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  Citation statistics : Table of Contents
   2016| October-December  | Volume 35 | Issue 4  
    Online since November 28, 2016

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Crohn’s disease limited to the appendix, case report
Ahmed El-Saady
October-December 2016, 35(4):460-463
Crohn’s disease is a chronic, idiopathic transmural inflammatory disease of the alimentary tract, which may be limited to the appendix in 0.2–1.8% of patients. Here, we report a male patient aged 24 years who presented with typical manifestations of acute appendicitis that proved histologically to be Crohn’s disease. On operation, an early phlegmon was found. The appendix was dissected and delivered. It was so large with very thick wall, with induration of the nearby cecal wall. Therefore, segmental right hemicolectomy was performed with iliocolic anastomosis. The specimen was sent for histopathologic examination, which demonstrated Crohn’s disease limited to the appendix, with other parts of the specimen free. We reviewed the literature on such clinical entity, its clinical significance, differential diagnosis, and best method of management. Actually, the disease needs to be differentiated from a long list of causes of appendicular granuloma as well as tumors and diverticulosis of the appendix. Histological confirmation is frequently required because of difficulty of conclusive diagnosis during surgery when the disease is limited to the appendix. The disease is usually benign and has indolent course than that developed elsewhere. Some authors debate the need for follow-up at all in those patients, believing that the appendectomy alone is curative in the majority of patients.
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Tack fixation versus nonfixation of mesh in laparoscopic transabdominal preperitonaeal hernia repair
Ahmed A Darwish, Ashraf A Hegab
October-December 2016, 35(4):327-331
Context Laparoscopic transabdominal preperitoneal (TAPP) repair of inguinal hernia is traditionally performed by fixing the mesh to the abdominal wall by spiral tacks. However, mesh fixation might not be necessary as there is little space for the mesh to migrate; besides, tack fixation predisposes to postoperative pain. Aim The present study aimed to compare mesh fixation versus nonfixation regarding postoperative pain and recurrence rates. Settings and design This study was a prospective, controlled, randomized study. Patients and methods In total, 60 patients with inguinal hernias were divided into two equal groups, were compared regarding mesh fixation versus nonfixation by TAPP technique, and followed-up for up to 12 months for postoperative complications, pain, and recurrence. Statistical analysis Continuous variables are expressed as means and SDs. Categorical variables are expressed as frequencies and percentages. Results There was significant reduction in postoperative pain and chronic pain in patients without mesh fixation in comparison with patients with mesh fixation and early return to work. There was no significant difference between the two groups regarding postoperative complications and recurrence rates. Conclusion Mesh nonfixation reduces the incidence of postoperative pain and chronic pain in patients undergoing TAPP repair without increase in postoperative complications or recurrence rates.
  1 1,406 174
Omentoplasty versus tachosil in preventing leakage after colonic anastomosis
Ashraf A Hegab
October-December 2016, 35(4):372-379
Context Leak from an intestinal anastomosis is the complication most feared by colorectal surgeons. The role of omentoplasty in securing colorectal anastomoses is controversial. Collagen-bound fibrin sealant sheets have recently been used in many aspects of surgery and many experimental animal studies have proven its efficacy in securing gastrointestinal anastomoses. The safety and feasibility of a collagen-bound fibrin sealant has been proven. Its application in sealing colonic anastomosis is a new field and needs to be evaluated. Aim The aim of this study was to evaluate and compare the efficacy of omentoplasty versus TachoSil in decreasing the rate of anastomotic leakage in colorectal anastomoses. Settings and design This is a prospective randomized trial. Materials and methods Ninety-seven patients with colonic anastomosis were divided into two groups; 48 were subjected to omentoplasty and 49 to TachoSil for prevention of leakage. The patients were followed up for symptoms and signs of leakage postoperatively. Statistical analysis Continuous variables were expressed as means and SD. Categorical variables were expressed as frequencies and percentage. Results The rate of clinical leakage in the omentoplasty group was 8.3% and that in the TachoSil group was 2%, which was within the reported range of 1.5–16%. Three out of four leakages in the omentoplasty group were severe (>500 ml/day) and the only case in the TachoSil group was less severe (<500 ml/day). The average hospital stay in the omentoplasty group was 9.3 days and that in the TachoSil group was 7.2 days (P<0.05). Conclusion The study proved that TachoSil is more effective than omentoplasty in preventing anastomotic leakage. The use of the collagen-bound fibrin sealant TachoSil appears to be beneficial, being better than omentoplasty with respect to the length of hospital stay and severity of leakage, if leakage is inevitable.
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Management of residual gallbladder and cystic duct stump stone after cholecystectomy: a retrospective study
Ayman El Nakeeb, Helmy Ezzat, Waleed Askar, Aly Salem, Yousef Mahdy, Ahmed Hussien, Ahmed Shehta, Talaat Abd Allah
October-December 2016, 35(4):391-397
Purpose There is no doubt that cholecystectomy relieves presurgical symptoms of gallbladder (GB) disease. The persistence of symptoms following cholecystectomy is termed as postocolecystectomy syndrome, the incidence of which ranges from 10 to 30%. The present study was conducted to evaluate patients who had a residual GB stone/cystic duct stump stone after cholecystectomy, and to study the surgical outcomes. Patients and methods This retrospective study was conducted on 21 cases with residual GB/cystic duct stump stone. The diagnosis was guided by ultrasound and magnetic resonance cholangiopancreatography. All the cases were managed by using completion cholecystectomy − either open or laparoscopic. All preoperative, operative, and postoperative data were collected. Results Preoperative endoscopic retrograde cholangiopancreatography and papillotomy were required in nine cases that presented with obstructive jaundice. Laparoscopic completion cholecystecomy was feasible in 14 cases. The conversion rate was 1/14 cases. The mean operative time was 127±31.3?min and the mean blood loss was 165±74.5?ml. Intraoperative minor biliary injury occurred in one case. The mean hospital stay was 3.1±1.8 days (1–9 days). All patients were reported to be symptom-free at the follow-up after surgery. Conclusion Residual GB/cystic duct stump stone is a preventable and correctable cause of postocolecystectomy syndrome. Completion cholecystectomy is a proven treatment of choice to relieve symptoms and avoid complications, and, furthermore, it can be carried out laparoscopically.
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Bouveret's syndrome: a report of two cases
Mohamed El Sorogy, Ehab El Hanafy, Hosam Hamed, Ehab Atef, Ahmed Abdel Rafee, Gamal El-Ebeidy
October-December 2016, 35(4):456-459
Introduction Bouveret's syndrome, a rare and clinically challenging condition, is a variant of gall stone ileus caused by impaction of a large gallbladder stone in the duodenum secondary to a cholecystoduodenal fistula. Case presentation We present two cases of duodenal obstruction in old patients due to gall stone migration and impaction in the duodenum. Both were treated surgically. Discussion Bouveret's syndrome is a rare variant of gall stone ileus. Risk factors include old age, female sex, large-sized stones, and long history of gall stone disease. Treatment options include extracorporeal shock wave lithotripsy, endoscopy, and surgery. Conclusion Bouveret's syndrome is a clinically challenging diagnosis to make. Although surgical stone extraction remains the classic treatment option with the least failure rates, leaving the fistula alone is associated with the least morbidity and mortality rates.
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Comparison of one-stage endoscopic retrograde cholangiopancreatography and cholecystectomy versus two-stage endoscopic retrograde cholangiopancreatography and cholecystectomy for treatment of cholelithiasis with choledocholithiasis
Mohamed A.F. Selimah, Amr M El Sherief, Medhat M Anwar
October-December 2016, 35(4):398-402
Introduction The optimal management of symptomatic or suspected common bile duct (CBD) stone continues to be controversial despite the fact that laparoscopic cholecystectomy (LC) has turned out to be the standard method for gallbladder removal and despite innovations in endoscopy and laparoscopic surgery. Aim The aim of this study was to compare the two-stage intervention [endoscopic retrograde cholangiopancreatography (ERCP) under total intravenous anesthesia followed by interval LC] with the one-stage intervention (ERCP combined with LC) in terms of feasibility, safety, effectiveness, and hospital stay. Patients and methods Eighty patients admitted to the Medical Research Institute, University of Alexandria, during the interval between January 2012 and January 2013, diagnosed as having cholelithiasis with choledocholithiasis proven by laboratory and radiological investigations (abdominal ultrasonography and/or MRCP), were studied prospectively, and they were classified into two equal groups: group A, in which a two-stage procedure was performed; and group B, in which a one-stage procedure was performed. Data were recorded, including patients’ demographic, endoscopic, and operative details, success rate, postoperative complication (ERCP and LC), overall operative time, and length of hospital stay. Results The operative time was significantly lower in the two-stage group (group A). There were no statistically significant differences between both groups as regards CBD stone retrieval, morbidity rates, or the mean hospital stay. Conclusion Taking in consideration that our results showed no statistical difference between the two groups, there is still no gold standard of care for patients having chronic calcular cholecystitis and CBD stones. We prefer separating the two procedures in our routine practice.
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Role of drug-eluting balloon in infragenicular angioplasty
Aymen Salem, Ahmad M Tawfik, Amr Elboushi
October-December 2016, 35(4):403-407
Introduction Below knee arterial occlusive disease occurs more commonly in diabetic patients and leads to critical limb ischemia (CLI). Infragenicular angioplasty is considered as one of the most attractive lines of treatment in cases of below knee arterial occlusive disease with CLI. This study was designed to evaluate the short-term results of the use of drug-eluting balloons (DEBs) in infragenicular angioplasty procedure for treating CLI. Patients and methods This study was conducted on 35 patients from the attendees to the vascular surgery outpatient clinic, Zagazig University, during the period from December 2014 to February 2016. Results There was a significant difference in the percentage of binary stenosis in favor of the DEB group, leading to less clinically driven target lesion revascularization. Conclusion DEB angioplasty has shown less binary stenosis and less need for clinically driven target lesion revascularization in comparison with standard angioplasty in infragenicular arterial disease.
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Value of using the anterior rectus abdominis sheath turnover flap for fascial repair of gapping ventral midline incisional hernia
Ahmed Fawzy, Ahmed S Elgammal, Tamer Fakhry
October-December 2016, 35(4):408-413
Background Complex abdominal wall defects are a dangerous situation to the patient and challenging to the surgeon. The defects can occur after trauma, oncologic resection, infection or any other reason. Those patients are frequently left with retracted abdominal musculature. Patients and Methods During a period from June 2012 to November 2015, thirty six patients with complex ventral abdominal wall defect were repaired by autologous fascial reconstruction using bilateral anterior rectus abdominis sheath turn over flaps that were sutured in the medline, then the repair was completed byprolene mesh enforcement. Results All the 36 patients passed without recurrence. The complication rate was 25%, including mild skin infection, seroma, partial superficial skin necrosis, and hematoma. Factors associated with increased rate of overall complications included chronic obstructive pulmonary disease, diabetes mellitus, obesity and factors related to the indication for the primary surgery. Conclusions Ventral incisional hernia and burst abdomen are a frustrating event to the patients. In this study the repair using anterior rectus abdominis sheath turn over flap, was feasible, successful, reliable and effective method for repair of ventral incisional hernia.
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Endovascular interventions for long occlusive disease of the superficial femoral artery in critical limb ischemia
Ayman Hasaballah, Mahmoud Saleh, Haitham Ali
October-December 2016, 35(4):414-420
Background The real challenges for the treatment of femoropopliteal disease are long and chronic total occlusions. These lesions continue to represent a major challenge for currently available endovascular approaches. The aim of this study was to evaluate the outcomes of an endovascular intervention for Transatlantic Intersociety Consensus (TASC)-II C and D femoropopliteal disease. Patients and methods Sixty-four patients, including 16 patients with TASC-C and 48 patients with TASC-D lesions, underwent an endovascular intervention for femoropopliteal lesions between January 2014 and December 2014. Patients’ demographics and preprocedure and postprocedure ankle brachial indices were analyzed. The outcomes of our study were primary patency, periprocedural complications, and limb salvage. Results Our cohort included 41 (64%) men and 23 (36%) women. Twenty-one (33%) patients had rest pain and 43 (67%) patients presented with tissue loss. All patients underwent initial balloon angioplasty of occluded arterial segments, with a technical success achieved in 58 (91%) patients. Nitinol stents were used in 15 (26%) patients. Eight (14%) patients developed periprocedural complications. Primary patency rates were 96.6, 89.7, 80.9, and 62.1% at 1, 3, 6, and 12 months, respectively. Univariate analysis of sex, risk factors, Rutherford staging, and TASC-II lesion could not find any statistically significant effect on the 1-year primary patency rate in the current study. Conclusion Our experience showed the benefficial results of an endovascular intervention for TASC-II C and D lesions with good acceptable early-term and medium-term patency and limb salvage rates.
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Hepatocellular carcinoma from diagnosis to treatment: 15 years of challenges and modification of resection strategies
Alaa A Redwan
October-December 2016, 35(4):421-432
Background Hepatocellular carcinoma (HCC) is a dismal tumor with a high incidence, prevalence, and poor prognosis and survival. Management necessitates multidisciplinary clinics due to the wide heterogeneity in presentation, different therapeutic options, and variable biologic behavior, especially with a background of chronic liver disease. Patients and methods This study was conducted in a specialized hepatobiliarypancreatic (HBP) clinic in Assiut University Hospital and Sohag University Hospital. We studied different types of patients and tumor characteristics with evaluation of the surgical management applied to them. Further analysis was performed using univariate and multivariate statistics. Results From December 2000 till March 2014, 220 patients with HCC presented to our clinics; they were predominantly male (mean age 56 years), mostly with cirrhosis due to hepatitis C virus (71%), with Child–Pugh A (52%) or Child−Pugh B (32%), and with a single lesion. Transarterial chemoembolization was the most common treatment (32.4%), followed by ablation therapy (27%). A major section was treated palliatively due to delayed discovery and advanced stage of the disease (63%); resection was the standard in operable cases (25.4%). Nonanatomic resection was commonly performed in 58% of the cases; however, other techniques were also used such as anatomic resection (27%) and laparoscopic resection (15%); unfortunately, the transplantation program was not yet started to be added in treatment. The overall survival was 80% at 6 months, 55% at 1 year, and 20% at 2 years. Serum bilirubin, portal hypertension, the site of the tumor, and the type of treatment were significant independent prognostic factors for survival. Conclusion Early discovery by surveillance protocols is very essential for better outcome; early interference, whether by surgery or by ablation, is a good substitute in the absence of transplantation programs. Our main prognostic variables are the bilirubin level, portal hypertension, bilobar affection, and the application of specific curative or palliative treatment. Multidisciplinary clinics enhance better HCC management.
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Angiosome-targeted isolated tibial angioplasty for healing of ischemic foot ulcer: a retrospective study
Mohamed Farag, Khaled El Alfy, Hosam Roshdy, Hesham Sharaf
October-December 2016, 35(4):433-437
Purpose On the basis of the angiosome concept in critical limb ischemia patients who presented with isolated tibial lesions and foot ulcers, we evaluated and compared clinical outcomes, ulcer healing, and amputation-free survival between patients with successful angiosome-targeted tibial angioplasty alone [direct revascularization (DR)], patients with indirect revascularization (IR) in whom the dilated vessels successfully were the nonangiosome target, and those who underwent combined revascularization (CR) (both DR and IR were achieved). Patients and methods We retrospectively analyzed a total of 66 critical limb ischemia patients who presented with ischemic foot ulcer with isolated tibial vessel lesions at Mansura University Hospital during the period from January 2014 to January 2016. DR of the ischemic angiosome was performed in 37.8% (n=25), IR in 33.3% (n=22), and CR in 28.7% (n=19) of patients. All patients were evaluated for the status of wound healing and limb salvage at 1, 3, 6, 9, and 12 months. The study endpoints were major amputation or death, limb salvage, and ulcer epithelialization at 12 months. Results The mean follow-up was 11.08±3.2, ranging from 3 to 13 months. On Kaplan–Meier analysis, 65% of patients were diabetic. Ulcer healing rate at 12-month follow-up based on angiosome hypothesis among groups CR, DR, and IR was 94.7, 66.7, and 57.17%, respectively, with a significant P value (0.013) between CR and DR and a significant P value (<0.001) between CR and IR. However, on comparing the DR and the IR group, mean time to complete ulcer healing was not statistically significant (P=0.222). Amputation-free survival rate was 94.7, 75.6, and 72.7% in CR, DR, and IR, respectively. Conclusion If technically feasible, dilation of angiosome target artery plus any other significant tibial artery lesions should be considered. We should orient procedures toward multiple angiosome reopening with better ulcer healing rate and limb salvage. However, with limitations and challenges of angiosome-based strategies, especially in diabetic patients with depletion of choke vessels, we believe that IR should not be denied with acceptable result over the time.
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Nonparasitic liver cysts: different treatment strategies
Mohamed Abou-Shady, Hazem Zakaria, Mohamed Alwaraky
October-December 2016, 35(4):438-444
Objective The aim of this work was to study the clinicopathological data of nonparasitic liver cysts (NPLCs), its different management modalities, and outcome. Patients and methods This retrospective study included patients who were diagnosed as having NPLCs from January 2000 to the start of 2016. The clinicopathological data, surgical and nonsurgical treatment, and outcomes of these patients were studied. Results NPLC was present in 118 patients. There were 78 (66.1%) female patients and the median age was 48 years. The majority of cases (95; 80.5%) were of simple liver cysts and its management was conservative treatment with follow-up (51 patients; 53.7%), percutaneous aspiration, puncture aspiration injection and reaspiration or pig-tail catheter drainage (26 patients; 27.4%), and surgical treatment (18 patients; 18.9%) with either laparoscopic deroofing (12 patients) or open surgery (six patients). Six (5.1%) patients with intrahepatic biloma underwent percutaneous aspiration or pig-tail drainage. Five (4.2%) patients had cystadenoma and underwent resection or pericystectomy. Five (4.2%) patients had post-traumatic hematoma and underwent conservative treatment. Three (2.5%) patients had polycystic liver disease; one of them underwent laparoscopic deroofing of large ones and two patients underwent conservative treatment. Two (1.7%) patients had Caroli’s disease and were prepared for liver transplantation. Two (1.7%) patients had cysts with biliary atresia and underwent Kasai operation with excision of the cyst. Conclusion Most of the NPLCs are simple liver cyst that can be managed conservatively if it is asymptomatic and small, or with percutaneous radiological intervention or laparoscopic deroofing for large symptomatic or recurrent ones. Open or laparoscopic resection or pericystectomy is reserved for cystic neoplasms which is not common.
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Intracapsular total thyroidectomy: no more complications in benign thyroid diseases
Tarek M Rageh, Ahmed S El Gammal, Alaa Elsisi, Ahmed Gaber
October-December 2016, 35(4):445-448
Introduction There is ongoing debate on the operative management strategies for benign thyroid diseases in terms of safety and efficacy. Aim This study was conducted to evaluate the results of a new intracapsular thyroidectomy technique in the management of benign thyroid diseases. Patients and methods This is a prospective study carried out in Department of General Surgery, Menoufia University Hospital, from May 2014 to March 2016 on 50 patients with benign thyroid disease who were treated with a new surgical procedure: intracapsular total thyroidectomy. Results Fifty patients underwent intracapsular total thyroidectomy. There was no patient with transient or permanent recurrent laryngeal nerve injury and no complication of external laryngeal nerve injury. There was no complication of hypoparathyroidism with decreased operative time and hospital stay either. Conclusion Intracapsular thyroidectomy is an effective and safe procedure for benign thyroid diseases and can be performed easily by junior staff.
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Endoscopic retrograde cholangiopancreatography through laparoscopically created gastrotomy for the management of biliary complications of Roux-en-Y gastric bypass
Mustafa Bayoumi, Hisham Hussein, Badawy A Abdul Aziz, Hatem S Abd El-Raouf
October-December 2016, 35(4):449-455
Objective The aim of this study was to evaluate the feasibility, safety, and surgical outcome of laparoscopically assisted endoscopic retrograde cholangiopancreatography (ERCP) through gastrotomy in patients who had undergone Roux-en-Y gastric bypass as a bariatric procedure and indicated for ERCP. Patients and methods The study included 12 patients who had undergone Roux-en-Y gastric bypass surgery in the past 1–4 years and developed biliary obstruction since 23.3±7 days (range: 13–36 days). The operative procedure involves laparoscopic creation of gastrotomy; a sterile ERCP scope was inserted through a 12-mm port site and passed manually under laparoscopic visualization through the gastrotomy orifice, and then sphincterotomy (papillotomy) and cannulation were performed. Preprocedural and postprocedural dye injection was performed to ensure the patency of biliary passages. The gastrotomy site was closed in two layers. Results Laparoscopic exploration was performed successfully in all patients, with successful adhesiolysis in three patients. In all patients, laparoscopic creation of gastrotomy in the gastric remnant was uneventful and successful, but gastrotomy site bleeding occurred in two cases and was controlled. Sphincterotomy was successful in all patients, but cannulation and injection of dye for intraoperative choledochography were performed successfully in 10 (83.3%) patients. Two patients required sphincter stenting. The mean operative time was 66.9±10.5 min (range: 55–90 min); the mean time until first ambulation and oral intake was 1.6 and 11.5 h, respectively, and the mean duration of postoperative hospital stay was 32.9 h. Eight minor postoperative complications were encountered. Conclusion Laparoscopic transgastrotomy ERCP is feasible and safe for the diagnosis and treatment of biliary complications secondary to bariatric surgery, with minimal treatable complications.
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Morbidity and mortality after total thyroidectomy for nonmalignant thyroid disorder: 10 years’ experience
Wael Barakaat Ahmed Mohamed, Ahmed Eisa Ahmed
October-December 2016, 35(4):380-383
Background In the last two decades of the 20th century, surgery for nonmalignant thyroid disease had changed from function-preserving surgery towards ablative surgery. This was due to higher recurrence rates of goitre (9–43%) and an increased risk for postoperative complications in reoperations after subtotal resection. Patients and methods This retrospective study included patients with nonmalignant thyroid disease who were referred and enroled for total thyroidectomy from December 2004 to December 2014 in Sohag University Hospital, Egypt. Operation, anaesthesia, rescue analgesia and postoperative care were standardized. All patient records were reviewed for demographic data, indication for surgery, intraoperative complications, postoperative complications, histopathology and follow-up period. Results Between December 2004 and 31 December 2014, 180 patients underwent total thyroidectomy for nonmalignant thyroid disease at the General Surgery Department, Sohag University Hospital, Sohag, Egypt. Of them, 136 were female and 44 were male. Their ages ranged between 20 and 58 years. Primary total thyroidectomy was performed in 177 patients. Completion thyroidectomy was performed for three cases of recurrent goitre. Two patients who had postoperative bleeding returned to the theatre for haemostasis. No wound infection or recurrence was found in this study. Fourteen patients had postoperative hypocalcaemia (7.77%); 10 of them had temporary hypocalcaemia (5.55%) and four patients had permanent hypocalcaemia (2.22%). Eight patients had recurrent laryngeal nerve palsy (4.44%); seven of them were unilateral injurious. One patient had temporary bilateral recurrent laryngeal nerve injury. None of the patients had permanent bilateral recurrent laryngeal nerve palsy. Conclusion Total thyroidectomy is a valuable treatment option for nonmalignant thyroid disease. With no recurrence, complete cure of the diseases, and a lower complication rate.
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Sometimes endovascular salvage of failing hemodialysis access is indispensable as you may not get another
Hisham Ahmed, El-Sayed A Abd El-Mabood, Refaat S Salama
October-December 2016, 35(4):384-390
Purposes This study aimed at salvaging fistulas using percutaneous transluminal balloon angioplasty (PTA) and evaluated the feasibility and safety of this PTA. Patients and methods A retrospective study was conducted on 15 patients to evaluate the results of endovascular intervention for the treatment of failing arteriovenous fistula from August 2015 until March 2016; these patients included eight (53.3%) men and seven (46.7%) women; most patients were aged between 40 and 60 years. Results Immediate success rate was 66.4% in anastomotic stenosis, 75% in juxta-anastomotic stenosis, and 100% in cases of central venous and arterial stenosis. Success rate after 6 months was mostly 50%, which necessitated re-PTA, except in central stenosis cases, which showed a success of 100%. Failed procedure was observed in three cases; two were due to puncture site hematoma and vein or anastomotic site rupture; these were treated with open surgery and ligation of the artery and vein proximal and distal to the anastomosis. Thrombosis was the cause of failure in the third case. Conclusion From this study we conclude that saving access can save life. Failing arteriovenous fistulas can be salvaged with PTA safely and effectively. Results are obtained with less trauma to the patient, preservation of access sites, and less postprocedural pain and wound edema. Centrally located stenoses are accessible. Re-PTA is needed in half of the patients.
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Total laparoscopic versus endolaparoscopic common bile duct stone extraction and cholecystectomy
Tarek M Sherif, Abd E Amin Sarhan, Ashraf A Abdel-Elaziz
October-December 2016, 35(4):311-320
Background Endoscopic retrograde cholangiopancreatography followed by laparoscopic cholecystectomy (LC) was the traditional method for the treatment of common bile duct (CBD) stones associated with gall bladder (GB) stones. With advances in laparoscopic instrumentation and skills, totally laparoscopic transcystic common bile duct exploration is technically feasible and increasingly practiced by surgeons worldwide. Objective The aim of this study was to compare the results of the two procedures in the management of CBD stones associated with GB stones. Patients and methods A prospective randomized clinical study was carried out from December 2010 to December 2015. It included 252 patients with concomitant GB stones and CBD stones who were divided into two groups: group A (126 patients) included patients who underwent laparoscopic transcystic common bile duct exploration and stone extraction with LC in one stage, and group B (126 patients) included patients who underwent endoscopic retrograde cholangiopancreatography for CBD stone extraction followed by LC after 2–3 days in two stages. Patients were followed up postoperatively at 1 week, 1, 6 months, and 1 year. Results The success rate was similar in groups A and B (88.1% in group A vs. 80.2% in group B; P = 0.2). The average number of procedures per patient was significantly lower in group A (P < 0.001). Operative time in group A was significantly shorter (P < 0.001). The complication rate was comparable between the two groups (P = 0.6). On the first day after surgery, the pain score was lower in group A (P = 0.03). Hospital stay of group A patients was significantly shorter (P = 0.03). The cost of treatment per patient in group A was significantly lower (P = 0.001). The patients in group A had higher satisfaction scores (P = 0.006). Conclusion Although both approaches have equivalent success rates, the one-stage approach is better in terms of shorter hospital stay, fewer procedures, and better satisfaction and cost-effectiveness compared with the two-stage approach. Our study suggests that one-stage management is the treatment of choice for patients with concomitant GB and CBD stones.
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Temporary abdominal closure using transfer bag in the management of patients with open abdomen
Moheb S Eskandaros, Ahmed A Darwish, Ashraf A Hegab
October-December 2016, 35(4):321-326
Context Open abdomen is associated with significant morbidity and mortality. Leaving the abdomen open may be necessary in case of severe peritonitis and associated wound dehiscence. Many techniques are available for temporary abdominal closure (TAC), but none has been proven to be superior. Aim In our work, we propose early TAC using a transfer bag that can prevent the eviscerartion of the abdominal contents. Moreover, it will allow continuous drainage of the patient’s septic wound with continuous serial assessment. Setting and design It was a prospective case series study. Patients and methods The study included 25 patients with difficult abdominal closure in whom a double-layered large transfer bag was used for TAC. Statistical analysis Continuous variables were expressed as mean±SD. Categorical variables were expressed as frequencies and percentage. Results The average timing of the application of TAC ranged from first to fourth operation, with a mean±SD of 2±1.38. Early mortality occurred in six patients, whereas delayed mortality occurred in two patients. The net survivors included 17 (68%) patients. Of them, two patients were subjected to simple skin closure, six were subjected to split thickness skin graft, and nine were subjected to early fascial closure with lateral release and mesh application. Average timing for closure or coverage was 10–45 days, with a mean±SD of 25.8±11.8 days. An intestinal fistula was seen in three (12%) patients. The average length of hospital stay was 38.84±11.75 days. Conclusion The use of transfer bag TAC for open abdomen is a safe, cheap, available, simple, and effective procedure that can provide an easy access to the abdomen when needed.
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Comparison between laparoscopic and open surgery of rectal cancer in terms of pathological findings and early outcome: a randomized controlled trial
Khaled S Abbas, Walid G Elshazly
October-December 2016, 35(4):332-338
Background Laparoscopic surgery has progressively replaced open colonic surgery in recent decades owing to favorable short-term outcomes, such as less pain, reduced blood loss, and improved recovery time. The current study was designed to compare laparoscopic surgery with open surgery in patients with rectal cancer by incorporating clinical endpoints and detailed pathological analysis of all resected samples. Methods A prospective randomized controlled trial was conducted to compare laparoscopic surgery with open surgery for rectal cancer patients. The primary endpoint was postoperative clinical outcome in terms of morbidity and mortality. Secondary endpoints were adequacy of surgical margins and number of lymph nodes harvested for rectal cancer cases. Results Sixty patients underwent 40 laparoscopic and 20 open rectal resections between January 2014 and January 2016. There was no mortality, and there were significantly improved short-term surgical outcomes (less blood loss, less use of epidural analgesia, earlier restoration of bowel function, and reduction of the hospital stay) in the laparoscopic group. There were similar rates of intraoperative complications as open surgery, and the incidence of anastomotic leakage was similar between the two techniques. The conversion rate in the laparoscopic group was 12.5%. The short-term outcomes of the current study showed that the radicality of laparoscopic resection (as assessed by pathology report) in patients with rectal cancer is no different from that of open surgery; the median number of lymph nodes harvested for malignancies was 14 in the laparoscopic group and 13 in the open surgery group. Conclusion Laparoscopic surgery in patients with rectal cancer may confer clinical benefits in terms of faster recovery, smaller incisions, and a shorter hospital stay. The procedure can be technically difficult and time consuming. Laparoscopic resection of rectal cancer provided oncological radicality, using the pathology report as a proxy, similar to open surgery. Long-term follow-up to assess local recurrence and survival is necessary to ascertain oncological safety of laparoscopic resection in patients with rectal cancer.
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Livin gene expression in breast carcinoma: correlation with prognostic factors and patient outcome
Khaled E Soliman, Dina M Abdalla, Gehan A Khedr
October-December 2016, 35(4):339-347
Background Livin, the most recently identified inhibitor of apoptosis protein, is one of the most tumour-specific genes in the human genome. Its role in breast cancer progression remains unknown. Aim The aim of the study was to evaluate the expression of livin gene in human breast cancer tissues and examine its correlation with prognostic factors, including patient outcome. Patients and methods A total of 34 female patients with breast cancer enroled for modified radical mastectomy or conservative breast surgery were included in this study. The surgically resected breast cancer tissue specimens were analysed for the expression of livin protein by immunohistochemistry. All study patients received adjuvant treatment and were followed up for disease-free and overall survival. Results The positive expression pattern of livin protein was found in 88.2% of breast cancer specimens analysed. Livin gene expression was significantly correlated with tumour size (P≤0.05). No significant correlation was found between livin gene expression and patient age, menstrual status, tumour grade, lymph node metastasis, oestrogen receptor, progesterone receptor hormonal status, and human epidermal growth factor receptor 2 status (P>0.05). No significant association was found between livin gene expression and triple-negative breast cancer cases (P>0.05). There was a significant correlation between livin gene expression and TNM tumour stage (P≤0.05). Patients with livin-positive breast cancer had a poor disease-free survival and a shorter overall survival as compared patients with livin-negative tumours, but the difference was not significant (P>0.05). Conclusion Overexpression of livin gene may play a prominent role in breast cancer progression. It could be useful as a biomarker in breast cancer therapy.
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Laparoscopic-aided transanal pull-through procedure for the management of Hirschsprung’s disease: an observational prospective study for children older than 12 months
Mohamed Rabea
October-December 2016, 35(4):348-356
Objective The aim of the present study was to evaluate the surgical and functional outcome of the laparoscopic-aided transanal pull-through procedure for the management of Hirschsprung’s disease (HD). Patients and methods The study included 17 patients older than 12 months. Diagnosis of HD relied on the inability of the patients to relax the anal internal sphincter in response to colonic extension on anorectal manometry. The laparoscopic part entailed transition zone identification, seromuscular biopsy for fresh frozen histopathology, and sigmoid and rectal mobilization up to 1 cm down the peritoneal reflection. The transanal part included mobilization of the rectal lower by 2 cm, resection till the ganglionic segment, and anastomosis. Patient outcome included evaluation of fecal consistency, frequency of soiling, and presence of perianal skin excoriation at 1, 3, and 6 months after the procedure. Colonic manometry and functional outcome evaluation according to qualitative clinical Holschneider scoring were carried out at 1 and 6 months after the procedure. Results One (5.9%) patient required open conversion for dissection of thick adhesions. Frequency of patients that passed formed stool and free of soiling increased progressively till the end of 6 months after the procedure. At 1 month after the procedure, six patients developed perianal skin excoriation, but all were free by the sixth postoperative (PO) month. Manometric pressure measures at 3 and 6 months after the procedure were significantly higher compared with the preoperative measures, with significant difference in favor of 6-month measures. At 6 months after the procedure, Holschneider scoring was significantly higher compared with that at 1 month, and 10 patients had a score of 14. No surgery-related complications were detected. Conclusion Laparoscopic-aided transanal pull-through is a feasible procedure for the management of children older than 12 months and who have HD. The procedure is safe with minimal PO complications, which are gradually resolved within 6 months PO.
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Evaluation of surgical complications in 204 live liver donors according to the modified clavien classification system
Amr M Aziz, Sherif Saleh, Hossam E Soliman, Hany Shoreem, Osama Hegazy, Mohamed Taha, Emad H Salem, Hazem Zakaria, Sameh Hamdy, Hesham Abdeldayem, Tarek Ibrahim, Khaled Abuelella
October-December 2016, 35(4):357-366
Background Several large centers have reported outstanding outcomes of living donor liver transplantation in decreasing mortality on the liver transplant waiting list. Nevertheless, living donor liver transplantation is not without risk to the volunteer donors. The rate of complications differs widely among transplant centers. Yet, there is no consensus on how to define and stratify complications by severity. Participants and methods This retrospective study to identify and analyze the surgical outcomes of 204 consecutive living donor hepatectomies was carried out between April 2003 and October 2013 by using the modified Clavien classification system, according to which grade I=minor complications, grade II=any deviation from the normal postoperative course requiring pharmacologic treatment, grade III=complications requiring invasive treatment, grade IV=complications causing organ dysfunction requiring ICU management, and grade V=complications resulting in death. Results The present study included 129 (63.2%) males and 75 (36.8%) females, with the donor’s mean age being 27.72±6.4 years (range: 19–45 years). There were 64 (31.4%) donors who developed postoperative complications, with a total of 74 complications. Ten (4.9%) donors had more than one complication. Twenty-nine (39.2%) donors had Clavien’s grade I complications, 38 (51.3%) donors had Clavien’s grade IIIa, six (8.1%) donors had Clavien’s grade IIIb complications, and there was one (0.5%) case of mortality (Clavien’s grade V). Conclusion Donor hepatectomy is a relatively safe procedure when performed by a dedicated and well-trained team. A prompt diagnosis and meticulous intervention is considered the first priority whenever a donor complication is expected. Furthermore, a continuous standardized reporting and a comprehensive database are crucial to precisely define true donor morbidity.
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Correction of proximal hypospadias with severe chordee with a new technique using vertical preputial double-layered island flap
Amin M Saleh, Mohammad A Al Ekrashy, Wael M Elshahat
October-December 2016, 35(4):367-371
Background Hypospadias is a common genitourinary anomaly affecting every 1/300 male newborn. Numerous operative techniques have been reported for the repair of hypospadias. Patients and methods A vertical preputial double-layered island flap technique for correction of perineal and penoscrotal hypospadias with or without penoscrotal transposition and with severe chordee with the utilization of both the foreskin and the hind skin of the prepuce was performed and completed with glanuloplasty using one-stage or two-stage technique. A total of 40 patients with perineal and penoscrotal hypospadias with or without penoscrotal transposition and with severe chordee were managed with this technique. Results All corrected patients showed accepted cosmetic outcome without penile rotation or remaining gross ventral curvature. Fistulas were seen in 5% of patients at the site of anastomosis between the flap and the hypospadic meatus, and 2.5% of them needed surgical closure. Conclusion The vertical preputial double-layered island flap technique corrects proximal hypospadias with severe chordee in one stage and can be performed in all patients with reasonable outcomes.
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