Laparoscopic versus open repair for perforated peptic ulcer, a randomized study

Between June 1998 and June 2002, 23 patients with a clinical diagnosis of perforated peptic ulcer were randomly allocated to open repair [group 1] or laparoscopic repair [group 2], in El Minia University Hospitals. Open repair was performed in 14 patients [9 men and 5 women, with a mean age of 45.2 +/- 14.1 years]. Laparoscopic repair was performed in 9 patients [6 men and 3 women, with a mean age of 46.1 +/- 15.1 years]. The risk factors were similar in both groups. Laparoscopic repair had a significantly longer operative time than open repair [group 2, 115.6 +/- 45.3 versus 58.6 +/- 43.2 minutes in group 1, but the amount of analgesic required after laparoscopic repair was significantly less than in open surgery [median 3 doses versus 6 doses. There was no significant difference in the two groups of patients in terms of duration of nasogastric aspiration, hospital stay, time to return to normal activities, morbidity and mortality rates

Endoscopic and laparoscopic treatment of mirizzi syndrome

Endoscopic followed by laparoscopic treatment of Mirizzi syndrome has been shown to be safe and effective. This technique was applied in 15 patients with Mirizzi syndrome. Ten patients had a single large stone and five had multiple stones impacted in the cystic duct. Nasobiliary drainage tube [NBDT] or stent was applied in patients for preoperative drainage of biliary tree and to prevent acute cholangitis by endoscopic retrograde cholangiopancreatography [ERCP]. Laparoscopic cholecystectomy was tried in all patients within 3 days after endoscopic intervention. In 6 cases, conversion was done from laparoscopic to open cholecystectomy. Conversion was due to fistula in three cases, injury to common bile duct in two cases and bleeding from slipped cystic artery in one case. Mortality was zero. Preoperative endoscopic drainage has many advantages including abortion of endotoxaemia in acute cholangitis, lowering the elevated serum bilirubin, improving the clinical condition of the patient, allowing easy identification of the anatomy of the bile ducts intraoperatively and immediate detection of any injury to bile ducts. The presence of stented bile duct allows for primary closure of the injury

Management of malignant dysphagia with self expanding metallic stents

The use of self -expanding metal stents [SEMS] for palliation of malignant dysphagia is increasing. Early experience in 26 patients was included with respect to the value of stenting and management of complications encountered. SEMS were inserted in 26 patients [18 men and 8 women] of mean age 64.6 years with malignant esophageal obstruction. Data regarding stent insertion and score of dysphagia were gathered prospectively. The insertion of covered SEMS was successful in all 26 patients. Improvement in dysphagia grade by at least one grade was achieved in 96.2 percent of our patients. There were no mortality related to the procedure. Recurrent dysphagia was recorded in four cases [15.3 percent]. Two were due to stent migration and treated by another stenting. One was due to tumor overgrowth while the last was due to epithilial hyperplasia and treated by balloon dilation. Self -expanding metallic stents offer an excellent way of palliating dysphagia due to esophageal carcinoma with shorter hospital stay. It is usually successful, safe [minimal morbidity and mortality] and effective [ability to eat a near -normal diet]. Problems such as migration of the stent may be overcome by future improvements in stent design

Laparoscopic appendectomy does not change the incidence of postoperative infectious complications

It is not clear whether the laparoscopic approach does decrease the incidence of postoperative infectious complications after appendectomy. One hundred twenty nine patients were randomized, 67 with laparoscopic [LA] and 62 with open appendectomy [OA]. Patients in the OA group had a Mc Burney incision, LA was performed in the Lithotomy position. Acute appendicitis was confirmed in 85 percent of patients. The appendix was perforated in 5 patients of the LA versus 2 of the OA group. No conversion to the open procedure was necessary. The median operating time was 35 minutes in the LA group and 31 minutes in the open group [P=0.58]. The median postoperative hospital stay was shorter after Laparoscopic than after open surgery [2 days versus 5 days P= 0.026], where as the time required for return to work was not significantly different [14 versus 15 days]. There were 5 [7.4 percent] patients with superficial wound infection following LA and 6 [9.6 percent] after OA [P=0.67]. Intra-abdominal fluid collections were found in 2 [2.9 percent] patients following LA and 3 [4.8 percent] patients following OA [P =0.60]. In the LA group, 3 patients presented with intra abdominal hemorrhage and another 3 developed a paralytic ileus that was treated conservatively. Laparoscopic appendectomy is as safe as and as effective as the open procedure, however it does not decrease the rate of postoperative infectious complications

Risk of lymphoedema following the treatment of breast cancer

This study included 20 female patients who had lymphoedema following a variety of treatment for operable breast cancer .Our study was assessed in the surgical department of El Minia University Hospital from 1992 to 1997.Patients who had been followed for at least one year after breast surgery were eligible for inclusion in the study, while those with bilateral breast cancer were excluded. Lymphoedema was assessed in two ways: subjective [patient plus observer impression] and objective [physical measurement]. Arm volume measurement 15 cm above the lateral epicondyle was the most accurate method of assessing difference in size of the operated and normal arm. Arm circumference measurement were inaccurate. Subjective lymphoedema was present in 15 percent whereas objective lymphoedema [a difference in limb volume >200 ml] was present in 80 percent. Independent risk factors contributing towards the development of subjective late lymphoedema were the extent of axillary surgery [P <0.05], axillary radiotherapy [P<0.001] and pathological nodal status[P<0.10]. The risk of developing late lymphoedema was unrelated to age, menopausal status, handedness, early lymphoedema, surgical and radio therapeutic complication, total dose of radiation, time interval since presentation, drug therapy, surgery to breast, radiotherapy to the breast and tumor T stage. The incidence of subjective late lymphoedema was similar after axillary radiotherapy alone or axillary sampling plus radiotherapy [0 percent], while axillary clearance alone was [25 percent]. The incidence after axillary clearance plus radiotherapy was significantly greater [33.3 percent, P<0.001]. Axillary radiotherapy should be avoided in patient who have had a total axillary clearance

Unusual abscess pattern following dropped gallstones during laparoscopic cholecystectomy

Laparoscopic Cholecystectomy has become the standard treatment for symptomatic cholelithiasis. Numerous clinical trials have deemed it a safe procedure, regardless of the known increased risk of bile duct injury. However, the consequences and incidence of less well-known complications are still being addressed. Between 1995 and 1998, 200 laparoscopic cholecystectomy were performed at El-Minia Surgical Department, 3 patients [1.5 percent] subsequently developed abscesses as a consequence of dropped stones during the Laparoscopic Cholecystectomy, while 2 [1 percent] other patients developed trocar site "tumor" masses that were secondary to inflammatory tissue around gallstone fragments. All patients were successfully treated by surgical drainage, stone removal, and antibiotics. Trocar site inflammatory masses required excision only. This experience closely resembles that of the other centers and points out the existence of late postoperative complications following laparoscopic cholecystectomy that was rarely encountered with open cholecystectomy. Strategies from avoiding this problem are discussed. Whether dropped stones are an indication for conversion to open cholecystectomy remains unclear. Thorough irrigation at time of surgery with or without placement of a drain in the subhepatic space does not prevent this complication

Evaluation of the value of laparoscopy in acute abdominal pain

Acute abdominal pain always presents a problem to the attending surgeon. Despite the availability of many diagnostic aids such as clinical investigations, study of peritoneal aspirate, radiological examination and ultrasonography, negative exploratory laparotomies are still not rare. Laparoscopy in the management of patients with an acute abdominal pain proved to be very helpful in selected cases not only in reaching accurate diagnosis but also in avoiding unnecessary laparotomies. One hundred consecutive patients with acute abdominal pain were included in this work. Laparoscopy was indicated in 72 cases [72%] and its use helped to avoid laparotomy in 54 patients [62.5%] and in correcting clinical diagnosis in 5/24 [20.8%] of cases. Laparoscopy is also one of the major armamentation in cases where we were reluctant to operate when clinical diagnosis is indeterminate where it was diagnostic in 47/58 cases [81.03%]

Anorectal sepsis: a problem still not always optimally treated

254 patients suffering from anal or anorectal sepsis were included in this work, 183 were males and 71 were females, [sex ratio M:F 2.58:1]. Age ranged from 7 to 93 years, a mean age of 32.7 +/- 12.3 years. 48.8% were found to have a history of previous sepsis. Bacterial cultures showed bowel derived organism in 50.6% of cases, skin derived organism in 23.5%, mixed growth in 19.7% and in 6.2% cultures were sterile due to antibiotics intake. Abscesses were found in 147 patients, ischiorectal abscesses were found in 83 [56.57%], perianal abscess in 26 [17.68%], submucous abscess in 6 cases [4.08%]. Adequate linear drainage was done for all, but associated partial internal sphincterotomy was added in 62 cases [42.17%], 32 with intersphincteric abscesses and 30 with ischiorectal abscesses. Anal fistulae were detected in 38 cases [37.3%] out of 102 patients who could be followed up for a period of 6 months to 2 years and it was found that cases complicated after drainage by anal fistulae had no sphincterotomy during the initial drainage procedure. 107 patients presented by anal fistulae, low intersphincteric or transphincteric fistulae making the highest finding [79.4%] of all fistulae. Fistulectomy could be done as one stage operation in all except in one of submucous fistula and two stage fistulectomy was done for 3 cases of suprasphincteric fistulae. Recurrences were detected in 5 cases [6.7%] after a follow-up for 6 months to 2 years. The overall recurrences in this group of patients was 24.4%. Adequate abscess drainage associated with partial internal sphincterotomy for cases with ischiorectal and intersphincteric abscesses is the key to avoid recurrence of anorectal sepsis, cultures should be done for all cases with anorectal sepsis and cases showing bowel derived organisms should be considered risk group and should be followed up to detect and treat possible recurrences

Tuberculous lymphadenopathy in Mina

1208 patients with lymphadenopathy were examined. Tuberculous lymphadenitis topped the list with 516 i.e. 42.7 percent of total cases studied, 60% were in the age group 20-29 years, 51.61% were females and 48.8% were males, 84.3% were found in cervical nodes which inguinal lymph nodes were the least group affected by tuberculosis 1.35%. Caseation necrosis were found in 51.53% of cases. Tubercle bacilli could not be found in attempt cultures for acid fast bacilli

modified warren shunt by using 8-mm interposition Gore-Tex graft

Thirty nine patients with oesophageal varices were included in the work. All patients have a history of at least one attack of bleeding oesophageal varices. Patients were operated upon by a modified distal splenorenal splenorenal shunt using 8mm. interposition Gore- Tex Graft. The operations were urgent in 9 and elective in 30 patients, 29 patients were males and 10 were females, age ranged from 18 to 58 years with a mean age of 32 years, 14 patients have bilharzial periportal fibrosis, 8 patients have chronic active hepatitis and 17 patients have combined pathology of chronic hepatitis and bilharzial periportal fibrosis, 24 patients were in child's class A, 14 patients in class B and 1 class C. Emergency shunts were performed only when conservative therapy had failed to stop variceal bleeding; 2 patients died in the elective group [6.7%] due to hepatic failure and 2 patients died in the emergency group [22.2%]. One due to hepatic failure and the second of haemorrhage. Patients were followed up for 6 to 48 months, shunts were found to be patent in 30 patients [85.7%] and thrombosis was found in 5 patients [14.2%], recurrence of bleeding occured in 4 patients [11.4%.]. Patients who showed thrombosis or rebleeding were treated by sclerotherepy in 3 patients, splenectomy and devascularization in 2 patients, one of them died of hepatic failure, temporary encephalopathy occurred in 3 and ascites in 2. It can be concluded that modified distal splenorenal shunt using an 8mm. interposition Gore-Tex H- Graft is a reliable operative method in the treatment of bleeding oesophageal varices as it is technically less demanding operation with less blood loss and shorter operating time. The high venous flow in the portal circulation in portal hypertension can prevent occlusion of the graft but pressure measurements during surgery is a must to assure this high flow rate along the graft

Hepatic abscess

Thirty- four patients were included in this work. 18 were males, 16 were females, Age ranged from 8 to 85 years with a mean age of 42 years. Amoebiasis was responsible in 24 [70.6%] patients but in 18 [75%] patients of them secondary bacterial infection was found, Cholecystitis was responsible in 2 patients, generalized sepsis in 2, trauma in one. Carcinoma bile duct in one and unknown source in 4 patients. Streptococcal species were isolated in 37% of positive cultures, Escherechia coll in 33%. Bactcroides in 24%, Klebsiella pneumonia in 18% and microaerphillic streptococi in 12% growth was found in six patients. All patients received a combination of metronidazoh and aminoglycosides. Closed- open drainage after exploration of the abdomen was done except in three patients with multiple scattered abscesses where only specimens were taken for culture and sevsitivity. Intercostal tube drainage was in four patients. Three patients died due to generalized septicemia and multiple scattered hepatic abscesses in two patients and cholemia due to advanced carcinoma of common bile duct in the third patients. Associated cholecystectomy and common bile duct exploration was done in two patients, and rigid tube drainage of the common bile duct in one patient with inoperable cancer. Postoperative recovery was smooth in most survivals, six patients developed pneumoniae, deep vein thrombosis occured in one patient and wound sepsis in eight patient. Closed- open drainage seems to be reasonable line of treatment for our patients who came late with gigantic liver abscesses, left lobe abscesses, deep seated abscesses of the right lobe and ruptured hepatic abscesses

Thoracic outlet syndrome

15 cases of Thoracic outlet syndrome were included in this study, 12 patients were females and 3 were males, their ages ranged from 23-48 years with a mean age of [39.3] years. 6 cases [4%] were due to bony compression and 9 cases [60%] were due to soft tissue compression. All these cases failed to respond to conservative treatment.In 6 cases resection of the first rib by transaxilary approach with scalenectomy. For both scalenus anticus and scalenus medius. was done. In 5 cases resection of a cervical rib with scalenectomy-for scalenus Anticus-was done by supraclavicular approach. Scalenectomy-for scalenus anticus only was done in 4 cases. In 10 cases [66.7%] the results were excellent with complete recovery of the symptoms, in one patient the improvement was not complete with persistence of mild paresthesia and pain on the ulnar side of the arm and there was no improvement in 4 patients. Pneumothorax developed in 4 patients in the post-operative period but completely recovered with intercostal tube drainage. In conclusion treatment of thoracic outlet syndrome is stilI a challenging problem we believe that accurate clinical diagnosis, adequate investigation by venography, arteriography, electromyographic study and proper surgical intervention are the comerstone for a high degree of surgical success