Reporting of the circumferential tumour margin involvement and preoperative levels of carcinoembryonic antigen as prognostic risk factors in colorectal cancer patients

Background and study aims: The two very important prognostic risk factors of colorectal cancer are circumferential tumour margin [CTM] involvement and preoperative levels of carcinoembryonic antigen [CEA]. The aim of this study is to monitor the frequency of reporting of the CTM in the postoperative pathology reports after colorectal cancer resection in addition to monitoring the frequency of reporting of preoperative levels of CEA and exploring the possibility of improving the frequency of reporting of both

Patients and methods: Reports of the CTM and preoperative level of CEA were found in 730 [664 retrospective and 66 prospective] patients with colorectal cancer. The possibility of improving the incidence of reporting was estimated by comparing the reporting frequency of both [retrospective and prospective] groups

Results: The percentage of reporting the involvement of the CTM was 46.08% and 81.81% for the retrospective group and the prospective group, respectively. The percentage of reporting the preoperative CEA levels was 40.9% and 68.7% for the retrospective and the prospective groups, respectively. There was a statistically significant difference in reporting both CTMs and the preoperative level of CEA between retrospective and prospective groups to the side of prospective group in which the p-value was <0.0001 for both groups

Conclusion: There was inadequate reporting of both the CTM involvement and preoperative levels of CEA in the retrospective patients with statistically significant improvement of this reporting in patients in the prospective group. This may point to the unawareness of the importance of both in the prognosis of colorectal cancer, which may be because both are not involved in the widely used tumour, node, metastasis [TNM] staging system

Diagnostic Validity of serum and peritoneal TNF-alpha, high sensitivity CRP and plasma cell-free nuclear DNA [ccf nDNA] as biomarkers of pelvic endometriosis- a case control study

Introduction: Endometriosis is a disease defined by the presence of endometrial glands and stroma located outside the uterine cavity. These ectopic implants can be found throughout the pelvis, on and within the ovaries, abutting the uterine ligaments, occupying the rectovaginal septum, invading the intestinal serosa, and along the parietal peritoneum. Endometrial implantation at distant sites such as the pleura, lung, within surgical scars, and along the diaphragm also has been reported. [1] . It results often in subfertility and pain, occurs mainly in women of reproductive age [16-50 years] and has a progressive character in at least 50%, but the rate and risk factors for progression are unknown. Endometriosis can be classified into four stages: minimal, mild, moderate and severe. The gold standard for the diagnosis of endometriosis is laparoscopic inspection, ideally with histological confirmation. [2], however, is an invasive technique and should be performed only after imaging techniques prove insufficient for confident diagnosis. [3] Lack of a non-invasive diagnostic test contributes to the long delay between onset of symptoms and diagnosis of endometriosis. [2] Additional tools are needed for non-invasive classifications in order to reduce the number of unnecessary laparoscopies without adversely affecting outcomes. Finding specific and more sensitive biomarkers in endometriosis is critical, because endometriosis is usually diagnosed only in advanced stages, and there is a high rate of morbidity for this disease. [4]

Aim of the work: The aim of the current study is to assess the validity of serum and peritoneal high sensitivity CRP and TNF-alpha and plasma cell-free nuclear DNA [ccf nDNA] as biomarkers in early diagnosis of pelvic endometriosis

Methods: This study was conducted at the Obstetrics and Gynecology department, Maternity Hospital, Ain Shams University. This is a case control study of 120 women scheduled for diagnostic laparoscopy. Laparoscopy was indicated in these women whether for various causes of subfertility or for chronic pelvic pain between January 2011 and January 2012. The patients were divided into the following groups: Group I [endometriosis group/ study group] consisted of 80 patients diagnosed to have endometriosis during laparoscopy. Group I cases were subdivided into two subgroups, Group IA: consisted of 34 cases with stage 1or minimal endometriosis and Group IB: consisted of 46 cases with stage 2 or mild endometriosis. Group II [non-endometriosis group/Control group]: consisted of 40 cases with no detected pelvic pathology. During the laparoscopy procedure, both peripheral venous blood and peritoneal samples were withdrawn. Serum and peritoneal levels of high sensitivity CRP and TNF-alpha as well as plasma levels of ccf nDNA were compared in both groups and in early stages [minimal and mild] of endometriosis within the study group

Results: Serum TNF-a, serum hs-CRP and plasma ccf DNA were significantly elevated in cases compared with the control group. They were also elevated in patients with group IA and group IB as compared to control group. However, there was no statistically significant difference between cases and control group as regards peritoneal TNF-a and peritoneal hs-CRP. There was no significant difference between the group IA and group IB as regards all biomarkers

Conclusion: Our results showed that serum TNF-alpha , serum hs-CRP and plasma ccf DNA are highly reliable biomarkers for screening and early diagnosis of endometriosis, but they can not be used to discriminate between stage I and stage II. On the other hand, peritoneal TNF-a and peritonealhs-CRP are non reliable for early diagnosis of endometriosis and can not be used to discriminate between stage I and stage II of endometriosis

Evaluation of the results of operative treatment of hip dysplasia in children after the walking age

Treatment of neglected developmental dysplasia of the hip [DDH] in children after the walking age has been a challenge to the orthopedic surgeons. It is usually surgical at this age group. The study included 35 patients [42 hips], they had been treated by different combinations of open reduction, femoral [shortening, derotation and varus] and pelvic [Salter or Dega] osteotomy. The age at the time of the operation ranged from 18 to 96 months. At the end of follow-up [a mean of 33.5 months], the overall final clinical result was excellent in 13 [31%] patients, good in 24 [57%] patients, fair in four [9.5%] patients and poor in one [2.5%] patient satisfactory in 37 [88%] patients and unsatisfactory in five [12%] patients. The radiological end result was Class I [excellent] in 26 [62%] patients, Class II [good] in 11 [26%] patients, Class I [fair] in three [7%] patients and Class IV [poor] in two [5%] patients. It was satisfactory in 37 [88%] patients and unsatisfactory in five [12%] patients. We concluded that operative treatment of neglected DDH after the walking age is a technically demanding procedure but when performed properly by an experienced surgeon it gives satisfactory results

comparative study between lidocaine spray [10%] and lidocaine spray plus intravenous nalbuphine to facilitate laryngeal mask airway insertion in minor gynecological procedures

Background: This prospective, randomized, double blind study was designed to evaluate the effect of adding nalbuphine [mixed agonist antagonist opioid] to lidocaine spray [10%] on the hemodynamics as well as the laryngeal mask airway insertion conditions in patients scheduled for elective minor gynecological procedures

Methods: Forty adult female patients, ASA physical status I-II subjected for elective minor gynecological procedures at Mansoura University Hospital were enrolled in this study. Patients were randomly assigned using sealed envelope method into two groups [n= 20 for each group]. One group received lidocaine spray 10% in the oral cavity and oropharynx before LMA insertion while the other group received lidocaine spray in addition to IV nalbuphine 0.2 mg/kg. Anesthesia was induced in all patients with propofol injection in a sleep inducing dose [1-2 mg.kg-1], titrated to loss of consciousness with oxygen mask. Anesthesia was maintained with 1% isoflurane, nitrous oxide [60%] and oxygen [40%]. The following data were recorded during LMA insertion, six variables were noted on a 3-points scale, jaw relaxation [good-incomplete-poor], ease of insertion [easy-difficult-impossible], swallowing [nil-slight-gross], coughing/gagging [nil-slight-gross], limb movement [nil-slight-gross], laryngospasm [nilslight-gross] and blood pressure [MPB], heart rate [HR] and peripheral arterial oxygen saturation [basal and every one minute for 5 minutes]. Patients were monitored with electrocardiogram, noninvasive arterial blood pressure, pulse oximetry and capnogram. All noted and recorded before induction[basal] and every minute for 5 minutes

Results: As regard LMA insertion characteristics, there was statistical significance observed between both group in coughing/gagging and laryngospasm [p= 0.003 and 0.018respectively] favoring nalbuphine with lidocaine group. Comparison of hemodynamic parameters between groups has shown that nalbuphine plus lidocaine group had generally better control of blood pressure throughout and shortly after the insertion procedure. In addition, this group had significantly better control of heart rate in two time stations and remained better later in spite of lack of statistical significance

Conclusion: Nalbuphine administration with lidocaine spray has the advantage of better control of hemodynamics and improved some laryngeal mask airway insertion criteria like significant decrease in coughing/ gagging and laryngospasm. We can conclude that IV nalbuphine is a safe and cheap opioid that can be used for facilitation of LMA insertion

Non-invasive technique in the early detection of hepatocellular carcinoma and nodules at high risk of neoplastic transformation in cirrhotic patients

Hepatocellular carcinoma in cirrhosis is a multistage process that includes large regenerative nodules, dysplastic nodules, and hepatocarcinoma. The aim of this study was to establish whether contrast-enhanced Doppler ultrasonography [US] is able to distinguish between early hepatocellular carcinoma [HCC] and small nonmalignant nodules in cirrhosis. Between January 2002 and December 2002, 250 cirrhotic patients with no previous history of HCC or evidence of hepatic focal lesions were enrolled and prospectively followed-up with US every 6 months until December 2002. Thirty patients developed focal lesions, 6 multifocal, and 24 monofocal. Biopsy of focal lesions, contrast enhanced Doppler US and spiral computed tomography [CT] were performed in 21 patients with small [<3 cm] monofocal lesions. Ten nodules were diagnosed as HCC and II as nonmalignant [8 large regenerative nodules, 1 low-grade, and 2 high-grade dysplastic nodules] by liver biopsy. Iritratumoral arterial blood flow was detected in 9 of 10 [90%] HCC and 3 of 11 [27%] nonmalignant nodules by contrast-enhanced Doppler US [P<.0001]. The mean peak resistance and pulsatility indices were 0.82+0.09 and 1.56+0.2 in HCC and 0.62+0.08 and 0.82+0.08 in dysplastic lesions [P=.002 and .0001], respectively. Spiral CT revealed arterial perfusion in 9 of 10 HCC and in 2 of 11 nonmalignant nodules [high-grade dysplastic nodules]. Two of the apparently false-positive nodules at enhanced Doppler VS were high-grade dysplastic nodules and evolved to HCC during follow-up. In conclusion, contrast-enhanced Doppler US is a noninvasive, very sensitive technique in differentiating malignant and premalignant lesions from nonmalignant focal lesions in the liver

Surgical correction of congenital vertical talus by one-stage peritalar reduction and tibialis anterior transfer

Twenty-eight feet of 16 children with true congenital vertical talus [CVT] were treated surgically by one-stage peritalar reduction and tibialis anterior transfer to the neck of the talus. The male to female ratio was 3:1. Fifty percent [8 patients with 15 feet] were isolated CVT and the remaining [8 patients with 13 feet] were CVT associated with other congenital anomalies mostly arthrogryposis. Patients with the neurological disorders were not included. Familial occurrence was encountered in 4 children [7 feet] of the same family. The mean age at operation was 19.1 +/- 7.1 months [range 6-36]. All patients were operated by the author and were available for clinical and radiological follow-up for a mean of 9 +/- 5.3 years [range 2-16]. A modified scoring system with 32 points for clinical and 8 points for radiological parameters was utilized for assessment of the final outcome. Nine feet [32.1%] had excellent results, 15 [53.6%] good, 3 [10.7%] fair and one [3.6%] poor. The mean score for all patients was 31.9 +/- 2.8 points. All patients and their parents, except one, were satisfied by their functional results and appearance of the feet. Radiologically there was a statistically significant improvement of the measured angles at the final follow-up compared to the preoperative angles. Unsatisfactory results occurred in 4 feet [14.3%]; in 3 due to partial recurrence of the deformity; these were associated with arthrogryposis. The fourth had overcorrection. No talar avascular necrosis was encountered in this study. Early treatment of CVT by simultaneous correction of all the anomalies during the same sitting led to very satisfactory medium term results

Subacromial decompression using modified acromioplasty

The aim of this work was to study the clinical results of subacromial decompression using modified acromioplasty in cases of shoulder impingement syndrome. Thirty two patients who had shoulder impingement syndrome were included in this study. Twenty patients were females and 12 were males. The average age at the time of operation was 43.2 years; 40.6 years for females and 47.6 for males. There were two indications for operation. One was the persistence of pain in the anterior aspect of the shoulder when the arm was elevated and the second was progression of symptoms despite the use of anti-inflammatory medications and rehabilitation program. All cases were managed operatively with a modified Neer acromioplasty. In the classic anterior acromioplasty as described by Neer emphasis was placed on resection of the inferior prominence of the acromion. Modified acromioplasty was done in two steps; the portion of the acromion that projects anteriorly beyond the anterior border of the clavicle was resected vertically and then an anteroinferior acromioplasty was performed. The follow up period ranged between 6-24 months, average 13 months. Nineteen patients had excellent result, 7 had good result and 6 had no improvement