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   Table of Contents - Current issue
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April-June 2018
Volume 37 | Issue 2
Page Nos. 139-269

Online since Wednesday, May 30, 2018

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ORIGINAL ARTICLES  

Therapeutic reduction mammoplasty techniques in management of breast cancer in large-breasted females – a comparative study between inferior and superior pedicle reduction mammoplasty Highly accessed article p. 139
Sherief M Mohsen
DOI:10.4103/ejs.ejs_89_17  
Background Oncoplastic surgery for breast cancer in patients with macromastia is a new concept that has evolved to associate breast conserving surgery with techniques of breast reshaping. This study aims to compare the outcomes of therapeutic reduction mammoplasty in medium-sized to large-breasted females with breast cancer using superior pedicle versus the inferior pedicle mammoplasty for early stages of breast cancer. Patients and methods From January 2013 to January 2017, 50 females patients with medium-sized to large-sized breasts diagnosed with early breast cancer and suitable for breast conservation underwent reduction mammoplasty depending on either inferior pedicle (group 1) or superior pedicle (group 2). Patients with central breast cancer and inability to obtain free resection margin after excision were excluded from the study. Surgical outcomes, oncologic safety, and cosmetic result were assessed and compared between both techniques. Results There was no significant difference between the two groups regarding age and weight of the patients (median: 42 vs 40 years) (P>0.05). Most cases had a mass in the upper outer quadrant of the breast (60%). On follow-up, wound dehiscence occurred more frequent in the inferior pedicle group, which occurred in four (16%) cases, than in the superior pedicle group, which occurred in two (8%) cases. The cosmetic outcomes were assessed in inferior pedicle versus superior pedicle mammoplasty groups, showing excellent results in 15 (60%) cases versus 16 (64%) patients, respectively. In a median follow-up of 24 months, no cases showed local recurrence. Conclusion Therapeutic reduction mammoplasty using inferior and superior pedicles was shown to be oncologically safer than traditional conservative surgery with more satisfactory esthetic outcome. Moreover, the superior pedicle mammoplasty yields a lower morbidity with better cosmetic outcome than inferior pedicle mammoplasty in large-breasted women with breast cancer.
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The outcome of using a prosthetic mesh in the repair of emergent abdominal midline incisional hernias: a prospective comparative study p. 147
Ashraf M Abd El-Kader, Hazem E Ali
DOI:10.4103/ejs.ejs_96_17  
Objective The aim of the study is to evaluate the efficiency and safety of mesh repair in emergent complicated midline incisional hernias as well as the impact on the early postoperative (PO) morbidity and mortality to implement the best patient management procedure. Patients and methods The study includes 60 patients with emergent midline incisional hernias. Patients were divided according to the type of closure of hernia defect into two groups, group A (30 patients) was managed with a prosthetic mesh repair and group B (30 patients) was managed by primary suture repair. We used the alternation method as an allocation process. Patients in both groups were monitored during operations and along the PO period. The data collected include the patients’ condition at presentation, coexisting disease, operative data and PO complications, length of hospital stay, surgical site infection (SSI) and recurrence rates. Results A total of 60 patients underwent operations for emergent midline incisional hernias with (N=30) and without (N=30) the use of mesh repair. There is no significant difference between mesh and nonmesh groups about the mean operative time (P>0.05). Besides, there was no significant difference between both groups concerning the total hospital stay days. The SSI rate in the mesh repair group was 10%, while it was 6.7% in the primary suture repair group. The SSI rate was high among diabetic patients and those with chronic liver illness. The follow-up period ranged between 25 and 48 months with a significant difference between both groups regarding the recurrence rate (P<0.05). Conclusion Our prospective study offers an evidence that with adequate antiseptic precautions, it is possible and safe to use a nonabsorbable mesh in the repair of emergent abdominal wall midline incisional hernias with a significant decline in the recurrence rate.
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Value of cluster of differentiation 56, Hector Battifora mesothelial-1, and cytokeratin 19 expression in predicting the risk of papillary thyroid carcinoma occurrence in Hashimoto’s thyroiditis patients, which will advise early total thyroidectomy in those patients p. 155
Mona S Mohamed, Ola A Harb, Loay M Gertallah, Taha A Baiomy, Osama Abd Elaziz, Eman A Eltokhy
DOI:10.4103/ejs.ejs_103_17  
Background There were no previous studies that have tried to find the prediction of papillary thyroid carcinoma (PTC) occurrence in Hashimoto’s thyroiditis (HT) that will advise early thyroidectomy in HT cases with high risk of progression to PTC. We aimed to use a panel of cluster of differentiation 56 (CD56), Hector Battifora mesothelial-1 (HBME-1), and cytokeratin 19 (CK19) to detect their predictive ability for HT progression into PTC. Patients and methods We included five groups of paraffin blocks that were retrieved from 70 patients. The first group included 20 cases of PTC, the second group included 20 samples from the same cases previously diagnosed as HT, the third group included 30 cases of HT, the fourth group included 30 samples from the same cases previously diagnosed as HT, and the fifth group had 20 cases of PTC without a history of HT. The sections were stained by CD56, HBME-1, and CK19 using immunohistochemistry. Results There is a significant difference between the second (HT that will be transformed to PTC) and the fourth (HT that will not be transformed to PTC) groups as regards CD56, HBME-1, and CK19 expression (P=0.012). For the differentiation between HT that will be transformed to PTC from HT that will not be transformed to PTC, negative CD56 expression was of highest sensitivity (90%) and diffuse positive HBME-1 expression was of highest specificity (95.7%). Conclusion A combination of negative CD56 expression and diffuse positive HBME-1 could be used with high sensitivity and specificity in predicting PTC occurrence in certain cases of HT and these patients will be advised to early total thyroidectomy to avoid PTC occurrence in the future.
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Value of laparoscopic exploration of penetrating abdominal trauma p. 166
Ahmed A Al Aziz
DOI:10.4103/ejs.ejs_118_17  
Objective The aim was to evaluate the role of laparoscopy in the management of patients with penetrating abdominal trauma. Patients and methods This prospective study included 60 hemodynamically stable patients with penetrating abdominal trauma presenting to the Casualty Department. The patients were subjected to routine investigations including routine laboratory and radiological investigations and were randomly divided into two groups: local wound exploration (LWE) group (n=30) and laparoscopy group (n=30). In the LWE group, the patients were subjected to LWE under local anesthesia followed by laparotomy if the wound penetrated the deep fascia. In the laparoscopy group, the patients were subjected to diagnostic laparoscopy and managed laparoscopically or converted to laparotomy according to the circumstances. Otherwise, the patient was discharged within 24 h. Results In the LWE group, six (20%) patients were discharged as having intact peritoneum; one of them was back 2 days later, had exploratory laparotomy and a small bowel injury was repaired. A total of 24 (80%) patients with perforated peritoneum proceeded to laparotomy; 17 (56.7%) of them had negative laparotomy. In the laparoscopy group 18 (60.0%) patients showed negative laparoscopy, four (13.3%) patients were managed laparoscopically, and eight (26.7%) were converted to laparotomy. Thus, 33 laparotomies were performed; the rate of complications was 39.4% with significant difference between negative and therapeutic cases (P=0.619). The operative time and hospital stay were significantly longer in cases of laparotomy compared with laparoscopy (P<0.001). Conclusion Routine laparotomy has a negative rate of 57%. Laparoscopy did not miss intra-abdominal injuries, was therapeutically effective in 12%, and was negative in 60% of cases.
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Assessment of limb salvage in single peroneal runoff versus single tibial runoff in patients with critical limb ischemia having complex lesions p. 172
Baker Ghoneim, Hussein Elwan, Hossam Elmahdy, Ahmed Taha, Amr Gad
DOI:10.4103/ejs.ejs_135_17  
Introduction The value of peroneal artery revascularization has always been debatable, especially in patients with tissue loss. As one of the most important factors of wound healing is the establishment of in-line flow to the foot, the role of peroneal angioplasty has to be defined. Aim The aim was to assess the adequacy of single peroneal vessel runoff in endovascular revascularization of patients with TASC C-D lesion and critical limb ischemia (CLI) as infrapopliteal disease. Patients and methods This is a prospective study involving patients with TASC C-D lesions presenting with CLI along 1 year. Patients were stratified into two groups according to their runoff states. Group P includes patients with single peroneal vessel runoff, whereas group T includes patients with single tibial runoff other than peroneal. Patients with two or three vessel runoff were excluded from the study. Results The study included 180 patients, with age ranging from 42 to 86 years; 55% were male patients. Of the 180 patients, 60 patients had single peroneal vessel runoff (group P) whereas 120 patients had a single tibial runoff (group T). The mortality rate along 2 years was 10 and 5% in groups P and T, respectively. Limb salvage rate along 2 years was 68.8% in group P and 79.8% in group T (P<0.036). The primary and secondary patency rates over 2 years in group P were 31.3 and 54.2%, respectively, and in group T were 47.7 and 62.4%, respectively. Conclusion In patients having CLI with TASC C-D lesion, although single peroneal runoff showed slightly lower limb salvage rate compared with single tibial runoff, it is valuable in patients with no other alternative for revascularization. We think that further studies are required to examine the importance of presence of direct pedal communication and its effect on the clinical success (limb salvage and disappearance of rest pain) of peroneal artery angioplasty.
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Platelet-rich plasma for the treatment of diabetic foot ulcer: a randomized, double-blind study p. 178
Asser A Goda, Mohamed Metwally, Ashraf Ewada, Hossam Ewees
DOI:10.4103/ejs.ejs_139_17  
Background Diabetic foot ulcer is a major complication of diabetes mellitus. Over the recent years, great progress has made in the techniques of wound healing, among which autologous platelet-rich plasma (PRP) has attracted the most substantial attention. Platelets are known to start the wound healing process through the release of locally active growth factors. The evidence from studies of autologous PRP to support its use in wound healing is not robust, and further rigorously designed blinded trials are needed. The aim of the study was to evaluate the efficacy and safety of the autologous PRP for diabetic foot ulcer in a randomized control multicenter double-blind design. Patients and methods The study included 50 patients with diabetic foot ulcers, who were divided into two groups: PRP and platelet-poor plasma (PPP) groups. The PRP group was treated with autologous PRP in gel form as a dressing. The PPP group was treated with autologous poor plasma as a dressing. The frequency of dressing change for each group was twice weekly. Results The healing rate of the PRP group was found to be significantly higher than that of the PPP group. The healing rate per week of the PRP group was significantly higher than that of the PPP group. The rate of complete healing was significantly higher in the PRP group than that of the PPP group. Conclusion Autologous PRP is effective and safe for treatment of diabetic foot ulcer.
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Endovenous radiofrequency ablation of lower extremity varicose veins: short-term outcomes of the initial experience p. 185
Ashraf G Taha, Ahmed H.B Elbadawy, Ayman E Hasaballah
DOI:10.4103/ejs.ejs_140_17  
Context Radiofrequency ablation (RFA) has proven acceptable efficacy and safety in the treatment of truncal varicose veins. Faulty technique may, however, result in primary failure or serious complications, especially during the early time points of the surgeon’s learning curve. Aim The aim of the present study was to evaluate the safety and effectiveness of RFA procedures in the treatment of great saphenous vein reflux during the initial experience in endovenous thermal ablation. Materials and methods A retrospective review was conducted on 47 patients with varicose veins of clinical, etiological, anatomical, physiological (CEAP) class 2–6 who received RFA at the Department of Vascular and Endovascular Surgery, Assiut University Hospitals, to treat refluxing great saphenous veins between 2014 and 2016. Outcome measures were technical success rate and perioperative complications. Short-term outcomes included complete occlusion of the ablated veins and symptom improvement at 1 year. Results RFA achieved a technical success rate of 97.9%. Perioperative complications were paresthesia (10.6%), ecchymosis (6.4%), phlebitis (6.4%), and hyperpigmentation (2.1%). No skin thermal injuries, hematomas, deep venous thrombosis, or endovenous heat-induced thrombosis were detected. One-year complete occlusion rate was 87%. Vascular clinical severity score and venous disability score improved at 1 year to 1.08±0.85 versus 4.03±1.88 (P<0.0001) and 0.60±0.545 versus 1.55±0.552 (P<0.0001), respectively, compared with preoperative values. All treated CEAP-6 patients showed complete healing of their ulcers postoperatively. Conclusion RFA is an effective and safe procedure, with satisfactory technical success, closure rates, and symptom improvement. The procedure could be performed in centers with initial experience in endovenous thermal ablation, provided careful commitment to the procedure steps and guiding supervision.
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Portal vein thrombosis with cirrhosis: is it an indication for early liver transplantation? p. 191
Hany Said, Kamal Mamdouh, Ahmed F Hilal
DOI:10.4103/ejs.ejs_145_17  
Introduction Portal vein thrombosis (PVT) is an independent risk factor for perioperative mortality and graft loss but not long-term outcomes in patients with cirrhosis after LT. The aim of this study was to assess the effect of timing of Living Donor Liver Transplantation (LDLT) on early results in patients with cirrhosis with PVT and decompensated liver (early vs. late). This was a retrospective study. Patients and methods This study included 24 patients with cirrhosis with PVT who underwent LDLT between January 2015 and June 2017 in Ain Shams University Hospitals. Fifteen patients were Child C and Model for End stage Liver Disease (MELD) more than 15 (group A) at time of transplantation and nine patients were transplanted early (Child B and MELD <15) owing to other indications, for example, Hepato Celluluar Carcinoma (HCC) (group B). Comparisons were done between both groups regarding operative data and perioperative mortality. Results Both groups were comparable in age, sex, etiology of liver disease, and presence of HCC. Operation in group B was easier than in group A, with statistically significant difference regarding operative time (7.4±1.2 vs. 10±2.1 h, P=0.002), need for blood transfusion (55.6 vs. 100%, P=0.005), and amount of blood transfusion [2 U (0–6) vs. 3 U (1–10) (P=0.048)]. Blood loss was only significantly lower in group B at 1900 ml (700–2600) versus 3000 (1000–6000) in group A (P=0.073). No statistically significant differences in ICU stay (P=0.570), hospital stay (P=0.432), and perioperative mortality (22.2 vs. 26.7%) were observed in group B and group A (P=0.562). Conclusion LDLT in patients with cirrhosis with PVT is technically more feasible when done early (Child B and MELD <15), but this is not associated with better outcome. PVT in patients with cirrhosis is not an indication for early transplantation.
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Negative pressure wound therapy for chronic venous ulcer: a randomized-controlled study p. 196
Yahia Alkhateep, Nehad Zaid, Abdelmieniem Fareed
DOI:10.4103/ejs.ejs_147_17  
Objective The purpose of this study was to evaluate the efficacy of negative pressure wound therapy (NPWT) in promoting wound healing of venous leg ulceration. Patients and methods This study was designed as a single-center randomized-controlled trial. Patients with venous leg ulcer of at least 3 months in duration were enrolled in this study. The first group (NPWT group) was treated by NPWT using standardized method. Intermittent negative pressure at −100 to −150 mmHg was applied, and the dressings were changed every 48–72 h. The second group (control group) was treated by conventional daily dressing using normal saline. Results After 15 days of treatment, significant differences in ulcer size and percent of ulcer healing were detected between the two treatment groups. The wound healing rate was 13.1 and 2.8 mm2/day in NPWT group and control group, respectively. After 30 days of treatment, 17 (68%) ulcers revealed 90% healing in NPWT group, with mean duration of 24 days needed for healing. None of the ulcers in control group completed 90% healing after the 30 days of treatment. Conclusion NPWT improved wound healing and may be considered as treatment for venous leg ulcer.
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Bougie size 32 versus 40 french in laparoscopic sleeve gastrectomy p. 200
Medhat Helmy
DOI:10.4103/ejs.ejs_1_18  
Background Laparoscopic sleeve gastrectomy (LSG) is considered as one of the most popular bariatric procedures worldwide. Although LSG appears simple, there is still no standard procedure across different surgical teams. The most debatable issue in sleeve gastrectomy is the gastric pouch size; by changing the size of the bougie, we can create different volumes of the stomach tube. Aim The aim was to compare the outcome following LSG results when using 32 versus 40-Fr bougie as regards the effects of each on the clinical outcome: weight loss of the patients and possible complications. Patients and methods Our study is a prospective, comparative study of 60 patients, who underwent LSG between ‘March 2015 and March 2016’ with a 1-year follow-up. The patients were classified into two groups: group A (n=30) who underwent LSG using a bougie size of 32 Fr and group B (n=30) who underwent LSG using a bougie size of 40 Fr. We recorded the operative time, hospital stay, and intraoperative and postoperative complications. Results A total of 60 patients [17 (28.3%) men and 43 (71.7%) women] underwent LSG. Patients had a mean age of 35±10 years (range: 18–58 years). The mean;Deg;BM;Deg;I was 46.66±4.30 kg/m2 (range: 34.6–57.5 kg/m2); the duration of hospital stay in group A was 56±28.07 h, with group B being 36.4±10.68. As regards the weight loss both groups had the same excess weight loss over 1 year; postoperative persistent vomiting was in favor of group A with four (13.3%) patients, two of them required intervention either by endoscopy or conversion to bypass, in comparison to one patient in group B who was managed conservatively. Conclusion The use of bougie size 32 Fr did not result in significant excess weight loss differences than bougie size 40 Fr; however, more complications were observed.
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Potassium titanyl phosphate 532 nm laser for treatment of facial vascular lesions: a prospective analysis of 27 cases p. 209
Jalal F Alromi, Abdulsalam Y Taha, Saadallah M Al-Zacko
DOI:10.4103/ejs.ejs_3_18  
Background Facial vascular lesions are often disfiguring. Potassium titanyl phosphate (KTP) laser is an appropriate vascular-selective therapy. This prospective study was conducted in Mosul, Iraq, and intended to evaluate KTP laser in treating such lesions. Patients and methods The study involved infantile hemangioma smaller than 3 cm, port-wine stain (PWS), and telangiectasia in light-skin patients. Pretherapy pictures were taken. KTP laser (532 nm wavelength) with 1-mm spot size was used in multiple sessions under local or general anesthesia (for adults and children, respectively). Ice cubes were used for cooling. The immediate clinical endpoint in telangiectasia was blood vessels clearance. Post-therapy photographs were evaluated and improvement graded from poor to excellent. Results There were 27 patients (21 females) aged 7 months–50 years, with a mean of 15.2±14.3 years. There were 15 (55.6%) PWSs, eight (29.6%) hemangiomas, and four (14.8%) telangiectasias. All hemangiomas were infantile. PWS, on the contrary, occurred in an age range of 3–36 years. Patients with telangiectasia were 11–50 years old. Near half of PWSs were in the maxillary region. The nose was a common site for both hemangioma (n=3) and telangiectasia (n=3). PWS had more treatment sessions (6.6) compared with hemangioma (4.25) and telangiectasia (4). Overall, 55.6% of patients had good to excellent results. The best results were obtained in telangiectasia and hemangioma. There were few transient complications, and the commonest was blistering (n=22, 82%). Conclusion KTP laser is an effective safe therapy for facial telangiectasia and hemangioma but is less satisfactory in PWS.
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Silver-coated graft as bailout option in managing femoral artery-infected pseudoaneurysm: a review of 30 patients p. 217
Ahmed K Allam, Ahmed K Gabr, Mohamed Ismail
DOI:10.4103/ejs.ejs_7_18  
Context Femoral artery-infected pseudoaneurysm (fa-IPA) is very common in modern societies, and it represents a difficult problem to the vascular surgeon, as surgical management remains controversial, which ranges from ligation with debridement to extra-anatomical bypass. The present study was carried out to evaluate the outcome of silver-coated grafts used for the management of fa-IPA secondary to illegal drug injections. Aim To assess the outcome of silver-coated graft as bailout revascularization conduit in patients with infected pseudoaneurysm regarding success of the procedure, limb salvage, infection rate, and primary patency rate. Settings and design A prospective study was conducted. Patients and methods The study included 30 patients who presented with fa-IPAs and were admitted to Emergency Department of Benha University Hospital, Ain Shams University Hospitals, and Security Forces Hospital, Makkah, Saudi Arabia, during a 30-month period. Overall, 24 (80%) patients were male and six (20%) patients were female, with age range from 25–46 years. Twenty-one (70%) patients underwent surgical resection and immediate revascularization using silver collagen-coated polyester graft (InterGard Silver; Maquet), whereas nine (30%) patients underwent surgical ligation, with delayed revascularization in four (13.3%) patients through transobturator bypass using the same graft. Results Immediate revascularization using either in situ or extra-anatomic bypass is associated with risk of graft infection [early, five patients of 21 (23.8%); late, two patients of 21 (9.5%), with limb salvage rate of 86.7%]. Conclusion However, no surgical treatment for fa-IPA has been proved to be safe in terms of the overall surgical complications. Our study shows promising results for possibility of using silver-coated grafts as bailout option for limb revascularization. Long-term antimicrobial therapy is advised, and longer follow-up periods are needed to provide accurate results.
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Management of cholecystectomy-induced biliary injuries at Zagazig University Hospital p. 223
Ahmed M.A Yehia
DOI:10.4103/ejs.ejs_9_18  
Objective To evaluate the management strategies following bile duct injuries. Design and duration This was a prospective analysis conducted from March 2015 to March 2017. Setting The study was conducted at the Department of Surgery, Zagazig University Hospitals. Patients and methods The study included all patients who were admitted with iatrogenic biliary injuries during this period. The patients were evaluated according to their clinical features and certain laboratory and imaging investigations. After appropriate preparations, they were managed based on Bismuth Classification. Results A total of 27 patients presented with iatrogenic biliary injuries over a period of 2 years among all 420 cases that underwent cholecystectomy during this period. There were 16 females and 11 males, with a median age of 40 years. A total of 18 patients had laparoscopic cholecystectomy, whereas nine had open cholecystectomy. Twelve cases belonged to our unit whereas 15 were referred from other institutes. Four patients were detected intraoperatively, 15 patients presented with obstructive jaundice, four patients presented with biliary fistula, and four patients presented with collection. Of which, one had ultrasound-guided aspiration and five had endoscopic retrograde cholangiopancreatography (ERCP) stenting done, whereas two underwent peritoneal lavage with drain placement, 16 patients had hepaticojejunostomy, and one patient had choledechodoudenostomy. We had one postoperative mortality owing to hepatorenal failure. Conclusion Strategies need to be developed for dealing with bile duct injuries, with a view to reduce morbidity and mortality, as early recognition and timely management improve the outcome of these patients.
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Endovenous laser ablation versus conventional surgery in treatment of primary truncal varicosities p. 230
Ahmed M.M Morshed, Mohammed F Kamel, Ayman El-Sayed Abd El-Samea El-Nakeeb, Abd El-Salam Fathi Megahed
DOI:10.4103/ejs.ejs_10_18  
Aim of the Work In this study we compare the outcome of laser ablation and conventional surgery in treatment of patients with primary trunkal varicose vein with a period of one year. Background It is estimated that varicose veins in the distribution of the great saphenous vein (GSV) are present in about 25% of women and 15% of men. Endovenous Laser Therapy (EVLT) is one of the most promising techniques in treatment of varicose veins. Methods This is a prospective randomized study. This study was conducted on 36 patients presented to our clinic in Mansoura university hospital (MUH) in the period from November 2015 to January 2017 with trunkal varicosities. Results In this study, female predominance was remarkable, with a 32 year old mean age. All patients in our study were presented by limb heaviness. Only 5 patients (13.8%) seeked intervention for varicose veins due to cosmetic issues. this study showed different results according to the operative time with 46 minutes difference in the mean operative time between both groups. Conclusion In our study we found that EVLA has the same results as surgical stripping regarding the efficacy and the recurrence rate, which was our primary outcome, so that we recommend EVLA as a main method for varicose vein treatment used in treatment of varicose veins with no scars or cosmetic discomfort.
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Ligation of intersphincteric fistula tract for high trans-sphincteric fistula-in-ano: our experience p. 237
Mohammedy M El-Said, Ahmed Shaaban, Mohsen A Abdelmohsen
DOI:10.4103/ejs.ejs_13_18  
Background Fistula is a common perianal pathology. Management of high fistula is challenging, and up till now, there is no sole gold standard surgery for its management. The ideal treatment must eradicate local infection without endangering anal continence. This encouraged us to conduct this study to evaluate the use of one of the newly developed sphincter-saving procedures, which is ligation of intersphincteric fistula (LIFT) technique for management of high trans-sphincteric fistula, regarding fistula healing, anal continence, and recurrence. Patients and methods This study was a prospective study. From January 2016 to January 2017, 26 consecutive patients underwent LIFT procedure for high trans-sphincteric fistulae-in-ano in Damanhur National Institute Hospital and Medical Research Institute Hospital, Alexandria University. Results Success rate of the procedure was 80.8% after a follow-up period of 8 months. No change of continence had occurred in any of patients in this study. Relapse of fistula occurred in 11.5% of patients and nonhealing occurred in 7.7% of patients. The time of fistula healing was 20.0–45.0 days with a median of 26.5 days. Conclusion LIFT procedure is a safe procedure for management of high trans-sphincteric fistula with promising short-term results and zero incontinence rate.
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Associated maxillofacial bone fractures with zygomatic complex fracture: experience from a tertiary referral hospital in Riyadh, Kingdom of Saudi Arabia p. 244
Alsuliman Dawood, Braimah R Ramat, Ibrahim Al-Hakim
DOI:10.4103/ejs.ejs_15_18  
Background The zygoma plays a fundamental role because the underlying bony structural design directly influences the facial contour. As a result of the intimate association of the zygomatic complex (ZC) with the rest of the facial skeleton, associated maxillofacial fractures are quite common. Patients and methods All cases diagnosed with ZC fracture over a 10-year period starting from December 2002 to December 2012 at Riyadh Dental Center at King Saud Medical City, Riyadh, Saudi Arabia, were studied. Patient’s sex, age, etiology, and associated maxillofacial bone fracture were retrieved and recorded. Data were stored and statistically analyzed using SPSS. Results were presented as simple frequencies and percentages. Results Overall, 1487 patients presented with maxillofacial trauma and 306 cases were diagnosed with zygomatic bone fractures. There were 271 (88.6%) male patients and 35 (11.4%) female patients, with male : female ratio of 7.7 : 1. Patients in the age range of 21–30 years had the highest number of maxillofacial fracture. Ninety-six (31.4%) patients had associated maxillofacial bone fractures, whereas 231 (69.6%) patients did not have any associated fracture. Road traffic accident was the leading cause of the maxillofacial trauma [221 (72.2%)]. Mandibular fracture had the highest frequency of 35 (11.4%), whereas Le-Fort III and frontal bone fractures had the least number of cases [two (0.7%)]. Conclusion Associated maxillofacial bone fracture with ZC fracture is quite common. Efforts should be made by the attending surgeon to identify these injuries.
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Circumventing the difficulties induced by popliteal artery variation during tibial endovascular intervention p. 248
Omar A El Kashef, Mohammed Ali, Hossam Zaghloul, Hossam El Mahdy, Mahmoud Naser, Samir Abou Zeid
DOI:10.4103/ejs.ejs_16_18  
Aim The aim was to provide schematic assessments for the popliteal artery variation in order not to misinterpret the vessel of interest as collateral or occluded artery and consequently increase the efficiency of the territorial revascularization. Materials and methods This is a prospective observational study conducted over a period of 2 years including 452 patients who underwent popliteal and infrapopliteal endovascular angioplasty. Results A total of 437 (98.2%) patients had the usual pattern of popliteal artery branching, which usually correlates with the current published data. There were two (0.44%) patients with type Ib, two (0.44%) patients with type Ic, one (0.22%) patient with type IIa, one (0.22%) patient with type IIb, six (1.32%) patients with type IIIa pattern, and three (0.66%) patients with type IIIb. Conclusion With adequate preoperative assessment and applying the steps of our technique, the incidence to misinterpret the variation and consequently missing a chance for territorial revascularization become very low.
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Evaluation of the round block technique in early breast cancer p. 256
Sherif M Akram, Ahmed F El Kased, Hossam A.E Kader El Fol, Mahmoud G Hagag
DOI:10.4103/ejs.ejs_17_18  
Introduction Conservative surgery has become a well-established alternative to mastectomy in the treatment of breast cancer. However, in case of larger lesions or small-sized breasts, the removal of adequate volumes of breast tissue to achieve tumor-free margins and reducing the risk of local relapse may compromise the cosmetic outcome, causing unpleasant results. To address this issue, surgical techniques, the so-called oncoplastic techniques, have been introduced in recent years to optimize the efficacy of conservative surgery in terms of both local control and cosmetic results. Patients and methods A Clinical Interventional descriptive single arm randomized prospective study, conducted on twenty female patients presenting with operable breast cancer stages 1 and 2 located at the Upper or Central breast. Ages ranging 25 to 75 years to be treated using the “round block” technique. Results Cosmetic results were found to be excellent in three cases, good in eight cases, fair in five cases, and poor in two cases. In this study, the cosmetic results were unacceptable (fair and poor) in patients who underwent 25% resection or in whom the resected area was part of the lower portion of the breast. Conclusion These techniques are useful for performing breast-conserving surgery in the upper portion of the breast. However, if the excision volume is greater than 20% or excision of part of the lower portion of the breast is required, other procedures should be considered. This article discusses the indications, advantages, and limitations of the round block breast-conserving oncoplastic techniques and its results in terms of feasibility, maintaining breast esthetics, limitations, and early complications.
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Outcome after preservation of Scarpa’s fascia in abdominoplasty p. 260
Mahmoud A Shahin, Mahmoud G Hagag, Mohamed H El-Meligy
DOI:10.4103/ejs.ejs_19_18  
Background Postoperative seroma formation remains the most frequent complication following abdominoplasty. The exact pathogenesis of postabdominoplasty seroma remains unclear. Both the process of flap elevation and redundant skin resection disrupt lymphatic drainage in the immediate postoperative period. Preservation of the Scarpa’s fascia in abdominoplasty leads to preservation of deep lymphatic vessels. Patients and methods Thirty-eight patients underwent abdominoplasty (18 of them with Scarpa’s fascia preservation) in the General Surgery Department of Menoufia University Hospital in the period between April 2015 and May 2017. Comparison was done between classic technique and Scarpa’s fascia preservation regarding early outcomes and postoperative complications. Results With Scarpa’s fascia preservation, the mean total drain output (171.5±72.18 ml) was much lesser than classic abdominoplasty (702±136.7 ml); moreover, drains were removed earlier with Scarpa’s fascia preservation (P=0.001 and 0.002, respectively). All patients passed without seroma formation in Scarpa’s fascia preservation group; however, in the group of classic abdominoplasty, seroma was detected in three (15%) patients. In Scarpa’s fascia preservation group, minor wound dehiscence occurred in two (11%) patients and asymmetry in two (11%) other patients, whereas in the other group, two (10%) patients presented with minor wound dehiscence and two (10%) patients developed wound infection. Conclusion Preservation of Scarpa fascia during abdominoplasty has a beneficial effect on patient recovery, reducing total drain output, time to drain removal, and hospital stay.
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Volumetric pouch study after laparoscopic sleeve gastrectomy p. 265
Ahmed A Sabry, Doaa Emara
DOI:10.4103/ejs.ejs_29_18  
Background Laparoscopic sleeve gastrectomy (LSG) is frequently performed as a definitive bariatric procedure today. The aim of this study is to evaluate the volumetric changes of gastric reservoir 1 year after LSG using multislice spiral computed tomography (MSCT) and to analyze their relationship with weight loss. Patients and methods This is a prospective study of 50 morbidly obese patients submitted to LSG in the Upper Gastrointestinal Surgery Unit, Alexandria Main University Hospital. All patients were referred for abdominal MSCT with volumetric assessment of gastric pouch 1 month and 1 year after surgery. Results A significant increase in total gastric reservoir volume (111.90±41.56 and 144.14±42.87 ml at 1 and 12 months, respectively) was observed. The percentage of excess weight loss was not significantly correlated with reservoir volume after 1 year of LSG. Conclusion MSCT allows for a comprehensive and quantitative evaluation of the gastric pouch volume. Gastric dilatation seems to be a normal behavior after LSG, yet it is not correlated with insufficient weight loss or weight regain after 1 year of LSG. A long-term follow-up is mandatory to confirm this conclusion.
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