Assessment of the serum level of lnterlukin-12 and soluble vascular adhesion molecule-1 in multiple sclerosis patients

Multiple sclerosis [MS] is a complex and heterogeneous disease, and our understanding of the disease initiation mechanism and its wide clinical variability is limited. Cytokines and leukocyte endothelial adhesion play an important role in the initiation and maintenance of the inflammatory reaction in multiple sclerosis. The present study aimed to estimate the serum levels of IL-12 [a cytokine] and sVCAM-1 [an adhesion molecule] in different MS clinical subtypes and to assess their relationship to disease activity, grade of disability and MRI findings of cerebral atrophy. The study included 53 female patients suffering from definite MS [20 relapsing-remitting in remission [RRMS in remission], 16 relapsing-remitting in relapse [RRMS in relapse], and 17 secondary progressive [SPMS]] and 15 healthy age and sex matched controls. Patients were subjected to: thorough clinical evaluation, clinical grading of disability using Expanded Disability Status Scale [EDSS] and Magnetic resonance imaging [MRI] of the brain. For patients and controls, the serum levels of interleukin 12 [IL-12] and soluble vascular cell adhesion molecule-1 [sVCAM-1] were estimated. The mean serum levels of IL-12, and sVCAM-1 were significantly elevated in all MS groups compared to the control group. Significantly higher serum levels of IL-12, and sVCAM-1 were detected in SPMS versus RRMS groups [whether RRMS in relapse or in remission], and were significantly higher in RRMS in relapse versus RRMS in remission. The two biomarkers were significantly correlated to each other. Significant positive correlation was detected between mean EDSS score with mean serum levels of IL-12 and sVCAM-1. MRI signs of cerebral atrophy were detected in 17 patients, mainly from SPMS group. Patients with cerebral atrophy showed significantly higher serum levels of IL-12, and sVCAM-1 compared to patients without cerebral atrophy. Serum levels of IL-12 and sVCAM-1 are elevated in remission-relapse and progressive subtypes of MS and in MS associated with brain atrophy denoting that the inflammatory status in MS tends to persist in early and advanced stages of the disease. Immunomodulatory therapy targeting the above parameters might seem to be beneficial to delay disease progression and/or reduces lesion activity. Moreover, serum levels of IL-12, and sVCAM-1 were significantly correlated with the degree of disability induced by MS, thus suggesting their utility as reliable markers of disability in MS patients

value of magnetic resonance cholangiopancreatography and selective use of endoscopic retrograde cholangiopancreatography in patient management prior to laparoscopic cholecystectomy

Different diagnostic modalities have been used to asses patients with cholelithiasis before laparoscopic cholecystectomy [LC] for the suspicion of choledocholithiasis. The aim of this study is to define predictive guidelines for patient management with selective use of magnetic resonance cholangio-pancreatography [MRCP] and endoscopic retrograde cholangiopancreatography [ERCP] before LC. ERCP is considered the gold standard for diagnosis and clearance of common bile duct [CBD] stones before LC. MRCP has recently developed as a noninvasive imaging modality for the detection of choledocholithiasis. However it needs further evaluation as regards its diagnostic accuracy in patient management before LC. Between October 2001 and December 2004, 128 patients [88 females, 40 males; mean age 48 [range 14-78 years] with cholelithiasis were prospectively evaluated before LC applying predictive guidelines that include patient information obtained from clinical assessment, blood chemistry tests, and abdominal ultrasonography. Patients were put into one of four groups according to the level of suspicion for choledocholithiasis [group 1, high; group 2, moderate; group 3, low; group 4, very low]. Group 1 patients underwent ERCP with or without endoscopic sphincterotomy for clearance of common bile duct stones; group 2 patients were subjected to MRCP; group 3 patients were operated on by LC with intraoperative cholangiography; and group 4 patients underwent LC without intraoperative cholangiography. CBD stones were demonstrated in 15 [11.7%] of 128 patients. The incidence of choledocholithiasis in groups 1, 2, 3 and 4 was 83.3% [10/12], 27.3% [3/11], 7.1% [1/14], and 1.1% [1/91]. rescectively [P < 0.001]. ERCP was successfull in diagnosis and therapeutic clearance of CBD stones before LC in 91.7% [11/12] of patients. It showed a sensitivity, a specificity, and an overall accuracy of 92.3%, 100%, and 91.7% respectively. MRCP was utilized in 8.6% [11/128] of patients. It was unable to detect a CBD stone in one patient, with a sensitivity, a specificity, and an overall accuracy of 75%, 100%, and 91% respectively. lntraoperative cholangiography detected a CBD stone in one patient in group 2, and in another patient in group 3 which were extracted using postoperative ERCP. Only one patient in group 4 had a missed CBD stone which was manifested three months after operation and the patient underwent ERCP with stone clearance. It was concluded that initial evaluation using certain predictive guidelines in patients with cholelithiasis can accurately predict the probability of choledocholithiasis with selective use of MRCP which is an accurate non invasive diagnostic method and ERCP for therapeutic clearance of CBD stones before LC. Thereby improving patient care and resource utilization

role of fine needle aspiration cytology and imprint cytology in cervical lymphadenopathy

To determine the diagnostic accuracy of cervical lymphadenopathy by fine needle aspiration [FNAC] and imprint cytology [IC]. This study included 94 patients with cervical lymphadenopathy. They were subjected to clinical examination and FNAC of one of the enlarged lymph nodes. This was followed by IC and histological examination of this lymph node after its excision. Clinical examination was correct in 78% of the cases. The overall accuracy of fine needle aspiration was 93%. It was accurate on all cases of reactive hyperplasia, 93% of tuberculosis Iymphadenitis, 90% in Hodgkin's lymphoma. 86% in non-Hodgkin's lymphoma, and 91% of metastasis lymphadenopathy. On the other hand, the overall accuracy of IC was higher than that of fine needle aspiration, being 97%. It diagnosed all cases of reactive hyperplasia and non-Hodgkin's lymphoma, 97% in tuberculosis lymphadenitis, 90% in Hodgkin's lymphoma and 95% in metastasis lymphadenopathy. These techniques proved to be reliable, rapid, and inexpensive procedures in diagnosis of lymphadenopathy. They can differentiate well between inflammatory and neoplastic lesions, in cases of lymphoma, cytological diagnosis should be followed by histological diagnosis for accurate classification and grading

Liver abscess, modalities of treatment: percutaneous, laparoscopic, and open drainage

Liver abscesses, although relatively rare in the Western World [Cushieri and Giles 1995 and Johnson and Taylor 1992] are commonly encountered in tropical regions Traditionally, surgical treatment for such abscesses involved open drainage of the abscess through a hepatotomy via a transperitoneal or retroperitoneal approach [Greenstein et at, 1984]. Other modalities of treatment of liver abscess include percutaneous and laparoscopic drainage. This paper presents our experience in the treatment of 12 patients of liver abscess using different modalities of drainage with comparison between them. Twelve patients suffering from hepatic abscess were managed interventionally between July 2001 and June 2004 in Al Jedani and Al Riyadh Care hospitals in Saudi Arabia. Eight patients were treated with percutaneous drainage and 7 patients were judged to require surgical drainage, 6 of them selected for laparoscopic drainage of the abscess. Only one patient was openly drained early in our series. The patients were followed prospectively and factors studied included clinical presentation, investigations, surgical indications, surgical technique and outcome. We divided the patients into two groups: Group I: with percutaneous drainage of liver abscess [8 patients]. Group II: with laparoscopic or open drainage of liver abscess [7 patients] including 3 patients with failed percutaneous drainage. We compared between the two groups in different aspects. There were eight men and four women with a mean age of 45 [range 36-65] years. All patients presented with fever and upper abdominal pain. All patients had preoperative ultrasonographic confirmation of the abscess and 10 also underwent CT for preoperative localization of the abscess. Nine patients had right lobe and three had left lobe abscesses. The diameter of the abscesses ranged from 4.5 to 15 [mean 8.5] cm, as measured by ultrasonography and CT. In seven patients etiological factors for the liver abscess could be identified. For group I [percutaneous drainage], 3 cases failed [2 with persistent fever and pain and one case with recurrence of abscess after catheter removal]. For group II [laparoscopic drainage], initial success was achieved in 6 out of the 7 patients. There was no wound infection or death. Repeat ultrasonography or CT gave normal findings in all patients at the end of follow up period. Comparison between percutaneous and laparoscopic drainage: The duration of the procedure was 25 [20-60] min. in group I [percutaneous group] and 35 [25-120] min. in group II [laparoscopic group] with statistical significant difference. The mean amount of pus drained was 80cc in group I and 150 cc in group II with statistical significant difference. The duration of drainage was 5 days in group I and 4 days in group Il [no statistical significant difference]. Resolution of symptoms was 5 cases out of 8 [62.5%] in group I and 6 cases out of 7 [85.7%] in group II with statistical significant difference. Adequacy of drainage with decrease in size of abscess cavity was 5 cases out of 8[62.5%] in group I and 6 cases out of 7 [85.7%] in group II with statistical significant difference. Three cases were converted in group 1[37.5%] and one case with blocked drain in group II [14.3%]. Recurrence rate was [12.5%] in group I and 0% in group II. There were no complications nor deaths in both group I and group II. Although each modality of drainage has its indication. laparoscopic drainage had several advantages over other modalities. Laparoscopic drainage was more effective than other modalities of drainage perhaps because of larger drainage tube as revealed by greater mean amount of pus drained in group II [laparoscopic] with statistical significant difference. Also, the better adequacy of drainage in the laparoscopic group was shown by resolution of symptoms in [85.7%] in group 11 [laparoscopic] compared to [62.5%] in group I [percutaneous]. Adequacy of drainage with decrease in size of abscess cavity was 5 cases out of 8[62.5%] in group I and 6 cases out of 7 [85.7%] in group II with statistical significant difference. The failure rate was lower in laparoscopic group. There are also other advantages over percutaneous drainage, including the opportunity to explore the abdomen adequately [Tay et al., 1998]

Surgical management of post endoscopic retrograde cholangiopancreatography [ERCP] duodenal perforation

Traditionally post ERCP duodenal perforations have been managed surgically; however, in the last decade, management has shifted toward a more selective approach. Those who favor a selective approach have not elaborated distinct management guidelines. To evaluate the authors experiences in management of post ERCP duodenal perforations to define the criteria for operative management and a systematic management approach. A retrospective review of consecutive cases of ERCP related perforation [from May 2000 to May 2004] was carried out. Seventy-four out of 3050 ERCP performed [2.4%] were complicated by duodenal perforations and were included in the study. Forty-two perforations [56.8%] were discovered at ERCP while 32 cases [43.2%] required additional radiological assistance. Twenty-nine patients [39.2%] were operated early within 6 hours whereas 45 patients [60.8%] were initially treated conservatively. Fifteen patients had surgery after failure of medical treatment. Four cases [8.9%] died under conservative treatment and 14 cases [31.8%] died after surgical intervention. Pyloric exclusion procedure [PE] was done for 33 patients [75%]. Early diagnosis is important but difficult especially for retroperitoneal perforations. Clinical and radiographic features of ERCP - related duodenal perforations can be used to stratify patients into surgical or non-surgical cohorts. A selective management scheme is proposed based on the features of each type. Pyloric exclusion procedure is the operation of choice when the diagnosis is delayed and when the perforation is not detected or can't be repaired

New closed technique in treatment of pilonidal sinus

Although many methods of surgical and non-surgical approaches for treatment of pilonidal sinus [PNS] have been proposed, an optimal treatment modality has not been achieved yet. In the case of pilonidal sinus treated with primary intention surgery, the uneventful healing is still difficult to obtain as indirectly proven by the number of different procedures. The aim of this study was to determine the advantages of adding an antibiotic carrier [Septocoll, septomycin] in the closed method technique after primary excision of the PNS. This randomized controlled prospective study included one hundred sixty-four consecutive patients who had primary or recurrent pilonidal sinus. These patients were treated by excision of the pilonidal sinus and primary closure. They were divided into 2 groups each included 82 patients: For Group I an antibiotic carrier [Septocolll] was introduced into the resulted cavity after excision of the PNS before skin closure. For Group II no antibiotic carrier was used and the cavity was closed directly. For group I: There was no operative mortality. Seventy-two patients [88%] had complete healing by the end of the study and were asymptomatic. Sixty six patients [80%] had healing by primary intention and in 16 patients [20%], the wounds healed by secondary intention. Fourteen patients [17%] developed postoperative prolonged pain. Ten patients [12%] developed recurrence. Mean length of hospital stay was 2.2 days [range Ito 3 days]. For group II: There was no operative mortality. Forty-nine patients [60%] had complete healing by the end of the study and were asymptomatic. Forty-six patients [56%] had healing by primary intention and in 36 patients [44%], the wounds healed by secondary intention. Thirty-three patients [40%] developed recurrence. Eighteen patients [21%] developed postoperative prolonged pain. Mean length of hospital stay was 3.1 days [range hto4 days]. Wide excision and primary closure by tension sutures after application of antibiotic carrier in the cavity is associated with short postoperative hospital stay, low morbidity, and low recurrence rate. It can be performed for managing primary or recurrent, clean or infected pilonidal sinuses with good long-term results

Sentinel node mapping in colorectal cancer: is it worth the effort?

Background: Lymphatic mapping [LM] with sentinel node [SN] biopsy is an interesting recent development in surgical oncology. This approach has the potential of accurately identifying the first lymph node [or nodes] that drain primary tumors. These nodes are the most likely to harbor metastatic or micrometastatic disease. Sentinel node mapping and the pathologic search for micrometastasis may therefore increase the accuracy of the pathologic staging, which may alter the further management and the prognosis

Aim of the Study: To evaluate the usefulness of intra-operative in-vivo and ex-vivo sentinel node mapping in colorectal cancer [CRC] resections, and its effect combined with selected pathologic focus node examination on upstaging of CRC and consequent therapeutic strategies

Patients and Methods: Twenty- nine [after exclusion of six] patients with CRC were enrolled in a study of lymph mapping [LM] with peritumoral and submucosal injection of isosulfan blue dye. In-vivo LM was undertaken intraoperatively during colon resection in 23 patients. Ex-vivo LM was done after specimen removal in 6 patients [1 rectosigmoid and 5 extraperitoneal low rectal carcinoma]. All nodes wereexamined with hematoxylin and eosin [H and E] staining; in addition, negative sentinel lymph nodes [SNs] for metastasis with H and E were multi-sectioned and examined by immunohistochemical staining with cytokeratin[CK-lHC]

Results: SNs were successfully identified in 27/29 patients [93%][at least one SN was identified]. SNs were not identified in 2 cases; one case of very low rectal cancer and the other one was a locally advanced rectosigmoid colonic cancer. LM .demonstrated primary lymphatic drainage to SNs outside the margins of conventionally surgical planned resections in 2 cases [7%] and guided multiple sections and histochemical staining that identified occult micrometastases in 3 of the SN negative patients [11%]. Upstaging was thus achieved in 5 cases [18%] using mapping and focus nodal examination. Overall, the specificity and the negative predictive value in this series were 100% and 67%, respectively, whereas the sensitivity and positive predictive value were 89% and 78% respectively. There was a significant positive correlation between the tumor T stage and lymph node metastases [P< 0.001]

Conclusion: Sentinel node mapping is easy to do intraoperatively during colorectal resections. Ex-vivo LM can be applied when in- vivo techniques are unsuccessful and could beuseful for rectal carcinoma. LM techniques appear to improve staging accuracy in CRC through detection of more node metastases as well as guiding the use of sophisticated histopathologic studies to search for occult nodal micrornetastases. It may demonstrate an unexpected pattern of lymphatic drainage requiring modification of the conventional resection

Modified shoelace technique for repair of large midline incisional hernia

Operations for large and recurrent abdominal hernia have a high associated recurrence rate although it is lower when prosthetic material is used. Many techniques were prescribed for repair of such hernia with varying degree of success. We present in this study a modification of the old shoelace technique used for repair of large midline incisional hernia discussing the results and the complications associated with such modification especially infection, respiratory complications and recurrence. We concluded that modified shoelace technique is a good method for repair of large midline incisional hernia as it is associated with low incidence of respiratory complications and recurrence

Effect of length of oesophageal stump on postoperative gastro-oesophageal function after resection of lower oesophageal carcinoma

Oesophageal carcinoma is not uncommon. One common goal of curative and palliative resection of oesophageal carcinoma is to achieve good functional outcome. During the last decade, Ivor Lewis operation with intrathoracic oesophagogastric anastomosis has been rising as the operation of choice for lower oesophageal carcinoma. It is wdl known that no oesophageal substitute is able to function as proper as the original organ, the peristalsis of which is essential to propel food into the gastric reservoir. Many authors think that the greater the length of the remaining oesophageal stump the better the postoperative functional outcome. The aim of this work was to evaluate the functional outcome after Ivor Lewis oesophagectomy and gastric pull-up for oesophageal cancer and to correlate the results with the length of the preserved oesophageal stump. Twenty patients [15 males, mean age 60 ys] were studied at the sixth postoperative month by questionnaire, stationary manometry and upper GI endoscopy. The commonest postoperative unpleasant complaints were early postprandial sensation of fullness [70%], diarrhea [40%] and gastrooesophageal reflux disease [GORD] [40%]. GORD was more profound in the left lateral position. According to the actual site of the oesophago-gastric anastomosis away from the central incisors as seen during endoscopy, patients were classified into 2 groups: High anastomosis group [A] with anastomosis lying less than 25cm from the central incisors [i.e. the anatomical length of the oesophageal stump < 10 cm] and low anastomosis group [B] with anastomosis lying at or below 25cm from the central incisors [ie. the anatomical length of the oesophageal stump >/= 10 cm]. It has been found that in low anastomosis group, there was a significant difference between the anatomical length of oesophageal stump and the functional length [as measured by manometry]. Patients in low anastomosis group had significantly better postoperative oesophageal body functions as revealed by better mean peristaltic pressure amplitudes [37 mmHg in group B versus 20.1 mmHg in group A, P < 0.05], better duration of contractions [2.11 sec. in group B versus 1.62 sec. in group A, P < 0.05] and better propagation velocity of the muscular contractions [2.7 mm/sec, in group B versus 2.01 mm/sec, in group A, P < 0.05]. This was reflected clinically by significant increase in body weight and significantly higher proportion of patients regaining their normal preoperative body weight in the low anastomosis group. It has been concluded that, provided oncological rules are not breached, Ivor Lewis operation with low intrathoracic anastomosis gives better functional outcome than high anastomosis in patients with lower oesophageal carcinoma

Re-do operations for failed anti-reflux surgery

Advances in the classical operations for gastroesophageal reflux disease [GERD] and the recent application of laparoscopic fundoplication have led to dramatic increase in the number of patients undergoing such operations and consequently their complications. To define the common technical defects responsible for failed operations for gastro-esophageal reflux disease [GERD] and how to manage such failures. This study included 17 patients who were reoperated upon for complications that developed after fundoplication done for treatment of gastro-esophageal reflux disease. The study was carried out at La Cavale Blanche Hospital, Brest University [France] and El Demerdash Hospital, Ain Shams University [Egypt] between November 97 and March 2000. Most of the post fundoplication complications were due to tight crurae [41.2%] and torsion of the lower esophagus [23.5%]. Rare causes were slipped stomach [11.8%], complete disruption of the wrap [5.9%], intrathoracic migration of the stomach [5.9%] and long wrap [5.9%]. In one patient, no operative abnormalities were detected. Operative management of these complications was presented. The major side effects of fundoplication can be minimized with further patient selection and attention to technical details in the construction of the wrap. Results of redo operations for failed anti-reflux procedures are encouraging for patients who are profoundly affected in their daily activities and their ability to lead a full and productive life

Selective versus routine intra-operative cholangiography during cholecystectomy

This study aimed to examine the selective criteria for intraoperative cholangiography by measuring their sensitivity, specificity, positive predictive value and negative predictive value. The ability of these indicators to predict CBD stones at cholecystectomy was measured, so the role of selective intraoperative cholangiography can be evaluated. The study included 70 patients with gall bladder stones with no prove of concomitant CBD stones by clinical and ultrasonographic examination. Patients were subjected to cholecystectomy with routine intraoperative cholangiography. Out of them, eight had positive cholangiograms and common bile duct [CBD] stones. So, many unnecessary cholangiograms were performed with loss of money and time with associated morbidity. The clinical, laboratory, radiological and operative data of all cases were reviewed compared with cholangiograms. Certain parameters or criteria were common in patients with positive cholangiograms. The study also tried to determine certain criteria to select patients at high risk to perform selective intraoperative cholangiography