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   Table of Contents - Current issue
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April-June 2017
Volume 36 | Issue 2
Page Nos. 97-197

Online since Thursday, April 13, 2017

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ORIGINAL ARTICLES  

Comparative study between one-stage total transanal endorectal pull-through and assisted transanal Soave for treatment of rectosigmoid Hirschsprung’s disease p. 97
Hisham H Ahmed, Mostafa B Abd Elwahab
DOI:10.4103/1110-1121.204521  
Purpose The aim of this study was to compare one-stage total transanal endorectal pull-through (TEPT) and assisted transanal Soave (either by minilaparotomy or by laparoscopy) for treatment of rectosigmoid Hirschsprung’s disease. Patients and methods This study was conducted on 40 pediatric patients with rectosigmoid Hirschsprung’s disease. The patients were divided into two groups: group A, consisting of 20 cases that underwent one-stage total TEPT, and group B, consisting of 20 cases that underwent assisted transanal Soave [10 cases underwent minilaparotomy (B1) and 10 cases underwent laparoscopy (B2)]. Results The mean age of the patients was 20.01 months in group A and 17.14 months in group B. The male to female ratio was 3 : 1. P values less than 0.001 were considered highly significant. The mean operative time in group A was 102 min, whereas that in group B was 117 min. The mean onset time of oral feeding in group A was 1.7±0.86 days and that in group B was 2.25±0.97 days. The mean postoperative hospital stay in group A was 4.2±1.73 days and that in group B was 5±1.87 days. As regards the postoperative complications, they were more common in group B than in group A, and more common in subgroup B1 than in subgroup B2. Conclusion TEPT is characterized by a shorter operating time, less bleeding, shorter hospital stay, less morbidity, and earlier recovery compared with similar open pull-through procedures.
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Effect of laparoscopic sleeve gastrectomy on upper gastrointestinal symptoms p. 106
Sherif M Mokhtar, Shady El-Ghazaly Harb, A Hussein, Mohamed Elnady
DOI:10.4103/1110-1121.204523  
Background Laparoscopic sleeve gastrectomy (LSG) is one of the most well-known, safe, and effective bariatric procedures worldwide with the lowest incidence of complications and satisfactory results. Altered gastric anatomy following LSG is likely to induce upper gastrointestinal (UGI) symptoms. Patients and methods The validated Rome III criteria symptom questionnaire for UGI symptoms was used for 30 patients who underwent LSG. Before surgery, patients were tested for Helicobacter pylori in stool, eradicated and underwent UGI endoscopy for identification of any pathological finding. Symptoms were analyzed separately and UGI endoscopy was performed postoperatively to classify the findings and correlate these with UGI symptoms. Results Before LSG, 60% of the patients were asymptomatic, 40% had gastroesophageal reflux disease (GERD), and 6.7% had dyspepsia. All were subjected to UGI endoscopy and no significant finding was found in 40%, gastritis in 60%, esophagitis was found in 20%, duodenitis was found in 13.3%, and duodenal ulcer was found in 6.7% of patients. Forty percent of patients were H. pylori positive and 60% of patients were H. pylori negative. After a median follow-up of 6 months, 93.3% of the patients complained of UGI symptoms, the most prevalent being dyspepsia (66.7%) (P<0.001). The prevalence of GERD did not differ before and after LSG, but GERD symptoms disappeared in 83.3% of patients. Vomiting increased significantly, occurring in 20% (P=0.030) of all patients, associated with GERD. A significant correlation was found between GERD and hiatus hernia in all patients (P<0.001) and a correlation was also found between vomiting and incompetent cardia in 66.7% of patients (P=0.029). Conclusion After a median follow-up of 6 months following LSG, dyspepsia, rather than GERD, was the main complaint. Hiatus hernia was strongly related to GERD and incompetent cardia was related to vomiting taking into consideration that all patients who developed vomiting had associated GERD.
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Anorectal function after total colectomy with ileoanal anastomosis for total colonic aganglionosis p. 119
Tarek Gobran, Wael Elshahat, Mohammad A Al Ekrashy, Mohammed Khalifa
DOI:10.4103/1110-1121.204524  
Background/purpose Total colonic aganglionosis is a rare form of Hirschsprung’s disease. Many techniques have been described for its management to improve the outcome as regards anastomotic leakage, recurrent constipation, and incontinence. The aim of this study was to assess the function of anorectum as regards the frequency and continence using the standard scoring system. Patients and methods In this retrospective study, 15 patients were evaluated after treatment in Zagazig University Hospitals. All cases underwent transanal endorectal pull-through with ileoanal anastomosis. All patients were evaluated by applying the Wexner score at 1, 3, and 6 months postoperatively. Results Fifteen infants were included in the study. None of them reached a high score level at sixth month postoperatively (i.e. totally incontinence). On applying the scoring system, the mean±SD result of all patients at first postoperative month was 15.0667±2.52039; at the second evaluation in the third month postoperatively the mean±SD score was 11.0667±3.28344, and lastly at the sixth month evaluation the mean±SD was 5.8667±2.82506. All results were significant on comparing the third month results with the first month results and on comparing the sixth month score results with either the first or the third month postoperatively. Conclusion Although total colonic aganglionosis is a rare form of Hirschsprung’s disease, it needs staged surgical intervention. The most important stage is the second definitive one. Despite variable methods described for reconstruction after total colectomy, ileoanal one carries less major surgical complications and acquires accepted anorectal functional results with more improvement with time postoperatively.
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Outcome of the laparoscopic total extraperitoneal approach with direct dissection and mesh hernioplasty in the treatment of inguinal hernias p. 124
Osama H Abd-Raboh, Taha A Ismael, Hamdy A.H. Mohamed, Mostafa M El-Sheikh
DOI:10.4103/1110-1121.204525  
Aim The aim of this study was to evaluate the laparoscopic total extraperitoneal (TEP) approach with direct telescopic dissection and mesh hernioplasty for inguinal hernias. Patients and methods This study was conducted at the Gastrointestinal, Liver, and Laparoscopic Surgery Unit, General Surgery Department, Tanta University Hospital, over the period from 1 January 2014 to last of June 2015 on 20 patients having inguinal hernias. Results This prospective study included 20 adult patients with primary unilateral inguinal hernias, and all of them were males. The age of patients ranged from 22 to 64 years. There were 11 (55%) patients with right inguinal hernias and nine (45%) patients with left inguinal hernias. The mean operative time was 99.30±25.13 min (range: 60–160 min). The mean analgesia time was 3.75±1.62 days (range: 2–7 days). Twenty-four hours postoperatively, mean visual pain score was 2.8±1.15. There was one (5%) case with scrotal edema. Minor surgical emphysema occurred in two (10%) cases. Hospital stay ranged from 1 to 3 days, and the mean value was 1.35±0.67 days. The mean time until return to work was 14.8±4.26 days (range: 7–21 days). The mean follow-up time was 7.6±2.1 months (range: 6–12 months). There were no reported cases of hernia recurrences. Conclusion The laparoscopic TEP repair is an excellent alternative to open preperitoneal repair of inguinal hernias. The operative time was relatively long, but comparable with many studies discussing the TEP technique, which improved over the time of the study, indicating the need for a long learning curve. This technique was proved to be safe, as it was not associated with major morbidity or recurrence. The complication rate was average as compared with other studies, and there was no hernia recurrence during the follow-up period.
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Application of different methods for stump closure in laparoscopic appendectomy p. 131
Ahmed Elshoura, Osama Hassan, Sherif Saber
DOI:10.4103/1110-1121.204526  
Background Appendicular stump closure is the most critical event in laparoscopic appendectomy. The aim of the present study was to verify the effectiveness of stump closure using the endostapler, extracorporeal sliding knot, and intracorporeal suture in different stages of appendicitis. Materials and methods This prospective study was conducted from July 2014 to March 2016 and included 135 patients who underwent laparoscopic appendectomy. We reviewed patients’ demography, operative time, hospital stay, and complications in different stump closure techniques. Results The stapler group consisted of 45 patients − 27 men and 18 women. The mean age was 33.5 years, mean operation time was 56.4 min, complication rate was 6.6%, and average hospital stay was 1.73 days. The extracorporeal sliding knot group consisted of 43 patients − 24 men and 19 women. The mean age was 36 years, mean operation time was 71.5 min, complication rate was 2.3%, and average hospital stay was 1.8 days. The intracorporeal suture group consisted of 47 patients − 21 men and 26 women. The mean age was 33.6 years, mean operation time was 84.3 min, complication rate was 4.2%, and average hospital stay was 2.3 days. Conclusion Laparoscopic staplers had the least hospital stay and the shortest operative time, inspite of the insignificant difference regarding the complication rates among the three groups. Although the application of the suture knot and the extracorporeal knot had the longest surgical procedure time, they were more suitable because of the economic conditions of our country.
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Comparative study between enhanced recovery after surgery and conventional perioperative care in elective colorectal surgery p. 137
Hussein Elgohary, Mostafa Baiuomy, Ashraf Abdelkader, Mohamed Hamed, Ahmed Mosaad
DOI:10.4103/1110-1121.204527  
Objective This joint research between the Departments of General Surgery and Anesthesiology aimed to examine the feasibility and safety of enhanced recovery after surgery (ERAS) in elective colorectal surgery. Patients and methods The study included 80 patients who were candidates for abdominal colorectal surgery, and were randomly divided into two groups: group C contained 40 patients managed perioperatively through conventional management procedures and group E contained 40 patients managed according to ERAS protocols. Patients in both groups were monitored throughout the perioperative period. Collected data included compliance data, operative data, postoperative complications, bowel recovery as well as the length of ICU and hospital stay. Results The overall compliance rates with the ERAS protocols was 80%. No significant difference was found between the two groups concerning operative time. Pain scores were significantly low (P<0.001) between patients of the ERAS group compared with the other group. First flatus occurred at the first postoperative day in both groups with a significant difference in a number of cases (P<0001) among both groups. Median postoperative length of stay was significantly different (P<0.001) between the two groups. Conclusion ERAS pathway is feasible for application in colorectal surgery, as it shortened the postoperative hospital stay and showed no risk to patients in terms of morbidity or mortality.
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Component separation technique versus inlay mesh technique in patients with large incisional hernia p. 145
Moheb S Eskandaros, Ahmed A Darwish
DOI:10.4103/1110-1121.204528  
Context In large incisional hernias, fascial reapproximation is difficult, and it may lead to hernia recurrence. Component separation (CS) can reconstruct the abdominal wall by functional advancement. Mesh repair (‘inlay’ or ‘bridging’ of the defect) also can be done. But meshes carry risk of infection and visceral erosion. In addition, meshes may separate with time because of the vector forces of the contracting oblique muscles leading to recurrence. Aim of the study This study aimed to evaluate the outcomes in patients with large defects undergoing nonperforator-sparing CS versus standard inlay mesh repair. Settings and design This is a prospective controlled randomized study. Patients and materials A total of 68 patients were included in the study. They were divided into two groups, each including 34 patients. One group was operated with the CS technique and the other with the inlay mesh technique. The patients were observed for postoperative complications and were followed up for 1 year for recurrence. Statistical analysis used Continuous variables were expressed as mean and SD. Categorical variables were expressed as frequencies and percentage. Results There were no statistically significant differences between the two groups regarding the postoperative complications or recurrence rates. The CS technique had less incidence of recurrence than the inlay mesh technique. Conclusion The choice of surgical approach in large incisional hernia is difficult. In the current study, the CS technique was better regarding the shape of the abdominal contour than the inlay mesh technique with less incidence of complications such as adhesions of the bowel to the mesh and hernia recurrence.
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Effects and clinical outcomes of laparoscopic appendectomy in young children with complicated appendicitis: a case series p. 152
Rasha Kassem, Khalid Shreef, Mohammed Khalifa
DOI:10.4103/1110-1121.204529  
Background and purpose Laparoscopic appendectomy for uncomplicated appendicitis is associated with good outcomes but the role of laparoscopy in complicated appendicitis is more controversial because of high incidence of infectious complications. The aim of this current study is to evaluate the efficacy of laparoscopic appendectomy in complicated appendicitis in young children. Patients and methods From May 2015 to May 2016 83 patients aged less than 7 years old underwent laparoscopic appendectomy for complicated acute appendicitis. The following variables were analyzed : age, sex, operative findings, operative time, return of bowel function, resumption of oral feeds, length of hospital stay, postoperative complications (ileus, wound infection and intraabdominal abscess). Results The mean age of studied cases was 6.3 years. In 81 patients (97.6%) the procedure was completed laparoscopically. Two (2.4%) patients required conversion to open appendectomy. The operative time was 75.5±28.8 minutes. Two patients (4.6%) had post-operative ileus. One patient (1.2%) developed superficial wound infection. Four patients (4.8%) developed intra-abdominal collections. The mean length of hospital stay was 5.3±2.1 days. No mortality was recorded. Conclusion Laparoscopic appendectomy can be the first choice for cases of complicated appendicitis in children. It is a feasible, safe procedure and is associated with acceptable post-operative morbidity with rapid recovery and better cosmetic results.
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Safety and stability of inguinal hernia repair in Egyptian patients suffering from portal hypertension-associated ascites using ultrasound-guided nerve block p. 156
Ayman Farouk, Mohamed A Selimah, Marwan El-Fakharany
DOI:10.4103/1110-1121.204530  
Background Inguinal hernia repair in patients suffering from liver disease-induced ascites may be a matter of controversy due to high vulnerability of these patients to stresses. Ultrasound (US)-guided local anesthesia is an effective and safe method that can be applied in such vulnerable patients, giving the surgeon a chance to assess feasibility and stability of hernia repair in such patients. Patients and methods Tension-free hernioplasty under a US-guided nerve block was performed for 14 patients with inguinal hernia-associated abdominal ascites due to portal hypertension (16 procedures) at the Department of Clinical and Experimental Surgery, Medical Research Institute, Alexandria University, from September 2013 to December 2015. Results There was neither operative-related mortality nor major complications during the follow-up period of 16.5 (9–24) months, with no reported recurrences for all patients. Conclusion Inguinal hernia mesh repair using an US-guided nerve block is a safe and effective procedure in patients suffering from liver diseases complicated by ascites.
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Three-year outcomes of laparoscopic sleeve gastrectomy using a 36 Fr bougie p. 162
Ahmed A Darwish, Moheb S Eskandaros
DOI:10.4103/1110-1121.204531  
Context Laparoscopic sleeve gastrectomy (LSG) is a bariatric procedure that causes weight loss by reducing gastric capacity. The evaluation of the effectiveness of this procedure is in constant research. Aim The aim of this study was to evaluate the 3-year outcomes of LSG and its effect on preoperative diabetes mellitus (DM) and hypertension (HTN) and to develop the de-novo gastroesophageal reflux disease (GERD) using a 36 Fr bougie size. Settings and design This is a prospective case series. Patients and methods Seventy-seven patients were included in the study that underwent LSG using a 36 Fr bougie. The preoperative BMI was recorded. The postoperative BMI and percentage excess weight loss were recorded at 3, 6, 12, 24, 36 months. Furthermore, the postoperative status for DM and HTN were noticed with the development of de-novo GERD symptoms. Statistical analysis Continuous variables were expressed as mean±SD. Categorical variables were expressed as frequency and percentage. Results The mean±SD BMI preoperatively was 43.13±3.77 kg/m2. The mean±SD BMI after 3, 6, 12, 24, and 36 months was 37.19±3.28, 32.9±2.91, 29.23±2.75, 27.86±2, and 26.6±1.5 kg/m2, respectively. The mean percentage excess weight loss after 3, 6, 12, 24, and 36 months was 34.62±1.36, 55.94±5.88, 68.53±5.87, 72.08±4.92, and 74.99±4.99%, respectively. Of patients having type II DM, 70.3% showed dramatic improvement. In addition, with respect to HTN, 64.5% of the patients having HTN showed improvement. After the procedure, 17 (22.1%) patients suffered from GERD after 1 year, eight (10.4%) after 2 years, and four (5.2%) after 3 years. Conclusion LSG is an effective operation in weight loss and in the management of type II DM and HTN. However, long-term studies (>6 years) should be conducted to justify the maintenance of weight loss and the alleviation of the symptoms of GERD.
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Is mesh fixation considered a routine step in transabdominal preperitoneal hernia repair? The Zagazig-Benha experience p. 168
Taha A Baiomy, Ehab M Oraby
DOI:10.4103/1110-1121.204532  
Introduction Inguinal hernia repair is the most common procedure in general and visceral surgery worldwide. Over the past two decades, laparoscopic inguinal hernia repair has become more and more popular. Objectives The aim of the present study was to compare between fixation and nonfixation of the mesh in laparoscopic inguinal hernia repair. Patients and methods This prospective study was carried out on 58 consecutive male patients with inguinal hernia. The patients were divided into two groups (A and B). Group A patients were treated by using the mesh fixation transabdominal preperitoneal (TAPP) repair, and group B patients were treated by using the mesh nonfixation TAPP repair. Then, postoperative pain and hernia recurrence were evaluated for the two groups. Results Highly significant difference was detected between the two groups as regards postoperative pain. Whereas, only one (3.44%) recurrent case was found in group B patients, which was found to be nonsignificant. Conclusion Mesh fixation as a routine appears to be unnecessary in TAPP repair. It is associated with higher operative costs and an increased chronic groin pain without increasing the risk for early hernia recurrence.
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Primary ventral hernia repair: mini-component separation technique versus onlay mesh repair p. 174
Hussein Elgohary, Ehab Oraby, Mostafa B Abdelwahab
DOI:10.4103/1110-1121.204533  
Introduction Although with the increased frequency of ventral herniorrhaphy use, it is somewhat surprising that the question of optimal choice of repair is not yet settled. The published data of numerous studies revealed results with major differences. Objectives The aim of this study to compare the results of mini-component separation technique (mini-CST) repair of primary ventral hernia cases with onlay mesh repair. Patients and methods This prospective randomized controlled study was carried out on 64 consecutive adult patients with primary ventral hernia. Patients were divided randomly into two groups. Group A was treated using mini-component separation technique. Group B was treated using suture repair reinforced with onlay polypropylene mesh. Results Group A repair demonstrated 9.4% seroma rate and 6.3% surgical site infection rate (SSI), no wound dehiscence, and 3.1% recurrence rate. Group B repair demonstrated 15.6% seroma rate, 25% SSI, 3.1% wound dehiscence, and no recurrence. For seroma rate, infection, wound dehiscence, and recurrence, P values were 0.44, 0.038, 0.31, and 0.31, respectively, between both the group. These results indicate that mesh repair has a small reduction in recurrence rate compared with mini-CST for primary ventral hernias, but an increased risk of SSO (seroma, SSI, and wound dehiscence). Conclusion The repair of primary ventral hernia cases can be made simple without foreign body implantation by holding the concept of CST to allow for tension-free midline fascial closure. We prefer to retain the mesh repair for big defects or complex cases that need either mesh reinforcement or even bridging of the defect.
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Safety and efficacy of laparoscopic splenectomy in hematologic diseases with massive splenomegaly p. 181
Hany M El-Barbary, Mohamed A.M. El-Menoufy
DOI:10.4103/1110-1121.204534  
Splenomegaly and massive splenomegaly are common clinical findings in hematological diseases especially in inherited hemoglobin disorders (sickle cell disease and thalassemia) and hematologic malignancies. Laparoscopic splenectomy (LS) is the gold standard management of most splenic pathologies in which medical therapy fails to control the symptoms or complications. However, splenomegaly could be a challenging task for a laparoscopic removal. In this study, the authors explored the feasibility of LS in patients with splenomegaly and massive splenomegaly using a totally laparoscopic approach. This is a prospective case series of 18 patients (4–27 years old) who were operated from January 2014 till April 2016 with splenomegaly because of sickle cell disease, thalassemia, or both in a secondary-level hospital, Qatif, Eastern Province, KSA. A total of eight patients had hypersplenism, and 10 patients had very big spleens with abdominal pain and pressure symptoms. Male : female ratio was 3 : 1. The operative time was significantly prolonged in massive splenomegaly, mainly because of extraction time. One case was converted to open because of intraoperative bleeding. The operated maximum spleen size was 23 cm in longitudinal axis. Median hospital stay was 2.5 day. There was no overwhelming postsplenectomy sepsis. There were no mortalities. Although massive splenomegaly was associated with increased rates of open conversion, LS in splenomegaly is feasible and safe in experienced hands.
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Laparoscopic cholecystectomy in hepatic patients p. 189
Emad M Elsageer, Ahmad M Atiya, Tohamy A Tohamy
DOI:10.4103/1110-1121.204535  
Aim The aim of this study was to compare low-pressure with high-pressure pneumoperitoneum laparoscopic cholecystectomy in hepatic patients. Patients and methods This prospective study included 40 consecutive patients with calcular gall bladder and hepatitis C who were admitted in The Department of General Surgery, Minia University Hospital, between July 2016 and December 2016. We classified them into two groups, group I (high pressure) and group II (low pressure). Results In group I, aspartate aminotransferase (AST), alanine aminotransferase (ALT), γ-glutamyltransferase, and lactate dehydrogenase (LDH) were significantly increased 24 h postoperatively. AST and ALT were elevated three-fold, and AST, ALT, and LDH reached levels over upper normal limits after 24 h postoperatively. However, in group II patients the elevation of enzyme levels did not reach two-fold and remained within the normal limits. On comparing the two groups, the elevation of AST, ALT, and LDH was significant for group I (P=0.0001). Moreover, elevation of γ-glutamyltransferase was significant (P=0.041), whereas alkaline phosphatase level changes were nonsignificant. Conclusion We conclude that pneumoperitoneum 14 mmHg pressure decreased blood flow to the liver with increased postoperative serum enzyme levels, and pneumoperitoneum 10 mmHg pressure is superior to 14 mmHg pressure pneumoperitoneum in laparoscopic cholecystectomy. Therefore, we recommend this low-pressure pneumoperitoneum in hepatic patients.
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CASE REPORT Top

Huge retroperitoneal liposarcoma: a case report and review of literature p. 193
Basel Refky, Mohamed Abdelkhalek, Mohamed Zuhdy, Khaled Gaballa, Mohammad Arafa, Khadega Mohamed Ali, Amr Hany Metwally, Basma Gadelhak, Waleed Elnahasa
DOI:10.4103/1110-1121.204522  
Introduction Liposarcoma is the most common malignant tumor of the retroperitoneum. We report a case of huge retroperitoneal liposarcoma weighing 44 kg that was successfully resected. Case presentation A 53-year-old Egyptian male patient was presented to our department with progressive abdominal enlargement. Computed tomography scans of the chest, the abdomen, and the pelvis revealed a huge pelviabdominal mass highly suggestive of liposarcoma. Abdominal exploration was performed with resection of a huge retroperitoneal mass weighing 44 kg that was proven pathologically to be liposarcoma. Conclusion Despite the huge size of retroperitoneal liposarcomas, they can be surgically resected successfully.
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