A 65-year-old woman was admitted with a complaint of a constant dull aching pain in the epigastrium for 4 days, with subsequent worsening and generalization of the pain. Clinically the abdomen was tender all over with board-like rigidity. Chest radiography revealed pneumoperitoneum and a decision was made to explore the patient. During laparotomy we found mild peritoneal collection with no perforation in the anterior surface of the stomach, duodenum, or the entire gastrointestinal tract. After opening the gastrocolic omentum, we found a large perforation of the posterior wall of the stomach. After direct repair with an omental patch, the patient recovered and was discharged after 14 days, with only wound infection. Posterior perforation of a gastric ulcer is a very rare condition.

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Background: The thyroglossal duct cyst (TDC) results from a failure of complete obliteration of thyroglossal duct. It represents the most common type of developmental cyst seen in the neck region. Objective: Evaluate our experience in the management of primary and recurrent thyroglossal cyst and fistula and to determine the role of pre- and postoperative infection as an important factor associated with thyroglossal duct recurrence after surgery. Methods: During the period from January 2013- April 2014, in General and Pediatric Surgery Department, 50 patients with thyroglossal duct cyst (35 patients) and fistulae (15 patients) were diagnosed and treated. All records were reviewed for age and sex, diagnostic methods, surgical management and postoperative infection and recurrences. Results: The recurrence rate was high in cases with infection occurred preoperative or postoperative. Conclusion: Infection very important leading factor for recurrence of thyroglossal cyst.

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Background Laparoscopic sleeve gastrectomy (LSG) is a safe and effective surgical treatment modality for morbid obesity. Variations in surgical technique could affect the results. The optimal size of the bougie remains controversial. The aim of this study was to evaluate the first-year outcome of LSG using two different sizes of bougies. Patients and methods Between March 2011 and January 2014, 102 morbidly obese patients underwent LSG. These patients were divided into two groups: group 1 (50 patients) and group 2 (52 patients). In group 1, 32-Fr bougies (orogastric calibration tube) were used, and in group 2 40-Fr bougies were used. Patients completed at least 6 months of follow-up visits. Results The excess body weight loss percentage in group 1 was 53.6 ± 10.96% at 6 months and 69.4 ± 15.6% at 1 year postoperatively, whereas in group 2 it was 52.7 ± 11.27% at 6 months and 66.4 ± 13.4% at 1 year postoperatively, with no statistically significant difference between the two groups. There were neither intraoperative complications nor postoperative mortalities. The overall complication rate was 14.7% (15 patients) with no statistically significant difference between the two groups (14% in group 1 vs. 15.4% in group 2). The postoperative hospital stay was 2.3 days in group 1 versus 2.2 days in group 2. There was 58.8% complete resolution of diabetes mellitus, 60% resolution of hypertension, and 87.5% resolution of sleep apnea 6 months after sleeve gastrectomy with no statistically significant difference between the two groups. Conclusion LSG is a safe and effective treatment method for morbid obesity. Bougie size does not affect the short-term outcomes.

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Introduction Appendectomy is one of the commonest operations performed annually. Despite the advancement in the laboratory tests and radiological tests, still the rate of negative appendectomies is 15-30%. This study was designed to assess the diagnostic value of quantitative C-reactive protein (CRP) and white blood cell count (WCC) in patients suspected to have acute appendicitis. Patients and methods Our study is a prospective study that was conducted between December 2012 and March 2013 after approval of the ethical committee. Inclusion criteria

1. Patients with clinically diagnosed acute appendicitis without generalized peritonitis.

Exclusion criteria

1. Patients with generalized peritonitis

All patients were subjected to the following

1. Clinical examination
2. Routine bloods immediately after decision to admit including full blood count and CRP.
3. Urine test
4. Pregnancy test for all females
5. Ultra sound scan to rule out other causes of abdominal pain

All the patients were operated upon via open approach and the appendix was sent for histopathological analysis and the results were compared with C-Reactive protein (CRP) and the WBC (White blood cell count) and the results were compared using t-tests. Results Our study recruited 100 patients, 60 males (60%) and 40 females (40%), in the age range 20-55 years. The histopathological analysis showed acute appendicitis in 85 patients (85%), the operative notes showed 60 patients with noncomplicated appendicitis, 25 patients with complicated appendicitis; the WCC alone has a sensitivity of 85%, specificity of 75%, CRP alone has a sensitivity of 93.3% and specificity of 86.6%, WCC alone had positive predictive value of 44% and it improves to 70% when both parameters are combined together, whereas the negative predictive value of the WCC was 100%. In patients with normal appendix the mean CRP level was 10.6 mg/l, the median level was 10.6 mg/l, and the mean WCC was 8 Χ 10 ⁹ cells/l, the median WCC 7 Χ 10 ⁹ cells/l, whereas in patients with noncomplicated acute appendicitis (n = 60) the mean CRP was 40 mg/l, the median was 20 mg/l; in patients with complicated appendicitis (n = 25) the mean CRP was 90 mg/l and the median was CRP 60 mg/l. Conclusion We suggest that patients experiencing lower abdominal pain, with normal CRP values and normal WCC are unlikely to have acute appendicitis and need further investigations before embarking onto surgery.

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Background Gastrointestinal stromal tumors (GISTs) are a group of unusual neoplasms arising from the interstitial cells of Cajal. GISTs are the most common mesenchymal tumors of the gastrointestinal (GI) tract. Diagnosis always requires immunohistochemical staining for the expression of c-KIT protein (CD-117). Purpose The aim of this study was to present the prospective and retrospective experience of the Gastrointestinal Surgery Department, Alexandria Faculty of Medicine, in the management of GISTs. Materials and methods This study was carried out on 102 patients: a prospective study on 22 patients from April 2013 to April 2015 and a retrospective study on 80 patients between January 2009 and March 2013. All patient data, the different clinical presentations, the impact of surgical treatment, complications, follow-up, and survival data were collected and analyzed. Results This study included 102 patients (63 men and 39 women) who presented with GISTs on clinical, radiological, and/or endoscopic aspects. Their mean age at diagnosis was 49.18 ± 14.58 years. The most frequent presenting symptom was GI bleeding, seen in 42 patients (41.18%). Twenty-five patients (24.51%) presented with abdominal swelling and pain. Twenty-four patients (23.53%) presented with anemia for investigation. Eight patients (7.84%) presented with repeated attacks of abdominal pain only. The tumors were located in the stomach in 54 patients (52.9%). Upper gastrointestinal endoscopy was performed in 64 patients (62.75%). Upper gastrointestinal endoscopy revealed the presence of a gastric lesion in 46 patients and a duodenal lesion in six patients and was completely free in 12 patients. Complete resection was achieved in 92 patients (92%), whereas eight patients (8%) had incomplete resection. Conclusion This study concludes that GISTs can occur anywhere in the GI tract but most commonly in the stomach. The prognosis is strictly related to the size of the tumor, number of mitoses, and completeness of surgical resection.

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Objective The aim of this study was to compare the efficacy and clinical outcome after rubber-band ligation (RBL) and Doppler-guided hemorrhoidal artery ligation (DG-HAL) for primary symptomatic (grades II and III) hemorrhoids. Patients and methods Fifty patients with symptomatic grade II and grade III uncomplicated internal hemorrhoids were randomly assigned to be treated with either RBL or DG-HAL. Patients were assessed clinically for postoperative complications and recurrence through 6 months after surgery. Results Preoperative characteristics were similar between the two groups. The main preoperative complaint was protrusion of piles followed by bleeding. The overall rate of complications was 16% after RBL (9.1% for grade II and 21.4% for grade III) and 4% after DG-HAL (6.7% for grade II and 0% for grade III) (P = 0.07). The overall rate of recurrence was 12% after RBL (9.1% for grade II and 14.3% for grade III) and 4% after DG-HAL (0% for grade II and 10% for grade III) (P = 0.2). All complications were conservatively controlled with no need for reintervention. At the end of 6 months of follow-up, the overall freedom from symptoms was 88% after RBL (90.9% for grade II and 85.7% for grade III) and 96% after DG-HAL (100% for grade II and 90% for grade III). With regard to grade of hemorrhoids (II or III), there were statistically insignificant differences between the two procedures in terms of recurrence and complications. Conclusion DG-HAL is safer and effective compared with RBL in the treatment of grade III hemorrhoids; however, in grade II patients, both procedures had nearly equal rate of complications despite no recurrence with DG-HAL.

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Context Despite many years of experience, there is still an ongoing debate over the potential benefits of incision site, anatomical pocket, and the types of breast implant. Aim The aim of this study was to evaluate a new approach for subfascial breast augmentation as regards the site of incision and the plane of placement of the silicone implant. Patients and methods Twenty-five female patients suffering from bilateral breast atrophy underwent breast augmentation through an incision made in the pectoral fold along the anterior axillary line, with insertion of the implant in the subfascial plane, deep to the pectoral fascia. Statistical analysis Continuous variables were expressed as mean and SD. Categorical variables were expressed as frequencies and percentage. Results During the postoperative follow-up period, the breast projection was optimal in all patients with establishment of the superior mammary slope and the inferior pole of the breast, with good reconstruction of inframammary fold and adequate breast volume, and both breasts were symmetrical in all patients. Conclusion The subfascial insertion of breast implant through an incision along the anterior axillary line has a low complication rate compared with any other technique and leads to better cosmetic results and high patient satisfaction.

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Aim The aim of this study was to evaluate the impact and safety of neonatal circumcision under a uniform hospital policy using a Gomco clamp and its complication and parents' satisfaction. Patients and methods A prospective analysis of 300 consecutive cases of neonatal and infant circumcisions performed with a Gomco clamp at Al Omooma Private Hospital, Kuwait, during the period from March 2012 through March 2015, was carried out. Outcome measures for the study were the number and type of complications in terms of procedure, the adequacy of circumcision, and parents' satisfaction with the final appearance. Results An overall 10.6% of cases suffered from intraoperative bleeding, most of which were controlled by means of chemical hemostasis or bipolar diathermy, whereas 2.6% of cases needed vicryl plus 5/0 stitches. All of them were older than 2 weeks. Two cases (0.67%) returned on the same day of discharge with surface oozing; both cases were sutured with vicryl plus 5/0 stitches. The overall percentage of postoperative bleeding that needed sutures was 3.3% (10 cases). All cases of significant bleeding requiring stitches were older than 14 days (mean age, 38 days). Four parents (1.3%) came during the follow-up period complaining of inadequate circumcision; only one of them needed a redo after 6 months of follow-up. 0.67% of cases suffered from frenulum ulcer and only 1% of patients. Conclusion Circumcision with a Gomco clamp is a safe and effective technique with satisfactory cosmetic results, provided care is taken in exact marking of the site on the foreskin for excision and selecting a correct size of the clamp. Gomco clamp is a bloodless, sutureless, simple, and safe method of circumcision in the neonatal period and in early infancy. The use of the Gomco clamp for circumcision beyond early infancy (3 months of age) has substantial morbidity.

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Background Laparoscopic greater curvature plication (LGCP) is a new bariatric procedure that until now has not found universal acceptance and is practiced by a limited number of surgeons with both promising and disappointing results. Objectives The aim of the study was to investigate the impact of LGCP on weight loss and associated metabolic diseases and evaluate its safety. Patients and methods A total of 120 morbidly obese patients, 50 hypertensive patients, 48 dyslipidemic patients, and 32 type II diabetic patients underwent LGCP and were followed up for 1 year. Results This study comprised 64 women and 56 men. Their mean age was 35.4 ± 11.8 years. Their mean preoperative BMI was 43.7 ± 7.6 kg/m ² , the mean procedural duration was 73 ± 19.7 min, the mean length of hospital stay was 42.3 ± 4.5 h, and the average BMI at 12 months was 27.7 ± 3.6 kg/m ² (P < 0.001). Of 32 type II diabetes mellitus patients, 23 (71.8%) became normoglycemic, 37 (77%) of 48 patients experienced disappearance of dyslipidemia, and 36 (72%) of 50 hypertensive patients became normotensive at the sixth and 12th month. Three patients (2.5%) had gastric stenosis, and three patients (2.5%) had gastric leak. One patient (0.8%) had partial disruption during the first week at the upper end. One patient had prolapse of the intragastric fold causing gastroduodenal intussusception and obstructive jaundice after 8 months. Conclusion LGCP has a positive impact on weight loss and associated metabolic comorbidities but has potential specific complications.

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Background Laparoscopic common bile duct stones exploration (LCBDE) is a potential option for the management of stones within the biliary tree at the same time as laparoscopic cholecystectomy. Materials and methods All data on LCBDE were prospectively collected from April 2014 to June 2015; 36 consecutive patients diagnosed with cholelithiasis and common bile duct stones were enrolled in this study. There were 10 men and 26 women, median age 57 years (range 43-71 years). Our inclusion criteria were as follows: patients with obstructive jaundice because of stones, patients who had not undergone upper abdominal surgery, surgically fit patients with concomitant gallstones and common bile duct (CBD) stones (de-novo cases), patients in whom endoscopic retrograde cholangiopancreatectomy retrieval had failed previously mainly because of instrumentation failure; large or multiple CBD stones requiring extraction and drainage with remaining stent; LCBDE that could be approached either through the cystic duct or directly through a choledochotomy incision. Results All patients survived the operation. Successful LCBDE and stone clearance were achieved in 34 of 36 patients, whereas treatment failure occurred in the other two patients. The reasons for failure were due to instruments issues e.g. balloon rupture and broken basket. No incidences of bile leakage, hemobilia, abdominal bleeding, or pancreatitis occurred in the patients in our series. Transient colic pain occurred in two patients and was treated conservatively. A transient increase in the liver function tests (aspartate aminotransferase and alanine aminotransferase) was observed in three patients and returned to normal on postoperative day 3 without any treatment. The external drainage tube was removed 48 h postoperatively. Conclusion LCBDE can be performed after proper training and with the availability of adequate equipment and laparoscopic facilities. LCBDE is a safe and cost-effective treatment option for gall bladder and CBD stones in the short term.

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Background Pancreatitis is the most common and serious complication that occurs after endoscopic retrograde cholangiopancreatography (ERCP), resulting in substantial morbidity and occasional mortality. Biliary cannulation is unsuccessful during 5-10% of ERCP procedures. Needle-knife sphincterotomy can improve the success of cannulation but is often used as a last resort. Aim The aim of this study was to assess the role of precutting and multiple cannulations in the occurrence of post-ERCP pancreatitis in patients with bile duct stone disease. Patients and methods This prospective randomized study was performed at the General Surgery Department of Sohag University Hospital between June 2012 and June 2014. It included 515 patients with bile duct stone disease who were subjected to ERCP. Pancreatitis rate was assessed in relation to the number of cannulation attempts (<10 and ≥10) and precutting. Results Cannulation was performed without precutting in 467 cases (90.7%) and with precutting in 48 cases (9.3%). Pancreatitis occurred in 9.21% of patients who had undergone biliary cannulation without precutting and in 18.75% of patients who had undergone biliary cannulation with precutting (P = 0.006). Pancreatitis rate was lower in patients with less than 10 attempts than in those with 10 or greater attempts at cannulation (P < 0.0001), either without (P < 0.0001) or with precutting (P < 0.01). Pancreatitis rate did not differ without and with precutting when less than 10 attempts at cannulation were performed, whereas it was lower when precut was performed before 10 attempts than when 10 or more attempts were made without precutting (P = 0.02). Conclusion Pancreatitis rate was lower when precut was performed with less than 10 attempts than when 10 or greater attempts were made without precutting. In experienced hands, precut biliary sphincterotomy does not seem to be an independent risk factor for post-ERCP pancreatitis in patients undergoing ERCP for bile duct stones.

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Objective The aim of the study was to evaluate the efficacy, adverse effects, and success rate of oral propranolol versus liquid nitrogen oxide gas cryotherapy in the management of cutaneous hemangiomas in infants and children. Patients and methods A prospective study was conducted between March 2011 and May 2015 on 43 patients with cutaneous hemangioma treated either with oral propranolol (group A, 23 cases) or with liquid nitrogen (cryotherapy) (group B, 20 cases). The outcome of treatment was evaluated clinically and with serial photographs before starting treatment and monthly thereafter as regards the size and color of the lesion. Propranolol was given orally 2 mg/kg per day in two divided doses for 4-6 months. Cryotherapy settings were applied two to four times for a period of 2-6 months under inhalation anesthesia using sevoflurane. Results With propranolol, complete involution occurred in 78.2% of cases and good response in 17.3%. Regrowth of the lesion occurred after stopping propranolol in two cases; the parents of the children were instructed to continue the treatment for a further 3 months. With cryotherapy complete involution of the lesions occurred in 65% of cases. No recurrence was observed during the follow-up period. Hypopigmentation at the site of the treated area was evident in eight cases. Conclusion Oral propranolol could be considered a safe and effective treatment strategy for cutaneous hemangioma. Although inhalational anesthesia is needed for application of cryotherapy, it is a simple method for treatment of cutaneous hemangioma and has minimal side effects. However, a randomized controlled study on a large number of patients should be conducted.

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Objective: To compare Efficacy and durability immediately, after one, 6 months results of balloon angioplasty alone versus balloon angioplasty and stenting of multiple tandem lesions in superficial femoral artery (SFA). Methods: percutaneous transluminal angioplasty (PTA) with dilatation was done for 20 cases (group I) and PTA and stenting was done for 20 cases (group II) with (stenosis or occlusion). Results: On stratifying our cases according to TASC II classification, cases showed that in group I: 11(55%), 9 (45%) TASC B and C respectively, group II: 9 (45%), 11(55%) TASC B and were C lesions of the SFA. At one month, six month follow up, group I: 3occluded cases, no more occluded cases while in group II: all cases were successful, 9 cases occluded respectively. Conclusion: Although primary stenting of SFA provide excellent results in patients with TASC B& C lesions (short term). It doesn't provide Superior (Mid-term) to results to angioplasty alone. (Leave no Metal behind Policy).

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