Feasibility of combined laparoscopic cholecystectomy and anti-reflux surgery: evaluation and outcome

This study was designed to evaluate the outcome of combined laparoscopic cholecystectomy and fundoplication during one single laparoscopic procedure. The study included only patients assigned to undergo cholecystectomy for calcular cholecystitis and had symptomatic gastroesophageal reflux disease [GERD], 22 patients [7 males and 15 females] were enrolled in the study. All patients underwent clinical history taking including duration of symptoms, physical examination and upper gastrointestinal endoscopy. Esophageal manometry was performed preoperatively and 2 and 6 months after surgery. Laparoscopic procedures were performed through 5-port access. Operative time and the frequency of conversion to open surgery, time till initiation of oral intake, postoperative hospital stay and complications and time to recover full activity were recorded. Through a monthly visit for 6 months after surgery, patients were monitored for the extent of resolution of GERD-related symptoms. There was a significant increase [p<0.001] of postoperative lower esophageal sphincter [LES] pressure compared to preoperative pressure with a non-significant difference between pressures estimated at 2 and 6 months. No intraoperative complications were encountered and there was no need for conversion to open surgery in any case. The mean operative time was 78.3+/-9.7; range: 60-90 minutes. All patients tolerated oral ingestions after the first 48 hours. The mean duration of postoperative hospital stay was 4+/-0.8; range: 3-5 days and 9 patients [40.9%] were discharged on the 3[rd] postoperative day. The mean duration till resumption of full daily activities was 11.6+1.4 [10-14] days. Clinically, a marked resolution of symptoms due to reflux was observed, only one patient developed dysphagia for solid food and a sensation of trapped air occurred in two patients causing discomfort, however, these three patients were asymptomatic at 6 months after the surgery. It could be concluded that combined laparoscopic surgery for cholelithiasis and GERD is an appropriate procedure, when indicated, giving excellent short-term outcome results and could be managed during one single laparoscopic procedure

One-stage primary ileo-colic or ileo-rectal anastomosis. For acute malignant left colonic obstruction

The aim of this study was to evaluate the immediate and short-terme follow-up results of one-stage subtotal or total colectomy and anastomosis for patients with malignant left colon obstruction. The study comprised 21 patients [10 males and 11 females] with age range of 36-81 years; presented by acute large bowel obstruction with clinical and radiological evidence of obstruction. The choice of the extent of resection was determined by the extent of fecal load, the presence of colonic perforation, serosal tears of the cecum and/or massive colonic distension with concomitant ischemia: the presence of these features in a hemodynamically stable patient favored subtotal or total colectomy and ileo-colic or ileo-rectal anastomosis. The site of obstruction was at the sigmoid colon in 9 patients [42.9%], rectosigmoid in 8 patients [38.1%], splenic flexure in 3 patients [14.3%] and descending colon in one patient [4.7%]. Ileosigmoid anastomoses were done in 13 patients [61.9%] and 8 patients [38.1%] had ileorectal anastomoses. The mean operative time was 201+/-33.2; range: 150-270 minutes, the mean operative blood loss was 633.3+/-408.2; range: 250-1800 cc; 11 patients [45.8%] required blood transfusion with a mean number of blood bags used was 2.8+/-1.2; 1-5 bags. Oral feeding was resumed after a mean period of 4.9+/-0.9; range: 4-7 days and the mean postoperative hospital stay was 10+/-2.2; range: 8-18 days. Overall, after 12-months follow-up only one patient had anastomotic line recurrence with a recurrence rate of 4.75%, one patients died of acute liver failure secondary to hepatic metastasis with mortality rate of 4.75% and 19 patients had follow-up free of morbidity with no-local recurrence or metastasis and a follow-up free rate of 90.5%. Thus, it could be concluded that one-stage subtotal or total colectomy and ileo-colic or ileo-rectal anastomosis are safe procedure with satisfactory outcome for management of obstructing malignant lesions of the left colon

Haemorrhoidectomy for advanced haemorrhoidal disease, comparative study between the conventional and modern techniques

Surgical excision is considered the ideal treatment for the third and fourth degree haemorrhoids. Inspite of being safe, surgical excision is liable to some complications as postoperative bleeding, pain, discharge, stenosis and recurrence So, a wide variety of techniques had been developed to avoid these complications. This study was performed for two hundred patients complaining of third or fourth degree haemorrhoidal disease. Their ages ranged between 18 and 66 years, [mean 40.28 +/- 11.84 years]. The patients were divided into four groups. Group I, [50 patients], for whom stapler haemorrhoidectomy was done. Group II, [50 patients], for whom rubber band ligation was performed. Group III, [50 patients], for whom Good-Sall's stitch technique was done. Group IV [50 patients], for whom conventional haemorrhodectomy was performed. The aim of this study was evaluation of the four techniques regarding, the operative time, hospital slay, time off work, postoperative pain, bleeding and post operative complications: For each technique the study concluded that: The shortest mean operative time was in group II, [5.7 +/- 2.14 mins.]. The shortest hospital slay and shortest time-off work was in group II, [1.60 +/- 0.91 days] and [3.12 +/- 1.39 days] respectively. Minimal post operative pain was in group I. The highest incidence of postoperative minor bleeding pruritis and wound discharge was recorded in group IV. The highest incidence of recurrence was recorded in group II. The results seen with stapler haembrrhoidectomy are very promising and actually superior to that of conventional haemorrhoidectomy in treatment of third and fourth degrees haemorrhoidal disease. Cost which remains high, seems to be balanced by the superior results obtained and the significant rapid return to normal activities and patient satisfaction

Equivocal acute appendicitis is a diagnostic problem does abdominal ultrasonography have a role?

The clinically equivocal acute appendicitis remains a diagnostic problem. The aim of this study was to assess the diagnostic accuracy of ultrasonography and the classical clinical factors employed in the diagnosis of suspected acute appendicitis. This study included 182 patients presenting with equivocal acute appendicitis, 88 patients [48.4%] were males and 94 patients [51.6%] were females. The age of the patients ranged from 6 to 64 years [mean: 24.3 +/- 15.3 years]. The clinical, radiological and ultrasonographic data of all patients were collected. One hundred and ten patients [60.4%] had histologically confirmed appendicitis. After analysis of the possible association between the diagnostic variables recorded and the presence of appendicitis, 9 variables were found to be significant. UItrasonography displayed the greatest diagnostic weight, with a sensitivity of 85.5%, specificity of 94.4%, and accuracy of 89%. Out of the clinical data, localization of pain in the right iliac fossa and total leucocytosis showed the greatest diagnostic weights over the others. Localization of pain in the right iliac fossa showed an 84% sensitivity. Specificity of 50%, and accuracy of 70%. Total leucocytosis showed an 81% sensitivity, specificity of 49%, and accuracy of 68%. It was concluded that ultrasonography increases the diagnostic accuracy in patients with suspected acute appendicitis

Evaluation of splenectomy and devascularization operation on portal hemodynamics using Doppler ultrasonography

The present prospective study was designed to evaluate the effects of splenectomy and devascularization operation on the hemodynamics of portal circulation and the reliability of color Doppler ultrasonography as a non-invasive tool in the assessment of portal hemodynamics before and after the operation. Thirty patients [19 males and 11 females] with clinical diagnosis of portal hypertension and endoscopic evidence of oesophageal and/or gastric varices who underwent splenectomy and devascularization were included in this study. The mean age of the whole group was 32.12 +/- 1.8 years [range: 17-52 years]. Doppler scanning of the portal vein before and after the operation revealed a sign reduction in the maximum blood velocity postoperatively [mean 10.59 +/- 2.66 cm/sec. versus 12.51 +/- 3.16 cm/sec preoperatively], and a sign reduction in the volume blood flow postoperatively [mean 884.3 +/- 233.9 ml/mm. versus 1073.8 +/- 422.4 ml/mm., preoperatively], and insignificant change in the diameter. Also, the direction of blood flow was hepatopetal in all patients after operation, while it was bidirectional in. one patient and hepatopetal in 29 patients before operation. The study revealed a sign positive correlation between the size of the spleen and the decrease in the blood velocity and volume blood flow of the portal vein after operation. Also, there was a positively sign correlation between the presence of a history of injection sclerotherapy and the diameter and volume blood flow of the portal vein before the operation. From the present study, it was concluded that splenectomy and devascularization could be performed with extremely low mortality in selected elective patients, particularly the non alcoholic, with virtually no postoperative encephalopathy. This is in addition to the preservation of the vascular anatomy of the right upper quad rant for future use in potential liver transplant. The operation did not lead to complete disappearance of oesophageal varices, but sign reduction in their grades and injection sclerotherapy is recommended for variceal remenants. Based on the fact that there is a sign positive correlation between the size of the spleen and the decrease in the blood velocity and volume blood flow of portal vein after the operation, it is suggested that this splenic venous flow contributes, in part, to portal hypertension. The Doppler scanning is an ideal investigation for portal circulation, as it is noninvasive, cheap and provides accurate data about the velocity, volume flow, direction of blood flow and patency of portal circulation

Breast conservation therapy in treatment of cancer breast

Breast conservation therapy [B.C.T.] comprises local excision, axillary dissection and post operative radiotherapy. Numerous studies have now shown that although local recurrence may be slightly more common after breast conservation than mastectomy, disease-free survival and overall survival are the same. The primary goals of breast conservation therapy are tumour control and acceptable appearance of the breast. Twenty female patients were included in this study. All patients were suitable for B.C.T. Their ages ranged from 25 to 60 years [mean age 41.3 +/- 8.8 years]. All patients were subjected to mammography, fine needle aspiration cytology [FNAC] and metastatic work up [chest x -ray, abdominal ultra sonography and bone scans].The study included 4 patients [20%] in stage I, 14 patients [70%] in stage II and 2 patients [10%] in stage III One patient showed positive safety margin of the lumpectomy specimen and for whom mastectomy was done. The remaining 19 cases were followed up for two years. The study showed an excellent cosmetic appearance however, local recurrence occurred in 3 cases [15.78%]. The higher incidence of total recurrence in the present study may be related to the histopathological nature of the tumour, the biological behavior of breast cancer in Egypt or even the sample is so small in number