Surgical outcome of modified Karydakis flap and modified Limberg flab in the management of sacroccygeal pilonidal disease: a comparative study

Introduction: Sacrococcygeal pilonidal disease (SPD) is a chronic suppurative condition of the sacrococcygeal region causing chronic sinus tract or cyst. It is an acquired complex disease more common in young adult males, causing considerable morbidity and long periods of interruption in work or education. From simple conservative techniques to complex flap reconstruction, many debatable treatment options are offered; however clear dynamics toward the widespread use of minimally invasive methods and off-midline flap reconstruction are suggested in all guidelines, which recommend the Karydakis and Limberg flap modification. The plethora of literature compares procedures for identification of a single best treatment approach, which has proven to be difficult. The surgical outcome of both techniques is compared in the present study. Objective: To compare the surgical outcomes of the modified Karydakis flap (MKF) versus the modified Limberg flap (MLF) in SPD. Materials and Methods: The present study was conducted at the general surgery department on SPD patients who were ≥18 years old. A total of 67 participants were included after obtaining the informed consent, with group A comprising 33 patients undergoing the MLF procedure and group B comprising 34 patients undergoing the MKF procedure. Results: The mean patient age was 28.85 (range, 18-44) years old. For the MKF and MLF methods, the average operating duration was 32.5 (range, 25-40) and 54.5 (range, 45-65) minutes, respectively. The MKF approach was found to significantly improve pain score, mean sitting painless time, return to normal activity, wound healing time, and patient satisfaction. Conclusion: Comparative outcomes were seen between both MKF and MLF; however, our findings show that MKF is a more favourable method than MLF with superior outcomes. (AU)

Factors Associated with Early Adverse Events after Coronary Artery Bypass Grafting Subsequent to Percutaneous Coronary Intervention

BACKGROUND: A previous percutaneous coronary intervention (PCI) may affect the outcomes of patients who undergo coronary artery bypass grafting (CABG). The objective of this study was to compare the early in-hospital postoperative outcomes between patients who underwent CABG with or without previous PCI. METHODS: The present study included 160 patients who underwent isolated elective on-pump CABG at the department of cardiothoracic surgery, Minia University Hospital from January 2010 to December 2014. Patients who previously underwent PCI (n=38) were compared to patients who did not (n=122). Preoperative, operative, and early in-hospital postoperative data were analyzed. The end points of the study were in-hospital mortality and postoperative major adverse events. RESULTS: Non-significant differences were found between the study groups regarding preoperative demographic data, risk factors, left ventricular ejection fraction, New York Heart Association class, EuroSCORE, the presence of left main disease, reoperation for bleeding, postoperative acute myocardial infarction, a neurological deficit, need for renal dialysis, hospital stay, and in-hospital mortality. The average time from PCI to CABG was 13.9±5.4 years. The previous PCI group exhibited a significantly larger proportion of patients who experienced in-hospital major adverse events (15.8% vs. 2.5%, p=0.002). On multivariate analysis, only previous PCI was found to be a significant predictor of major adverse events (odds ratio, 0.16; 95% confidence interval, 0.03 to 0.71; p=0.01). CONCLUSION: Previous PCI was found to have a significant effect on the incidence of early major adverse events after CABG. Further large-scale and long-term studies are recommended.

Correlation of synovium osteoprotegrin with magnetic resonance imaging in rheumatoid arthritis

To demonstrate the role of Osteoprote grin [OPG] expression in the synovium in the pathogenesis of rheumatoid arthritis [RA] joint damage, and correlate it with Magnetic Resonance Imaging [MRI] finding. Twenty RA patients and five controls were included. RA disease activity was assessed by disease activity score [DAS 28]. MRI examination of knee joint, including evaluation of inflammation using synovitis score and evaluation of destruction with an erosion score, were performed. Knee joint's synovial biopsy specimens were obtained, by arthroscopy, to demonstrate the degree of expression of OPG by using immunohistochemical staining with monoclonal antibodies, and to study the histopathological activity scores by histopathological examination. The OPG expression was deficient [grade 0, 1] in 70% of synovial cells and 85% of endothelial cells lining of the synovial blood vessels, and grade I and 2 in 70% of infiltrating cells in active RA synovium. There was no significant association between OPG expression score [synovial, endothelial, infiltrating cells] and disease duration, number of tender swollen joints, ESR and Larsen score. There was a significant inverse correlation between OPG expression [synovial, infiltrating] and MRI erosion score. There was a highly significant correlation between MRI synovitis score and ESR, CRP, pain score, histopathological synovium score [p<0.01] and significant negative correlation with erosion score. We concluded that decrease in OPG expression in synovium has a role in pathogenesis of joint damage in RA patients, and MRI is considered a sensitive test to detect pathological lesion in joint damage in RA patients

feasibility of spinal anesthesia with sedation for laparoscopic general abdominal procedures in moderate risk patients

One of the major advantages of laparoscopic surgery is minimizing postoperative morbidity. The previous limitations to the use of spinal anesthesia in laparoscopic surgery were the limited work space, high failure rate, more intra-operative morbidity and significant arterial blood gas alterations. However, the addition of a small-dose Ketamine infusion to propofol might provide a suitable sedative combination to be used with high spinal anesthesia, producing titerable sedation, increased hemodynamic stability, and minimal respiratory depression. At KFSH and RC Hospital, after Ethical Committee approval and informed written consent, 18 ASA III patients scheduled for various laparoscopic abdominal procedures were enrolled. Exclusion criteria consisted of ejection fraction below 45% and or peak expiratory flow rate and forced vital capacity of less than 65% of predicted values. Following oral premedication with midazolam 7.5-10 mg 30 min preoperatively, spinal anesthesia was conducted by bupivicaine 0.75% 3-3.5 ml at L3-4, in the lateral position to reach a sensory level at T4. Sedation was started by intravenous injection of 0.4 mg/kg propofol and 0.1 mg/kg ketamine prior to spinal anesthesia. This was followed by infusion of 1.0-1.5 mg/kg/h and 0.3-1.0 mg/kg/h. of the same drugs respectively. The sedation requirements were adjusted to keep the patient sleepy with conservation of airway reflexes at level 3 on a 5 point sedation score. Heart rate, respiratory rate and SpO[2] were monitored, together with direct arterial blood pressure monitoring and arterial blood gas analysis through arterial cannulation. Postoperative first time call for analgesia, total morphine consumption during the first hour and incidence of complications were recorded. Twenty Four hours later, surgeons' and patients' satisfaction were obtained and recorded. Heart rate and mean arterial blood pressure were significantly decreased after spinal anesthesia and intra-peritoneal insufflations of CO[2], with significant increase in arterial carbon dioxide tension accompanied by increase in the respiratory rate. The increase in respiratory rate led to gradual decrease of CO[2] level down to near the pre-operative PaCO[2] values. However, there was insignificant decrease in oxygen saturation throughout the intra-operative time. Postoperatively there were excellent surgeon and patient's satisfaction. Only one patient regained sensation before completion of surgery and sedation was deepened to level 5 sedation score. The mean surgical time was 98.5 +/- 21.4 min while the mean anesthesia time was 117.7 +/- 20.1 min. First mean time call for analgesia was 50 +/- 8 min. 7/18 patients required single dose of morphine of 4 mg during the 1[st] hour postoperatively. The addition of a sedative combination of ketamine and propofol to spinal anesthesia was found to be safe and efficient from both the anesthetic and surgical point of view, especially for sick patients with intermediate clinical predictors

Total thyroidectomy in treatment of non-malignant goiter: is it worthwhile?

Total thyroidectomy is increasingly being accepted as a treatment of choice for differentiated thyroid cancer. However, because of presumed increased morbidity associated with this procedure, it is still not considered a viable option for management of benign thyroid disorders. To assess the safety and efficacy of total thyroidectomy for management of benign thyroid disorders, we analyzed our data from 100 total thyroidectomies performed for benign thyroid disorders. Demographic details, biochemical findings, indications for operation, specimen weight, and complications were noted. Among these patients, 35 had a toxic goiter and 65 had a non toxic goiter. The mean duration of goiters was 3.8 +/- 3.06 years [3 - 8 years], and the mean weight of the specimens was 85 gm +/- 180 gm. The incidence of permanent hypothyroidism and permanent recurrent laryngeal nerve plasy were 1% in both. According to this study, we can conclude that: total thyroidectomy should be considered as the treatment of choice for multinodular goiter and Graves' disease in a setting of palpable nodule[s] or ophthalmopathy [or both] because reoperation for recurrent goiter in such a setting would be hazardous with distressing complications

Early graft function and carboxyhemoglobin level in liver transplanted patients

Heme-Oxygenase-1 catalyzes hemoglobin into bilirubin, iron, and carbon monoxide, a well known vasodilator. Heme-Oxygenase-1 expression and carbon monoxide production as measured by blood carboxyhemoglobin levels, increase in end stage liver disease patients. We hypothesized that there may be a correlation between carboxyhemoglobin level and early graft function in patients undergoing liver transplant surgeries. In a descriptive retrospective study, 39 patients who underwent liver transplantation between the year 2005 and 2006 at KFSH and RC, are included in the study. All patients received general anesthesia with isoflurane in 50% oxygen and air. Levels of oxyhemoglobin, carboxyhemoglobin and methemoglobin concentration in percentage were recorded at preoperative time, anhepatic phase, end of surgery, ICU admission and 24 hr after surgery. The level of lactic acid, prothrombin time [PT], partial thrombin time [PTT], serum total bilirubin and ammonia were also recorded at ICU admission and 24 hr after surgery. The numbers of blood units transfused were recorded. 39 patients were included in the study with 13/39 for living donor liver transplant [LDLT] compared to 26/39 patients scheduled for deceased donor liver transplant [DDLT]. The mean age was 35.9 +/- 16.9 years while the mean body weight was 60.3 +/- 20.9 Kg. Female to male ratio was 21/18. The median packed red blood cell [PRBC] units was 4 [Range 0-40]. There was a significant increase in carboxyhemoglobin level during the anhepatic phase, end of surgery and on ICU admission compared with preoperative value [p < 0.005]. However, there was insignificant changes in methemoglobin level and significant decrease in oxyhemoglobin levels throughout the study period compared to the preoperative value [p < 0.005]. The changes in carboxyhemoglobin level on ICU admission and 24 hrs postoperatively were positively correlated with the changes in serum total bilirubin and prothrombin time [R = 0.35, 0.382, 0.325 and 0.31] respectively p < 0.05] but not with the changes in serum lactic acid. The same strong correlation was found when analysing LDLT and DDLT patients separately between carboxyhemoglobin concentration and PT and total bilirubin while still the correlation with lactic acid was weak. There was no correlation between average perioperative carboxyhemoglobin concentration during different timing of measurements and average units of transfused blood [R = -0.02] p > 0.05. The changes in carboxyhemoglobin level significantly correlate with the changes in graft functions particularly prothrombin time and serum total bilirubin and may be used as an early, rapid and simple test for early evaluation of graft function

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

Intra-peritoneal bupivacaine alone or in combination with morphine patients undergoing vertical bypass gastroplasty

Intra-peritoneal instillation of local anesthesia and morphine has been used to alleviate post-operative pain in laparoscopic surgery. Controversy exists about the efficacy of this technique. We studied 48 patients scheduled for Vertical Bypass Gastroplasy [VBG]. All of them received the same technique of general anesthesia [GA]. Patients were randomly allocated into four equal groups. They received equal volumes of the test drug instilled in the peritoneal cavity at the end of laparoscopy, 50 ml of normal saline [Group S]: 50 ml of bupivacaine 0.25% [Group B], 50 ml of bupivacaine 0.25%, plus morphine 40 mcg.kg-1 [maximum of 5 rug] Group M or [Group D] patients received the same regimen as Group M in addition, they received 75 mg intra-muscular diclophenac after induction of general anesthesia. Wound edges were infiltrated with 10 ml bupivacaine 0.25% in all patients. Morphine 25-50 mcg.kg-1 was given intravenously every 10 mm as a rescue analgesic to control postoperative pain in Post Anesthesia Care Unit [PACU]. Post operative pain was evaluated using Visual Analogue Scale [VAS]. vital signs and morphine consumption, and time to receive rescue analgesia were measured at different intervals. The incidence of post-operative complications [respiratory depression. oxygen de-saturation. arid nausea and vomiting] was recorded as well as hospital stay. There was significant decrease in VAS, HR. MBP and morphine consumption in Groups M and D when compared to Groups S and B on admission and on discharge from PACU. There were significant decrease in time to receive rescue analgesia as well as significant reduction in hospital study in Groups M and D when compared to Groups S and B. However, there was no significant difference between group S and B regarding the same parameters. The presented technique is safe and easy to use with good postoperative morphine sparing analgesia, excellent patient satisfaction and short hospital stay

Evaluation of different treatment modalities in dukes B and C rectal adenocarcinoma

A retrospective analysis of 291 eligible patients with carcinoma of rectum and rectosigmoid was undertaken. The patients were assigned to one of four treatment groups: Preoperative chemoradiotherapy [CRT], followed by postoperative chemotherapy [POCT], postoperative radiotherapy [PORT], postoperative chemotherapy [POCT] and postoperative CRT. The results showed that with a median follow up of 57.2 months, the 5-year overall survival was 47.8%, the 5-year DFS was 42.4%. The 5-year OS was 48.3% in the preoperative CRT group, 42.4% in PORT group, 34.3% for POCT group and 55% in the POCRT group. The 5-year DFS was 44.8%, 39.4%, 31.5% and 50% in the four treatment groups, respectively. Local failure [LF] occurred in 14.1% of the patients and distant metastasis [DM] was observed in 28.9%

strategy of wide local excision followed by postoperative radiotherapy in adult rhabdomyosarcoma: is it worthwhile?

This study was done on 20 patients with adult rhabdomyosarcoma of lower extremities. They were subjected to careful history taking, general and local examination. Investigations were done to confirm the diagnosis and to be sure that there was no distant metastasis. They included biopsy [Tru-Cut, incision and excision], plain X-ray chest, computed tomography [CT] chest, bone scan and magnetic resonance imaging [MRI] on the tumor area. The preoperative investigations included complete blood picture, liver functions, serum creatinine, blood sugar and ECG. Operation was done in the form of wide local excision [conservative surgery or limb salvage technique]. Radiotherapy was applied at the tumor area after surgery in the form of 6000 rad divided on six doses over six weeks. A long-term follow up for two years was done regarding local recurrence, distant metastasis and other complications

Special tactics in repair of epigastric hernia

This study included 30 patients presented with epigastric hernias of different sizes. Careful clinical examination and preoperative investigations were done to evaluate the general conditions of the patients and to treat any correctable medical disease. After assuring that there was no contraindication to surgery, the elective surgically correction of the hernia was done by a special technique in all patients using three-layer repair [vest-over pants repair, gel foam packing and prolene mesh [hernioplasty]. A follow up of the patients was done for one year. The results were very satisfactory with no recurrence

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