BACKGROUNDOpen appendectomy is still the most common method of treating appendicitis. Laparoscopic procedures for removal of the appendix by the “in” technique as an alternative to conventional appendectomy have gained wide popularity, but have been criticized for their technical difficulty and high cost. We assessed the safety and efficacy of the laparoscope-assisted appendectomy (the two-trocar technique) in adults.PATIENTS AND METHODSWe retrospectively studied 129 patients who had appendectomy using the laparoscope-assisted two-trocar technique between July 2002 to December 2003. The procedures were done by consultants and surgeons-in-training with experience in minimally invasive and open techniques. Locally modified endoloop and reusable trocars were used to reduce the cost. Appendectomy was performed extra-abdominally after the appendix was identified by using a laparoscope through one port and then delivered outside through the second port using reusable laparoscopy instruments.RESULTSThe two-trocar technique was successful in 101 (78.3%) cases; 14 (10.8%) needed a third trocar to complete the operation extra-abdominally, 6 (4.6%) were converted to open surgery, and 5 (3.8%) had an intra-abdominal laparoscopic appendectomy. The mean operation time was 35 minutes (range, 30–90 minutes). Six cases (4.6%) had infection. The mean hospital stay was 2.8 days (range, 2–7 days). No case of port hernia was reported during the follow-up period (range, 14–30 months).CONCLUSIONThe laparoscope-assisted two-trocar technique for removal of the appendix can be performed as safely and efficiently as the open technique, but at a lower cost than the complete laparoscopic ‘in” method and does not need much technical expertise. This method is recommended as an alternative procedure to open appendectomy or the complete laparoscopic “in” technique in adults.

Esophageal malignancies are commonly seen in the sixth, seventh, and eighth decades of life, and are rare at a young age and in children. 1 To date, only a few cases of esophageal carcinoma in children have been reported in the world literature.2 Epidemiological studies have shown that these esophageal malignancies are predominantly environment-produced, and require a long, latent period of carcinogenesis, thus accounting for its rarity in childhood. [3][4][5][6][7] There is no mention of etiological or environmental risk factors in the majority of these reported cases, and therefore, the pathogenesis of the condition is still unknown. A case of esophageal carcinoma in a 15-year-old girl is reported because of its rare incidence in this teenage group. A brief review of the literature is also provided. We believe that this is the first case of its kind to be reported from the Middle East. Case ReportA 15-year-old Sudanese female presented to the Gastroenterology Clinic of King Fahad Hospital, Medina, for progressively increasing dysphagia over a one-month period. The problem started with difficulty in swallowing solid food, and a feeling of food getting "stuck" in the retrosternal region. Initially, she could wash down the food with liquids. However, in a matter of only four weeks, she could not even swallow liquids without difficulty. Limitation in her oral intake resulted in weight loss. There was some chest discomfort, however, the swallowing was not painful. There was an associated feeling of ill health and lack of appetite. The patient had lived in Saudi Arabia for eight years, and had been in excellent health without any prior sickness. There had never been any previous swallowing problem. She denied having any chest pain, heartburn, regurgitation, nausea or vomiting, and there was no history of ingestion of any corrosive substance. She was not on any medications, such as antibiotics, NSAIDs, etc. She had no skin disease, had never smoked cigarettes or taken alcohol. She also denied drinking excessive "hot" coffee or tea, but admitted to occasionally taking soft drinks. There was no family history of esophageal problems or gastrointestinal malignancies, and there was no known familial or genetic disorder.Physical examination revealed a thinly built, apprehensive girl. There were no signs of chronic sickness. Her vital signs were stable, BP 110/80 mm Hg and pulse 70/minute. There was no icterus and skin was normal. There was no keratinization of her palms or soles to suggest tylosis. There were no signs to suggest nutritional deficiencies. The neck was supple, and there were no palpable lymph nodes. Examination of heart, lungs and abdomen were unremarkable. Liver was not enlarged and there was no ascites.Laboratory investigations showed hemoglobin of 14.5 g/dL, and normal WBC and platelet count. Urea, creatinine, electrolytes and liver enzymes, including alkaline phosphatase, were normal. Amylase was also normal, and chest x-ray was within normal limits.A barium swallow revealed an ulcerated mass about 7 cm ...

Background: Chest trauma in childhood is relatively uncommon in clinical practice, and has been the subject of few reports in the literature. This study was undertaken to examine our experience in dealing with chest trauma in children. Patients and Methods:This was a retrospective study of 74 children who sustained chest trauma, and were referred to King Fahad Hospital in Medina over a two-year period. The age, cause of injury, severity of injury, associated extrathoracic injuries, treatment and outcome were analyzed. Results: The median age of the patients was nine years. Fifty-nine of them (80%) sustained blunt trauma, and 15 (20%) were victims of penetrating injuries. Road traffic accident was the cause of chest trauma in 62% of the children, gun shot wounds were seen in five, and stab wounds in 10 children. Head injury was the most common injury associated with thoracic trauma, and was seen in 14 patients (19%), and associated intraabdominal injuries were seen in nine patients. Chest x-ray of the blunt trauma patients revealed fractured ribs in 24 children, pneumothorax in six, hemothorax in four, hemopneumothorax in three, and pulmonary contusions in 22 patients. Fifty-one percent of children were managed conservatively, 37% required tube thoracostomy, 8% were mechanically ventilated, and 4% underwent thoracotomy. Conclusion:The prevalence of chest trauma in children due to road traffic accidents is high in Saudi Arabia. Head injury is thought to be the most common associated extrathoracic injuries, however, most of these patients can be managed conservatively.

Chylous effusions into pleural and peritoneal cavities are unusual, and are often a manifestation of an underlying disease process. A sudden outpouring of chyle into the peritoneal cavity may, on rare occasions, produce acute chylous peritonitis. Such patients usually present with features of acute abdomen, however, the diagnosis is rarely suspected preoperatively. Very few cases of acute chylous peritonitis have been described in the literature, and to the best of our knowledge, this is first of its kind in Saudi Arabia. Due to its rarity and presentation as compared to a common surgical emergency such as acute appendicitis, the clinical features and management of acute chylous peritonitis are discussed. Case ReportA 25-year-old Nigerian male was referred to the emergency room of King Fahad Hospital, in Medina, Saudi Arabia, because of generalized abdominal pain, vomiting and anorexia of three days' duration. The pain had started as a dull ache just above the umbilical region, had gradually increased in severity and become generalized. A day prior to his admission, the pain had localized to the right lower quadrant of the abdomen. The pain was continuous, severe and aggravated by any movement. The patient did not give any history of previous trauma or similar pain. He had been unable to take anything orally for over 24 hours prior to admission. There was nothing relevant in his past medical history, except that five years previously, he had been hospitalized for respiratory infection for five days. Details of this were not available. For the previous six years, the patient had been smoking about thirty cigarettes per day. He had not consumed alcohol for the past two years. There was no history of diabetes, hypertension, hyperlipidemia or recurrent abdominal pains in his family.On examination, the patient was mildly dehydrated. His temperature was 37.5°C, pulse rate was 115/min, and blood pressure was 110/85 mm Hg. Systemic examination was unremarkable. The abdomen was not moving adequately with respiration, and there was pain on coughing, especially in the right lower quadrant. The flanks were not full. There was guarding and tenderness all over the abdomen, especially in the right iliac fossa. Bowel sounds were audible. Total leukocyte count was 20,000/μL, Hb 16.8 g%, urea 4.3 mmol/L, creatinine 87.9 mmol/L, glucose 4.6 mmol/L, ALT 22 IUL, AST 28 IUL, amylase 104 IUL, cholesterol 3.5 mmol/L and triglycerides 0.34 mmol/L. Chest x-ray was normal. Abdominal x-ray showed nonspecific gas-filled loops of large intestine. The patient was suspected to have acute appendicitis with possible perforation.The abdomen was opened by right grid-iron incision, revealing unusually pale and white subcutaneous fat. The epimysium over the fibrous sheath aponeurosis of external oblique showed multiple strands with an interwoven network of whitish streaks. Between the strands was a whitish thickening of 1-2 mm. When the peritoneum was opened, milky white, odorless, non-clotting fluid gushed out. About one liter of this fluid was dra...

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