BackgroundAcute appendicitis is the most common surgical emergency and becomes serious when it perforates. Perforation is more frequent in the elderly patients. The aim of this study was to identify the risk factors of perforation in elderly patients who presented with acute appendicitis.MethodologyThe medical records of 214 patients over the age of 60 years who had a pathologically confirmed diagnosis of acute appendicitis over a period of 10 years (2003-2013) were retrospectively reviewed. Patients were grouped into those with perforated and those with nonperforated appendicitis. Comparison was made between both groups in regard to demography, clinical presentation, and time delay to surgery, diagnosis, hospital stay and postoperative complications. Clinical assessment, Ultrasonography and Computerized tomography, in that order, were used for diagnosis. The incidence of perforation was also compared with a previous report from the same region 10 years earlier.ResultsDuring the study period, a total of 214 patients over the age of 60 years had acute appendicitis, 103 males and 111 females. Appendix was found perforated in 87 (41%) patients, 46 (53%) males and 41 (47%) females. Of all patients, 31% were diagnosed by clinical assessment alone, 40% needed US and 29% CT scan. Of all the risk factors studied, the patient’s pre-hospital time delay was the most important risk factor for perforation. Perforation rate was not dependent on the presence of comorbid diseases or in-hospital time delay. Post operative complications occurred in 44 (21%) patients and they were three times more common in the perforated group, 33 (75%) patients in the perforated and 11 (25%) in the nonperforated group. There were 6 deaths (3%), 4 in the perforated and 2 in the nonperforated group.ConclusionAcute appendicitis in elderly patients is a serious disease that requires early diagnosis and treatment. Appendiceal Perforation increases both mortality and morbidity. All elderly patients presented to the hospital with abdominal pain should be admitted and investigated. The early use of CT scan can cut short the way to the appropriate treatment.

Bouveret's syndrome is a rare cause of gastric outlet obstruction. Its diagnosis is often delayed or overlooked. It is characterized by the passage of a large gall bladder stone through a bilio-duodenal fistula, which becomes lodged in the duodenum causing duodenal obstruction. We report the case of a 70-year-old male with a history suggestive of gall bladder disease over a 1-year period. The diagnosis was confirmed by ultrasound, which showed a single large gall bladder stone and the patient was planned for elective laparoscopic cholecystectomy. One week prior to the elective surgery he presented with upper gastrointestinal bleeding for which he was admitted, diagnosed by a gastroenterologist as bleeding duodenal ulcer and treated by local epinephrine injection and blood transfusion. One week later he presented with a picture of acute gastric outlet obstruction, which proved by endoscopy to be due to a large stone impacted in the duodenum. Endoscopic management failed and the stone was managed by open surgery. The patient made a good postoperative recovery and for the last year he has remained free of symptoms.

The objective of this study was to estimate the incidence of incidental extirpation of the parathyroid glands during thyroid operations, and to investigate possible risk factors and post-thyroidectomy complications using a descriptive design in a university hospital setting. Hospital records for all thyroidectomies performed in the period between 1st February 2004 and 31 January 2008 for Incidence of incidental extirpation of the parathyroid glands during thyroid operations and post-thyroidectomy hypocalcemia were reviewed. Results showed that incidental parathyroidectomy occurred in 8.6%. Most of the excised parathyroid tissues were extracapsular. Malignant thyroid disease was a risk factor. Extent of surgery, age and sex were not risk factors for incidental parathyroidectomy. Results also showed that incidental parathyroidectomy was associated with transient hypocalcemia.

Xanthogranulomatous cholecystitis is rare. Acute presentation, associated jaundice, and gallbladder wall thickening should raise the suspicion of the condition. Laparoscopic cholecystectomy is associated with high conversion rate.

Abdominal cocoon is a rare cause of small bowel obstruction. It is characterized by the encasement of a variable length of the small intestine by a fibrous membrane. It occurs primarily in females with only few reported cases in males. We report the case of a 42-year-old male with a history suggestive of recurrent attacks of small bowel obstruction over a 6-month period, which used to resolve spontaneously or by conservative measures. At presentation, a mildly tender mobile mass was felt in the right lower part of the abdomen. Computed tomography scan of the abdomen showed clusters of small bowel loops encased within a well-delineated sac. The diagnosis was confirmed by diagnostic laparoscopy. Laparoscopic lyses and release of the entrapped bowel was performed. The postoperative period was uneventful. Follow-up over 18 months showed no clinical evidence of recurrence.

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Hemodynamic instability and evisceration should continue to prompt urgent LAP. For stable patients, a sequence of LWE followed by focused abdominal sonography for trauma and computed tomography scanning for unclear cases primed by RCA was found to be efficient in limiting hospital admissions and reducing the rate of non-therapeutic LAP.

VAI was common in hemodialysis patients, and the risk varied substantially among different VA types and different dialysis units. The infection rate from catheters and AVFs was similar to that reported in many studies, but the infection rate in the arteriovenous graft group was lower than that for AVFs. These results can be improved by strictly following the National Kidney Foundation Disease Output Quality Initiative clinical practice guidelines for dialysis access.