Objective: To describe the clinical presentation as well as the outcome of surgically explored acute scrotal swellings among children and adolescents recorded at the Al-Jahra Hospital, Kuwait during the period 1985–1995. Methods: Hospital records of 120 cases were reviewed. Results: Seventeen percent of the cases were found to be testicular torsions (TT) and 40% torsions of testicular appendages (TAT). Other etiologies included traumatic swelling (15%), idiopathic edema (13%), epididymo-orchitis (10%), hydroele (4%) and others (2%). Ages of patients ranged from 6 months to 18 years, averaging 9.3 years (SD = 2.9) for TAT cases and 10.1 years (SD = 6.4) for TT cases. Swelling and pain were located on the left side for 65% of the torsion cases. Direct trauma was reported in 22% of the torsion cases. In 90% of TT cases, orchidopexy was performed with success. Subsequent testicular atrophy occurred in only 1 patient who had symptoms for more than 48 h prior to surgery. Orchidectomy was directly performed on necrosed testes in a patient with signs lasting more than 48 h, and another patient with signs lasting 4 days. Conclusions: Primary health care physicians in Jahra district should continue to educate parents and adolescents to recognize the gravity of scrotal pain, and the importance of early response as a way of avoiding testicular necrosis.

Objectives: The aim of this study was to introduce the concept of non-operative management (NOM) for blunt liver trauma by establishing a protocol and a prospective Liver Trauma Registry in Kuwait. Subjects and Methods: A prospective Liver Trauma Registry was started in 4 hospitals and it included 117 patients who had sustained blunt liver trauma (94 men and 23 women). Unstable patients were taken to surgery while stable patients were managed conservatively regardless of the grade of liver injury. High-grade (III-VI) liver injuries were managed in collaboration with the liver surgery specialist. Results: The mean age of the 117 patients was 29.02 ± 11.18 years (range 7-63). NOM was successful in 94 (96%) patients and failed in 4 (4%) (these 4 then underwent successful surgery). Nineteen (16.2%) were unstable and underwent surgery immediately; 15 (79%) of them survived (they had had grade III-V injuries) and 4 died (2 with grade V injuries and 2 with grade VI injuries). Perihepatic packing was necessary in 8/19 (42%) patients. The overall mortality was 3.4% (4/117). Conclusions: This study showed that NOM was successful in a majority of patients with blunt liver trauma. In addition, it confirmed that the magnitude of liver injury and haemoperitoneum did not preclude NOM as long as the patient was haemodynamically stable.

<i>Objective:</i> To report a case of mixed adenocarcinoma and carcinoid in the gastrointestinal tract. <i>Clinical Presentation and Intervention:</i> A 52-year-old man presented with a mass at the base of the appendix. On microscopic examination of the tumor, mixed adenocarcinoma and carcinoid was identified. The carcinoid component was insular/trabecular in morphology, and the epithelial component revealed mucinous adenocarcinoma. Morphologically and immunohistochemically the 2 components showed a clear-cut distinction, without any intervening intermediate cell population. The adenocarcinomatous component displayed omental deposit and metastasis to the regional lymph nodes. One year later, the patient developed multiple metastatic deposits of adenocarcinoma in the liver, rectus muscle, ileum and sigmoid colon. <i>Conclusion:</i> This tumor had an aggressive clinical course and behaved more like adenocarcinoma than carcinoid.

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Objectives: Bile duct injuries were analysed in a prospective study of 1,250 cases of laparoscopic cholecystectomy. The aim of the study was to identify the incidence and causes of bile duct injuries in the course of laparoscopic cholecystectomy, and to recommend the possible ways to avoid this serious complication. Materials and Methods: Special computer forms were created to record detailed patient pre-operative, operative, and postoperative follow-up data for later study. Operative cholangiography was done only on a selective basis. Bile duct injuries were classified according to the Bismuth classification. Results: Four cases (0.3%) of bile duct injuries were encountered in the study: 2 of them were classified as major (Bismuth classification grade II) and the other 2 as minor (diathermy puncture). All injuries were attributed to distortion of Calot’s triangle and failure to clearly identify the anatomy. A recent history of acute cholecystitis, a history of jaundice, pancreatitis and repeated or technically difficult endoscopic retrograde cholangiopancreatography (ERCP) were associated with local inflammatory changes that had possibly contributed to the distorted anatomy at Calot’s triangle and consequently to the injury. All injuries were detected during surgery and immediately repaired. Major bile duct injuries were repaired by choledocho-enterotomy, while minor injuries were treated by simple sutures around the T tube in the common bile duct. All patients were asymptomatic with normal liver function tests on follow-up for a period up to 3 years after surgery. Conclusions: The incidence of bile duct injuries in laparoscopic cholecystectomy is comparable to open surgery. Patients with a clinical history of acute cholecystitis, or a recent history of jaundice and repeated ERCP should be considered for operative cholangiography in order to help reduce the chances of bile duct injuries.

Objective: To present a case of ascending cholangitis with resulting necrosis of the biliary system with perforation. Clinical Presentation and Intervention: A 40-year-old male patient presented with upper abdominal pain, fever and jaundice assessed clinically and investigated by laboratory and radiological tests. Endoscopic retrograde cholangiogram and surgery were performed. However, because of extensive suppurative pancholangitis involving most of the intrahepatic radicles, sound surgical drainage could not be accomplished. Unfortunately, the patient died 2 days after surgery. Conclusion: In this case of severe cholangitis, endoscopic and surgical interventions were not successful and might have contributed to the worsening of the condition.