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   Table of Contents - Current issue
July-September 2017
Volume 36 | Issue 3
Page Nos. 199-331

Online since Thursday, July 27, 2017

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Burst abdomen: should we change the concept, preliminary study Highly accessed article p. 199
Hesham Amer, Sherif M Mokhtar, Shady E Harb
Background Burst abdomen represents one of the most frustrating and difficult postoperative complications encountered by surgeons who perform a significant volume of surgery. Burst abdomen occurs because of various preoperative, operative and postoperative factors, which can be prevented to some extent by being aware of them. The choice of incision for laparotomy depends on the area that needs to be exposed, the elective or emergency nature of the operation, and personal preference. Type of incision may, however, have an influence on the occurrence of postoperative wound complications, which is discussed in our study. There is little consensus in the literature as to whether a particular incision confers any advantage. Objective The purpose of this study was to provide an evidence-based consensus regarding the patients who underwent laparotomy for various intra-abdominal conditions included in our inclusion criteria and who developed burst abdomen in relation to the type of abdominal incision (vertical vs. transverse), as well as to know the rates of incidence, morbidity and mortality due to burst abdomen, and study other variables within the scope of postoperative complications. Other variables within the postoperative complications spectrum were also studied alongside the main one, burst abdomen. Patients and methods This is a prospective, randomized study (by card picking under supervision of the ward nurse) that compared the postoperative complications (mainly burst abdomen) after two main types of abdominal incisions, vertical and transverse, within a period of 12 months from October, 2015 to October, 2016. The study was conducted at the Emergency Unit, General Surgery Department, Kasr Al Ainy University Hospital, Faculty of Medicine, Cairo University. Sixty patients underwent open abdominal operations (exploration) after following distinctive inclusion and exclusion criteria. Thirty patients underwent vertical and thirty patients underwent transverse incisions. The main outcome measures were early complications such as burst abdomen, pulmonary complications and hospital stay. Results The transverse incision offers as good an access to most intra-abdominal structures as a vertical incision. The incidence of burst abdomen is higher in the vertical incision (midline) group, with 71.4% of the total patients suffering a burst abdomen. Respiratory complications occurred significantly in cases of burst abdomen (P<0.001). Hence, hospital stay was longer in cases of burst abdomen (P<0.001), which added to the economic burden. Conclusion Transverse incisions in abdominal surgery are based on better anatomical and physiological principles. It should be preferred, as the early postoperative period is associated with fewer complications (burst abdomen and pulmonary morbidity). A midline incision is still the incision of choice in conditions that require rapid intra-abdominal entry (such as trauma with suspected intra-abdominal haemorrhage).
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Short-term surgical and functional outcome of laparoscopic ventral mesh rectopexy for management of complete rectal prolapse p. 208
Mostafa B Abdulwahab, Hussein Elgohary
Background There is no clear treatment of choice for the problem of complete rectal prolapse (CRP). The treatment of CRP in adults is essentially surgical. Surgical management is aimed at restoring physiology by correcting the prolapse and improving continence and constipation with acceptable mortality and recurrence rates. Objectives The aim of this study was to determine the safety and outcome of laparoscopic ventral mesh rectopexy (LVMR) for the management of patients with CRP. Patients and methods The study included 33 patients with CRP: 20 females and 13 males. Female patients were significantly obese than male patients were; however, male patients were significantly older. A total of four female patients had associated vaginal vault prolapse. All patients underwent LVMR. Surgical outcome included intraoperative, postoperative, and follow-up data. Functional outcome was assessed at 6- and 12-month postoperatively and compared versus preoperative evaluation for severity of fecal incontinence (FI) using Vaizey score, frequency, and severity of constipation using Cleveland Clinic Constipation score, and effect of FI on patient’s quality of life (QOL) using the Fecal Incontinence Quality of Life Scale score. Results All patients passed smooth uneventful operative and immediate postoperative course. No patient required conversion to laparotomy. Mean operative time was 151.9±31.6 (range: 120–240)min, and mean amount of intraoperative blood loss was 75.2±16 (range: 50–130)ml. Laparoscopic surgery provided its usual advantages concerning low postoperative pain score, and early ambulation, oral intake, and hospital discharge. Only three (9.1%) patients developed immediate postoperative complications. All patients showed significant functional improvement manifested as a significant decrease of Vaizey FI and Cleveland Clinic Constipation scores with a significant increase of Fecal Incontinence Quality of Life Scale score at 6-month postoperatively, and these scorings were progressively improved till 12-month postoperatively. Throughout the course of the 12-month postoperative follow-up, two female patients developed recurrent rectal prolapse for a frequency of 6.1%. Conclusion LVMR is a safe procedure for management of CRP within reasonable operative time and with minimal immediate postoperative morbidities. LVMR provided significant improvement of CRP-associated FI and constipation and its effect on patients’ QOL. LVMR was associated with low frequency of postoperative recurrence throughout the 12-month follow-up.
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Laparoscopic left lateral bisegmentectomy for hepatocellular carcinoma: moving from peripheral to anatomical p. 217
Hossam El-Deen M Soliman, Mohamed Taha, Hany Shoreem, Osama Hegazy, Ahmed Sallam, Islam Ayoub, Amro Aziz, Maher Osman, Tarek Ibrahim, Ibrahim Marwan, Khaled Abuelella
Context The use of the laparoscopic approach for liver resections became popular worldwide and is now of increasing popularity in Egypt. The growing experience in laparoscopic liver resections has made it more applicable in cirrhotic livers with hepatocellular carcinoma. Aim The aim of this study was to assess the feasibility and safety of laparoscopic left lateral liver resections in a tertiary centre in Egypt. Patients and methods A retrospective analysis of laparoscopic liver resections was undertaken in patients with preoperative diagnoses of a hepatocellular carcinoma with compensated cirrhosis. Surgical technique included CO2 pneumoperitoneum and liver transection with a harmonic scalpel and laparoscopic Habib 4X sealer without portal triad clamping or hepatic vein control. Portal pedicles and large hepatic veins were stapled. Resected specimens were placed in a bag and removed through a separate incision, without fragmentation. Nonparametric data were presented as medians (range), and categorical data as frequency and proportion (%). P value less than 0.05 was considered statistically significant. Statistical analyses were performed using the IBM SPSS software, version 23. Results From August 2008 to February 2016, 38 liver resections were included. Eleven patients with a diagnosis of HCC were planned for laparoscopic left lateral resection. The mean tumour size was 5.6±2.1 cm. There were five conversions to laparotomy: two cases because of bleeding, one because of stapler failure, one because of accessibility failure, and one because of failure to extract the specimen. Mean blood loss was 150±75 ml. Mean surgical time was 160±40 min. There were no deaths. Complications occurred in two patients: only one patient developed postoperative ascites and the other developed bile leak. Conclusion Laparoscopic left lateral bisegmentectomy is feasible and safe in selected patients with adequate training and preparation.
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Efficacy of endovenous laser ablation (endovenous laser ablation) versus conventional stripping in the treatment of great saphenous vein reflux p. 222
El-Sayed A Abd El-Mabood, Refaat S Salama
Purpose The purpose of this study was to find out the advantages and efficacy of endovenous laser ablation (EVLA) versus conventional stripping in the treatment of great saphenous vein (GSV) reflux. Background Varicose vein treatment places a considerable strain on the medical system, with long waiting time for operation in the public hospital system. EVLA allows efficient treatment of many patients on an outpatient basis. Patients and methods This prospective study included 44 patients with primary varicose veins. Patients were randomly allocated into two groups according to the intervention performed − group A: conventional surgical stripping of the GSV [22 (50%)], and group B: EVLA ablation [22 (50%)]. All patients underwent clinical evaluation, routine hematological tests, and venous duplex of both lower limbs. The follow-up period was 6 months. Results There were satisfactory results in the EVLA group (group B); in about 20 (90.8%) cases of this group the procedure was performed under tumescent anesthesia with less mean postoperative time, 69.1±3 min, less postoperative pain rate, 4.05±1.23, less 1-week complications limited to Bruising and Ecchymosis in five (23.8%) cases, superficial phlebitis in three (14.28%) cases, developed thrombosis in two (9.52%) cases, or skin burn in one (4.76%) case. Rapid return to normal activity (5.8±1.5) and overall results were better in group B, 19 (90.47%), compared with group B, 14 (66.66%), with a P-value of 0.001. Conclusion EVLA of GSV, being simple to perform and well accepted by patients, is a safe and effective method with low rate of complications, one-day hospitalization, short recovery time, and quick return to professional activities. For these reasons, this method is considered a very promising technique especially in female patients for cosmetic reasons as compared with surgical stripping.
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Cholecystectomy for combined choledocholithiasis and cholelithiasis in elderly patients: do we need it? p. 233
Mohamed Abdel Fatah Selimah, Moustafa R Abo Elsoud, Ayman Farouk
Background After endoscopic common bile duct (CBD) stone removal, physicians always recommend prophylactic cholecystectomy even in the absence of gall bladder (GB) stones to prevent further complications such as acute cholecystitis, recurrent CBD stones, or cholangitis despite the fact that management of GB after endoscopic stone removal remains a matter of debate. The main options in managing concomitant CBD stones and the GB stones include selective preoperative endoscopic retrograde cholangiopancreatography (ERCP), postoperative ERCP, open explorations, and laparoscopic common bile duct exploration. Aim The aim of this study was to assess the need for cholecystectomy after endoscopic sphincterotomy for CBD stones in elderly patients aged more than or equal to 70 years with coexisting cholelithiasis. Patients and methods A total of 336 patients who underwent successful endoscopic CBD stone removal at the endoscopy unit of the Medical Research Institute Hospital, Alexandria University from January 2013 to December 2015, were analyzed retrospectively. Patients were divided into three groups: the in-situ group comprised 168 patients with an intact GB, the cholecystectomy group comprised 72 patients who had cholecystectomy performed after ERCP, and the third group comprised 36 patients who had cholecystectomy before ERCP. Results After endoscopic CBD stone removal, 72 (30%) patients underwent subsequent cholecystectomy and 168 (70%) patients did not. There was no significant difference as regards morbidity and mortality among the study groups. Age was not a contraindication for surgery; however, the presence of multiple comorbidities, mainly diabetes and cardiac diseases, was a significant contraindication for prophylactic cholecystectomy. Conclusion A wait-and-see policy may be recommended for elderly patients with comorbidities and GB in situ taking in consideration regular follow-up for early detection of acute biliary complications.
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How far is sleeve gastrectomy more effective than diet regimen in treating obesity-associated hyperlipidemia p. 239
Nader M Milad, Ahmed H Khalil, Sherif M Mokhtar, Marian M Daoud
Background The global epidemic of obesity is one of the major health issues in the 21st century that influences many aspects of public health, including psychosocial and socioeconomic aspects. Hyperlipidemia is one of the health hazards associated with morbid obesity. Patients and methods This was a prospective study conducted in Kasr Al-Aini University Hospital (sleeve gastrectomy group) and the National Nutrition Institute (diet group) during the period from June 2015 till December 2015 with a follow-up of 12 months till December 2016 for both groups. One hundred patients were included in the study and were equally divided into two groups: group A (sleeve gastrectomy group) and group B (diet group). Objective The objective of this study was to compare the effects of laparoscopic sleeve gastrectomy (LSG) and a dietary regimen on hyperlipidemia in morbidly obese patients. Results LSG significantly decreased total cholesterol in 70% of cases and triglycerides in 78% of cases; however, diet caused a decrease of total cholesterol in 30% of cases and triglycerides in 54% of case. Low-density lipoprotein was not significantly changed in both groups. Conclusion LSG is more effective than diet programs in treating obesity-associated hyperlipidemia due to more significant and sustained excess body weight loss.
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Transhernial diagnostic laparoscopy for detection of contralateral subclinical patent processus vaginalis in cases with negative preoperative ultrasound p. 246
Mohamed Y Batikhe, Ahmed M Gafar
Introduction and objective Bilateral inguinal hernias are relatively common in children; this fact has led to a controversy about the necessity of bilateral surgical exploration during the repair of unilateral inguinal hernia in children. The aim of our study is to evaluate transhernial laparoscopy as a tool for the detection of subclinical contralateral patent processus vaginalis (CPPV) in cases with negative preoperative ultrasound (US). Patients and methods This prospective study included 60 kids who underwent unilateral herniotomy in the period from October 2015 to October 2016 at Pediatric Surgery Unit, Sohag University Hospitals, Sohag, Egypt. Ethics committee approval was obtained. Patients with bilateral hernia and those with detected subclinical CPPV by preoperative US all were excluded. Two parameters were used for evaluation of subclinical CPPV, using transhernial diagnostic laparoscopy technique: the first was inflation of the contralateral scrotal compartment in males or labia in females and the second was laparoscopic visualization (exploration) of contralateral internal ring. Demographic data, laparoscopic operation time, difficulties in the procedure, and results were all reported and analyzed. Results Of 60 patients, 48 were male and 12 were female. Laparoscopic operative time ranged from 5 to 12 min. Hernia side was right in 40 patients (32 male and eight female) and left in 20 patients (16 male and four female). Subclinical CPPV was proved, using transhernial diagnostic laparoscopy technique in five patients and the procedure was completed by contralateral herniotomy. Conclusion Transhernial diagnostic laparoscopy, for cases with negative preoperative US regarding CPPV, is a feasible, rapid, safe, accurate method, with easy technique and it seems to be more sensitive than preoperative US.
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Posterior hyoid space; a brilliant concept in managing thyroglossal duct cyst (TGDC) p. 249
Ehab M Oraby, Mohamed I Abdelhamid, Taha A Baiomy, Hayam E Rashed
Introduction Thyroglossal duct cyst and/or fistula represent the most common congenital anomalies of the neck. Many procedures have been described for excising thyroglossal cysts. These procedures vary from simple cyst excision to anterior block neck dissection. Objective The aim of the paper was to evaluate the concept of posterior hyoid space according to the Maddalozzo modification of the Sistrunk operation. Patients and methods This prospective study was carried out at the general surgery departments of Benha and Zagazig University Hospitals. Twenty-eight patients diagnosed with primary thyroglossal duct cyst were included in this study. The surgical technique used was that described by Maddalozzo et al. Results Twenty (71%) patients had anterior neck cystic swelling and eight (29%) patients had neck fistula. After histopathological examination, the tract passed in front of the hyoid bone in all cases (100 %), whereas ectopic thyroid follicles were detected ventral to the hyoid bone in 11 (39%) cases, behind the hyoid bone in three (11%) cases, and in four (14%) cases, it was found in both the ventral and the dorsal position. Conclusion Our results were promising, and this approach of posterior hyoid space should be studied more extensively for assessment of its efficacy and benefits. This method should also be used to evaluate the possible role of ectopic thyroid tissues in recurrence with the use of the classic Sistrunk procedure.
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Predictors of occult nipple–areola complex involvement in breast cancer patients: clinicopathologic study p. 254
Mohamed I Abdelhamid, Mohammed M Alkilany, Hayam E Rashed
Context Although oncoplastic breast-conserving surgery is a standard approach for treatment of breast cancer patients, mastectomy is still performed in 20–30% of patients undergoing surgeries. Nipple-sparing mastectomy provides a cosmetic and psychological outcome for patients; however, the oncologic safety of nipple–areola complex (NAC) sparing is a major concern. Aim The focus of this study was to determine the predictive factors of NAC involvement to define the indicators for NAC preservation. Patients and methods We analyzed NAC involvement in 180 patients during the period between October 2013 and December 2016 as regards the relation between the pathological affection of the NAC and clinical criteria, pathological and molecular features of the tumor (size, site, tumor–nipple distant, nodal affection, and molecular classification of breast cancer). Results Among 180 patients, 38 (21.1%) demonstrated NAC involvement, and it was mostly associated with tumor size 4 cm (P=0.047), tumor–nipple distant of 2.5 cm (P=0.003), positive lymph node (P=0.05), negative estrogen receptor (P=0.00013), negative progesterone receptors (P=0.000001), and HER2 receptor overexpression (P=0.001). Triple-negative breast cancer was significantly associated with increased risk of NAC involvement followed by HER2/neu-enriched subtype (P=0.001). Conclusion Tumor–nipple distant, tumor size and state of lymph nodes are the most important clinical predictors of nipple involvement and should be considered as risk factors. At the pathological and molecular level, triple-negative breast cancer is the worst subtype. The presence of one or more of these factors indicates high risk of occult nipple invasion.
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Negative-pressure wound therapy in pediatric extremity trauma: a single-institution experience p. 260
Hazem Eltayeb, Rasha Kassem
Background The value of negative-pressure wound therapy as a bridge to definitive closure of traumatic extremity wounds has been established in adults. Negative-pressure wound therapy has been used to assist granulation tissue formation and promote closure of wounds. In this study, we evaluated our experience with negative-pressure wound therapy for pediatric extremity wounds requiring delayed closure. Patients and methods A prospective study was conducted on 20 pediatric patients presenting with extremity injuries involving soft-tissue defects not suitable for immediate primary closure. Initial evaluation of the traumatized patient, wound irrigation, debridement, and antibiotic therapy were carried out and a plan for each case was outlined. Negative-pressure wound therapy was established using the vacuum-assisted closure system and dressings were changed every 3 days before definitive closure either by skin graft, Integra dermal matrix followed by skin graft, or local flaps. Results Granulation tissue was noted in all wounds by day 3. The mean duration of vacuum therapy was 12±3.3 days in patients whose wounds were closed by local flap advancement (n=4), 9±3.6 days in patients whose wounds were closed by skin grafts (n=8), and 6±4.8 days in patients whose wounds were closed by Integra dermal matrix (n=8). There was no incidence of skin graft or Integra losses. All local flaps healed complet ely. The mean follow-up period was 18±6.8 months, during which no complications were noted. Conclusion As a relatively atraumatic wound care technique with little complications, negative-pressure wound therapy provides a highly effective option as a bridge for soft-tissue management of extremity trauma in pediatric patients.
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Single-port laparoscopic-assisted appendectomy using the nephroscope for percutaneous nephrolithotomy at low cost p. 265
Hesham M Abdelkader, Ahmed S.M. Omar, Mohab G Elbarbary
Context Laparoscopic appendectomy had been accepted over the last years, as a goal of improved diagnostic accuracy and wound complication rate, over the open procedure. However, the new techniques require single port and manoeuverable instruments, which are expensive. In this study, the cost of single-port laparoscopic appendectomy is reduced through conventional instrumentation using a side-arm viewing operative laparoscope, which is the nephroscope used for percutaneous nephrolithotomy. Aim The aim of this study was to present the retrospective experience of reducing the cost of single-port laparoscopic-assisted appendectomy using the nephroscope for percutaneous nephrolithotomy. Settings and designs The study design was a retrospective case series one. Materials and methods Our study was conducted between December 2014 and August 2015. The study included 40 patients with clinical diagnosis of acute appendicitis. Patients with complicated appendicitis, obese patients (BMI ≥35 kg/m2) and those who needed the insertion of another port were excluded from the study. Statistical analysis Continuous variables were expressed as mean and SD. Categorical variables were expressed as frequencies and percentage. Results The study included 40 patients, 24 (60%) male and 16 (40%) female. The mean operative time was 35±12 min. The age of participants ranged between 8 and 25 years. There was no significant perioperative morbidity or mortality. The mean follow-up period was 6 months. Conclusion Our experience with this technique of single-port laparoscopic-assisted appendectomy using the nephroscope for percutaneous nephrolithotomy demonstrates its feasibility and safety at a very low cost.
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External laryngeal nerve to identify or not during thyroidectomy: a single-institute experience p. 269
Ahmed Shaaban, Aymen Farouk, Mostafa M Donia
Background Iatrogenic injury to the external branch of the superior laryngeal nerve (ESLN) may occur during thyroidectomy because of its close proximity to the upper pole of the thyroid gland. Injury to the ESLN results in postoperative voice changes, which may be severe, especially in professional voice users. Although the main principle in neck surgery is proper dissection and identification rather than avoidance of important structures for their preservation, many surgeons do not routinely identify the ESLN during thyroidectomy because the nerve has variable anatomical courses. This encouraged us to conduct this study to evaluate the incidence of ESLN injury during thyroidectomy when superior thyroid vessels were ligated individually close to thyroid capsule without prior identification of the nerve. Patients and methods The present study included 200 patients with goiters who underwent either total or hemithyroidectomy at the Department of Surgery, Medical Research Institute Hospital, Alexandria University. In all patients, superior thyroid vessels were ligated in branches very close to thyroid capsule without prior positive search for the ESLN. Results In the present study, 185 (92.5%) patients underwent total thyroidectomy, whereas the remaining 15 (7.5%) patients underwent hemithyroidectomy. Transient ESLN injury occurred in 3% of patients, whereas 2% suffered from permanent nerve injury. Conclusion Preservation of the ESLN is necessary during thyroidectomy, especially in professional voice users. Ligation of superior thyroid vessels in branches close to thyroid capsule without prior identification of the ESLN is a safe procedure and does not increase the incidence of nerve injury.
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Surgical outcome of choledochal cysts in adults: a prospective cohort study p. 274
Mohamed I Kassem, Hany M El-Haddad, Mohamed T Elriwini
Background Choledochal cysts (CCs) are cystic dilatation of the biliary ductal system. Adult cases comprise around 20% of all cases. Purpose The aim of this study was to integrate all possible technical methods to prevent complications arising from residual choledochal tissue by presenting our experience in adult patients. Patients and methods A prospective cohort study of 24 adult patients, who underwent surgery for CC, over a 4-year period from March 2013 to February 2017 at the Gastroenterology Surgical Unit, Faculty of Medicine, Alexandria University, Egypt, was carried out. Cysts were classified according to the Todani classification. Biliary anatomy was defined by intraoperative cholangiography. Results The present study included six males and 18 females. Their ages ranged from 18 to 43 years (mean 26.4 years). Pain was the most common symptom at presentation (20 patients, 83.3%). Eighteen patients (75%) had type I cysts. All patients underwent excision of the extrahepatic bile duct cyst. The mean follow-up period was 34.6 months. Conclusion The present study showed satisfactory medium-term results following surgical resection of adult CC. Our approach was effective, to a great extent, in preventing complications of residual cysts. Excision of the extrahepatic bile duct should be guided by intraoperative cholangiography and distal clips to avoid pancreatic duct injury.
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Stent fracture after provisional stenting using four brands of nitinol stents in trans-atlantic inter-society consensus c and d femoropopliteal lesions: in 1 year’s follow-up p. 283
Magdy A Wahab Hagag, Ahmed R Tawfik
Introduction Stenting Trans-Atlantic Inter-Society Consensus C and D lesions of the femoral–popliteal segment is still controversial. There is a wide range of stent fractures ranging between 2 and 62% with different clinical outcomes. This study aimed to investigate the clinical impact and outcome of stent fracture of complex lesions of the femoral–popliteal territory using four brands of stents after 1 year. Patient and methods This was a retrospective study on 102 limbs that had Trans-Atlantic Inter-Society Consensus C and D femoral–popliteal lesions. All of them were treated with balloon angioplasty with bailout stenting (self-expandable nitinol stents, Portege EverFlex, E-Luminexx, and Absolute Pro). Patients were followed up by clinical assessment, and duplex and biplane radiography to detect stent fracture. Results After a mean 9±5.6 months’ complete follow-up of 150 stents in 102 limbs, mean length of the stented segment being 16.5±9.9 cm, the following results were obtained. An overall 78% of stents were fractured. An overall 88.2% of the treated limbs were occluded and presented with critical limb ischemia. The patency rate was 0% for type III and type IV stent fractures, 50% for type II stent fracture, and 6.25% for type I stent fracture. There was no correlation between the type of stent fracture and either stent location (proximal, mid, distal superficial femoral artery and supragenicular popliteal artery) or stent design (brand). Conclusion The patency rate for the stented femoral–popliteal segment was very poor, despite great advances in the designs of stents to withstand the highly varied forces applied to this segment. Stenting this segment should be the last option, in which surgery has a great risk (drug-coated balloon and/or atherectomy devices, failed or unavailable).
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Value of staging laparoscopy for the assessment of operability in periampullary cancer patients: a comparative study versus exploratory laparotomy p. 291
Hany A Balamoun, Sameh A Mikhail, Khaled Nour El Din
Objectives The aim of this study was to evaluate the diagnostic yield of staging laparoscopy (SL) for patients with periampullary cancer with no signs of inoperability on computed tomography (CT) imaging. Patients and methods Thirty-eight patients with malignant obstructive jaundice were considered for this study. Only patients with no distant metastases and with lesions potentially resectable on CT criteria were included. Patients were randomized to two groups: group A included patients who underwent exploratory laparotomy (EL) based on CT findings, and group B included patients who were subjected to SL and then proceeded to laparotomy according to SL findings. Primary outcomes included the frequency of cancelled laparotomy and the frequency of positive laparoscopy, indicating inoperability or irresectability. Results EL confirmed CT findings in eight (42.1%) patients of the EL group. In total, resection was not indicated nor possible in 11 patients of the, Replace:=wdReplaceAll, Format:=True, Forward:=True, MatchWildcards:=False, Wrap:=wdFindStop EL group and were considered as false positive for CT. SL confirmed CT findings in seven (36.8%) patients of the SL group. SL detected signs of inoperability in 12 patients. In total, resection was not indicated nor possible in 13 patients of the SL group and were considered as false positive for CT. Collectively, CT could define operability and lesion resectability with a positive predictive value (PPV) of 36.8% and low specificity. However, preliminary SL could define operability and lesion resectability of patients with free CT with a PPV of 85.7% (95% confidence interval: 47.72–97.53) and specificity rate of 92.3% (95% confidence interval: 63.97–99.81). Conclusion Reliance on CT imaging alone for defining operability of patients with periampullary is accompanied by a relatively high unnecessary laparotomy rate. SL should be considered for defining inoperability with high PPV and specificity. SL could spare unnecessary laparotomy in around 50% and allowed shorter theater time and postoperative hospital stay for inoperable patients compared with EL.
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Abstracts p. 297

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Poster Hall p. 321

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