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   Table of Contents - Current issue
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October-December 2018
Volume 37 | Issue 4
Page Nos. 419-619

Online since Friday, November 23, 2018

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ORIGINAL ARTICLES  

One-day surgery laparoscopic sleeve gastrectomy: 96 patients at a Menoufia University Hospital Highly accessed article p. 419
Asem Fayed, Mahmoud Hagag, Mohammed Elbalshy
DOI:10.4103/ejs.ejs_8_18  
Background Laparoscopic sleeve gastrectomy (LSG) is one of the most performed bariatric surgeries, although its safety as a 1-day surgery is not yet approved. Patients and methods An analysis of a prospectively collected bariatric surgery data, in Menoufia University Hospitals was conducted between February 2016 and August 2017. There were120 patients who underwent LSG; 96 (80%) patients were operated as a 1-day surgery (hospital stay<12 h). Results All procedures were primary LSG performed on 82 women and 14 men, with a mean age (±SD) of 29.2±13.5 years. Mean±SD preoperative BMI was 45.4±3.8 kg/m2. Operative time was 49.8±9.6 min (mean±SD). There were no deaths. All patients were discharged home on the same day of the surgery. There were one (1.04%) case of gastric staple line leak, three (3.12%) of intra-abdominal bleeding, and one (1.04%) case of gastric stenosis. All patients went well. Conclusion LSG can be performed as a 1-day surgery in selected patients, with no complications.
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Laparoscopic lymph node dissection using ultrasonically activated shears: comparison with electrosurgery p. 423
Mohamed H Elmeligy, Mahmoud G Hagag, Mahmoud A Shahin
DOI:10.4103/ejs.ejs_18_18  
Purpose The aim was to assess and compare perioperative parameters in two groups of patients treated by different laparoscopic techniques of lymph node dissection (LND) for gynecologic cancer. Patients and methods Between October 2015 and October 2017, 59 consecutive women with microinvasive cervical cancer (N=5) or clinical stage I endometrial cancer (N=54) underwent laparoscopic LND during a primary staging procedure using an electrosurgery (ELC) or ultrasonic (US) operative technique. The two groups were compared for perioperative outcomes. Differences between the two groups were determined by the Wilcoxon’s rank-sum test. Results Laparoscopic LND and other staging procedures were completed successfully in 58 (98.3%) women. There were no statistically significant differences between the groups regarding preoperative outcomes (operation time, time for LND, blood loss, hospital stay, and complications), but there was a significant difference (P=0.0008) in the number of lymph nodes harvested: a mean of 13.7 in the ELC group and 17.5 in the US group. The pathologists found that the reading of histology slides was easier after US dissections because of the greater depth of thermal injury in the lymphatic tissue in ELC group. Conclusion The US operative technique ensures efficient coagulation, cutting, dissection, and grasping for laparoscopic LND in patients with cervical and endometrial cancer.
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Factors contributing to local recurrence after conservative breast surgery for early-stage breast cancer p. 429
Youhanna S Shafik, Hany Rafik, Medhat Helmy
DOI:10.4103/ejs.ejs_39_18  
Background Breast-conserving surgery is the standard procedure for early breast cancer. Local recurrence after conservation is the main problem, and many factors can predict this local recurrence. Aim To highlight factors that may contribute to local recurrence after conservative breast surgery for early breast cancer in our Egyptian patients. Patients and methods A prospective cohort study was conducted that included 137 patients from breast clinic, Ain Shams University Hospitals. All patients were candidates for conservative breast surgery for primary early-stage breast cancer. They were followed up from January 2016 to December 2017 based on a fixed schedule. Results Incidence of local recurrence was 2.9%. Mean time to local recurrence was 14 months (range: 12–16 months). Tumor grade and estrogen receptor and progesterone receptor status were the most important prognostic factors affecting local relapse. On the contrary, age, family history, tumor size, safety margin, tumor type, lymph node (LN) status, HER-2 status, Ki-67, and intraductal component did not have a significant effect on local recurrence. Conclusion Patients with high-grade tumors, estrogen receptor and progesterone receptor negativity should be treated aggressively. As all cases of local recurrence occurred in the first 16 months in our study, we strongly recommend that the scheduling of surveillance visits should be more frequent during the first 2 years (at least every 3 months).
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Conversion and complications of elective laparoscopic cholecystectomy in a West African population p. 440
Adewale O Adisa, Olalekan Olasehinde, Olusegun I Alatise, Bolanle O Ibitoye, Aramide F Faponle, Oladejo O Lawal
DOI:10.4103/ejs.ejs_40_18  
Background Laparoscopic cholecystectomy (LC) is increasingly adopted in Nigeria, but the procedure is limited due to the low incidence of gallstone diseases. This study aims to determine the incidence of conversion and complications following elective LC. Patients and methods Consecutive patients undergoing elective LC at the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria, were the participants. Patients’ preoperative characteristics including ultrasonographic findings, instances of conversions, and intraoperative and postoperative complications were documented. The influence of gallbladder wall thickness on the outcome was analyzed. Results There were 150 patients, including 124 (82.7%) women and 26 (17.3%) men aged 18–82 years (mean=45.4, SD=13.38). Indications for LC were chronic calculous cholecystitis in 101 (67.3%), 45 (30%) acute calculous cholecystitis, whereas four (2.7%) had acalculous cholecystitis. Gallbladder wall thickness was normal (≤3 mm) in 98 (65.3%), thick (4–9 mm) in 35 (23.6%), and very thick (≥10 mm) in 17 (11.3%) patients, whereas 11 patients had pericholecystic fluid collection. Gallbladder mucocele was encountered in nine (6%), empyema in six (4%), and gangrenous gallbladder in two (1.3%) cases. Ten (6.7%) procedures were converted to laparotomy including two patients with hemoglobinopathies. Postoperatively, bile leaks occurred in two patients, bleeding requiring reeploration in one, and bile duct dilatation after 4 months in one patient. Acute cholecystitis, hemoglobinopathy, and thickened gallbladder wall significantly influenced conversions and occurrence of complications in this series. Conclusion We observed a low rate of conversion and complication following LC. Acute cholecystitis and thickened gallbladder wall significantly influence the conversion of LC to open procedure in our setting.
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Laparoscopic intraperitoneal onlay mesh for Spigelian hernia repair: a prospective study p. 445
Tarek A.O Abouzeid, Mohammed M.E Amin
DOI:10.4103/ejs.ejs_41_18  
Background Spigelian hernia is a rare variant of the ventral hernia protruding from a small defect in the Spigelian fascia. The surgical treatment is recommended once diagnosed. Objective In this study, we tried to spotlight on this mysterious disease as a cause of vague abdominal pain, evaluating the laparoscopic intraperitoneal onlay mesh (IPOM) technique as regards the efficacy and complications. Patients and methods A prospective study had been conducted at the Abha Private Hospital, Abha, Saudi Arabia, on 10 consecutive patients who suffered from Spigelian hernia, between 1 June 2015 and 31 December 2017. The patients were scheduled for laparoscopic IPOM using a composite mesh (Symbotex). Results During the period of the study, 10 patients had undergone 11 IPOM (one bilateral hernia); the mean age of the patients was 63.7 years (range: 37–82 years). The preoperative diagnosis was made in nine (81.8%) patients. The reformatted thin-cut axial computed tomographic scan with multiplanar reformatted modality was found to be more sensitive than the superficial ultrasound (81.8 vs. 72.7%). The laparoscopic IPOM is a fast procedure (average: 44.7 min), and was associated with relatively short postoperative hospital stay (average: 1.2 days). Only one patient developed chronic pain related to the mesh. No recurrence has been detected during a follow-up period of 6 months. Conclusion The Spigelian hernia is a rare type of ventral hernia. Reformatted computed tomographic scan is the best imaging modality. Although the open approach is the classic way of treatment, laparoscopic IPOM has been shown to be a safe, fast, and efficient alternative.
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Onlay hernioplasty versus Rives–Stoppa repair for paraumbilical hernia associated with divarication of recti in diabetics in terms of recurrence and surgical site infection: a prospective randomized controlled trial p. 453
Walid M Abd El Maksoud, Khaled S Abbas
DOI:10.4103/ejs.ejs_42_18  
Purpose The aim of this study was to compare between onlay hernioplasty and Rives–Stoppa repair (RS) for management of paraumbilical hernia associated with divarication of recti in diabetic patients in terms of recurrence and surgical site infection. Patients and methods A total of 60 diabetic patients with primary paraumbilical hernia and divarication of recti were randomly allocated into two groups: group I included 30 patients (mean age: 49.77±11.15 years) who were subjected to onlay repair and group II included 30 patients (mean age: 51.80±10.84 years) who were subjected to RS. Results Eight (26.7%) patients in group I showed superficial wound infection, of whom three (37.5%) progressed to mesh infection. Three (10%) patients in group II developed superficial wound infection, with no progression to mesh infection. Seroma occurred in five (16.7) cases in group I, compared with one case in group II. All were treated conservatively, except one patient in group I who was infected and later led to mesh infection. Late mesh infection occurred in one patient in group I and one patient in group two. Recurrence was encountered in five patients after onlay repair compared with one patient after RS. All recurrent cases were owing to mesh infection and its removal. After 1 year, visual analog scale showed no significant difference between both groups regarding chronic postoperative pain. Conclusion After 1-year follow-up, RS was favorable to onlay repair for management of diabetic patients with paraumbilical hernia and divarication of recti regarding recurrence and surgical site infection.
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A clinical study on the hemorrhoidectomy and the elevation of the flaccid anal transition cuties in the fourth-grade internal hemorrhoid p. 460
Kim Chol Ryong, Sok Gum Jong
DOI:10.4103/ejs.ejs_46_18  
Background We established the ligation and ablation of the fourth-degree internal hemorrhoid by elevation of the flaccid anoderm. Patients and methods We analyze the clinical result of this operation method. Results The average healing period with the technique used in the study was 21.3±0.68 days compared with the Milligan-Morgan technique of 24.2±0.92 days, and the complications and aftereffects were also less. Conclusion The study reports that the ligation and ablation of the fourth-degree internal hemorrhoid by elevation of the flaccid anoderm is very satisfactory rather than the former operation methods.
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Laparoscopic versus open ventral hernia repair: a comparative study p. 465
Magdy Basheer, Ahmed Negm, Hosam El-Ghadban, Mohamed Samir, Amro Hadidy, Ibrahim Dawoud
DOI:10.4103/ejs.ejs_53_18  
Background Ventral hernia repair has changed dramatically over the past decades by the introduction of laparoscopy and prosthetic biomaterials. This study aimed to compare the short-term outcomes of laparoscopic ventral hernia repair (LVHR) versus open ventral hernia repair (OVHR). Patients and methods This prospective study was conducted on 40 patients with ventral hernia who were randomized to LVHR group or OVHR group to compare operative time, intraoperative complications, postoperative pain, postoperative hospital stay, postoperative complications, and cosmetic results. Results LVHR was performed in 20 patients having a mean age of 43.60±8.18 years, and 60% were females. OVHR was performed in 20 patients having a mean age of 48.40±9.45 years, and 50% were females. Operative time of laparoscopic repair (86 min) was shorter than that of open repair (91 min). Only one case was converted from laparoscopic repair to open repair. There was no significant injury to viscera or vessel and no recurrence in either group. In LVHR group, the percentage of patients requiring additional analgesia was 30%, whereas in OVHR group, the percentage of patients requiring additional analgesia was 65% (P=0.027). The mean postoperative hospital stay was shorter for the laparoscopic group than for the open hernia group (1.15 vs. 4.55 days; P=0.002). More wound infection occurred in the open group (15%) than in the laparoscopic group (5%) (P=0.292). Conclusion LVHR is better than open repair, with less postoperative pain, shorter hospital stay, faster return to normal activity, lower rate of postoperative complications, and better cosmetic appearance.
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Safety and efficacy of infraclavicular arterioarterial chest wall prosthetic loop graft for hemodialysis access: a review of 45 patients p. 472
Ahmed K Allam, Ahmed M Elmahdi
DOI:10.4103/ejs.ejs_54_18  
Introduction With raising the demand for hemodialysis (HD) owing to concomitant increased incidence of nephropathic disease, which has led to associated increased patients’ life expectancy in the past three decades, it becomes necessary to establish a secondary or a tertiary HD vascular access to overcome the exhausted peripheral veins and central venous occlusion. Aims Our case study reports midterm (24-month follow-up) results with infraclavicular arterioarterial loop graft and evaluates its efficacy and safety in construction of HD vascular access for patients with end-stage renal disease. Material and methods This was a prospective study. From December 2014 to December 2017, 45 patients with end-stage renal disease on chronic HD with exhausted all peripheral and central veins or were considered unsuitable for creation of arteriovenous fistula/graft owing to heart failure underwent arterioarterial chest wall prosthetic graft implantation for creation of HD vascular access. The data analysis was done using SPSS version 20.0 for Windows. Results The primary patency rates were 100, 97.7, 93, 77.5, and 73.7% at 6, 9, 12, 18, and 24 months, respectively. The secondary patency rates were 100, 85.7, and 66.6% at 6, 9, and 12 months, respectively, after successful thrombectomy in nine patients. There were 20 (44.4%) secondary variable procedures performed in 18 (40%) patients during follow-up period, with no procedure-related mortality or limb-threatening conditions being documented in our study. Conclusion Our case study reports a reasonable midterm patency rate, and complications associated with this pattern of vascular access show that infraclavicular arterioarterial loop grafts are a valid alternative option for complex patients. We advocate the use of this technique in patients with exhausted all vascular access possibilities in both upper extremities with central venous obstruction. We also indicate it in case of patients with cardiac insufficiency who could not tolerate long-term hemodynamic effect of arteriovenous fistula/graft.
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The impact of routine omentopexy to staple line on the incidence of early postoperative complications after laparoscopic sleeve gastrectomy: is it worth? p. 479
Karim Sabry, Mohamed G Qassem
DOI:10.4103/ejs.ejs_56_18  
Background In laparoscopic sleeve gastrectomy (LSG), the patients may experience serious postoperative complications such as hemorrhage or leakage. The aim of this study was to evaluate the benefit of routine omentopexy (RO) to staple line in decreasing postoperative hemorrhage and leakage. Patients and methods A retrospective cohort study analyzing prospectively collected data including 2000 LSG from March 2015 to December 2017. The patients were evenly divided into two groups: Group A of 1000 LSG with no omentopexy (NO) and group B of 1000 LSG with RO to staple line with full thickness stitches till the level of the incisura above. Results The mean age was 33.2±15.7 and 30±10.9 for group A (NO) and group B (RO), respectively. The mean BMI in group A is 45±7, while it is 46±9 in group B. Staple line leakage occurred in 9 cases (0.9%) of group A, while none (0.0%) of the group B patients experienced evidence of leakage (P=0.003). In group A, 26 cases were diagnosed to have significant postoperative bleeding, compared with only eight (0.8%) patients of group B (P=0.003). Perigastric localized collection was found in three (0.3%) cases and only one case in the two groups (P=0.625). The operative time spent in group A was 55±20 min, much lower than that in group B which was 85±35 (P=0.001). The mean hospital stay was 30±18 and 24±12 in group A and Group B, respectively (P=0.001). Conclusion RO to staple line has shown to be effective in decreasing staple line bleeding and leakage and hospital stay, although it prolongs the operative time.
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Comparative study between Graham’s omentopexy and modified-Graham’s omentopexy in treatment of perforated duodenal ulcers p. 485
Hassan A Abdallah, Abd-El-Aal A Saleem
DOI:10.4103/ejs.ejs_61_18  
Background Peptic ulcer perforation is an emergency and requires urgent surgical treatment. In spite of rare incidence of elective surgery for duodenal ulcer, frequency of emergency operations is on the rise. Objective This study is aimed at comparing success rate between Graham’s omentopexy (GO) and modified-Graham’s omentopexy (MGO) as an emergency management technique for duodenal perforation. Patients and methods A prospective study was carried out for 2 years with 80 patients. GO was done in 40 patients and 40 patients underwent MGO between March 2015 and March 2017 in the Department of Surgery in Aswan University. Data regarding age, sex, time elapsed between onset of symptoms and hospital admission, comorbid diseases, morbidity, and mortality were recorded. Results MGO was associated with longer operative time, but the incidence of reperforation is less than GO. Mean hospital stay in GO group is higher than MGO group. Conclusion Graham’s patch repair is as effective as modified-Graham’s patch repair in terms of morbidity and mortality. There is no statistically significant difference in undergoing either procedure for repair.
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Stump pressure measurement as a predictor of limb salvage in infected femoral artery pseudoaneurysms in recreational drug abusers p. 490
Hossam El-Mahdy, Baker Ghoneim, Mohammed Ali
DOI:10.4103/ejs.ejs_62_18  
Introduction The management of infected femoral pseudoaneurysms due to local injury after drug injection is a challenging debatable armamentarium. Patients and methods Twenty patients presented with infected pseudoaneurysm of the femoral artery due to recreational drug injection. Measurement of stump pressures (SPs) in the femoral arteries intraoperatively was done in all patients after ligation. Results All patients were men with a mean age of 36.9 years. The mean SP was 54.85 mmHg. SP was less than 60 mmHg in eight patients in whom transobturator bypass was mandatory to be performed. SP was at least 60 mmHg in 12 patients who underwent ligation without any trial of subsequent revascularization. Conclusion SP measurement in the superficial femoral artery is a good indicator for the need of revascularization after femoral artery ligation in patients with infected femoral pseudoaneurysms due to recreational drug injection.
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Fully covered self-expandable metal stent for management of refractory postcorrosive esophageal strictures, is it justified? p. 497
Mohamed Abdel-Shafy M Mohamed, Asmaa Gaber R., Mohamed Yousef A., Mohammed A Omar, Hamdy M Husein
DOI:10.4103/ejs.ejs_64_18  
Introduction Management of refractory benign esophageal strictures remains a challenge for clinicians. Randomized trials are needed to determine the optimal treatment strategy for patients with refractory and recurrent benign postcorrosive esophageal strictures. Aim The aim of this study was to evaluate the management of refractory postcorrosive esophageal stricture by fully covered self-expandable metal stent (SEMS) and also the optimum time for stent placement. Patients and methods This study was conducted in GIT Endoscopy Unit in Qena University Hospital from June 2014 to June 2016 in collaboration with General Surgery, Cardiothoracic Surgery, and Tropical Medicine Departments, Qena Faculty of Medicine, South Valley University. Eleven patients with refractory postcorrosive esophageal strictures were managed by dilations and fully covered SEMS placement. Results Successful stent placement was done in all patients. The mean follow-up time was 22 (12–26) months. Stent migrations occurred in two patients, and minor bleeding in one patient, with no mortality and no recurrences in dysphagia during the follow-up period. Conclusion Fully covered SEMSs are safe and effective in treatment of postcorrosive esophageal stricture, with optimum duration for stent placement range from 6 to 8 weeks.
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Evaluation of preoperative predictive factors for difficult laparoscopic cholecystectomy in comparison with intraoperative parameters p. 504
Abd-El-Aal A Saleem, Hassan A Abdallah
DOI:10.4103/ejs.ejs_66_18  
Objective The aim was to assess the preoperative predictive factors that determine difficult laparoscopic cholecystectomy (LC) in comparison with intraoperative parameters and outcome. Patients and methods This prospective study include 100 patients having symptomatic cholelithiasis. All patients underwent elective LC in Department of General Surgery in Aswan University Hospital. The collected data include the parameters of preoperative scoring system, which were male sex, old age, history of hospitalization, obesity (BMI), abdominal scar, palpable gallbladder (GB), wall thickness of GB, pericholecystic collection, and impacted stone. The difficulty levels according to preoperative score were easy (0–5), difficult (6–10), and very difficult (11–15). Various intraoperative parameters were faced while doing LC that were considered for intraoperative scoring system, which categorizes the patients into easy, difficult, and very difficult surgical procedure on the basis of time taken in minutes, bile/stone spillage, injury to duct, and conversion to open cholecystectomy. Results In this study, previous history of hospitalization (P=0.001 and 0.01) and wall thickness (P=0.007 and 0.02) were found to be statistically significant in predicting difficult LC in both univariate and multivariate analyses. Other factors such as age (P=0.002), BMI greater than 27.5 (P=0.02), palpable GB (P=0.003), and impacted stone (P=0.01) were found to be statistically significant in univariate analysis in predicting difficult LC. Remaining factors such as sex, abdominal scar, and pericholecystic collection were not found to be statistically significant in predicting difficult LC. Receiver operating characteristic curve for prediction of intraoperative outcome based on preoperative score for difficult/very difficult versus easy cases at cutoff point greater than 5 and area under the curve of 0.86, with 95% confidence interval=0.77–0.92, showed sensitivity of 74.3, specificity of 96.9, positive predictive value of 92.9, negative predictive value of 87.5, and accuracy of 85.6. Conclusion We concluded that the preoperative scoring system is statistically and clinically a good test for predicting the operative outcome in LC.
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Evaluation of weight loss one and two years post-laparoscopic sleeve gastrectomy and laparoscopic adjustable gastric banding p. 512
Ahmed M Hassan, Ahmed M Hussein, Mohamed Y Ibrahim
DOI:10.4103/ejs.ejs_71_18  
Background Being a major health problem, surgical management of obesity has become a successful variant. Many laparoscopic procedures are readily available with their advantages and drawbacks. One of the major determinants of the choice of procedure is the expected weight loss. Laparoscopic sleeve gastrectomy (LSG) and laparoscopic adjustable gastric banding (LAGB) are well-known procedures with a good reputation regarding postoperative weight loss. Aim The aim of this study was to compare excess weight loss (EWL) percentage between both procedures after 1 and 2 years postoperatively. Patients and methods This study included 60 morbidly obese patients divided equally into two groups: group A patients underwent LSG and group B patients underwent LAGB. %EWL was compared between both groups after 1 and 2 years in the postoperative period. Results All LSG cases continued follow-up for 2 years while four cases of the LAGB group discontinued follow-up due to band removal. Both procedures achieved a satisfactory weight loss over 1 and 2 years with better results in LSG. Conclusion Both LSG and LAGB are the commonly performed restrictive procedures for morbid obesity with acceptable results. LSG achieved more reduction of BMI and higher %EWL after a follow-up of 12 and 24 months.
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Health-related quality-of-life improvement using catheter-directed thrombolysis for iliofemoral deep venous thrombosis p. 518
Amr El-Boushi, Abd El-Rahman M Gameel, Mohamed E El-Sherbeni
DOI:10.4103/ejs.ejs_74_18  
Purpose Catheter-directed thrombolysis (CDT) effectively eliminates thrombus in patients with iliofemoral deep vein thrombosis (DVT) with good patency and low complication rates. Thus, an effective measure of treatment success is the assessment of health-related quality of life (HRQOL). This study evaluates whether CDT for iliofemoral DVT is associated with improved HRQOL compared with standard anticoagulation (AC) treatment. Patients and methods Between January 2016 and June 2017, 33 (33 limbs) patients having acute iliofemoral DVT were allocated in two groups: group A (18 patients) received standard AC therapy alone and group B (15 patients) was managed with CDT. All patients were candidates for thrombolysis. Follow-up included clinical exanimation and ultrasound. Mean age was 32.6 years (19–57 years) in group A and 34.2 (20–53), in group B. The percentage of male and female was 38.8 and 61.2%, respectively, in group A and 33.3 and 66.4%, respectively, in group B. The venous clinical severity score and the modified Arabic version of the Chronic Venous Insufficiency Questionnaire 20 questionnaires were used to assess the quality of life and symptoms of post-thrombotic syndrome. Results Thrombus lysis was completed in 10/15 (66.6%) patients, partial in four (26.6%) patients, and not achieved in one (6.6%) patient. Successful CDT was followed by stent angioplasty in 33.3% (5/15) of the patients. There was significant difference between the two patient groups regarding Chronic Venous Insufficiency Questionnaire 20 questionnaire at 1 and 12 months, with P value of 0.01. Moreover, venous clinical severity scores at 6 and 12 months were statistically different between the two groups, with P values of 0.005 and 0.009, respectively. Conclusion CDT for the management of patients with iliofemoral DVT significantly improves HRQOL compared with similar patients treated with AC alone. Improved quality of life is related to successful thrombolysis.
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Below-the-ankle angioplasty: early and mid-term outcome p. 526
Mohammed Ali, Hossam Zaghloul, Hossam El Mahdy
DOI:10.4103/ejs.ejs_77_18  
Aim The aim of the study was to investigate the clinical effect of additional below-the-ankle angioplasty in patients with critical limb ischemia (CLI) attributed to pedal artery occlusion with insufficient wound blushing after conventional above-the-ankle percutaneous revascularization regarding the wound healing, amputation survival-free rate, limb salvage, and quality of life. Patients and methods This is a prospective observational study conducted over a period of 1 year including 21 patients who underwent below-the-ankle angioplasty. Results A total of 21 patients were included in the study; successful recanalization of the pedal-plantar arch was achieved in 19 (90.5%) patients, and complete wound healing was achieved in all patients. Primary and secondary patency rates after 1 year were 84.2 and 89.4%, respectively. Limb amputation rate at 1 year was 5.3%. Conclusion With the rapid advancement in the endovascular tools and equipment, angioplasty of the pedal arch can be a valuable revascularization strategy for adequate wound healing and limb salvage which in turn add an extra therapeutic option for patients with CLI to avoid major limb amputation.
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Laparoscopic cholecystectomy in cirrhotic patients with symptomatic cholelithiasis p. 533
Ashraf Goda, Hany Mohamed, Islam Ibrahim
DOI:10.4103/ejs.ejs_78_18  
Background Gallstones are twice as common in cirrhotic patients as in the general population. Although laparoscopic cholecystectomy (LC) has become the gold standard for symptomatic gallstones, cirrhosis has been considered an absolute or relative contraindication. Many authors have reported on the safety of LC in cirrhotic patients. We reviewed our patients retrospectively and assessed the safety of LC in cirrhotic patients at our unit of Zagazig University Hospital. Patients and methods From January 2014 to December 2016, a total of 200 patients underwent LC for symptomatic gallstone disease. All the cirrhotic patients with Child–Pugh class A and B cirrhosis undergoing LC were included in the study. Cirrhosis was diagnosed based on clinical, biochemical, ultrasonography, and intraoperative findings of the nodular liver and histopathological study. Results Of the 200 patients undergoing LC, 20 (10%) were cirrhotic. Of these 20, 12 (60%) were Child’s group A and eight (40%) were group B; 65% had hepatitis C, 5% had hepatitis B, 20% had combined C and B hepatitis, and 10% were had hepatitis. Preoperative diagnosis of cirrhosis was possible in 90% of cases, and 10% were diagnosed during surgery. The morbidity rate was 20% and no mortality was seen. One patient had hemorrhage, one patient developed postoperative ascites, one patient showed wound infection, and another one had trocar site hematoma. The mean hospital stay was 2.9±0.1 days. Of the 20 cases, two (10%) were converted to open cholecystectomy. The mean operation time was 75.2±32.54 min. Conclusion LC is an effective and safe treatment for symptomatic gallstone disease in select patients with Child–Pugh A and B cirrhosis. The advantages over open cholecystectomy are the lower morbidity rate and reduced hospital stay.
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Diagnostic accuracy of laparoscopy in staging of pancreatic cancer patients p. 537
Mohammed Faisal, Hamada Fathy, Ahmed Abo Bakr, Emad Hokkam
DOI:10.4103/ejs.ejs_79_18  
Introduction Pancreatic cancer is a devastating malignancy with nearly as many deaths as newly diagnosed cases each year. The 5-year survival rate is reported in the range between only 15 and 25% in most series. Accurate staging of patients with pancreatic cancer is crucial to clarify whether meaningful resection is indeed possible. Staging laparoscopy (SL) has been suggested as a tool for staging, which may spare up to two-fifth of these patients from undergoing nontherapeutic laparotomy. This study aimed at assessment of the role of laparoscopy in preoperative staging of patients with pancreatic cancer. Patients and methods This study was a prospective cross-sectional study, in which 26 patients with pancreatic cancers from May 2014 till May 2017 were included at Suez Canal University Hospital. Patients were subjected to undergo abdominal ultrasonography and abdominal computed tomography scan with pancreatic protocol. Patients had undergone SL with standard technique. Results Our study found that one patient in the resectable group was metastatic (1/16), whereas three patients in the borderline group were metastatic (3/10), with overall four patients (4/26) having metastasis on SL. Pattern of metastasis was liver metastases in 4% and peritoneal metastases in 11%. Male patients, older than 63 years, diabetic, cancer antigen (CA) 19-9 level more than or equal to 352 U/ml, tumors located at head, larger than 3 cm, and borderline resectable by computed tomography all may predict laparoscopically detectable metastases (P<0.05). Conclusion SL is necessary for patients with suspicious occult distant organ metastasis; but it is not a substitute of high-quality imaging.
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Early versus interval laparoscopic cholecystectomy for treatment of noncomplicated acute calcular cholecystitis p. 543
Tarek O Hegazy, Salah S Soliman
DOI:10.4103/ejs.ejs_82_18  
Laparoscopic cholecystectomy (LC) is widely established as the standard treatment in uncomplicated acute calcular cholecystitis (ACC). Despite the relevant frequency of ACC, controversies remain regarding the timing of LC. Traditionally treatment for ACC included two stages with an initial conservative management followed by an interval LC. Early LC was avoided for ACC owing to concerns about potential hazards of complications and a high conversion rate. The aim of the study is to compare between patients with uncomplicated ACC treated with early LC (within 72 h) versus interval LC (after 6 weeks of conservative treatment) regarding primary and secondary outcomes. A total of 100 patients with uncomplicated ACC are divided randomly into two groups, group A, early LC, and group B, interval LC. From this study, we conclude that there is no significant difference between both groups regarding primary and secondary outcomes. Early LC is feasible and safe, and interval LC is not associated with a lower conversion rate. In group A, there is a significantly high rate of infection, with longer hospital stay in diabetics, and in group B as well, the bile leak and rate of conversion are high, with longer hospital stay in diabetics.
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Laparoscopic anterior cystogastrostomy p. 549
Abdel F Saleh, Emad Al Sageer, Khaled Mahran, Amr Abd El-Hameed El Heeny
DOI:10.4103/ejs.ejs_83_18  
Aim This study aims to evaluate feasibility, advantages, disadvantages, and outcome of anterior approach of laparoscopic cystogastrostomy in treatment of pancreatic pseudocyst (PP) in Minia University Hospital. Patients and methods This prospective study included consecutive patients with PP who were admitted to the Department of General Surgery, Minia University Hospital, between January 2017 and January 2018. All of them were operated upon using laparoscopic anterior approach cystogastrostomy. Results This prospective study was conducted in El-Minia University Hospital after being approved by the faculty ethical committee. This study included 15 patients with nine (60%) male patients and six (40%) female patients, and their age ranged from 14 to 61 years, with mean±SD of 39±13.27). The operative time ranged from 58 to 88 min, with mean of 74 min. The intraoperative blood loss ranged from 100 to 700 ml with mean of 285 ml. Overall, two cases were converted to open surgery. The mean hospital stay after surgery for all patients was 9 days. One patient developed postoperative pain and vomiting (6.6%) and another patient developed postoperative pancreatitis (6.6%). Conclusion Laparoscopic anterior approach cystogastrostomy is an effective safe approach for management of PP with little complications.
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Different surgical techniques for lower limb permanent vascular access for hemodialysis p. 556
Mahmoud S Eldesouky, Hesham A Greda, Osman Aboelcibaa Osman, Heba E Kasem
DOI:10.4103/ejs.ejs_85_18  
Background Lower limb vascular access is used as a last option after exhaustion of all options and central venous obstruction of both upper limbs. Objectives This study describes our experience about the different techniques for lower limb permanent vascular access for hemodialysis. Patients and methods A prospective study from February 2015 till February 2017 was done on patients with end-stage renal disease with exhausted upper limb vascular access and obstructed central veins who underwent lower limb permanent vascular access for hemodialysis. Different techniques were used according to the patient condition either (a) femoral loop graft by Poly-Tetra-Floro-Ethylene (PTFE) graft, (b) saphenous vein transposition loop fistula, or (c) tunneled femoral vein catheter. Results During the study period, 64 patients were included, with 24 male and 40 female, having a mean age of 63 years. Twenty-two had tunneled femoral vein catheter, 18 had saphenous vein transposition loop fistula, and 24 had femoral loop synthetic graft. The primary patency rate during the first year after access creation was 67, 89, and 67% for the tunneled catheter, saphenous vein transposition loop fistula, and femoral loop synthetic graft, respectively. The infection rate was 22, 11, and 25% for tunneled catheter, saphenous vein transposition fistula, and femoral loop synthetic graft, respectively. Conclusion Lower extremities vascular access is a suitable and durable procedure in patients with exhausted upper limb vascular access and obstructed central veins. Different techniques are available that fit each patient according to his/her examination and evaluation.
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Double mesh technique (mesh plug and onlay) in repair of lumbar incisional hernia: a novel technique p. 562
Gamal Osman, Fady M Habib, Ahmed M Sallam, Loay M Gertallah
DOI:10.4103/ejs.ejs_87_18  
Background Patients having lumbar incisional hernia are presented with a mass in the suprailiac region posteriorly at the site of the previous operation and might be associated with occurrence of pain. Repairing such types of hernias is difficult, and it has high rates of recurrence after operation. There is a plethora of surgical techniques that have been described in performing the lumbar incisional hernia open repair, and it is difficult to detect the best technique of management, and no surgical procedure has been proved to be better than the others. The aim of this study was to provide a novel, efficient, simple and safe technique in the repair of lumbar incisional hernia and then to evaluate the short-term outcome of applying such technique to solve the recurrence problem. Patients and methods In our study, we have included 20 cases having lumbar incisional hernia and were divided into two groups: group 1 contained 10 cases that were managed by double-mesh technique and group 2 contained 10 cases that were managed by single mesh. Results We found that putting two meshes is better than a single mesh in the management of lumbar incisional hernia regarding decreasing incidence of postoperative complications (P=0.028) and decreasing incidence of postoperative recurrence (P=0.020). Conclusion Our double-mesh technique in the management of lumbar incisional hernia is a novel technique, with no intra-abdominal injuries or collections and provides better results without recurrence.
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Efficacy of multiple arterial levels of percutaneous transluminal angioplasty on limb salvage p. 569
Ayman M Samir, Amro Elboushi, Mahmoud Soliman, Asser A Goda, Hosam A Tawfek
DOI:10.4103/ejs.ejs_94_18  
Background Endovascular recanalization has become the preferred method of treatment for many patients with symptomatic femoropopliteal (FP) occlusive disease. Aim To study the efficacy of multiple level arterial angioplasty on limb salvage. Patients and methods This is a prospective, nonrandomized study that included 35 patients with critical lower limb ischemia due to multilevel arterial atherosclerotic occlusive disease treated with endovascular revascularization between August 2015 and July 2016 and followed up for 12 months. Primary outcome parameters included technical success proved by completion angiogram and distal pulse retrieval. Secondary outcome parameters included limb salvage, disappearance of the rest pain, wounds healing, and claudication distance improvement. Results Angiographically, 62.9% had both FP and infrapopliteal segment lesions while 37.1% had FP lesions only, and about 50% of our cases were Trans-Atlantic Society Consensus (TASC) II A. Technical success was recorded in 31 (88.6%) patients with failure to cross the lesion occurring in four (11.4%) patients. Cumulative limb salvage rates were 96.7, 90.3, and 80.6 at 3, 6, and 12 months, respectively. Conclusion The endovascular approach is safe and effective in the management of multilevel arterial atherosclerotic occlusive disease with high technical success rate and accepted percent of limb salvage for 1 year.
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Evaluation of superior lateral pedicle extension technique for oncoplastic resection of medial breast tumors p. 575
Ahmad F Alkarmouty
DOI:10.4103/ejs.ejs_95_18  
Introduction Oncoplastic techniques expanded the spectrum of breast conservative surgery for the management of early breast cancer. Planning for resection of medial breast tumors is difficult. The scars are apparent and deformity is eminent. Mammaplasty techniques do not leave scars in the medial area and reshaping can avoid deformity. Aim The study was carried out to evaluate the use of superior lateral pedicle and its inferior extension to fill the medial defects that occur after resection of medial breast tumors exploring the technical issues and results in terms of resection volume, adequacy of resection, deformity, complications, and esthetic results. Patients and methods Thirty consecutive patients with early breast cancer and medial tumors underwent wide excision to negative margins followed by reconstruction of defects using the extended superior lateral pedicle technique. Results All cases had negative resection margins. The weight of the specimen ranged from 65 to 565 g with an average weight of 262.47±165.31 g. Complications occurred in eight patients. No major complications or nipple loss occurred. Esthetic results were considered very good to excellent by both surgeons and patients. Conclusion Oncoplastic techniques for medial breast quadrants enabled wide resection, achieved adequate resection to negative margins with minimal complication rates and favorable esthetic results.
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A new evolving incision for partial superficial parotidectomy p. 581
Ahmed Shaaban, Mohsen Abdelmohsen
DOI:10.4103/ejs.ejs_101_18  
Background The lazy S incision (Blair’s incision) is the standard incision for parotidectomy. This incision gives an excellent exposure of the parotid gland, but may leave an ugly cervical scar, which may impair the patient’s quality of life. Many incisions had been proposed as alternatives to Blair’s incision with the aim of getting a sound scar but without impairing the adequacy of exposure of the operative field. Periauricular incision is one of these incisions which was compared in this study with the standard lazy S incision for partial superficial parotidectomy (PSP) regarding feasibility of the procedure, operative time, postoperative complications, and patient’s satisfaction with cosmetic appearance of the scar. Patients and methods The present study was a prospective, randomized, controlled study which included 60 patients with the diagnosis of superficial benign parotid lesions who were candidates for PSP. Patients were divided into two groups. Group A included 30 patients who underwent PSP via periauricular incision and group B included 30 patients who underwent PSP via the standard Blair’s incision. Results Preoperative data of patients were comparable in both groups. PSP was not feasible via the periauricular incision in two (6.66%) patients of group A. Completion of the procedure required adding a hairline incision in these two patients. Operative time was significantly longer in group A compared with group B (P=0.026). Both groups were comparable to each other’s regarding postoperative complications. Patient’s satisfaction with cosmetic appearance of scar using the visual analog scale was significantly higher in group A compared with group B (P<0.001). Conclusion PSP can be performed safely via a periauricular incision with a longer operating time, comparable postoperative complications, and significantly higher patient satisfaction with cosmetic appearance of scar compared with the standard Blair’s incision.
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Evaluation of duplex guided balloon angioplasty for salvage of failing hemodialysis access p. 588
Mohammed M El Yamany, Hatem H Mohamed, Ahmed M Abd El Rahim Hamed
DOI:10.4103/ejs.ejs_102_18  
Background Duplex ultrasonography plays a vital role in imaging of endovascular procedures of dialysis fistulas. Endovascular procedures coupled with ultrasonography gives a simple and reliable visualization of vessels forming fistula, avoiding the hazards associated with radiological imaging and lowers the financial burden. Trials have started depending on the ultrasonography imaging for intravascular interventions. Adding duplex to these procedures facilitate the accurate sizing of balloons and stents and enables us to objectivThe results ofintervention showed success rate in 18 (90%) patients evidenced by improvedpalpable thrill, residual stenosis less than 30%, restoring the function of AVF inhemodialysis. Local complications were treated conservatively, such as hematomain four (20%) cases and local inflammatory signs in two (10%) cases. None of thepatients lost his access due to intervention, two (10%) cases failed despiteintervention; one case due to thrombosis, a trial of thrombectomy by fogertycatheter was done. The other case failed to mature and maintained smallcaliber. Follow up was done for all cases for at least 3 months to confirmrestoring function of the hemodialysis accesses.ely and quantitatively assess the need and the results of intervention. Aim Evaluation of the effectiveness of duplex-guided balloon angioplasty for salvage of failing hemodialysis accesses and maintain their function. Patients and methods Twenty patients presented to the vascular surgery unit, in Suez Canal University Hospital between February 2017 and February 2018, eight (40%) presented with failing to mature arteriovenous fistulas (AVF) postcreation by more than 4 weeks,12 (60%) presented with failing AVF after usage in hemodialysis,6F sheath was used, 5-6 mm balloons were appropriate for most of the cases, arterial and venous approaches were used. Results The results of intervention showed success rate in 18 (90%) patients evidenced by improved palpable thrill, residual stenosis less than 30%, restoring the function of AVF in hemodialysis. Local complications were treated conservatively, such as hematomain four (20%) cases and local inflammatory signs in two (10%) cases. None of thepatients lost his access due to intervention, two (10%) cases failed despite intervention; one case due to thrombosis, a trial of thrombectomy by fogerty catheter was done. The other case failed to mature and maintained small caliber. Follow up was done for all cases for at least 3 months to confirm restoring function of the hemodialysis accesses. Conclusion Duplex-guided balloon angioplasty of nonmaturing and failing AVF is a safe and effective procedure. It is associated with high success rates, low complication rates, and maintained long-term patency of the hemodialysis access.
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White test versus conventional saline test in detecting intraoperative bile leakage in liver resection p. 595
Mohamed Aboul Naga, Hatem Sayed, Kamal Mamdouh
DOI:10.4103/ejs.ejs_103_18  
Background Intraoperative bile leakage testing is an important procedure in liver resection as it helps in detection of bile leaking points on the cut surface, thereby decreases postoperative bile leakage, which is one of the most dreadful complications following liver surgery. In this study, we tried to assess the efficacy of using White test in comparison with conventional saline test in detecting intraoperative bile leakage. Patients and methods In this study, we assessed whether the White test is better than the conventional saline test for the intraoperative detection of bile leakage in patients undergoing liver resection. This study included 100 patients who underwent elective liver resection. The conventional saline test (injecting an isotonic sodium chloride solution through the cystic duct) was carried out in 50 patients and the White test (injecting a fat emulsion solution through the cystic duct) was carried out in 50 patients. Results Incidence of postoperative bile leakage was compared between the conventional method and the White test. Bile leakage occurred in 22 (44%) patients in the conventional method group and in four (8%) patients in the White test group. In addition, the White test detected intraoperatively a significantly higher number of bile leakage sites compared with the conventional method. Therefore, the White test seems to be better than the conventional test for the intraoperative detection of bile leakage. Conclusion Based on our study, we recommend that surgeons investigating bile leakage sites during liver resections should use the White test instead of the conventional saline test.
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Economics and clinical implications of delayed presentation of children with intussusceptions: minimizing healthcare cost in the context of limited resources p. 600
Abdulrasheed A Nasir, David Nwosu, Kayode T Bamigbola, Lukman O Abdur-Rahman, Moneme A Obiora, Aisha A Gobir, Aisha O Saka, James O Adeniran
DOI:10.4103/ejs.ejs_113_18  
Background A basic strategy in today’s resource-limited healthcare environment is limiting cost while maintaining quality. Objective To estimate the impact and healthcare cost of treatment of intussusceptions (ISs) presenting late. Patients and methods We performed a chart review of children managed for ISs over 44 months. Our care pathway included resuscitation, ultrasound-guided hydrostatic reduction of children presenting early (≤24 h) with no peritonitis. Results There were 46 children seen at a median age of 8.5 months. Thirty-two (69.6%) presented late (>24 h). The total charge was higher for patients who presented late ($259.6 vs. $168.9, P=0.012). There was an average of 21% ($50.0) additional charges incurred for each day’s delay. There was significantly higher cost of drugs ($45.1 vs. $23.7, P=0.008) and procedures ($154.4 vs. $99.5, P=0.025). Those who presented late had increased risk of bowel resection (40 vs. 0%, odds ratio=1.74, P=0.005), and higher complication rates (56 vs. 21%, odds ratio=0.21, P=0.018). The length of stay was doubled for those who presented late (10.6 vs. 4.6 days, P=0.001). Conclusion Delayed presentation of ISs translates to increased hospital cost and an extra week in hospital with increased morbidity.
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Residual liver volume as a predictive value for donor outcome in adult right lobe living donor liver transplant p. 606
Kamal Mamdouh, Mohamed Aboelnaga
DOI:10.4103/ejs.ejs_116_18  
Background Right lobe liver donation is a widely accepted procedure that results in the expansion of the indication for living donor liver transplantation (LDLT). Precise preoperative evaluation of a donor is important for performing LDLT successfully and safely in both the recipient and the donor. Objective The aim was to evaluate postoperative donor outcome regarding liver functions and complications after adult right lobe LDLT with different residual liver volumes. Design A prospective study was conducted. Patients and methods Between September 2014 and April 2016, we prospectively compared 41 donors having a remnant liver volume (RLV) of 35–40% (group A) with 42 donors having a RLV of 41–49% (group B) for donor outcomes. All the complications in donors were systematically classified. Results Donors of the group A showed significantly higher peak international normalized ratio and bilirubin levels and lower albumin level than group B. The incidence of postoperative complications was seen in 15 (36.6%) patients in group A and in nine (21.4%) patients in group B. The overall incidence of complications was 28.9%. Conclusion The use of donors with more than 35% RLV is safe regarding the postoperative donor outcome. The use of donors with less than 35% RLV is controversial, so, we recommend more advanced studies on lower RLV less than 35% to increase pool of potential donors for LDLT, especially in countries in which deceased donor liver transplantation is still forbidden.
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CASE REPORTS Top

A life-saving approach utilizing simple recourses in penetrating neck injuries: a case report p. 616
Amro El Hadidi, Amr M Abdellatef, Abd El-Mohsen Hamad, Taha Yaseen
DOI:10.4103/ejs.ejs_68_18  
Penetrating neck injuries are a crucial area of trauma care and represent nearly 5–10% of all trauma cases in the emergency department. Injuries in the zones 1 and 3 of the neck are more difficult to investigate than zone 2 and require extensive effort and knowledge. We report the case of a 35-year-old male patient with penetrating neck injury in zone 1 of the neck, causing left-sided hemothorax. Effective patient management was challenging as the patient was unstable and could not be transferred to any nearby tertiary hospital. Therefore, he was immediately transferred to the operative table. A longitudinal neck incision was made on the left side of the neck to control the bleeding, and median sternotomy in addition to anterior thoracotomy was performed. Two injuries were observed at junction of the jugular, subclavian, and brachiocephalic veins, and one injury was seen in a side branch of the subclavian artery. The patient was treated successfully through this treatment approach, thereby overcoming the challenges of a complicated case and limited facilities in the hospital.
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