Endoanal advancement flap repair for high-leveled anal fistulae: clinical and manometric results

The aim of this prospective study was to evaluate the functional outcomes after endoanal advancement flap [EAF] in treatment of high leveled anal fistulas. From October 2001 to December 2005, 32 patients with high anal fistulae underwent EAF. They were 26 males and 6 females, with a mean age 37.75 +/- 7.2 years. Seven patients had recurrent fistulae and five had minor anal incontinence. All patients underwent coring fistulectomy followed by endoanal advancement flap that was sutured to the anoderm below the level of the internal opening. Patients were followed up for 20.16 +/- 5.87 months. Continence was evaluated using a special questionnaire. EAF was successful with a complete healing in 24 patients [75%] whereas; the overall recurrence rate was 25% after a second operation. Also, 25 patients [78.3%] experienced improved or unaffected anal continence, whereas, seven patients [21.9%] experienced minor degrees of anal incontinence. Manometrically, all patients showed significant decrease in mean resting pressure [MRP] [P: 0.000] while there was no significant changes in mean squeeze pressure [MSP] [P: 0.069] or in the functional anal canal length [P: 0.753]. EAF allows the treatment of trans-sphincteric fistulae as well as supra-sphincteric fistulae without sacrificing anal sphincter function, which is likely to be superior to alternative procedures even in case of recurrence

Evolution of colorectal cancer in schistosomiasis

Aim: To define the clinico-pathologic character of schistosomiasis mansoni associated colorectal cancer [S.CRC] and the possible carcinogenic relation of Schistosoma mansoni [S.M]

Methods: This study included 176 patients with colorectal cancer associated with S.M. Their clinical database and surgical pathology sheets were documented with the detection of S.M on stool analysis, serologic tests, pathologic associated lesions and tumor P53 protein expression using immuno-cytochemical assay

Results: Sixty eight patients [40%] with S.CRC were below 40 years with male predominance [1.8 - 1], distal CRC predominance in 109 patients [62%], mucinous type in 58 patients [33%], higher grades II, III in patients [79%], with significant angio-invasion in 50 patients [30%], lymph vessels invasion in 50 patients [35%] and perineural invasion in 17 patients [10%], associates with poor immune response in 8 patients [5%], preceded with schistosomal lesions especially in patients with schistosomal colitis >/= 10 years, associates with TP53 in 114 cases [65%] and presented at advanced stages in 99 cases [56%] with only hepatic metastasis in 28 cases [90%]

Conclusion: S.CRC is a special clinical entity that has all pathologic pattern, bad biologic behavior and the SM is implicated in SCRC progression

Parathyroidectomy for patients with tertiary hyperparathyroidism [Mansoura experiences]

Objective: The aim of this work was to study the effect of parathyroidectomy on patients with tertiary hyperparathyroidism, and to determine whether patients with tertiary hyperparathyroidism due to single- or two- gland disease undergoing limited resection have similar outcomes compared with patients with hyperplasia undergoing subtotal parathyroidectomy

Patients and Methods: A total number of 15 patients with manifestations of tertiary hyperparathyroidism underwent parathyroidectomy, where patients with adenoma[s] of parathyroid gland underwent excision of only the adenoma[s], and patients with hyperplasia of parathyroid gland underwent subtotal parathyroidectomy

Results: There were significant changes in both clinical and laboratory values between pre- and post operative measures in both types of patients [adenoma and hyperplasia]. This was proved by the significant decrease in serum calcium, serum alkaline phosphatase and parathyroid hormone as well as the great clinical improvement in the preoperative manifestations

Conclusion: From this study we can conclude that the optimal treatment of tertiary hyperparathyroidism is surgical excision of adenoma[s] in patients with parathyroid adenoma[s] or subtotal parathyroidectomy in patients with hyperplasia of parathyroid gland

Evaluation of overlapping anal sphincteric repair [OASR] with internal sphincter imbrication for fecal incontinence due to sphincteric injury [ten months follow up]

Purpose: this prospective study was undertaken to evaluate the efficacy of overlapping external sphincter repair [OASR] with internal anal sphincter [IAS] imbrication in the treatment of traumatic fecal incontinence and its impact on anal canal physiology

Methods: Between June 1999 and May 2001, a total number of 12 patients with traumatic anal incontinence were treated in the Colorectal Surgery Unit in Mansoura University Hospital. They were 10 females and 2 males with a mean age 32.7 years. The cause of incontinence was obstetric trauma in 8 patients, surgical trauma in 3 patients and penetrating anal trauma in one patient. All Patients underwent complete anorectal laboratory investigations in the form of manometric studies, endoanal ultrasound and pudendal nerve terminal motor latency. OASR with IAS imbrication was carried out for all patients and they were followed up thereafter for a period of 6 - 10 months [mean 7.75 +/- 1.29 M]

Results: 11 / 12 patients were clinically improved with complete continence observed in five patients [41.60%]. This was associated with significant improvement in the manometric parameters, maximum resting pressure [MRP], maximum squeeze pressure [MSP], functional anal canal length [ACL]. and recto anal inhibitory reflex [RAIR]. Postoperative morbidity was only related to wound infection in one patient [8.4%] and fecal impaction in another one [8.40%]

Conclusion: Overlapping external anal sphincter repair with internal anal sphincter imbrication is a good technique that continues to give good results in the majority of patients, with an anatomic sphincter defect through the augmentation of MRP, MSP, ACL as well as the recto anal inhibitory reflex

Human leucocyte antigen [HLA] class one [A1, B7] and class two [DR-11] are new factors affecting the incidence of colonic carcinoma

The problem of colonic carcinoma is still a dilemma regarding, diagnostic and therapeutic strategy. Many factors have been found to affect the incidence of this type of cancer such as age, sex, diet and previous abdominal surgery. A survey study revealed that in normal [control] population HLA-A1 was positive in about 50%. HLA-B7 was positive in about 8% and HLA-DR11 was positive in about 40%. The aim of this study was to find a relation between the above-mentioned types of HLA and the increased or decreased risk of incidence of colonic carcinoma. Thirty patients were diagnosed after using: careful history taking, clinical examination, laboratory, and radiological investigations. Finally colonoscopy and biopsy were done. Detection of [HLA- A1. B7] was done serologically using Sigma USA. Detection of [HLA-DR 11] was done using lymphobeads method [Biotest Great Britain [UK] Itd]. HLA-A1 was found to be positive in eight patients while HLA-B7 was positive in seven patients, and HLA-DR 11 was positive in ten patients. HLA-A1 positive results were associated with increased risk of incidence of colonic carcinoma by 45%, while HLA-B7 positive results were associated with increased risk of incidence by 233% and presence of HLA-DR11 positive results were associated with decreased risk incidence by 80%. So we can consider the above-mentioned HLA types as new factors affecting the incidence of colonic carcinoma

Rhomboid flap in treatment of chronic sacrococcygeal pilonidal sinus disease

Sacrococcygeal pilonidal sinus disease [SPSD] is still an important disease owing to its morbidity. Surgery is the principal method of treatment. Several techniques have been proposed and up till now there is no standard treatment approved by all surgeons. Recurrence impairs the success of all forms of therapy, but the lowest rates have been reported for reconstructions involving local flaps. this prospective study was undertaken to evaluate the results of rhomboid excision and rotational rhomboid flap in patients with SPSD. between June 1998 and October 2000, a total number of 42 patients with SPSD [recurrent in 12 patients], were treated in our Colorectal Surgery Unit. They were 27 males and 15 females with a mean age 26.02 years. Rhomboid excision including all of the sinus[s] and its tract[s] was performed followed by reconstruction with a rotational rhomboid fasciocutaneous flap. The patients were followed up thereafter for about 6 - 26 months [mean: 16.38 +/- 6.14]. Recurrence has been encountered in only one patient [2.4%]. The complications were in the form of flap edema in one patient [2.4%], subcutaneous seroma formation in 3 patients [7.1%], marginal ischemia of the flap in 2 patients [4.8%], and wound infection in one patient [2.4%]. The mean hospital stay was 6.62 days and complete healing was achieved in a mean period of 15.71 days. we conclude that the Limberg flap is an alternative treatment option in the primary and recurrent sacrococcygeal pilonidal sinus disease with low morbidity, mortality and recurrence rates

Laparoscoplciversus conventional mesh repair of inguinal hernia; comparative randomized trial

This prospective randomized study was undertaken to compare laparoscopic transabdominal mesh repair versus open preperitoneal mesh repair and anterior tension free mesh repair in the treatment of inguinal hernia. between August 1997 and August 1999, a total number of 140/175 patients with nyhus type2, 3A, and 3B and type4 passed the exclusion criteria and agreed randomization. Laparoscopic inguinal mesh repair was carried out in 45 patients [mean age 39.2 years], open preperitoneal mesh repair was performed in 47 patients [mean age 43.2 years] and anterior tension free mesh repair was performed in 48 patients [mean age 43.9 years]. The mean follow up period was 29.1 months in laparoscopic group, 28.3 months in the open preperitoneal group and 29.2 months in the anterior group laparoscopic group showed a significant longer operative time [75.1 +/- 10.2 mm] than the open preperitoneal group [25.8 +/- 7.1 rain] and the anterior group [40.1 +/- 9.4]. On the other hand, hospital stay was significantly shorter in laparoscopic and open preperitoneal group [1.1 +/- 0.3. and 1.2+0.6 days respectively] than the anterior group [2.4+0.5 days]. The mean time to return to the normal activity was significantly less in laparoscopic group and open preperitoneal groups [6.7 and 8.6 days respectively] compared with the anterior group [13.7 days]. Postoperative morbidity was in the form of nerve injury and hydrocele, which were significantly more in the anterior group and pneumoscrotum that was most frequently encountered in laparoscopic surgery. Recurrence rate was more common in the anterior group [8.3%]. compared with both the open preperitoneal and laparoscopic groups [2.1%, and 4.3% respectively]. We can conclude that both laparoscopic mesh repair and open preperitoneal mesh repair have less postoperative pain, short hospital stay, early pain free return to work and normal activity, low complication and recurrence rates. However, the open preperitoneal mesh repair has the advantage of a shorter operative time and low operative charges

Effect of varicocelectomy on sperm count, motility and morphology: comparative randomized study of different approaches

This prospective study was undertaken to estimate the effect of varicocelectomy on the count, motility and sperm morphology and how the morphological criteria predict outcome in patient population. Also, to estimate which approach can improve this outcome in a comparative randomized study. Between June 1996 and June 2000, a total number of 346/425 patients suffering from varicocele with primary infertility passed the exclusion criteria and agreed randomization. Their mean age was 33.4 years. All patients were clinically examined and fully investigated using semen analyses, testicular ultrasound and color doppler flow imaging. Bilateral high ligation, bilateral laparoscopic approach and subinguinal varicocelectomy with 5.5X magnification were carried out in 119, 112 and 115 patients respectively. Postoperatively, patients were followed up at 1, 3, 6 and 12 months intervals. Surgical correction of varicocele was associated with significant overall improvement in sperm count and motility in all-surgical groups. According to WHO classification, the percentage of sperms with normal morphology was significantly increased with a significant decrease in percentage of amorphous forms. Also, according to Kruger classification, there was a significant improvement in the overall percentage of normal forms after varicocelectomy. Moreover, the pregnancy rate was significantly higher in the subinguinal approach with magnification [53%] when compared with high ligation and laparoscopic groups [21.8% and 29.4% respectively]. On the other hand, postoperative hydrocele formation occurred more frequently in the high ligation approach [24.3%] when compared with laparoscopic [5.3%] and subinguinal [0%] approaches. Also the postoperative recurrence was significantly higher in the high ligation group [23.5%] when compared with the laparoscopic [14.2%] and the sabinguinal with magnification groups [0.8%]. From this study, we conclude that varicocelectomy has a positive effect on sperm count, motility and morphology and the subinguinal varicocelectomy with magnification is a safe, and a minimal invasive approach to varicocelectomy that lessens the incidence of hydrocele formation and varicocele recurrence, and assures preservation of testicular artery. Moreover, it has a higher positive effect on the sperm motility and morphology, which are the predictors of pregnancy