Pancreatic cystic neoplasms: predictors of malignant behavior and management

Pancreatic cystic neoplasms are being increasingly identified with the widespread use of advanced imaging techniques. In the absence of a good radiologic or pathologic test to preoperatively determine the dianosis, clinical characteristics might be helpful. The objectives of this analysis were to define the incidence and predictors of malignancy in pancreatic cysts. Patients with true pancreatic cysts who were treated at our institution were included. Patients with documented pseudocysts were excluded. Demographic data, clinical manifestations, radiological, surgical, and pathological records of those patients were reviewed. Eighty-one patients had true pancreatic cyst. The mean age was 47 +/- 15.5 years. There were 28.4% serous cystadenoma, 21% mucinous cystadenoma, 6.2% intraductal papillary tumors, 8.6% solid pseudopapillary tumors, 1.2% neuroendocrinal tumor, 3.7% ductal adenocarcinoma, and 30.9% mucinous cystadenocarcinoma. Malignancy was significantly associated with men [P = 0.04], older age [0.0001], cysts larger than 3 cm in diameter [P = 0.001], presence of solid component [P = 0.0001], and cyst wall thickening [P = 0.0001]. The majority of patients with malignancy were symptomatic [26/28, 92.9%]. The symptoms that correlated with malignancy included abdominal pain [P = 0.04] and weight loss [P = 0.0001]. Surgical procedures were based on the location and extension of the lesion. The most common pancreatic cysts were serous and mucinous cysts. These tumors were more common in females. Old age, male gender, large tumor, presence of solid component, wall thickness, and presence of symptoms may predict malignancy in the cyst

Extent of lateral internal sphincterotomy for chronic anal fissure: spasm controlled versus conventional method: a prospective randomized study

This study was designed to compare the results of spasm controlled lateral sphincterotomy by using anal calibrator with those of conventional sphincterotomy. This study included 96 patients with chronic anal fissure divided into two groups. In conventional sphincterotomy group, the extent of sphincterotomy was up to dentate line and in spasm controlled group the extent of sphincterotomy at first to the apex of fissure then serial small sphincterotomies and anal caliber measurements followed up until an anal caliber of 30 mm was obtained The preoperative anal caliber was 26+2.9 [19-26] and 26+2.7 [18-28] mm in conventional group and spasm controlled group respectively. Postoperatively the spasm controlled group had a mean anal caliber 32.8+2.4 and in conventional group had 34.7+2.4. Delayed healing was occurred in 12.5% of patients in conventional group vs. 4.2% in spasm controlled group p =0.06. Incontinence to flatus occurred in 4.2% of patients in spasm controlled and 16.7% in conventional group p =0.05. relief of pain postoperatively was after 2.1+2.6 days in conventional group and in controlled sphincterotomy group after 3.7+3.5 days p=0.09. spasm controlled sphincterotomy provided better healing with lower rate of early and late postoperative disturbance of continence compared with conventional sphincterotomy

Clinical impacts of oral gastrografin follow through in adhesive small bowel obstruction [ASBO]. [a prospective randomized study]

Many studies have shown that Gastrografin can be used for diagnosis of adhesive small bowel obstruction [ASBO] and for assessing the need for surgical intervention .However; several the studies have reported conflicting results. Therefore the aim of this study is to assess the diagnostic and therapeutic effect of Gastrografin in ASBO. Altogether 110 patients with ASBO were randomized into control and Gastrografin groups. In the Gastrografin group, 100 ml of the dye was administered through a nasogastric tube. Obstruction was considered complete if the contrast failed to reach the colon on the 24-hour film. Patients with Gastrografin in the colon within 24 hours after dye administration were considered as partially obstructed and were submitted to non operative treatment. The patients were operated on if they developed signs of strangulation or failed to improve within 48 hours. The overall operative rate 14.5% in Gastrografin group versus 34.5% in control group: P = 0.04 .The time from admission to resolution of symptoms was significantly lower in Gastrografin group [19.5 vs. 42.6 hours: P = 0.001] and the length of hospital stay shorter in Gastrografin group [3.8 vs. 6.9 days 0.002] and in non operative patients [3.1 vs. 5.1 days]. Sensitivity, specificity, positive predictive value and negative predictive value for Gastrogrqfin follow-through as an indicator for operative treatment of ASBO were 87.5%, 100%, 100%, and 97.9% respectively. Oral Gastrografin helps in the management of ASBO. Oral Gastrografin is safe and reduces the operative rate and time of resolution as well as hospital stay

Early oral feeding in patients undergoing elective colonic anastomosis

Recent evidence seems to indicate that immediate postoperative feeding if feasible is safe after either laparoscopic surgery or laparotomy. This study is done to assess the safety, outcome of early oral feeding and shows factors affecting early postoperative feeding after colorectal procedures. Between June 2005 and April 2008, 120 consecutive patients underwent elective colonic anastomosis were then randomized into 2 groups. Early feeding group began fluid on the first postoperative day and regular feeding group were managed in the traditional way- nothing by mouth until the resolution of the ileus. The majority of patients [75%] tolerated the early feeding. The time to first passage of flatus [3.3 +/- 0.9 d vs. 4.2 +/- 1.2 d] and stool [4.1 +/- 1.2 d vs 4.9 +/- 1.2 d] were significantly sooner in group 1. Hospital stay is significantly shorter in early feeding group [4.2 +/- 0.2 d vs. 6.9 +/- 0.5 d]. Operative time and amount of blood loss had a significant impact on tolerability of early feeding while age, gender, type of operation, and previous abdominal operation had no significant impact. Early oral feeding after colorectal surgery is safe, tolerated by the majority of patients. Operative time and amount of blood loss has impact on the tolerability of early feeding

Influence of fibrin glue on seroma formation after modified radical mastectomy: a prospective randomized study

The pathophysiology of seroma after modified radical mastectomy [MRM] is still poorly understood. The optimal ways to reduce the incidence of seroma formation are unknown. This study was done to evaluate the effect of fibrin glue on seroma formation and drain removal time after MRM. This study was carried out from January 2005 to December 2007 at Mansoura university hospital. Fifty patients had breast cancer were included in the study, MRM was done for all patients. Patients were randomly divided into two groups. Group I where 8 ml of fibrin glue was sprayed on the surgical area with Y canula and group II without fibrin glue. Preoperative, Operative and Postoperative data were collected included postoperative measurement of drainage, date of removal of the drain, state of the wound, incidence of Seroma formation. The duration of axillary drainage was 7.88 +/- 2.56 days in group I and 11.62 +/- 2.68 days in group II [p value =0.04]. Total drainage volume was 770.48 +/- 70.81 in group I and 1089.51 +/- 75.8 in group II [p value =0.002]. The volume of aspirated fluid after removal of drain was significantly less in group I. The date of Seroma resolution was delayed in group II [11.8 +/- 5.32 vs 19.81 +/- 8.12p value =0.05]. Fibrin glue leads to a significant reduction in postoperative drainage, earlier removal of drain and decrease amount of aspirated fluid after removal of drain after MRM. So, fibrin glue reduces the amount of seroma formation but not prevent its formation

Clinical impact of routine abdominal drainage after laparoscopic cholecystectomy. A prospective randomized study

Laparoscopic cholecystectomy [LC] has become the standard treatment for gall bladder stones. Routine drainage after laparoscopic cholecystectomy is an issue of considerable debate. In this study we elucidate the clinical impact of intraperitonial drain following LC. Fifty patients were included in this study. They were divided into two groups, group [A] with drain and group [B] without drain. We recorded the effect of drainage on, postoperative pain using visual analogue scale VAS at 6, 24, 48 h and 1 week postoperative, nausea / vomiting [PONV] at 6, 24, 48 h postoperative, abdominal collection .hospital stay, chest complication, and postoperative body temperature. Hospital stay was significantly longer in group A 32 + 10 h us, 28 + 11 h in group B. Neither the incidence nor the location of postoperative pain [Po-P] at different postoperative time points, differe significantly between both groups .VAS in group B was lower than in group A, at 24 h postoperative [5.86+2.35 in group A vs. 3.95+2.49 in group B, P value 0.004] and at 48 h postoperative [2.78+1.52 in group A vs. 162+1.57 in group B, P value 0.001]. PONV was higher in group B but was not significant at different time points. Abdominal drain is not effective in alleviating Po-P and PONV after LC but the use of drainage tube is considered to intensify Po-P. Hospital stay is longer in drained group. So, routine intraperitoneal drain is not recommended after LC unless there is serious intraoperative complication

Rubber band ligation for 550 patients of symptomatic haemorrhoids out of 2200 patients retrospective study

This retrospective study was conducted to elucidate the results of the treatment for symptomatic haemorrhoids using rubber band ligation [RBL] method. Method: a retrospective study for 550 patients who came to the colorectal unit from June 1998 to June 2006, data was retrieved from archived files. Forty four patients with haemorrhoid had liver cirrhosis.RBL was performed using the Mc Gown applicator on an outpatients basis. The patients were asked to return to out-patient clinic for follow up at 2 week, 1, 6, months and through telephone call every 6 month for 2 years]. After RBL 496 patients [90.18%] were cured with no difference in outcome for first, second or third degree haemorrhoids [P value = 0.31]. symptomatic recurrence was detected in 16.03% after 2 years then repeated RBL or surgery were done for them. A total of 88 patients [16%] had 155 complications from RBL which required no hospitalization. Complications were registered; pain in 10.37%, rectal bleeding in 8.36% and vaso-vagal symptoms in 7.81%. RBL is a safe and successful method for treating symptomatic haemorrhoids, even in cirrhotic patients

Comparative study between biofeedback retraining and botulinum neurotoxin in treatment of anismus patients

Anismus is a significant cause of chronic constipation. This study came to revive the results of biofeedback BFB retraining and botulinum toxin A BTX- A injection in treatment of anismus patients. Forty eight patients with history of constipation underwent anorectal manometry, balloon expulsion, defecography, and electromyography. All patients had a non relaxing puoborectalis muscle. The patients were randomized into 2 groups. Group I patients receive biofeedback, two times per week for one month. Group II patients were injected with BTX- A. Follow up was conducted weekly in the first month then monthly for one year. In BFB training group 3 patients quite before the end of sessions with no improvement, initial improvement was recorded in 12 patients [50%] while long term success was recorded in 6 patients [25%]. In BTX-A group, initial improvement recorded in 17 patients [70.83%] with long term improvement in 8 patients [33.3%] There is a significant difference between BTX-A group and BFB group as regarding the initial success, but this significant difference disappeared at the end of follow up. Biofeedback retraining has therapeutic effect on patients suffering from anismus also, BTX-A injection is successful for temporary treatment of anismus and need repeated injection. Initial improvement is better after BTX-A injection

Trans-perineal VS. trans-rectal repair of rectocele in obstructed defecation: a prospective randomized trial

To evaluate functional outcome of transperineal [TP] versus transrectal [TR] repair of rectocele presented with obstructed defecation. 48 multiparous females with obstructed defecation due to rectocele were randomly allocated into 3 groups: Group A [16 patients]: TP repair with levatorplasty [LP].Group B [16]: TP repair without LP.Group C [16]: TR repair. The study included defecographic assessment, anal manometry / /[Maximum anal resting pressure [MARP], maximum reflex volume [MRV] and urge to defecate volume [UTDV] and functional score [0 -26]. These were done preoperative and 6 months postoperative. Defecography showed significant reduction in size of rectocele in all groups. Constipation improved significantly in the groups of transperineal but not in transrectal repair. We had significant reduction in MARP, UTDV and MRV only in transperineal approach. Functional score was significantly improved in group A [P<0.001] and B [P<0.001] while the improvement was insignificant in group C. LP significantly improved the overall functional score in group A compared to group B and C [P= 0.032] Rectocele repair improves anorectal function by improving the rectal urge sensitivity. TP repair of rectocele is superior to TR repair in both the structural and functional outcome. Levatorplasty improves functional outcome, but should be avoided in young sexually active females

Proximally based versus distally based gluteus muscle flap in treatment of end stage fecal incontinence

To compare proximally based versus distally based gluteus maximus muscle flap transposition in patients with end stage fecal incontinence. Between August 2005 and August 2007, this prospective randomized study was performed on twenty patients with an end stage anal incontinence. They were sixteen men and four women with an age ranging from 7 to 31 years. A proximally based gluteus maximus flap [group III] was carried out in ten patients while, a distally based flap [group I] was done in the other ten. Patients were followed up for 6 - 18 months both subjectively and objectively with evaluation of their incontinence score, anorectal manometry, saline enema test and magnetic resonance imaging [MRI]. Overall, 6/10 patients [60%] in group I and 8/10 patients [80%] in group II were clinically improved with down staging of their incontinence scores from C3 to 0 [P 0.003 and 0.0001 respectively]. This was confirmed by the significant changes in anorectal manometry and saline enema test. MRI done one month postoperatively showed disruption in three patients. Proximally based gluteoplasty appears to be an excellent encirclement procedure that restores voluntary squeeze pressure as well as rectal sensation when compared with unilateral distally based gluteoplasty

Laparoscopic versus open cholecystectomy in cirrhotic patients: a prospective randomized study

Improved laparoscopic experience and techniques have made laparoscopic cholecystectomy [LC] feasible options in cirrhotic patients. This study was designed to compare the risk and benefits of open cholecystectomy [OC] versus LC in compensated cirrhosis. A randomized prospective study, in the period from October 2002 till December 2006, where 110 cirrhotic patients with symptomatic gallstone were randomly divided into OC group [55 patients] and LC group [55 patients]. There was no operative mortatity. In LC group 4[7.33%] patients were converted to OC. Mean surgical time was significantly longer in OC group than LC group [96.13+17.35m vs. 76.13+15.12] P<0.05, associated with significantly higher intraoperative bleeding in OC group [P<0.01], necessitatating blood transfusions to 7 [12.72%] patients in OC group. The time to resume diet was 18.36+8.18h in LC group which significantly earlier than in OC group 47.84+14.6h P<0.005. Hospital stay was significantly longer in OC group than LC group [6+1.74 days vs. 1.87+1.11 days] P<0.01 with low postoperative morbidity. LC in cirrhotic is still complicated and highly difficult which associates with significant morbidity compared with that pf patients without cirrhosis. However, it offers lower morbidity, shorter operative time, early resume dieting with less need for blood transfusion and reducing hospital stay than OC.

Effect of helicobacter pylori eradication on ulcer healing and recurrence after simple closure of perforated duodenal ulcer

Helicobacter pylori [H.Pylori] plays a fundamental role in the causation of duodenal ulcer. This study was conducted to elucidate the prevalence of H.Pylori in patients with a perforated duodenal ulcer and to determine whether eradication of H.Pylori prevent ulcer recurrence following simple repair of the perforation. Eighty three patients admitted with perforated duodenal ulcer, only seventy seven patients treated with simple closure included in our study. Sixty five patients [84.4%] who had H.Pylori infection were randomly divided into triple therapy group [34 patients] and alone group [31patients]. Follow up endoscopy was performed at 8 w, 16 w and 1 year to show the ulcer healing and determine H.Pylori. The eradication of H.Pylori was significantly higher in triple therapy group than omeprazole alone group [at 8 weeks 91.2% vs. 22.6% respectively]. Initial healing of ulcer was significantly better in eradication group and after one year the difference in ulcer recurrence between the two groups was statistically significant [2[6.1%] in eradication group vs. 8 [29.6%] in omeprazole alone group P=0.001]. H.Pylori was present at a high ratio in patients with duodenal ulcer perforation. Eradication of H.Pylori after simple closure of a perforated duodenal ulcer reduces the incidence of recurrence ulcer