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   Table of Contents - Current issue
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October-December 2017
Volume 36 | Issue 4
Page Nos. 333-463

Online since Monday, November 13, 2017

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ORIGINAL ARTICLES  

Pectoral fascia preservation during modified radical mastectomy: why and when Highly accessed article p. 333
Mohamed I Abdelhamid, Mohammed M Alkilany, Mohamed Lotfy
DOI:10.4103/ejs.ejs_23_17  
Context The surgical treatment of breast cancer has changed significantly over time, but modified radical mastectomy (MRM) is still performed in about 20–30% of patients undergoing surgeries. Many articles that have studied the breast lymphatic system claim that the deep fascia is very poor in lymphatic vessels. Aim The aim of our study was to detect the benefits and oncological safety of pectoral fascia preservation in patients undergoing MRM. Materials and methods Totally, 73 patients with early breast cancer underwent MRM. The patients were randomized between removal (n=37) and preservation (n=36) of pectoral fascia. Results The amount of blood loss, operative time and drain output was significantly reduced in a case of pectoral fascia preservation (P>0.00001); in addition, seroma was significantly reduced (P=0.025). No chest wall recurrence had occurred in both groups. Conclusion Pectoral fascia preservation is safe and has many advantages as regards operative time, blood loss, seroma formation and cosmetic appearance of the flaps. It is oncologically safe compared with pectoral fascia resection, provided that good selection of the patient was done.
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A comparative study on the effect of laparoscopic simulation on skill training in laparoscopic surgery p. 336
Mohamed Lotfy, Mohamed I Abdelhamid, Hazem N Ashri
DOI:10.4103/ejs.ejs_29_17  
Context This study examined the effect of using laparoscopic simulation on the enhancement of psychomotor capabilities linked to performing laparoscopic appendectomy. Participants and methods Thirty surgical trainees carried out a laparoscopic appendectomy in the operating room (OR). The participants were then randomized to have a training course of six sessions (1 h each) on our simple simulator (MED-SIMU) or no training. Subsequently, all participants performed a further laparoscopic appendectomy in the OR. Both operations of each participant were recorded on video tapes, and assessed by two blinded laparoscopic senior surgeons using the predefined objective criteria such as time to complete the operation and the error counting. Results No differences in baseline variables were found between the two groups. Surgeons who received simulator training carried out laparoscopic appendectomy significantly faster than those in the control group (P=0.0006) and showed a greater improvement in error (P=0.0001). Conclusion Surgeons who had simulator training showed a greater enhancement in performance in the OR than those in the control group. Our simple surgical simulator is, therefore, a suitable tool for the training of laparoscopic motor skills and could be included in surgical training programs.
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Improved detection of lymph nodes in cases of rectal cancer using combined methylene blue injection and fat clearance compared with fat clearance alone p. 340
Ayman Farouk, Radwa Rashad
DOI:10.4103/ejs.ejs_35_17  
Introduction Evaluation of lymph nodes (LNs) in rectal cancer is a fundamental component of all staging systems. Fat clearance and ex-vivo injection of methylene blue into the inferior mesenteric artery are known methods that can improve LN yield in patients with rectal cancer especially after neoadjuvant chemoradiation. Both techniques were widely compared with routine manual palpation of LNs. The question is that ‘Do adding ex-vivo injection of methylene to fat clearance as a single combined technique give further superiority on fat clearance alone regarding detection of nodal harvest and status?’. Patients and methods This study was carried out through comparing clinicopathological data of 40 patients whose specimens were subjected to combined ex-vivo injection of inferior mesenteric artery and xylene fat clearance (group I) with that of 30 patients whose specimens underwent only xylene fat clearance. All patients presented with resectable rectal cancer and have received neoadjuvant chemoradiotherapy. Results There was a statistically significant difference regarding total nodal harvest in group I compared with group II (17.52±6.32 vs. 14.56±5.64; P<0.05). Similarly, detection of at least 12 LNs was statistically different (87.5 vs. 63.3%; P<0.05). However, it was not the case regarding detection of nodal metastases (55 vs. 56.7%), which was not significantly different (P=0.085). Conclusion Using ex-vivo methylene blue injection into the inferior mesenteric artery and xylene fat clearance as a single combined technique shows a significant difference when compared with xylene fat clearance alone regarding total LN harvest and detection of the optimal number of LNs in cases of rectal cancer. However, it did not show such significance regarding detection of nodal metastases.
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Comparison between full and partial revascularization during endovascular management of multilevel lower limb arterial disease in diabetic patients: assessment of functional outcomes and midterm results p. 346
Ahmed Taha, Haitham Eldamarany, Ahmed Sayed, Amr Abou Elrous
DOI:10.4103/ejs.ejs_47_17  
Introduction The multilevel arterial arteriosclerosis leads to a major loss of blood perfusion to the target tissues with resultant critical limb ischemia. Aim The aim of this article is to compare the results between total revascularization of all level arterial lesions versus revascularization of the proximal lesions regarding limb salvage rates, midterm primary patency rates, and secondary patency rates. Patients and methods A prospective study conducted on diabetic patients with symptomatic peripheral arterial disease affecting more than one level of lower limb arterial tree, from January 2013 till the end of December 2013, with critical limb ischemia and no previous attempts of revascularization. Follow-up was 1 year. Results A total of 101 diabetic patients were included. Their mean age was 64.4±14 years, and 62.4% were males. They were divided into two groups: group F had full revascularization for all diseased arterial levels and group P had revascularization for the proximal lesion only. Lesions were crossed intraluminal in 54 (53.5%) and subintimal in 47 (46.5%). Stents were used in 44 (43.6%). Primary patency rate was higher in group F than in group P (72.3 vs. 33.3%, P=0.002). The secondary patency rates were higher in group F compared with group P at 6 months (84 vs. 44%) and at 12 months (78 vs. 38%) (P=0.001). Total limb salvage rate was 80.2% and a major amputation rate was 19.8% over a 1-year follow-up period; limb salvage in group F was 88% and in group P was 44% (P=0.001). Conclusion In diabetic patients with multilevel arterial lesions affecting more than one arterial territory, total correction of all arterial lesions should be done with direct pulsatile flow to the foot as it is associated with better primary and secondary patency rates and higher limb salvage rates than correction of the proximal lesions.
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Portal and mesenteric vein resection during pancreaticoduodenectomy and total pancreatectomy p. 352
Hazem M Zakaria, John A Stauffer, Eijiro Harada, Horacio J Asbun
DOI:10.4103/ejs.ejs_48_17  
Background Portal vein invasion by a malignant pancreatic mass is currently not a contraindication to pancreatic resection with acceptable oncologic outcomes. Aim The aim of this paper was to identify the perioperative morbidity and long-term outcomes of venous resection (VR) during pancreaticoduodenectomy (PD) and total pancreatectomy (TP) operations. Materials and methods We carried out a retrospective study of patients undergoing PD or TP between March 1995 and December 2014 at Mayo Clinic in Jacksonville, Florida, using data collected from an institutional review board-approved prospective database. Preoperative, operative, and postoperative clinicopathological data were collected and analyzed. Results Out of 601 patients who underwent PD and TP in this study, 104 (17.3%) underwent VR. The types of VR and reconstruction were as follows: type I (lateral venorrhaphy) in 49 (47.1%) patients, type II (patch graft) in 10 (9.6%) patients, type III (primary anastomosis) in 27 (26%) patients, and type IV (interposition venous graft) in 16 (15.4%) patients. Two (1.9%) patients underwent no portomesenteric reconstruction. The 90-day major postoperative complications and mortality in patients with VR were 44.2 and 7.7%, respectively, versus 29.2 and 4.4%, respectively, in patients with standard resection. The 1-year, 3-year, 5-year, and 7-year survival rates in VR with periampullary adenocarcinoma (PAAC) were 55.1, 27, 21.9, and 15.4%, respectively, whereas in patients with PAAC without VR, the survival rates were 78.4, 45.6, 34.6, and 30.9%, respectively (P<0.01). Conclusion VR and reconstruction with PD can be performed safely with acceptable perioperative morbidity and long-term survival rates to achieve complete removal of the tumor.
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Comparative study between the complications of laparoscopic sleeve gastrectomy and laparoscopic mini-gastric bypass p. 360
Tamer Nabil, Ahmed Hussein, Ahmed Nabil
DOI:10.4103/ejs.ejs_49_17  
Background Obesity is considered a preventable worldwide epidemic. It can cause high rates of morbidity and mortality. Laparoscopic sleeve gastrectomy (LSG) and laparoscopic mini-gastric bypass (LMGB) are both safe and effective procedures for the surgical management of morbid obesity. Bleeding and leakage are the most fearful life-threatening complications. Patient and methods This prospective study comprised 150 morbidly obese patients. The study was conducted between July 2015 and March 2016, after which there was a follow-up for 12 months among all the patients. The patients were divided equally into two groups: group A comprised LSG patients, whereas group B comprised LMGB patients. Results Among the Group A patients, four (5.3%) exhibited complications: hemorrhage (1.3%), gastric leakage (1.3%), and gall-bladder stones (2.6%). In group B, five (6.6%) patients had complications: biliary reflux (1.3%), deep venous thrombosis (1.3%), and gall-bladder stones (3.9%). No mortality occurred in the study. Conclusion Both LSG and LMGB are safe and effective procedures. The study found no statistically significant difference between either procedure, in the incidence of complications.
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Value of pharmacologic thromboprophylaxis for prevention of thromboembolic complications in bariatric surgery p. 368
Ibrahim G Khalifa, Hany A Balamoun, Khaled El Kaffas
DOI:10.4103/ejs.ejs_50_17  
Objective The objective of this study was to assess safety and efficacy of pharmacologic thromboprophylaxis in morbidly obese patients undergoing bariatric surgery for prevention of silent deep vein thrombosis (DVT). Patients and methods This prospective study included 50 morbidly obese patients scheduled for primary one-stage laparoscopic bariatric surgery randomly allocated into one of two treatment groups according to the method of thromboprophylaxis. Group M (n=25) was subjected to mechanical prophylaxis with bilateral graduated compression stockings. Group MC (n=25) was subjected to mechanical plus pharmacologic prophylaxis using 40 mg of the low-molecular-weight heparin enoxaparin subcutaneously, 12 h before surgery, and postoperatively daily for 2 weeks. Bilateral lower limb venous duplex was done to detect silent DVT (the primary outcome measure), before discharge and after 2 weeks. Results Three patients developed silent DVT (6%); all of them were among group M (P=0.235, relative risk: 0.47, 95% confidence interval: 0.35–0.64). There was no significant difference between patients with DVT and those without DVT regarding age, BMI, operative time, comorbidities, or type of surgery. No bleeding complications were recorded in the two studied groups. Conclusion Perioperative low-molecular-weight heparin extending for 2 weeks postoperatively combined with graduated compression stockings is safe and effective for the prevention of silent DVT following laparoscopic bariatric surgery.
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Repair of uncomplicated umbilical hernia in cirrhotic patients: experience of an institute p. 372
Ashrf El-Kholy A Othman
DOI:10.4103/ejs.ejs_52_17  
Objective The objective of this study was to present experience of a single institute in the management of uncomplicated umbilical hernia (UH) in cirrhotic patients. Patients and methods The study included 232 patients with UH: 103 patients class A, 83 Child–Pugh class B, and 46 Child–Pugh class C. Ascites was mild in 46 patients, moderate in 80 patients, and severe in seven patients, whereas 99 patients had no ascites. All patients underwent classic repair with proline mesh insertion if required. Results A total of 71 patients had direct defect closure and 161 patients had mesh repair. Operative time was significantly longer in class C patients than other classes and in patients of class B than class A. Peritoneal drainage was required in 109 patients with significantly higher frequency in class C. ICU admission was required in 33 patients with significantly higher frequency and longer duration in patients of class C. Duration of subcutaneous wound drainage was significantly longer, frequency of patients who developed short-term postoperative complications was significantly higher and hospital length of stay was significantly longer for patients of class C. During the follow-up for 23.2±7.9 months, 23 patients developed recurrent UH with significantly higher frequency in class C than other classes. Recurrence rate was significantly lower with mesh repair than direct closure (6.8 vs. 16.9%). During follow-up, 14 (6%) patients died secondary to causes not related to surgery with significantly higher in class C. Conclusion Elective UH repair in cirrhotic patients is feasible and is associated with acceptable rate of postoperative complications and no surgery-related mortalities. Mesh repair significantly reduced the recurrence rate. The pronounced outcome of patients of class A points to the necessity of early repair of UH to get the benefit of hepatic reserve and minimal volume of ascetic fluid.
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Prediction of nipple and areola complex invasion in breast cancer patients: clinical and pathological study of surgical specimens p. 380
Wael Elsayed Lotfy Mokhtar, Adel Mohamed Ismail, Mohamed Ahmed El Gharbawi, Yehia Ali El-Alfy, Mai Mohammed Abdelwahab
DOI:10.4103/ejs.ejs_56_17  
Background Nipple–areola sparing (NAS) mastectomy is nowadays considered the most common conservative procedure used for both risk reduction (prophylaxis) and cancer treatment. We regard the oncological safety as a first concern in the management of breast cancer (BC) patients. Aim The aim of this study was to assess the predictive value of clinical and pathological criteria that might affect decision making for NAS mastectomy in BC patients. Patients and methods This study included 60 cases of operable BC that underwent MRM. All specimens were subjected to histopathological examination of the subareolar tissue to prove or disprove malignant infiltration of the nipple–areola complex (NAC), and their data were plotted against the preoperative predictive factors. Results The incidence of occult NAC malignancy was 15%. Predictive factors influencing NAC invasion were tumour–nipple distance less than 4 cm, grade III tumour, lymph node metastasis, lymphovascular invasion, human epidermal growth factor receptor-2 positivity, oestrogen receptor/progesterone receptor negativity, retroareolar/centrally located tumour and multicentric tumours. Conclusion NAS mastectomy for the management of BC would be appropriate in carefully selected patients who have peripherally located tumours, grade I or II, not multicentric or multifocal, with tumour-to-nipple distance greater than 4 cm, and human epidermal growth factor receptor-2 negative with no lymphovascular invasion of the subareolar plexus or axillary lymph nodes metastasis.
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Short-term outcome of infrapopliteal percutaneous transluminal angioplasty for isolated infrapopliteal lesions in patients with critical limb ischemia p. 389
Asser A Goda
DOI:10.4103/ejs.ejs_60_17  
Objective The aim of this study was to evaluate the efficacy of percutaneous transluminal angioplasty for isolated infrapopliteal (IP) arterial disease in patients with critical limb ischemia (CLI). Patients and methods This prospective study included all CLI patients with IP disease who underwent primary IP angioplasty between January 2014 and January 2016 in our institution. Study endpoints were technical success rate, primary patency, secondary patency, limb salvage, and wound healing. Results The mean age of patients was 64.6±13.5 years, with 23 74% men. Twenty limbs were identified as Rutherford category 4 (48%), 16 limbs as Rutherford category 5 (38%), and six limbs as Rutherford category 6 (14%). Initial technical success was 90.5%. Among 38 limbs with initial technical success, primary patency and secondary patency rate were, respectively, 60.5 and 75% at 1 year. Limb salvage rate was 86.8% at 1 year. Wound healing rate was 76.3%. Wounds were completely healed in 15.8%, improved in 60.5%, stable in 13.2%, and worse in 10.5%. Conclusion Percutaneous transluminal angioplasty is effective and preferred procedure for IP angioplasty for patients who presented with CLI.
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Laparoscopic purse-string suture sac closure is appropriate procedure for children with unilateral indirect inguinal hernia: comparative study versus laparoscopic sac excision and closure procedure p. 394
Ayman Hasanein, Mohamed Rabea, Mohamed Fathi, Alaa El Sayed
DOI:10.4103/ejs.ejs_62_17  
Objective Evaluation of immediate and 6-month postoperative (PO) outcomes of laparoscopic repair of unilateral indirect inguinal hernia (IIH) and comparison of outcomes of purse-string versus stitch closure of the deep inguinal ring (DIR). Patients and methods The study included 84 children who had unilateral IIH, and they were randomly divided into two groups: group I included patients who underwent sac disconnection and stitch closure, and group II included patients who underwent purse-string suture closure of DIR without manipulation or sac dissection. PO pain sensation was evaluated using the observational pain-discomfort scale. Time till first oral intake, length of PO hospital stay, and immediate and 6-month PO outcomes were determined. Results One patient in group I was converted to open procedure and another patient in group II required sac disconnection. Patients of group II had significantly shorter operative time, lower collective observational pain-discomfort scale pain score, and shorter time till first oral intake and duration of PO hospital stay compared with patients of group I. A total of three (3.6%) patients developed port site wound infection. At the end of follow-up, in group I, one patient developed hydrocele and three patients developed recurrent hernia, for a 6-month PO complication rate of 9.8%. In group II, one (2.4%) patient developed recurrent hernia. Conclusion Application of laparoscopic purse-string suture closure of the DIR shortens operative time, time till first oral intake, and home return of children with unilateral IIH with low 6-month recurrence rate than disconnection and stitch closure of the DIR (2.4 vs. 7.3%).
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Endovascular management of Trans-Atlantic Inter-Society Consensus C and D aortoiliac occlusive disease as a feasible, effective, and durable intervention p. 401
Ahmed A Taha, Engie T Hefnawy, Ahmed R Tawfik, Alaa A Ibrahim
DOI:10.4103/ejs.ejs_63_17  
Context The progress and innovations in endovascular tools have replaced standard surgical intervention with endovascular intervention, including long, complex lesions. Aim The aim of the study was to evaluate the results of endovascular management as the first-approach intervention for symptomatic extensive Trans-Atlantic Inter-Society Consensus (TASC) C and D aortoiliac disease. Patients and methods This was a prospective study. Fifty patients with long, complex TASC C and D aortoiliac lesions underwent revascularization by endovascular-first approach. Technical success and follow-up results after 6, 12, and 24 months were documented. SPSS software version 18 was used for statistical analyses. Results Of the 50 patients, 84% were male. All the patients had TASC C and D lesions and 66% of them had critical limb ischemia. All the patients were treated by endovascular-first approach. A total of 92 stents were used, of which 66.3% were balloon mounted, and they were located in the common iliac artery. The technical success rate was 90%, and the ankle–brachial (A/B) index improved significantly (P=0.0001). The primary patency rates were 100, 81.8, and 80% at 6, 12, and 24 months, respectively. A total of 6.6% of patients developed major complications, which were successfully managed. Mortality rate was 2.2%, which was not procedure related. Conclusion The endovascular-first approach could be a good alternative and replace the standard surgical management for long, complex aortoiliac occlusive disease.
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Radiofrequency ablation (RFA) for primary varicose veins: a feasible day-case procedure with good surgical and functional outcomes p. 407
El-Sayed A Abd El-Mabood, Hussein G El-Gohary, Atef A Salem
DOI:10.4103/ejs.ejs_66_17  
Objective The aim of this study was to find out surgical and functional outcomes of the feasible day-case radiofrequency ablation (RFA) procedure for primary varicose veins (VV). Background Management of VV has changed rapidly in recent years. RFA being less invasive alternative to vein stripping can be done by percutaneous catheter-based closure without the necessity of incision. Patients and methods This prospective randomized controlled study was conducted on 26 patients (31 limbs) with primary VV; all patients were treated with RFA using VNUS closure under tumescent anesthesia. Patients were randomly allocated into two groups according to the performed RFA technique: group A: ‘standard technique’ [16 (51.6%) limbs] and group B: ‘modified technique’ [15 (48.4%) limbs]. Follow-up period was 6 months. Results There were satisfactory results with no complications in both groups at 3–6 months of follow-up (93.3% in group A and 86.7% in group B) and marked improvement of patients symptoms (P=0.011). The mean operative time was 62.9±5.4 min in group A and 51.8±3.2 min in group B. Patients in both groups were discharged within hours and returned to work within few days. On 1-week postoperative follow-up, minor complications were observed that disappeared with time, except for one (3.3%) limb with deep venous thrombosis, which was reported in group B. Conclusion Endovenous RFA and foam sclerotherapy, whichever is the performed technique, have shown to be very promising techniques as they are minimally invasive and highly effective, with high patient satisfaction and quality of life, better cosmetic results, and fewer days off work.
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Pattern of maxillectomies: an analysis of 44 cases in a tertiary referral hospital, Sokoto, Northwest Nigeria p. 419
Abdurrazaq O Taiwo, Mohammed Abdullahi, Ramat O Braimah, Adebayo A Ibikunle, Kufre R Iseh, Olalekan M Gbotolorun, Moshood F Adeyemi, Mike Adeyemi
DOI:10.4103/ejs.ejs_70_17  
Background The maxilla occupies a prominent and crucial position in the facial structure. Maxillectomy is an ablative surgical resection of the maxilla with attendant serious cosmetic deficit. There is paucity of data on the indications and pattern of maxillectomy in our centre. This study would help in better management of patients requiring this treatment. Aim The aim of this study was to determine the pattern of presentation of patients for maxillectomy at Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria. Patients and methods This study was a retrospective review of theatre records of the hospital between January 2007 and March 2017. Patients data were collected for sociodemographics (age and sex), indication(s), clinical presentations, diagnosis/histologic subtypes, and type of maxillectomy performed. Result During the 11-year study period, a total of 44 patients underwent maxillectomy, aged 4–77 years (mean±SD=37.6±19.6 years) with a modal age of 31–40 years [11 (25.0%)]. There were 26 (59.1%) male and 18 (40.9%) female patients (male : female=1.8 : 1). Overall, benign lesions accounted for 12 (27.3%) cases and malignant lesions for 32 (72.7%) cases. There was statistical difference between the ages of benign (mean±SD=24.9±16.2 years) and malignant lesions (mean±SD=42.3±18.8 years) (t=−2.83, d.f.=42, P=0.0071). Benign lesions [11 (25.0%)] were commonly detected in those aged 40 years and younger, whereas malignancies [16 (36.4%)] were equally distributed across both divide. Total maxillectomy [34 (77.3%)] was the major surgical resection carried out, followed by subtotal maxillectomy [6 (13.6%)]. Conclusion There is urgent need to focus on the prevention of orofacial malignancy to avoid surgery and complex rehabilitative expenses.
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Management of difficult hepatic artery anastomosis in living donor liver transplantation: mansoura experience p. 424
Ayman El Nakeeb, Mohamed El Shobary, Tarek Salah, Ayman El Nakeeb, Ahmad M Sultan, Ahmed Elghawalby, Mohamed Abdel Wahab
DOI:10.4103/ejs.ejs_73_17  
Background One of the most difficult and important procedure in living donor liver transplantation (LDLT) is hepatic artery reconstruction. Difficult hepatic artery reconstruction may be because of pathological factor such as intimal dissection (ID) and anatomical variation. Difficult hepatic artery reconstruction is a risk factor for hepatic artery complications. This study was done to evaluate difficult hepatic artery reconstruction in LDLT at our center and its surgical outcomes. Patient and methods Consecutive patients who were treated for end-stage liver cirrhosis by LDLT were retrospectively reviewed. The management of hepatic artery with ID is carried out according to the extent of ID. Results Hepatic artery ID was found in 21/375 (5.6%) cases. Overall, seven (33%) cases were reconstructed with the graft hepatic artery after trimming the edge until reaching a healthy segment. A total of 11 (52.4%) cases were reconstructed with the graft hepatic artery after intimal fixation of ID. Moreover, three (14.3%) cases had severe ID and failed intimal fixation and were reconstructed with the recipient splenic artery. Biliary stricture developed in two patients who had severe ID, and three patients developed transient bile leak. No hepatic artery complications, graft failure, or mortality occurred. Conclusion Intimal fixation technique proved to be an effective technique in most of the cases, with good short-term and long-term follow-up results. In severe ID or failure of intimal fixation, alternative recipient arteries other than hepatic artery can be used.
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Laparoscopic sleeve gastrectomy compared with Roux-en-Y gastric bypass surgery: 2-year outcome of body weight, obesity-associated comorbidities, and quality of life p. 432
Ashraf M Abdelkader, Hazem E Ali, Ramy A Mitwally, Mohammed S Yousef
DOI:10.4103/ejs.ejs_75_17  
Objective The objective is to check the efficacy and safety of two operative techniques designed for treating morbidly obese patients: laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). Patients and methods The study includes 72 morbidly obese patients, who were divided into two groups: group A, 40 (55.5%) patients treated using LSG, whereas group B, 32 (44.5%) patients managed by LRYGB. Operations were completed according to the rules of laparoscopic surgery. Collected operative data included operative time, intraoperative complications, postoperative (PO) complications, ICU, and hospital stay. All patients were monitored throughout the first 2 PO years at 3rd, 6th, 12th, and 24th PO months. Results There is a significant difference between both groups regarding operative time. The rates of early PO complications were higher in LRYGB than LSG group. Both groups showed a significant weight loss at the first 12 months postoperatively. The mean BMI dropped from 39.5±3.03 to 33.10±3.56 kg/m2 among LSG patients compared with 40.18±3.18 to 30.23±2.64 kg among LRYGB patients. However, at the end of the second PO year, no difference in patients’ weight, BMI, The percentage of excess weight loss (%EWL), or EBMIL was noticed in both groups. At the end of the first PO year, a dramatic improvement in both groups was seen about frequency and severity of associated comorbidities except for gastroesophageal reflux disease. At the end of the second PO year, all comorbidities showed prominent remission among patients of LSG group. Patients of LRYGB showed complete resolution of type 2 diabetes mellitus, obstructive sleep apnea, and depression. Conclusion Both LSG and LRYGB are safe bariatric surgical procedures that deliver convenient outcomes in weight loss and resolution of most obesity-associated comorbidities.
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Mesh or not in the repair of complicated umbilical hernia in cirrhotic patients with decompensated liver cell failure p. 440
Fady M Habib, Ahmed M Sallam, Loay M Gertallah
DOI:10.4103/ejs.ejs_76_17  
Background Umbilical hernia had been found to occur in 20% of cirrhotic patients with decompensated liver cell failure who had ascites; in such patients, umbilical hernia had a marked liability for complications such as irreducibility, obstruction, and strangulation. Management of complicated hernias especially irreducible hernias in such patients could be done by excision of the hernial sac, closure of the defect and then fixation of the prolene mesh (hernioplasty), or by reduction and repair in two layers of continuous sutures using polypropylene sutures without mesh (herniorrhaphy). Aim The aim of our study was to compare hernioplasty with the use of prolene mesh and the conventional anatomical repair (herniorrhaphy) in complicated umbilical hernia in patients with decompensated liver cell failure. Patients and methods In our descriptive study, we included 101 cases who were followed up for a period of 24 months, and we divided them into two groups: group A contained cases who had complicated umbilical hernia and were managed by hernioplasty with the use of prolene mesh, and group B contained cases that had complicated umbilical hernia and were managed by reduction and repair in two layers of continuous sutures using polypropylene sutures without using a mesh (herniorrhaphy). Results We found a statistically significant difference between both groups regarding recurrence of the umbilical hernia and duration of hospital stay (days) (P=0.004). Conclusion Complicated umbilical hernia in cirrhotic patients with decompensated liver cell failure who were managed by hernioplasty with the use of prolene mesh showed lower incidence of recurrence than the conventional anatomical repair (herniorrhaphy).
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The role of covering the facial nerve and parotid surface in prevention of the postparotidectomy complications p. 446
Ahmed S Elgammal, Alaa El Sisi, Tarek Rageh, Ahmed Gaber
DOI:10.4103/ejs.ejs_77_17  
Background Few operations in the head and neck region present challenges such as parotidectomy. The tumors detected are usually benign and patients expect normal function postoperatively. Complications of parotidectomy can be divided into early and late complications. The most serious of late complications are Frey syndrome and cosmetic deformity. Our aim is to evaluate the role of dermal fat graft interposition in preventing postparotidectomy complications. Patients and methods This study included 72 patients with benign parotid tumors who were treated between May 2012 and December 2015 in the Department of General Surgery, Menoufia University Hospitals. These patients are randomly divided into two groups: group A (control group) included 36 patients treated with parotidectomy without using dermal fat graft, and group B (study group) included 36 patients treated with parotidectomy and interposition of dermal fat graft. Results Most of our patients were females in both groups (66.7 and 77.8%), respectively. The most common pathology was pleomorphic adenoma in both groups (61.1 and 66.7%). There are no statistically significant differences between both groups as regards the operative time and the incidence of facial nerve palsy. Group B (study group) had a significantly lower incidence of Frey syndrome compared with group A (control group) either by subjective or objective methods (P=0.011 and 0.002). There was also a significant reduction in the incidence of sialocele and cosmetic unsatisfaction in the study group (P=0.030 and 0.003, respectively). Conclusion The dermal fat graft is a simple idea for restoring facial contour and preventing the postoperative complications after parotidectomy.
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A study on road traffic accidents in Arar, Saudi Arabia p. 451
Muharib M Alshammari, Nagah M Abo El-Fetoh, Mushref S Alshammari, Abdulaziz S Alshammari, Abdulaziz M Alsharari, Othman M Alshammari, Yousef N Alshammari, Abdullah Z Alshammari, Alwaleed K Alshammari, Omar T. M. Alenezi, Arwa B Alanazi
DOI:10.4103/ejs.ejs_81_17  
Background Road traffic accidents (RTAs) are responsible for a substantial portion of morbidity and mortality and are responsible for more years of life lost than most human diseases. Aim of the study The aim of this study was to determine the type and contributing factors to RTAs in Arar, Northern Saudi Arabia. Participants and methods A cross-sectional study was carried out on randomly selected drivers in Arar city, Northern Saudi Arabia, KSA. Data were collected from 407 drivers aged between 18 and more than 55 years using predesigned questionnaires, which include questions designed to achieve the study objectives. Results RTAs were frequent with persons aged less than 20 years old, with a percentage of 36.9%, followed by 33.9% in the age between 20 and 35 years old and just 1.7% above 50 years. Distraction habits while driving were as follows: 49.6% use the cellphone while they drive and 30.5% smoke. Most of the RTAs happened during sunny weather (63.9%) and rainy weather (13.5%). The most frequent occurrences of RTAs were angle collision (40.8%), back collision (19.9%), and hitting a fixed object (13.3%). Place of accidents was main road in 43.2% followed by crossroad in 20.9 and 11.3% at traffic light site. Limbs, head, and upper body parts were the most injuries (35.1, 23.6, and 10.6%, respectively). After treatment, 3.4% of the injured drivers have distortion as a permanent disability, 2.9% have paralysis, and 2.5% have a limp. In all, 5.2% of the accidents resulted in one death, 2.5% resulted in two deaths, and 86% of the accidents did not result in any deaths. Conclusion and recommendations The findings of the present study will be helpful in the prevention of RTAs and its associated complications and hence will be vital for policymakers, health service managers, and stakeholders.
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CASE REPORTS Top

Laparoscopic cholecystectomy for symptomatic multiseptate gallbladder p. 457
Tarek A Sabra, Mohammed H Takrouney, Mohamed A Osman, Mahmoud M Mostafa
DOI:10.4103/ejs.ejs_82_17  
Multiseptate gallbladder is a rare congenital anomaly that may be silent or with symptoms. Herein, we report a case of 12-year-old male child with abdominal pain associated with nausea and vomiting. The diagnosis of multiseptate gallbladder was settled at 6 months after the first episode of abdominal pain by screening ultrasound and was confirmed by magnetic resonance cholangiopancreatography. We performed laparoscopic cholecystectomy with complete resolution of preoperative symptoms. The patient was discharged on postoperative day 1. The postoperative course was uneventful without complications.
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Intestinal obstruction caused by mesenteric fat necrosis masquerading as small bowel malignancy p. 460
Saleh S Saleh, Islam H Metwally, Islam A Elzahaby, Abdelhadi M Shebl
DOI:10.4103/ejs.ejs_65_17  
Retractile mesenteritis had been described a century ago. However, the manifestations are variable and the diagnosis is difficult. We report a case presenting with a subacute intestinal obstruction. In conclusion, surgeons should add this variety in their differential diagnosis of bowel obstruction.
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