Evaluation of serum fetuin-A: relationship with endothelial dysfunction in hemodialyzed patients

The aim of this study was to evaluate the association between serum fetuin-A concentrations and endothelial dysfunction in hemodialyzed [HD] patients. 85 patients on regular HD [55 males and 30 females] and 30 healthy controls [17 males and 13 females] were studied. We measurd serum fetuin-A by enzyme-linked immunosorbent assay. Assessment of endothelial dysfunction by measuring common carotid artery intima media thickness [CCA-IMT] and intima media thickness-inhomogeneity using high-resolution ultrasound. In addition, C-reactive protein [hsCRP], serum calcium, phosphate, intact parathyroid hormone [iPTH], albumin, total cholesterol, triglycerides, high density lipoprotein cholesterol [HDL-C], low density lipoprotein cholesterol [LDL -C] and fasting blood sugar were performed. Compared with controls, HD patients had a lower levels of serum fetuin - A, higher levels of CRP and 'iPTH, a greater CCA-IMT as well as CCA-IMT-inhomogeneity. Dialysis patients with cardiovascular disease [CVD] had a greater CCA-IMT and IMT-inhomogeneity compared with patients without CVD. IMT-inhomogeneity strongly correlated with IMT. In multiregression analysis, serum fetuin-A correlated with IMT-inhomogeneity but not with IMT, and hsCRP neither correlated with IMT-inhomogeneity nor with IMT. In conclusion, serum fetuin-A concentrations were decreased in HD patients and may be one of the contributing factors for the development of endothelial dysfunction in these patients

Serum adiponectin in type 1 diabetic patients with nephropathy

The aim of the study was to elucidate whether serum adiponectin is associated with renal function, low - grade inflammatory markers, metabolic control and insulin resistance in type 1 diabetic patients with and without nephropathy. A total of 95 type 1 diabetic patients were divided into three groups based on their urinary albumin excretion rate [AER]: patients with normal AER had no antihypertensive medication, while patients with microalbuminuria or macroalbuminuria were all treated with an angiotensin converting enzyme [ACE] inhibitor. Renal function was estimated with the Cockroft-Gault formula. Adiponectin was measured by an immunofluorometric assay. In addition, glycosylated hemoglobin [HB[AIC]], estimated glucose disposal rate [GDR], urinary albumin levels, triglyceride, total cholesterol, high density lipoprotein cholesterol [HDL-c] were performed for all patients. Adiponectin concentrations were higher in women than in men. The levels of adiponectin in type 1 diabetic patients with nephropathy increased gradually according to the clinical stage of the disease, being highest in macro album inuric stage. In a univariate analysis, adiponectin was positively associated with serum creatinine, systolic blood pressure, HB[AIC], total cholesterol, HDL-C and negatively with estimated glomerular filtration rate [GFR] and waist to hip ratio [WHR]. In a multiple linear regression analysis including the above variables, estimated GFR, AER and WHR were independently associated with adiponectin levels. In conclusion, serum adiponectin concentrations were increased in type 1 diabetic patients with nephropathy, and levels were further associated with renal insufficiency

Stapled hemorrhoidectomy versus diathermy hemorrhoidectomy: the outcomes after two years

Excisional hemorrhoidectomy such as Milligan-Morgan or diathermy hemorrhoidectomy has for long remained the standard procedure in the operative management of hemorrhoids. Innovations in surgical techniques have recently been introduced in an attempt to decrease the pain associated with it. The notable popularity of stapled hemorrhoidectomy in recent years has stimulated the comparison of this technique with diathermy hemorrhoidectomy which is a standard technique for hemorrhoidectomy. To compare the outcomes of stapled hemorrhoidectomy [SH] versus diathermy hemorrhoidectomy [DH] for both, the short-term as well as the long-term follow up periods. Seventy patients with third degree piles have been randomly assigned for SH or DH with postoperative follow up and evaluation for two years. SH had a lower pain scores, less analgesic requirement and shorter recovery period than DH. Anal complications over the long-term follow up were higher for SH than DH. Stapled hemorrhoidectomy is associated with anal complications which may persist or evolve over the long-term follow-up. Until the pathophysiological sequelae of stapling the hemorrhoids are fully-investigated, it may be prudent to keep its use under close scrutiny and to avoid its use as the standard care of hemorrhoidectomy. Diathermy hemorrhoidectomy offers a better long term control of bleeding and recurrence

first postoperative year results of transthoracic Ivor-Lewis esophagectomy with stapled intrathoracic esophagogastric anastomosis for treatment of lower esophageal cancer

Esophageal cancer represents one of the most lethal malignancies affecting mankind. This is compounded by the fact that adenocarcinoma of the esophagus is increasing in incidence at a rate exceeding that of any other neoplasm. At most centers, esophageal resection remains the therapeutic alternative of choice for patients who are considered to be surgical candidates. The surgeons' opinions about Ivor Lewis operation has long been sceptic because of the consequences if leakage of the intra thoracic anastomosis occurred. However, with the advent of stapling devices and with the advances in operative techniques, a well vascularized oesophageal substitute can be prepared and a safe anastomosis can be constructed. In the present work, we managed 17 patients with carcinoma of the lower oesophagus by Ivor-Lewis subtotal esophagectomy with 2 field lymphadenectomy from May 2000 to July 2004. We used the stomach as an oesophageal substitute and a stapled oesophagogastric anastomosis was done at the apex of thorax. The median ICU stay was 2 days [1-38 days] and the median postoperative stay for those patients without complication was 14 days. The proximal longitudinal resection margin was infiltrated in 1 case while 3 cases showed involvement of the circumferential margin. Primary pulmonary complication occurred in 6 patients with 1 related mortality. Leakage occurred in 4 patients, 3 among them were managed conservatively. Three patients died postoperatively [17.6% with only one case died from surgical rather than medical complication], one from acute respiratory distress syndrome, second from profound sepsis following extensive mediastinal leakage and third one from massive myocardial infarction. At the end of the 1[st] postoperative year, 10 patients were alive. It has been concluded that Ivor Lewis operation is a good option for patients with carcinoma of the lower oesophagus and a better outcome depends on early recognition and aggressive management of complications that can minimize subsequent mortality

Is nerve growth factor deficiency a marker for early detection of subclinical diabetic neuropathy?

Nerve growth factor [NGF] and nerve conductive study [NCS] were evaluated in 80 diabetic patients [35 males and 45 females and their mean age was 44.2 +/- 7.2 years] and 15 healthy control subjects [6 males and 9 females, their mean age was 43.7 +/- 6.1 years and their neuropathy score was zero]. The patients were classified into three subgroups. Subgroup A [diabetic without neuropathy] included 20 patients. Subgroup B [diabetics with subclinical neuropathy] included 40 patients. Subgroup C [diabetic with neuropathy] included 20 patients. Also, patients were classified according to some variables [according to age into two subgroups, according to duration of diabetes into three subgroups and according to type of treatment into two subgroups]. It can be concluded that, nerve growth factor is deficient in diabetics, nerve growth factor is a sensitive and reliable marker for early detection of subclinical neuropathy in diabetics, and early insulin prescription to type II diabetics who are in need could be of neuroprotection value

Sentinel node mapping in colorectal cancer: is it worth the effort?

Background: Lymphatic mapping [LM] with sentinel node [SN] biopsy is an interesting recent development in surgical oncology. This approach has the potential of accurately identifying the first lymph node [or nodes] that drain primary tumors. These nodes are the most likely to harbor metastatic or micrometastatic disease. Sentinel node mapping and the pathologic search for micrometastasis may therefore increase the accuracy of the pathologic staging, which may alter the further management and the prognosis

Aim of the Study: To evaluate the usefulness of intra-operative in-vivo and ex-vivo sentinel node mapping in colorectal cancer [CRC] resections, and its effect combined with selected pathologic focus node examination on upstaging of CRC and consequent therapeutic strategies

Patients and Methods: Twenty- nine [after exclusion of six] patients with CRC were enrolled in a study of lymph mapping [LM] with peritumoral and submucosal injection of isosulfan blue dye. In-vivo LM was undertaken intraoperatively during colon resection in 23 patients. Ex-vivo LM was done after specimen removal in 6 patients [1 rectosigmoid and 5 extraperitoneal low rectal carcinoma]. All nodes wereexamined with hematoxylin and eosin [H and E] staining; in addition, negative sentinel lymph nodes [SNs] for metastasis with H and E were multi-sectioned and examined by immunohistochemical staining with cytokeratin[CK-lHC]

Results: SNs were successfully identified in 27/29 patients [93%][at least one SN was identified]. SNs were not identified in 2 cases; one case of very low rectal cancer and the other one was a locally advanced rectosigmoid colonic cancer. LM .demonstrated primary lymphatic drainage to SNs outside the margins of conventionally surgical planned resections in 2 cases [7%] and guided multiple sections and histochemical staining that identified occult micrometastases in 3 of the SN negative patients [11%]. Upstaging was thus achieved in 5 cases [18%] using mapping and focus nodal examination. Overall, the specificity and the negative predictive value in this series were 100% and 67%, respectively, whereas the sensitivity and positive predictive value were 89% and 78% respectively. There was a significant positive correlation between the tumor T stage and lymph node metastases [P< 0.001]

Conclusion: Sentinel node mapping is easy to do intraoperatively during colorectal resections. Ex-vivo LM can be applied when in- vivo techniques are unsuccessful and could beuseful for rectal carcinoma. LM techniques appear to improve staging accuracy in CRC through detection of more node metastases as well as guiding the use of sophisticated histopathologic studies to search for occult nodal micrornetastases. It may demonstrate an unexpected pattern of lymphatic drainage requiring modification of the conventional resection

Minimally invasive technique for the palliation of pain in inoperable pancreatic cancer

Introduction:Severe, intractable pain from pancreatic cancer is mediated through the celiac plexus, the celiac ganglia, and the splanchnic nerves. Interruption of the pathway with alcohol or phenol injection of the celiac plexus can be temporarily effective in controlling this visceral pain, but diminishing results occur with repeated injections. Complications related to the injury of vascular structures in proximity to the neural structures may occur. Refinement of thoracoscopic technique has led to the introduction of thoracoscopic splanchnicectomy to interrupt the afferent visceral pain pathway. We were able to demonstrate excellent short-term palliation of malignant pancreatic pain with unilateral thoracoscopic splanchnicectomy. This procedure could be a reasonable approach for pain control for these patients without incurring the morbidity and failures of other maneuvers

Objective: The objective of this work is to evaluate the short-term effect of unilateral thoracoscopic splanchnicectomy on pain due to pancreatic malignancy

Patients and Methods: This prospective study included 10 patients with inoperable pancreaticcarcinoma presenting with refractory upper abdominal pain. The study was conducted in Ain Shams University Hospitals between January 2001 and July 2002. The pain was assessed using adjectival score 24 hours before surgery and 24 hours, 7 days and one month, postoperatively. The right side was targeted in patients presenting with mainly right sided upper abdominal pain, whereas the left side was operated upon in patients with central and left sided upper abdominal pain

Results: 4 patients [40%] and 6 patients [60%] presented with right upper and central and left upper abdominal pain, respectively. The operation was successfully completed in 7 patients only with 2 right splanchnicectomies and 5 left splanchnicectomies. The mean operative time was 95 minutes. There was significant improvement in the pain score in the postoperative follow-up period [p <0.001]. There were no postoperative mortalities or major morbidities

Conclusion: We conclude that unilateral thoracoscopic splanchnicectomy to date is beneficial in the treatment of pancreatic pain associated with inoperable pancreatic malignancy without untoward complications

Feeding gastrostomy: surgical or endoscopic ? a prospective study

This study compared operative gastrostomy [OG] [performed by surgeons] with percutaneous endoscopic gastrostomy [PEG] [performed by physician endoscopists] in a prospective randomized fashion to determine whether one technique was superior. PEG [Sachs-Vine] and OG [Stamm] were done using local anesthesia. Patients were assessed for complications, mortality, tube Junction, and cost Groups were equally matched for indications and underlying disease. Fifty-seven had OG and 64 had attempted PEG. Complications occurred in 26% of OG patients and 9% died. Complications occurred in 25% of PEG patients and 12% died. Tube feeding was initiated in both groups within a mean of 29 [24 to 72] hours of the gastrostomy placement OG costed 1675 and PEG 979 local currency units to perform. We conclude that, there is no difference between OG [using local, anesthesia] and PEG with regard to morbidity, mortality, or tube Junction. The endoscopic technique does appear to have economic advantage