilepsy in a 10-year-old girl

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Hamartoma of the hypothalamus may presents as central precocious puberty and gelastic epilepsy.

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It may be asymptomatic for long period.

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MRI is diagnostic in most of the cases.

Background

Hamartoma of the hypothalamus represents a well-known but rare cause of central precocious puberty and gelastic epilepsy. Due to the delicate site in which a tumor is located, surgery is often difficult and associated with considerable risks.

Case presentation

10-Year old girl presented with early and regular menstruation at the age of 1 year each cycle lasted for 3 days. She had developed breast, axillary and pubic hair at the age of five, and seven years respectively, with history of difficulty in speech especially articulation and epilepsy since childhood for which she is on medications. She had attacks of an inappropriate laugh. The laboratory tests were consisted with central precocious puberty, MRI shows suprasellar mass. She received leuprolide and antiepileptic medicines until surgery planned. Surgery was done with complete resection, with histopathology showing hypothalamic hamartoma. After surgery, there was complete remission of seizure.

She developed recurrence 4 years later and she is currently on anticonvulsant medications with few attacks of convulsions per week, and she has intellectual disabilities and low school performance.

Conclusion

The treatment of hypothalamic hamartoma associated with generalized epilepsy has been found to improve seizures and behavioral disturbances with an acceptable morbidity rate by using a variety of surgical approaches. Partial resection of a tumor may be sufficient to reduce seizure frequency and to improve behavior and quality of life with few side effects. Best outcomes are achieved when the patients are managed by an experienced multidisciplinary team and lifelong follow up is recommended.

Duodenal gangliocytic paraganglioma: A very rare cause for upper gastrointestinal bleeding: Case report with review of literature

INTRODUCTION

Gangliocytic paraganglioma is a rare tumors mainly arises from the second part of the duodenum. The tumor is generally benign, but some cases are associated with lymph node or distant metastasis. It must be differentiated from other tumors. The main treatment is good local surgical resection. Most patients have good prognosis after an appropriate resection.

CASE PRESENTATION

A 47-year-old male patient presented with recurrent attacks of epigastric pain and melena. The general examination revealed pallor with no jaundice. The abdomen was soft with no tenderness. There were no stigmata of chronic liver diseases. The hemoglobin level was 8 gm/dl with normal liver and renal functions. The patients received compatible blood. Endoscopy showed a large pedunculated polyp with ulceration in the second part of the duodenum just distal to ampulla of Vater. During surgery, the anterior wall of duodenum was opened, and a 4 cm pedunculated polyp was excised which was arising from the posterior wall of the duodenum just distal to the ampulla of Vater. The frozen section examination revealed a benign lesion. The final histopathology result was consistent with the diagnosis of gangliocytic paraganglioma. The patient had smooth post-operative recovery and no postoperative complications.

CONCLUSIONS

Gangliocytic paraganglioma is a rare tumor which mostly affects the second part of the duodenum. The tumor is considered benign but the possibility of the malignancy with lymphatic and distant metastases must be excluded before any surgery. The management plan must be addressed carefully and continuous follow up is recommended.

Crossed testicular ectopia: Case report with review of literature

BACKGROUND

Crossed testicular ectopia is a rare form of urogenital anomalies in which both testes are migrated and descend through a single inguinal canal, one or both testes may be ectopic in the abdomen, the inguinal region or descent to the hemi-scrotum with empty contralateral hemi-scrotum.

CASE PRESENTATION

A 1.5-year-old male patient had an empty left scrotum with no palpable testis in the inguinal region with a palpable testis in the right scrotum with palpable other testis in the right inguinal region. Ultrasound examination showed the right testis in the right scrotum and another testis measuring in the right inguinal region giving suggestion of both testes in the right side. During operation two testes was found in the right inguinal region with two small indirect inguinal sacs. Herniotomy was performed for both sacs. The right testis was placed and fixed in the right hemi-scrotum and the left testis was fixed in the left hemi-scrotum through trans-septal window.

CONCLUSION

During surgery, the surgeon should adopt a conservative approach to preserve the fertility. Trans-septal orchiopexy or extra-peritoneal transposition orchiopexy is advised. In case of persistent Müllerian duct syndrome, preservation of the Müllerian remnants is recommended to preserve blood supply to the vas deferens and testis. Karyotyping may be required in some cases specially if associated with other congenital anomalies of the genitalia. Patients usually need long term follow up because such patients may have future fertility problems and there is an increased risk of the development of testicular cancer.

Effects of thyroid dysfunction on hematological parameters: Case controlled study

Introduction

The thyroid gland has a very important role in hematopoiesis, blood disorders are frequently seen in patients with thyroid disorders. Thyroid hormones have direct effect on blood parameters by stimulating erythrocytes precursors and indirectly by enhancing erythropoietin production.

Patients and methods

This is a case-control study which included 300 subjects who were grouped to 3 equal groups as a control, hypothyroidism, and hyperthyroidism groups. Patients with inherited or acquired red cell abnormalities, those receiving treatment for thyroid disorder or anemia, patient with chronic diseases, aged <12 years, pregnant ladies and patients unwilling to participate in the study were excluded.

Results

The mean age of patients is 40.72 years, and females constituted 60.7% of cases. The analyses showed a significant difference the RBC, HB, MCV, MCHC, RDW, and WBC (P values 0.000, 0.000, 0.001, 0.012.0.002, and 0.027) respectively, while platelets showed no significant correlation (P value 0.08). The univariate analyses showed that RBC, the HB, and the WBC were the most severely affected parameters (Sig. 0.000, 0.000, and 0.005) respectively.

Conclusion

The study concluded that females are more affected by thyroid disorders than males and the peak age is at the forties, thyroid dysfunction affect all blood parameters except platelets.The follow up of patients with thyroid disorders should include the complete blood count and patients diagnosed with anemia should be evaluated for thyroid disorders before iron therapy. Cases of anemia that resist treatment should be investigated for the possibility of thyroid dysfunction.

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The thyroid gland has a very important role in hematopoiesis.

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Females are more affected by thyroid disorders than males.

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Thyroid hormones directly stimulate erythrocytes precursors and indirectly by enhancing erythropoietin production.

Agenesis of the gall bladder, an unexpected finding during laparoscopy; case report

Congenital agenesis of the gall bladder is a very rare ranging from 0.02% to 0.002% in clinical practice. There is complete absence of the gall bladder with normal intra and extra hepatic biliary tree. The exact etiology remains unclear. Low index of suspicion and failure of routine investigations will result in its unexpected discovery during surgery. The condition usually results in diagnostic dilemma both before surgery and intraoperatively. A 25-year-old lady presented with repeated attacks of right side abdominal pain for 1 year. Abdominal examination showed tenderness on palpation in the right hypochonrdium. Abdominal ultrasound showed normal common bile duct with suspicion of small contacted gall bladder. MRCP showed extrahepatic biliary tree and not visualized gall bladder. During diagnostic laparoscopy exploration of the whole peritoneal cavity was performed. The gall bladder was not visualized after complete visualization of biliary anatomy. The appendix was inflamed with multiple adhesions with the bowel. The cecum was high placed in the sub-hepatic region. Laparoscopic appendicectomy was performed. Patients with gall bladder agenesis surprisingly have symptoms similar to cholecystitis, the pain may be attributed to cholangitis, biliary stones, or sphincter of Oddi dysfunction. When the condition diagnosed at operation extensive dissection to identify the gall bladder must be avoided because it may result in biliary injury.

Gastro-colo-bronchial fistula after laparoscopic sleeve gastrectomy; case report

Obesity and its related comorbidities is a major health problem worldwide. Sleeve gastrectomy is regarded to be one of the most effective bariatric surgeries with a relatively low risks of complications. Gastrobronchial fistula is an extremely rare and a serious complication after bariatric surgeries, it is associated with major morbidity.

A 48-year-old obese lady with a BMI of 40 had underwent laparoscopic sleeve gastrectomy 7 years ago, she developed leak at the 10th postoperative day which was treated with drainage. After 4 years she presented with left subphrenic abscess which was treated with drainage, splenectomy and endoscopic stent. After one year she had repeated chest infections and was coughing-up recently ingested food items. CT-scan showed left subphrenic collection with abnormal fistulous tract between the bronchial tree and the subphrenic cavity. Left thoracotomy was performed, a complex fistula was found between the remnant parts of the gastric fundus, transverse colon and lung. Resection of the fistula was performed, the stomach and colon were closed in 2 layers, resection of the affected segment of lung was performed and the diaphragm was sutured. The BMI was 19 at the last admission.

Gastro-colo-bronchial fistula is unreported after sleeve gastrectomy and the management is challenging. Surgeons may follow the same principles of management as in cases of gastrobronchial fistula, but we suggest earlier surgical intervention with the administration of broad spectrum antibiotics. Nutritional deficiencies must be corrected, and such patients must be treated with multidisciplinary team, with an extended duration of follow-up.

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Sleeve gastrectomy is one of the most effective bariatric surgeries with a relatively low complication rates.

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Gastro-colo-bronchial fistula is unreported after sleeve gastrectomy and the management is challenging.

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Multidisciplinary team is required for the management of such patients.

Squamous cell carcinoma of the thyroid gland in an elderly female presenting as a rapidly enlarging thyroid mass

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Squamous cell carcinoma of the thyroid gland is an extremely rare tumor.

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It may be primary tumor within the thyroid gland or as a component of anaplastic or undifferentiated tumors.

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The tumor has a very aggressive clinical behavior with a median survival of few months.

Background

Squamous cell carcinoma of the thyroid gland is an extremely rare tumor with a very aggressive clinical behavior and poor prognosis. The tumor may arise as a primary tumor within the thyroid gland or as a component of anaplastic or undifferentiated thyroid tumors.

Case presentation

A 70-year-old lady with history of long standing multinodular goiter presented with progressive enlargement of a midline nodule for 3 months which was associated with dyspnea and dry cough. The mass was hard and fixed. The voice was normal, other parts of the general examination were unremarkable. Fine needle aspiration was done for the mass which revealed malignant cells mixed with inflammatory cells. During surgery there was a hard and fixed mass arising from the isthmus of the thyroid gland that was locally invading, complete excision was not possible, debulking was done. Histopathology showed moderately differentiated squamous cell carcinoma of the thyroid gland. The tumor underwent local progression 6 months later and the patient was sent for radiotherapy.

Conclusion

When thyroid tumor is advanced at time of diagnosis, radiotherapy is the main form of treatment which may induce reduction in the size of the tumor and decrease pain, radiotherapy may also be given on neoadjuvant bases which may render resection possible in some patients. The tumor is usually not responsive to chemotherapy. The overall survival is uniformly poor regardless of the primary form of treatment, the median survival of the patients from the time of diagnosis is few months in most cases.

Erectile dysfunction pre and post kidney transplant recipients in Duhok city; cross sectional study

Introduction

Sexual dysfunction is a common problem in patients with chronic kidney disease. Disturbances in sexual function are noticed in early stages of chronic kidney diseases and deteriorate further as renal function declines. This is due to uremic effects, comorbid illness, anemia, hormonal disturbances, autonomic neuropathy, vascular diseases, hyperparathyroidism, hyperprolactinemia, side effects of medications, and psychosocial factors.

Patients and method

This is a cross-sectional study which included 59 male patients who underwent renal transplantation for more than 6 months. The International Index of Erectile Function (IIEF-5) was adopted in our study to record the erectile function.

Results

The mean age was 49.41 years, and the mean number of hemodialysis per month was 5.31. The cause of the chronic kidney disease was diabetes mellitus in 35.59%, glomerulonephritis in 20.34%, and hypertension in 16.95%, other causes were diagnosed in order of decreasing frequency. Most patients developed improvement in the erectile function after transplantation. There was significant correlation with 3 of the elements of the IIFE-5.i.e; penile hardness pre-penetration, Maintaining erection during intercourse, and Difficulty to maintain erection to complete the intercourse (p values 0.015, 0.011, and 0.023) respectively, and the overall improvement after transplantation which showed a p-value of less than 0.031, while there was no significant correlation with Confidence with erection and Satisfaction with intercourse before and after transplantation (p values 0.113 and 0.121) respectively. One of the patients (1.7%) developed severe dysfunction after that.

Conclusion

ED is common sequel of chronic kidney disease. The etiology is multifactorial and may be worsen by advanced age, presence of diabetes mellitus and prolonged duration of hemodialysis. Renal transplantation has a positive impact on sexual function and lead to improvement of erectile dysfunction. Erectile dysfunction that persists after kidney transplantation is usually attributed to multiple preexisting comorbidities.

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Sexual dysfunction is a common problem in patients with chronic kidney disease.

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The etiology of Sexual dysfunction is multifactorial.

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Renal transplantation has a positive impact on sexual function.

Two Concomitant Right Nonrecurrent Laryngeal Nerves Encountered During Thyroidectomy (Type 4 Course): Reported for the First Time

INTRODUCTION

The recurrent laryngeal nerve gains its name because after branching from the vagus nerve, it turns superiorly (recur) around the subclavian artery on the right and around the ligamentum arteriosum on the left, the nonrecurrent nerve has a straight direct course to the larynx and doesn't follow this course. It presents mostly on the right side. The presence of this variation places the nerve at higher risk of injury during neck surgery especially thyroid operations.

CASE PRESENTATION

A 45-year-old lady presented with painless thyroid enlargement for 1 year. Thyroid examination showed a 3-cm firm nodule at the right thyroid lobe with normal thyroid function tests. Right thyroid lobectomy was done and the histopathology showed a benign follicular lesion. During surgery, we discovered 2 nonrecurrent laryngeal nerves at the right side which were arising from the vagus nerve and both were entering the larynx.

CONCLUSION

Failure in identification of the nerve or overlooking the possibility of the non-recurrent laryngeal nerve may result in a serious sequelae of nerve damage, ipsilateral injury may lead to permanent hoarseness and bilateral injury may result in severe dyspnea or aphonia. Currently, there are 3 types of nonrecurrent laryngeal nerve courses. Type 1 passes near to the superior thyroid vessels. Type 2 (2A) passes parallel to the inferior thyroid artery and has a transverse course above it. Type 3 (2B) passes parallel to the inferior thyroid artery and transversely between branches of or under the inferior thyroid artery, we can add to this classification type 4, which are 2 nonrecurrent laryngeal nerves (double nerves) passing above and parallel to the inferior thyroid artery.

Evaluation of mastalgia in patients presented to the breast clinic in Duhok city, Iraq: Cross sectional study

INTRODUCTION

Mastalgia is a common condition that may affect up to two-thirds of patients during the reproductive period. It can be divided into cyclical and noncyclical. It is mostly due to benign causes, but breast cancer should be excluded. It may be associated with a high level of stress and anxiety. Patients need to be assessed fully, breast and general examinations, and investigations such as breast imaging and hormonal assay.

PATIENTS AND METHODS

This is a prospective study that was done in the breast clinic in the period between February 2019 and July 2019. A total number of 445 patients with mastalgia included were in the study. Patients were examined and evaluated using various imaging modalities.

RESULTS

The mean age of the patients was 34 years. Mastalgia was present in 54.2% of our patients, in about 70.1% of our patients it was noncyclical mastalgia. Mastalgia was positively correlated with smoking, oral contraceptive pills, and positive family history of breast cancer (p values: 0.000, 0.009, and 0.000) respectively with no correlation with other factors. The type of pain was less in women having early first pregnancy and with the site of the pain showed a positive correlation with the type of pain, (p values: 0.001 and 0.000) respectively.

CONCLUSION

Mastalgia is a common complaint which may affect most females. It is caused by benign breast disorders in the majority of patients. A systematic approach must be followed for the management of mastalgia. Reassurance, regular exercise, and local analgesics may be very effective initial measures. In severe, intractable cases, hormonal therapy may be used.

Intussusception of the vermiform appendix caused by mucinous tumor of the appendix: Case report

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Acute appendicitis is the commonest surgical emergency worldwide.

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Surgery is usually needed which could be done by open or laparoscopic techniques.

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Tumors of the appendix may cause intussusception of the appendix.

Introduction

Intussusception of the appendix occurs when part of the appendix passes the part next to it or the whole appendix to the cecum. It is classified as primary or secondary, or can be classified to partial or complete. Most cases are secondary and partial. Patients usually presents with right lower abdominal pain and most cases are diagnosed during surgery.

Case presentation

A 27-year-old female presented with right iliac fossa pain and nausea for 2 days. Abdominal examination showed tenderness, guarding, and rebound tenderness at the right iliac fossa. The WBC count was 11,000 c/mm and the urinalysis was normal.

At surgery, there was intussusception of the vermiform appendix in its middle part with palpable mass attached to its wall. Appendicectomy was performed successfully. The result of the histopathology was consistent with mucinous cystadenoma of the appendix with no evidence of malignancy.

Conclusion

Surgery is the main form of treatment as most of the cases are diagnosed during surgery, the operation type may include appendicectomy or more extensive surgery is required such as right hemicolectomy depending on the cause. Surgery can be performed laparoscopically. Trials of colonoscopic reduction are not recommended.

Lymphangioma of the ileum causing acute abdominal pain in an adult, a very rare finding during surgery; Case report with literature review

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Lymphangioma of the gastrointestinal tract is very rare, 75 % of the lesions affect the neck and 20 % affect the axillary region.

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The majority of cases are asymptomatic but some cases presented with emergency presentations.

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Complete surgical resection is the main form of therapy whenever possible.

Introduction

Lymphangioma of the gastrointestinal tract is very rare, 75 % of the lesions affect the neck and 20 % affect the axillary region, the rest are seen in the mediastinum, the visceral organs, the retroperitoneum, the mesentery, or in the bones. Lymphangioma of the gastrointestinal tract comprises less than 1 %. The majority of cases are asymptomatic but some cases presented with emergency presentations.

Case presentation

A 31-year-old male presented to emergency department complaining of central abdominal pain for 2 days, with nausea, dyspnea but no vomiting.

The abdominal examination revealed a mildly distended abdomen, with guarding and tenderness mainly in the right lower abdominal quadrant. There were no any palpable masses or organ enlargement. The white blood cells count was elevated (14,000 c/mm).

Abdominal ultrasound showed an evidence of 10*7 cm multiloculated thick walled lesion in the right lower abdomen, suggesting the possibility of an appendicular abscess. The patient was admitted for 2 days with little clinical improvement. Therefore, a laparotomy was performed at which there were 2 yellowish cystic lesions 60 cm from the ileocecal valve that were arising from each side of the small bowel and related to its mesentery causing luminal narrowing. Resection was done with end-end anastomosis. The histopathology results revealed a diagnosis of ill lymphangioma of the ileum.

Conclusion

Complete surgical resection is the main form of therapy whenever possible, sometimes is impossible when there is local invasion. When complete resection is performed long term follow up is not recommended as the recurrence is very rare.

Effect of synbiotics on thyroid hormones, intestinal histomorphology, and heat shock protein 70 expression in broiler chickens reared under cyclic heat stress

This study examined effect of a dietary synbiotic supplement on the concentrations of plasma thyroid hormones, expressions of heat shock protein 70 (HSP70), and intestinal histomorphology in broiler chickens exposed to cyclic heat stress (HS). Three hundred and sixty day old male Ross 708 broiler chicks were randomly distributed among 3 dietary treatments containing a synbiotic (PoultryStar meUS) at 0 (control), 0.5 (0.5×), and 1.0 (1.0×) g/kg. Each treatment contained 8 replicates of 15 birds each housed in floor pens in a temperature and lighting controlled room. Heat stimulation was established from days 15 to 42 at 32°C for 9 h daily. The results indicated that under the HS condition, both synbiotic fed groups had lower liver and hypothalamus HSP70 levels (P < 0.001) compared to control group; however, HSP70 mRNA expression was not different among treatments (P > 0.05). There were no treatment effects on the levels of triiodothyronine (T3) and thyroxine (T4) as well as T3/T4 ratio (P > 0.05). Compared to controls, 1.0× HS broilers had greater villus height in the duodenum (P < 0.01), and greater villus height and villus height:crypt depth ratios in the ileum (P < 0.01). There were no differences among treatments on the measured intestinal parameters in the jejunum (P > 0.05). The results suggest that the synbiotic may ameliorate the negative effects of HS on chicken health as indicated by the changes in the intestinal architecture and the levels of HSP70. Dietary synbiotic supplement could be a feasible nutritive strategy for the poultry industry to improve the health and welfare of chickens when exposed to hot environmental temperature.

Esophageal stricture as a complication of stent placement for leak after sleeve gastrectomy

Obesity is defined as body mass index (BMI) greater than 30. Weight loss improves the quality of life and alleviates or even treats some obesity-related comorbidities with general improvement in the quality of life. Sleeve gastrectomy results in major reduction of the size of the stomach and decreases the sense of hunger due to various hormonal and neuronal pathways. A 31-year-old lady had BMI of 49 underwent sleeve gastrectomy. Three weeks after surgery, she presented with epigastric pain and vomiting with radiological signs of leak. Endoscopic esophageal stent placed with resultant improvement of the condition; after stent removal, she developed esophageal stricture diagnosed with barium study. The patient underwent repeated successful endoscopic dilatation. Leak and bleeding are the most serious complications after sleeve gastrectomy. Subclinical leak is treated with antibiotics, drainage of the collection and stent, critical patients need stenting with operative repair of the site of leak.

Hydatid cyst of the fallopian tube; Case report with literature review

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Hydatid disease rarely affect the female genital organs.

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Most cases are seen in the liver and the lungs.

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Surgery is the main form of treatment which can be done laparoscopically.

Introduction

Hydatid disease is a zoonotic disease which is caused by a parasite belonging to the Echinococcus species. It may affect all part of the body mostly the liver and the lungs, involvement of the fallopian tube is a very rare.

Case presentation

A 30-year-female presented with acute lower abdominal pain, fever and vomiting for 2 days. The past medical history was negative and she had history of surgery for hydatid cyst of the right lobe of liver 3 years before presentation. During examination there was tenderness at the right iliac fossa with guarding. Ultrasound of the pelvic organs showed a left adnexial cyst. During surgery there was an evidence of hydatid cyst involving the left fallopian tube. Left salpingectomy was performed with excision of the cyst. The patient remained three days in the hospital with no reported complication.

Conclusion

Hydatid cyst is one of the differential diagnoses of any cystic lesion in patients from an endemic areas of hydatid disease. Hydatid cysts of the female pelvic organs may be diagnosed initially as ovarian cyst, ovarian tumor, or pelvic infection. Most of the cases are diagnosed during surgery which is the main treatment modality; anthelminthic medications may help to decrease the recurrence rate.

Hydatid cyst of the lumbar plexus: case report with review of literature

Background

Hydatid disease is widely distributed worldwide; it is caused by a parasite belonging to the Echinococcus species. It mostly affects the liver and the lungs, involvement of the spinal canal is reported to be around 0.2%, but affection of the peripheral nerves is extremely rare.

Case presentation

A 42-year-old lady was complaining from left loin pain and backache, with pain in the outer aspect of the left thigh for the last 5 years. During clinical examination, the ankle and the knee reflexes were normal and there was no muscle wasting. There was hyperesthesia on the outer aspect of the left leg.

Magnetic resonance imaging of the back demonstrated a cystic lesion between the 4th and the 5th lumbar vertebrae which was pushing the psoas muscle anteriorly and causing atrophy of the muscle. The patient received anthelminthic medications for 1 month before surgery with little improvement of the clinical and the radiological condition.

During surgery the cyst was found to arise from the lumbar nerve sheath and was apparent to be hydatid cyst because it was containing small daughter cysts. Isolation of the cyst was done and complete evacuation with deroofing of the cyst was done. The cavity of the cyst was irrigated with a solution of chlorhexidine as a scolicidal agent. The patient was discharged home after 3 days with no post-operative complications, anthelminthic medications prescribed for 3 months.

Conclusion

The treatment options vary depending on the region affected by the cyst; it may be treated by complete cyst excision, evacuation, and deroofing. Preventing spillage of the contents of the cyst during surgery and the use of scolicidal agents are mandatory to decrease the rate of recurrence. It is very important to exclude other organ involvement particularly pulmonary involvement before surgery.

Leiomyosarcoma of the inferior vena cava presenting as deep venous thrombosis; case report

Primary tumors arising from the inferior vena cava are extremely rare, leiomyosarcoma is the most common one arising from the smooth muscle cells in the media of the wall of the vena cava. A 42-year-old lady had epigastric pain and back pain for 4 months with signs of deep vein thrombosis of the right lower limb. CT-scan showed a mass related to the inferior vena cava which was proved by histopathological examination to be leiomyosarcoma of the inferior vena cava. A multidisciplinary team is required for the diagnosis and management of tumors the vena cava. Long term follow-up is recommended.

Quantitative assessment of Ki67 expression in correlation with various breast cancer characteristics and survival rate; cross sectional study

Background

Ki-67 is a cellular proliferative index that has variable expression during cell cycle. The absence of Ki-67 in the quiescent tissues and its expression in the proliferating cells had linked its possible role in the proliferative capacity of the tissues.

Materials and methods

This retrospective study included 314 patients with breast cancer who underwent various types of breast surgeries. Analyzed was done to find any possible correlation between the level of Ki67 and various patient and tumor characteristics and the survival rates.

Results

The mean age was 48.73 years, the overall survival was 30.77 months, 90.8% of the patients were alive and 8.3% died from breast cancer. In 85.67% no recurrence was reported and 5% had local and axillary recurrences, the commonest sites of metastases were bones and the vertebrae (2.2% and 1.9%) respectively. The mean size of the tumor was 34.39 mm and the mean number of the positive axillary nodes was 4. The expression of Ki67 was around 5–10% in the majority of patients, the mean expression was 28.54%. There was significant correlation between the level of Ki67 and the histopathological grade of the tumor, p value 0.003, and there was no significant correlation with other variables. There was no relation between the overall survival and the Ki67 level.

Conclusion

Ki67 is correlated with the grade of the tumor, and is not a predictor for the survival of breast cancer patients. It may predict aggressive behavior of the tumor and higher histopathological grades.

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Breast cancer is the commonest cause of cancer related deaths among women.

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It has variable biological behavior and prognosis depending on variable factors.

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The usefulness of the Ki67 evaluation as an independent prognostic factor in breast cancer is a matter of great debate.

Fibrous tumor of the stomach causing abdominal pain and melena: Case report with review of literature

INTRODUCTION

Fibrous tumor of the stomach is a rare mesenchymal tumor composed of hyalinized fibrous tissue with spindle shaped fibroblasts. This type of tumor usually occurs in the subcutaneous tissues and the deep soft tissues. Its occurrence in stomach is extremely a rare finding and only few cases have been reported worldwide, the exact etiology is still unclear.

PRESENTATION OF CASE

A 68-year-old female was complaining from epigastric and right hypochondrial pain for few months. It was associated with attacks of non-bilious vomiting and early satiety, with attacks of melena. During abdominal examination there was a palpable mass in the epigastric region which was oval in shape, soft, mobile in the vertical direction, and was non-pulsatile. The hemoglobin was 9 gm/liter. Ultrasound and CT-scan of the abdomen showed a well-defined non-enhancing, multi-loculated mass related to the body of the stomach. Gastroscopy showed soft tissue mass with intact mucosa in the anterior gastric wall, multiple biopsies were taken which revealed fatty tissue with no evidence of malignancy. Laparotomy was done and a soft, mobile mass was found in the anterior gastric wall in the pre-pyloric region, the serosa was intact, complete excision of the mass was performed. The histopathological result showed fibrous tumors of the stomach.

CONCLUSION

The treatment of this tumor is mainly through surgical intervention. Which should be done at the time of diagnosis. The prognosis after successful resection is excellent, few cases are reported with local recurrence.

Epithelioid hemangioendothelioma of the pancreas presented as massive hematemesis

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Hemangioendothelioma is vascular tumors characterized by the presence of an “epithelioid” or “histiocytoid” endothelial cell.

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The majority of the tumors affects the liver.

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The natural history of the disease is still poorly understood and there is no uniform treatment form for such tumors.

Introduction

Hemangioendotheliomas are vascular tumors characterized by the presence of an “epithelioid” or “histiocytoid” endothelial cell. They consist of blood filled spaces mixed with cellular areas that mostly occur in the liver, but other organs can be affected. These lesions cause a wide spectrum of clinical presentations depending on the organ involved. Complete surgical excision is the primary form of treatment; they tend to recur after surgery in some cases.

Presentation of case

A-45-year old lady presented with 2 attacks of massive hematemesis. Upper GIT endoscopy was done which showed a vascular tumor arising from the duodenal ampulla, biopsy was not taken because of the risk of bleeding.

Laparotomy and duodenotomy were performed, there was a soft irregular 3 cm mass with areas of hemorrhage arising from the duodenum, complete excision was done and frozen section examination showed a benign lesion.

Two months later the patient presented with melena and anemia. CT-scan of the abdomen showed a mass at the head of pancreas. Second surgery was done and during surgery a firm mass was found in the region of the head of pancreas, pancreaticoduodenectomy was done and the sample was sent for histopathological examination which showed an epithelioid hemangioendothelioma of the head of the pancreas.

Discussion & conclusion

The treatment strategy should be tailored to the individual patient, the clinical presentation, and the rate of progression of the tumor. The natural history of the disease is still poorly understood and there is no uniform treatment form for such tumors.

Abdomen cocoon causing chronic abdominal pain and intestinal obstruction; a case series

Abdomen cocoon is a rare disease in which a thick peritoneal membrane wraps the intestine causing the bowel loops to adhere to each other. It may be either primary(idiopathic) or secondary to other causes like previous abdominal surgery. Most patients present with abdominal pain and intestinal obstruction. The condition is usually diagnosed intraoperatively.

Case 1

A 30-year-old male patient presented with abdominal pain and bilious vomiting. The patient had similar previous attacks. Examination showed distension abdominal distension with central tenderness. Plain abdominal X-ray showed multiple air fluid levels. During surgery most of ileum was enclosed by thin membrane with dilated proximal jejunum. Release of the bowel loops was done. The patient was well after surgery and was discharged with no post-operative complications.

Case 2

A 35-year old male presented with chronic right lower quadrant abdominal pain, the past medical and surgical histories were non-relevant. Abdominal examination showed tenderness on deep palpation at the right iliac fossa, abdominal ultrasound and abdominal X-ray were normal. During diagnostic laparoscopy the terminal ileum was enclosed with a thick whitish membrane with dilated proximal ileum. Release of the adhesions was done. The patient was well in the post-operative period and he was discharged home with no post-operative complications.

In both cases the biopsy from the membranes showed features of chronic inflammatory process.

Abdomen cocoon is one of the rare causes of small bowel obstruction. The bowel adhesions should be opened and nonviable segments resected. Most patients have good long term outcome.

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Abdomen cocoon is a rare disease in which a thick membrane wraps the intestine.

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It is either primary(idiopathic) or secondary to previous abdominal surgery.

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Most patients present with abdominal pain and intestinal obstruction which is usually diagnosed intraoperatively.

Enormous gastrointestinal stromal tumor arising from the stomach causing weight loss and anemia in an elderly female: Case report

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Gastrointestinal stromal tumors are the most common mesenchymal tumors of gastrointestinal tract.

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Surgical excision with normal safety margins is the main form of treatment.

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Preoperative imatinib therapy is used in unresectable or recurrent tumors.

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Huge tumors may not respond to medical therapy.

Introduction

Gastrointestinal stromal tumors are the most common mesenchymal tumors of gastrointestinal tract originating from the interstitial cell of Cajal. The presentation is variable depending on the size and site. CT scan is the most widely used imaging. The primary treatment is surgical resection. Imatinib may be used in unresectable tumors or preoperatively.

Case presentation

A 65-year-old lady had weight loss and repeated vomiting for one year. Examination showed a non-tender mass in the left hypochonrdium arising below the costal margin extending to 15 cm toward the left iliac fossa. It was firm with smooth surface. CT-scan examination showed a 45 cm × 21 cm mass arising between the spleen and the left kidney and displacing the kidney toward the midline. Gastroscopy and biopsy showed gastrointestinal stromal tumor. During surgery an enormous gastric tumor attached to the spleen. Total gastrectomy en-block with splenectomy and reconstruction done through roux-en-y esophago-jejunostomy and jejunojejunostomy.

Conclusion

GISTs most commonly affect the stomach, most tumors are treated by primary surgical excision with normal safety margins, advanced disease may need imatinib before surgery which helps in decreasing the size of the tumor and makes surgery easier.

Intra-peritoneal rupture of large hydatid cyst of the liver containing innumerable daughter cysts after blunt abdominal trauma

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Hydatid disease is a real health problem in endemic regions.

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The disease may be discovered incidentally during routine investigations.

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Intraperitoneal rupture is very serious that may result in severe anaphylactic reaction.

Introduction

Hydatid disease is a major health concern in the Mediterranean countries and many other parts of the world. The route of transmission is fecal-oral, and then spread by the portal venous system almost all part of the body.

The liver is the most commonly involved organ, followed by the lungs, and other organs are involved in order of decreasing frequency.

Presentation of case

A middle-age male patient presented with acute abdominal pain and repeated vomiting after blunt abdominal trauma. CT-scan showed a large hydatid cyst of the right lobe of the liver with features of intraperitoneal rupture. Emergency laparotomy was performed with extraction of a countless number of daughter cysts from the peritoneal cavity. We further examined the bowel and found no abnormalities. The cyst was not causing any compression on the bile duct. Omentoplasty was performed for the cavity. The patient was discharged home eight days after the operation and the drain removed after twenty-five days when the bile leak stopped, anthelminthic drugs were given for three months after the surgery.

Conclusion

Prevention of hydatid disease is the most effective way to control the disease, the cyst may reach a very large size and be asymptomatic. Intraperitoneal rupture may occur as a result of blunt abdominal trauma which could be trivial.

Effect of a synbiotic supplement on cecal microbial ecology, antioxidant status, and immune response of broiler chickens reared under heat stress

The aim of this study was to examine the effect of a dietary synbiotic supplement on the cecal microflora, antioxidant status, and immune response of broiler chickens under heat stress (HS). A total of 360 one-day-old male Ross 708 broiler chicks were randomly distributed among 3 dietary treatments containing a synbiotic (PoultryStar consists of Bifidobacterium animalis, Enterococcus faecium, Lactobacillus reuteri, Pediococcus acidilactici, and fructooligosaccharides) at 0 (control), 0.5 (0.5X), and 1.0 (1.0X) g/kg. Each treatment contained 8 replicates of 15 birds each housed in floor pens. Heat stimulation was at 32°C for 9 h daily from day 15 to 42. Heat stress-induced changes of cecal bacteria were detected using bacteria-specific agars, and spleen protein concentration and mRNA expression of interleukins and antioxidants were examined using ELISA and real-time PCR, respectively. Under the HS condition, synbiotic fed broilers regardless of dose had lower cecal enumerations of Escherichia coli and coliforms, and a lower heterophil/lymphocyte (H/L) ratio (P < 0.05) compared to controls. 1.0X group also had higher cecal enumerations of Bifidobacterium spp. and Lactobacillus spp., spleen glutathione peroxidase (GPx), and plasma nuclear factor erythroid 2-related factor 2 (Nrf-2), and a lower H/L ratio compared to both control and 0.5X groups (P < 0.05). However, there were no treatment effects on the levels of Enterococcus spp., the circulating monocytes, eosinophils, and basophils, Toll like receptor-4 (TLR-4), interleukin-6 (IL-6), interlukin-10 (IL-10), and their mRNA expression, as well as plasma Kelch-like ECH-associated protein 1 (Keap-1) (P > 0.05). These results suggest that the synbiotic could inhibit the negative effects of HS on broiler health through the reduction of cecal pathogens, regulation of stress reactions, and improvement of antioxidant status.

Giant intracholecystic papillary tubular adenoma of the gall bladder with gall stones in an elderly woman; case report

Gall bladder polyps occur in 0.4% of patients undergoing cholecystectomy, the majority of gall bladder polyps are benign, they are classified into 3 types: epithelial or adenomatous polyps, mesenchymal polyps, and pseudopolyps. Gall bladder polys mostly affect females and those more than 50 years of age. Ultrasound is a very sensitive tool in the diagnosis.

An 88-year-old woman presented with epigastric pain and right hypochondrial pain, fever, and vomiting for 1 week. Clinical examination showed jaundice and tenderness at the right hypochondrial region. Investigations showed elevated WBC, bilirubin level and the alkaline phosphatase. MRCP showed multiple gall stones with a large irregular polyp in the fundus of the gall bladder, and dilated common bile duct with multiple stones in the lumen of common bile duct. Cholecystectomy was done with exploration of the common bile duct with extraction of stones, T-tube was placed inside the CBD. At the 14th day T-tube cholangiography was done which showed passage of the dye to the duodenum, the tube was extracted and the patient was discharged home with no postoperative complications. The histopathology showed intracholecystic papillary tubular adenoma of the gall bladder with no evidence of malignancy.

The general indications of surgery for gall bladder polyps include the size if more than 10 mm especially if solitary, the presence of associated gall stones, the age if more than 60 years, and if the polyps are causing symptoms. In this patients the large size of the polyp and obstructive jaundice were the two indications for surgery.

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Gall bladder polyps are commonly diagnosed and may be associated with gall stones.

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Most patients are worried about the possibility of malignancy.

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Laparoscopic cholecystectomy can be safely done when there is indication for surgery.

Laparoscopic cholecystectomy for left-sided gall bladder in situs inversus totalis patient, a technically demanding procedure

Situs inversus is a condition in which the anatomical viscera are placed in a reverse anatomical location, it may be partial affecting the thoracic organs or the abdominal organs, or total affecting both.

A 28-year-old man who was a known case of situs inversus totalis presented with epigastric pain and left hypochondrial pain. ultrasound revealed multiple gall stones in a left-sided gall bladder, laparoscopic cholecystectomy was done successfully for him with no complications.

Patient position during surgery and the sites of the laparoscopic ports greatly affect the performance during surgery. Identification of the anatomical structures which are arranged in a mirror image pattern is the key for successful surgery. The critical view of safety should be identified before any structure is clipped or divided.

A right-handed surgeon will feel more impairment during surgery for a left-sided gall bladder, while a left-handed surgeon will do it with better comfort. Surgeries for such cases are better to be performed by a surgeon with massive experience in laparoscopy or by a hepatobiliary surgeon, it may not be suitable for surgeons in training. MRCP will show the biliary anatomy prior to surgery and CT-scan with dual phase contrast will help to show any associated vascular abnormalities.

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Gall bladder stones are commonly diagnosed and many patients need surgical intervention.

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Situs inversus patients have a mirror image anatomy.

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A left-handed surgeon can perform laparoscopic cholecystectomy with more comfort than a right-handed one.

Scrotal abscess as a manifestation of posterior duodenal perforation; a very rare presentation

Posterior perforation of duodenal ulcers is very rare; the infection may spread from the retroperitoneal space to the scrotum.

A 75-year-old male presented with painful right scrotal swelling for 2 days associated with fever. During abdominal examination there was abdominal tenderness and scrotal swelling and tenderness.

CT scan of the abdomen showed large amount of air collection in the retroperitoneal space extending to the right scrotum with contrast media passing to the retroperitoneum and right scrotum.

Laparotomy done and there was a perforation in the posterior wall of the duodenum, suturing done and right scrotal abscess drained.

Huge toxic goiter extending to the posterior mediastinum; Case report with literature review

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Retrosternal goiter is defined when the thyroid gland extends below the thoracic inlet.

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It causes compression over the respiratory and the digestive passages, or pressure over the superior vena cava.

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It needs surgical treatment in most patients and usually requires the combined cervical and the thoracic approach.

Introduction

Retrosternal goiter may occur in up to 7% of the cases, most of them extend to the anterior mediastinum, extension to the posterior mediastinum is very rare. It causes compression on mediastinal structures such as the trachea, the bronchi, the esophagus, and great vessels. The diagnosis is done mostly by CT scan. Most cases need surgery which is done by the combined cervical and the thoracic incisions.

Case presentation

A 70-year-old man had history of thyroid enlargement for 10 years which was hyper-functioning and controlled with medical therapy. For the last 2 months the patient was complaining from dyspnea especially during supine posture and dysphagia. CT-scan showed huge extension of the thyroid gland to the posterior mediastinum causing compression over the tracheal and the esophagus. Surgery done through both cervical incision and manubriotomy and the huge thyroid gland extracted. The patient had uneventful recovery with no postoperative complications.

Conclusion

Retrosternal goiter causes airway compromise in most patients. Surgery for such cases is a challenging procedure with higher rate of complications, CT-scan is the most single valuable tool in selecting patients for sternotomy before surgery but the final decision for sternotomy is best done during surgery. A team work between a thyroid surgeon and a thoracic surgeon has better results.