Saudi Journal of Laparoscopy

: 2017  |  Volume : 2  |  Issue : 1  |  Page : 48--56

Abstracts Presented In The 16TH Annual Surgery Research Day


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 Age Pattern and the associated Factors of Healthy Saudi Children towards Toilet Training Initiation

Sara Al Jebrin1, Rana al Humeamydi1, Jawaher Al Emran1, Mashael Hussein1, Al Johara Al Dhish1, Mahmoud Trbay2, Hamdan Al Hazmi2,

1Medical Student, School of Medicine, King Saud University, 2Faculty, Division of Urology Department of Surgery, King Saud University

Objectives: To determine average age of initiating toilet training in Saudi children and the factors that may affect this training.

Methods: Our study is a cross-sectional study done by distributing questionnaires to mothers attending various clinics in King Khalid University Hospital/Riyadh Saudi Arabia. A sample size of 1000 healthy Saudi children was obtained.

Results: The mean age of initiating in healthy Saudi children was 25.6±SD of 9.4 months and the mean duration of training was 6.3 ± SD of 9.1 months. Most of children 92% were trained in summer and minority 7% in winter. Maternal education level, number of siblings, and socioeconomic status were positively correlated with age of initiation. Whereas the job of the mother, marital status, caregiver, order, and gender of the child were proven insignificant.

Conclusion: The mean age of toilet training among healthy Saudi children was same as international literature. Summer is the preferable season. Maternal education, number of children and socioeconomic status play a major role in the initiation age of toilet training.

 Neonatal Plastibell Circumcision: Does the Thread Type Matter? A Prospective Randomized Study

Dr. Alaa Ibrahim Elsarrag (intern) –Presenter, Dr. Saifullah Khan (Senior Registrar), Dr. Tariq Altokhais (Consultant)

Department of Surgery, College of Medicine, King Saud University Medical City, Riyadh, Kingdom of Saudi Arabia

Background: There are many techniques to perform circumcision in neonates. Plastibell (Hollister Incorporated, Illinois, USA) is one of the most common disposable devices used for circumcision in neonates where the Plastibell ring is tied around the foreskin using a thread. This plastic ring has to be worn for few days (between 5 to 14 days) until it falls off by itself. The aim of the study is to determine whether changing the thread type would result in faster separation of the ring and thus, decreases the complications associated with long retained and non-separation of the ring and decreases the anxiety of the parents and care givers until the ring falls off.

Patients and Methods: After ethical committee approval and an informed consent from the parents, a prospective randomized clinical study was conducted comparing the use of cotton thread (provided by Plastibell Company) and Prolene 0 thread (Prolene®; Ethicon, Somerville, NJ) to tie the foreskin around the Plastibell ring in male neonates who undergo routine circumcision at King Saud University Medical City between the period of April, 2016 and December, 2016. All circumcisions were done by a single surgeon under local anesthesia. Demographic data, complications, outcome and follow-up were analyzed. Threads characteristics including the diameter, breaking load and tensile strength were measured. Parents were interviewed to determine the degree of satisfaction.

Results: 200 male neonates aged between 12-48 hours were circumcised using Plastibell. Plastibells were randomly tied either by cotton thread (control group) or by Prolene 0 (study group). 100 neonates in each group. Both groups were similar regarding gestational age, age at circumcision, body weight, height, head circumference, Apgar score at 1 and 5 minutes, procedure time, and Plastibell size. The mean duration for Plastibell fall off was 8.98 days and 7.74 days in original thread and Prolene respectively (P value < 0.001). The diameter of the cotton and Prolene 0 threads are 0.7 mm and 0.35 mm respectively. The tensile strength of Prolene 0 is higher than the cotton thread: 457 MPa Vs 180 MPa. No complications in both groups. Parent's satisfaction was similar in both groups.

Conclusion: Plastibell tied by Prolene 0 falls off faster than by the Original cotton thread supplied by the manufacturer. And thus, might decrease the complication related to long retained Plastibell ring and decrease the parent's anxiety about the ring. Further studies are needed to examine other types and sizes of threads.

 Primary Spontaneous Pneumothorax: A Clinical Profile and Recurrence of 112 Adult Patients from 2010 to 2014 in King Khalid University Hospital, Kingdom of Saudi Arabia

Rahaf ALTWIJRI433200197,

Amani ALSULAMI433200974,

Dalal ALSHAGHA433201924,

Ghaida ALAWAJI433202094,

Najla ALOTAIBI433200160

Supervision: Dr. Wassem HAJJAR, MD.MS.FRCS, FCCP

Assistant Professor and Consultant Thoracic Surgeon

Office Tel. No: 4671994, Departments Tel. No: 4671575,

Mobile No. 0507240914. Email: [email protected]

Objectives: To study the presenting features of Primary Spontaneous Pneumothorax (PSP) patients regarding gender, age, smoking, height and weight, Body mass index (BMI), symptoms and seasonality in adult patients in KKUH from 2010 to 2014.To describe the recurrence of PSP and length of hospital stay in patients who were managed surgically in KKUH from 2010 to 2014.

Methods: Quantitative, Observational, Retrospective, Case-series study. 112 Patients was studied whom diagnosed with primary spontaneous pneumothorax disease from Jan 2010 to Dec 2014in King Khalid University Hospital Data was collected by review of the transfer sheet case report form (CRF), by reviewing variables in medical records of PSP patients.

Results: The mean age was 24.62 (S.D±8.8) years old. 88.4% of patients were males (11.6% females). 52.7% were non-smoker. The average of body mass index (BMI) was 19.4. The season of the attack was more in spring and summer by 29.5% for each. Patients who treated surgically were 93.8%, the average length of hospital stay after surgical management was 6.45 days (S.D±3.15), recurrent after surgical management was (3.8%).

Conclusion: Based on this case series study, majority of primary spontaneous pneumothorax (PSP) patients were male, at young age group, with low body mass index (BMI). Most of the admissions occurred in warm climate (spring/summer). Furthermore, short hospital stay and low state of recurrence were noted among the patients treated surgically.

Key words: Primary Spontaneous Pneumothorax, variables, seasonality, recurrence

 The Efficacy of Laparoscopic Heller's Myotomy in Achalasia Patients – A University Experience

Sami Alnassar, Nouf Alballa, Afaf Almutairi, Sarah Aljabri, Munira Almehsen, Kholoud Aldosari, Iftikhar Ahmed, Waseem Hajjar

Department of Surgery, Division of Thoracic Surgery, King Saud University, Riyadh, Saudi Arabia

Objectives: To determine the impact of Laparoscopic Heller Myotomy on patients' symptoms with esophageal achalasia by evaluating pre-operative and post-operative Eckardt's score.

Method: The patients involved in this study were diagnosed with esophageal achalasia and underwent Laparoscopic Heller Myotomy(LHM) between 2008 and 2015, in King Saud University Medical City, Saudi Arabia. Record of 25 patients who underwent LHM was reviewed; out of this only 19 patients met the conclusion criteria who were included to conduct a retrospective cohort designed study. Patients' demographic data, time of admission, hospital stay and surgical complications were obtained through Hospital Information System(HIS). Clinical symptoms were assessed using the Eckardt's score, which is the sum of the individual symptom score for dysphagia, regurgitation, retro-sternal pain and weight loss. The pre-operative score was collected before the surgery in the surgical clinic. The post-operative score was collected by contacting the patients via telephone. The post-operative Eckardt's score was recorded twice. First, between 3 to 6 months after the surgery and second, at the time of the phone call (January 2016).

Results: A total of 19 patients were included in the study, with a mean age of 36.6 years, 13 of them were males (68.4%). The mean of the pre-surgical Eckardt score was 6.2 which was improved to (1.3–2.5) after Laparoscopic Heller Myotomy (P<0.01), with a clinical remission of 84.2% after the surgery.

Conclusion: Laparoscopic Heller Myotomy is an effective procedure in Achalasia patients with clinical remission of 84.2%.

Key words: Achalasia, Laparoscopic Heller Myotomy. Esophagus, Eckardt's score

 Biofeedback as Single First-Line Treatment for Non-Neuropathic Dysfunctional Voiding Children with Diurnal Enuresis

Tamer Ewida, Fahad Alyami, Hamdan AlHazmi, Mahmoud Salem, Mostafa Arafa, Moina Tahir, Khalid Fouda Neel

Division of Urology, Department of Surgery, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia

Introduction and Objective: Non-neurogenic Dysfunctional Voiding (DV) accounts a significant portion of outpatient pediatric urologist clinics patients, and it may be associated with UTIs, urinary enuresis, or voiding discomfort. Biofeedback (BF) is a modern non-invasive promising modality of treatment for children with DV and daytime wetting. Our objective is to investigate the efficacy of BF as a single first-line treatment for DV children with diurnal urinary incontinence.

Material and Methods: It was a retrospective cohort study, where data was obtained from prospectively maintained database between January 2009 to March 2016. All children with non-neuropathic DV, and started BF as first line treatment were included. Full urological history and physical examination, Dysfunctional Voiding Symptom Score (DVSS), urine analysis, Ultrasound (US) and Uroflowmetery (UFM) + Electromyogram (EMG) were performed and recorded for all patients before and after finishing last BF cycle. Patient's satisfaction scale was collected.

Results: Our sample comprised 61 patients, their mean age was 10 years (SD ±2.6), most of them (80.3%) were females. When we analyzed the symptoms individually we found: 52 patients (85.2%) complained of diurnal incontinence, 16 (26.2%) of UTI, and 38 (62.3%) complained of voiding discomfort. Six months after last BF cycle, there was a statistically significant objective improvement in US and UFM+EMG findings, with disappearance of EMG signals in 40/61 (65.5%) patients, in addition to the subjective symptomatic improvement as the mean DVSS decreases from 14 to 7.9 (P=0.003). Forty-seven patients (77%) were satisfied, while only 8 patients (13.1%) were not satisfied.

Conclusion: BF could be considered as a potential effective single first-line treatment modality for children with DV with diurnal enuresis.

 Is BMI ≥50 kg/m2 a predictor of higher morbidity during doing laparoscopic sleeve gastrectomy? An Observational

Dr. Fahad Bamehriz, Yara Alanazi, Rawan Alotaibi, Nawt Alfuweres, Najla Alsaikhan, Waad Almanie, Munira Alghafaily

Surgery Department, College of Medicine, King Saud University, Study at King Khalid University Hospital Saudi Arabian Experience

Objectives: This study was to assess operative and post-operative complications of laparoscopic sleeve Gastrectomy (LSG), in super dose-obese and compare it to morbid obese in KKUH, Saudi Arabia.

Methods: We reviewed the 708 medical record of consecutive patients who underwent LSG surgery at KKUH from 2009 till 2015. Then, we compare our SMO (BMI≥50 kg/m2) patients' data results to (our/international reports) MO (BMI, 50kg/m2) patients' category who underwent LSG.

Results: Male sex was predominant in SMO (63.6%). Both groups had homogeneous baseline characteristics and comorbidities except Sleep apnea was higher in SMO. There is no significant difference in the duration of operation, length of stay, and Recovery room time between the two groups. Mean number of trocars was 4 for both groups. HDU admission 62 (28.6%) patients of SMO, and 32 patients of MO. No conversion to open or documented intraoperative complications in both groups. For postoperative complications: has developed in 6% of patients in SMO included 1.4% of patients developed leakage, and 10 patients developed bleeding in the drain. On the other hand, 4.3% of patients in MO had developed complications, included, (2.2%) patients developed leak, and 2% patients developed bleeding that four patients only needed blood transfusion. There was no surgical mortality.

Conclusion: There's no significant difference in the duration of operation, number of trocars and intra operative complication between SMO and MO. The BMI≥50kg/m2 is not a predictor of higher morbidity during doing LSG if done in a tertiary care center with dedicated bariatric center serves.

Key Words: Obesity, Sleeve, Bariatric Surgery

 Interleukin 17 and Colorectal Cancer risk in Middle East: Gene Polymorphisms and Messenger RNA Expression

Omar Al Obeed, Khayal Al khayal, Ahmad Zubaidi, Zahid Khan and Maha-Hamadien Abdulla, Mansoor-Ali Vaali-Mohammed

Department of Surgery, King Saud University, Riyadh, Saudi Arabia

Background: Interleukin (IL) 17 is a relatively newly discovered inflammatory cytokine that bridges the adaptive and innate immune response. IL-17 expressed by Th17 cells and play a role in tissue inflammation by induction of proinflammatory and neutrophil mobilizing cytokines. IL-17 polymorphisms have been reported to be associated with inflammatory diseases as well as cancer including colorectal cancer (CRC).

Objective: We sought to investigate mRNA expression of IL-17 and the association of IL-17 gene polymorphisms with the susceptibility to CRC in Middle East population.

Methods: The study was performed in 217 subjects, 117 diagnosed CRC patients and 100 healthy controls that were age and gender matched. mRNA expression levels of IL-17A was assessed by RT-PCR. IL-17A rs2275913 (G197A) and IL-17 F rs763780 (T7488C) SNPs were determined by TaqMan allelic discrimination assay.

Results: We observed significant association between rs2275913 in IL17A and susceptibility to colorectal cancer (P=0.016228). The distribution of three genotypes of rs2275913 as GG, AG and AA were significantly different in the controls compared to the CRC patients even after Bonferroni's correction. The AG and AA genotypes were detected at higher proportions in CRCs relative to the controls and conferred 2-fold and 2.8-fold, respectively higher risk of developing CRC compared with individuals having GG genotype. Additionally, stratification of the data based on gender and age revealed very strong association of CRC with IL17A rs2275913 only in males and 'AG' genotype in patients ≤57 years of age at disease diagnosis. The rs763780 in IL17F were not linked with CRCs in our cohort. Furthermore, IL17A mRNA expression in CRC tumors were significantly elevated compared to adjacent normal tissue. Significant mRNA expression were related to early stage (stage I &II) compared to late stages (stage III and VI) (P=0.0005).

Conclusion: IL-17 A may be useful as a biomarker for early detection of CRC in Saudi population although, further validations in larger cohorts are needed.

Keywords: Interleukin (IL), genetic polymorphism, colorectal cancer (CRC) and Saudi population

 Adrenocortical Carcinoma Co-occurrence with a Hepatocellular Carcinoma within an Adrenohepatic Fusion: A Case Report

Alfaqeeh F1, Algehani G2, Hassanain M2, Alsharabi A2, Alsuhaibani M3

1College of Medicine, King Saud University, 2Liver Disease Research Center, College of Medicine, King Saud University, 3Department of Pathology, College of Medicine, King Saud University

Adrenohepatic fusion is a relatively common condition that has been reported in the literature and explained as a result of normal aging. However, the presence of a neoplastic process in the adrenohepatic fusion is relatively uncommon. A 48-years-old male presented with RUQ abdominal pain with findings of a huge liver mass with adrenohaptic fusion in the CT scan. Histopathological studies revealed a mixed, although distinctly separated, adrenocortical carcinoma and a hepatocellular carcinoma within an adrenoheaptic fusion.

Keywords: Adrenohepatic, HCC, Adrenocortical, Mixed, Union, Neoplastic

 Human Wharton's Jelly-derived Mesenchymal Stem Cells as a Therapeutic Target for Type 1 Diabetes Mellitus

Dr. Awadh Robaan Alqahtani, Norah Sulaiman Alnajashi, Dr. Walid A Zaher, Dr. Duria Ahmad

Department of Gynecology and Obstetrics, King Saud University

Type 1 diabetes mellitus (T1DM) is an autoimmune disease that resulted from an inflammatory destruction of pancreatic β-cells. It is one of the commonest autoimmune diseases during childhood which compromises 5 to 10% of all cases of diabetes in human being. Treatments available at present time for T1DM include insulin injection, which is a lifelong therapy type of treatment does not completely reduce the risk of the development of diabetic complications. In the recent years, rapid progress is being made in the use of Mesenchymal stem cells (MSCs) for the treatment of T1DM. Mesenchymal stem cells derived from Wharton's jelly (WJ-MSCs) of umbilical cord have gained much attention over the last few years due to their own unique properties of highly pro;iferation rate, they can be easily isolated, they have a wide multipotency, hypoimmunogenic, non-tumorigenic and they do not from teratomas.

 Outcome of pregnancy and neonate after Laparoscopic Sleeve Gastrectomy

Fahad Yaslam Bamehriz, Faisal Nasser Alshuwair

Department of Surgery, King Saud University, Riyadh, Saudi Arabia

Introduction: Obesity is a global major growing public health problem. About 25% of the women are suffering from obesity, of which one-third are at childbearing age. The Laparoscopic Sleeve Gastrectomy is one of the main Bariatric surgeries that is known to be safe and effective in weight reduction. Little is known about pregnancy and neonate outcomes post-LSG.

Methodology: A retrospective study was done in Riyadh, KSA. Data were collected from two centers KKUH and SMC. Inclusion criteria all females who underwent LSG and been pregnant.

Results: From a total of 145 pregnancies in 106 females, there are 21 Spontaneous abortion (14.5%), 13 preterm delivery (10%), 45 Caesarean section (36.3%) and six females had complications during pregnancy (4.2%). Moreover, two cases ended up with the death of the neonate (1.6%). Also, two cases had abnormalities (1.6%). 38 neonatal birth with a weight less than 2.5 kg (30.6%), and the mean birth weight was calculated to be 2.6 kg (S.D±0.6 kg). For each BMI unit increase, odds of preterm delivery significantly increased by a factor of 1.31 (P<0.05). Moreover, odds of C-section delivery significantly increase for each one year increase in age by a factor of 1.27 (P<0.05).

Conclusion: Weight reduction post-LSG will decrease the rate of obesity complication on pregnancy and neonate. On the other hand, LSG is associated with a high rate of low birth weight but the cause still not clear. A good follow up post-LSG, and nutritional advice could improve the outcome.

Key words: Pregnancy, Neonate, LSG

 Assessment of Spinal Cord motion using MRI CINE-FIESTA Protocol

Amro F. Al-Habib,1 Abdulrahman Albakr,1 Metab Alkebayer,2 Fahad Albadr,2 Abdullah AbuJame,2 Abdulaziz Abobotain1

1Division of Neurosurgery, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia, 2Department of Radiology, College of Medicine, King Saud University, Riyadh, Saudi Arabia

Background and Objectives: Spinal cord motion (SCM) is related to pulsatile arterial blood flow. The assessment of SCM has several clinical implications. A completely free spinal cord on intraoperative ultrasound was found to correlate with better outcome. Furthermore, detailed knowledge on SCM motion is necessary in the assessment of accurate radiation therapy to the spinal cord. However, characterization of SCM in healthy individuals is not clear. Magnetic resonance imaging (MRI) has the potential for advancing the understanding of SCM in healthy and diseased subjects. Few reports examined the value of MRI to characterize SCM. The aim of the current study is to investigate healthy volunteers for cervical and thoracic SCM.

Materials and Methods: SCM was examined in 23 healthy volunteers (10 males, 13 females; mean age 31±10 years) with no history of neurologic disease or any comorbidity. The volunteers underwent MRI (Cine-FIESTA sequence) of the cervical and thoracic spine. SCM was examined at three levels (upper-mid-lower) of the cervical and thoracic region. The SCM was assessed at different directions including anteroposterior (AP), transverse (TR), and superior-inferior (SI). Quantitative assessment of SCM was done using an image processing software (Fiji). The spinal level that marks the inferior end of the spinal cord was assessed. All volunteers provided informed consent before enrollment in the study, which had been approved by the institutional human research ethics board.

Results: Considering all levels, the mean magnitude for SCM in AP direction was less in the cervical region compared to the thoracic area (0.25±0.23 mm vs. 0.30±0.18 mm respectively, P=0.241, no statistical significant). SCM in SI direction for thoracic area was found significantly higher than the cervical spine (0.42±0.23 mm vs. 0.23±0.21 mm, respectively, P<0.0001). The TR cervical SCM, however, was found to be minimal with a mean value of 0.18± 0.12 mm. The maximum AP SCM occurred in the majority of the cases at the lower thoracic spine, with a mean value of 0.35± 0.18 mm. Furthermore, the maximum SI SCM was also found in the mid thoracic spine, with a mean value of 0.44±0.26 mm. interestingly, patient's age was found to have a negative correlation with AP cervical SCM, (P=0.043). In addition, with increasing patient weight, cervical SCM has increased in all the directions, AP (P=0.017), TR (P=0.003), and SI (P=0.002). With increasing patient height, cervical SCM has increased in all the directions, AP (P=0.002), TR (P=0.003), and SI (P=0.010).

Conclusion: SCM was found to be variable from one patient to another and from one level to another. SCM was largest in the SI direction of the thoracic spine and mainly the lower part of the thoracic spine. Studying the normal SCM may advance our understanding of spinal cord physiology and aid in applied therapies and/or prognosis of different spinal cord illnesses.

 Novel Quinazoline-Based Sulfonamide Derivative (3D) Induces Apoptosis in Colorectal Cancer by Blocking STAT3 Pathway

Khayal Al-Khayal, Wagdy M Eldehna,

Amer Mahmood, Hatem A Abdel-Aziz,

Ahmed Zubaidi, Omar Al-Obeed, Ahmed Alafeefy, Maha Abdulla and Rehan Ahmad Mansoor-Ali Vaali-Mohammed

Department of Surgery, King Saud University, Riyadh, Saudi Arabia

Colorectal cancer is a major worldwide health problem owing to its high prevalence and mortality rate. Developments in screening, prevention, biomarker, personalized therapies and chemotherapy have improved detection and treatment. However, despite these advances many patients with advanced metastatic tumors will still succumb to the disease. New anti-cancer agents are needed for treating advance stage colorectal cancer as most of the deaths occur due to cancer metastasis. A recently developed novel sulfonamide derivative, 4-((2-(4-(dimethyl amino) phenyl) quinazolin-4-yl) amino) benzene sulfonamide (3D) has shown potent antitumor effect; however the mechanism underlying the antitumor effect remains unknown. Our study revealed that 3D treatment significantly reduced the viability of human colorectal cancer cells HT-29 and SW620. Furthermore, 3D treatment induced the generation of reactive oxygen species (ROS) in human colorectal cancer cells. Confirming our observation, NAC significantly inhibited apoptosis. This is further evidenced by the induction of p53 and Bax, release of cytochrome c, activation of caspase-9, caspase-7 and caspase-3 and cleavage of PARP in 3d treated cells. This compound was found to have significant effect on the inhibition of anti-apoptotic proteins, Bcl2 and BclxL. The results further demonstrate that 3D inhibited JAK2-STAT3 pathway by decreasing the constitutive and IL-6-induced phosphorylation of STAT3. 3D further decreased STAT3 target genes like Cyclin D1 and Survivin. Collectively these findings indicate that 3D induces ROS-mediated apoptosis and inhibited JAK2-STAT3 signaling in colorectal cancer.

Keywords: Sulfonamide, apoptosis, colorectal cancer, STAT3 pathway, Bcl2 Proteins

 Spinal Cord Elasticity; Shear Wave Ultrasound Assessment in Dogs

Amro Al-Habib1, Abdulrahman Albakr1,

Abdullah Al Towim1, Metab Alkebayer2,

Abdullah AbuJame2, Fahad Albadr2,

Abdelazeem eldawlatly3, Tarek Kashour4

1Division of Neurosurgery, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia, 2Department of Radiology, College of Medicine, King Saud University, Riyadh, Saudi Arabia, 3Departments of Anesthesia, College of Medicine, King Saud University, Riyadh, Saudi Arabia, 4Department of Cardiac Sciences, College of Medicine, King Saud University, Riyadh, Saudi Arabia

Background: The ability to measure living tissue elasticity has potentially wide applications in recognizing malignant tumors and predicting disease prognosis. Previously, spinal cord elasticity (SCE) was assessed in dogs using load-elongation curve. The modulus of elasticity of the spinal cord tissue was estimated to be 16.8 kPa and 11.9 kPa at different loading mode. There are no studies that assessed SCE in vivo. Recently, Ultrasound elastography (USE) was developed to characterize and evaluate elastic properties of living tissues to differentiate benign from malignant lesions, particularly in the breast and the liver. Using USE, the objective of the current study is to define dogs' SCE in vivo and characterize its response to compression.

Methods: Ten Greyhound dogs weighing 8.6–20 kg (14.3 kg), with a mean age of fourteen-months were used. Anesthesia was induced with intramuscular Ketamine and Xylazine 2 mg/kg body weight. Tracheal intubation was then performed followed by connecting the dog to the respirator for volume controlled ventilation mode with oxygen and sevoflurane maintenance anesthesia. Additionally, an intravenous (IV) line was inserted and an infusion of Ringer's lactate was maintained. Continuous intraoperative monitoring of blood pressure, heart rate, mean arterial blood pressure (MAP), and oxygen saturation were performed every 10 minutes. Intraoperative neurophysiological monitoring was performed during the procedure. Motor evoked potentials (MEP) was used to assess the responses from both upper and lower limbs. Three levels mid-cervical laminectomy was performed, the dura and spinal cord were carefully kept intact. Basic B-mode ultrasound was performed to evaluate the spinal cord. SCE was studied using AixplorerTM ultrasound system (SuperSonic Imagine S.A., Aix-en-Provence, France). Both sagittal and axial Supersonic Shearwave Elastography (SSWE) acquisitions were acquired by placing the probe directly on the dura. Elasticity for the spinal cord, central canal, pia mater, and dura mater was determined using the smallest SSWE target circle (1mm) to isolate the location of interest and avoid inclusion of adjacent tissues. To determine the response of SCE to compression, an application of a 1.3 cm-balloon compression was performed anterior to the spinal cord. Assessment of SCE at the maximum point of compression was performed as well as at another point distal to the maximum point of compression. The research protocol was approved by the Ethical Committee of King Saud University, College of Medicine.

Results: The mean SCE was 18.5±7 kPa. Elasticity of the central canal, pia mater, and dura mater were 21.7±9.6 kPa, 26.1±14.8 kPa, and 63.2±11.5 kPa, respectively. There was no statistically significant difference in the elasticity of the spinal cord and central canal. Furthermore, spinal cord and dura mater had significantly different elasticity values; the dura mater showing larger values than the spinal cord (P<0.0001). Similarly, the pia mater elasticity was higher than the spinal cord with a trend toward significance (P=0.08). Notably, after the application 1.3 cm-balloon compression, there was a significant twelve times increase in SCE (233±73 kPa Vs. 18.5±7 kPa, P<0.0001). Even the degree of compression showed significant differences in SCE, the use of 1.3 cm-balloon compression resulted in stiffer spinal cord compared to 0.8 mm-balloon compression (233±73 kPa Vs. 185±68 kPa, P<0.048). Interestingly, in one dog, areas with different echogenicity revealed significantly higher elasticity values compared to the adjacent tissue (P=0.04). Lastly, during this experiment, we found no correlation between age, sex, gender, and SCE.

Conclusion: In vivo SCE values using USE was comparable to in vitro results done previously by cutting the spinal cord. SCE showed some variability from one dog to another. The elasticity values were biggest in the dura mater. We noted a linear increase in SCE under the influence of mechanical compression. Nonetheless, with such amount of compression and enormous changes in SCE, some dogs were still preserving the motor function in the upper and lower limbs. These parameters have to be taken into account for interpretation of tissue changes. We believe that studying the SCE with SSWE may advance our understanding of normal spinal cord physical properties. It may also have possible implication in diagnosis and differentiation between different types of spinal tumors and pathologies. Similarly, this modality may have a strong utility to be used as a prognostic indicator for the amount of recovery following surgeries of spinal cord injury and different chronic degenerative diseases.

 Abstract: The Pattern of Occupational Injuries among GOSI Insured Workers in Riyadh Office between 2009-2014

T. Nouh, R. Al-Shehri, K. Al-Baqmi, A. Aba-Alkhail, N. Al-Rushid, R. Al-Otaibi, H. Al-Otaibi

Department of Surgery, King Khalid University Hospital, Riyadh, Saudi Arabia, King Saud University, College of Medicine, Riyadh, Saudi Arabia

Objectives: The aim of this study is to describe the pattern of occupational injuries among General Organization of Social Insurance (GOSI) insured workers in Riyadh between 2009 & 2014 and determined the relation between the workers' social demographic factors and occupational injuries.

Methods: Six years of occupational injuries, from 2009 to 2014, were analyzed in order to investigate the changing profiles according to the various characteristic of injuries; age, gender and nationality of the injured. Also, type of injuries and their outcome. The changing profile of occupational injuries was investigated by calculating the frequencies and incidence rate. Furthermore, we compared mean values using Chi-square test to test the difference categorical data.

Results: The mean age standard deviation was 38.4±9.4 years. The most frequent occupational injuries occurred in workers aged between 30 and 39 years. Non-Saudis, made the majority of injuries. The most common cause that lead to occupational injuries was struck by or against an object. We found bruises to be the most common type of injury and led mostly to cure without disability. Disability rate for the past 6 years was 287.6 per 100,000 and mortality rate for the same period was 30.2 per 100,000.

Conclusion: This study found that the population at risk is non-Saudi men workers aged 30-39 years. Hence, they should be the target of safety strategies and further studies should be done to study the causes.

 The Adherence of King Saud University Medical City (KSUMC) to Cholecystectomies Timing Guidelines, and Its Effect on Healthcare & Patient Centered Outcomes

Presenter: Nourah AlBeeshi / Sara Al-Baqmi, Supervising Consultant: Dr. Mazen Hassanain

Adherence of King Saud University Medical City (KSUMC) o Cholecystectomies Timing Guidelines, and its Effect on Healthcare & Patient Centered Outcomes

Background: The timing of the treatment of symptomatic gallstones is a major in determinant of many outcomes. In early timed procedures the hospital stay is shorter than delayed. Early laparoscopic cholecystectomy was found to have a higher complication rate than delayed. Complications included bile duct injury and surgical site infections. Delayed timing was associated with a high rate of readmission. Patients treated early were more satisfied, while delayed patients were less satisfied. It was found that early cholecystectomy is less costly and more effective in comparison to delayed.

Objectives: To report the adherence of King Saud University Medical City (KSUMC) to the set guidelines in the treatment of symptomatic gallstones via laparoscopic cholecystectomy and its effect on the clinical outcomes. To assess patients centered outcomes in symptomatic gallstones patients in both early and delayed laparoscopic cholecystectomy and to determine the increased cost associated with not being adherent to the set guidelines.

Methods: We identified and collected data from the medical files of patients that underwent the procedure during May 15, 2015- October 31, 2016. To measure the patient centered outcomes, patients that underwent the procedure between July and October 2016 were interviewed via the RAND 36-Item Health Survey 1.0.

Results: Of the 536 patients that underwent laparoscopic cholecystectomy, 429 of them were female (80.03%), the median age was 41. Most patients did not need admission and were done as day surgery however, the median delay from diagnosis to surgery was 37 days (0-1800) days, 348 (72%) patients were treated appropriately while 135 (28%) were treated delayed. There was no difference in intraoperative complications however infectious complications were signicantly associated with early timing. Overall complication rate was. The average total cost was found to be 11,696 SAR. Of the 58 patients interviewed, reported pain was strongly associated with a difference in timing between those treated early and delayed.

Conclusion: The timing of the surgical intervention is important for optimal clinical and patient-centered outcomes as well as a lower associated cost.

 Rare Behavior of Follicular Variant of Papillary Thyroid Cancer

Hadeel Helmi1, Abdulaziz Alsaif2

1Medical Intern, King Saud University, 2Breast and Endocrine Surgery Division, E-mail: [email protected],

Introduction: Many variants of papillary thyroid cancer (PTC) exist, including follicular variant. Clinically, it mimics PTC regarding nodal spread. We report a case of follicular variant of PTC (FVPTC) with hematogenous metastasis and describe the staged management approach.

Presentation of Case: A 60 years old man presented with left-sided neck swelling that was easily appreciated on physical examination. Neck ultrasound showed a left thyroid lobe mass with cystic component. Ultrasound-guided fine needle aspiration cytology was suggestive of follicular neoplasm (Bethesda class IV). Computerize Tomography confirmed a let thyroid lobe mass and shoed a large chest wall lesion, multiple visceral metastases and multiple bony lesions. The step-wise management for this patient included multiple surgical procedures followed by radioactive iodine ablation. The pathological diagnosis of FVPTC was confirmed in all specimens obtained in surgery.

Discussion: Follicular thyroid carcinoma has affinity for hematogeneos spread while PTC usually metastasizes to lymph nodes with rare distant metastasis. FVPTC typically behaves as PTC invading the lymph nodes. However, cases have been reported in which FVPTC involved distant organ metastasis lesions to lungs, liver, both kidneys and bone. Finally, metastatic lesions from FVPTC typically show papillary formation, however in our case the primary tumor and the secondary lesions in the distant sites all showed follicular appearance.

Conclusion: We are reporting this case because of its rarity and its interest to surgeons and physicians who are treating thyroid diseases.

 Awareness, Acceptance and Perspective of Women for Reconstruction Post Mastectomy

Dr. Abdullah Kattan (Consultant), Thuga AlKaffi

Department of Surgery, King Saud University, Riyadh, Saudi Arabia

Objectives and Background: Breast reconstruction positively impacts patients' self-esteem and femininity. However, many women refuse this option. There are limited studies in the Middle East exploring the awareness of breast reconstruction, thus we conducted this study to assess the level of awareness and acceptance of women for reconstruction post mastectomy.

Methods: This observational cross sectional study included 209 women with breast masses aged from 19-65. Data was collected over a 6-month period, by interviewing them using a questionnaire in the breast surgery outpatient clinic and inpatients wards at KKUH in Riyadh, Saudi Arabia. SPSS was used for analysis. Pearson Chi-square test was used to compare the responses of categorical outcome variable in relation to the categorical study variables.

Results: Out of 224 study subjects, 209 (93, 3%) had responded to our study. 50.7% of participants considered having reconstruction and 49.3% did not or were not sure. 46.4% read or heard about breast reconstruction. The majority of these patients did not know details about the methods of reconstruction (42.6%). Online sources were the most common information source. The most influencing factor for reconstruction was improving their psychological status (40.2%) and the most common reason for refusal was old age (12.4%).61.3% of women with college level consider having breast reconstruction. Patients who were 40 years or younger were 5.65 times more willing to undergo breast reconstruction than women who were older than 40 years (P-value= 0.001).

Conclusion: The majority of the participants accepted breast reconstruction. However, patients with knowledge about breast reconstruction were more willing to accept reconstruction. Thus, increasing the awareness of breast reconstruction correlates with an increase in breast reconstruction rate. The rate of reconstruction can even raise more if we properly educate the patients on the different types and benefits of breast reconstruction.

 The Use of Recombinant nAG Protein in Spinal Cord Crush Injury in the Rat: A Pilot Study

Presenter: Feras Alshomer, MBBS (resident in Plastic Surgery), Supervisors: Mohammad M Al-Qattan, MBBS, Amro Al-Habib, FRCSC, MPH

Division of Plastic Surgery, King Saud University, Riyadh, Saudi Arabia and Division of Neurosurgery, King Saud University, Riyadh, Saudi Arabia

Background: nAG is a protein expressed in the Schwann cells of regenerating axons in salamanders when they regrow their amputated limbs. nAG is also known to exhibit anti-fibrotic properties in healing skin wounds.

Objective: To evaluate the therapeutic properties of nAG protein in the recovery following acute spinal cord injuries in the rat.

Methods: A total of 8 rats were studied (4 control rats and 4 experimental rats). All rats were subjected to an acute spinal cord injury using the aneurysmal clip injury model. Immediately after the injury, a single intra-dural injection of either normal saline (in the control group) or the nAG protein (in the experimental group) was done. Assessment of both groups was done over a 6-weeks period with regards to weight maintenance, motor recovery scores, MRI and histopathology of the injury site.

Results: Weight maintenance was seen in the experimental and not in the control rats. Starting at 3 weeks after injury, the motor recovery was significantly (P<0.05) better in the experimental group. MRI assessment at 6 weeks showed better maintenance of cord continuity and less fluid accumulation at the injury site in the nAG-treated group. Just proximal to the injury site, there was less gliosis in the experimental compared to the control group. At the crush injury site, there was less tissue architecture distortion, less vacuole formation, and less granulation tissue formation in the experimental group.

Conclusion: The local injection nAG protein enhances neuro-restoration, reduces gliosis, and reduces vacuole/granulation tissue formation following acute spinal cord crush injury in the rat aneurysmal clip animal model.

 Delayed Recognition of Anorectal Malformations: Avoidable mishaps

Muhammed Almosaibli, Muhammed Aqil Soomro, Tariq Altokhais, Abdulrahman Albassam

Department of Surgery, Division of Pediatric Surgery, King Saud University, Riyadh, Saudi Arabia

Background: Anorectal malformations (ARMs) usually diagnosed at birth by routine neonatal physical examination. Delayed diagnosis and mismanagement are associated with significant morbidity and even mortality. The aim of this study is to examine the magnitude of the problem and to find out the most common type of ARM that is misdiagnosed and consequently mismanaged and the sequallae to that, in addition, factors that contribute to the delay in diagnosis and management would be looked at, finally to suggest ways to prevent this from ever happening.

Material and Methods: This is a retrospective analysis of cases managed between March 2009 and November 2016 with delayed recognition and management at king Saud university medical city, Riyadh, Saudi Arabia. Delayed recognition is defined as the diagnosis that takes longer than 48 hours after birth. The charts were reviewed for demographic data, clinical presentation, complications related to misdiagnosis, final diagnosis of an anomaly, associated anomalies, surgical treatment, follow-up, outcome and possible cause of the delay. All the parents were interviewed either personally or by phone for detailed perinatal history and post-surgery fecal continence.

Results: There were 31 patients were admitted with the diagnosis of ARM over the period of the study. 12(38.7%) patients had a delay or mismanagement. 8(72.7%) were male and 4(27.3) female. 5(45.4%) patients were examined at birth but the anomaly was not detected. The remaining 7(54.6 %) patients the anomaly were identified at birth but inappropriate treatment was offered. The age at diagnosis of undetected patients was ranged from 3 to 570 days (median 150 d). They presented with different symptoms including bilious vomiting, sepsis, severe constipation abdominal distension, failure to thrive, anemia, perineal excoriation and colostomy prolapse.All patients had perineal fistula as their primary defect. Their age at surgery was ranged from 3 to 570 days (medium 105 d). The causes of delayed recognition and misdiagnosis were shared by the failure of the pediatrician to detect the anomaly at birth and incorrect decision by the surgeon. Seven patients had minimal posterior sagittal anorectoplasty and five had cut back anoplasty. All of them were doing fine except for one female infant with colostomy had partial wound disruption and colostomy prolapse. Three patients were over three years and they were continent, the remaining were below two years of age and could not be assessed for continence. Follow up varied from 2-36 months (M 10.45 months).

Conclusion: Delays in the diagnosis of ARMs are common, more than third of these patients present late for proper treatment. Optimal perineal examination at birth and appropriate surgical decisions are the only way to prevent these mishaps. There is a need for clear guidelines to aid the diagnosis of ARMs at birth to avoid the delay in the diagnosis.

 The Relationship between the Quality of Informed Consent and Perioperative Care Patients' Satisfaction in King Khalid University Hospital in Riyadh, Saudi Arabia

Dr. Thamer Adnan Nouh, Shaikha Hamed Aldossari, Shaden Saleh Alfayez, Deema Ibrahim AlTurki, Raghad Ibrahim Al Mutlaq,

Alhanoof Khalid AlJasser

Department of Surgery, King Saud University, Riyadh, Saudi Arabia

Objectives: To assess the association between patients' satisfaction and the quality of the informed consent obtaining process at King Khalid University Hospital, Riyadh, Saudi Arabia.

Methods: A cross sectional study was carried out using pre- and postoperative structured interviews in King Khalid University Hospital (KKUH) with both being a pre-developed questionnaires with some modifications. The study took place between December 2014 and April 2015. The target sample was calculated to be 196 patients assuming that 50% of postoperative patients are satisfied. Accepting 7% precision, and 95% confidence interval. A consecutive sample of patients admitted for an elective general surgery. Data collection was done in two stages: 1- Structured, face-to-face interviews of preoperative patients undergoing general surgery to assess the quality of the informed consent one day before their surgeries. 2- Structured, face-to-face or telephone interviews with these patients two days postoperatively, to assess their level of satisfaction about perioperative care. Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) version 20 software.

Results: The number of participants was 198 of general surgery patients operated in a period of 7 weeks. The majority (60,6%) were females. Most of the respondents were married (71,7%) and older than 45 years of age (45,9%). Quality of informed consent in KKUH demonstrated by Patient-physician Relationship and Disclosure and Understanding scores showed no significant relation of Patient-physician Relationship with the level of perioperative care patient satisfaction since (P=0,105, r=-0,147), while disclosure and understanding score showed a strong positive relationship with the level of satisfaction using Pearson correlation coefficient since P=0,037, r=0,188. The LPPSq score was found to be significantly related to patients' having children since P=0.003 < 0,05. Otherwise, no significant difference was found between the rest of variables with respect to LPPSq score since P>0.05.

Conclusion: In conclusion, there was a statistically significant relation between disclosure and understanding score and patient satisfaction. However, the quality of informed consent was found to be moderate in KKUH. The majority of the patients were completely satisfied. Significant patient factor related to perioperative care satisfaction was found to be having children. Further studies should emphasize on the effect of patients' level of education on their level of postoperative satisfaction. Physicians should be aware of these factors that may affect the quality of informed consent and patient satisfaction. Observational studies should be conducted in order to assess the quality of informed consent to see if physicians adhere to hospital's policies and international guidelines.

Key words: KKUH, IC, LPPSQ, Patient Satisfaction of perioperative care

 Has Color Duplex Arteriography Replaced Digital Subtraction Arteriography is the First Line Imaging Modality for Decision Making in Peripheral Arterial Disease Management – KKUH Experience

Walid B, Al Humran A, Magdi I, Hussam A,

Kaisor I, Al Shehri A, Khoja E, Al Salman

Vascular Division, Dept of Surgery, KSU Riyadh

Digital Subtraction Angiography a gold standard was a routine imaging for evaluation of Lower Limb Peripheral Arterial Disease till 2003 at our center.

After our comparative study of Duplex Scan & DSA in the management of chronic leg ischemia in 2003, which guided us to utilize Color Duplex Arteriography as first line imaging modality for decision making in PAD management

All the consecutive patients referred with PAD from 2003 onwards underwent Color Duplex Arteriography and plan of management was based on this – Best Medical Treatment, Endovascular interventions or Surgery, and was compared with either DSA or CTA when treated by Endovascular Intervention or Surgery respectively & outcome of management was compared and followed.

In our series Color Duplex Arteriography was found to be accurate enough to guide initial clinical management of patient with PAD & outcome was comparable & was the preferred first line imaging modality for decision making at our center.

A noninvasive, in expensive, portable imaging modality but needs dedicated expertise in this field.