Effect of Roux-en Y gastric bypass on bone metabolism in patients with morbid obesity: [Mansoura experiences]

Roux-en-Y gastric bypass [RYGBP] has been found to be the most efficient way to lose weight and maintain the weight loss in morbid obesity. However, with the formation of a new stomach and the modification of intestinal anatomy, there are significant changes on bone metabolism .The objectives of this study were to evaluate effects of weight loss on bone metabolism after Roux-en Y gastric bypass in patients with morbid obesity. Our study included 70 patients with morbid obesity, RYGBP was done for all patients. Daily postoperative oral supplementation with 1000 mg of calcium and 800 IU of vitamin D was done for each patient Body weight, BMJ, also Total body fat, Total lean tissue mass, Bone Mineral content [BMC], Bone Mineral density [BMD], Total bone area [TBA] [using DEXA], also, serum calcium, parathyroid hormone [PTH], 25-OH vitamin D, 24 hours urinary calcium and bone specific Alkaline phos-phatase [BSAP] were assessed preoperatively and one year after surgery. In our study: females comprised 70% of cases. The mean age was 35 +/- 8.8 years. One year after RYGB: Body weight [BW] decreased significantly from 132.8 +/- 26.5 to 90.3 +/- 17.3 kg [P=0.001]. Body Mass Index [BMI] decreased significantly from 48 +/- 7.3 to 32.6 +/- 4.1 kg/m2 [P= 0.001]. BMC decreased significantly from 2968.6 +/- 71.4 to 2700.8 +/- 45.4 gm [p = 0.001] BMD decreased significantly from 1.026 +/- 0.03 to 1.22 +/- 0.015 gm/cm[2] [P=0.001]. TBA decreased significantly from 2356.2 +/- 35.4 to 2216.3 +/- 43.5 cm2 [P=0.001]. Serum calcium, 24 hours urinary calcium and BSAP were non significantly decreased while 25 OH-vitamin D and PTH were non significantly increased after surgery. From this study, it is shown that Roux-en-Y gastric bypass operation gives very good results as regards reduction of body weight in morbidly obese patients. Postoperative supplementation with calcium and vitamin D partially correct osteoporosis. So, These patients need periodic follow up for Bone Mineral Density [BMD], PTH, calcium, serum vitamin D and markers of bone resorption and formation specially postmenopausal female

Comparative study between botulinium toxin injection and partial division of puborectalis for treating anismus

To compare the results of partial division of puborectalis [PDPR] versus local botulinium toxin [BTX-A] injection in treating patients with anismus. This prospective randomized study included 30 male patients with a mean age 38.93 +/- 12.39 years and a mean duration of 5.80 +/- 3.96 years. Diagnosis was made by clinical examination, barium enema, colonoscopy, colonic transit time, anorectal manometry, balloon expulsion test, defecography, and EMG. Patients were randomized into: Group [I]: included 15 patients injected with BTX-A, and Group [II]: included 15 patients who underwent bilateral PDPR. Follow up was conducted for one year. Both BTX-A and PDPR significantly reduced the preoperative constipation scores. The initial and long term success rates were 86.7% and 40% in BTX-A group versus 100% and 66.6% in PDPR group. Recurrence was observed in 7 patients [53.8%] and 5 patients [33.4%] following BTX-A and PDPR respectively. Minor incontinence had occurred in 2 patients [13.3%] following PDPR. BTX-A injection seems to be successful for temporary treatment of anismus. However, PDPR has been found to be a promising method for treatment of anismus with a relatively lower morbidity in relation to its higher success rate

T4 sympathectomy for palmar hyperhidrosis: looking for the right operation

Most surgeons still perform T2 or T2-3 sympathectomy for palmar hyperhidrosis, but both these treatments can cause severe side effects. Some recent articles have advocated T4 sympathectomy and obtained satisfactory results. The aim of this study was to compare the outcomes of 3 different levels of sympathectomy. Between July 2003 and July 2006, we treated 60 patients [20 males and 40 females, mean age 26 years] suffering from palmar hyperhidrosis by Endoscopic thoracic sympathectomy [ETS]. Patients were randomized into three groups according to the level of sympathectomy, ETS2, ETS3 and ETS4 groups [20 patients in each group]. Data was collected by review of medical charts, outpatient clinic and telephone interviews. patients were asked to state whether they considered their symptoms to be cured', or unchanged'. The degree of hand dryness was assessed .Postoperative complications [including wound infection, chest pain, and Horner's syndrome] were assessed. Any occurrence of gustatory sweating, rhinitis, reflex [compensatory] sweating [CS], regions of CS and recurrence was noted. Patient satisfaction was assessed. Treatment success at follow-up was 90% for the ETS2, 95% for ETS3 patients and 100% for the ETS4 patients. In the ETS2 group and ETS3 group, a higher rate of over dryness of limbs was observed in 7 patients [35%], 4 patients [20%]; respectively. The reflex sweating was mild in the ETS4 group, while moderate and severe reflex sweating were more common in the ETS2and ETS3 group patients. Around 40% of ETS2 groups and 25% of ETS3 group patients were unsatisfied with their surgery. All patients of ETS4 group were satisfied with the outcome of surgery. In conclusion, ETS4 sympathectomy is an effective method for treating PH. The success rate is 100% and there is no recurrence. Most importantly, the rate of CS is reduced to a minimum

Thyroid surgery: use of ligasure vessel sealing system versus conventional knot tying method

The aim of this study was to compare the use of conventional knot tying vs. LigaSure Vessel Sealing System [Valley lab, Boulder, Colorado] in patients undergoing thyroid surgery. We hypothesized that the use of LigaSure would reduce the time of operation without more complications. This study was conducted in Endocrine Surgery Unit, Mansoura University Hospital on patients who underwent thyroid surgery from January 1, 2006 to December 31, 2006. 110 patients were operated upon by the same team of surgeons using conventional knot tying in 55 and LigaSure in 55 patients for hemostasis. The medical records of patients enrolled regarding age, sex, histopathological diagnosis, type of operation performed [lobectomy vs. subtotal thyroidectomy vs. total thyroidectomy]; the operation time, intraoperative blood loss, postoperative complications, length of incision, hospital stay and cost, as well as the postoperative pain and outcome were reviewed and compared. The two groups had nearly similar demographic data. We have noticed that patients in the LigaSure[TM] group had significant lower operating times [P = 0.000], lower intraoperative blood loss [P = 0.000], less postoperative pain and early pain-free return to normal activity and return to work [P = 0.0001]. LigaSure Vessel Sealing System was as safe as conventional knot tying method for thyroidectomy, with the benefit of a reduced operating time, decreased postoperative pain and early pain-free return to normal activity and return to work

Laparoscopic intraperitonealmesh repair of ventral hernia :prospective comparison toconventional mesh repair

The recurrence rate after standard repair of ventral hernias may behigh and the wide surgical dissection required often results in wound complications. Use of laparoscopic approach may decrease rates of complications and recurrence after ventral hernia repair. The laparoscopic repair of ventral hernias is still a controversial therapeutic op-tion. To evaluate the efficacy and safety of laparoscopic repair we compared the results of open and laparoscopic repair of ventral her-nias. Fifty three patients were randomized prospectively to undergo laparoscopic or open repair of ventral hernias. Thirty-eight patients presented with incisional hernias [12 upper midline, 15 lower midline, and 10 transverse abdominal], 8 had epigastric hernias, 8 had periumbilical hernias. All defects were estimated to be larger than 5 cm in diameter. Twenty six patients underwent attempted laparoscopic ventral hernia repair [LVHR] with mesh and twenty seven patients underwent open ventral hernia repair [OVHR] with mesh. Two of the 26 attempts of LVHR were converted to OVHR for a conversion rate of 7.6 percent The mean duration of surgery was significantly longer in the open group. The analgesic requirement was lower in the laparoscopic group. Time to oral solid food intake was longer in the open group. Post-operative stay was shorter in the laparoscopic group. Also, we noticed that there were significant early pain free return to activity and work in LVHR. In LVHR, postoperative complications occurred in 8 patients inthe form of seroma, and ileus in one patient. Whereas, in OVHR, 10 patients had postoperative complications that included wound seroma in 4patients, wound infection in 4 patients [one required removal of mesh],postoperative ileus in one patient, and wound dehiscence in one patient. There was a significant less recurrence rate in LVHR in comparison with OVHR [0 vs. 3 patients]. In conclusion, laparoscopic incisional hernia re-pair, is a safe, feasible alternative to open techniques. However, largerstudies and long-term follow-up are required to further evaluate the true effectiveness of this operation

Diagnostic and prognostic utility of flow cytometric DNA measurements in solitary thyroid nodule

Objectives: to define the value of DNA ploidy in the management of solitary thyroid nodule

Patients and Methods: 50 patients were subjected to FNAB and flow cytometric DNA measurements and managed according to the results by either hemithyroidectomy or total thyroidectomy

Results: DNA aneuploidy was found to be more common in patients with thyroid carcinoma. DNA flow cytometric measurements have decreased the percentage of false negative results of FNAB. DNA aneuploidy was found to be more common in males, old age, extrathyroid extension, poor histological differentiation and metastasis. Also DNA aneuploidy was associated with recurrence and poor 2 years' survival

Conclusion: DNA flow cytomietry plays an important role in the diagnosis of thyroid nodules especially in suspicious and unsatisfactory samples. Cases with diploid DNA histogram associated with high proliferative index values are well going toward malignancy. Patients with aneuploid differentiated thyroid tumors have poorer prognosis compared with patients with diploid tumors. So DNA pattern of ENAB can be used in the diagnosis and the prognosis of patients with thyroid carcinoma

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

Intraoperative electrophysiological monitoring of the recurrent laryngeal nerve in thyroid surgery is it worthwhile?

Recurrent laryngeal nerve [RLN] injury is the most problematic complication impacting of the decision whether or not to perform total or completion thyroidectomy. Recurrent nerve paralysis is a less frequent complication when the nerve is routinely identified. A simple technique will be described for identifying the recurrent laryngeal nerve with a nerve stimulator to prevent damage to the nerve during thyroid surgery. 34 Women and 16 men undergoing thyroid Surgery over 12 months were subjected to intraoperative nerve stimulation with increasing voltage increments by both the traditional bipolar and concentric bipolar electrodes until both light and sound [audio signal] indicators on the nerve monitor were positive. All recurrent laryngeal nerves with associated preoperative normal vocal cord mobility were identified successfully and the location of the nerve was clearly established by the lowest stimulating current, which evoked the audio signal response only when the probe was over the nerve which was immediately confirmed by direct visualization. The integrity of these RLNs distal to the point of stimulation was confirmed on completion of the surgery. The threshold for stimulation of the recurrent nerve varied from 0.2 to 1 milliAmpere [mA] [mean 0.37 mA] for the standard bi- polar and 0.1 to 1mA [mean 0.27 mA] for the concentric bipolar electrode. The traditional bipolar electrode threshold stimulation was consistently higher than the concentric bipolar and had less variability. Comparison between minimal stimulation levels RLNs distal to the point of with the concentric bipolar probe pro dissection of the recurrent laryngeal nerve [that is at the time of initial nerve identification] mean 0.37 mA [range 0.2- 1 mA] and post- thyroidectomy [that is after removal of the surgical specimen] mean 0.369 mA [range 0.1-2 mA] showed no significant change. There were no endotracheal difficulties in our study since the electrode adheres to the normally used endo-tracheal tube. Mechanical or electromechanical stimulation of tissue adjacent to the RLN has been helpful in indicating its close proximity when dissecting. These aids may reduce the risk of iatrogenic RLN injury, particularly during redo surgery. In our study stimulation artifacts were also quite common with instrumentation contact, but did not interfere with monitoring to any great extent. False-positive responses may also occur primarily due to misinterpretation artifact. Electro physiologic monitoring of the RLN is shown to reduce the incidence of RLN injury, its benefit most likely is related to augmentation of the surgeon's ability to identify and thus protect the RLN from injury. Surgeon's skill, experience, and judgement will remain the most important elements in preventing RLN injury

Anoplasty for severe postsurgical anal stenosis: comparative randomized study

Cicatricial stenosis of the anal canal is a serious and disabling complication of anal surgery, which may be extremely difficult to manage. This comparative randomized study was performed to evaluate the efficacy, complication rate and recurrence of anal stenosis after Y-V anoplasty, diamond - shaped pedicle flap or house advancement pedicle flap and may be their indications in postoperative anal stenosis. In this study we reported 27 patients with severe anal stenosis. Eight of these patients underwent a Y-V anoplasty while nine had a diamond flap anoplasty and ten of these patients underwent house advancement flap anoplasty. All patients had bilateral anoplasty with or without partial internal sphincterotomy according to the presence or absence of an associated functional stenosis. All patients were seen 4 weeks, 6 months, one year and then annually after surgery. In the patients who underwent Y-V anoplasty, morbidity was in the form of haematoma and wound dehiscence in one patient and an ischemic contracture of the leading edge of the flap in other four patients. At 4 weeks follow up, all patients showed complete healing of wounds and most of them reported satisfactory results. Subjectively, one of the patients with house advancement pedicle flap complained of mild constipation, while, two patients with diamond pedicle flaps and 4 patients with Y-V anoplasty complained of moderate constipation. Six months postoperatively, neither further complications nor incontinence was observed. Furthermore, anorectal manometric studies revealed within normal resting and squeezing pressures for all patients. At one-year follow-up, all patients who underwent house advancement flap had complete remission of the symptoms. Among the 9 patients who underwent diamond pedicle flap, 7 judged their clinical results satisfactory while 2 patients had restenosis. OF the 8 patients who underwent YúV anoplasty, 4 patients had restenosis after one year. Although our cohort of patients is not huge, and randomized studies comparing the results of many different operative procedures used to correct anal stenosis are lacking in the literature, we can conclude that house advancement flap is a simple and safe method to correct postoperative anal stenosis with good long term results

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

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