Hassan Ali Alzahrani

Background/Objectives: Stapled transanal rectal resection (STARR), introduced in 2004 for obstructed defecation syndrome (ODS), remains of uncertain comparative efficacy and safety relative to other therapeutic approaches. This study systematically evaluated and meta-analyzed STARR surgery versus alternative interventions for ODS. Methods: MEDLINE (PubMed), CENTRAL, ProQuest, SAGE, and Web of Science were searched up to May 2026 for randomized controlled trials and observational comparative studies evaluating STARR against any comparator for ODS. Primary outcomes included improvement in validated ODS constipation scores and postoperative morbidity (bleeding, pain, urgency/incontinence). Secondary outcomes were operation time and hospital length of stay. Pooled effect sizes were calculated using random-effects models, heterogeneity assessed via I² statistics, and cumulative meta-analyses performed to examine temporal trends. Results: Twelve studies (4 RCTs, 8 observational) comprising 995 participants were included. No significant difference in ODS score improvement was found between STARR and comparators (SMD = 0.26, 95% CI: −0.17 to 0.70; I² = 89.2%); however, due to substantial clinical and statistical heterogeneity and wide prediction intervals, this pooled estimate reflects an average of diverse underlying effects rather than a single definitive treatment effect with cumulative analysis revealing loss of initial efficacy after 2010. STARR showed numerically higher but non-significant odds of bleeding (OR = 1.73) and urgency/incontinence (OR = 2.91), with comparable postoperative pain (OR = 0.70). STARR demonstrated significantly shorter operation time (MD = −21.23 min) and hospital stay (MD = −1.15 days). Conclusions: STARR surgery offers no superior efficacy in ODS symptom improvement compared with alternative treatments. However, the extreme heterogeneity of the primary outcome limits the interpretive value of the pooled estimates. While there are numerically higher odds of postoperative bleeding and urgency/incontinence, these differences did not reach statistical significance. STARR is associated with significantly shorter operation time and hospital stay. The declining effect size over time and substantial heterogeneity suggest that patient selection is critical. Future large multicenter RCTs with long-term follow-up and standardized patient-reported outcomes are needed to define optimal surgical strategies for specific ODS phenotypes.

Ectopic intravagal parathyroid adenomas represent an exceedingly rare clinical entity. Embryologically, parathyroid glands develop from the third and fourth pharyngeal pouches, migrating to their definitive locations on the inferior and superior aspects of the thyroid. While ectopic locations are well described, intravagal variants are rare, with few documented cases in the literature. We report an additional unique case of a patient with persistent hypercalcemia and severe osteoporosis following a failed bilateral neck exploration for primary hyperparathyroidism. Following multimodal structural and functional radiological evaluation, an ectopically undescended parathyroid adenoma was identified and subsequently confirmed intraoperatively to be situated intravagal.

Background: Despite the use of sentinel lymph node biopsy (SLNB) to stage the axilla in clinically node‐negative breast cancer patients’ postneoadjuvant therapy, the incidence and clinical significance of axillary recurrence (AR) after a negative SLNB remain under‐explored in the literature. Understanding these factors is essential to improving patient outcomes and guiding future treatment strategies. Methods: We conducted a systematic review and meta‐analysis using PubMed, Scopus, ScienceDirect, and Google Scholar. A random effects model was used to calculate pooled incidence of AR, while heterogeneity was assessed using the I ² and Q‐statistics. Publication bias was evaluated with a funnel plot and Egger’s test. We performed all analyses using the R meta and metafor packages. Results: A total of 37 studies were included in the qualitative synthesis and meta‐analysis. The pooled analysis of these studies highlights a remarkably low incidence of AR, with an overall proportion of 1% (95% CI: [0.0%, 1.0%]) under a random‐effects model and no significant heterogeneity ( I ² = 0%, p = 0.95). Egger’s test for publication bias was conducted to assess the presence of funnel plot asymmetry in the meta‐analysis, indicating no significant evidence of publication bias ( z ‐value = 0.6074, p ‐value = 0.5436). Conclusion: The meta‐analysis demonstrated a remarkably low incidence of AR after a negative SLNB in initially node‐positive breast cancer patients postneoadjuvant therapy. These findings suggest that such recurrences are rare, supporting the reliability of SLNB in accurately staging the axilla. This highlights its importance in clinical decision‐making for treatment strategies.

Background: Obesity is a global epidemic, with rising prevalence rates in both developed and developing countries. In Saudi Arabia, the prevalence exceeds the global average, reaching 35%, and is associated with increased morbidity and mortality. This study explores changes in quality of life (QoL) following laparoscopic sleeve gastrectomy (LSG) among adults in the Aseer region, an area previously unexamined in this context. Methods: A retrospective study was conducted involving patients who underwent LSG in Abha between January 2018 and December 2023. The study included 385 participants, selected from an initial pool of 450 after excluding individuals with incomplete data. QoL was assessed using the RAND 36-Item Health Survey, which evaluates various domains such as physical functioning, emotional well-being, and general health perception. Results: Postoperative assessments revealed significant improvements in QoL, with patients reporting enhanced physical and emotional health. Mean scores demonstrated notable gains, particularly in energy/fatigue and emotional well-being domains. A substantial majority (79%) expressed satisfaction with their weight loss outcomes. Furthermore, many participants experienced significant improvements in obesity-related comorbidities, including diabetes and gastroesophageal reflux disease. Statistical analyses identified key predictors of patient satisfaction, such as age, education level, and income. Conclusion: This study confirms the effectiveness of LSG as a viable intervention for obesity management in the Aseer region, leading to improved health-related quality of life. It underscores the importance of a comprehensive approach to obesity treatment that combines surgical intervention with ongoing lifestyle support. Future research should focus on long-term outcomes and the psychological aspects of post-bariatric surgery to optimize patient care. Overall, this study provides valuable insights into obesity management and QoL enhancement following surgery in Saudi Arabia.

Laparoscopic sleeve gastrectomy (LSG) is a common bariatric surgical procedure for treating obesity. Understanding factors influencing weight loss outcomes post-LSG is crucial for optimizing patient care. This study aimed to investigate demographic and clinical factors associated with weight loss outcomes following LSG. A retrospective cohort study was conducted on 253 patients undergoing LSG at Abha Private International Hospital in Saudi Arabia between January 2018 and June 2022. Data on gender, age, blood group, chronic diseases, body mass index, and percentage of excess weight loss (%EWL) were analyzed using descriptive statistics, chi-square tests, t tests, ANOVA, logistic regression, and post hoc analyses. Males achieved higher %EWL compared to females (P < .05). Blood group A+ and age group (P < .05). Logistic regression identified gender, blood group A+, and age group (<25 years) as significant predictors of weight loss outcomes post-LSG. Gender, blood group A+, and age group (<25 years) are important determinants of weight loss outcomes following LSG. Personalized treatment strategies considering these factors may enhance the effectiveness of bariatric surgery interventions. Further research is needed to explore additional factors impacting weight loss outcomes in bariatric surgery.

Background/Objectives: Rapid weight loss after bariatric surgery is linked to a higher risk of symptomatic gallstone disease, which could require a cholecystectomy. This meta-analysis aimed to assess the efficacy and safety of conducting laparoscopic cholecystectomy concurrently with sleeve gastrectomy in morbid obese patients. Methods: Scopus, PubMed, ProQuest, Web of Science, and Google Scholar were searched for this review. Quality assessment was conducted using the Newcastle-Ottawa Scale for observational studies and ROB2 for randomized clinical trials. Eight of thirteen studies were high-quality. Pooling for BMI difference and LOS was used to measure efficacy, and the pooled proportion was utilized to assess safety through bleeding, wound infection, and leakage. Heterogeneity was explained via leave-one-out analysis and meta-regression. Results: The pooled standardized mean difference in BMI peri-operation was 3.26 (95% CI: 2.51–4.01, p < 0.01), where the age and initial BMI explained 98% of the heterogeneity through meta-regression. The pooled mean of LOS was 3.18 days (95% CI: 2.23–4.14, I² = 99%, p < 0.001), where age explained 33.22% of the heterogeneity through meta-regression. The pooled proportion of bleeding was 0.03 (95% CI: 0.02–0.04, I² = 2%, p = 0.42). The pooled wound infection was 0.04 (95% CI: 0.02–0.08, I² = 80%, p < 0.001), where age accounted for 99% of the heterogeneity. The pooled biliary/gastric leakage was 0.02 (95% CI: 0.01–0.05, I² = 0, p = 0.52). Conclusions: These findings indicate that the combined procedures can be executed with an acceptable safety profile. The heterogeneity in outcomes underscores the necessity of personalized patient care, standardized perioperative practices, and continuous research to enhance results and mitigate dangers.

Backgrounds We aimed to assess the feasibility and outcomes of immediate breast reconstruction with prepectoral direct prosthesis placement under the skin envelope in patients with small-to medium-sized breasts with immediate lipofilling of the skin cover. Methods Demographic and clinical data of female patients with small-to medium-sized breasts diagnosed with breast cancer who were eligible for skin-sparing mastectomy and immediate reconstruction were included in this retrospective study. Information concerning the surgical technique, implant size, procedure duration, and intraoperative complications were also obtained. All early or late postoperative complications were recorded. Postoperative patient satisfaction was routinely assessed using the Kyungpook National University Hospital Breast Reconstruction Satisfaction Questionnaire. Results The study included data from 52 female patients (mean age: 49.1±8.6years); the mean follow-up was 30.3 ± 9.7 months. Reconstruction was successful in 50 (96.2%) patients. Capsule contracture developed in 11 patients (21.2%), with six requiring capsulectomy. Three patients (5.8%) showed a slight reduction in the range of motion, mainly due to axillary procedures. Two patients (3.8%) developed rippling that was treated successfully with delayed lipofilling. Forty-eight patients (92.3%) showed postoperative satisfaction, with three being satisfied only after the management of postoperative complications. Conclusions The prepectoral technique for breast reconstruction without mesh support is an effective option in patients with small-to medium-sized breasts. This approach has few complications and offers high postoperative patient satisfaction at a reasonable cost. Proper patient selection is necessary to achieve favorable outcomes, and immediate lipofilling improves the results. Moreover, immediate lipofilling seems to improve outcomes of prepectoral breast reconstruction; however, future studies are required to support this finding. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Objective To assess the feasibility and outcomes of immediate breast reconstruction using a dermal sling and polypropylene mesh for fixation after skin-reducing mastectomy with prepectoral prosthesis placement in patients with large breasts who were diagnosed with cancer. Methods This retrospective study included demographic and clinical data from female patients with breast cancer and large breasts, who were candidates for skin-reducing mastectomy and immediate reconstruction. Data regarding operative technique, implant size, operative duration, and intraoperative complications were retrieved. Early and late postoperative complications were recorded. Routine assessment of postoperative patient satisfaction was performed using the Breast Reconstruction Satisfaction Questionnaire. Results The study included data from 49 female patients with a mean (± SD) age of 40.88 ± 8.03 years; the mean follow-up was 31.5 ± 8.1 months. The operation was successful in 47 (95.9%) patients, whereas reconstruction failed in 2. Capsule contracture occurred in 9 (18.4%) patients, 4 of whom required capsulectomy. Severe wound infections occurred in 2 (4.1%) patients, 1 of whom was treated conservatively. Implant exposure occurred in 2 (4.1%) patients, 1 of which was managed using a skin rotational flap. Five (10.2%) patients experienced mildly impaired range of motion. Forty-four (90.0%) patients reported postoperative satisfaction, with 3 expressing satisfaction only when postoperative complications were treated. Conclusions The prepectoral approach using a combined synthetic mesh and dermal sling yielded a good solution for patients with large breasts. The technique was associated with minimal complications, yielded good postoperative patient satisfaction, and is affordable. The results of using a synthetic mesh appeared to be equivalent to those of ADM. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Diverticular disease is a common condition that has numerous complications. Understanding the impact of diabetes mellitus (DM) on these complications, especially diverticulitis, is crucial for optimizing patient care. This study aimed to determine the relationship between type II DM and the complications of colonic diverticulitis. A retrospective cohort study was conducted on 158 patients complaining of diverticulitis at Asir Central Hospital, Abha, Saudi Arabia, between January 2013 and December 2023. Data on gender, age, and chronic diseases, especially DM, were collected. Data retrieved regarding diverticulitis included the involved segment, complications, Hinchey classification, and management. We classified the patients into groups A for nondiabetics and B for diabetics. We analyzed the data using descriptive statistics, chi-square tests, t tests, and analysis of variance. Diabetic patients were significantly older than their nondiabetic counterparts. Diabetic patients showed a significantly higher complication rate (62.5%) and a higher degree of Hinchey classification compared to nondiabetic patients (43.7%). Furthermore, in comparison to individuals without diabetes, they were hospitalized for a considerably extended period (8.06 ± 7.38 days vs 5.26 ± 5.90 days, respectively). In addition, surgical intervention was observed to be considerably more common in patients with diabetes (46.9%) than in those without diabetes (16.5%). The study showed that DM adversely affected patients with diverticulitis. A greater incidence of complications and a higher category of Hinchey classification were associated with DM compared to nondiabetics. Additionally, diabetics underwent more surgical interventions and had longer hospital stays. Diabetics with diverticulitis require particular care to prevent severe complications.