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   Table of Contents - Current issue
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July-September 2020
Volume 39 | Issue 3
Page Nos. 513-806

Online since Friday, August 28, 2020

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EDITORIAL  

“Primum non nocere” – first do no harm – in the time of SARS-CoV-2/COVID-19 Pandemic p. 513
Majid Bassuni, Ahmed-Hazem I Helmy
DOI:10.4103/ejs.ejs_145_20  
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Predicting the risk factors of difficult laparoscopic cholecystectomy step by step p. 515
Taha Yassein, Islam Iyoab, Ahmed Sallam, Manal Gomaa, Amr Sadek, Maher Osman, Tarek Ibrahium, Amr Mostafa Aziz
DOI:10.4103/ejs.ejs_8_20  
Background Laparoscopic cholecystectomy (LC) has become the gold standard in the treatment of symptomatic gallstones. It has replaced open cholecystectomy as the therapeutic modality in the treatment of cholelithiasis. Aim The aim of the study is to determine the predictive factors for difficult LC step by step using clinical and ultrasonography parameters. Patients and methods This is a prospective study conducted on 75 patients suffering from chronic calculous cholecystitis and planned for LC at the National Liver Institute, Menoufia University . All patients were compared according to demographic data, clinical data, laboratory profile, abdominal ultrasound result, and operation data. Results Difficult gallbladder (GB) bed dissection was found significantly related to patients with a history of acute cholecystitis, positive Murphy’s sign, history of endoscopic retrograde cholangiopancreatography (ERCP) and GB wall thickness more than 3 mm during inspection. Distended GB and dense adhesions were found statistically significant in increasing the risk of bile and stone spillage during operation. Difficulty of extraction of GB was found in patients with a history of ERCP, distended GB and GB wall thickness more than 3 mm. Risk of conversion to open was found significantly related to patients with a history of biliary pancreatitis and patients with a history of ERCP. Operative time was found prolonged in cases with a history of biliary pancreatitis, history of ERCP, distended GB, multiple stones, and dense adhesions encountered during the first 5 min inspection. Conclusion BMI, history of acute attacks, positive Murphy’s sign, history of ERCP, history of biliary pancreatitis, GB wall thickness more than 3 mm, multiple GB stones, and dense adhesion does pose difficulty in various steps during LC. So, preoperative prediction of possible difficulties may help a surgeon in choosing the approach (open/laparoscopic) most suitable for a particular patient, counseling the patient about it.
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Impact of intraoperative ultrasound on pancreatic tumor resectability p. 523
Hesham A Elmeligy, Mohamed M Ali Esawy, Amr M Gomaa, Mohamed A Elashry
DOI:10.4103/ejs.ejs_9_20  
Background Usually, there is no intraoperative image guidance performed during abdominal exploration of pancreatic tumor. Intraoperative ultrasound (IOUS) enhances the visualization of pancreatic tumor during resection, so it needs to be investigated in detail. Objective The aim of the study was to assess the impaсt of IOUS on preoperative surgical strategy. The authors compare IOUS findings with the operative assessment of the radicality of resection and vascular contact. Patients and methods The study proceeded in the Department of Surgery, Theodor Bilharz Research Institute from 2016 to 2019. This prospective cross-sectional study was to assess the impact of IOUS on preoperative surgical planning and to assess whether the radicality and vascular affection of the tumor would be correctly evaluated or not. IOUS was conducted on 38 patients by a competent surgeon during abdominal exploration of the pancreatic tumor and was then compared with intraoperative assessment. Results IOUS affects surgical planning in 66.6% of cases. Radical resection was achieved in 36 out of 38 malignant tumors (94.7%). By using preoperative imaging vascular contact was assessed correctly in 68.4% of the patients compared with 89.4% by using IOUS. Conclusion IOUS assessment in pancreatic tumors changed the surgical strategy in 21% of the patients. So, the authors can use IOUS to assess the resectability of the tumor and the possibility of vascular contact during surgical resection.
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Endoscopic stenting as a bridge to elective surgery versus emergency laparotomy for patients with acute malignant large bowel obstruction p. 529
Taher H Elwan, Nasser A Zaher
DOI:10.4103/ejs.ejs_11_20  
Objectives To evaluate the effect of colonic decompression using endoscopic colonic stenting (ECS) followed by elective surgery versus emergency surgical intervention in cases of acute obstructive malignancy of the colon. Patients and methods The current prospective comparative study includes 60 patients who presented with a picture of acute malignant colonic obstruction. The large bowel obstruction was defined as colonic dilation with multiple air-fluid levels on plain abdominal radiograph plus the findings of an abdomen computed tomography result compatible with a malignant stricture. Patients were classified according to the type of management into emergency surgery (ES) and ECS. Data were gathered and analyzed. Results In the ES group, 18/30 (60%) patients had a resection and primary anastomosis, 8/30 (26.7%) patients underwent Hartman’s operation, whereas the remaining 4/30 (13.3%) underwent colostomy only. In the ECS group, 24/30 (80%) patients had a resection and primary anastomosis in an elective surgery, whereas the remaining 6/30 (20%) cases had a diverting stoma. All patients with obstructed colon cancer on the right side showed a clinical and technical success rate of 100% in both groups. However, obstructed colon cancer on the left side did not show the same rate of success in ES and ECS group. The ECS group showed a remarkably lower (P=0.02) rate of ICU admission than the ES group. The mean total hospital admission was remarkably longer (P=0.047) in the group ES group compared with the ECS group. Postoperative complications were remarkably higher (P=0.028) in the ES group compared with the ECS group. Conclusion ECS for patients having acute malignant right or left colonic obstruction is a safe and effective procedure, with excellent technical and clinical success rates.
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Oral B-blockers versus intralesional corticosteroids in treatment of infantile cutaneous hemangiomas p. 536
Ahmed O Mohamed, Tamer F Abd El-Aziz, Nehad Abdo Ahmed Zaid, Yahia Mohameed Alkhateep, Magdi Ahmed Loulah
DOI:10.4103/ejs.ejs_12_20  
Aim Infantile hemangioma (IH) is one of the most common benign tumors of childhood, with an incidence of between 4 and 10%. Multiple modalities for treatment for IH were proposed, most commonly B-blockers and corticosteroids. Our study objective was to compare between oral B-blockers and intralesional corticosteroids injections in treatment of IHs. Patients and methods This was a prospective study that included 52 patients diagnosed with IH in two pediatric surgery tertiary centers in Egypt. Patients were divided into two groups: group A patients underwent intralesional injection of betamethasone at a dose of 10–40 mg/ml in three to six separate sessions at an interval of 1 month, whereas group B patients were given oral propranolol at a low dose of 0.5–1 mg/kg/day for 3–6 months. Changes in size and color of the hemangioma each month and the occurrence of any complications were recorded for 6 months. Regression of size was classified into excellent (75–100% decrease in size), good (50–75% decrease), poor (25–50% decrease), and no response. Results ‘Good’ response to intralesional corticosteroids was achieved in nine patients, whereas most patients had either ‘poor’ or ‘no response’ (n=14). On the contrary, most patients in the propranolol group exhibited ‘excellent’ or ‘good’ response (n=21) with only four patients not responding to treatment. Ulceration occurred in two patients who underwent intralesional steroid injection, whereas hypotension occurred in one patient with B-blockers. Conclusion Our study confirms the superiority of oral B-blockers in treatment of superficial IH when compared with intralesional injection of steroids.
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Role of laparoscopy in acute abdomen p. 540
Morsy M Morsy, Tarek A Mostafa, Mahmoud M.G Hassan
DOI:10.4103/ejs.ejs_13_20  
Background and aim Admission with an acute abdomen is one of the commonest reasons for emergency surgical admission. The aim of this study was to examine the role of laparoscopy in the management of such cases. Patients and methods A total of 35 patients who presented with acute abdomen in the period between January 2016 and March 2018 were enrolled. Their age was ranged between 10 and 55 years. After history taking and examination, baseline laboratory data were done. All patients were subjected to plain abdominal radiography, abdominal ultrasound, and computed tomography if needed. Under general anesthesia, laparoscopy was performed in all patients in a supine position. Results The mean age of enrolled patients was 33.51±10.54 years. Approximately two-thirds of them were females. Besides the abdominal pain, 80.0% patients had a fever, and more than one-half of them (54.3%) had vomiting. Based on an abdominal ultrasound, one-third of the cases had acute calculous cholecystitis. Approximately half (48.6%) of the cases had unremarkable findings and needed another test to reach a final diagnosis. Based on clinical, laboratory, and radiological data, we reached conclusion in up to 40% of the cases as acute appendicitis and 28.6% as acute cholecystitis, but we could not reach a diagnosis in approximately one-third of the cases. Only 5.7% could not be completed by laparoscopy and were converted to open surgery owing to bleeding. The majority (77.1%) of the cases had no postoperative complications. Conclusion Laparoscopy provided higher diagnostic accuracy and improved quality of life in cases of acute abdomen.
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En bloc high hilar dissection versus conventional hilar dissection in living donor liver transplantation donors: a comparative, single-center study p. 547
Ahmed A Abdelshafy, Kamal M Elsaid, Abdelrahman M Elghandour, Dalia F Emam
DOI:10.4103/ejs.ejs_14_20  
Background Living donor liver transplantation (LDLT) has become an accepted treatment option for end-stage liver disease. Biliary complications still remain a major concern and are considered the Achilles’ heel of LDLT, with a morbidity ranging between 20 and 42.1%. The high incidence of biliary complications can be attributed mainly to the affection of the blood supply of bile ducts. The high hilar dissection technique was described aiming at preservation of bile duct vascular supply. Patients and methods A total of 66 adult LDLT donors were operated in a single, liver transplant center (Ain Shams University Specialized Hospital) between January 2017 and August 2018. The study cases were divided into two groups: group A with conventional hilar dissection and group B with en bloc high hilar dissection. A comparative study was conducted between the two groups as regards early and late biliary complications. Results The 66 LDLT donors were divided into two groups: group A included 33 donors with conventional hilar dissection and group B included 33 donors with en bloc high hilar dissection. The occurrence of postoperative biliary leak was significantly more in the conventional hilar dissection group (18.2%) compared with the en bloc high hilar dissection group (3.0%) (P=0.046). Conclusion The en bloc high hilar dissection technique may decrease the incidence of biliary complications in LDLT donors as it protects the biliary vascular supply and facilitates the closure of the donor stump.
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Feasibility and intermediate-term outcome of catheter-directed thrombolysis in management of acute nontraumatic viable and/or marginally threatened lower limb arterial thrombosis p. 553
Amr El Bahaey, Haitham A Eldmarany, Samy A Khalefa, Ahmed Elmahrouky
DOI:10.4103/ejs.ejs_15_20  
Introduction Although catheter-directed thrombolysis (CDT) has been shown to be an effective method to salvage the ischemic limb resulting from acute thrombotic occlusion and bypass graft thrombosis, bleeding complications remain a major problem of this treatment. Aims To evaluate the success rate, the patency rate, the limb salvage rate, and possible complications of CDT therapy in patients presented with acute nontraumatic unilateral lower limb ischemia. Patients and methods CDT was offered to patients with acute lower limb ischemia (ALI) who presented to Vascular Surgery Emergency Department at Cairo University hospitals in the period between May 2018 and December 2018. We only included patients with unilateral ALI with viable or marginally threatened limbs (Rutherford class I and class IIa). Results During the period from May 2018 till December 2018, we received 20 patients (12 males and eight females) who were admitted with acute unilateral lower limb ischemia, in whom CDT was done. The mean age of patients was 54.25±9.2 years (range, 36–73 years). Complete thrombolysis had been achieved in 14 (70%) cases, whereas in six cases, it was unsuccessful (30%), of which three (15%) cases had incomplete thrombolysis and in the other three (15%) cases thrombolysis failed. Above-knee amputation had been carried out to one of the failed thrombolysis cases, representing 5% of the total number of patients. All cases with successful thrombolysis have achieved 6-month follow-up with patent treated arteries (patency rate, 100%). Two (10%) patients died during the period of follow-up, both of them had successful thrombolysis and died within the first 4 weeks owing to medical problems unrelated to thrombolysis procedure (cardiac problems). Conclusion Thrombolysis remains a safe and effective alternative to surgery for treating ALI.
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Management of isolated deep postanal space suppuration via posterior sphincterotomy p. 561
Walid M Abd El Maksoud, Mohamed Mazloum Zakareya, Ahmed D Mohii
DOI:10.4103/ejs.ejs_16_20  
Aim The aim of this study was to evaluate the treatment of isolated deep postanal space (DPS) suppuration, using the posterior midline approach in terms of recurrence and post-drainage fistula formation. Patients and methods The study included 16 patients (13 men and three women) with isolated DPS suppuration without clinical or radiological evidence of extension. DPS affection was demonstrated by bidigital examination and preoperative MRI. All patients were managed by the posterior sphincterotomy approach performed by senior colorectal surgeons. Results Patients complained for a mean period of 23.75±19.43 days before seeking medical advice. There was great variability between duration in patients complaining of acute pain only (6.80±2.28 days) and chronic discharge only (31.40±14.09 days). Recurrence was encountered in two (12.5%) patients in the form of recurrent abscess (6.25%) that developed 3 months after the first drainage and anal fistula (6.25%) that developed 4 months postoperatively. Patients in the study reported satisfactory results with regard to postoperative continence after 3 months. These results showed further improvement at 6 and 12 months. Conclusion Isolated DPS suppuration should be managed with a senior colorectal surgeon. Without awareness of the problem and a clear understanding of anatomy, it is impossible to achieve successful treatment of the isolated DPS suppuration. Management of isolated DPS by the posterior sphincterotomy approach seems to be a successful technique with low recurrence rate and satisfactory postoperative continence status.
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Three-year experience with Integra dermal regenerative template as a reconstructive tool p. 567
Muneera E Ben-Nakhi, Hazem I Eltayeb
DOI:10.4103/ejs.ejs_17_20  
Background Since the introduction of Integra dermal regeneration template, several reports have been published worldwide proving its ability as a less invasive reconstructive tool. Our aim is to report our 3-year experience with Integra as the first report from Kuwait. Patients and methods Integra was used for reconstruction of a wide variety of complex wounds in different body locations. The dermal regenerative template replaced soft tissue defect as a first stage followed by skin grafting as a second stage. Forty patients were included with mean age of 40.2±20.7 years, with 24 cases having one or more comorbidities. Twenty-five patients were female and 15 were males. We had 20 cases with exposed underlying structures in wound bed, including bones, tendons, and joints. Results The average engraftment rate of Integra was 97±10.2%. Average time for skin grafting was 20.4±4.8 days and average skin graft take was 95±10.9%. Early complications included a case of Integra infection and another case of hematoma. After skin grafting, there were two cases of partial graft losses that healed without the need for regrafting. Complete wound healing was achieved in all cases within 8 weeks. Mean follow-up period was 16.65±8.4 months. No contracture or recurrent ulceration was documented. Apart from hyperpigmentation, 95% of the patients were satisfied with reconstruction outcome, with normal skin pliability in 95% cases, and normal range of movement in 85% of cases. Conclusion Integra is efficient and safe, with wide range of clinical indications. It has very high engraftment rate even in complex wounds with exposed bone or tendon. We observed high patient satisfaction and excellent pliability and final function.
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Impact of mesh fixation vs non-fixation in laparoscopic transabdominal preperitoneal inguinal hernia repair on chronic groin pain and quality of life: a prospective randomized study p. 574
Mohamed E Zayed, Mohamed S Essa
DOI:10.4103/ejs.ejs_19_20  
Aim A randomized controlled study comparing the impact of fixation vs non-fixation of mesh in laparoscopic transabdominal preperitoneal (TAPP) inguinal hernioplasty on chronic groin pain and quality of life of patients. Patients and methods This study includes 100 patients presented with primary unilateral indirect inguinal hernia treated at Benha University Hospital from June 2016 to August 2018. Patients were randomized to TAPP inguinal hernia repair with fixation of mesh (group A, n=50) and without fixation of mesh (group B, n=50). Parameters assessed included operative duration, time to early ambulation, postoperative pain, and postoperative complications and quality of life. Assessment of pain was done using the visual analog scale at 1 day, 3 months, and 6 months after surgery. Evaluation of quality of life was done using the 36-item short-form health survey 3 months postoperatively. Results The mean operative duration and time to early ambulation in group B (without mesh fixation) were reduced significantly in comparison to group A (with mesh fixation). The visual analog scale score at 1 day, 3 months, and 6 months after surgery for group B was significantly lower than in group A. The physical function (PF), bodily pain (BP), role physical (RP), and general health (GH) in group B were significantly higher than group A while there is no statistically significant difference in vitality (VT), role emotional (RE), social function (SF), and mental health (MH) between group A and group B. Conclusion Mesh fixation and non-fixation in laparoscopic TAPP approach for the repair of inguinal hernia are comparable regarding operative duration, postoperative complications, and time to ambulation while pain scores and quality of life were significantly better in the non-fixation group.
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Laparoscopic inguinal hernia repair: is dual-approach better than classic transabdominal preperitoneal repair? p. 582
Sulaiman A Saif, Salah I Mohammed, Almoutaz A Eltayeb, Mostafa A Hamad
DOI:10.4103/ejs.ejs_22_20  
Background Transabdominal preperitoneal repair (TAPP) and total extraperitoneal repair (TEP) are the two major types of laparoscopic repair for inguinal hernia. Although TAPP is easier, there is still some difficulty in sac and peritoneal dissection. As a result of this, a new modification of TAPP, under the name of ‘dual approach’ (DA), was introduced by inflating the preperitoneal space with CO2 aiming to facilitate dissection and save time. The early reported results of this approach were encouraging. Aim The authors aimed to compare TAPP with the DA. Patients and methods In all, 40 consecutive patients with inguinal hernia were prospectively randomized into two equal groups; group I underwent TAPP and group II underwent DA. Preoperative, intraoperative, and postoperative data were collected and statistically analyzed. Results The mean age was 43±16 years and the mean BMI was 27.5±3.4. The mean operative time was 76.8±15.9 and 81.2±11.9 for TAPP and DA, respectively, with no significant difference. Within each group, the learning state of the operator affects the operative time significantly. Regarding the operative difficulty from the operator’s perspective, there was no significant difference considering both procedures as a whole. However, the lateral and medial preperitoneal dissection was significantly easier for the DA. On the other hand, the difficulty in sac dissection did not significantly improve with the DA. There was no significant difference between both groups regarding hospital stay, intraoperative and postoperative complications, number of analgesic doses, postoperative pain, or recurrence. Conclusion DA offers easier dissection of the lateral and medial pre-peritoneal pockets but not the sac. However, this new approach does not offer advantages over the classic TAPP regarding operative time, hospital stay, complications, postoperative pain, or recurrence.
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Carotid body tumor surgery: challenges and management p. 590
El-Sayed A Abd El-Mabood, Hosam A Tawfek, Waleed A Sorour
DOI:10.4103/ejs.ejs_23_20  
Purpose To assess the challenges and management of carotid body tumors (CBTs). Adequate planning by the surgeon can greatly reduce adverse events of such rare and difficult tumors. Background CBTs are rare. Despite over a century of describing surgery, controversy remains surrounding details of their treatment. Most complications are considered technically preventable. Patients and methods This prospective study included 13 cases diagnosed as CBT. Patients were subjected to clinical evaluation, carotid duplex ultrasound, computed tomography angiography scan, and sometimes MR angiography. All patients underwent CBT resection and when needed vascular reconstruction. Patients were classified into three groups depending on Shamblin classification. Results Mean operative time was longer in patients of Shamblin class 3 (5.4±0.77 h; range, 4.5–6 h; P<0.001). Regarding vascular reconstruction, all patients of Shamblin class 3 were reconstructed by interposition vein graft and two patients of Shamblin class 1 were reconstructed through primary repair, but patients of Shamblin class 2 were reconstructed by all means. In postoperative follow-up complications, bleeding was more significantly in Shamblin class 3 (P=0.032). Cranial nerve deficit was observed in four (33.3%) patients, and all of them were transient. The mean size of excised tumor was 5.17±1.4 cm, with range of 3–7.5 cm. Conclusion Early surgical excision by a vascular surgeon is the only proven cure for CBTs, because they are small and easy to remove. However, if neglected, there will be many challenges, as most tumors can become locally invasive. Meticulous periadventitial (and sometimes subadventitial) dissection can greatly reduce the rates of complications.
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Single-dose preoperative vitamin D and calcium supplementation to prevent hypocalcemia after total thyroidectomy: a comparative clinical trial p. 599
Tamer M El Shahidy, Mahmoud A Yassin, Fady Fayek
DOI:10.4103/ejs.ejs_24_20  
Background Hypocalcemia is not a rare complication after total thyroidectomy. It may be predisposed by preoperative low serum calcium, malignancy, prolonged surgery, inexperienced surgeons, inappropriate use of diathermy, and lack of loop magnifier during surgery. It causes patient distress and may prolong hospital admission time. Calcium and vitamin D administration may help decrease its rate. Patients and methods Two groups of patients undergoing total thyroidectomy were included. Each group included 43 patients. One group was given a single dose of calcium 3 g and vitamin D 40 000 IU on the preoperative day (supplementation group), and no calcium or vitamin D was given to the other group (non-supplementation group). Patients were monitored for clinical hypocalcemia and serum calcium level at 6, 12, 24, and 48 postoperative hours, as well as postoperative vitamin D level and serum calcium after 1 month. Results In the supplementation group, the authors reported three cases of clinical hypocalcemia and seven cases of laboratory hypocalcemia. In the nonsupplementation group, the authors reported 19 patients with laboratory hypocalcemia and 10 patients with clinical hypocalcemia, with significant difference between groups. Postoperative calcium and vitamin D levels were significantly higher in the supplementation group. Conclusion A single-dose preoperative calcium and vitamin D administration is effective in prevention of postoperative hypocalcemia after total thyroidectomy, especially in simple cases. Complicated and malignant cases may need postoperative calcium administration.
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Comparative study between drug-coated balloon angioplasty vs plain balloon angioplasty in management of venous stenosis in hemodialysis access circuit p. 603
Mohamed A Ali, Mohamed A Abdulrahaman, Mohamed Hamza
DOI:10.4103/ejs.ejs_25_20  
Introduction Juxta-anastomotic venous stenosis is a major concern associated with arteriovenous fistulas, which is mainly a result of neointimal hyperplasia. Although balloon angioplasty remains the cornerstone treatment for vascular access stenosis, the combination of venous anatomy and physiology, with the pre-existing endothelial dysfunction of uremic patients, generally leads to poor mid-term and long-term results. Theoretically, vascular access patency may be optimized by a technology that would both block negative vessel wall remodeling and inhibit fibromuscular hyperplasia. One such approach could be the use of angioplasty with drug-coated balloon (DCB) angioplasty. Patients and methods Within a 10-month period, 80 patients with different types of hemodialysis access stenosis in whom percutaneous transluminal angioplasty (PTA) was indicated were prosTectively, randomized to have either DCB or plain balloon angioplasty (PBA). This study was designed to compare primary patency rates and target lesion revascularization of DCB vs PBA to preserve the patency of the vascular access circuit in patients undergoing hemodialysis after 1 year of follow-up. Results All patients enrolled in the study completed the 1-year follow-up period. Access circuit primary patency results were also significantly in favor of DCB angioplasty (DCB, 287 days, and PBA, 156 days; P=0.04). Target lesion revascularization-free survival was significantly superior in the DCB group according to the Kaplan–Meier survival analysis curve (DCB, 316 days, and PBA, 172 days; P=0.041). There was no statistically significant difference in this subgroup analysis (P>0.1). Conclusion In this two-center study, DCB angioplasty results in improved vessel patency and is superior to plain balloon dilation in the treatment of venous stenoses of failing native or prosthetic arteriovenous shunts used for dialysis access.
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Feasibility of gluteus maximus myocutaneous pedicled flap for presacral pressure sore reconstruction: a simple approach p. 613
Ayman M Abdelmofeed, Mohamed F Abdelhalim
DOI:10.4103/ejs.ejs_26_20  
Background Pressure sore, bed sores, and decubitus ulcer have the same meaning and are used to describe ischemic tissue loss resulting from prolonged pressure over bony prominence. They can develop anywhere in the body, but often are located in the trochanteric, ischial, heel, and sacral areas. Although tissue destruction can occur over areas like the scalp, shoulders, calves, and heels when a patient is lying down, ischial sores occur in wheelchair-bound patients who are sitting, making ‘pressure sore’ the better term. Objectives The purpose of the study is to describe our experience in the management of sacral pressure sore with a gluteus maximus myocutaneous flap, its feasibility and outcome. Patients and methods Our prospective study has been conducted in the Surgery Department of Benha University Hospital from February 2017 to February 2019 on 20 patients treated with a unilateral gluteus maximus myocutaneous flap to reconstruct the presacral defect due to pressure sore and all patients have signed informed consents before they have been involved in this study. Results Gluteus maximus flap in presacral pressure sores is a highly feasible and effective method for the treatment of presacral pressure ulcer defect. It has been associated with short operative time (average 45 min) and small amounts of intraoperative blood loss (average 338 ml), three cases out of 20 showed postoperative hematoma, two cases developed wound dehiscence, two cases developed infection, one case developed partial flap necrosis, four cases developed pigmentation, two cases developed keloid, and only one case developed postoperative recurrence. Conclusion The gluteus maximus myocutaneous flap is a useful, safe, and versatile flap for the repair of presacral decubitus ulcer by a simple approach. It may be recommended as the procedure of choice for surgical treatment of this type of wound.
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A comparison between reversed cross-finger flap and Quaba flap in reconstruction of proximal dorsal digital defects p. 622
Mohamed S.A Elhoda, Tarek F Keshk, Ahmed S El Gamal, Ahmed A Taalab
DOI:10.4103/ejs.ejs_28_20  
Background The aim of the study is to compare between reversed cross-finger flap and Quaba flap in reconstruction of proximal dorsal digital defects. The hand is an important part of the body with unique characteristics that plays an indispensable role in human life. Soft-tissue defects and deformities of the hand are caused by trauma, burn, infection, and tumor. These defects if not managed properly can cause a temporary or permanent disability in the hand. Patients and methods This cohort prospective study was conducted at Menoufia University Hospitals from January 2018 to January 2020, with a follow-up of 6 months. The population of the study was 43 patients with proximal dorsal digital defects. We divided the cases into two groups: the first underwent reversed cross-finger flap and the second underwent Quaba flap. Follow-up was done over 6 months regarding donor and recipient site functional and esthetic outcomes. Results This study was done on 43 patients: 22 (51%) patients underwent Quaba flap and 21 (49%) patients reversed cross-finger flap. Thirty-seven (86%) patients in our study had posttraumatic defects and six (14%) patients had postburn deformity on dorsum of fingers. There was a statistically significant difference in incidence of complications between the two groups, in favor of Quaba flap. Conclusions Both reversed cross-finger flap and Quaba flap are reliable for treating small to moderate site defects and deformities on the dorsum of the fingers up to distal interphalangeal joint (DIP). However, Quaba flap has limited donor site impairments, such as contour defect and movement restrictions, in contrast to reversed cross-finger with better functional and esthetic outcome.
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Lymph node expression of cytokeratin 7 and 20 in extended lymph node dissection with radical cystectomy for muscle-invasive disease: value in pathologic staging, treatment strategies, and outcomes p. 632
Amr E Riad, Ismail O Abd-El-Hafeez, Khaled M Kamal, Hossam M El-Ganzoury, Olfat A Hammam, Pierre Mongiat-Artus, Jerom Verine
DOI:10.4103/ejs.ejs_30_20  
Background Precise staging of lymph node (LN) status is an important clinicopathological prognostic parameter following radical cystectomy. Aim The aim was to assess tumor recurrence in patients with T2 transitional cell carcinoma undergoing radical cystectomy with extended pelvic lymphadenectomy. Patients and methods A total of 80 patients underwent bilateral extended lymphadenectomy during radical cystectomy that reached up to the aortic bifurcation and sentinal LN. This was a multicenter study among Urology Departments of Ain Shams University Hospital, Theodor Bilharz Research Institute, and Saint Louis University Hospital. Comparison was based on classification of patients into two groups: cytokeratin 7 and 20 (CK7 and CK20) positive and negative. Results In this study, the authors used both CK7 and CK20 for evaluating the metastatic and micrometastatic burdens in LNs, and these markers were correlated with the primary bladder and its nodal metastases. After displaying the results, we evaluated the markers as follows: CK7 sensitivity is 100%, whereas specificity is 65% and showed 48.8% positive predictive value and 100% negative predictive value, with overall accuracy of 73.8%. CK20 has a sensitivity of 100%, whereas specificity is 65% and showed 48.8% positive predictive value and 100% negative predictive value, with overall accuracy of 73.8%. Conclusion The use of molecular markers provides a better and proper nodal staging but what is thought to be a disadvantage is the exaggerated sensitivity sometimes gives false-positive results.
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Does difficulty assessment of laparoscopic cholecystectomy using currently available preoperative scores need revision? p. 641
Sherif Boraii, Doaa H Abdelaziz
DOI:10.4103/ejs.ejs_31_20  
Introduction Risk factors used for preoperative anticipation of a difficult laparoscopic cholecystectomy should be identified to prevent complications beforehand. The aim of this study was to evaluate factors predicting difficulty and the possibility of conversion to open cholecystectomy before surgery. Patients and methods Patients diagnosed with symptomatic cholelithiasis and scheduled for elective laparoscopic cholecystectomy were enrolled in the study. Patient’s age and sex, previous hospital admissions, BMI, previous abdominal scar, a palpable gall bladder, gall bladder wall thickness, the presence of pericholecystic fluid collection, and impacted stone are considered risk factors that were used to calculate preoperative scores. Surgical procedure was categorized intraoperative as easy, difficult, or very difficult on the basis of duration of surgery or conversion to open cholecystectomy. Results There was no significant difference between intraoperative difficulty regarding age, sex, BMI, and the presence of either abdominal scar or impacted stone. The absence of previous history of hospitalization and the presence of nonpalpable gall bladder were significantly associated with intraoperative categorization as easy cases (P=0.002). Discussion and conclusion The evaluated scoring system requires meticulous revision for the factors included. Insensitive factors could be removed without negative effect on the outcome. Focus should be directed toward significant items regarding sonography findings. It could be applied as a useful tool to predict easy cases but needs adjustment for the factors considered in case of predicting difficult and very difficult cases. The experience of the surgeon is an important factor in assessing difficulty intraoperative.
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Outcome of inlay ventralex hernia patch among patients with ventral hernia at Zagazig University Hospitals, Egypt p. 647
Abd-Elrahman M Metwalli, Ahmed S Arafa, Mostafa M Elaidy
DOI:10.4103/ejs.ejs_38_20  
Background Multiple techniques have been clarified for mesh placement in the hernia repair surgery, including onlay, sublay, and inlay positioning. Meshes with a dual layer have been developed to prevent the formation of adhesions of the viscera to the intraperitoneal mesh. So, the present investigation was conducted to compare the outcome of the ventral hernia repair using inlay ventralex hernia patch with the classic onlay prolene mesh. Patients and method s A randomized clinical trial was carried on 60 patients with a ventral hernia in the Department of General Surgery, Zagazig University Hospitals, Egypt, from January 2018 to January 2020. The patients were equally divided into two groups: group A with inlay ventralex hernia patch and group B with onlay prolene mesh. Results Regarding demographics and clinical presentation, no statistically difference was found between both groups, whereas there was a highly significant differences between group A and group B in the operative time, with mean of 35.4±0.25 and 50.2±0.14 min, respectively, with no significant difference between them in anesthesia type, defect size, and mesh size. On comparing the postoperative complications, a significant difference was found between them regarding wound seroma, wound infection, and postoperative pain. Moreover, a highly significant shorter hospital stay, time of return to work or normal activity, and mean postoperative follow-up were observed in group A. Conclusion The inlay ventralex hernia patch is an effective and easier technique and can also save the operative time with less postoperative complications and better outcomes as compared with the classic onlay prolene mesh. So, its use is considered cost-effective.
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Acute and intermediate-term outcome of endovascular stenting of native aortic coarctation in adolescents and adult patients p. 654
Ahmed Meawad Alimam, Ahmed Azmy, Ashraf Abd Alhamid
DOI:10.4103/ejs.ejs_39_20  
Introduction Coarctation of aorta (CoA) is a common form of cardiac lesions requiring intervention. Recently, endovascular management with stent implantation has emerged as the preferred strategy. We aim to report our single-center experience of stenting in a wide range of patients using different types of stents and later on its complications. Patients and methods Between January 2012 and December 2017, 56 patients who underwent treatment with stents for CoA were retrospectively studied. All the patients underwent echocardiography and computed tomography scans at 6–12 months follow-up. Results There were 18 women and 38 men with a mean age of 23.24±15.75 years (range, 9–55 years). The median sheath size and balloon diameter were 12 mm (10–14 mm) and 14 mm (12–25 mm), respectively. We achieved an immediate success rate of 94.6% with only three cases recording major complications in the form of migration of stent, infective endarteritis, and stent fracture. At 1-year follow-up, no complications were noted in the computed tomography scans. Conclusion Stent implantation is a good choice for the treatment of CoA in adolescents and adults. It is associated with a low-residual gradient and a low rate of restenosis, both immediately and at mid-term follow-up. It has a relatively low incidence of complications.
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The role of homograft in management of major burn in children p. 662
Mohamed Lethy, Dalia El Sakka, Shereef Al Kashty, Mostafa M Abdelhady
DOI:10.4103/ejs.ejs_40_20  
Background Major burns in children are associated with high mortality and morbidity in any developing countries. Excision within 24–48 h after burn is associated with decreased infection, blood loss, length of hospital stay, and mortality. The authors present a standardized method for homograft to evaluate whether the use of the homograft as a biological dressing is beneficial compared with standard topical treatment. Patients and methods Children aged 14 years with major partial thickness burn of 20% total body surface area of burn (TBSA) or more were included in this study. They were divided into two groups to be managed with either homograft (group A) (n=20) or treated with topical antimicrobial twice daily applications (silver sulfadiazine) (group B) (n=23). The two groups were compared. Results Treatment of major second-degree burns with homograft in pediatrics corrected anemia and hypoalbuminemia and decreased pain during the dressing changes. There was a significantly decrease in dressing changes in group A than in group B (P<0.05). Moreover, the length of stay in hospital reduced (P<0.01) in group A. The use of homograft decreased the risk of infection. Time of total healing, and the burn scar contracture development was different between the two groups. Conclusion Early excision of partial thickness burn and coverage with homograft is beneficial in children compared with the standard topical therapy.
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Outcome of hybrid visceral debranching endovascular aortic repair p. 668
Ahmed Eleshra, Tilo Kölbel, Axel Larena-Avellaneda, Giuseppe Panuccio, Fiona Rohlffs, Nikolaos Tsilimparis, Eike S Debus, Khaled Elalfy, Ehab Saad, Hisham Sharafeldin
DOI:10.4103/ejs.ejs_43_20  
Objective The aim was to study the outcomes of hybrid debranching endovascular aortic repair (H-EVAR) for thoracoabdominal aortic aneurysm. Patients and methods Patients who had H-EVAR for treatment of thoracoabdominal aortic aneurysm between January 2010 and December 2018 were included in this study. Early outcome (30 days) in terms of mortality, morbidity, and target vessel patency were analyzed. Follow-up outcomes in terms of late death, endoleak, and re-intervention rates were evaluated. Results A total of 33 patients (48% males) with a mean age of 68±13 years were included. Eighteen (55%) patients were asymptomatic, whereas eight (24%) patients were symptomatic and seven (21%) patients had a contained rupture. Six (18%) patients died after the visceral debranching operation (stage 1), and 27 (82%) patients completed both stages of H-EVAR. The 30-day mortality in completed H-EVAR was 5 (19%) of 27 patients. Five (15%) patients developed spinal cord ischemia. Four (12%) patients had post-operative dialysis. Two (6%) patients had a stroke. Four (12%) patients experienced respiratory failure. Four (12%) patients had mesenteric ischemia and two (6%) had ischemic colitis. The 30-day overall primary target vessel patency rate was 92±3%. Early endoleak I rate was 3 (11%) of 27 patients, and endoleak III rate was 2 (7%) of 27 patients (completed H-EVAR). The mean follow-up period was 23±11 months for 22 patients who survived the completed H-EVAR. Late death occurred in 4 (18%) of 22 patients. Conclusion Hybrid EVAR had several advantages that included avoiding thoracotomy, aortic cross-clamping, single-lung ventilation, and the need for extensive dissection in multiple aortic segments. However, the controversial outcomes led to criticism, and there is a need to examine the three techniques (open, hybrid, and total endovascular) simultaneously, which would give a unique definition of the selection criteria to achieve the optimum results in each patient.
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Subtotal pancreatectomy in risky patients with periampullary cancers: new surgical center experience p. 677
Bashir A Fadel, Tameem Ibraheem, Magdy M Mahdy, Khaled S Mohamed, Sahar M Hassany
DOI:10.4103/ejs.ejs_44_20  
Background The pancreatic leak is the most dangerous complication postpancreaticoduodenectomy. There are many risk factors for the development of pancreatic fistula (PF) such as texture of the pancreas and its duct size. The aim was to decrease the incidence of PF in these risky patients. Patients and methods A retrospective study was performed on 20 periampullary tumors patients treated by subtotal pancreatectomy between April 2015 and September 2017, which were performed in Assiut Al Rajhi Liver Hospital. Subtotal pancreatectomy was performed in patients with soft pancreas which could not hold stitches and small duct size of less than 3 mm. Also, the authors follow the results of postoperative pancreatic leakage, other morbidity and mortality. Results A PF type A developed in three cases and did not require any further management, one case developed PF type B who also developed delayed gastric emptying and improved after 3 months; one case of abdominal abscess was managed by insertion of pig tail; two cases of wound infection improved by repeated dressing; the mean hospital stay was 7 days except for the patient who developed PF type B and delayed gastric emptying whose hospital stay was prolonged to 1 month; the mortality rate was one case, who was a female patient of 70 years old and died by myocardial infarction 1 week postoperatively. Conclusion Subtotal pancreatectomy with stapling can be done safely in risky patients to decrease the incidence of PF, but further large randomized trials are needed.
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Open access for pneumoperitoneum during laparoscopic cholecystectomy (transumbilical vs. conventional) p. 682
Hesham A.A Elmeligy, Mohamed E Esmat, Mohamed A Elashry, Amr M Gomaa, Ahmed H Helmy
DOI:10.4103/ejs.ejs_45_20  
Background The gold standard technique in the management of symptomatic gall bladder stones is laparoscopic cholecystectomy; it provides minimal postoperative pain, less hospital stay, and good cosmetic outcome. The placement of the umbilical trocar remains the most critical step. There are two common techniques, which are open and closed methods. Transumbilical technique is preferred as it includes a natural opening and is a fast and safe technique. Objective In this study, the authors compared transumbilical and the conventional supraumbilical and infraumbilical open methods access for pneumoperitoneum during laparoscopic cholecystectomy regarding the time for port site entry, the time for port site closure, postoperative pain, and intraoperative and postoperative complications. Patients and methods This prospective comparative study was conducted on 160 cases, candidates for laparoscopic cholecystectomy, divided into two groups, that is, group A (transumbilical technique) and group B (supraumbilical and infraumbilical technique), starting from October 2017 to January 2019, in the Theodor Bilharz Research Institute. Results The mean±SD time for port site entry in transumbilical technique (group A) was 40.3±1.2 s compared with 131.9±5.5 s in the conventional infraumbilical and supraumbilical open techniques (group B), with significant difference between the groups, in favor of the transumbilical technique (group A) (P<0.0001). Conclusion Transumbilical access for establishing pneumoperitoneum in laparoscopic cholecystectomy is considered as a fast, safe, effective, and simple technique with mild postoperative pain and less morbidity.
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Comparison between Acute Physiology and Chronic Health Evaluation II and Ranson’s scores in prognosis of acute pancreatitis p. 690
Ahmed Maher Elbastawisy, Mohammed L Alameldeen, Mohammed Nazeeh Shaker Nassar
DOI:10.4103/ejs.ejs_49_20  
Objective Our aim was to compare the efficacy of Acute Physiology and Chronic Health Evaluation (APACHE) II and Ranson’s scores in detecting the severity and prognosis of acute pancreatitis in a tertiary care hospital in Menoufia, Egypt. Patients and methods A total of 30 cases diagnosed as acute pancreatitis were admitted to our hospital during the period from March 2017 to July 2019. APACHE-II and Ranson’s scores were calculated for all the cases. The best cutoffs for both scores and the area under the curve were estimated based on the receiver operating characteristics curve, and both scores were compared prospectively. Results The total number of patient selected for the tests was 30 patients. The mean age was 52.4 years, with range from 19 to 80 years. Females represented most cases (70%), with dominance of females in the Ranson’s score. All patients showed pain in the epigastric region (100%) as a first symptom to start the scoring system. We found high accuracy, sensitivity, and specificity of APACHE-II score at cutoff point of 8.4 (92, 97, and 84%, respectively) compared with Ranson’s score at cutoff point of 3.1, which shows less accuracy, sensitivity, and specificity (86, 90.4, and 82.4%, respectively), with significant P value of 0.001. Conclusion APACHE-II can be a suitable score in detecting patients who are suspected to have severe disease early from the start of their disease illness, and it may be better than Ranson’s score in this concern.
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Laparoscopic splenectomy in benign splenic lesions: Tanta University experience p. 699
Kareem A Farouk, Amir F Abdelhamid, Hamdy A Mohamed, Mohammed A Hablus, Mohamed Elsheikh
DOI:10.4103/ejs.ejs_52_20  
Background Elective splenectomy is a surgical treatment for a wide range of diseases, including unexplained splenomegaly, autoimmune, malignant, hereditary, and congenital disorders. Aim The aim was to evaluate the outcomes of laparoscopic splenectomy (LS) in different benign splenic disorders. Materials and methods This prospective cohort study was conducted on 40 patients prepared for splenectomy in the Gastrointestinal, Liver and Laparoscopic Surgery Unit, General Surgery Department, Tanta University Hospitals, through 2 years. The authors included all patients with age more than 18 years with benign splenic lesions with splene size up to 24 cm. The authors excluded all patients with suspicion of malignancy. Procedure LS with posterolateral approach was performed. Conclusion LS is a safe procedure in the treatment of benign splenic lesions.
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The impact of donor’s biliary anatomy variations on the procedure of living donor liver transplantation p. 706
Eslam Ismail Ayoub, Yahya Fayed, Hazem Omar, El S Soliman, Tarek Ibrahim, Ibrahim Abdelkader, Taha Yassein
DOI:10.4103/ejs.ejs_53_20  
Background Anatomical variation of biliary anatomy is the cornerstone for the procedure of living donor liver transplantation (LDLT). Aim The aim was to study the effect of donor’s biliary variant anatomy on the procedure of adult LDLT. Participants and methods A retrospective study was conducted using the data of all donors and recipients of LDLT (June 2013–December 2017) in HPB Department and Liver Transplant Surgery. A total of 120 potential donors were assessed preoperatively by MRCP to evaluate the biliary anatomy of the liver and classified into four types according to Varotti and colleagues. Results Of 120 donors, 13 (10.8%) were excluded from donation before surgery owing to various causes; six (46.1%) of them were excluded owing to donor’s biliary anatomical variation. According to the classification of Varotti and colleagues, biliary variations were seen in 27 (25.2%) of 107 donors (five of type 2, 14 of type 3a, and eight of type 3b); type 1 with short stump was seen in 25 (23.1%) cases. Biliary complications (BCs) occurred in 53 (49.5%) of 107 recipients, including bile leak in 40 (37.5%) cases, biliary strictures in 13 (12.1%) cases, and concomitant biliary stricture and leak in 17 (15.9%) cases. There was a statistically significant correlation between the presence of donor’s right hepatic duct (RTH) duct (type 1 with short stump) and BCs in their recipients (P=0.04). There was a statistically significant between the occurrence of BCs in recipient and hospital stay (P=0.046). BCs presented in eight (7.4%) donors, where six (5.6%) of them had bile leak and two (1.8%) had a biliary stricture. Anatomical biliary variations were a risk factor for potential donor exclusion (P=0.021). Conclusions There was a statistically significant difference between donor’s RTH (type 1 with short stump) and BCs in their recipients, and between the occurrence of BCs in recipient and hospital stay. Donor biliary anatomical variations had a statistically significant effect for potential donor’s exclusion.
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Clinical outcome of thoracoabdominal aortic aneurysm surgical repair: preoperative predictors, intraoperative challenges, and postoperative sequelae p. 716
Magdy A Haggag, Karim A Hosny, Ahmad A Mohammad, Maher A Mahdy
DOI:10.4103/ejs.ejs_55_20  
Background Thoracoabdominal aortic aneurysm (TAAA) represents 10% of thoracic aneurysms and 5% of all aortic aneurysms. TAAA open surgical repair has been a challenging operation since decades, as it conjugates the pathological comorbidities of AAA and surgical challenges of TAA. Patients and methods A prospective cohort nonrandomized study was carried out on 20 patients with TAAA of different Crawford extents. A bad outcome was considered when mortality or irreversible morbidity that affects the patient’s lifestyle occurred. Different preoperative and intraoperative factors were correlated reciprocally with the bad outcome cases to line out the possible risk factors. Results The total studied cases were 20. The postoperative morbidities among the cases were chest complications (35%), cardiac morbidities (30%), renal impairment (25%), superficial surgical site infection (SSI) (25%), multiorgan system failure (10%), and paraplegia (10%). Early mortality was seen in 35% of the studied cases. The direct cause of mortality was cardiac insults (43%), chest complications (28.5%), and multiorgan system failure (28.5%). Reciprocal correlation between both preoperative predictors and intraoperative events and bad outcome group revealed a strong association between age +65 years (75% of bad outcome group), preoperative ischemic heart disease (IHD) (50%), preoperative renal impairment (37.5%), aneurysmal Crawford extent II (37.5%), ruptured aneurysm (37.5%), aneurysmal size greater than 7 cm (25%), total operative time greater than 4 h (75%), and bleeding greater than 2500 ml (50%) and bad outcome. Conclusion Age +65 years, preoperative cardiac and renal comorbidities, and aneurysmal extent II are the most important predictors of bad outcome. Prolonged total operative time and massive intraoperative bleeding are the most important operative challenges.
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Laparoscopic evaluation of medial-to-lateral approach of for management of left-sided colon cance p. 723
Mostafa I Seif El-Deen, Magdy A Sorour, Mohamed T Elriwini, Hany M El-Haddad
DOI:10.4103/ejs.ejs_57_20  
Background To date, there remain limited data supporting either medial or lateral approach for laparoscopic left colectomy; therefore, the purpose of the study was to evaluate the medial approach (MA) in left-sided colonic cancer. Patients and methods A total of 40 patients with nonmetastatic left colonic adenocarcinoma were prospectively subjected to MA laparoscopic colectomy in the Department of Gastrointestinal Surgery, Faculty of Medicine, Alexandria University, Egypt, in the period from July 2017 to July 2019. Data regarding operative time, bleeding, number of lymph nodes dissected, functional recovery (bowel sounds, gases passage intake of liquids and solids), length of hospital stay, and morbidity and mortality rates were all collected and recorded. Results There were 22 males and 18 females. Their ages ranged from 32 to 70 years, with a mean±SD of 55.61±9.78 years. Bleeding per rectum was the most common presentation in 52.5% of patients. A total of 20 (50%) patients underwent left hemicolectomy, nine (22.5%) patients underwent sigmoidectomy, and 11 (27.5%) patients underwent anterior resection. The mean operative time was 227.3±40.3 min, and the mean blood loss was 212.2±101 ml. Anastomotic leak was detected in six (15%) patients, and surgical site infection developed in five (12.5%) patients. Conclusion The medial (artery-first) approach is preferred in patients with left-sided colon cancer undergoing laparoscopic colectomy. We think that stapled reconstruction of colonic continuity decreases the risk of surgical site infection.
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Endovenous laser ablation vs conventional surgery in the management of superficial venous insufficiency p. 731
Ahmed G Karmota, Hisham F Desoky
DOI:10.4103/ejs.ejs_60_20  
Background and objective Endovenous laser ablation (EVLA) of the great saphenous vein (GSV) is much more used as an alternative method of treatment instead of conventional surgery procedures. EVLA is thought to decrease postoperative morbidity with rapid recovery and early return to daily activity. The goal of this study was to compare the effectiveness, postoperative pain, complications, and patient satisfaction following either EVLA or conventional surgery for varicose veins of the lower limbs. Patients and methods This is a retrospective study that was conducted on 50 consecutive patients/60 limbs (10 bilateral and 40 unilateral) presented to Kasr Al Aini Hospitals, Cairo University and Asir Central Hospital Saudi Arabia from January 2015 to January 2018 with truncal varicose veins involving GSV. Patients were divided into two groups: group I (30 limbs) who underwent conventional surgery in the form of high ligation and striping and group II (30 limbs) who underwent EVLA. Results The EVLT group was associated with good patient satisfaction with early return to daily activities and work. Pain, paresthesia, ecchymosis, hematoma were significantly higher in group II (P<0.05), with low rate of recurrence in both groups with no statistically significant difference between both groups. Conclusion Both EVLT and conventional surgery techniques were performed well as regards efficacy with low rate of recurrence for incompetent GSV. Less postoperative pain and complications were observed with EVLT as compared with conventional surgery such as ecchymosis, hematoma, superficial thrombophlebitis, and paresthesia.
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Catheter-directed foam sclerotherapy: a new technique for treating varicose veins p. 738
Islam Atta, Amr El Abd, Haitham Fouda, Ahmed Sawaby
DOI:10.4103/ejs.ejs_61_20  
Objectives This was an observational prospective study to assess the safety and efficacy of catheter-directed foam sclerotherapy (CDFS) in the treatment of axial reflux and incompetence of saphenous veins with short-term to mid-term follow-up. Patients and methods A total of 20 patients [11 (55%) male and nine (45%) females] with either reflux of the long saphenous vein and/or short saphenous vein were subjected to CDFS. Overall, 10 ml of foam using polidocanol 2% was injected via long catheter into the saphenous vein. Then patients were followed up on 1 day after procedure, 1 month, 3 months, 6 months, and 1 year by duplex and clinically using visual analog scale (assess satisfaction of the patients which is related to improvement of their symptoms). Results After 1 year, 90% of the patients were satisfied by using visual analog scale, 85% (17 patients) had total ablation of the saphenous vein and 15% (three patients) had partial recanalization, with resultant reflux in two (10%) patients and one (5%) patient had competence of the saphenous vein owing to reduction of its diameter. One patient had deep venous thrombosis (5%), one patient had superficial thrombophlebitis (5%), and one patient had hyperpigmentation of the skin (5%). Conclusion CDFS is a safe and cost-effective procedure for treating axial reflux and incompetence of saphenous veins in terms of clinically and duplex-based outcome at short-term and mid-term follow-up.
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Reporting of lymphovascular invasion and non-nodal tumor deposits as prognostic risk factors in colorectal cancer patients p. 745
Mohamed Y Elbarmelgi, Abdrabou N Mashhour
DOI:10.4103/ejs.ejs_65_20  
Background and purpose Both lymphovascular invasion (LVI) and non-nodal tumor deposits (TDs) are essential prognostic risk factors for colorectal cancer that many oncologists may not be aware of. This study aimed to detect the incidence of reporting of the state of the LVI and non-nodal TDs with operable colorectal malignancy, which are very important prognostic risk factors. Patients and methods Reporting of LVI and non-nodal TDs were traced in 900 patients (818 retrospective and 82 prospective individuals) with cancer of the colon and the rectum. The ability of improving the incidence of reporting was estimated by comparison of incidence of reporting in both groups. Results Percentage of reporting of LVI was 39% in the retrospective group and 49.9% in the prospective group, while reporting of non-nodal TDs was 7.228% in the retrospective group and 24.24% in the prospective group. There was a statistically significant difference between reporting of non-nodal TDs, prospective patients over retrospective patients (P<0.0001); while there was no statistically significant difference between reporting in retrospective and prospective patients in the LVI with P value of 0.865. Conclusion There were inadequate reporting of both non-nodal TDs and LVI in retrospective patients with improvement in prospective patients although statistically nonsignificant in the LVI, which may necessitate a new staging system that could accommodate all this prognostic risk factors.
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ORIGINAL ARTICLE Top

Predictors of satisfactory outcome following repair of postcholecystectomy bile duct injury p. 748
Ramy A Hassan, Mohamed I Omar, Murad A Jabir, Ahmed M Elkoussy, Mahmoud S Aly, Ahmed M.I Taha
DOI:10.4103/ejs.ejs_68_20  
Background We aim to report the short-term and long-term outcome of surgical repair following Roux-en-Y hepaticojejunostomy for postcholecystectomy bile duct injury (BDI) in a tertiary hepatobiliary center in Upper Egypt (Assiut University). Patients and methods A retrospective study was conducted on all patients diagnosed with postcholecystectomy BDI during the period 2014–2018 at Al-Rajhi Liver Institute, Assiut University, who had undergone surgical repair of BDI. Patients were grouped according to the time interval between previous surgery and surgical repair into two groups: group 1: time interval less than or equal to 6 weeks and group 2: time interval more than 6 weeks. Results Of 43 patients enrolled, 18 were in group 1 and 25 in group 2. The overall incidence of stricture was 14% (27.9% in group 1 and 4% in group 2), which is statistically significant (P=0.026). Other factors that have a significant association with incidence of stricture included bilirubin level. On multivariate analysis, none of these factors had a significant effect on the development of biliary stricture. Conclusion We believe that timing of repair of BDI following cholecystectomy has a significant effect on the outcome of repair. Moreover, best results in biliary reconstruction can be achieved in a specialized hepatobiliary center.
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Outcomes of balloon angioplasty for failing upper extremity dialysis access p. 756
Mahmoud Saleh, Mohamed Ibrahim, Haitham Ali
DOI:10.4103/ejs.ejs_69_20  
Background Percutaneous transluminal angioplasty (PTA) is the mainstay of treatment in stenosed hemodialysis access. Being less invasive and outpatient procedure, PTA is a safe and useful intervention to maintain access patency in patients with failing hemodialysis arteriovenous fistulas (AVFs). The aim of this study was to evaluate the efficacy of balloon angioplasty in treatment of patients with failing upper extremity hemodialysis access. Methods This is a prospective study of all adult patients who underwent balloon angioplasty for the treatment of patients with symptoms of a failing dialysis access due to presence of significant stenosis in dialysis access circuit. The study conducted at the Department of Vascular and Endovascular Surgery, Assiut University Hospital (a tertiary referral hospital), between January 2017 and December 2018. Both the primary and assisted primary patency rates were analyzed by the Kaplan-Meier plot method. Results 149 patients underwent PTA for treatment of failing dialysis access symptoms. The most common site of stenosis in our study was the juxta-anastomotic site (49 %). The overall success rate was 96.6%. Balloon angioplasty was performed in all patients without stent placement. Sixteen (10.7%) complications were encountered in the study. At 1 year, the primary patency and the assisted primary patency rates was 60.5% and 80%, respectively. Age of the fistula (P=0.017), presence of multiple lesions (P=0.016), total lesion length >5cm (P=0.030), and diabetes mellitus (P=0.012) were significant independent predictors of loss of primary patency. Conclusions Balloon angioplasty is safe and effective treatment modality for treatment of stenosis in failing hemodialysis access patients with good technical success and acceptable short-term primary patency rates. Repeated interventions are required to maintain patency.
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Short-term outcomes of laparoscopic intraperitoneal onlay mesh with facial repair (ipom-plus) for ventral hernia: a randomized controlled trial p. 764
Bassem M Sieda, Osama H Khalil
DOI:10.4103/ejs.ejs_73_20  
Background Laparoscopic ventral hernia repair has become a widely used technique. Objective This study evaluates the outcomes of laparoscopic ventral hernia repair with and without fascial repair, with particular reference to complications, seromas, and early recurrence. Patients and methods A total of 177 patients were divided into three groups. Group I underwent laparoscopic [intraperitoneal onlay mesh (IPOM)] hernioplasty without repair. Group II underwent laparoscopic IPOM hernioplasty with intracorporeal repair. Group III underwent laparoscopic IPOM hernioplasty with transfacial closure using PDS loop. Patients were followed for 6 months for early postoperative morbidity, including seroma formation, whereas the secondary end points were the adequacy of transfacial repair and its effect on early hernia recurrence. Conclusion Transfacial suture closure of hernia defect is the simplest method of the hernia repair and effective with less incidence of seroma and early recurrence as compared with nonfascial repair technique. Defect closure strengthens the abdominal wall by regaining its whole function and gives more space for mesh insertion. Whatever technique used for ventral hernia repair, obesity is still the most important risk factor for seroma and hernia recurrence.
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Surgical management of iatrogenic anal stenosis p. 774
Mahmoud Salah Shehata
DOI:10.4103/ejs.ejs_74_20  
Aim Anal stenosis is an uncommon but troublesome complication of some anorectal operations, most often seen after surgical hemorrhoidectomy. Several methods are used to control this problem, ranging from medical to various surgical procedures, depending on the severity and extent of the stenosis. This study aims to evaluate diamond-shaped flap anoplasty with partial lateral internal sphincterotomy as a treatment option of iatrogenic severe anal stenosis. Study design A prospective study was conducted, which was approved by the ethics committee of the faculty, and the patients were consented before being included in this study. Place and duration of study The study was performed at the General Surgery Department, Al-Hussein Hospital, Faculty of Medicine, Al-Azhar University, from January 2017 to December 2019. Patients and methods A total of 14 patients with post-surgical severe anal stenosis were included in this study. All patients were treated by diamond-shaped flap anoplasty with partial lateral internal sphincterotomy. After the procedure, every patient was evaluated in the first week, second week, first month, third month, sixth month, and the first year regarding pain, bleeding, wound infection, wound healing, and incontinence. Results A total of 14 patients (10 females and four males) with severe anal stenosis, with a mean age of 43.65 years, were included. Post-hemorroidectomy anal stenosis represented the main etiology in 13 (93%) patients, with post-defecation pain being the major complaint in all patients. Unilateral diamond-shaped flap anoplasty with partial lateral internal sphincterotomy was done in all patients. Post-operative pain ranged from moderate to mild over the first week, and anal spotting, which occurred in only two patients, stopped spontaneously in the first few days, and no flap loss occurred, but wound infection occurred in four (28%) patients, who were treated conservatively. Gas incontinence occurred in seven (50%) patients but improved over the first month. Complete satisfaction was achieved in 12 (86%) patients, and in the other two patients with recurrent symptoms, complete satisfaction was reached at the end of the follow-up period by having the same operation on the other side. Conclusion Diamond-shaped flap anoplasty with partial lateral internal sphincterotomy is a good treatment option for severe anal stenosis, being simple with low complication rate and high success rate and an easy way to perform the same operation on the other side to obtain complete patient satisfaction in failed cases with recurrent symptoms.
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Total cyst excision with Roux-en-Y hepaticojejunostomy for choledochal cyst management: a single-center experience p. 780
Wael Mansy, Omar El Ekiaby, Morsi Mohamed
DOI:10.4103/ejs.ejs_80_20  
Background Choledochal cystis considered as a cystic dilatation of the biliary tract, which is a rare disease. It is more common in children, but its incidence and diagnosis are increasing in adults, representing 20% of the cases. Aim To evaluate morbidity and mortality rates following hepaticojejunostomy done for patients, either child or adult, with choledochal cyst. Patients and methods A total of 30 patients were evaluated, comprising 13 children and 17 adults. The study was done in the period from January 2013 till January 2020, in the Advanced Hepato-Pancreatico-Biliary Center, Zagazig University Hospital, Egypt. Results Abdominal pain was the commonest complaint in all patients. Jaundice was present in 80%. Total cyst resection with reconstruction of the biliary tract with a standard 60–60 cm Roux-en-Y hepaticojejunostomy was done in 28 (93.33%) patients. Left hepatectomy was done in two patients with Caroli’s disease. There was no recurrence in our follow-up period. Conclusion Total cyst excision with Roux-en-Y hepaticojejunostomy is the standard treatment of choledochal cyst. It was associated with low incidence of recurrence and also decreased long-term postoperative complications and malignancy.
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Assessment of outcomes of combined minimally invasive perineal procedures for treatment of complete rectal prolapse in children: an approach to reduce recurrence rate p. 787
Mohamed F Abdelhalim
DOI:10.4103/ejs.ejs_81_20  
Background Rectal prolapse in children is common in developing countries with low health resources. Open and laparoscopic abdominal approaches are ideal for the treatment of rectal prolapse but they are not suitable for frail children and countries with poor medical resources. Perineal procedures are usually well tolerated and simple but have high recurrence rates. Objective Our objective is to assess the short-term outcomes of combined minimally invasive perineal procedures, including anal encirclement, submucosal alcohol injection, and Gant–Miwa procedure, in the management of full-thickness rectal prolapse in children. Through this combination, we looked forward toward magnifying the advantages of perineal procedures and allaying their complications, particularly recurrence rates. Patients and methods A total of 31 children with complete rectal prolapse were recruited during the period from May 2017 to June 2019. All the patients underwent three combined perineal procedures: mucosal plication (Gant’s technique), anal encirclement, and submucosal injection sclerotherapy. Results The study group included children with a median age of 6.55±2.14 years (range, 3.0–10.0 years). Mean operative time was 37.58±5.61 min (range, 30.0–45.0 min). The end results of our study were renovating anorectal physiology by correcting the rectal prolapse and improving continence (93.5%) and constipation (93.5%), with no mortality (0%) and low recurrence rates (3.2%). Conclusion Our approach (combined minimally invasive perineal procedures) is simple, effective, and less invasive, with minimal morbidity and a negligible recurrence rate, particularly for children with complete rectal prolapse.
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Validity of S100B protein as a prognostic tool in isolated severe head injuries in emergency patients p. 795
Adel Hamed Elbaih, Mahmoud A.A Mohammed, Mohammed A Ali, Amany A Elshemaly, Mohamed S Mostafa
DOI:10.4103/ejs.ejs_54_20  
Introduction Trauma results in 10% of all deaths or five million died annually. In spite of the progress in monitoring and imaging studies, definite, correct prediction of brain death after brain trauma is not possible until now, and brain injury is the third most common cause of mortality in the world. Aim The aim of the study is to identify the validity of S100B protein as a predictor of mortality in isolated severe head trauma patients. Patients and methods Th study was a cross-sectional one that was carried out among 44 patients who presented with isolated severe head trauma to the emergency room. All the patients fulfilled our inclusion and exclusion criteria of this study. The initial level of S100B protein was obtained from each patient on admission, 48 h later, and every patient was followed up for 28 days. Results This study demonstrates that the mean of S100B dimer levels within the first 2 h was 0.12 mg/l, while after 48 h the mean was elevated to 1.09 mg/l. In addition, the S100B protein to roll in as a prognostic marker in severe head trauma is 76 and 100%, respectively (sensitivity), while the ability of the test to roll out is 75 and 86% (specificity) and the overall accuracy is 76 and 90%. Conclusion The results of this study confirm the value of quick prognosis for the S100B protein to inform the relatives about the most expected outcome for the patient as this is the most common question asked to the physician and he his answer should have a scientific basis.
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