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   Table of Contents - Current issue
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July-September 2018
Volume 37 | Issue 3
Page Nos. 271-417

Online since Friday, August 17, 2018

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ORIGINAL ARTICLES  

Round block technique in the management of early stages of breast cancer: an assessment of the technique, oncological safety, and cosmetic outcomes Highly accessed article p. 271
Sherief M Mohsen, M.A. Marzouk
DOI:10.4103/ejs.ejs_90_17  
Background The round block technique is a unique breast resection through a periareolar doughnut incision. However, it is more technically challenging and time consuming. The aim of this study was to introduce our round block technique and to evaluate the results of oncological and cosmetic outcomes. Patients and methods A total of 60 female patients diagnosed with early stages of breast cancer (T1–2, N0–1, ≤M0) were treated with breast-conserving surgery using the round block technique at Ain Shams University Hospitals from March 2014 to March 2017. Patients with advanced breast cancer, with tumors less than 1.5 cm from the nipple, multicentric breast cancer, and pregnant women were excluded from the study. We minimized the extent of skin removal and used the purse–string technique in doughnut closure. Patients’ related complications, oncologic safety, cosmetic outcome, and patient satisfaction were assessed. Results The mean size of the tumors was 2.7 cm (range: 0.9–4.5 cm). The mean distance of the tumors from the nipple was 6.25 cm (range: 1.5–11 cm) on sonogram and most of the tumors were located on the upper breast (46.6%). The median operative time was 120 min (range: 90–145 min), including axillary surgeries. The median follow-up duration was 12 months (range: 2–36 months). Up to the longest 3 years of follow-up, favorable cosmetic results have been found in patients treated with the round block technique, with no cases of local recurrence. Conclusion The round block technique is oncologically safe and feasible for early stages of breast cancer, with favorable cosmetic results.
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Percutaneous radiofrequency ablation compared with surgical resection in the treatment of early hepatocellular carcinoma p. 286
Ashraf M Abd El-Kader, Hazem E Ali, Magdy A Gad, Badawy A Abdel Aziz, Sharaf Elsayed Ali Hassanien, Ali Hasaneen, Ramy A Mitwally
DOI:10.4103/ejs.ejs_97_17  
Objective The primary objective of this study was to compare between liver resection (LR) and radiofrequency ablation (RFA) in the management of early hepatocellular carcinoma (HCC). We are trying to provide an update that can be valuable in clinical practice for determining the most suitable first-line management option for early HCC. Patients and methods The study included 80 patients with early HCC according to the Barcelona Clinic Liver Cancer staging system. Patients were divided into two groups: group A included 40 (50%) patients treated through LR, whereas group B included 40 (50%) patients managed through percutaneous RFA. In this study, we used the alternation method as an allocation process in this study. Procedures in both groups were done according to conventional principles. Percutaneous RFA technique was done under the guidance of ultrasonography (US) in complete aseptic conditions. Collected data included procedure time, intraoperative bleeding, postoperative complications, pain score, ICU, and the total hospital stay days. After procedures, patients were monitored every three months throughout the follow-up period. Results A total of 80 patients with early HCC underwent treatment with LR (N=40) and with RFA (N=40). There is a significant difference between both groups regarding the mean time of the procedure: 145±19.8 versus 40.6±7.8 min for LR and RFA, respectively. Rates of recurrence significantly (P<0.05) correlated with age and tumor size in both groups. No significant difference was observed in rates of recurrence or the time of recurrence (P>0.05) between LR and RFA groups. However, the recurrence percentage was slightly higher among patients treated by RFA compared with LR group. Conclusion Our prospective comparative study offers evidence that RFA provides a novel treatment for early HCC, and it shows survival and tumor relapse rates comparable to LR.
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Predictive value of angiographic characteristics for endovascular revascularization of the ischemic diabetic foot p. 294
Abdelmieniem Fareed, Nehad Zaid, Yahia Alkhateep
DOI:10.4103/ejs.ejs_123_17  
Background Endovascular techniques have undergone major advances with respect to the treatment of infrapopliteal arterial occlusive disease, mainly as a result of development of new devices. Objective The aim was to evaluate the agreement between the angiographic characteristics and the clinical outcomes after endoluminal revascularization in diabetic patients with critical limb ischemia (CLI). Patients and methods During the study, 64 patients were subjected to angioplasty and followed during an average of 12 months. Clinical and procedural data of diabetic patients with CLI were collected. Preprocedural and postprocedural angiographic images were reviewed to classify lower limb arterial involvement according to the Joint Vascular Society Council calf and foot scores classification. Foot lesions were graded according to the University of Texas classification. Clinical results (healing, nonhealing, or major amputation) were compared with baseline clinical data and angiographic results. Results During the study period, 64 percutaneous procedures were performed, with an immediate technical success rate of 89.8%. Preprocedurally, the mean±SD calf and foot scores were 7.8±1.6 and 7.3±2.3, respectively. After the procedure, the mean calf and foot scores were 4.8±2.3 and 5.9±2.6, respectively. The limb salvage rate was 87% and the major amputation rate was 9.4%. Among all the clinical and angiographic variables included in the analysis, only preprocedural and postprocedural foot scores were associated significantly with the clinical outcome (P<0.05). Conclusion Endoluminal revascularization represents a valuable treatment option in diabetic patients with CLI. Preprocedural and postprocedural foot scores represent the most significant angiographic parameters to evaluate treatment success.
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Endovenous laser versus radiofrequency ablation of great saphenous vein: early postoperative results p. 304
Hossam El-Mahdy, Hussein El-Wan, Baker Ghoneim, Mohammed Ali, Amr Gad
DOI:10.4103/ejs.ejs_136_17  
Background Minimally invasive endovenous thermal ablation therapy has revolutionized the treatment of varicose veins. Comparison of radiofrequency ablation (RFA) versus Endovenous Laser Ablation (EVLA) needs to be more elaborated in the context of better management of patients. Patients and methods A total of 50 young patients (10 patient bilateral and 40 patients unilateral) were enrolled in a prospective interventional study over a period of 2 years starting from June 2014. All patients were blinded to the chosen method to achieve a single-blinded study, with two groups. Exclusion criteria included deep vein thrombosis, peripheral arterial disease, severe tortuosity of Great saphenous Vein (GSV), and refusal of consent. All patients were assessed for deep system patency and flow in ablated segment by duplex immediately after procedure and 1 month later. Results Overall, 60 limbs were equally allocated to two groups. There was no significant difference between both groups concerning the demography and clinical, etiologic, anatomic, and pathophysiologic classification. All patients were blinded to the method of venous ablation. Postoperative duplex shows no failed recanalization or deep vein thrombosis. Pain, ecchymosis, and superficial thrombophlebitis were significantly higher in EVLA group versus RFA group (P<0.05). Surprisingly, first-degree burn occurred in two (6.6%) cases in EVLA group. Conclusion Both thermal ablative techniques performed well concerning high occlusion rates for incompetent GSV. Less postoperative complications were observed with RFA as compared with EVLA, namely, postoperative pain, ecchymosis, superficial thrombophlebitis, and first-degree burn. However, such complications were deemed to be benign and managed conservatively.
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Short-term patency of catheter-directed thrombolysis for iliofemoral deep vein thrombosis p. 309
Mahmoud I Saleh, Khaled A Atalla, Ashraf G Taha, Ahmed K Sayed
DOI:10.4103/1110-1121.239113  
Background Catheter-directed thrombolysis (CDT) for the treatment of acute iliofemoral deep venous thrombosis (IFDVT) has the advantages of prompt thrombus removal, restoration of the vein patency, and maintenance of the valve function. It also facilitates endovascular treatment of the commonly-encountered vein lesions. Therefore, the aim of the study is to assess the efficacy, safety, short-term patency rates, and incidence of post-thrombotic syndrome (PTS) following CDT treatment of IFDVT. Patients and methods This is a prospective study of all adult patients who underwent CDT for the treatment of acute, nonrecurrent, radiologically proven IFDVT at the Department of Vascular and Endovascular Surgery, Assiut University Hospital (a tertiary referral hospital), between June 2015 and November 2016. Results Sixty-four patients (64 limbs) underwent CDT for treatment of acute IFDVT. The overall success rate was 93.8%. Balloon angioplasty was performed in 58 (96.7%) patients, of which, 54 (90%) required stent placement. Eight (12.5%) bleeding complications were encountered in the study, with only one major bleeding event. No periprocedural cerebral hemorrhage, pulmonary embolism, or deaths occurred. At 1 year, the cumulative primary patency rate was 76.5%. Seven (12.1%) patients had symptoms of PTS (four mild, two moderate, and one severe) without occurrence of venous ulceration in any patient. Conclusion CDT is a safe and effective treatment option for patients with acute IFDVT, with satisfactory technical success and acceptable short-term primary patency rates. Prompt thrombus lysis associated with adjunctive treatment of vein lesions can help reduce rate of rethrombosis and the subsequent development of PTS.
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Autogenous leucocyte-rich and platelet-rich fibrin for the treatment of leg venous ulcer: a randomized control study p. 316
Asser A Goda
DOI:10.4103/1110-1121.239205  
Background Venous ulcer (VU) is a serious health problem that has no satisfactory treatment. Platelet-rich fibrin (PRF) is one of regenerative medicines that promote wound healing by sustained release of growth factor (GF) and protein matrix for more than 7 days. Aim This study aims to evaluate the efficacy and safety of autologous leukocyte-platelet-rich fibrin (L-PRF) with venous leg ulcer. Patients and methods A randomized controlled study was conducted that included 36 patients with VUs. The eligible patients were enrolled in one of two groups (PRF and control groups) according to randomization schedule. Each group included 18 patients. The PRF group was treated with autologous L-PRF dressing, and dressing change was done once weekly. The control group was treated with conventional dressing of VU, but dressing change was done once in 2 days. Results The mean percentage of wound reduction of PRF group was found significantly higher than that of control group. There was a statistically significant difference between the PRF group and control group regarding the rate of completely healed ulcer at the fourth week for ulcer size less than 10 cm2 and at the seventh week for ulcer size more than 10 cm2. Conclusion Autologous L-PRF is effective and safe for treatment of venous leg ulcer.
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Factors affecting the short-term outcome of open surgical repair of esophageal atresia and tracheoesophageal fistula through an extrapleural approach with azygous vein sparing p. 322
Wael Elshahat, Hesham Kassem, Mohammed Alakrashy
DOI:10.4103/ejs.ejs_5_18  
Background Congenital esophageal atresia (EA) and tracheoesophageal fistula (TEF) are common congenital anomalies, affecting one in 2400–4500 neonates. The surgical management of EA/TEF has evolved over the last 60 years and is associated with a progressive improvement in survival. In this study, we performed open surgical repair of EA with TEF, type (Gross C). In all cases, we proceeded with the azygous sparing retropleural approach and early extubation if circumstances permitted. In all cases, we studied all other factors affecting the results in our institute. Aim To evaluate the immediate outcome of open surgical repair of the EA/TEF (Gross C) sparing azygous vein through the retropleural approach. Patients and methods In this prospective study, 26 neonates diagnosed with EA/TEF were admitted to NICU and prepared for surgery. All patients were operated on through right thoracotomy with an extrapleural approach and preservation of the azygous vein. Perioperative factors affecting the outcome were evaluated and recorded. Results Of the 26 neonates operated on, 15 were males and 11 were females. The mean age of the neonates at operation was 5.5 days. Their mean weight was 2875 g. Twenty-one (80.7%) cases survived and were discharged, whereas five (19.2%) cases died in the early postoperative period because of sepsis, respiratory, and ventilator complications. The mean preoperative C-reactive protein (CRP) level was 112. Leakage as a potential complication occurred in eight out of 26 (30.7%) cases. Immediate extubation was achieved in 12 (46.1%) cases. The operative time ranged from 45 to 100 min and the mean hospital stay was 12 days. Conclusion Open surgical repair of EA/TEF by the extrapleural approach, with preservation of the azygous vein and if possible immediate or early extubation, leads to good results if performed by an experienced surgeon with respect to other perioperative factors.
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Changes in bile acid profile after laparoscopic sleeve gastrectomy p. 326
Ahmad Abd Al-Aziz
DOI:10.4103/ejs.ejs_6_18  
Introduction Bile acids (BAs) have an effect on lipid and metabolic profile, as they are mediators of different regulatory functions in glucose and cholesterol homeostasis and energy expenditure. After sleeve gastrectomy, many changes occur in many biomarkers and in the metabolic profile. Objective The aim of this study was to evaluate the effect of laparoscopic sleeve gastrectomy (LSG) on BA profile. Patients and methods A total of 93 obese patients were evaluated before and after LSG (1, 6, and 12 months). BA profile was evaluated through the serum marker, 7α-hydroxy-4-cholesten-3-one (C4). Primary and secondary BA and C4 were determined by high-performance liquid chromatography coupled with tandem mass spectrometry detection, and then the data were collected and interpreted. Results From May 2015 to January 2017, 93 patients (age 44.6±10.4 years; BMI 42.7±9.3 kg/m2; 62.4% female) were included in this study. Mean weight loss at 1, 6, and 12 months was 14.1, 22.1, and 26.3 kg, respectively (P<0.0001). Serum C4 levels at baseline and at 1, 6, and 12 months were 22.4±11.1, 4.4±7.1, 14.8±12.9, and 18.8±16.8 ng/ml, respectively (P<0.0001). Conclusion Serum BA levels decrease after LSG as the fasting serum levels of C4 decrease after LSG, but then these levels increase gradually.
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A modified technique for a common problem after major duct excision p. 330
Mahmoud G Hagag, Mohamed H Elmeligy, Ahmed F Elkased
DOI:10.4103/ejs.ejs_14_18  
Objective The present study aims to describe and evaluate a modified major duct excision (MDE) technique as regards its role in minimizing postoperative complications. Patients and methods We included female patients who underwent total duct excision due to the following indications: suspicious nipple discharge, periductal mastitis, and nipple retraction with a history of periductal mastitis. The modified MDE was performed under general anesthesia. All the patients were discharged home on the same day of the procedure and they were followed up for 6 months. In the follow-up, the patients were assessed for any complications to the wound, any retraction or necrosis to the nipple, the nipple sensation compared with the other one, or the nearby skin in bilateral cases. Results In this study, a total of 29 operations were performed on the 25 patients. No seroma or hematomas were observed. On follow-up of the patients, two patients suffered from infection of the wound, three cases developed breakdown that healed by daily dressing, one case presented with nipple necrosis most probably occurred as a result of excessive dissection with diathermy, while the remaining 31 patients recovered by primary intention with no recurrent discharge. Loss of nipple sensation occurred in four patients, impaired sensation occurred in six patients, and normal sensation in the rest of the patients was observed at 6 months of follow-up. Conclusion The modified MDE technique is a safe alternative to the classic technique with low rate of postoperative complications.
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Anterior component separation versus posterior component separation with transversus abdominus release in abdominal wall reconstruction for incisional hernia p. 335
Sherif Albalkiny, Medhat Helmy
DOI:10.4103/ejs.ejs_20_18  
Background Abdominal wall reconstruction after huge incisional hernias considered one of challenges that face surgeons, component separations, either anterior component separation (ACS) or posterior component separation (PCS) with transversus abdominus release (TAR), are novel and less expensive solutions for this problem. Aim This prospective randomized trial compares the results of ACS procedure versus PCS with TAR in repair of incisional hernias. Patients and methods This study included 40 patients who underwent surgical repair for midline incisional hernias with defects larger than 5 cm in width between March 2016 and October 2017 at Ain Shams University Hospitals. Patients were randomly assigned to surgical procedures. Patients in group Ι (n=20) underwent ACS, and patients in group II (n=20) underwent PCS with TAR. Results In group Ι (ACS), wound morbidity significantly exceeded that in group II (PCS with TAR) such that 10 (50%) patients in group I developed surgical wound infection compared with four (20%) patients in group II. Regarding wound dehiscence, seven patients in group I had this sequel, whereas two patients in group II had wound dehiscence. Hernia recurrence occurred in seven (35%) patients in group I, but only one (5%) patient in group II developed this. Conclusion PCS with TAR provides equivalent myofascial advancement with significantly less wound morbidity and recurrence rate when compared with ACS.
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Local tongue flap for posterolateral tongue defects after partial glossectomy: a prospective cohort study p. 344
Mahmoud G Hagag, Mahmoud A Shahin, Asem Fayed, Ahmed F El-Kased
DOI:10.4103/ejs.ejs_24_18  
Objectives Tongue is a common site of squamous cell carcinoma of the oral cavity (OTSCC) with the subsequent high rate of local or regional recurrence owing to the complexity of its structure. In the present prospective study, we aimed to evaluate the novel local tongue flap technique for reconstruction of posterolateral tongue defects after partial glossectomy. Patients and methods The present study was approved by the Institutional Review Board of the Menoufia University Hospital. We conducted a prospective cohort study on 17 patients with OTSCC who underwent partial glossectomy. Local tongue flap was performed to reconstruct posterolateral tongue defects after partial glossectomy. Patients were followed for 2 months postoperatively. Results Most patients were male (70%), and the mean age of included patients was 57.47±9.53 years. Tumors were locally excised with mean safety margins of 1.06±0.48 cm and 64% of the patients with OTSCC underwent neck dissection. Postoperatively, 82.5% of the patients exhibited a good tongue healing result with adequate tongue function. Three (17.6) patients experienced tongue infection with partial dehiscence, which healed completely after 2 weeks with conservative treatment. Conclusion Local tongue flap is an effective technique for reconstruction of posterolateral tongue defects after partial glossectomy.
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Should we prescribe ursodeoxycholic acid after laparoscopic sleeve gastrectomy? A two-center prospective randomized controlled trial p. 349
Tarek A.O Abouzeid, Ahmed A.A Shoka
DOI:10.4103/ejs.ejs_29_18  
Background In the recent era, laparoscopic sleeve gastrectomy (LSG) had emerged as a safe and effective bariatric procedure. Rapid weight loss is associated with deranged cholesterol metabolism in the form of gallstones. Several studies have shown that ursodeoxycholic acid (UDCA) has a prophylactic role after gastric bypass, vertical banded gastroplasty, and adjustable gastric banding. Yet, data about its effect after LSG are scarce. In this study, we tried to unveil the prophylactic role of UDCA in the prevention of post-LSG gallstones. Materials and methods This two-center prospective randomized controlled trial had been conducted at Abha Private Hospital, Saudi Arabia, and Ain-Shams University hospitals, Egypt, from May 2016 to June 2017 on 89 post-LSG patients. After block randomization, patients were allocated into either group A (UDCA treatment) or group B (control). UDCA was prescribed as 250 mg twice daily for 12 months or until the development of gallstones. Results A total of 44 patients were included in group A and 45 patients were included in group B. There was no significant difference between both the groups regarding the baseline parameters. At the sixth month, group A showed a significantly lower incidence of gallstones (6.8 vs. 22.2% in group B; P=0.028). This pattern was maintained till the 12th month (5.8 vs. 14.7%; P=0.031). The overall percentage of gallstones was 23.5% (20/85); it was significantly higher in the first 6 months than in the second 6 months (14.6 vs. 9.7%; P=0.043). Conclusion UDCA is a safe prophylactic measure against gallstones formation and should be integrated into the post-LSG prescription.
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Modified limberg versus lateral advancement flaps in the surgical treatment of pilonidal sinus p. 355
Ahmed A Sabry, Aliaa Selim
DOI:10.4103/ejs.ejs_30_18  
Sacrococcygeal pilonidal disease is a frustrating health problem that occurs at least two times as frequently in men as in women usually between the ages of 15 and 30 years with exceptional occurrence before puberty or after the age of 60 years. During the past years a wide variety of approaches have been developed for treating pilonidal disease ranging from conservative methods (simple opening, curettage, brushing, and phenol injection) to wide surgical excision. Lately, surgical procedures have changed in favor of the flap techniques as they effectively provide wide excision of the diseased tissues and obliteration of the natal cleft thus neutralizing the causative factors that lead to a vicious circle of infection and recurrence. The aim of the study was to compare the short-term results of modified Limberg flap transposition, a widely used technique in pilonidal sinus surgical treatment, with lateral advancement flap (LAF) transposition, a relatively less frequently used technique, from the point of view of operative time, wound complications, recurrence, and patient satisfaction regarding cosmetic appearance using visual analog scale in the first 12 months postoperatively. The study included 60 consecutive patients with chronic pilonidal sinus disease admitted to Alexandria Main University Hospital between January 2013 and June 2014. The current study has proved equivalence between the modified Limberg flap and LAF in terms of postoperative wound complications and late disease recurrence. On the other hand, the LAF has proven its superiority with a statistically significant shorter operative time and more accepted aesthetic results.
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Incidental thyroid carcinoma after thyroidectomy for benign thyroid disease in Suez Canal region p. 361
Mohammed Faisal, Hamada Fathy, Ahmed Risk, Maha M Atwa
DOI:10.4103/ejs.ejs_34_18  
Background The term ‘incidental’ thyroid cancer is a term applied to a very small, unsuspected cancer identified incidentally on pathologic examination of thyroid tissue removed for benign disease. Aim The aim was to evaluate the prevalence of incidental thyroid carcinoma (ITC) after thyroidectomy for benign thyroid lesions with its different pathological types. Patients and methods The study population was selected by comprehensive sampling. All the patients attended the General Surgery Department in the Suez Canal University hospital for thyroidectomy of previously diagnosed benign thyroid diseases within the period between 1 July 2009 and 31 December 2014 and fulfilled the inclusion criteria. Results In this study, 211 patients underwent thyroidectomy. The female (n=179) to male (n=32) ratio was 5.6 : 1, and the age ranges from 18 to 75 years. The highest age incidence was found to be in the fifth decade of life (60 patients). In this study, the incidental carcinoma was found in 22 (10.4%) patients. The frequency of papillary carcinoma was 8.5% of all thyroid diseases and 81.8% of ITC (18/22). Moreover, the frequency of follicular carcinoma was 1.4% of all thyroid diseases (three cases) and 13.6% of ITC. Conclusions A correct preoperative assessment, with a careful selection of nodules for fine-needle aspiration cytology on the basis of ultrasound pattern, could better address the choice of surgical procedure.
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Nontraditional criteria for prediction of patient survival following pancreaticoduodenectomy for malignancy p. 368
Mohammed M Mohammed, Amr Abd El-Hameed El-Heiny, Mohamed M.T Zaazou, Ashraf Abd El-Azeem Mohamed, Nisreen D Toni, Zahraa I Khalil
DOI:10.4103/ejs.ejs_36_18  
Introduction This study analyzed the histological features modifying the outcome after pancreaticoduodenectomy operation for periampullary tumors. Patients and methods This study is a prospective cohort. A total of 35 cases of pancreaticoduodenectomy operations were performed from March 2011 to February 2013. Of the procedures, 23 cases were diagnosed as pancreatic carcinoma, and the rest were ampullary carcinomas (7), cholangiocarcinomas (3), and duodenal carcinomas (2). Statistical analysis was completed by using log-rank and Cox regression multivariate analyses. Results The 5-year survival rate was 29% for all patients who went through pancreaticoduodenectomy. For periampullary carcinomas other than pancreatic carcinoma, the 1, 3, and 5-year survival rates were 100, 66.7, and 58.3%, respectively. The 1, 3, and 5-year survival rates for pancreatic carcinoma were 42.1, 10.5, and 10.5%, respectively (P=0.01). In the multivariate analysis, the existence of both perineural and lymphovascular invasions were the only independent factors influencing outcome. The 5-year survival rate was 88.9% in patients negative for both factors and 0% in patients positive for both (P=0.02). Conclusion Cases with both perineural and lymphovascular invasions on histopathological analysis have poor 5-year survival outcomes after Whipple’s procedure for pancreatic and periampullary malignant tumors.
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Resection of hepatocellular carcinoma in cirrhotic patients: laparoscopic versus open resection p. 375
Ahmed Khalil, Mohamed Aboelnaga, Wael Omar
DOI:10.4103/ejs.ejs_37_18  
Background Liver resection is an established modality of treatment for hepatocellular carcinoma although not commonly used in liver cirrhosis due to the poor liver reserve and the risk of decompensation. Laparoscopic surgery is known for its short-term and long-term benefits. Also, laparoscopic hepatectomy has many advantages in cirrhotic patients like minimizing the destruction of collateral blood and lymphatics. Our study aims at evaluating the effectiveness and safety of laparoscopic approach in patients with cirrhotic livers and compares it with the open approach. Patients and methods This prospective study involved 65 patients with hepatic tumors (with Child A classification) managed by hepatic resection at Ain Shams University Hospitals (Ain Shams University) and Badr Hospital (Helwan University) during the period from October 2014 to August 2016. The patients were randomly divided into two groups, group A (32 patients) was managed with laparoscopic hepatic resection technique and group B (33 patients) was managed with open hepatic resection technique. The patients were followed up to 12 months from the time of operation. Results Group A showed significantly shorter hospital stay; the mean hospital stay in the open group was 5.51±1.28 days ranging from 4 to 7 days, while in the laparoscopic group it was 3.75±1.16 days ranging from 3 to 5 days with highly statistically positive correlation difference between the two groups (P<0.001). Also, postoperative complications (mainly postoperative ascites) were significantly lower in the laparoscopic group, with no statistically significant difference in 1-year survival or recurrence rate. Conclusion The laparoscopic approach has superior short-term outcome compared with the open approach. Laparoscopic approach carries less postoperative complications and should be considered when possible.
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Dermal sling used in the management of breast cancer in Egyptian women with large breasts p. 384
Ahmed F Al-Karmouty, Ahmad Abdel-Fattah Sabry
DOI:10.4103/ejs.ejs_44_18  
Introduction Large breast sizes are prevalent among Egyptian women. When breast reconstruction is performed in these patients, it is difficult and unsafe. Wound dehiscence leads to the risk of implant exposure. Acellular dermal matrices are expensive and infections occur. Aim To evaluate the safety and efficacy of the use of inferior–lateral dermal flaps to create complete pocket coverage of implants and expanders together with the pectoral muscles. Patients and methods Thirty patients with breast cancer underwent skin-reducing mastectomies and prostheses using the dermal slings were evaluated for technical issues and rates of postoperative complications. Results Early postoperative complications occurred in four patients in the form of wound dehiscence, nipple necrosis, and persistent drainage of serum for more than 2 weeks. Cases with wound dehiscence were managed by operative debridement of the edges and re-closure. Nipple loss occurred in one case; in this patient, we deflated the expander, removed the areola, and closed the gap. Cases with persistent drainage were treated conservatively. No exposure was encountered even in complicated cases. Conclusion Dermal slings enabled the creation of complete pocket coverage for implants and expanders, with a low complication rate. The procedure is safe and reliable. It is suitable for our patients with large breasts and major ptosis.
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Percutaneous revascularization as a feasible option for complex aortoiliac occlusive disease with fair 1-year outcome p. 390
Ahmed K Allam, Atef Salem, Ahmed K Gabr
DOI:10.4103/ejs.ejs_47_18  
Background Aortoiliac arterial occlusive disease (AIOD) is one of the commonest patterns of systemic atherosclerosis with a spectrum of chronic symptoms from intermittent claudication to critical limb ischemia, which is a common therapeutic challenge. A meaningful shift has evolved in treating symptomatic AIOD from open to endovascular repair, which are becoming an attractive treatment option even in complex lesions, especially in patients with considerable risk. Aim The aim of this study was to assess the feasibility, that is, technical success rates, primary patency, and safety outcome for Trans-Atlantic Inter-Society Consensus (TASC) D lesions treated endovascularly with analysis of outcome of stent graft versus bare metal stent in patients with advanced Leriche syndrome. Patients and methods A prospective case series study: over 30 months, our case study was conducted on 22 patients with TASC D lesion morphology undergoing treatment for symptomatic chronic AIOD at the Vascular Unit, General Surgery Department, Benha University Hospitals, Vascular Surgery Department, Nile Insurance Hospital and Vascular Surgery Department, Security Forces Hospital and Al-Noor Specialist Hospital, Makkah, Saudi Arabia. The patients were enrolled from April 2015 until October 2016 with a 12-month follow-up period from the last patient enrolled. SPSS, version 20.0 for Windows was used for statistical analysis. Results Our study had a technical success rate of 95.5% in crossing TASC D lesion with immediate angiographic success (91%). The 12-month primary patency rate was 85% for TASC D lesions with a target lesion revascularization of 15%. Stent grafts had a higher 1-year patency rate (91.7%) versus bare metal stent (75%). The total procedure-related complications rate was 18.1% and 30 days procedure-related mortality was 4.7%. Conclusion Our study shows that technical success of endovascular therapy for TASC D lesions was 95.5% with a 1-year primary patency of 85% and a complication rate of 22.7% in TASC D lesions. Utilizing more than one access with antegrade crossing the lesion through brachial access was paramount for technical success. Long-term follow-up is mandatory to support the durability of the procedure.
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Evaluation of the efficacy of duplex-guided foam sclerotherapy in the management of low-flow vascular malformation p. 400
Ayman M Samir, Abdelrahman M Gameel, Hosam A Tawfek, Amr Elboushi, Waleed A Sorour, Mohamed E Elsherbeni
DOI:10.4103/ejs.ejs_49_18  
Objectives The main objective of this prospective study was to clarify the therapeutic efficacy and tolerance of duplex-guided polidocanol foam injection in the treatment of low-flow venous malformations (LFVM), residual symptomatic hemangiomas after medical treatment, and Klippel-Trenaunay syndrome (KTS) performed at Vascular Surgery Department at Zagazig University Hospitals. Patients and methods This prospective study included 36 patients divided into three groups: 17 cases with LFVM, 11 cases with vascular tumors (hemangiomas), and eight cases with KTS. All cases were treated by duplex-guided polidocanol foam sclerotherapy. Results The study included 20 (56%) males. The mean age of the patients was 15.19 years. The final outcome was good response regarding the decrease in size and symptoms in 13 cases of LFVM, six cases of hemangiomas, and six cases of KTS. The remaining four cases of LFVM, five cases of hemangiomas, and two cases of KTS had fair or poor results after sclerotherapy (unfavorable outcome), for which surgical excision was done. There was no statistically significant difference among the three different types of patients regarding outcome or occurrence of complications. Conclusion Duplex-guided polidocanol foam sclerotherapy is easy to perform and is a safe procedure that provides excellent outcome for venous malformations and good outcome for infantile hemangiomas and KTS.
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Improvement of surgery department performance after implementing hospital quality standards’ policies: two decades experience p. 405
Afaf El Ayyat, Hanan Ali Sayed, Ahmed Hazem Helmy, Mohamed Emad Esmat
DOI:10.4103/ejs.ejs_59_18  
Background Theodor Bilharz Research Institute (TBRI) Hospital comprises clinical departments, research laboratories, and different supporting services. General Surgery Department (GSD) in TBRI hospital has over 30 years of cumulative surgical and research experience. New managerial policy and quality procedures were developed and implemented from 2007 onwards in GSD. The aim of this study was to assess the pattern of change in utilization and performance in GSD in TBRI hospital after implementing the new policies and procedures, from 2007 onwards. Methods This was a retrospective observational study. Electronic data were collected from the medical record unit and annual reports of TBRI hospital from the year 2001 to the year 2016. Hospital utilization indices, admission, surgical operations performed, bed utilization indices, average length of stay (ALOS), bed occupancy rate (BOR), bed turnover rate (BTR), and mortality rate (MR) were calculated before and after implementing the new policies and procedures from the year 2007 onwards. Results The shift to more skilled and major surgical operations was doubled, and the increase of elective surgeries increased to more than three-folds of emergency operations. There was marked increase of outpatient flow to more than three-folds, and decreased MR. The indicators used to show increase of performance in GSD were as follows: improvement in hospital bed indices decreased ALOS, increased BOR, and increased BTR. The year 2016 showed the optimization of all hospital indices: ALOS 5.5, BOR 74.2, BTR 48.9, and MR 0.1. Conclusion Quality improvement may not appear in the initial years of a program. It is recommended to keep up the implemented hospital quality policies and procedures to continue future improvement for better quality of patient care in GSD at TBRI hospital.
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Diaphragmatic rupture due to blunt trauma: a limited series case report p. 412
Abdulsalam Y Taha, Waleed M Hussen, Mohammed B Mahdi
DOI:10.4103/ejs.ejs_22_18  
Background Traumatic diaphragmatic rupture is an uncommon but potentially serious injury. Over the last 2 decades, the prevalence of blunt trauma as a cause of diaphragmatic rupture has increased five-fold. Five such patients surgically treated in two hospitals from Iraq are described herein. Methodology A retrospective analysis. Results All patients were men with a mean age of 31.6 years (range: 26–40 years). The cases consisted of injury following road traffic accidents (n=4) or falling from a height (n=1). Time intervals between trauma and diagnosis were 2 h, 3 days, 3, 7 and 20 years. The diagnosis was based on clinical grounds besides plain chest radiography, contrast gastrography and abdominal ultrasonography. Computed tomography scan of the chest and abdomen was carried out twice, whereas oesophagogastrodudenoscopy was perfeormed once. Tube thoracostomy was placed twice but failed to drain significant blood and/or air. The tear involved the whole diaphragm in two cases, whereas it was 6–10 cm long in others. Three diaphragmatic tears were directly closed by thoracotomy, one by left thoracoabdominal approach and one by laparotomy. There were no complications, and all patients survived. Conclusion Chronic diaphragmatic ruptures are actually missed rather than late-presented. High clinical index is essential to early diagnosis and prompt treatment of traumatic diaphragmatic rupture.
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