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   Table of Contents - Current issue
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January-March 2018
Volume 37 | Issue 1
Page Nos. 1-137

Online since Wednesday, February 14, 2018

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ORIGINAL ARTICLES  

Lazy lateral technique: an innovative approach for upper outer quadrant breast cancer near the anterior axillary fold Highly accessed article p. 1
Mohamed I Abdelhamid, Mohammed M Alkilany, Mohamed Lotfy
DOI:10.4103/ejs.ejs_38_17  
Context Surgical treatment of breast cancer was challenged over years. Breast conservation is as oncologically safe as mastectomy and gives better cosmetic and psychological outcomes. Aim The aim of our study was to evaluate the oncological and esthetic outcomes of the lazy lateral technique as a new approach for tumor located at the upper outer quadrant near anterior axillary fold. Patients and methods Between October 2012 and September 2014, 18 patients with early breast cancer at the upper outer quadrant and near the anterior axillary fold were surgically treated with the lazy lateral technique. Results The age of our patients ranged from 36 to 58 years (median: 47 years). Most of the patients in this study were diagnosed as having infiltrating ductal carcinoma (14 patients, 77.7%). The size of the tumor ranged from 0.9 to 3.8 cm. No involved margin on frozen section. Seroma was the most common postoperative complication and developed in two (11.1%) patients. The cosmetic outcome was excellent in 12 (66.6%) patients, good in five (27.7%) patients, and satisfactory in one (5.5%) patient. No local recurrence or systemic metastasis was noticed in our patients during a median follow-up period of 38 months (range: 27–49 months). Conclusion The lazy lateral technique is a novel approach for surgical treatment of upper outer quadrant breast cancer near the anterior axillary fold. It is an oncologically safe procedure and promotes satisfactory esthetic outcomes.
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Is re-sleeve gastrectomy after sleeve gastrectomy failure feasible? p. 5
Mohammed Hany, Mohamed Ibrahim
DOI:10.4103/ejs.ejs_51_17  
Background There is an increasing incidence of inadequate loss of weight or weight regain after sleeve gastrectomy (SG) accounting for 5–10%, with the potential recurrence of obesity-linked diseases. Aim To determine the safety and outcome of redo-SG in patients with failed SG. Patients and methods A total of 21 patients with failed SG who received redo-laparoscopic sleeve gastrectomy were evaluated. Results Entire cases were accomplished laparoscopically, with a mean operative time of 96.9±10.3 min. The mean percentage excess weight loss, percentage excess;Deg;BM;Deg;I loss, and mean;Deg;BM;Deg;I were 12.4±4.1, 13.5±3.6%, and 49.5±8.0 kg/m2, respectively, at 1 month; 40.5±6.8, 43.3±7.8%, and 41.5±6.6 kg/m2, respectively, at 6 months; and 56.8±8.5, 60.3±8.9% and 36.5±4.8 kg/m2, respectively, at 12 months. At a mean follow-up of 15±2.2 months, two patients were cured of hypertension, dyslipidemia resolved in two patients, diabetes disappeared in two patients, and all patients were cured of joint problems. Conclusion In a short period of follow-up, redo-laparoscopic SG after failed SG is a feasible option and has good results regarding weight loss and comorbidity improvement.
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Is single-layer better than double-layer interrupted intestinal anastomosis? A comparative study in pediatric patients p. 9
Mohamed R Abdella, Mohamed Fathi, Alaa El-Sayed, Adel Shehata
DOI:10.4103/ejs.ejs_78_17  
Objective The aim of our study was to evaluate the efficacy and safety of single-layer anastomosis compared with double-layer interrupted anastomosis in pediatric patients. Patients and methods The study included 60 patients, and it was carried out in Pediatric Surgery Unit, El-Minia University Hospital from February 2016 to February 2017, and the patients were classified into two groups, each group comprising 30 patients. Group A was operated with single-layer interrupted intestinal anastomosis and group B was operated with double-layer interrupted intestinal anastomosis. All patients were subjected to carful preoperative assessment and preparations. Postoperatively, intravenous fluids were continued until oral fluids begin, usually on the third day postoperatively. The patients were followed up for 1 month postoperatively with special emphasis on postoperative complications. Results The most frequent diagnosis was intussusception; it represented 33.3 and 36% in groups A and B, respectively. The operative time and the postoperative hospital stay were less in group A, with P values less than 0.001 and 0.049, respectively, which is statistically significant. Intestinal leakage was reported in two (6.7%) cases in both groups, whereas postoperative distension was reported in four (13.3%) cases in group A and 13 (43%) cases in group B, with a P-value of 0.01, which was statistically significant. Wound infection was reported in two cases in group A and five cases in group B. Two cases needed re-exploration in group B. Postoperative vomiting was reported in five (16.7%) cases in group A and 10 (33%) cases in group B. Conclusion We concluded that single-layer interrupted intestinal anastomosis is effective, safe, successful, of less operative time, less hospital stay, and valuable cost-effectiveness.
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Platelet-rich plasma versus conventional dressing: does this really affect diabetic foot wound-healing outcomes? p. 16
El-Sayed A Abd El-Mabood, Hazem E Ali
DOI:10.4103/ejs.ejs_83_17  
Purpose This study aimed to compare platelet-rich plasma (PRP) versus conventional ordinary dressing in the management of diabetic foot wounds. Background Diabetic foot wound treatment poses a considerable burden on the medical system, with long waiting times for healing in the public hospital system. PRP enables efficient treatment of many patients with hemostatic, anti-inflammatory, and analgesic substances. Patients and methods This prospective study was focused on 80 diabetic feet wounds. Patients were divided into two groups: group A received conventional ordinary dressing (N=40, 50%) and group B received PRP dressing (N=40, 50%). The mean follow-up period was 12 weeks. Results The estimated time of wound healing was 12 weeks for 82.5% of the patients in group A and 97.5% of the patients in group B; the PRP group was found to be more effective with fewer complications, less infection, exudates, pain, and failed healing: 17.5, 12.5, 32.5, and 2.5% versus 27.5, 42.5, 62.5, and 17.5% in group B, respectively (P=0.001). The highest healing rate was observed for both groups at the fourth week, but it was better for the PRP group (group B): 0.89±0.13 versus 0.49±0.11 cm2/week in group A. Conclusion There have been considerable advancements in the use of PRP in therapeutic processes in recent years in tissue regeneration therapy. PRP is a powerful tool for the treatment of chronic wounds and very promising for diabetic foot wounds; PRP enables healing, and reduces infection rates and exudates.
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Evaluation of near total lower lip reconstruction using mcgregor musculomucocutaneous cheek rotational flap p. 27
Waleed Aldabaany, Sherif Maher, Ayman M Abdelhamid
DOI:10.4103/ejs.ejs_85_17  
Introduction The goals of lower lip reconstruction are maintenance of adequate oral stoma, restoration of oral competence, to maintain speech, to preserve sensation, to provide both skin cover and oral lining and to produce an aesthetically satisfying result. A number of local flaps are available for reconstruction of lip defects, although free flaps may also be used for more extensive defects. Local flaps achieve better aesthetic and functional results compared with free flaps. In this study, we evaluate the near total lower lip reconstruction using single-stage McGregor musculomucocutaneous cheek rotational flap. Aim The aim of this study was to evaluate the near total lower lip reconstruction using McGregor musculomucocutaneous cheek rotational flap. Patients and methods This prospective study was performed at the Plastic Surgery Unit, Fayoum University Hospital, in the period from October 2015 to April 2017. Eight patients with squamous cell carcinoma at the lower lip excised with safety margin ranging from 0.5 to 1 cm in each side, leaving defects more than 2/3 of the length of the lower lip, were included in this study. Reconstruction was done in all patients using McGregor musculomucocutaneous flap. Results The mean age of the patients was 61.4 years (range: 55–70 years). Five patients were male and three patients were female. In all patients the angles of the mouth were symmetrical with preservation of the anatomic proportions of the lip, except in two patients there were some mucosal folds at the rotation point at the commissure. In all patients, the philtrum had a normal shape and position. The oral mobility was good in all patients, which was evaluated by facial expressions and sound formations. Conclusion Although more number of cases are required to build up our conclusion, according to our results on this low number of patients McGregor musculomucocutaneous cheek rotational flap is considered a good option for near total lower lip reconstruction with good functional and aesthetic outcomes.
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Assessment of the efficacy and oncological safety of sentinel lymph node biopsy in node-negative breast cancer using methylene blue dye p. 31
Rania Elahmady, Sherief M Mohsen
DOI:10.4103/ejs.ejs_87_17  
Background Sentinel lymph node (SLN) biopsy in patients with breast cancer with clinically negative axillary nodes is an innovative technique in the management of the axilla. SLN biopsy has been performed using different techniques including injection of patent blue dye, radioactive colloid, and recently methylene blue dye. The aim of this study was to assess the safety and efficacy of methylene blue dye as a mapping agent for SLN biopsy in clinically axillary node-negative breast carcinoma. Patients and methods Between January 2014 and October 2016, 50 female patients with established diagnosis of breast carcinoma by tru-cut biopsy and clinically negative ipsilateral axillary lymph nodes were included in the study. All the patients were operated upon in Ain Shams University hospitals. After induction of anesthesia, 3–5 ml of sterile 1% methylene blue was infiltrated into the subareolar tissue on the affected side. The lymph nodes receiving the blue dye were excised as the SLN. Excised specimen with the axillary tissue was sent for histopathological examination. The presence or absence of metastasis in SLN and axillary lymph nodes was compared. Statistical analysis was carried out to know sensitivity, specificity, and accuracy of SLN biopsy in breast cancer. Results The incidence of breast cancer was highest at 41–50 years. Of our 50 cases, SLN was identified in 44 cases using methylene blue dye. The identification rate was 88%. None of the patients had negative SLN but positive axillary lymph nodes (false negative), and in six cases, SLNs were involved only but not the rest of the axilla (false positive). The sensitivity, specificity, positive predictive value, and negative predictive value were 100, 85.7, 25, and 100%, respectively. Conclusion This study confirms the safety and efficacy of methylene blue dye as a mapping agent for SLN biopsy in axillary node-negative breast cancer.
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Donut mammoplasty in management of gynecomastia: general surgeon experience p. 40
Sherief M Mohsen
DOI:10.4103/ejs.ejs_88_17  
Background Gynecomastia is benign enlargement of the male breast. Although treatment is not indicated in most cases, esthetic reconstructive surgery is commonly performed for psychological reasons. This clinical study discusses the outcomes of the surgical management of gynecomastia by subcutaneous mastectomy using the donut mastopexy technique in different grades of gynecomastia and assesses the morbidity and complication rates associated with the procedure. Materials and methods From January 2013 till January 2017, we operated on 20 patients with bilateral idiopathic grades 1, 2, and 3 gynecomastia by subcutaneous mastectomy using the donut mastopexy technique. Exposure was excellent with the circumareolar incision. Patients were followed for at least 6 months. Results Excised specimens were weighed and sent for histopathological examination. The mean weight of the resected specimen was 92±44 g (range: 38–280 g). One patient showed bilateral atypical hyperplasia on histopathological examination. All patients achieved good esthetic contour of the chest. Circumareolar scars were satisfactory for all patients. No wound infection, hematoma, seroma formation, or nipple–areola complex necrosis was seen in any of the patients Areolar sensation was diminished in one (5%) patient and recovered within 6 months postoperatively. The main disadvantage of the technique was the mild residual skin redundancy, which was noted in eight patients with grade 3 gynecomastia. Conclusion Donut mastopexy technique is indicated for grades 1, 2, and 3 gynecomastia. Circumareolar incision provides perfect exposure. It is considered to be less invasive, has minimal scarring, has low complication rates, and had good esthetic outcome. Moreover, it is oncologically safe through histopathological examination of excised specimens to discover pathological abnormalities and hidden malignancy.
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Laparoscopic cholecystectomy for management of acute calculous cholecystitis within and after 3 days of symptom beginning: a retrospective study p. 46
Ashraf M Abdelkader, Hazem E Ali
DOI:10.4103/ejs.ejs_91_17  
Objective The aim of this study was to evaluate the competency and safety of surgical management of acute calculous cholecystitis (ACC) through laparoscopic cholecystectomy (LC) within and after 72 h of symptom onset. We are reviewing our experience by comparing the outcomes of both ways to carry out an ideal therapeutic strategy used for ACC. Background ACC is a very frequent surgical insult. The timing of surgery in the management of such condition is a subject of controversy among all surgeons. In this study, we tried to share in solving this conflict to implement the optimal timing of LC for ACC. Patients and methods The study includes 100 patients with ACC, divided according to the timing of LC into group E (50 patients), operated within 72 h of symptom onset and group L (50 patients), operated beyond 72 h of symptom onset. Patients in both groups monitored since admission, during operations, and along the postoperative (PO) period. The data collected include demographic data, clinical data, duration of symptoms before surgery, coexisting disease, laboratory and image results, operative data, PO complications, the length of stay in ICU and the total length of hospitalization. Results Fever and Murphy’s sign were significantly greater in the early LC group. Initial total bilirubin and blood urea nitrogen are significantly higher (P=0.032 and 0.004, respectively) among the late LC group. The operative time and mean total hospital stay are significantly higher (P=0.005 and 0.010, respectively) in the late LC group compared with the early LC group. The rates of PO bile leakage and port-site infections were higher among patients of late LC group. Conclusion Emergent LC is a safe and reliable procedure for ACC within 72 h of symptom onset. Regarding the PO outcomes, financial costs and length of hospital stay, it is more helpful than LC beyond 72 h.
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Combined radiofrequency ablation and truncal foam sclerotherapy for greater saphenous vein incompetence can reduce recurrence and complications of radiofrequency ablation p. 53
Abdelrahman M Gameel, Mohamed E Elsherbeni, A. Elboushi, Ayman M Samir, Waleed A Sorour, Ahmed M Tawfik, Ayman Salem
DOI:10.4103/ejs.ejs_94_17  
Objective Although radiofrequency ablation (RFA) has been established as an effective method for the treatment of lower limb varicose veins with a good outcome, in all interventions, there were complications and recurrence, because of which in this study we are modifying our technique to reduce the rate of complications and recurrence that we faced in our previous work. Patients and methods A total of 74 patients (86 lower limbs) with greater saphenous vein (GSV) incompetence were randomized to two treatment groups; the first group was treated by RFA with duplex guided perforator injection and the second group was treated by RFA with duplex guided perforator injection plus below knee truncal sclerotherapy of incompetent GSV. Groups were followed up for 12 months and compared demographically; venous clinical severity scores (VCSS), need for sclerotherapy during follow-up and postintervention complications including recanalization and recurrence were determined. Results There was no statistically significant difference between both groups as regards demographic criteria, VCSS preoperatively, paresthesia around the medial malleolus and recurrence of varicose veins during the follow-up period. There was significant difference between both groups as regards GSV recanalization with a P value of 0.046; also there were significant difference between four different time periods of VCSS (preintervention, 3, 6 and 12 months postintervention) by pairwise comparison of the two groups. A significant difference was found between the two groups in the need for postintervention sclerotherapy all over 12 months with a P value of 0.038. Conclusion The addition of below knee truncal sclerotherapy to the above knee RFA of GSV can reduce the rate of recanalization, recurrence of varicose veins, and decrease the need for postintervention sclerotherapy without risk of increase in the total number of complications.
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Retrograde approach for complex lower limb arterial occlusions p. 60
Tamer Abd El-Hay, Samer Regal, Mohamed Farag, Ahmed Elmetwally
DOI:10.4103/ejs.ejs_104_17  
Introduction Despite the advancement of endovascular technology, there are complex lesions which cannot be passed through antegrade approach, a retrograde approach to cross the complex lesion was first described by Iyer and colleagues, and it was used in cases where antegrade approach failed to cross the lesion. This promising technique had good results and was done through surgical incision and direct arterial puncture. Patients and methods A registry of retrograde approach has been maintained since March 2014, when the first transposterior tibial retrograde recanalization was performed at our institution till March 2016. Thirty-six patients were selected from the registry with age range from 49 to 85 (65.14), male pateints were 21 (58.3%) and female patients were 15 (41.7%). Patients were Rutherford class 4 (six patients), 5 (21 patients) and 6 (nine patients). Results After retrograde angioplasty a Kaplan–Meier curve for patency was 77.7% (28 of 36), 63.8% (23 of 36) and 47.2% (17 of 36) at 6, 12 and 24 months, respectively. Limb salvage rates were 97.2, 80.6, and 66.4% at 6, 12, and 24 months, respectively. Conclusion Retrograde approach is a safe and effective way to pass a complex lesion and it provides an alternative way to surgery with less complications and faster recovery.
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Management strategies of grade I, II, III blunt pancreatic injuries: our center’s experience p. 68
Hazem N.A Ashri, Yasser Hussein, Islam Ibrahim, Amr Ibrahim
DOI:10.4103/ejs.ejs_108_17  
Background Pancreatic injuries are rare among solid organ injuries. Blunt pancreatic injuries are classified according to the American Association for the Surgery of Trauma. According to the American Association for the Surgery of Trauma scale, grade I and II injuries are generally managed by conservative treatment, whereas grades III, IV, and V typically require surgical treatment. Traumatic pancreatic injuries are characterized by high morbidity and mortality rates. Patient and methods Grade I, II, II pancreatic injury patients were included in this study and grade IV patients were excluded together with the pediatric age group. Patients of this study were divided into operative groups, where surgical exploration with drainage and/or pancreatic resection or necrosectomy and continuous saline lavage was done with application of hemostatic sealant sheets over the raw surface of pancreas and conservative groups, where conservative measures were carried out. Results According to The American Association for the Surgery of Trauma (AAST) grade I, seven patients, grade II, eight patients grade III two patients, 10 patients underwent operative intervention, drainage and/or pancreatic resection with continuous saline lavage, and application of hemostatic sealant material when needed. One patient developed pancreatic pseudocyst. Seven patients underwent conservative measures, with two patients having developed pseudocyst and one patient developing pancreatic fistula. Conclusion Operative intervention of grade II, III injuries with application of continuous saline lavage, and application of hemostatic sealant material when needed helps to decrease complications.
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Surgical management of gynecomastia: choice and outcome p. 73
Haytham M Fayed, Hassan M Kholosy
DOI:10.4103/ejs.ejs_111_17  
Background Gynecomastia is defined as a male breast benign condition that is characterized by enlargement of the breast owing to glandular tissue proliferation. The cause of gynecomastia includes an imbalance between estrogen and testosterone levels in male breast tissue. The primary mechanism is production of more estrogen, reduction of production of androgen, and increased peripheral conversion to estrogen from estrogen precursors. Patients and methods A total of 35 male patients who presented with unilateral or bilateral gynecomastia (63 breasts) in the duration between June 2014 and June 2017 were assessed and surgically treated. All our patients were healthy except for one patient who had liver cirrhosis and two diabetic patients. Different surgical procedures were used to remove the excess skin and glandular tissue including lateral circumareolar incision, round block technique, reduction mammoplasty, liposuction, or combination of these procedures. Results The commonest procedure used was round block technique. A total of four cases had complications in the form of hematoma in one case, seroma in one case, skin infection in one case, and skin necrosis in another case. Conclusion Surgical correction of gynecomastia is the only hope for correction of gynecomastia in symptomatic patients.
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Combined liver resection and transarterial chemoembolization versus liver resection alone for the management of solitary large exophytic hepatocellular carcinoma with extrahepatic arterial supply: is two always better than one? p. 78
Ahmed M El-Gendi, Mohamed El-Shafei, Essam Bedewy
DOI:10.4103/ejs.ejs_113_17  
Purpose Does the control of extrahepatic arterial feeders with preoperative transarterial chemoembolization (TACE) in large exophytic hepatocellular carcinoma improve surgical and oncological outcomes compared with surgery alone? Patients and methods A total of 545 patients were assessed for eligibility, and 108 patients fulfilled the inclusion criteria and were assigned to either upfront surgery (group I) or surgery after TACE (group II). Results Patients in both groups had no significant difference with respect to age (P=0.573), sex (P=0.464), α-fetoprotein (P=0.313), American Society of Anesthesiologists score (P=0.820), and Child–Pugh score (P=0.577). The mean tumor size was comparable (9.8±2.2 cm in group I vs. 10.3±2.3 cm in group II, P=0.265). In group I, four patients underwent major hepatectomy, whereas 48 patients underwent minor hepatectomy. In group II, 54 patients underwent 121 TACE sessions with a mean of number of 2±0.8 session (range: 1–4 sessions). The mean interval between first TACE and surgery was 45±10.7 days (range: 12–72 days). Surgery after TACE had significantly higher rate of perihepatic adhesions (P=0.006), longer operative time (P<0.0001), increased blood loss (P=0.035), and longer hospital stay (P=0.020) compared with upfront surgery but with comparable outcomes regarding in-hospital and 30-day morbidity (P=0.819). After a mean follow-up of 14.3±5.9 months, both groups had similar disease-free survival, with none of the tumors in both groups showed local recurrence. There was no significant difference in the type, time of recurrence following resection, or the mean numbers of new (de-novo) tumors detected in both groups (2.22±1.60 and 2.54±1.69 in groups I and II, respectively). Conclusion In patients with solitary large exophytic hepatocellular carcinoma, combined hepatic resection plus TACE is associated with increased perihepatic adhesions, increased operative time, blood loss, and postoperative hospital stay compared with liver resection alone. Preoperative TACE has no additional oncological benefit, with no reduction in recurrence rate or improvement in disease-free survival.
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Nitinol stent implantation for femoropopliteal lesions: 12-month results p. 89
Asser A Goda, Ayman M Samir
DOI:10.4103/ejs.ejs_120_17  
Objective To evaluate the 1-year efficacy and safety of the self-expanding nitinol stent in treatment of intermediate femoropopliteal lesions. Patients and methods This prospective study included patients with symptomatic (Rutherford grade 2–5) 5–15 cm femoropopliteal artery lesion between July 2014 and July 2016. Study end points were primary patency rate, improvement of Rutherford clinical criteria and ankle brachial indices, major adverse events (MAE), target lesion revascularization, and stent fracture. Results The study enrolled 45 patients. Technical success rate 100%. A total of 45 stents were implanted in 45 patients. A single stent was used for each lesion. The primary patency rate at 1 year was 75.5%. The mean Rutherford clinical criteria decreased from 3.84±0.85 at baseline to 0.71±0.84 at 1 year (P<0.001). Compared with baseline, a significant improvement in ankle brachial indices was found at 12-month (0.93±0.16; P<0.0001) follow-up visits. No MAE were present at 30 days. At 12 months, there was one MAE case that showed target vessel revascularization using angioplasty. Target lesion revascularization at 12 month was 8.9%. Stent fracture at 12 months was 4.4%. All stent fractures were type 1 fracture. Conclusion The outcome of the study demonstrates that the self-expanding nitinol stent is effective and safe device for treating intermediate femoropopliteal arterial lesions.
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Hybrid revascularization techniques in the management of multiple level peripheral vascular disease p. 96
AbdElmieniem Fareed, Nehad Zaid, Yahia Alkhateep
DOI:10.4103/ejs.ejs_122_17  
Objective Extensive multilevel atherosclerotic disease is common in patients with ischemia of the lower extremities. It is frequently associated with multiple medical comorbidities, resulting from disease in distant vascular territories and making these patients the high-risk group for extensive open surgical procedures. The purpose of this study is to evaluate the feasibility and efficacy of simultaneous, combined endovascular, and open lower extremity arterial reconstruction. Patients and methods A case series study with retrospective analysis of prospectively collected nonrandomized data. Results Thirty-five patients with multilevel ischemic peripheral vascular disease underwent hybrid procedures during the period from September 2014 to September 2016 with 100% technical success rate. Inflow endovascular procedure was performed in 48.57% and outflow in 37.14% of the cases. For five (14.28%) patients, both inflow and outflow percutaneous transluminal angioplasty were performed together with an open surgical revascularization. The open surgical procedures were a femoral procedure in the groin (34.3%) or with a bypass (65.7%). Patients are maintained on clopidogrel 75 mg daily for at least 6 weeks after hybrid interventions. Thereafter, lifelong aspirin therapy can be substituted for clopidogrel. The mean duration of the operation for all hybrid procedures was 290±110 min (range: 60–580 min). It was longest in procedures where an inflow percutaneous transluminal angioplasty (±stenting) and distal bypass were combined (279 min). Conclusion Hybrid revascularization procedures for the treatment of multilevel vascular disease in the fragile vascular patient population seem to be as good as with open revascularization, but with less morbidity and shorter intensive care and hospital stay.
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Effect of biliary stenting for unextractable choledocholithiasis p. 104
Hassan A Abdallah
DOI:10.4103/ejs.ejs_126_17  
Introduction Large choledocholithiasis is associated with higher rates of failed extraction with conventional endoscopic techniques. Alternative methods such as electrohydraulic lithotripsy and extracorporeal shock wave lithotripsy, laser lithotripsy, and dissolving solutions can remove 90% of difficult common bile stones. However, these methods are indicated only in special situations and require experience and additional equipment that may not be available in every center. Aim The aim of this study was to investigate the efficacy of biliary stenting in the treatment of endoscopically unextractable common bile duct (CBD) stones. Patients and methods A total of 46 patients with endoscopically unextractable CBD stones underwent placement of a plastic biliary stent. After 6 months, a second endoscopic retrograde cholangiopancreatography (ERCP) was performed and endoscopic stone removal was again attempted. Differences in stone size and CBD diameter before and after biliary stenting were compared. The complete stone removal rate after treatment was determined. Results The second ERCP procedure showed that the bile stone disappeared in 11 (23.91%) patients. Decreased stone size with complete stone removal was achieved in 29 (63.04%) patients. No significant changes were observed in the sizes of CBD stones and stone extraction eventually failed in six (13.04%) patients. Thus, in a total of 40 (87%) patients with unextractable stones, successful stone extraction was performed during the second ERCP. Conclusion Temporary biliary stenting has an established place in the management of large CBD stones and can facilitate stone extraction by a basket or a balloon catheter in the second ERCP.
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Outcome of obstetric anal sphincter injuries repair techniques p. 110
Muhammad A Baghdadi, Abd-Elrahman M Metwalli, Waleed A Abd-Elhady
DOI:10.4103/ejs.ejs_130_17  
Objective The objective was to compare outcomes of primary end-to-end repair versus overlap repair of the external anal sphincter following obstetric anal sphincter injuries. Materials and methods This study was carried on 30 patients with obstetric anal sphincter injuries in the Department of General Surgery, Zagazig University Hospitals, during the period from May 2015 to June 2017. The patients divided into two groups: group A was managed primarily with end-to-end repair technique of external anal sphincter and group B was managed using overlap repair technique. Results The age of the studied patients in group A ranged from 25 to 56 years, with mean of 30.8±9.9 years, and in group B, it ranged from 23 to 59 years, with mean of 31.5±8.2 years. Group A has shorter operative time and less intraoperative bleeding, with no difference between both the groups regarding fecal incontinence, flatus incontinence, dyspareunia, and perineal pain. Conclusion Obstetric anal sphincter damage and related fecal incontinence are common and can cause long-term sequelae if not detected and corrected. End-to-end repair is a simple operation that has shorter operative time and less intraoperative bleeding; however, there was no significant difference between both the groups regarding fecal incontinence, flatus incontinence, perineal pain, and dyspareunia. Early sphincter repair by a skilled surgeon minimizes the associated morbidity.
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Living donor liver transplantation for hepatocellular carcinoma: Milan criteria versus University of California San Francisco p. 116
Ahmed Khalil, Hani Said Abdelbaset, Ahmed Hilal
DOI:10.4103/ejs.ejs_132_17  
Introduction Hepatocellular carcinoma (HCC) is the most common primary liver cancer and most patients with HCC also suffer from coexisting cirrhosis. HCC recurrence is a major concern after liver transplant. The Milan criteria was accepted after a good 5 years survival but was criticized for being so restricted and this criticism promoted the appearance of more expanded criteria like the University of California San Francisco (UCSF). Our study compares the results of both Milan and UCSF criteria and the risk factors for recurrence. Patients and methods This study included 60 patients had living donor liver transplantation for HCC between January 2011 and December 2016 in Ain Shams Center for Organ Transplantation.They were divided into two groups. Group A: transplanted within the Milan criteria; and group B: transplanted while beyond Milan but within the UCSF criteria. Both groups are compared as regards the recurrence, survival, and risk factors for recurrence. Results There is no statistically significant difference between the two groups as regards the survival and recurrence. The 1 and 3 years survival were 86.5 and 71.9% for the Milan group and 81.7 and 61.4% in the group of patients beyond Milan (statistically nonsignificant, P=0.348). Seven (15.1%) patients from the Milan group had recurrence while in the beyond Milan group four (28.6%) patients had recurrence (statistically nonsignificant, P=0.258). There were no statistically significant difference in microvascular invasion (P=0.388), tumor grade (P=0.207), and α-fetoprotein (P=0.112) between both groups. Conclusion Milan criteria can be safely expanded to UCSF with comparable results if responding well to downstaging and with low α-fetoprotein.
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Role of ultrasound in diagnosis and management of inflammatory breast diseases p. 122
Ahmed A.A Aziz, Rasha M Kamal, Rania S Mohammed
DOI:10.4103/ejs.ejs_133_17  
Introduction Inflammatory breast diseases are frequently encountered clinical complaints, and they range from benign to malignant forms, namely inflammatory breast carcinoma (IBC). It is crucial to differentiate IBC from other types of mastitis because there are major differences in its prognosis and treatment. Ultrasound (US) is one of the main diagnostic tools for discriminating benign and malignant mastitis. US-guided aspiration and core needle biopsy are the mainstay in diagnosis and management of inflammatory breast diseases. Materials and methods The study is a prospective study that included 48 patients referred to the Radiology Department, Women’s Imaging Unit from the ‘Surgical Breast Clinic’, and surgical outpatient’s clinics and wards in the period between January 2016 and July 2016. US examination was performed for all the cases by 8–12 MHz linear array transducer. Full field digital mammography was performed for 33/48 patients. US-guided core biopsies of the breast were performed in indicated cases. Drainage under US guidance and cytological assessment was performed also in certain cases. Results In all, 36/48 (75%) cases were finally diagnosed as benign mastitis, and 12/48 (25%) cases were finally diagnosed as malignant. Within the examined group, 40/48 (83.3%) cases underwent short-term first look follow-up US study after a course of antibiotic therapy: seven/40 (17.5%) patients showed complete resolution of the symptoms and the diagnosis of simple infectious mastitis was confirmed, whereas 33/40 (82.5%) patients showed no response to treatment. Conclusion US plays a specific role in diagnostic approach and management of inflammatory breast diseases. It is essential to discriminate benign from malignant etiologies as there are major differences in their prognosis and treatment options.
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Combined stab high ligation with retrograde laser ablation compared to endovenous laser ablation in the treatment of symptomatic great saphenous varicose veins p. 132
Yahia Alkhateep, Nehad Zaid, Abdelmieniem Fareed
DOI:10.4103/ejs.ejs_134_17  
Objective To compare reflux recurrences and complications after combined stab high ligation and retrograde laser ablation (SHL/ablation) with endovenous laser ablation (EVLA) of the great saphenous vein (GSV) varicosity. Patients and methods This study was designed as a single-center, nonblinded, randomized controlled trial; patients with symptomatic primary GSV varicosity with an incompetent saphenofemoral junction (SFJ) were randomized into two groups: the first was treated by high ligation of GSV with SHL/ablation and the second group was treated by EVLA, both groups received laser therapy using 120 J/cm of 980 nm diode laser. Patients with bilateral GSV insufficiency were randomized separately for each leg. The primary outcome was anatomic success with complete obliteration of the GSV. Secondary outcomes were sonographically determined reflux and clinical recurrence in the treated area after 1 year. Results Between March 2014 and December 2016, 280 legs in 257 patients were treated by SHL/ablation (n=140) or EVLA (n=140). The mean age, preoperative complain, mean GSV diameter, and treated length were comparable in both groups. There were no significant differences in postoperative complications or pain experience during or after the procedure in both treatments. The procedure time was significantly longer in SHL/ablation group (88.5±9.8 min) than EVLA (66.5±11.76 min). Twelve months after procedures, SHL/ablation limbs had no recurrence of clinical complaints or venous reflux while EVLA limbs showed venous reflux in 17 (12.1%) limbs and recurrence of limb edema and heaviness in 15 (10.7%) limbs with significant difference between the two groups (P<0.05). Conclusion Combined high ligation through stab incision with laser ablation of GSV significantly decreases the risk of venous reflux and clinical recurrence after treatment of GSV varicosities.
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