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   Table of Contents - Current issue
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January-March 2020
Volume 39 | Issue 1
Page Nos. 1-282

Online since Friday, February 14, 2020

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EDITORIAL  

Egyptian consensus for the use of antimicrobial therapy in Preoperative prophylaxis, surgical site infections and diabetic foot infections Highly accessed article p. 1
Abdel M Hussein, Mohamed Farid
DOI:10.4103/ejs.ejs_172_19  
Use of antimicrobials in surgical prophylaxis These consensuses focus on primary perioperative prophylaxis for the prevention of an initial infection, the administration of the first dose of antimicrobial beginning within 60 min before surgical incision is recommended, but administration of vancomycin and fluoroquinolones should begin within 120 min before surgical incision because of the prolonged infusion times required for these drugs. Dosing In general, it is advisable to administer prophylactic agents in a manner that will ensure adequate levels of drug in serum and tissue for the interval during which the surgical site is open, If the duration of the procedure exceeds two half-lives of the antimicrobial or there is excessive blood loss (>1500 ml), the re-dosing interval should be measured from the time of administration of the preoperative dose, not from the beginning of the procedure. The selection of certain antimicrobial in most of the surgeries is shown in Table 2, and the special dosing of antimicrobials in patients with renal impairment is shown in Table 3. Surgical site infections “SSI” SSIs or wound infections are the most common adverse events affecting hospitalized surgical patients. The most important therapy for an SSI is to open the incision, evacuate the infected material, and continue dressing changes until the wound heals by secondary intention. Before starting an empiric antibiotics course, culture should be done. The antibiotic choice is usually empiric but can be supported by Gram stain, culture of the wound contents, the site of surgery, and the hospital antimicrobial susceptibility test system ‘Hospital Biogram’. The selection of Antibiotics for treatment of incisional surgical site infections is summarized in table 4. Diabetic foot infections Diabetic Foot infections typically begin in a wound, most often a neuropathic ulceration, while all wounds are colonized with microorganisms, and the presence of infection is defined by greater than or equal to 2 classic findings of inflammation or purulence. Most DFIs are polymicrobial, with aerobic gram-positive cocci, and especially Staphylococci spp., the most common causative organisms. Clinicians should consider the possibility of infection occurring in any foot wound in a patient with diabetes. Clinicians should evaluate a diabetic patient presenting with a foot wound at three levels: the patient as a whole, the affected foot or limb, and the infected wound. The clinically noninfected wounds should not be treated with antibiotic therapy. Prescription of antibiotic therapy for all infected wounds should be done, but with caution, as it is often insufficient unless combined with appropriate wound debridement. The clinicians need to select an empiric antibiotic regimen on the basis of the severity of the infection and the likely etiologic agent(s) (shown in Table 6).
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ORIGINAL ARTICLES Top

Evaluation of donut mammoplasty in early breast cancer near to nipple–areola complex p. 11
Mahmoud Abdelbaky Mahmoud, Mohamed A Amin Saleh
DOI:10.4103/ejs.ejs_52_19  
Background Breast cancer, according to National Cancer Institute, is the most common site of cancer in women in Egypt as it accounts for about 38.8% of total malignancies among Egyptian females; it is an important cause of mortality among women. Objective To focus on donut mammoplasty for management of early breast cancer near to nipple–areola complex (NAC) to assess the technique clinically regarding cosmetic outcome, operative complication, and oncological safety. Patients and methods It was a prospective analytical study that included 25 patients focus on donut mammoplasty for management of early breast cancer near to NAC to assess the technique clinically regarding cosmetic outcome, operative complication, and oncological safety. This study was conducted at Ain Shams University Hospitals and Bahya specialized breast cancer hospitals. Approval of the Ethical Committee and written informed consent from all participants was obtained. Results In our study we addressed donut mammoplasty technique in a prospective study conducted 25 patients that aimed to demonstrate the safety of those techniques and the comparable outcomes as regard preoperative and postoperative prospective. During our follow up period the overall incidence of complications was 12% which is quite similar to the other comparable studies. Conclusion Donut mammoplasty has excellent cosmetic outcome of about 84% of cases of the study, the overall cosmetic outcome of our study was more satisfactory which was reflected on the patient psychological health and self-well-being. It was best applied to small more than large-sized breast with possibly distant tumor from the NAC with the donut mammoplasty technique as it will yield less satisfactory cosmetic outcome. Donut mammoplasty shows low percentage of complications were simple in dealing with no risk in patient’s life. None of the stated complications resulted in delay of postoperative adjuvant therapy.
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Dissection by ultrasonic energy versus monopolar electrosurgical energy in laparoscopic cholecystectomy p. 23
Mahmoud A Mahmoud, Heba T.A Aziz El-Atar
DOI:10.4103/ejs.ejs_105_19  
Background Gallstones remain one of the commonest surgical problems in the developed world, and despite major therapeutic advances in recent years, there has been no progress in the prevention of gallstone development, and it may lead to serious complications that may affect patients’ quality of life. Laparoscopic cholecystectomy currently is accepted as the gold standard treatment of gallstones. The advantages of such a surgical approach have been reported by a number of authors, showing both the positive effect of this method on the postoperative quality of life of the patients and its optimal short-term and long-term results. Objective To assess the safety and efficacy of ultrasonic energy as a single alternative tool in the dissection of the gallbladder during laparoscopic cholecystectomy. Patients and methods This is a prospective study that included 60 patients with gallbladder stones who were operated upon for laparoscopic cholecystectomy over 1 year starting from August 2016 till August 2017. Approval from the Ethical Committee of Faculty of Medicine, Ain Shams University, was obtained before commencement of this study. The patients upon whom the study was based were operated on in El Demerdash Hospital and Ain Shams University Specialized Hospital. Results A total of 60 patients were included in this study. Group A included 30 patients for whom laparoscopic cholecystectomy had been done using a harmonic scalpel. Group B included 30 patient for whom laparoscopic cholecystectomy had been done using electrocautery tools (hook, grasper, and scissors) and surgical clips. For both groups, data were collected and analyzed: demographic data (sex, age, BMI, comorbidities, and previous surgeries). Conclusion The main advantages of ultrasonic dissection include the following: (a) utilization of a single instrument for both dissection of the gallbladder and dissection of the artery and dust, (b) shorter operating time, and (c) improved laparoscopic view and possibly a reduction of postoperative pain. The main disadvantage of ultrasonic dissection is instrument cost, which is particularly high if the surgical unit is equipped with reusable instruments.
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Early elective laparoscopic cholecystectomy during the same hospital admission after recovery of an attack of mild acute biliary pancreatitis: is it feasible and safe? p. 42
Ashraf M Abdelkader, Taher H Elwan, Sharaf E Ali Hassanien
DOI:10.4103/ejs.ejs_119_19  
Objective We are aiming to identify the safety and feasibility of early laparoscopic cholecystectomy (LC) directly after the improvement of manifestations of an attack of mild acute biliary pancreatitis (MABP). Patients and methods This study included 150 patients of MABP. Patients were allocated into two groups: group same admission-laparoscopic cholecystectomy (SA-LC) (n=80) who underwent LC in the same hospital admission of MABP after improving the indicator of the acute inflammation, and group delayed laparoscopic cholecystectomy (D-LC) (n=70) who underwent LC 4–6 weeks after recovery of acute biliary pancreatitis. Patients’ data were collected during and after surgery; thereafter, the gathered data were statistically analyzed. Results No significant differences between both groups about the mean operative time (P=0.162) were observed; however, the mean operative time was higher in the delayed elective group (SA-LC=48.12±10.44 and D-LC=50.56±11.43). The incidence of bile leakage was 1/80 and 1/70 in SA-LC and D-LC, respectively. Moreover, there was no significant difference between both groups with regard to the conversion rate, length of ICU admission, and the postoperative hospital stay days. Conclusion Undergoing LC during the same hospital admission after an attack of MABP is a feasible and safe operation. Furthermore, it stops the event of readmission due to gallstone-related complications.
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Duplex-guided foam sclerotherapy versus multiple-layer compression therapy in the treatment of chronic venous ulcers p. 49
Ahmed S Arafa, Ayman Salem, Ahmed Yehia, Mostafa M Elaidy
DOI:10.4103/ejs.ejs_133_19  
Background Compression therapy is considered the gold standard of care for chronic venous disorder and venous leg ulcer treatment. Sclerotherapy is the treatment of choice for reticular varicosities and telangiectasia. Duplex ultrasonography improves the safety and efficacy of conventional sclerotherapy, gives a better evaluation of its results, and provides an understanding of the advantages of using sclerosant in the form of foam. The aim of our study was to compare the results of Duplex-guided foam sclerotherapy for the injection of incompetent perforators versus multiple-layer compression therapy in the treatment of chronic venous ulcer. Patients and methods The present study included 58 patients of chronic venous ulcers. Patients were divided randomly into two equal groups: group I (foam) comprising 29 patients treated by Duplex-guided foam sclerotherapy and group II (compression) comprising 29 patients treated by multiple-layer compression therapy. The statistical analysis was carried out using SPSS. Results There were statistically significant increases in the frequency of perforation among group I, while there was a statistically significant increase in the frequency of incomplete perforation among group II. There was a statistically significant increase in the frequency of complications among group I compared with group II. The most frequent complication was abscess. Conclusion Compared with multiple-layer compression therapy of incompetent perforators to treat venous ulcers, the use of foam injection sclerotherapy of incompetent perforators is feasible and effective, without serious complications and with easy repeated access and ablation of recanalized or new incompetent perforator veins.
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Comparative outcome of patch angioplasty versus balloon angioplasty after surgical thrombectomy of thrombosed arteriovenous hemodialysis graft: 18-month results p. 60
Ahmed K Allam, Atef A.H Desouki, Abd E Mohammed
DOI:10.4103/ejs.ejs_126_19  
Background Repeated interventions to keep the well-functioning dialysis vascular access represent the Achilles heel for hemodialysis patients. Thrombosed permanent dialysis access, either arteriovenous fistula or arteriovenous graft (AVG) remains one of the most common and debatable complications regarding frequency of occurrence and how to manage. Objective Our study aims to evaluate mid-term outcomes of surgical thrombectomy of clotted AVG with adjunctive venous outflow procedures mainly patch angioplasty versus balloon dilatation to restore their function regarding patency as primary endpoint and safety as secondary endpoint. Patients and methods Between May 2016 and April 2019, 96 of 125 patients with first-time thrombosed dialysis AVGs were prospectively evaluated after block randomization for surgical patch angioplasty (group A) versus balloon angioplasty (group B) for venous anastomotic side after surgical thrombectomy in four tertiary referral hospitals in Egypt. Results Over 18-month follow-up period of our enrolled patients, immediate technical success was 100% with regaining graft functionality in 100% of 45 patients in group A patients versus 89.6% (P=0.056) in group B with achieving optimum graft functionality in 100% of technically successful declotting procedures (43 patients) in group B. The primary patency at 6, 9, 12 and 18 months in group A was 66, 63.6, 52.3 and 31.8%, respectively, versus 48.8, 48.8, 37.2 and 18.6%, respectively, in group B. The secondary patency in group A at 6, 9, 12 and 18 months was 86.4, 100, 88.6 and 77.3%, respectively, versus 72.1, 90.7, 79.1 and 69.8%, respectively, that was not statistically significant except 12-month primary patency (P=0.014). Conclusion Our study found no statistically significant difference in 18-month outcomes between patients treated with surgical thrombectomy with patch angioplasty and surgical thrombectomy with balloon angioplasty for thrombosed AVGs regarding regaining functionality and patency, however patients treated with balloon angioplasty required more additional secondary interventions and most of them were to manage graft venous anastomotic site restenosis.
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Laparoscopic conversion to open in rectal cancer resection: effect on short-term and oncological outcomes p. 73
Moamen S Abdelgawaad Shalkamy, Gamal A Ahmed, Abdelmoniem I Elkhateeb, Mahmoud R Shehata, Ragai S Hanna, Ahmed S Mohammed Abouelhassan
DOI:10.4103/ejs.ejs_123_19  
Background Laparoscopy has been accepted to be safe and feasible in rectal cancer resection. The effect of conversion to open on short-term and long-term oncological outcomes in colorectal patients with cancer is still unclear. The aim of this study was to evaluate the short-term and oncological outcomes of conversion in patients undergoing laparoscopic resection for rectal cancer. Patients and methods The data of 40 patients who underwent laparoscopic rectal cancer resection were prospectively collected. Of the 40 patients, eight (20%) patients underwent conversion to open surgery. Laparoscopic-successful group and laparoscopic-conversion group patients were compared. Results Locally advanced tumor was the commonest reason for conversion (37.5%). Laparoscopic-conversion group had more intraoperative complications (P=0.017), greater blood loss (P=0.051), longer operative time (P=0.001), and lower rate of total mesorectal excision completeness (P=0.046) compared with laparoscopic-successful group. Pathological T4 was significantly higher in laparoscopic-converted group than in laparoscopic-successful group. The rate of local recurrence (50 vs. 10.3%) was significantly higher in laparoscopic-conversion group than in laparoscopic-successful group (P=0.027). Two-year disease-free survival was significantly prolonged in laparoscopic-successful group than in laparoscopic-conversion group (P=0.033). Conclusion Conversion to open surgery in laparoscopic rectal resection has a negative effect on intraoperative outcomes and could be a negative predictive factor for long-term oncological outcomes.
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Risk of liver failure after major hepatectomy for patients with hepatocellular carcinoma p. 81
Nahed A Makhlouf, Mohammed O Abdel-Malek, Sahar M Hassany, Amira M Abd-Elmawgood, Ahmed M Taha, Tameem M Ibraheem, Bashir A Fadel
DOI:10.4103/ejs.ejs_141_19  
Background/aims Hepatectomies in cirrhotic patients are complex operative interventions. Extent of hepatectomy, in particular, has a direct relation to outcomes, with posthepatectomy liver failure (PHLF) being the main cause of morbidity and mortality. This work aimed to determine the frequency and the risk factors of PHLF in patients with hepatocellular carcinoma (HCC) undergoing resection of more than two segments of the liver. Patients and methods A retrospective study included all patients who underwent liver resection of more than two segments for HCC between 2013 and 2017. Preoperative parameters were evaluated and analyzed for their predictive value of PHLF, which was defined based on the 50–50 criteria [prothrombin index <50% (international normalized ratio >1.7) and serum bilirubin >50 µmol/l (2.9 mg/dl) on postoperative day 5]. Results A total of 28 patients underwent liver resection of more than two segments for HCC. The mean age of patients was 58.86±8.11 years, with range between 26 and 68 years, and 68% of them were males. Hepatitis C virus infection was the most frequent etiology of liver disease followed by hepatitis B virus infection. Sixteen (57%) patients developed PHLF. Patients with PHLF had significantly higher age, lower serum albumin, and higher Child’s and model for end-stage liver disease (MELD) scores. Based on multivariate regression analysis, only low serum albumin and high Child’s and MELD scores were predictors for PHLF. Conclusion Patients with liver cirrhosis who have low serum albumin and high Child’s and MELD scores who are indicated for resection of two or more liver segments have a higher risk of postresection liver failure.
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Role of GastriSail device in laparoscopic sleeve gastrectomy p. 86
Mostafa R Elkeleny
DOI:10.4103/ejs.ejs_140_19  
Background The aim of this study is to evaluate the possible merits of GastriSail device in laparoscopic sleeve gastrectomy (LSG) over the standard LSG. Patients and methods A prospective study was conducted on 40 patients who were randomly divided into two groups: group A included 20 patients who underwent LSG using GastriSail, and group B included 20 patients who underwent LSG with the standard bougie. The groups were compared regarding operative time, consistent sleeve formation, delineation and visualization, intraoperative and postoperative complication rates, hospital stay, gastric pouch design, and percentage of excess weight loss percentage. Results Regarding intraoperative time, the mean time was 72.0±13.58 and 79.0±11.74 for groups A and B, respectively. Although no patients in group B had consistent sleeve formation, 12 (60%) patients had consistent sleeve formation. Delineation and visualization was accomplished in 100% of group A patients but was not accomplished at all in group B patients. Alignment of the stomach was reached in 12 patients in group A but no patients at all in group B. There was no significant difference between both groups regarding hospital stay. The smaller tube design shown by gastrografin radiography at third postoperative day was accomplished in eight (80%) patients and two (20%) patients in groups A and B, respectively. Postoperative computed tomographic volumetric study illustrated smaller gastric volume in group A but without significant difference. Conclusion The use of GastriSail device is superior to the standard LSG in consistent sleeve formation, visualization and delineation, good alignment, and accomplishment of a small tube design, with no significant difference in excess weight loss. Operative time is less with the use of GastriSail but with no statistical significance.
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Enhanced recovery after surgery protocol in colorectal surgery p. 94
Ali H El-Shewy, Wael M Abdalla, Muhammad A Baghdadi
DOI:10.4103/ejs.ejs_142_19  
Background/purpose Principles of enhanced recovery have been used to enable early recovery and discharge from hospital and minimize potential complications, and thereby improve patient outcomes following colorectal surgery. Enhanced recovery after surgery (ERAS) implementation involves a team consisting of surgeons, anesthetists, an ERAS coordinator, and staff from units that care for the surgical patient. We compare ERAS with traditional protocol in colorectal surgery to detect advantages of ERAS over traditional care in colorectal surgery and to encourage application of ERAS in our hospitals. Patients and methods This study was carried on 18 patients who were scheduled for colorectal surgery in the GIT Surgical Unit in the Department of General Surgery, Zagazig University Hospitals, from April 2018 till April 2019. The patients were divided into two groups: group A was managed by traditional protocol and group (B) was managed by enhanced recovery protocol (ERAS). Results We found that ERAS decreased both primary hospital length of stay from 12 to 5 days and total hospital stay from 13.7 to 7 days. ERAS decreased mean cost from 6800 to 3900 pounds. General postoperative complications were also reduced from 22 to 11%. Pain scores in first postoperative day improved from 6 to 4, first time to flatus passage was reduced from 3.6 to 1.8 days, and mean time to first solid meal decreased from 5.5 to 3.2 days. Conclusions ERAS are multimodal perioperative care programs that resulted in an ERAS, reduced morbidity rates as well as primary and overall hospital stay, and improved postoperative pain and bowel function.
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Day-case laparoscopic cholecystectomy in obese patients: safety and feasibility p. 102
Mohamed M.T Zaazou, Ashraf A Mohamed
DOI:10.4103/ejs.ejs_148_19  
Objectives To assess the outcomes of day-case laparoscopic cholecystectomy (LC) in different BMI groups with stress on the safety and success of the procedure in patients with high BMI. Patients and methods Included patients have their LC in Departments of Surgery at Minia University Hospital and Misr University for Science and Technology Hospital over 2 years (2014 and 2015). Patients with gallbladder cancer or active malignancy were excluded. Comorbidities and American Society of Anesthesiologists (ASA) grading were recorded. According to BMI, patients were divided into six groups: underweight, normal weight, overweight, obese class I, obese class II, and obese class III. Results A total of 286 patients were included. ASA grading of patients yielded ASA I (23.4%), ASA II (56.7%), and ASA III (19.9%). Magnetic resonance cholangiopancreatography was performed in 16.4% of patients followed by endoscopic retrograde cholangiopancreatography with clearance of common bile duct. Intraoperative bile leak was observed in 0.7% of patients treated by endoscopic retrograde cholangiopancreatography and stenting. Open conversion happened in 2.8% of patients. Mean hospital stay was 1.13+0.06 days. Rate of overnight stay was increased in some cases owing to conversion to open procedure, drain insertion, wound infection, and intraperitoneal collection. Readmission happened for 1.7% of patients within 30 days of their operation with pain or nausea. Port-site bleeding was recorded in one (0.3%) patient. Conclusion Day-case LC is a safe and feasible treatment in patients with high BMI, resulting in cost reduction owing to shortening of hospital stay and reduction in the risk of nosocomial infections and thromboembolism.
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Treatment of hemodialysis related-central venous stenosis: 1-year results of venoplasty and follow-up in 50 patients p. 105
Mohamed Ibrahim Ahmed, Khalid Atalla, Mohamed A.H Taha
DOI:10.4103/ejs.ejs_143_19  
Purpose To analyze and evaluate the patency of the endovascular intervention for venous hypertension in upper-extremity hemodialysis access. Patients and methods A prospective cohort study of consecutive patients with chronic renal failure having symptomatic central venous stenotic lesions with hemodialysis access referred for endovascular treatment was conducted from May 2015 to May 2016. Procedure consisted of percutaneous angioplasty with or without stenting. Results A total of 50 patients (30 females and 20 males, with mean age of 47.7 years and range of 22–72 years) were included, and all had successful arteriovenous fistula (AVF) creation (native in 76% of patients and synthetic in 24% of patients). Overall, 64% of the patients had left-sided AVF, and the remaining 36% had right-sided AVF. Patency rates of 34 patients collectively were 100, 97, and 70% at 3, 6, and 12 months, respectively. One-year patency rate of cases with single-lesion group was 91.6%, and those with multiple lesions was 8.3%, with statistically significant difference between the two groups. However, the term patency rate for patients with short lesions (<3 cm) was 66.6% and for those with lesions more than 3 cm was 33.3%. This was statistically insignificant, with P value equal to 0.1. Conclusion Percutaneous central venous angioplasty could provide satisfactory symptomatic relief in patients who presented with central venous stenosis together with upper-extremity edema. Endovascular procedure offers a minimally invasive, first option of management for a difficult problem in a patient population with significant comorbidities and infrequent complications. However, the durability of percutaneous transluminal angioplasty is limited, and in most patients, adjunctive interventions were required to extend the symptom-free period.
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Evaluation of pancreaticogastrostomy using pancreas-transfixing sutures versus a single purse-string seromascular nonpancreatic suture in Whipple operation: a prospective randomized-controlled trial p. 112
Hamada Fathy, Ahmed H Mohammed, Mohamed Gamal Sayed, Haidi Abd-Elzaher Mohamed, Mohammed Faisal
DOI:10.4103/ejs.ejs_129_19  
Background Pancreatic fistula (PF) remains a persistent problem after pancreaticoduodenectomy (PD). The existence of soft, nonfibrotic pancreatic tissue is one of the critical risks for pancreatic leakage. Our aim was to compare continuous single purse-string sutures and transfixing suture for performing pancreaticogastrostomy to the pancreatic stump in terms of the outcome and the rate of postoperative complications for PD. Patients and methods Our study included 40 patients who were diagnosed with different stages of pancreatic cancer and admitted to the general surgery department of Suez Canal University Hospital. These patients were enrolled in the study and underwent PD. Results The rate of postoperative PF rate was lower when using single purse-string suture for performing pancreaticogastrostomy than when using the transfixing suture (0 vs. 15%, respectively). Conclusion We found a link between the occurrence of postoperative PF and possible risk factors such as soft pancreas and small Wirsung duct diameter.
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Three-port versus conventional four-port laparoscopic cholecystectomy: a comparative study p. 119
Ashraf Abd El-Azeem Mohamed, Mohamed M.T Zaazou
DOI:10.4103/ejs.ejs_149_19  
Objectives This prospective comparative study aims at evaluating the feasibility of three-port technique without affecting safety and at comparing the outcome of three-port and four-port techniques. Patients and methods This study included 94 patients with symptomatic gallstone disease and gallbladder polyp in Surgical Department, Minia University Hospital, from beginning of 2018 to beginning of 2019. Patients who were unwilling to be a part of the study, jaundiced patients with radiologically evidence of common bile duct stones, patients unfit for general anesthesia, patients with liver cirrhosis, patients with portal hypertension, patients with coagulopathy, patients with acute pancreatitis, patients with generalized peritonitis, or patients with malignancy were excluded. All patients were operated by the same operating team. Patients were randomized for three-port laparoscopic cholecystectomy (LC) group (45 patients) or four-port LC group (49 patients). Numeric Pain Rating Scale, operative time, operative difficulty, intraoperative and postoperative complications, duration required to stop oral analgesics, and duration required to return to normal activity were recorded. Results Numeric Pain Rating Scale, required number of diclofenac ampoules, duration required for oral analgesia, and duration required to return to normal activity were significantly less in three-port group. Other parameters were comparable between the two groups. Conclusion It seems that three-port LC is a safe and feasible technique with superior clinical outcomes to four-port LC.
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Diagnostic value of cervical lymphadenopathy in the detection of underlying pulmonary diseases p. 124
Waleed M Hussen, Ali Naif
DOI:10.4103/ejs.ejs_152_19  
Background Cervical lymphadenopathy is usually defined as cervical lymph nodal tissue measuring more than 1 cm in diameter, and can be caused by benign local or generalized infection, but occasionally, it might herald the presence of a more serious disorder such as malignancy. Cervical lymphadenopathy can be soft, firm, or stony hard according to the disease process by which they involved. Clinical examination, radiological studies, and biopsies can lead to a definitive diagnosis. Aim This work aimed to study in detail the results of cervical lymphadenopathy that was removed surgically, and its value in detecting pulmonary diseases (i.e. to analyze the pathological spectrum of variant benign or malignant diseases affecting the cervical lymph node). Patients and methods This was a prospective and retrospective study of 32 patients who presented with respiratory symptoms discovered during a physical examination to have cervical lymphadenopathy, were admitted, and were treated surgically at Al-Shaheed Ghazi El-Hareri Hospital of the Medical City Teaching Complex during the period from 1 July 2014 to 30 June 2015. Proper assessment of history and clinical examination, in addition to radiological studies and biopsy analysis, were performed to analyze the causes of cervical lymphadenopathy. Results Twenty-one of our patients were males; the remaining 11 patients were females. The youngest patient was a 10-year-old male and the oldest patient was a 50-year-old male. Fever was the most common presenting feature in 26 patients. All patients were referred for neck ultrasound to detect the size of the enlarged nodes; 23 patients had a lymph node diameter of more than 1 cm. Chest radiography was performed for all patients; it was found that 22 patients had central lesions (closed to the hilum). Computed tomography-chest showed pleural effusion in 18 patients, lung masses in 16 patients, and mediastinal masses in nine patients. Conclusion Cervical lymph node involvement has a major impact on the prognosis and treatment decision in patients with pulmonary malignancy.
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Catheter foam sclerotherapy of refluxing great saphenous vein combined with preterminal saphenous interruption and phlebectomy: 1-year clinical and ultrasound outcomes p. 130
Adel H Kamhawy, Ahmad H Elbarbary, Amr M Abo Rahma, Ahmed M.S Shaalan
DOI:10.4103/ejs.ejs_154_19  
Objectives To assess the efficacy and safety of catheter foam sclerotherapy of refluxing great saphenous vein (GSV) after preterminal saphenous interruption and phlebectomy. Patients and methods We describe the results of the first 80 patients who fulfilled the inclusion criteria. The study endpoints were procedural technical success, 1-year GSV recanalization by duplex, and its relation to clinical varicose veins’ recurrence and disease severity by comparing the presclerotherapy venous clinical severity score with the postsclerotherapy values. Results Technical success was 100%. After 1 year, venous clinical severity score improved from 7.3±2.2 to 2.5±0.3 (P<0.0001), with no clinical recurrence. The total GSV occlusion rate was 90% and reflux-free GSV was 95%, with no major complications. Conclusions Catheter foam sclerotherapy after preterminal saphenous interruption and phlebectomy yielded good short-term duplex and clinical results. It is simple, effective, safe, and easily repeatable. Long-term comparative study is essential taking into account the greater importance of clinical than duplex response.
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Outcome after angioplasty versus bypass surgery in patients with superficial femoral artery lesions p. 138
Mohammed M El Yamany, Hatem H Mohamed, Mohammed M Kamel
DOI:10.4103/ejs.ejs_147_19  
Background Management of patients with lower limb ischemia owing to superficial femoral artery lesions is very challenging, as there are two modalities for management, either with angioplasty or bypass surgery, after risk factor modification, exercise, and medical treatment. Every method has its advantages and disadvantages regarding patency, improvement of symptoms, and complications. Aim To compare the outcome after angioplasty versus bypass surgery in patients with superficial femoral artery lesions. Patients and methods During the period from July 2017 to May 2019, this study was carried out as an interventional prospective comparative study on 52 patients with superficial femoral artery lesion divided into two groups: group A and group B. The study was conducted in Vascular Surgery Unit, Department of Surgery Suez Canal University Hospital, to compare the outcome after angioplasty versus bypass surgery in patients with superficial femoral artery lesions. Results After 1-year follow-up, on comparison of both procedures, the results showed better patency rate in bypass surgery group (84.6%) than angioplasty group (61.5%). There was a slight decrease in ankle brachial index with time in bypass surgery group, with mean of 0.83±0.12, whereas in angioplasty group was 0.73±0.14. Symptoms showed better improvement in bypass surgery group than angioplasty group. Complications were higher in bypass surgery group (hematoma, wound infection, and thrombosis) than angioplasty group. Conclusion We found that bypass surgery had more complications but better results in patency and in improvement of symptoms. On the contrary, we found that angioplasty had less painful maneuver, less complications, and was suitable for high-risk patients, but had short time of patency.
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Effects of vertical sleeve gastrectomy on serum visfatin level and insulin resistance in obese diabetic and obese nondiabetic cases p. 147
Mohamed M Abouzeid, Ahmed M.B El-Din, Caroline A Girgis, Nihad S.M Shoeib, Khaled M Makboul, Gena M.A El Makromy
DOI:10.4103/ejs.ejs_161_19  
Introduction Visfatin is an adipokine that is highly expressed in visceral fat and has various functions, including activation of insulin receptor and has insulin mimetic effects and improving insulin sensitivity. Laparoscopic sleeve gastrectomy (LSG) is a technically less complex surgical procedure which is promising for the weight loss and treatment of obesity and type 2 diabetes mellitus (T2DM). Objectives To evaluate serum levels of visfatin before and after sleeve gastrectomy surgery and their relationship with insulin resistance in obese diabetic and obese nondiabetic cases. Patients and methods This study was conducted on 80 patients with age ranged between 18 and 60 years who underwent LSG in our Bariatric Unit. They were divided into two groups: group 1consisted of 40 nondiabetic patients. Group 2consisted 40 patients who were diagnosed with T2DM of more than 1-year duration. Results When comparing groups, there is a highly statistical difference (P≤0.001) as regards: fasting plasma glucose (FPG), homeostatic model assessment of insulin resistance (HOMA-IR), and glycated hemoglobin being higher in group 2. The visfatin level was significantly higher in group 2 (P≤0.05). Conclusion Weight reduction after LSG is associated with a significant decrease in visfatin in both morbidly obese patients and patients with obesity and T2DM.
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Desarda vs lichtenstein technique for the treatment of primary inguinal hernia p. 157
Ahmed S Arafa, Hassan A Saad, Fady Fayek
DOI:10.4103/ejs.ejs_165_19  
Background The Lichtenstein technique (LT) is currently the most popular open mesh repair method with recurrence rates of around 4% in long-term follow-up, but the cost of the mesh may be a barrier in developing and underdeveloped countries. Also, the presence of an infection can prevent implantation of a mesh. In these settings, it is good to have the option of a simple, mesh-free repair. Desarda, in 2001, has described a new method that seems to satisfy the above criteria. Desarda technique (DT) appeared as a promising tissue-based repair that provided low incidence of recurrence without the need for complicated dissection, suturing or implanting prosthetic or foreign materials in the inguinal canal. The aim of this study was to test the hypothesis that the DT is as effective as the standard LT, allowing successful hernia repair without mesh. Materials and methods A total of 80 cases were allocated into two groups. The Desarda group (D group) had 40 patients and the Lichtenstein group (L group) had 40 patients. The primary outcome measures were the recurrence of inguinal hernia and chronic groin. Secondary outcome measures included operating time (min), time to return to normal gait and to work, foreign body sensation in the groin, and postoperative complications such as testicular edema, groin discomfort, seroma, and surgical site infections. Statistical analysis was carried out using Statistical Package for the Social Sciences. Results There was significantly shorter operating time and earlier return to normal gait in favor of Desarda repair. Complication rates were nearly similar in the two study arms. Conclusion Both DT and LT provided satisfactory treatment for primary inguinal hernia with low recurrence rates and acceptable rates of complications that were significantly less after DT. The DT may potentially increase the number of tissue-based methods available for treating groin hernias. More well-designed RCTs with longer follow-up are required for further validation of the DT.
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Laparoscopic versus open total mesorectal excision in rectal cancers: a randomized-controlled trial p. 166
Mohamed Kamal Alhanafy, Moharram Abdelsamie, Mohammed Nazeeh Shaker Nassar, Ahmed F Elkased
DOI:10.4103/ejs.ejs_153_19  
Background Laparoscopic total mesorectal excision (lap TME) is a widely used approach for rectal cancers, but sometimes, it faces some challenges especially in obese patients with low rectal tumors and after chemoradiation. Some trials proved noninferiority of lap TME, whereas others failed, and much debate exists. Purpose This study was designed to compare the pathologic outcomes of laparoscopic and open TME regarding distal resection margin and circumferential resection margin. It also aimed to compare the operative and recovery data, in addition to the intraoperative and postoperative complication. Patients and methods We prospectively reviewed the medical records of 120 patients who underwent TME between February 2017 and February 2019. Cases were selected randomly using a closed envelope for the first admitted 120 patients. Patients were divided into two groups: laparoscopic and open groups. Results Each group had 60 patients with similar characteristics. Both groups revealed similar pathologic outcomes; circumferential resection margin was involved three (5.0%) in laparoscopic TME group versus five (8.33%) in open TME, with P value of 0.464. TME quality was complete or near complete in 57 (95.0%) in laparoscopic group versus 54 (90.0%) in open group, with P value of 0.298. Our trial revealed that laparoscopic TME had earlier recovery and shorter hospital stay compared with the open approach. Overall complications were similar: 19 (31.67%) in laparoscopic TME versus 25 (41.67%) in open TME (P=0.256); however, the blood loss and wound infection were higher in the open group. Conclusion Laparoscopic TME improves postoperative recovery, achieves similar morbidity rates, and seemingly does not jeopardize the short-term oncological parameters compared with open surgery. However, further trials are still required.
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Laparoscopy-assisted transumbilical extracorporeal cyst deroofing for the management of neonatal ovarian cysts p. 177
Ahmed A Youssef, Mahmoud M Marei, Mohamed H Abouelfadl, Wesam M Mahmoud, Atef S.A Elbarawy
DOI:10.4103/ejs.ejs_159_19  
Background Congenital ovarian cysts affect newborn female infants with an increasing incidence. Many of these cysts are clinically insignificant and resolve spontaneously. Complex cysts of any size and simple cysts larger than 5 cm should be operated upon. Laparoscopy is becoming the mainstay of management. We report our experience with the laparoscopy-assisted transumbilical extracorporeal approach in neonates with ovarian cysts. Patients and methods In this prospective cohort study, 17 pregnant ladies presented with a routine antenatal ultrasound anomaly scan showing an abdominal cyst in their female fetuses, likely ovarian in origin. A multidisciplinary counseling meeting was conducted with the expectant couple. Postnatal ultrasonography confirmed the diagnosis in 15 patients, whereas two patients showed resolution. Conservative management was pursued in patients with cyst size less than 5 cm. Patients with ovarian cysts larger than 5 cm were operated upon electively. Results Age at surgery ranged from 4 to 11 days, and patients’ weight ranged from 2.8 to 3.7 kg. Thirteen patients were full term, whereas only two were preterm. The cyst diameter (whether operated upon or not) ranged from 2.7 to 6.2 cm. All patients with cysts smaller than 5 cm resolved spontaneously over a 6-month period. Laparoscopy-assisted transumbilical extracorporeal cyst deroofing was attempted in 11 patients (mean cyst diameter, 5.6 cm). The mean operative time was 36 min. None of the patients showed recurrence or formation of new cysts. Conclusion Laparoscopy-assisted transumbilical extracorporeal cyst deroofing achieves safety, reproducibility, organ preservation, and minimal invasiveness in neonates with ovarian cysts.
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Abdominoplasty and sutureless retrorectus prosthesis for medium-sized and large-sized ventral hernia: assessment of outcomes p. 183
Amro El Hadidi, Omar Salah, Mohamed Abdelhalim, Ahmed Taha, Mohamed Shetiwy, Magdy Basheer
DOI:10.4103/ejs.ejs_169_19  
Aim The primary objective of this prospective cohort study was to assess the outcomes of aesthetic abdominal wall reconstruction with repair of associated hernia utilizing a sutureless retromuscular technique. Materials and methods A single-center follow-up study of 67 consecutive patients with medium-sized ventral hernia and pendulous abdomen was conducted between January 2016 and May 2019. A detailed classification of degree of herniation, surgical complications, postoperative pain analysis, and patient satisfaction were analyzed. Results The study revealed that the overall hernia recurrence rate was quite low; only one (1.5%) patient had to undergo reoperation for recurrence. The postoperative infection rate was noted as 4.5%. Overall, 73% patients reported that they were extremely satisfied with the surgery. Conclusion Although there are many alternatives for repair of medium-sized to large-sized ventral hernia, we found retromuscular repair especially if associated with aesthetic abdominal wall reconstruction to be safe with fewer complications and good patient satisfaction.
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Laparoscopic splenectomy: Assiut University early experience p. 189
Mohammed Y.F Aly, Mahmoud R Shehata, Ahmed A Abdelmotaleb
DOI:10.4103/ejs.ejs_170_19  
Purpose Laparoscopic splenectomy (LS) as a treatment for hematological diseases has proven its safety and efficacy with experienced surgeons. The authors present a series of LSs performed in the institution and review the experience with this approach. Patients and methods Medical records of 25 consecutive patients who underwent LS from October 2011 to March 2019 were retrospectively reviewed. Data on patient demographics, operative time, operative blood loss, hospital stay, and complications were evaluated. A comparison between the former period (group A, 2011–2015) and the latter period (2015–2019) was performed. Results The patients comprised 23 women and two men with a mean age of 35 years. The mean operative time, operative blood loss, and hospital stay were 150 min, 145 ml, and 3 days, respectively. Open conversion was performed in three (12%) patients due to intraoperative bleeding (all open conversions were in group A). Total complications occurred in three (12%) patients. A comparison between groups A and B revealed a significant shorter operative time in group B than in group A (P<0.05) with no significant difference in operative blood loss, open conversion, complications, and hospital stay. Conclusion LS is feasible and provides good results and safe outcomes. Further prospective studies on a larger number of patients are needed.
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Role of inferior vena cava ultrasound in diagnosis of shock in patients with trauma p. 194
Khalid Y.A Youssif, Zaynab M El Sayed, Mohammed A Ali, Amr M Moghazy
DOI:10.4103/ejs.ejs_179_19  
Background Hemorrhage is responsible for more than 35% of prehospital deaths. Hemorrhagic shock is the leading etiology in most cases. Objective The aim was to assess the reliability of inferior vena cave (IVC) sonographic parameters in diagnosis and evaluation of shock in patients with trauma. Patients and methods This diagnostic cross-sectional study was conducted on 45 traumatized patients with evident clinical picture of shock. Traumatized patients aged 18 years and older of both sexes were included. Patients who developed cardiopulmonary arrest or with stab wound around the epigastrium were excluded. Results The mean age was 36.6±13.8 years. There was a statistically significance between vital signs before and after resuscitation (P<0.001). Mean IVC diameter at inspiration and expiration after resuscitation was significantly higher than those before resuscitation. Moreover, mean IVC index before resuscitation was significantly higher than that after resuscitation (P>0.01). Conclusion Sonographic IVC parameters are feasible, easy, and noninvasive measures to assess hypovolemia in shocked patients.
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Short-term outcome of one-stage sphincter-saving anterior sagittal anorectoplasty in vestibular and perineal fistulae in female infants p. 199
Mohamed Ahmed Negm, Mohamed Ahmed Arafa, Khalid Mohamed Elshimy
DOI:10.4103/ejs.ejs_171_19  
Background/aim Vestibular and perineal fistulae are the most common anorectal malformations in female infants. The progress in surgical correction has been aimed at achievement of both good continence and cosmetic outcome. This study aimed to present two-center experiences in one-stage sphincter-saving modification of anterior sagittal anorectoplasty for vestibular and perineal fistulae in female infants. Patients and methods This prospective study was conducted on 38 patients. They were divided into vestibular and perineal groups. The position of anus was marked by Peña stimulator, and traction suture were placed around the fistula. With longitudinal midline perineal incision, separation of the rectum from posterior vaginal wall. The center of anal sphincter muscle complex was identified and the rectum was passed through it, finally anoplasty with reconstruction of perineal body. Continence was evaluated by Krickenbeck and Holschneider scores in patients older than 3 years. Results The mean age was 60.26 days. The mean operative time was 109.61 min. The rectum was passed through the intact sphincter in all cases. A total of three (7.89%) cases developed superficial wound dehiscence that was treated conservatively, one (2.63%) case needed colostomy and anal dilatation was done for 3 months, one (2.6%) case developed anal stenosis corrected by anoplasty, and five (13.15%) cases developed minor mucosal prolapse, with spontaneous improvement. Constipation occurred in six (15.78%) patients and was controlled by diet modification and laxatives. Good continence was obtained. Conclusion One-stage sphincter-saving anterior sagittal anorectoplasty is safe and feasible technique in vestibular and perineal fistulae in female infants. The short-term outcome show good cosmetic and functional results regarding continence.
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Clinical outcomes after wide resection of lower extremity soft tissue sarcomas with femoral vessel reconstruction p. 206
Samy Khalefa, Amr El Bahaey, Ayman El-Samadoni, Haitham A Eldmarany
DOI:10.4103/ejs.ejs_173_19  
Introduction With advancements in local control of lower extremity soft tissue sarcoma (STS) by modern oncology protocols, limb salvage surgeries have become the standard of care with good results in both limb function outcome and quality of life. Patients and methods This is a retrospective analysis of all patients with a localized STS of the lower extremity presented to Vascular Surgery Unit at Faculty of Medicine, Cairo University, and who underwent en bloc vascular resection of the tumor between January 2018 and April 2019. Results We have found 17 patients during the study period. In three patients, iliofemoral arterial repairs were performed. Above-the-knee femoropopliteal bypasses were implanted in six patients. In four patients, popliteoposterior tibial bypasses were performed. Venous reconstructions consisted of three iliofemoral, one femorofemoral, and four femoropopliteal bypass reconstructions. Another four venous reconstructions were performed in the popliteal region. All patients developed moderate degree of pitting lower limb edema at the early postoperative period. Only one patient had undergone lower limb above-knee amputation. There was one synthetic Dacron graft occlusion in a patient with arterial bypass procedures. Regarding venous bypasses, occlusion occurred in three patients. Freedom from local tumor recurrence at 6 months was 64.2%. The freedom from distant metastases at 6 months after primary tumor excision was 85.7% for more than 10 mm margins and 20% for less than or equal to 10 mm margins. The cumulative overall survival proportion at 6 months was 53.9%. Conclusion Vascular reconstruction after wide local excision of lower extremity STS prevents the complications of vascular ligation and local recurrence in case of subradical excision. The use of autogenous vein graft yields better patency rates than synthetic grafts.
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Role of D-dimer in guiding duration of anticoagulant therapy in the management of first unprovoked proximal lower limb deep venous thrombosis p. 215
Mahmoud S Eldesouky, Mohamed Hamed Elmeligi, Assma Mohamed Atef Geassa
DOI:10.4103/ejs.ejs_177_19  
Background The optimal duration of anticoagulant therapy in management of patients with first episode of unprovoked deep venous thrombosis is uncertain. D-dimer test may play a role in the assessment of duration of anticoagulant therapy to decrease the rate of recurrence. Aim To evaluate if D dimer test can be used as predictor to guide the duration of anticoagulation in patients with first unprovoked proximal lower limb deep venous thrombosis. Patients and Methods One hundred patients with a first unprovoked proximal deep-vein thrombosis who completed 3 months of Vitamin K Antagonists (VKAs) and had elevated d dimer test 1 month after discontinuation of anticoagulation were randomly assigned either to resume (group A) or to discontinue treatment (group B). The patients were followed up for 1 year for recurrent venous thromboembolism and treatment complications. Results The mean age of the patients was 49.96±7.88 and 51.78±7.98 years for group A and B respectively. Male to female ratio was nearly similar in both groups 3:2 . The base line D-dimer level was 3.05±0.84 and 3.15±1.00 for group A and B respectively with no statistical significant difference. The mean duration of follow up was 10.6 months for both groups. The recurrence rate was higher in group B (7 cases) compared to group A (1 case) (P value 0.027) and this difference was statistically significant. No major bleeding or pulmonary embolism have been noticed in any patients during follow up. Conclusion Elevated D dimer test 1 month after discontinuation of 3 months anticoagulation, in the absence of recent thrombosis, could be an indicator for resumption of anticoagulant therapy for another 3 months.
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Validity of sentinel lymph nodes biopsy after neoadjuvant chemotherapy in case of complete pathological response of axillary lymph nodes p. 220
Yasser S Ahmed, Walid M Abd El Maksoud
DOI:10.4103/ejs.ejs_178_19  
Aim To determine the validity of sentinel lymph node (SLN) biopsy after neoadjuvant chemotherapy (NAC) in case of complete pathological response of axillary lymph node. Patients and methods This is a prospective study that included female patients with cancer breast who became clinically and radiologically node negative (cN0) after receiving NAC during the period of March 2016 to October 2018 in Alexandria Medical Research Institute, Alexandria, Egypt. Dual technique was used to identify the SLN followed by standard axillary lymph node dissection (ALND). Analysis of the pathological reports was used to determine the false-negative rate (FNR) of SLN. Results Of the 86 patients who completed the NAC and showed cN0, SLN could be identified in 76 (88.4%) patients. ALND was completed for the 76 patients, and SLNs showed false-negative results in nine (11.8%) patients. Patients in whom three or more (10.3%) SLNs could be identified showed better FNR compared with patients with two SLNs or less (16.7%). Conclusions SLN biopsy after NAC for patients with cN0 seems to be a reliable technique to replace ALND if certain precautions are applied. The use of a dual technique for SLN identification and determination of at least three SLNs to be the minimum number accepted is an essential requirement to be applied in this selective approach to ensure FNR within accepted range. In addition, patients should be counseled regarding benefits of the SLN biopsy technique and the possibility of failure to identify the SLN or being false negative.
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Catheter-directed thrombolysis vs pharmacomechanical catheter-directed thrombolysis in acute iliofemoral deep vein thrombosis p. 228
Ahmad M Tawfik, Mohamed H Zaidan, Waleed A Sorour
DOI:10.4103/ejs.ejs_185_19  
Purpose The aim was to compare the effectiveness of catheter directed thrombolysis (CDT) and pharmacomechanical catheter-directed thrombolysis (PCDT) in the treatment of acute, massive iliofemoral deep vein thrombosis. Patients and methods A prospective study was conducted on 50 patients in Zagazig University Hospitals between March 2014 and April 2018. The patients were randomized into two groups. Group A underwent CDT and group B underwent PCDT (ASPIREX). Primary end points were venous patency, complication rate, patient satisfaction, and quality of life Chronic Venous Insufficiency Questionnaire-20. Secondary end points were recurrence and occurrence of post-thrombotic syndrome (PTS), (the Villalta score and revised Venous Clinical Severity Score) within 24 months. Results Aspirex was successful in the majority of patients and grade III, II, and I thrombolysis was achieved in 56, 32, and 12% of patients, respectively, while in the CDT group of patients achieved 44, 36, and 20%, respectively. Recanalization was achieved in 88% patients. At 24 months 32% patients who received CDT presented with PTS compared with 20.83% in the PCDT group after exclusion of one patient who died. Three cases of severe PTS were reported in the CDT group. There was statistically significant difference in PTS at 6 months between the two groups. When comparing Chronic Venous Insufficiency Questionnaire-20 scores between the two groups, there was statistically significant difference between them at 6, 12, and 24 months with more improvement in Aspirex group. Conclusion Aspirex is an effective treatment for lower limb deep vein thrombosis, and the clinical results achieved were superior in comparison with CDT alone.
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Submental island flap reconstruction of large and complex oral commissure defects p. 239
Islam A Elzahaby, Islam H Metwally, Amr Abouzid, Osama Eldamshety, Basel Refky, Khaled Abdelwahab, Ahmed Abdallah, Mahmoud Abdelaziz
DOI:10.4103/ejs.ejs_196_19  
Background Oral commissure squamous cell carcinoma frequently presents at advanced stage and surgical treatment will eventually result in large and complex lip, buccal, and facial skin defects. Reconstruction of such defects is a challenge. The authors hereby present the experience with the reconstruction of large and complex postexcisional defects of the oral commissure with submental island flap. Patients and methods Eighteen patients with stage IVA squamous cell carcinoma of the oral commissure were enrolled. For all patients wide surgical excision of the primary tumor with supraomohyoid neck dissection followed by immediate reconstruction of the resultant defect with submental island flap was done. During the follow-up period, surgical and oncologic outcomes were reported; and functional and aesthetic outcomes were evaluated using the Functional Lip Glasgow Scale score. Results Male predominates and the mean operative time was about 197 min. Surgical complications were unremarkable. Functional Lip Glasgow Scale score ranged from 18 to 25. Recurrence occurred in three cases. Conclusion Submental flap is a feasible reproducible reconstructive technique for oral commissure tumors surgery with satisfactory functional and aesthetic outcomes.
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Fingerprint patterns, a novel risk factor for breast cancer in Egyptian populations: a case–control study p. 247
Mohamed I Abdelhamid, Mohamed Lotfy, Joseph R.I Awad
DOI:10.4103/ejs.ejs_189_19  
Context Every single person has got a unique dermal ridge pattern; this pattern is genetically determined. Dermal ridge patterns once established become fixed all throughout life. Fingerprint patterns offer a simple, convenient, and economical technique for recognition of some diseases. Aims The aim of this study is to find a relation between dermal ridge patterns and breast cancer among female Egyptian populations. Patients and methods A total of 500 patients with breast cancer and 500 women without cancer were included in our study. The fingerprints of all fingers of both hands of our patients and control group were obtained, using classic method of ink and paper. The fingerprints were then examined by a forensic medicine specialist for identification of the patterns and ridge count. Results The whorl pattern was the commonest pattern among the diseased group, representing 46%; this pattern was significantly increased when compared with the same pattern in the control group. It was found that the mean ridge count of the diseased group was less than that of control group. The frequency of six or more whorls was more common in the diseased group (46%) when compared with the same number in control group (13.4%). Conclusion Fingerprint patterns and ridge counts are easy, simple, noninvasive, cheap, and applicable methods for screening high-risk groups of breast cancer.
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Drug-coated vs uncoated balloon angioplasty in the treatment of femoropopliteal arterial lesions p. 252
Mahmoud S Eldesouky, Mohamed M Sharaf, Yahia M Alkhateep
DOI:10.4103/ejs.ejs_199_19  
Background Inspite of immediate technical success, neointimal hyperplasia and restenosis remain the Achilles heel of endovascular interventions. Drug-coated balloons (DCBs) have shown promising outcomes regarding anti-restenotic efficacy in management of femoro-popliteal arterial lesions compared to uncoated balloon. Objectives To evaluate the efficacy of the paclitaxel-coated balloon versus uncoated balloon angioplasty in treatment of femoropopliteal lesions regarding primary patency and restenosis at 12 months. Patients and Methods Between Sept 2017 and Sept 2019, this prospective randomized study was performed at Menoufia University hospitals. Sixty patients suffering symptomatic lower limb ischemia (Rutherford category 3 to 5) were randomly assigned into group A (30 patients) that were treated by DCB angioplasty, and group B (30 patients) that were treated by uncoated balloon (UCB) angioplasty. The primary patency, mean diameter restenosis, and binary restenosis (≥50% diameter stenosis) of the treated lesions at 12 months were collected and analyzed. Results Baseline characteristics were comparable in both groups. The 12-month mean diameter restenosis was significantly lower in DCB group than UCB group (27.8±35.2% vs. 44.9±33.8% respectively, P<0.001). Furthermore, the binary restenosis rates was significantly lower in DCB patients as compared with the UCB’s (27% vs. 46% respectively, P<0.001). The primary patency was significantly better in DCB group (70% vs. 48% respectively, P<0.001). There were no procedure-related deaths in either study group. Conclusions Treatment of symptomatic femoro-popliteal disease with paclitaxel coated balloon angioplasty is associated with superior anti-restenotic efficacy that provides a better primary patency rate compared to uncoated balloon angioplasty at 12 months.
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The effect of bougie size on the short-term outcome of laparoscopic sleeve gastrectomy p. 261
Sameh T Abo-Elela, Hamdy Shaban, Ahmed H Hussein, Mustafa A Abo-Ali, Mohammed K Elhadary, Ahmed A Elgeidie, Mohamed G Sayed, Ahmed M.M Gomaa
DOI:10.4103/ejs.ejs_200_19  
Background Obesity is a worldwide epidemic. Laparoscopic sleeve (LS) gastrectomy has recently been identified as an innovative approach to the surgical management of obesity. One of the most debated issues is the size of the bougie used during the procedure. We conducted this study to elucidate a potential difference in the short-term outcome between 40 and 32 Fr bougies. Objectives To assess the effect of the size of bougie on the outcome of weight loss and quality of life (QOL). Design This was an interventional prospective randomized study. Study duration This study was carried out over a 27-month period (from January 2015 to March 2017). Patients and methods A total of 48 morbidly obese patients were candidates for LS gastrectomy with the aim to evaluate the effect of using 32 versus 40 Fr bougie on the outcome of laparoscopic sleeve gastrectomy. The patients were randomly divided into two equal groups: group 1 (24 patients), in which laparoscopic sleeve gastrectomy was carried out using 32 Fr bougie, and group 2 (24 patients), where LS gastrectomy was done using 40 Fr bougie. Body weight, BMI, bariatric QOL, lipid profile, and comorbidities were evaluated preoperatively and postoperatively for a duration of 12 months. Results There is no statistically significant difference between the two study groups according to the resolution of comorbidities throughout the postoperative follow-up (P>0.05). There was no statistically significant difference between the two study groups according to improvement of the QOL score during postoperative follow-up (P>0.05). There was no statistically significant difference between the two groups with regard to the incidence of complications (25% in group 1 vs. 25% in group 2; P>0.05). Conclusion Bougie size does not influence the short-term results of LS, that is, excess weight loss percentage, resolution of comorbidities, improvement of the QOL, and incidence of complications.
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Mechanical parameters and chemical composition of gallstones in Egyptian population: an approach to assess amenability to nonsurgical treatment p. 271
Gamal M Saied, Karim G Moustafa
DOI:10.4103/ejs.ejs_202_19  
Background This study aimed to describe the mechanical parameters and chemical composition of gallstones in Egyptian patients having gallstone disease to determine amenability to nonsurgical treatment. These parameters are related to environment, and to date, it is not available for patients living in the Middle East. Materials and methods Three hundred gallstone samples from 39 patients living in Egypt and presented for surgical treatment at Cairo University Hospitals and to the private practice of the first author were included in the study. They were indexed into soft, intermediate, and hard. Each was cut, polished, preserved, and stored in saline. Mechanical parameters were studied and then chemically analyzed to determine cholesterol, calcium, and bilirubin content. Trace metals and elements were determined by particle-induced radiographic emission. Results Except four, all cases were females (mean age: 45.9 years), having a single stone in 64.1%, and multiple in 35.9%. Stones were hard in 13 patients and soft in 26, with mean specific gravity of 0.86 (0.69–1.67). The percentage share for the three major components was as follows: cholesterol 70.8% (43–88), bilirubin 29.5% (10–66), and calcium 2.27% (0.02–7.5). The mean percentage for other elements was as follows: carbon 76.2, hydrogen 10.49, nitrogen 0.51 and sulphur 1.33. Trace metals − in micrograms − were copper (0.0019), iron (0.0108), potassium (0.015), magnesium (0.023), sodium (0.146), and zinc (0.012). Conclusion The patients are good candidates for nonsurgical treatment. In the light of the unique chemical composition of their stones, extracorporeal shockwave lithotripsy is the best. Oral dissolution needs a long time, whereas contact dissolution has no place. Apart from calcium, the concentration of basic elements and metals is of no value for planning treatment.
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CASE REPORT Top

Management of failure of sleeve gastrectomy p. 276
Amer N Omar
DOI:10.4103/ejs.ejs_166_19  
Background There is an increasing incidence of inadequate loss of weight or weight regain after sleeve gastrectomy (SG) accounting for 5–10%, with the potential recurrence of obesity-linked diseases. Aim The aim was to determine the safety and outcome of redo-SG in patients with failed SG. Patients and methods A total of 21 patients with failed SG who received redolaparoscopic SG were evaluated. Results Entire cases were accomplished laparoscopically, with a mean operative time of 96.9±10.3 min. The mean percentage excess weight loss, mean %EBL (entire body loss), and mean;Deg;BM;Deg;I were 12.4±4.1, 13.5±3.6%, and 49.5±8.0 kg/m2, respectively, at 1 month; 40.5±6.8, 43.3±7.8%, and 41.5±6.6 kg/m2, respectively, at 6 months; and 56.8±8.5, 60.3±8.9% and 36.5±4.8 kg/m2, respectively, at 12 months. At a mean follow-up of 15±2.2 months, two patients were cured of hypertension, dyslipidemia resolved in two patients, diabetes disappeared in two patients, and all patients were cured of joint problems. Conclusion In a short period of follow-up, redolaparoscopic SG after failed SG is a feasible option and has good results regarding weight loss and comorbidity improvement.
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ERRATUM Top

Erratum: efficacy of mastectomy flap fixation in minimizing seroma formation after breast cancer surgery p. 280

DOI:10.4103/1110-1121.278331  
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Erratum: A rare combination of synchronous quadruple neoplasms: a case report and literature review p. 281

DOI:10.4103/1110-1121.278332  
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Erratum: Outcomes of laparoscopic one-anastomosis gastric bypass in treatment of morbid obesity: a retrospective analysis p. 282

DOI:10.4103/1110-1121.278264  
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