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   2015| April-June  | Volume 34 | Issue 2  
    Online since April 23, 2015

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Tension-free primary closure compared with modified Limberg flap for pilonidal sinus disease: a prospective balanced randomized study
Tamer Youssef, Saleh El-Awady, Mohamed Farid
April-June 2015, 34(2):85-89
Background Pilonidal sinus disease (PSD) is a common disease that affects the patient's quality of life. We analyzed the outcome of the tension-free primary closure (TF 1ry) in comparison with the modified Limberg flap (MLF) technique. Patients and methods A total of 120 patients suffering PSD were assigned to one of two equal groups by closed envelope balanced randomization. Group I represents TF 1ry method and group II represents MLF. Results There were 102 (85%) male patients and 18 (15%) female patients elected for surgery. The mean follow-up period was 43.5 ± 3.4 months. There were no statistically significant differences between the two groups regarding patients' demographic data, clinical presentation, immediate postoperative complications, and disease recurrences. The operative time, blood loss, hospital stay, surgeon's performance scale, wound hypothesia, wound cosmoses score, patient satisfaction score, and patient quality of life (bodily pain and social functioning) were better in the TF 1ry group. The MLF group had better clinical results regarding frequency of seroma formation and time to drain removal. Conclusion Flap techniques are effective and efficient for PSD. TF 1ry closure can be tailored for female PSD patients and a junior surgeon. MLF can be tailored for male PSD patients and a senior surgeon.
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Preperitoneal versus Lichtenstein tension-free hernioplasty for the treatment of bilateral inguinal hernia
Ahmed Rabae Talha, Ahmed Shaaban, Rabie Ramadan
April-June 2015, 34(2):79-84
Background Inguinal hernia is one of the most common diseases in the surgical setting. Bilateral inguinal hernia is present in 12% of patients and its treatment has been debated for long, sequential or simultaneous repair especially after tension-free repairs. We carried out this study to compare the Stoppa procedure with bilateral Lichtenstein hernioplasty for the treatment of bilateral inguinal hernia. Materials and Methods The study included 40 patients with bilateral inguinal hernias who were allocated randomly to two groups. Group A included 20 patients who were operated by bilateral Lichtenstein hernioplasty. Group B also included 20 patients who were operated by Stoppa repair. Recording of preoperative data (age, sex, BMI, comorbidity, smoking, and type of hernia), operative data (operative time and operative complications) and postoperative data (complications, pain, hospital stay, return to normal daily activities, chronic groin pain, and recurrence) was performed for each patient in the study. Patients were assessed at 7 days, and 1, 6, and 12 months after the procedure at the outpatient clinic. Results All patients were men. There was no statistically significant difference between both groups in preoperative data. The Stoppa procedure took a significantly shorter time than bilateral Lichtenstein repair; the mean operative time for Stoppa and bilateral Lichtenstein was 39.0 ± 5.15 and 62.25 ± 7.95 min, respectively. Postoperative pain scoring using the visual analogue score at 12 h postoperatively was significantly lower with the use of the Stoppa procedure than bilateral Lichtenstein repair, but there was no statistically significant difference between both groups in postoperative pain scoring at 24 h and 7 days postoperatively. No significant difference was detected between both groups in operative complications, postoperative complications, hospital stay, return to normal daily activities, and chronic groin pain. No recurrence was detected in any of the patients after 1 year of follow-up. Conclusion Bilateral inguinal hernias can be repaired simultaneously in the same setting safely and effectively without an increase in morbidity or recurrence rate. The Stoppa procedure can be a good alternative to bilateral Lichtenstein repair for the treatment of bilateral inguinal hernia, with comparable outcome.
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Elevated serum bilirubin as a preoperative specific predictor for complicated appendicitis in children
Mohamed Rabae Abdella, Naglaa Sayed
April-June 2015, 34(2):71-78
Objective The aim of the study was to evaluate the diagnostic yield of preoperative high serum total bilirubin (TB) for cases of appendicitis in conjunction with clinical and other laboratory findings. Patients and methods The current study included 417 children presenting with right iliac fossa pain. All patients underwent clinical examination and gave blood sample on admission for estimation of serum TB and C-reactive protein (CRP) and total leukocytic count (TLC) and underwent surgical exploration and management according to operative findings. Results Surgical exploration defined 134 cases of complicated appendicitis (CA), 219 cases of simple appendicitis, and 64 cases of noninflamed appendix. Mean preoperative TLC and serum CRP showed high sensitivity (88.7 and 83.6%, respectively) for detection of acute appendicitis (AA), despite the lower specificity of CRP for diagnosis (57.8%), whereas the specificity rate of elevated TLC was 71.9%. For discrimination between simple appendicitis and CA, elevated serum CRP showed higher specificity compared with elevated TLC (70.3 vs. 65.8%) despite the higher sensitivity of elevated TLC compared with elevated serum CRP (91.8 vs. 80.6%). Serum TB showed the highest specificity rate for defining cases of AA and CA (79.7 and 86.3%, respectively) despite the low sensitivity for both. Receiver operating characteristic curve analysis defined the severity of rebound tenderness in the form of significant, sensitive, and elevated TLC as the most significant specific predictor for AA. Serum TB greater than 1 mg/dl was the most significant specific predictor for the diagnosis of CA. Conclusion Combined estimation of TLC and serum CRP and TB improves the diagnostic yield by combining the high sensitivity of TLC and CRP with the high specificity of TB, allowing early detection of cases that could develop CA and enabling better decision for patient discharge.
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Improving lymph node harvest in colorectal cancer by intra-arterial injection of methylene blue: a randomized trial
Ayman A Albatanony, Alaa A Alseesi, Mohamad S Ammar, Mohammad Shaaban
April-June 2015, 34(2):99-102
Background Prognosis in colorectal carcinoma is related to the state of lymph node involvement. Myriad studies demonstrate that both survival and prognosis are significantly influenced by the number of lymph nodes harvested, particularly in node-negative disease. Aim The aim of this study was to evaluate the usefulness of injecting methylene blue into the main artery/arteries of resected colorectal specimens in terms of the total number of lymph nodes identified. Patients and methods The study included 54 patients randomly divided into two groups: group 1 (26 patients), in which resected specimens of colorectal carcinoma were injected with methylene blue, and group 2, in which no injection was carried out. Results The total number of lymph nodes per patient in group 1 was 19.5 (17-39) [median (range)] and that in group 2 was 16.5 (8-19). The difference was statistically highly significant (P < 0.001). We also noticed that the best improvement in lymph nodes harvest was among the very small and small lymph nodes. Conclusion Methylene blue injection into the main artery/arteries is an effective and simple method for improving the lymph node harvest in resected specimens of colorectal carcinoma.
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Subtotal cholecystectomy in difficult laparoscopic cholecystectomies: is it safe?
Essam F Ebied, Hossam Ebied
April-June 2015, 34(2):90-93
Purpose Laparoscopic cholecystectomy is now accepted as the 'gold standard' procedure for cholecystectomy. However, this procedure can be dangerous in cases of unclear anatomy at the Callot's triangle. A significant proportion of patients with unclear anatomy are still converted to 'open' to complete the procedure. The other option is subtotal cholecystectomy rather than open conversion. Our purpose was to study the safety of laparoscopic subtotal cholecystectomy in cases where the clear identification of the anatomical land marks in Callot's triangle is difficult. Materials and methods Patients who underwent laparoscopic subtotal cholecystectomy between January 2011 and December 2011 were evaluated prospectively. These patients underwent subtotal cholecystectomy without isolation of the duct or artery, as this was judged to be hazardous, and the Hartmann pouch was transacted, stones were evacuated and the gall bladder remnant was closed by endoscopic sutures and a subhepatic drain left in situ. Results Laparoscopic subtotal cholecystectomy was performed in 30 elective procedures among 30 patients, male patients 18 (60%) and female patients 12 (40%). Their mean age was 52.6 years ± 12.65 SD. The mean operative time was 92 min ± 20 SD, and the mean hospital stay was 72.43 h ± 22 SD. We encountered one conversion into open and two patients who developed intra-abdominal collection. No mortalities were recorded. Conclusion Subtotal cholecystectomy is a safe procedure in cases where there is no clear identification of the structures in Callot's triangle. However, it is not a substitute for conversion into open, if deemed required.
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Two-port retrograde laparoscopic appendicectomy for complicated pediatric appendicitis using a single Hem-O-Lock clip for the closure of the appendicular stump
Basem M Sieda
April-June 2015, 34(2):103-109
Objective The aim of this study was to assess the safety and the technical feasibility of retrograde laparoscopic appendicectomy for the pediatric population with complicated appendicitis (gangrenous, perforated, or forming mass) and to evaluate the security and advantages of closing the appendicular stump with a single Hem-O-Lock polymer clip. Materials and Methods This is a prospective review of 82 pediatric patients presenting with acute appendicitis, of whom 50 patients were selected, according to computed tomographic abdomen and pelvis, to have a complicated appendicitis. All the data were collected and interventions were performed in Zagazig University Hospitals during the period from December 2012 to August 2014. All cases were operated by two-port retrograde appendicectomy using single Hem-O-Lock polymer clips to close the appendicular stump. The age, the sex of the patients, and complications were evaluated. Treatment complications and outcomes were recorded for all cases. Results Four of the 50 patients (8%) had postoperative complications; four patients developed intra-abdominal abscess postoperatively: two of them underwent laparoscopic drainage during the same admission and the other two patients were readmitted after 1 and 2 weeks, respectively, when one of them underwent ultrasound-guided drainage and the other one improved within 48 h by medical treatment. No other complications were noted apart from one case that converted to open surgery due to a large cecal mass with a gangrenous cecal wall. The cases of postoperative abscess occurred early during our initial experience, with laparoscopic appendectomy for complicated cases. Conclusion Retrograde appendicectomy allows easy access to operate complicated appendicitis. The use of two ports adds an advantage to the procedure by decreasing postoperative pain. The use of a single polymer clip is as secure as two clips for the closure of the appendicular stump even for a complicated appendix.
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Carotid endarterectomy in Iraq: a single-center experience
Abdulsalam Y Taha, Akeel S Yousr, Saoud Y Al-Neaimy, Muhammad Y Al-Shaikh
April-June 2015, 34(2):110-117
Background Carotid endarterectomy (CEA) refers to surgical removal of carotid atheroma. It was first reported in 1956 and eventually became widely accepted as an effective operation for stroke prevention. Herein, we present the experience of a single Iraqi center in CEA. Patients and methods We conducted a retrospective study of 21 patients with significant symptomatic carotid stenosis that was surgically managed in Ibn-Alnafees Hospital, Baghdad, over the period 2009-2014. Workup consisted of duplex ultrasonography and computed tomography angiography of the carotid arteries. General anesthesia, a standard technique, and routine carotid shunts were used, followed by patch closure, mostly a venous patch. Aspirin and antiplatelets were given postoperatively to patients who underwent a venous patch; otherwise, warfarin was prescribed. Results There were 20 male patients. Ages ranged between 37 and 82 years, with a mean of 60.3 ± 12.2 years. One-third of the patients (n = 7) were in the seventh decade. Six of 12 patients had jobs consistent with a low economic status. Smoking, hypertension, and diabetes mellitus were the main risk factors. Most patients had hemiparesis (n = 17, 81%). All patients had significant carotid stenosis (moderate to severe). Twenty-two operations were performed (one patient underwent two operations). Left-sided operations were more frequent (14/8) (P < 0.05), as well as venous patches (20/2 Gore-Tex) (P < 0.05). There was no incidence of stroke, but cervical hematomas (n = 22), tongue deviation (n = 2), and hyperperfusion syndrome (n = 2) were seen, all of which resolved spontaneously; one case of mortality was reported (4.8%), in a 73-year-old-man. Conclusion Although this study is the first on CEA in Iraq with a small number of patients, the results compare favorably with the published literature.
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Evaluation of the role of endoanal ultrasonography in preoperative assessment of perianal fistula
Abdrabou N Mashhour, Haitham S Omar, Ahmed S Marzouk, Mohamed M Raslan, Ahmed Farag
April-June 2015, 34(2):122-126
Background Although anal fistula are encountered commonly in surgical practice and have been studied extensively, some complex forms still continue to represent a difficult surgical challenge for many surgeons. The corner stone and the main aim of treatment for an anal fistula is to permanently eliminate abscess formation and achieve healing at the same time preserving anal function and continence. Therefore, precise preoperative assessment of perianal fistulae is crucial to achieving optimal surgical results. Patients and methods In this prospective comparative study, 60 patients were enrolled during the period from December 2012 to June 2014. Endoanal ultrasonography (EAUS) (two-dimensional/three-dimensional) with or without H 2 O 2 enhancement was used for the preoperative assessment of perianal fistulae and abscesses, and the degree of accuracy and its agreement with the surgical findings were estimated. Primary fistulous tract and its relation to the sphincter complex, side tracts, internal opening, and any associated sepsis were determined by EAUS; the reviewers were blinded to the findings of the assessment. Results In classification of the primary tract, there was agreement between EAUS and surgical findings in 47 of the 60 (78.3%) patients. In terms of the presence of an internal opening, the corresponding figures were 53 (88%) cases. In assessment of the secondary (side) tracts by EAUS, 55 (91.7%) patients were diagnosed accurately. In terms of the diagnosis of the presence or absence of abscess cavity or collection in the cases, EAUS diagnosed 53 (88.3%) patients accurately. Conclusion EAUS with its recent innovations of three-dimensional technique and H 2 O 2 enhancement is an excellent modality when planning for fistula surgery, especially with experienced and well-trained operators.
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How much is the axillary nodal status in breast cancer affected by neoadjuvant chemotherapy? An Alexandria medical research institute hospital experience
Rabie Ramadan, Yasser Hamed, Heba G El-Sheredy, Hala K Maghraby
April-June 2015, 34(2):94-98
Background The multidisciplinary approach, including surgery, chemotherapy, endocrine therapy, and radiation therapy, has become the standard treatment for primary breast cancer patients. The status of axillary lymph nodes (AxLNs) remains the most important prognostic factor. The number of lymph nodes retrieved in axillary lymph node dissection (ALND) varies considerably. Removal of at least 10 AxLNs is generally considered as an adequate ALND for reliable lymph node staging. Several authors have reported a significantly lower AxLN count in patients undergoing ALND after the completion of neoadjuvant chemotherapy (NAC) compared with patients who underwent surgical resection first. Objective Our aim was to evaluate the effect of NAC on the axillary nodal status in breast cancer patients regarding the number of AxLNs retrieved at ALND and to compare the degree of response to NAC relative to the primary tumor's nodal status in the both studied groups. Patients and methods In this retrospective study, we reviewed the records of all patients with invasive breast cancer who were admitted to the Department of Surgery, Medical Research Institute hospital, Alexandria, during the period between August 2013 and July 2014 and were scheduled for ALND. Cases were categorized into two groups: group I included patients who received NAC and were then subjected to surgery, whereas group II included patients who were subjected to surgery without NAC. Data collected from both groups included patient demographics and clinicopathological characteristics. Results The study included 237 female patients who were allocated to one of the two groups: group I (GI) included 93 patients (39.2%), whereas group II (GII) included 144 patients (60.8%). There was no statistically significant difference between the two groups regarding the age, the tumor grade, and the tumor type. However, significant differences were seen in a variety of baseline criteria between the two groups; patients who received NAC had larger tumors (T) (P = 0.001), a higher lymph node (N) classification (P = 0.002), and a higher overall disease stage (P = 0.0001) compared with patients who underwent surgical resection first. After NAC in GI, AxLNs were significantly more responsive to NAC relative to the primary tumor (P = 0.003). The number of AxLNs harvested during ALND revealed a significantly lower LNY in patients who underwent NAC in comparison with patients who did not, with a median total number of nine nodes in GI compared with 14 axillary nodes in GII (P = 0.0001). The number of positive AxLNs was higher in patients who underwent surgical resection first, with a statistically significant difference (P = 0.006). Conclusion NAC is a significant independent parameter for a reduced AxLN number retrieved by ALND. Also, we can conclude that AxLNs are significantly more responsive to NAC relative to the primary tumor either clinically or pathologically.
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Subintimal angioplasty of chronic total superficial femoral artery occlusions in critical lower limb ischemia patients: the single center experience
Khaled Attalla, Ahmed El Badawy, Ashraf El Naggar, Bahgat Thabet
April-June 2015, 34(2):118-121
Objective The aim of this article was to report our results of subintimal angioplasty (SIA) of long superficial femoral artery (SFA) occlusions and try to appreciate factors that affect patency following this type of intervention in critical lower limb ischemia (CLI) patients. Patients and methods The current series was conducted prospectively over a 1-year period. Forty cases, 40 limbs (mean age = 65.8 years old) with long SFA occlusion (>15 cm) and patent popliteal artery continuous with at least one leg artery runoff were included. Exclusion criteria were: renal impairment, nonatherosclerotic occlusions (thrombosis, dissection, or compression), short SFA occlusions (<15 cm), or non-SIA revascularization intervention. Results were considered successful with primary technical success combined with improving ischemic rest pain or healing wounds following minor amputations. Nonrecanalization or major amputations were considered failures. One-year patency and salvage rates were calculated. Factors that affected patency such as patent leg arteries and TASC grading were analyzed. Results Results were considered successful in 34 (85%) patients and failure was noticed in six (15%) cases. At the end of the first follow-up year, the primary patency rate was 75% and the salvage rate was 87.5%. The 1-year patency rate was higher in TASC C patients (85.7%) in comparison with TASC D cases (69.2%). The patency rate was 50% or less with one patent leg artery and 80% or more with two or three patent leg arteries. Conclusion SIA is a good alternative for recanalization of chronic long SFA total occlusions in CLI patients with accep[table 1]-year patency rates. Number of patent leg arteries is an important determinant of durable procedures.
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