Midline posterior microendoscopic discectomy. Is it the future procedure of choice?

This is prospective study of 20 cases with solitary unilateral lumbar and lumbosacral disc prolapse were managed in Al-Azhar University Hospital, Ain, Shams University Hospital and Al-Sahel Teaching Hospital from January 2005 to January 2007. All the cases were operated by posterior midline microendoscopic discectomy procedure, utilizing microendoscopic tubular retractor system [METR'x] and Destandeau method. The postoperative clinical outcome was assessed according the MacNab's criteria. We assessed the factors which affect the outcome including the age, the value of clinical evaluation, pre operative MRI, degree of disc prolapse and duration of symptoms. Complication in the form of dural tear, discitis and superficial wound infection were recorded. We compare the result of our study to those reported in literature and the result of open microdiscectomy. Endoscopic lumbar discectomy is considered an alterative option of traditional open discectomy in appropriately well trained and experienced hands for appropriately selected patients

Outcome of surgical repair of iatrogenic injuries of major bile ducts

Bile duct injury is a severe and potentially life-threatening complication of open cholecystectomy [OC] or laparoscopic cholecystectomy [LC]. The management of bile duct injuries remains a challenge for most surgeons. The purpose of this study was to evaluate the presentation, characteristics, related investigation, and outcome of patents who underwent immediate or late repair of iatrogenic major bile duct injuries [MBDI]. Twenty three patients with post-cholecystectomy [OC or LC], and postoperative abdominal surgery presented with manifestation of biliary tract strictures or injuries between January 2000 and March 2005 in Sohag university hospital were included in this study. Those patients either underwent their primary surgery in the university hospital or were referred to the university hospital after their primary surgery was performed in other hospitals in our locality. Patients were subjected to clinical examination and to the following; laboratory investigations [blood picture, blood sugar, liver function test, serum urea and creatinine], abdominal ultrasound examination, CT scan, PTC, ERCP, and MRCP in selected cases. These patients then subjected to endoscopic and/or open surgical treatment. This study included 23 patients, 21[91.3%] after cholecystectomy [14 OC and 7 LC], and 2 patients after other abdominal surgeries. Bile duct injuries were recognized immediately in 5 patients [21.7%] [2 after OC and 3 after LC], and 18 patients [78.3%] presented later after the primary surgery. Their clinical presentations were obstructive jaundice in 13 patients [56.5%], external biliary fistula in 5 patients [21.7%], and biliary collection in 3 patients [13%]. The level of obstruction or injury was classified as Bismuth type 1 in 14 cases [61%], Bismuth type 11 in 6 cases [26%], and Bismuth type III in 3 cases [13%]. Bismuth IV and V types were not recorded among the studied cases. End-to-end anastomosis was done for 5 cases [21.7%]. The 5 patients [21.7%] to whom end-to-end anastomosis was done; failure was seen in 4 of these 5 cases [80%] and was corrected by re-exploration and reaired by hepaticojejunostomy. Choledochojejunostomy and hepaticojejunostomy were performed in majority of cases and showed no failures. Cholecystojejunostomy was done for the 2 cases [8.7%] that presented with bile duct obstruction after other abdominal operations. Postoperative complications includes, minor leakage in 5 [21.8%] patients was managed conservatively. Wound sepsis was seen in 8 [34.8%] with burst abdomen occurred in 3 [13%] of them. No operative mortality encountered in our patients. Late stricture encountered on long-term follow up [3 years] in 3 cases [13%]. The overall success after repair by Roux-en-Y hepaticojejunostomy was 78.3%. Major bile duct injuries after cholecystectomy and other abdominal surgeries are a considerable surgical challenge. Surgical reconstruction using Roux-en-Y hepaticojejunostomy mucosa to mucosa repair remains the golden standard procedure of choice for treating these injuries with successful outcome and better long-term result. Early recognition and adequate treatment at socialized institutions account for the key of prognostic parameters. Finally, as always, the true key to successful treatment of these injuries remains prevention

Inflammatory bowel disease: diagnostic and therapeutic modalities

Inflammatory bowel disease [IBD] is chronic conditions of unknown origin that result from continuous or intermittent inflammation of a part of the intestinal wall. The main classic types of IBD are ulcerative colitis [UC], Crohn's disease [CD] and indeterminate colitis that cannot be classified accurately as UC or CD with pure colonic involvement. The aim of this study is to highlight this rare disease in our locality including; clinical feature, investigations, indication of surgical interference, operative procedures, histopathological examination, and postoperative complications. Twenty nine patients were included in this study from January 2000 to May 2006. Histopathological examination proved to be UC in 18 patients and CD of the intestinal tract in 11 patients. Patients were subjected to history, tarnsclinical examination, and routine laboratory investigation, abdominal X-ray in an erect position, barium enema, intravenous urography, sigmoidoscopy and colonoscopy. Biopsy was taken, and CT and MRI were done in selected cases. All patients subjected to medical and/or surgical treatment according to their finding. Their mean age was 49.4 +/- 2.1 years [range 12 -65 ys]. Female to male ratio was 2:1. The main clinical manifestations were abdominal pain in 27 patients [93.1%], bleeding per rectum in 14 patients [48.3%], mucus discharge in 10 patients [34.5%], and chronic diarrhea in 6 patients. Palpable abdominal mass was found in 3 patients. Extra-abdominal manifestations were loss of weight in 15 patients [51.7%], pallor in 11 patients [37.9%], lower limb edema in 7 patients and skin changes 4 patients. Twenty three patients [79.3%] were received medical treatment; 18 patients [62.1%] UC and 5 CD but the remaining 6 patients [20.7%] admitted to emergency department. Successful treatment with complete cure was achieved in 12 patients [41.4%]; 10 patients had UC and 2 CD while surgery was done in 17 patients [58.6%]; 9 patients had CD and 8 UC. Right hemicolectomy was done for 7 of them and limited resection anastomosis was performed in the other 2 patients. Total colectomy with terminal ileostomy was carried out in one patient and subtotal colectomy with ileorectal anastomsis in 7 patients. Postoperative intestinal fistula detected in one patient and right hemicolectomy was done. Wound infection occurred in 3 patients and one of them developed burst abdomen. IBD is not rare in our locality and its treatment still remains the challenge despite growing knowledge about the disease, advances in medical treatment and surgical techniques. Proper assessment of IBD requires cooperation of gastroenterologists, radiologists, histopathologists and surgeons

First record of schistosoma intercalatum in upper Egypt; an abnormal locality and presentation simulating lymphoma

Schistosomiasis due to Schistosoma intercalatum is highly restricted to the Western regions of equatorial Africa. Its main clinical manifestation is rectal bleeding. A case is described of a 14 year old boy living in Upper Egypt who was presented to General Surgery Department, Sohag University Hospital, South Valley University, complaining of vague abdominal pain, rectal bleeding, multiple abdominal masses and splenomegaly. Laparotomy revealed moderate splenomegaly, multiple hepatic focal lesions, mesenteric and paracolic lymphadenopathy, and multiple nonobstructing colonic masses. Splenectomy was done, multiple lymph node biopsies and wedge liver biopsy were taken. Endoscopic rectal biopsy was also done. The primary diagnosis was abdominal lymphoma with hepatic and splenic involvement. Histopathological examinations of these biopsies revealed congested spleen and multiple bilharzial granulomata effacing the whole lymph nodal architecture, infiterating the portal tracts of the liver, and surrounding terminally spined-eggs of the rectal wall. Staining of the rectal specimen by Modified Ziehl-Neelsen showed red coloration of the egg-shell characteristic of S. intercalatum. We here announce the first record of S. intercalatum in Upper Egypt, Sohag Governorate and also report all interesting unusual presentation of S. intercalatum schistosomiasis by abdominal lymph node enlargement simulating lymphoma

Mild and moderate degrees of acute normovolemic hemodilution [ANH] for blood conservation in major gastro-intestinal surgery

Sixty patients were included in this prospective study to compare the effect of mid and moderate degrees of hemodilution on the homologous blood requirements in major gastro-intestinal surgery. The patients were classified into two groups according to the level of hemodilution [mild [group I] and moderate [group II] degrees]. The target hematocrit [Hct], level planned to be around 32 and 28%, at the start of surgery, then 25 and 22% intraoperative; while Hct of 27% was the postoperative transfusion trigger with transfusion of autologous or homologous units. Hemodilution started at five minutes after anesthesia and re-transfused when the target hematocrit reached with autologous units, then homologous blood. Total anesthesia time was longer in group II and the volume withdrawn by hemodilution was [781 +/- 154 and 1734 +/- 142] in the two groups, respectively. Homologous transfusion was less in group II regarding both patients number [12/30 and 5/30] and blood units number [19 and 7 units] in the two groups, respectively. In the postoperative period, 4/30 and 1/30 patients required transfusion to reach Hct of 27%. On discharge, the hemoglobin levels and platelet count was satisfactory in both groups and platelet count was higher in group II [28.4 +/- 1.9-307.5 +/- 67.7 versus 28.9 +/- 2.8-250.8 +/- 73.4]. The complications occurred can not be attributed to hemodilution per se

Gastric pedicle tube in reconstruction of gastrointestinal continuity after total laryngopharyngectomy

Gastric pedicle tube placed retrostrenally was performed to reconstruct gastro- intestinal continuity after laryngopharyngectomy in 11 patients [7 males and 4 females] aged from 50 to 67 years, with a mean age of 56 +/- 0.4 referred to hospital in the period from January 1999 to December 2000. These patients had extensive pyriform fossa tumors in five patients, posterior pharyngeal wall tumor in three patients and localized postcricoid tumor in three patients. A reconstruction of the gastro-intestinal tract was done in the same sitting after excision of the tumor by ENT surgeons. The postoperative complications were pneumothorax in two patients, cervical fistula in three patients, which closed spontaneously after 2-3 weeks and two patients suffered from stenosis of cervical anastomosis, but responding to intermittent dilatation. Two patients died from severe chest infection during the postoperative period. Temporary gastrotomy was done for all patients to be used for feeding during the postoperative period removed after complete healing of the anastomosis. Apart from two patients who died during the postoperative period, the remaining patients were discharged from the hospital in a fair general condition. They were subjected to regular follow up